NHS and DUK dietary advice - what would YOU promote?

[Northerner]

I'm interested in the debate that seems to crop up in various threads about the dietary advice promoted by the NHS and Diabetes UK. Some posters see it as 'seriously flawed' and that it runs contrary to evidence in establishing healthy glucose control as well as providing for other dietary needs.

I'm relatively new to diabetes - less than a year, in fact - and tend to follow the 'official' guidelines in that I eat what I consider to be a healthy, balanced diet. Yes, I'm Type 1 and can 'cover' whatever carbs I eat with insulin should I so wish, but I don't just think I'll eat whatever I want, whenever - everything is in moderation, and I do watch out for refined carbs in particular.

I certainly don't object to the principle that eating a more limited-carb diet can be used to improve BG control - it clearly works very well for many people. What I do wonder, though, is how you could put across such a disciplined approach to the general (diabetic) public? A huge industry exists in the promotion of weight-loss diets, and they continue to sell because people can't stick to the principles, perhaps because they are short-term and fundamentally at odds with 'normal' living, or people aren't prepared to make long-term and sometimes difficult life-style changes.

In light of this, I think the NHS/DUK guidelines are intended as 'least-harm', simple rules that can improve quality of life and life-expectancy with minimal impact. I think if the guidelines became more complicated and prohibitive a large number of people would ignore them completely.

I do think that the guidelines should go deeper in providing support for individuals who might benefit from a more disciplined approach - those receptive to education and prepared to self-monitor should have easy access to those facilities.

Should the message be changed, and how?

 

[C*5_Dodger]

Dear Northerner,

For me there can be no doubt that the more carbs you eat, the worse will be your blood sugar. As you say, type 1s can have more latitude because they can "cover" the carbs. However, if you eat less carbs the problem of covering the carbs will be less uncertain. As to the NHS/Diabetes UK I would like to see them offer an alternative low carb approach for those of us who can stick it, for it is not an easy alternative. The clinical trial UKPDS (which was hailed as a success!!!!) showed that a Diet such as they used (it was the BDA diet) resulted in a relentless increase in fasting plasma glucose and A1c, for both the normally treated and the intensively treated cohorts. Which is just another way of saying that in the long term diabetic drugs just don't work for type 2s.

Regards Dodger

 

[VBH]

Well they are certainly intended to be good, but they do fail on several counts. While the NHS through the NSF is making an effort at increasing education, they are not anywhere near yet.

DAFNE, BERTIE and similar courses do a lot of good for T1s but the supply is limited and in certain areas its still impossible to get a course. If you are LADA, MODY, T1.5 etc you stand very little chance of getting on a DAFNE course, although it does depend on the area. Those subtypes are really forms of T1 when it comes to treatment and education but they are used as a technicality to rule people out.

When it comes to T2 the situation is much much worse. Although DESMOND is intended to be a good education tool for T2s, it concentrates on "hidden sugars" and other such misleading subjects.

[If I ever get on a DESMOND course I will be taking a baked potato, a pot of pasta, a loaf of bread and a pot of rice to make the point(all as brown as possible). When they get to "hidden sugars" I'll plonk that lot on the table and the argument will commence.]

The basic problem is that medics and researchers do not listen to diabetics in general. Even when they do listen, they are faced with disobeying the policies of the NHS in general and the PCTs specifically. DUK are in a similar position because they would find it very hard to contradict the general medical stance on diabetic management.

DUK have an additional problem with what advice they dispense. Take a look at where DUK get their funding and that one becomes apparent.

Research is a particular problem where researchers get hold of a simple idea and approach it from the wrong direction. I've mentioned Farmer et al elsewhere but its also worth mentioning ACCORD. They put one group in the study into an "Intensive treatment" group intending them to have lower A1cs. This group was halted because too many of them were dying.

When you look at what "intensive treatment" entailed, it was simply more drugs. As a result those patients were having more hypos and basically their bodies were being battered by the effects of a lot of drugs. Despite having A1cs above the 6 level, they were suffering far more than many of us under 6% who manage carb intake.

And this is a fundamental problem. When suggesting to the medical community that carb management is the key to diabetes for T1 and T2, they point to this misleading research and claim that it proves SMBG does not help A1c and that if you try to control A1c too well then you will die.

This is because they have not looked past the headlines and the Conclusion section of the research.

Until there is some decent research to demonstrate what we already know works, its a brick wall across the path of progress.

And the shame of it is, its basically common sense. You start with the simple fact that carbs raise BG. If you want to control the rise in BG, you need to control the carbs. For T1 this means a smaller margin for error when dosing. For T2s this means lower rises in BG. The advice would not have to be terribly complicated, particularly in comparison with the existing advice which contradicts itself quite bizarrely.

And thats not to mention the "low fat" nonsense that dietary advice has been based on for the last 50+ years.

So until research is done to demonstrate what we already know, then the situation is unlikely to change.

And in the meantime, people will fail to achieve good control through the advice given and it will be seen as their failure. They have managed to convince the mass population that T2 is self-inflicted in the first place (which it isn't). So they take the "spinal tap" or "GCSE grade" approach* and move the target so that more people can reach it with the ineffective tools available.

The approach in the past has brought about an expectation of failure and the assumption that diabetes is progressive (particularly T2). If your A1c is too high, it IS progressive. Good control brings any progression down to a crawl or stops it completely.

So I think the answer is in the research and if we are going to have to wait for the likes of Farmer to listen to diabetics on how to use test strips properly in his next study, I think we are going to have to wait a long time.


*
"These exams go up to 11."
"Why don't you make 10 harder and do it that way?"
"These go up to 11"

 

[sofaraway]

For type 1's I would encourage a balnced varied diet that they enjoy. I would like them to be educated on carbohydrate counting how to adjust insulin. I think as with everyone healthy eating, plenty of fruit, veggies and less junk and processed foods should be encouraged. But I would say that no foods are forbidden. I don't go along with the fact that eating very low carb food are easy to bolus for.

For type 2's I would suggest reducing the total amout of carbohydrate in their diet, looking at losing weight if needed by reducing number of calories. But not to extreme levels, and changing from carbs that will spike very quickly to those that might be kinder to blood sugar levels e.g. cereals to porridge for breakfast. Maybe looking at portion sizes and % of meal makeup of carbs/fats/protien. I would also take into account the ages of the person, theres a difference between a newly diagnosed 50 year old and an 85year old with co-morbidities.

thats my first quick thoughts, may come back to it later

 

[Adrienne]

Can I just through children with type 1 into the mix here as well. We have had this 'discussion' before on the other email group I'm on as new people arrive and say what about low carbs. Whilst in theory this is ok and makes a lot of sense for children it is so important they get carbs so they cannot have a low carb diet. They need the carbs to keep their energy up to function at school, physically and mentally etc.

Just thought i would throw that gem in just in case any newly diagnosed parents out there start thinking a low carb diet would be a good idea as to all intents and purposes it would be easier to manage insulin wise.😎

 

[bev]

Adrienne,
I had considered it - but after further research i realised that it may 'harm' Alex - he needs energy to grow and if i restricted his diet he may not reach his full potential and i would worry that he would lose even more weight as he is quite skinny! I am not saying that its not acceptable for an adult to do though - it makes sense - if you dont put carbs in - you wont suffer high levels! Bev

 

[Adrienne]

Hi Bev

Yep I totally agree. Carbs are a nightmare, pasta - well don't start me on that and jacket potato with cheese and beans - oh dear worst food to control ever. But yes for children its a whole different ballgame.

 

[ikeymo]

What an excellent summary from VBH! A very concise guide to how we all came to end up in the current dietary cul de sac.

It seems to me that the development of numerous and effective medications enabling blood glucose control have rather distracted the attention from what causes the loss of control in the first place - refined carbohydrates.
It's something of an unholy trinity composed of highly profitable food manufacturers, drug companies and a medical profession increasingly reliant upon them for their funding which leaves us to deal with dietary advice bordering on medical negligence.
Rant over.

One possible way out might be to introduce serum insulin level measurements as a routine physical test, similar to the way in which total cholesterol is measured? Only that total cholesterol is a relatively meaningless test of course, but never mind.

There is a wealth of established evidence linking elevated insulin to all manner of conditions, metabolic syndrome being a prime example.
With standard testing (not expensive incidentally) we might identify those at risk of type 2 years before current diagnostic methods.
We might simultaneously see that current advice to base diets upon starchy carbohydrates leads only to a worsening of the very conditions those diets were supposedly created to ease.

ikeymo

 

[mikep1979]

i find that my levels are pretty stable if i get the carb content correct in my food and then just give the dose according to it. as for diet i just eat a healthy sensible diet and have fish at least 3 times a week. i think it helps if your into sports etc as you want good fuel for the body anyway. (not saying none sporty types dont like good food)

 

[Caroline Wilson]

I'd like more support. I find it difficult to keep to a low carb diet. While I go for the whole meal whole grain varieties I have a family to cook for and they wont touch whole meal or whole grain varieties, so in effect I am cooking two meals, one for themand one for me. I don't want them to give up eating 'normal' food, but after a day at work I don't want to spend all night cooking. At work I can either have a cooked meal which comes with some kind of potato oe white rice (no alternative offered) or a sandwich om white bread (no alternative offered) and there is no facility for heating stuff we have prepared ourselves and brought in from home.

The guidance given by the experts I often find confusing and contradictory. When i visit my GP for my diabetic care, one says it's OK to eat eggs and cheese for example and the other says cut out eggs and cheese and neither of them agree.

 

[Heike]

I agree that more support is needed. When you inject to cover your carb intake it certainly shows on the bg results. So a low carb diet is favourable, especially when you need to loose weight or try to keep it off. But having had only a mornings lecture on carb counting isn't really enough. It took a while before I heard about refined carbs. So I need to do a bit more research and learn more about nutrion.

 

[wallycorker]

I'd like more support. I find it difficult to keep to a low carb diet. While I go for the whole meal whole grain varieties I have a family to cook for and they wont touch whole meal or whole grain varieties, so in effect I am cooking two meals, one for themand one for me. I don't want them to give up eating 'normal' food, but after a day at work I don't want to spend all night cooking. At work I can either have a cooked meal which comes with some kind of potato oe white rice (no alternative offered) or a sandwich om white bread (no alternative offered) and there is no facility for heating stuff we have prepared ourselves and brought in from home.

The guidance given by the experts I often find confusing and contradictory. When i visit my GP for my diabetic care, one says it's OK to eat eggs and cheese for example and the other says cut out eggs and cheese and neither of them agree.

Hi Caroline,

Your situation sounds very difficult - you have my sympathy. I've said myself that all this would be far more difficult if I had still been working. I'm retired with a quite stable daily situation and I am very aware that this makes my efforts much easier to work at and achieve results.

I agree that the garbled messages that we receive do not help any of us.

Keep at it and good luck with your efforts. You know that it's worth it in the long run.

Best Wishes - John

 

[Caroline Wilson]

Hi Caroline,

Your situation sounds very difficult - you have my sympathy. I've said myself that all this would be far more difficult if I had still been working. I'm retired with a quite stable daily situation and I am very aware that this makes my efforts much easier to work at and achieve results.

I agree that the garbled messages that we receive do not help any of us.

Keep at it and good luck with your efforts. You know that it's worth it in the long run.

Best Wishes - John

John, thanks for the support. My husband retires in August, and will be home to prepare meals. As we have lots of cook books i am hoping he will be able to prepare meals ahead of time that we can all enjoy. As he has osteoarthritis it will help him to be able to do some stuff ahead of time too.

 

[Copepod]

Caroline

I realise you can't heat food at your workplace, but can you take a flask of soup - wide necked flask is best for soup with some pasta added if you want or low carb soup if you prefer? If only white bread sandwiches are available, why not make sandwiches at home and take to work? Or a sandwich box full of salad with cold pasta / rice / potato? That's the sort of food I take to work, as there's no work canteen nor eating place within miles.

Or perhaps talk with your work colleagues / trade union to see if a microwave and kettle could be provided?

 

[Caroline]

Caroline

I realise you can't heat food at your workplace, but can you take a flask of soup - wide necked flask is best for soup with some pasta added if you want or low carb soup if you prefer? If only white bread sandwiches are available, why not make sandwiches at home and take to work? Or a sandwich box full of salad with cold pasta / rice / potato? That's the sort of food I take to work, as there's no work canteen nor eating place within miles.

Or perhaps talk with your work colleagues / trade union to see if a microwave and kettle could be provided?

Thanks for advice. I tried the microwave/kettle aproach. No one is allowed any kind of microwave, several of us already tried. We have a variety of dietry needs. We can get hot water, so that is not a problem

I think I am noticing it more as we have a new caterer who seems to think everyone can eat cake and chips. Many of us are boycotting the new caterers until we can get some healthier alternatives that suit the wider variety of dietry needs within the organisation.