Diabetes/Metabolic Syndrome | Dr Briffa's Blog

Diabetes costs ‘out of control’, and why this is no surprise given standard dietary advice for diabetics

I saw this story on the BBC website this morning. It concerns the costs of treating those with diabetes. Apparently, the cost of drugs for managing diabetes is rising (a lot), and now accounts for 7 per cent of the total amount spent on prescribing in the UK. Between 2000 and 2008 prescriptions for diabetic drugs rose by 50 per cent, apparently, and costs (even taking into account inflation more than doubled.

What to do? Well, for a start, perhaps people could be given appropriate advice regarding how to eat to better control their diabetes. Sugary and starchy carbohydrate tends to cause considerable disruption in blood sugar levels. So, it makes sense that limiting such foods may well improve blood sugar (‘glycaemic’) control. Not so long ago I reported on a study which employed a low-carb diet in a group of type 2 diabetes. The result: more than 95 per cent of them were able to reduce or stop their medication.

Admittedly, the diet used in this study was really quite low in carb. But it gives some indication of the sort of results that can be achieved by employing the logical and correct nutritional approach to diabetes.

I was interested to read the comments of Dr Niti Pall – a spokesperson for Diabetes UK (the UK’s pre-eminent diabetes charity) – in the BBC news story linked to above. She claims, according to the article, that the job of GPs is to get blood sugar levels as low as possible by whatever means possible. Really? Because, such an approach may promote attacks hypoglycaemia (low blood sugar) that can cause symptoms such as weakness and confusion. Sometimes, hypoglycaemia can cause injury and even death.

Maybe Dr Pall is aware of this but neglected to mention it in her enthusiasm regarding getting blood sugar levels as low as possible. But even if we ignore the obvious gaff regarding hypoglycaemia, is it really true that getting blood sugar levels as low as possible is the best way forward? I ask this because there is some evidence that intensive lowering of blood sugar levels using pharmacological agents (i.e. insulin and/or other diabetes drugs) actually increases risk of death [1].

Should we be too surprised that perhaps not the best advice for diabetics has come out of Diabetes UK? Maybe not, bearing in mind that it is this organisation which continues to advise diabetics to eat like this (taken from the Diabetes UK website):

At each meal include starchy carbohydrate foods
Examples of these include bread, pasta, chapatis, potatoes, yam, noodles, rice and cereals. The amount of carbohydrate you eat is important to control your blood glucose levels. Especially try to include those that are more slowly absorbed (have a lower glycaemic index) as these won’t affect your blood glucose levels as much.

However, even the lower GI foods recommended here can be very disruptive for blood sugar levels, especially when eaten in quantity (as they often are). This advice, if acted on, will generally destabilise blood sugar levels in a way that will do little or nothing to help individuals control their condition and reduce their medication or even eliminate the need for medication entirely. But, then again, as I commented here, perhaps that’s the point.

References:

1. Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358(24):2545-59

Low-GI diet helps women with PCOS, but is there something that might work better?

Polycystic ovarian syndrome (PCOS) is a condition characterised by multiples cysts in the ovaries, but also other symptoms such as hirsutism (abnormal hairiness) and acne that may result from higher than normal levels of androgens (‘male’ hormones) in the female body. I wrote about this condition back in 2003 (see here), where I made the point that the best diet, generally speaking, was one based on low glycaemic index (low GI) foods – i.e. foods that release sugar relatively slowly into the bloodstream.

One of the rationales here is that women with PCOS tend to be insulin resistant. In other words, their insulin tends not to work so well. The chief function of insulin is to reduce blood sugar levels. So, if insulin isn’t working too well, it makes sense to avoid eating foods that cause spikes in blood sugar. Also, there is an idea that higher levels of insulin (common in insulin resistance) can stimulate androgen release. At the time, the idea of eating a low-GI diet was based on common sense and first principles. Recently, though, a group of scientists decided to test the merits of low-GI eating in the real world [1].

96 women started the study, and were assigned to either a low-GI diet or a ‘healthy’ diet. Both diets made half of their calories made up from carbohydrate. For each diet, calories contributed by protein and fat were the same too (23 and 27 per cent) respectively. The overall GIs of the two diets were 40 and 59 respectively. The study lasted for 12 months.

A number of measures were taken as part of the study including body composition, sex hormone levels, and blood sugar control (as assessed with an oral glucose tolerance test).

Compared to the group eating the standard diet, those eating the lower-GI diet saw significant improvement in the results of the glucose tolerance test, which would point to improved blood sugar control and insulin action.

Also, 95 per cent of women saw improvement in the regularity of their menstrual cycle, compared to 63 per cent of the other group. Overall, the lower-GI group did better, in other words.

This study provides some objective evidence that a low-GI diet has merit for women with PCOS. However, my advice for women with PCOS looking to improve their condition through diet is not to eat a low-GI diet, but to eat a low-carb one. The thing is, it is possible to eat a low-GI diet and still eat a lot of carb. And, in essence, the less carb someone eats, the less insulin they secrete and, in theory at least, the better the result.

I used to be a fan of low-GI diets (and still am, on some levels). However, over the years I’ve become convinced that for many, low-GI diets just don’t go far enough. This is not just true for PCOS, but for other issues too including excess weight and type 2 diabetes.

References:

1. Marsh KA, et al. Effect of a low glycemic index compared with a conventional healthy diet on polycystic ovary syndrome Am J Clin Nutr 19 May 2010 [epub before print]

Higher-protein diet with resistance exercise best for fat loss

There are a myriad of ways to lose weight, but I lean generally towards diets relatively low in carbohydrate and rich in fat. This is on the basis that such diets consistently out-perform diets explicitly low in fat in terms of weight loss. Also, such diets tend to, generally speaking, bring about desirable changes in markers for disease including blood pressure, blood fat and blood sugar levels.

When it comes to exercise, I am not particularly enthusiastic about conventional advice to take plenty of aerobic exercise (e.g. walking, swimming, cycling). While this may be good for all manner of things (e.g. reduced risk of disease and improved mental health), it tends not to work for weight loss. Over the years, I’ve become a gradual convert to resistance exercise. Part of the reason for this is that it can improve body composition, might reduce muscle loss during weight loss, and also generally improves functionality (particularly important as we age).

I was interested to read of a recent study in which two diets (one higher in protein than the other) were tried in a group of overweight and obese individuals with type 2 diabetics [1]. The breakdown of these two diets in terms of calories contributed by carbohydrate, protein and fat, respectively were:

Conventional diet – 53:19:26

Higher-protein diet – 43:33:22

Each of these group was also split into two, with only one of these groups also engaging in resistance exercise 3 time a week. The study last 16 weeks.

A number of body measurements were made, including weight, fat mass and waist circumference.

Overall, the people who did worst, were those who ate the ‘conventional’ diet and did not engage in resistance exercise. Those doing best were those who ate the higher-protein diet, who did resistance exercise too.

For example, non-exercising conventional diet eaters lost an average of 6.4 kg of fat and 8.2 cm off their waists. In comparison, the higher-protein diet eating exercisers lost an average of 11.1 kg of fat and 13.7 cm off their waists.

If I had my way, for optimum results, I’d swap some of those carb calories for fat. Nevertheless, this study supports the idea that for the most effective weight loss, diets lower in carb and richer in protein, coupled with some resistance exercise, delivers the goods.

References:

1. Wycherley TP, et al. A High-Protein Diet With Resistance Exercise Training Improves Weight Loss and Body Composition in Overweight and Obese Patients With Type 2 Diabetes. Diabetes Care 2010;33(5):969-976

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Diabetics continue to be misinformed regarding healthy eating

I was giving a presentation last night to a group of individuals of Indian sub-continent extraction. As a group, south Asians appear to be particularly prone to cardiovascular disease and type 2 diabetes. And judging by the expanded waistlines in the audience, this group were no difference. Part of my presentation focused on the potential hazards of carb-rich foods such as rice and chappatis in the development of abdominal obesity, heart disease and type 2 diabetes. I made point that a lower-carb diet is the, generally, the way to go for those wanting to lose fat and reduce their risk of these health issues.

One of the foods I recommended is nuts. Nuts are a highly nutritious food. A recent study found that those including nuts in their diet had generally more nutritious diets with regards to key nutrients including magnesium and potassium [1]. Nut-eating appears to be particularly beneficial for diabetics, and is associated with a reduced risk of heart disease. And, despite being rammed full of fat, nuts are not fattening.

After the presentation, I lost count of the number of people who came up to me to express how surprised (and pleased) to learn that nuts were ‘on the menu’. All had been advised not to eat them on accouint of their calorific nature. The people I spoke to were also, it seems, please to have been exposed to ‘the other side’ regarding healthy eating and disease prevention. Notably, among them were several type 2 diabetics. Without exception, each of these told me that they had been strenuously encouraged to eat a low fat, carbohydrate rich diet.

Just to ram home the points I’d made in my presentation, I asked each one of them (rhetorically), what type of foods diabetics have difficulty handling metabolically (carbohydrate). I then asked whether it made sense for them to base their diets on the very food type their bodies cannot handle. If high blood sugar is the hallmark of diabetes, why base the diet on foods that tend to raise blood sugar substantially? I also mentioned some studies that demonstrate that low-carb diets bring significant benefits for diabetics.

My impression was that again, without exception, these diabetics ‘got it’. Some of them asked how come something so wrong (diabetics should eat lots of carbohydrate) could become established as fact. Part of the reason, I explained, relates to the fact that if something gets repeated long enough and often enough, it becomes ‘fact’. At one point, for example, it was ‘fact’ that the world was flat. Now we know better. The problem is, I think, that even in the face of good evidence and common sense to the contrary, many health professionals continue to maintain that diabetics should eat a diet rich in the very foods that appear to do them most harm.

References:

1. O’Neil CD, et al. Tree nut consumption improves nutrient intake and diet quality in US adults: an analysis of National Health and Nutrition Examination Survey (NHANES) 1999-2004. Asia Pac J Clin Nutr, 2010;19(1):142-50

Higher protein diet plus resistance exercise aids weight and fat loss in type 2 diabetics

Where weight and fat loss is concerned, I favour a relatively low-carbohydrate, high-protein diet on the basis that such diets generally outperform low-fat, carb-rich diets traditionally advocated for weight loss. A lower-carb diet I think may have particular advantages for diabetics because, well, they have difficulty handling carbohydrate as a result of impaired insulin function (insulin resistance) and/or insufficient insulin.

There is a certain logic to the notion that diabetics should be careful consuming the very food type (carbohydrate) they have difficulty dealing with. However, not everyone agrees. You can see here how Diabetes UK (the leading diabetes charity in the UK) specifically recommends against carbohydrate restriction on the basis that:

• glucose from carbohydrate is essential to the body, especially the brain

• high fibre carbohydrates, such as wholegrains and fruit, also play an important role in the health of the gut

• some carbohydrates may help you to feel fuller for longer after eating

However, glucose can be made from other elements of the diet (e.g. protein) which makes the absolute requirement for carbohydrate none at all. Also, wholegrains are generally rich in insoluble fibre which has been shown to be quite irritant to the gut compared to soluble fibre found plentifully in fruits and vegetables. But if diabetics are looking for a heathy source of fibre, why not point them to green veg, say, rather than carb-loaded fruit. And it might be true that carbohydrates can help people feel fuller for longer, but protein has been found to be the most sating macronutrient and doesn’t cause wild swings in blood sugar levels (as many wholegrains do) either.

Getting back to weight loss, it appears that aerobic exercise is not particularly effective here (see here for more about this). That is not to say that aerobic exercise is a waste of time – it most certainly is not in my opinion (it just does not do much to shift surplus pounds).

In recent years there has been increasing interest in the idea that resistance exercise (e.g. weight training) can help fat loss and improve body composition. See here for a previous post about a relevant study.

I was interested to read about a recent study in which resistance exercise was tried in a group of obese type 2 diabetics [1]. Individuals either performed resistance exercise (3 days a week) or no exercise for 16 weeks. Each of these groups were further subdivided into groups eating either a conventional high-carbohydrate diet, or a lower-carb, higher protein diet. The make-up of these diets was as follows:

Conventional diet carb/protein/fat: 53/19/26

Higher protein diet carb/protein/fat: 43/33/22

The diets were ‘energy-restricted’ (about 1400 and 1700 calories a day for women and men respectively).

So, in effect, this study had four groups:

1. Conventional diet no exercise

2. Conventional diet plus resistance exercise

3. Higher protein diet no exercise

4. Higher protein diet plus resistance exercise

The participants were assessed in a variety of ways including weight loss, fat mass loss and waist circumference.

Overall, the group eating higher protein lost more weight and fat and saw greater reductions in their waist circumference too. However, these differences were much more marked when comparing the groups who were exercising.

Weight loss for exercisers in the conventional and high protein groups was an average of 10.5 and 13.8 kg respectively

Fat loss for exercisers in the conventional and high protein groups was an average of 7.9 and 11.1 kg respectively

Waist circumference reduction for exercisers in the conventional and high protein groups was an average of 11.3 and 13.7 cm respectively

Looking at the results as a whole, it’s clear that the group that did the best with regard to these measurements was the one eating less carb, more protein, with resistance exercise on top.

References:

1. Wycherley TP, et al. A High Protein Diet With Resistance Exercise Training Improves Weight Loss And Body Composition In Overweight And Obese Patients With Type 2 Diabetes. Diabetes Care 11th February 2010 [epub ahead of print publication]

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Diabetes costs ‘out of control’, and why this is no surprise given standard dietary advice for diabetics

Low-GI diet helps women with PCOS, but is there something that might work better?

Higher-protein diet with resistance exercise best for fat loss

Diabetics continue to be misinformed regarding healthy eating

Higher protein diet plus resistance exercise aids weight and fat loss in type 2 diabetics

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Editorial reminds us of the importance of looking to our nutritional past to improve our future health

Cinnamon shows promise as blood sugar-lowering agent

Abdominal obesity again linked with increased risk of dementia

Low vitamin D levels linked with increased risk of type 1 diabetes (again)