Are diabetics being given diet advice that just makes their problems WORSE?
- Each day, 400 people in Britain are given a diagnosis of type 2 diabetes
- Research indicates weight loss may be incredibly effective
- Yet many are not getting the lifestyle guidance they need
- Encouraged to eat balanced diet 'applicable to the general population'
- 'Some carbs rapidly turn into glucose in your blood and should be avoided'
There are more than three million people in this country living with type 2 diabetes and a further five million thought to be at risk of developing the disease. Diabetes UK has warned that the cost of treating patients 'could bankrupt the NHS'. In the second part of our series, we reveal the latest thinking on managing the complex condition.
When mother of three Sarah Gibbs was diagnosed with type 2 diabetes in May 2014, a nurse told her that her blood sugar levels were too high, gave her a prescription for medication to help reduce them - 'and that was it'.
Sarah, 42, from Newport, Gwent, went home, read about the complications she was likely to suffer if she couldn't control her blood sugar and panicked. 'I felt my life was finished,' she says.
Increasingly research indicates that the most effective way for people to hold type 2 diabetes in check is for them to lose weight by changing their diet and becoming more active
Each day, 400 people in Britain such as Sarah are given a diagnosis of type 2 diabetes - a disorder where blood sugar levels can become dangerously high unless they are managed effectively.
For the 3.3 million people in this country diagnosed with diabetes, working out how to lead your life with the condition can be bewildering and, as Sarah recognised, getting it wrong can have disastrous implications.
Two out of every three people diagnosed with type 2 diabetes do not manage to keep their blood glucose levels within healthy limits, according to statistics published by the charity Diabetes UK last month. It's as a direct result of this that 200,000 people every year develop severe diabetes-related complications: kidney and heart failure, nerve damage, blindness, heart attacks and strokes.
Yet how do you get that blood sugar control and why are so many people getting it wrong?
Medication can help, but increasingly research indicates that the most effective way for people to hold this disorder in check is for them to lose weight by changing their diet and becoming more active. Yet, as Sarah discovered, many are not getting the lifestyle guidance they need. The urgent need for this is underlined by new statistics from Public Health England showing that eight out of ten people with type 2 diabetes in England are both obese (ie with a BMI of 30 or more) and have unhealthy levels of inactivity.
Furthermore, there is evidence that, far from helping, the advice most frequently offered about diet may actually be making it harder for type 2 diabetics to keep their condition in check.
Type 2 diabetes normally occurs when fat clogs the liver, which regulates the supply of glucose to feed the body, and the pancreas, the tiny gland behind the stomach that produces the hormone insulin that takes glucose out of the blood stream and into cells.
But this fat can be eliminated, enabling normal insulin production to resume, by losing around 15 per cent of body weight (on average 2½ st). This means blood glucose levels return to normal immediately, an effect that lasts at least two years.
'We now know that once people with type 2 diabetes successfully lose weight and go below their personal fat threshold, the diabetes will disappear,' explains Professor Roy Taylor of Newcastle University.
'This knowledge is gold dust to many folk with type 2 diabetes. If I had the disorder, I would do this,' he says.
Guidelines from the National Institute for Health and Care Excellence (Nice), the NHS watchdog, recommend loss of up to 10 per cent of body weight. But the dietary advice on how to get there may do more harm than good, say some experts. According to Nice, anyone with type 2 diabetes should be encouraged to eat 'a healthy, balanced diet that's applicable to the general population' - in other words, meals containing a balance of protein, vegetables and, crucially, plenty of starchy carbohydrates including bread, rice and pasta.
However, some experts now insist that such a diet can actually contribute to type 2 diabetes.
'We know that type 2 diabetes develops when blood glucose rises above a certain level - and whether it's sugar, rice, bread or potatoes, these carbohydrates rapidly turn into glucose in your bloodstream and so should be avoided,' says Dr David Cavan, formerly a consultant physician at Bournemouth Diabetes and Endocrine Centre and now Director of Policy and Programmes at the International Diabetes Federation and author of Reverse Your Diabetes.
It's not just Nice which says type 2 diabetics can continue to eat carbo- hydrates or sugary foods. The charity Diabetes UK reassures visitors to its website (diabetes.org.uk) that having diabetes 'doesn't mean you have to cut sugar out of your diet completely. We all enjoy eating sugary foods occasionally, and there's no problem including them as a treat in a healthy balanced diet'.
However, Dr Aseem Malhotra, consultant clinical associate to the Academy of Royal Colleges, last month challenged the charity to explain why it continues to recommend 'carbo- hydrates known to promote fat storage and hunger' to a group of people most of whom urgently need to lose weight.
He said: 'Given that type 2 diabetes is a condition related to an intolerance to metabolise carbohydrates, it is puzzling why Diabetes UK recommends as part of a "healthy balanced diet" the consumption of plenty of starchy carbohydrates and modest amounts of sugary food and drinks including cakes and biscuits.'
The best long-term intervention for type 2 diabetes, says Dr Cavan, is to restrict carbohydrates by cutting back on sugar and starch and replacing it with non-starchy (green) veg, with some fatty foods such as cheese and full-fat, unsweetened yogurt along with calorie-dense protein.
Nigel Fowler is a living testament of the benefits of this approach. Now 44, he was diagnosed with type 2 diabetes in November 2014 and his blood sugar levels were so high that he needed six injections of insulin a day. Even this didn't stop his blood glucose from swinging chaotically, yet he says: 'I got no advice on diet from the nurse who started me on the injections except that I should continue as normal.
Nigel Fowler, 44, he was diagnosed with type 2 diabetes but got no advice on diet
'In my case, that meant four Weetabix for breakfast, several sandwiches during the day and usually a Bakewell tart in the evening.'
Rather than advising him to change his diet, the nurse put the cake into the calculation to decide how much insulin he'd need.
'That effectively meant that I had to eat it - or I risked having a hypo (when blood sugar becomes dangerously low). It was like hitting my head with a hammer and then taking painkillers for the pain.'
In March this year, property manager Nigel, from Norden near Rochdale, read an article discussing new evidence of the health benefits of low-carb, high-fat diets and decided to reduce the amount of starchy and sugary food in his diet - cutting out bread and cakes and replacing his breakfast cereal with berries and double cream to fill him up for the morning.
'Wow! What a difference,' he says. He has lost a stone since March - but says the real difference is 'the calming of the yo-yo effect on my blood glucose. I've lost the bit of fat around my middle and just feel fitter and generally happier.'
It's an approach that's gaining in popularity. Around 280,000 people now swap tips on the online forum diabetes.co.uk about controlling diabetes with a low-carbohydrate diet. Reading their stories led David Unwin, a Southport GP, to fundamentally change the way he approached diabetes with his patients.
Last year, the journal Diabetologia published a study of 19 patients with type 2 diabetes at Dr Unwin's surgery, who lost an average of 8.65kg (19lb) over seven months on a low-carb, high-fat diet, reducing their blood glucose levels by nearly a quarter.
Later this year, Dr Unwin is set to publish a further study of 69 patients with non-alcoholic fatty liver disease, a precursor of type 2 diabetes as well as heart disease, showing a 46 per cent improvement in liver blood tests, and therefore a reduced risk of high blood glucose levels after an average of 13 months on a low-carb high-fat diet.
The property manager decided to reduce the amount of starchy and sugary food in his diet
Another alternative is a very low calorie diet (VLCD). This was tested in a ground-breaking study carried out by scientists at Newcastle University and published in 2011 in the journal, Diebetologia. All 11 patients in the study reversed type 2 diabetes after an eight-week diet of 600-calorie-per-day liquid sachets of soups and shakes containing essential vitamins and minerals.
As yet it's not available on the NHS, pending a five-year ongoing study, funded by Diabetes UK, to test whether people can undergo such a diet under the supervision of their GP safely and effectively. A key factor is that dieters must stop their diabetic medication before they begin the VLCD, because the combination of drugs and diet could cause their blood glucose levels to plummet to dangerously low levels.
Despite the clear importance of diet to type 2 diabetics, anyone who feels they need weight and lifestyle advice should ask for it - don't presume it will be offered. While some GPs and their specialist diabetes nurses are very good at discussing this with patients, Dr Unwin says others can feel that mentioning weight problems, even obesity, is too personal, even rude.
'Until fairly recently, I was typical of the conventional approach to managing a patient newly diagnosed with type 2 diabetes,' he says. 'I'd warn patients that if they couldn't control their blood sugar with diet, they would have to go on drugs. As to how to lose weight, that wasn't my field so I'd send them to a dietitian.
'Yet I believe a well-informed, motivated doctor can really help people to manage their weight and turn their lives round.'
Why NHS drugs may not work
When the condition cannot be controlled by lifestyle changes alone, the first drug someone with type 2 diabetes is normally offered is metformin. These tablets reduce the amount of glucose released by the liver and make the body's cells more sensitive to insulin.
Yet some people find the drug does not work or they cannot tolerate it, and they need additional or different medication to help keep their blood sugar stable.
There are some effective alternatives that prevent hypos (when blood sugar dips too low) and weight gain. Together, these measures improve diabetes control and the risk of long-term complications, says Tony Barnett, emeritus professor of medicine at the University of Birmingham and Heart of England NHS Foundation Trust.
The first drug someone with type 2 diabetes is normally offered is metformin
Recently published data found that the injectable drug liraglutide, which increases the amount of insulin produced by the body, can help people with type 2 diabetes to lose an average of 6 per cent of their body weight over 56 weeks - as well as controlling glucose levels and reducing the risk of hypos.
Yet guidelines from the National Institute for Health and Care Excellence still recommend older drugs such as sulphonylureas, repaglinide and pioglitazone - which can cause weight gain, hypos and other unpleasant side-effects.
'The cost of these older drugs is between £1 and £3 per month compared to £30 to £35 a month for the newer drugs,' says Professor Roger Gadsby of Warwick Medical School.
'If doctors prescribe the new drugs to every new diabetes patient, the drugs bill for diabetes could increase by around £250 million annually.'
DIY kit that got me back on track
A glucometer is a device you can use to check your blood sugar as often as you want. There are several types costing less than £20 available from chemists.
You test a small drop of blood obtained by pricking the skin with a lancet (sharp blade) and placing it on a disposable strip, which is then inserted into the meter.
Measuring blood sugar levels yourself is 'one of the key skills of successful diabetes management', according to the online diabetes community, diabetes.co.uk. It wasn't until she started to use a glucometer that Marie Nimmo, 50, a healthcare worker and mother of two from Galston, Ayrshire, was able to achieve healthy blood sugar levels and overcome her symptoms of fatigue and confusion.
Maria Nimmo bought a meter and testing strips and started to test her blood glucose
Diagnosed in April 2013, she felt 'rotten' - until three months after the diagnosis when she discovered the diabetes.co.uk forum and found 'most members monitored the impact of high carbohydrate meals and activity on their glucose levels on a daily basis'.
She bought a meter and testing strips and started to test her blood glucose before and after meals. 'It gave me a clear idea of the impact of what I ate and different types of activity,' she says.
As a result, she cut down on bread, pasta, potatoes and rice, bought a second- hand exercise bike and lost 2 st (she's now 11 st and 5 ft 7 in).
'Most importantly, my blood glucose levels are normal. I'm not a saint - I'll have treats like everyone else. If I have two slices of cake, as I did for my 50th last week, I'll work off the excess glucose rather than becoming sweaty and irritable because my poor pancreas is having to work too hard,' she says.
Could standing up do more good than hitting the gym?
Dietary change is key to controlling or reversing type 2 diabetes - but it won't work for anyone who continues with a couch potato lifestyle.
And that includes people who exercise vigorously before flopping in front of the computer or TV.
A review of 47 studies, published in the Annals of Internal Medicine this year, revealed that sitting still for more than eight hours in a day raises the risk of type 2 diabetes by 90 per cent. And while there is some benefit in vigorous exercise, it's not enough to cancel out the risks of sitting down for hours on end.
'We need to do something when we're not exercising. We need to find excuses to stand up and move around,' says Dr Aviroop Biswas of the Toronto Rehabilitation Institute in Canada, who carried out the review.
He says take the stairs, not the lift; walk to the shops instead of driving; and carry groceries rather than using a trolley.
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