Type 2 insulin dependent diet

[lizz]

I was recently diagnosed with type 2 Diabetes and started on insulin.
As per guidelines I was started on of basal insulin titrated to achieve blood glucose levels of between 6 – 8 mmol/L.

I then started a low carb diet progressing to the point that the only carbs were the milk in my tea.
As the BGL went down my hips which were previously painful became less so and I was able to walk more so I lost some weight.
When I visited the diabetes nurse for my first review I brought this up and said I didn’t think the low carb diet was sustainable ( I was also only eating once a day ).
I was told don’t worry I can eat carbs and she suggested rice puddings etc. and gave what seems to be outdated and wrong dietary advise.
When I asked her what the BGL goal was she said there wasn’t one
She said the recommended BGL levels are a gold standard and there was no need to adhere to them and not to worry as long as the BGL is less than 15mmol/L and only test once a day


Now I get a fasting BGL consistently around and above 9mmol/L with peaks of 12, as I have started eating carbs again and the titrated dose was set when I was on a very low carb diet.

The nutritional info I was given states a max of 3 eggs a week so that will indicate how it out of date is.

My question is what the latest nutritional guideline are for an insulin dependent type 2 diabetic.



Should I be eating consistently thru the day?

Is food less than 5 grams carbs/sugar acceptable?

What GI value should I be looking at?

Is tinned rice pudding an acceptable food?

Carbohydrate	16.7g	33.4g
of which sugars	10.2g	20.4g

Where can I find a science based recommended carb intake per day and how should it be spread out over the day.

Or is the diabetes nurse correct and I don’t have to worry?

 

[everydayupsanddowns]

Welcome to the forum @lizz

I confess to being slightly confused by the advice you have been offered, and that your doses have not been adjusted to take into account a different eating plan.

As to the appropriateness of a food that has two thirds of its carbs as sugar - how does that strike you instinctively?

You’ve seen a deterioration in your blood glucose levels, and I can completely understand how this would make you feel concerned.

Guidelines for blood glucose in T2 are 4-7 before meals, and no higher than 8.5 by 2 hours after meals, which is approximately half the concentration advised by your nurse of ‘below 15‘.

NICE guidelines make these suggestions

1.6.7 For adults whose type 2 diabetes is managed either by lifestyle and diet, or lifestyle and diet combined with a single drug not associated with hypoglycaemia, support them to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support them to aim for an HbA1c level of 53 mmol/mol (7.0%). [2015]
1.6.8 In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:

• reinforce advice about diet, lifestyle and adherence to drug treatment and
• support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and
• intensify drug treatment. [2015]

1.6.9 Consider relaxing the target HbA1c level (see recommendations 1.6.7 and 1.6.8 and NICE's patient decision aid) on a case-by-case basis and in discussion with adults with type 2 diabetes, with particular consideration for people who are older or frailer, if:

• they are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
• tight blood glucose control would put them at high risk if they developed hypoglycaemia, for example, if they are at risk of falling, they have impaired awareness of hypoglycaemia, or they drive or operate machinery as part of their job
• intensive management would not be appropriate, for example if they have significant comorbidities. [2015, amended 2022]

1.6.10 If adults with type 2 diabetes reach an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example deteriorating renal function or sudden weight loss. [2015]

(https://www.nice.org.uk/guidance/ng28/chapter/Recommendations#blood-glucose-management)
​

So your targets should be individually tailored to your circumstances, and should include avoiding both reducing the risk of developing long term complications (generally achieved by aiming for an A1c around 53 or below), but also avoiding risks potentially associated with pushing too hard (hypoglycaemia… falls etc)

Hope this helps

 

[Docb]

Hi @lizz - I see you are posting from New Zealand but diabetes is diabetes no matter where you live. What does vary is local protocols for managing it and the ways things are done here in UK may not be the same as where you are. The suggestions from your nurse certainly are at variance with what would be expected here as you can see from the NICE guidelines used in the UK quoted by @everydayupsanddowns. Is there anything equivalent to them in NZ?

 

[Leadinglights]

It might be useful if you give a bit of information about your diagnosis as it would be unusual in the UK for somebody diagnosed as Type 2 to be started on insulin immediately before diet and oral meds had been tried and were not working to manage blood glucose level, unless their HbA1C was astronomically high.
Your advice does seem a more than a little strange. It is risky to be having pretty well zero carbs when taking insulin. I hope you have been advised to have hypo treatment to hand at all times.

 

[rebrascora]

Hi and welcome.

I too would be interested in how your original diagnosis came about..... I an guessing a sudden crisis if you were started on insulin straight away and that makes me wonder if perhaps you could be a misdiagnosed, late onset Type 1.

I hate to be pedantic about carbs but I too would be a little concerned about someone whose "only carb" intake was from milk as I think a variety of vegetables (green veg and salad and onions and tomatoes and courgettes etc) and low carb fruits like berries and nuts and seeds are important to a balanced diet. I absolutely do not consider a tin of rice pudding as a healthy option to manage your diabetes..... the complete opposite in fact although it is interesting to know that it isn't just the NHS which is behind the curve with dietary advice for diabetics even if it is sad!

I love that your hip pain improved on a low carb diet as this is something that I found with all my joints but particularly my knees and back. I went from hobbling down hils (I live at the bottom of a steep one) and wondering how much longer they would hold out until I needed replacements, to being able to hop, skip and jog down the same steep hill.

I think with diabetes, it is best to find what works for you as an individual. You will know if your diet is sustainable and healthy long term because your body and mind will tell you.... A low carb diet is only unsustainable if you find it really hard work and you can't stick to it or don't enjoy it or you are showing signs of vitamin or mineral deficiency. If you are having a good balance of nutrients.... bearing in mind that your body does not actually need carbohydrate because it can manufacture it from other foods..... you are just looking at ensuring a good balance of the other stuff through variety .... and eating as much or as little carbs as you need to make it enjoyable for you to continue with it long term.

As regards insulin with a very low carb diet, it sounds like you are just on a basal insulin, so provided that is adjusted to a level where it isn't causing you hypos on a low carb diet, then it shouldn't be a problem. Learning to adjust your insulin doses to suit your body, the seasons and your activity levels is part of good diabetes management and you will learn that by your own experience far better than a nurse who sees you once in a blue moon can assess. If you are also on bolus insulin then you would need to adjust your doses to account for carb reduction, but on a low carb diet you sometimes also have to factor in protein, because approx. 40% of protein breaks down into glucose in the ebsence of enough carbs and 10% of fat.... but you would have to eat massive amounts of fat for that to become a significant issue. Sometimes you can use the basal insulin to cover this protein breakdown because it releases so much more slowly than carbs.... it depends which basal insulin you use to some extent.... A twice daily basal like Levemir is helpful because the daytime dose can be higher to cover protein and fat and the nighttime lower when there is less protein release.

Anyway, I would encourage you to go back to the low carb way of eating IF you were happy with that and your body was more comfortable and more healthy. Bodies are capable of managing a huge variety of different diets and trying to get reliable data about what is healthy for everyone is really difficult, not least because monitoring exactly what people eat each day for weeks on end is challenging and people of course have a tendency to deliberately cheat or accidentally stray from a strict diet and sometimes not be entirely truthful about the extent of their misdemeanors. I abandoned the NHS low fat advice when I started eating a low carb diet and I still feel guilty enough about that decision and the amount of fat I eat to the extent that I would potentially lie to a health care professional, or at least be evasive, even though I know that it suits my body and I have not been this fit and healthy both inside and out for a lot of years. I have come to the decision that the best course of action for me is to listen to my body and eat in a way that seems to make me feel healthier. Not had a cold for years, stopped having migraines, significantly less joint pain, don't need asthma inhalers anymore, skin is better.... not so dry and I sleep better. Those things have all improved since I changed my diet and had been quite long running issues prior to that.... that tells me that this low carb, higher fat way of eating is agreeing with my body and I enjoy my food so I see no reason to change.