This section is for everyone.

What “they” say:

When referring to carbohydrate the terms sugars, starch and fibre are preferred to the terms simple sugars, complex carbohydrates and fast acting carbohydrates as the latter are not well defined.

Carbohydrate exchange systems based on 10g portions do not improve glycaemic control and are no longer used.

Many factors including the type of sugar, nature of starch, method of food processing and cooking, food form, other food components, blood glucose levels, severity of glucose intolerance, can affect patient’s glycaemic response to foods.

The total amount of carbohydrate in the dietary intake seems to be more important than the source or type.

Intake of foods with a low glycaemic index has not been shown to improve glycaemic control in type 2 diabetics but may improve the lipid profile.

Consumption of the sugar sucrose does not increase glycaemia more than isocaloric amounts of starch.

Fibre containing foods such as whole grains, fruit and vegetables, provide vitamins, minerals and other substances important for good health. However both diabetic and non diabetic individuals would need to consume very large amounts of fibre to produce metabolic improvements to glycaemia and lipid profiles.

Intake of foods that contain naturally occurring resistant starch (corn starch) may modify post prandial glycaemic response and reduce more extreme fluctuations in blood glucose levels but there is no published evidence of long term benefits to diabetics.

When calculating optimal intake, greater attention should be paid to the total amount of carbohydrate than to its source or type.

Food with carbohydrate from fibre rich foods, wholegrains, fruits and vegetables and from low fat milk should be included in the diet. There is no evidence to support increasing fibre intake in diabetics above the levels recommended for the rest of the population.

Sucrose or sucrose containing foods should not be restricted for diabetics, but can be used in substitution for other carbohydrate sources in the context of a healthy diet with appropriate hypoglycaemic medication cover.

The expert consensus is that carbohydrate and mono-unsaturated fat together should provide 60-70% of intake, but precise and relative proportions may vary according to individual factors, such as age, activity levels and weight.

What they got right:

Quite a lot of what is said in this carb section is factually correct.

The terms sugar, starch and fibre are better than simple sugars or complex carb or fast acting carb.  The latter terms do tend to confuse people.

Carbohydrate exchange systems on their own do not improve glycaemic control.

Many factors do affect how an individual will respond to a given amount of carbohydrate.

The total amount of carb is indeed a more important consideration than the source or type.

The intake of low glycaemic foods versus high glycaemic foods is insignificant in getting good control when high amounts  of total carb are consumed. I do o not know whether the lipid profile will be better or not on a high total carb/low glycaemic diet.

Sucrose, which is the usual table sugar is certainly no worse than many starches in raising blood sugar levels.

Fibre eaten in palatable amounts has indeed no proven health benefits in diabetics or anyone else.

The consumption of corn starch may indeed result in less post prandial blood sugar drops if a high carb diet is consumed.

The total amount of carb is indeed a more useful consideration than type or source when it comes to glycaemic control.

What they should have said:

Sugar and starch have about the same effect on raising blood sugars. They both raise blood sugars quickly, often within 15- 30 minutes.  Fibre tends to retard the process somewhat.   In addition fibre is remains undigested and does not contribute to the total effect on blood sugar or on calories taken in.

The term complex carbohydrate tends to confuse people the most. Many would assume that brown bread is a complex carb and it is often described as such but most versions of brown bread are made into sugar just as fast as white bread or sucrose.

The truly complex carbs are non starchy vegetables such as celery, broccoli or cauliflower that have a cellulose structure that is more difficult for humans to digest so sugar release is quite slow.

Exchange systems can work well if the total amount of carb consumed at each meal is kept moderate to low. Dr Allen and Dr Lutz’s 70g carb diet is an example of this.

Many factors affect an individual’s response to a meal.  Charts and guides can offer some help but experimenting on yourself is the only way to really find out.

The total amount of carb consumed is certainly more important than the type or source when high amounts of carb are consumed. When you lower the amounts it becomes more obvious what the relative glycaemic effects of different carbs are.

Low glycaemic index foods when consumed in moderate to low amounts do tend to produce lower sugar spikes than higher glycaemic foods in equivalent amounts.

Consumption of sugar and starch raises blood sugar fast and predictably high. This can be very helpful when dealing with hypoglycaemia but is less useful when planning meals that are aimed at keeping blood sugars within the normal non diabetic range.

Strictly scientifically no carbohydrates are required to be consumed by humans whatsoever.  Essential fatty acids – Yes.  Essential amino acids – Yes.  Essential carbohydrates – Well, no actually.

In real life, if you are on injected insulin you can’t rely on getting it perfect 100% of the time. So, fast acting sugars such as glucose to deal with hypos IS necessary.

Many people enjoy eating carbohydrates even though their body can function fine without them.  These days we don’t eat the lightly cooked or raw organ meats that our ancestors ate. We therefore could become deficient in certain nutrients eg vitamin C if we did not eat exactly as they did.  Lightly cooked liver has more vitamin C than an apple weight for weight. But what would you rather have in your lunch box?

For a diabetic you would certainly have a lower effect on your blood sugars if you ate the raw liver compared to an apple. So what is the best of both worlds?

Fortunately nature has provided us with a wide variety of non starchy vegetables.
These generally grow above ground.

There is no nutrient present in whole grains, fruit or milk that is not available from either a meat/ egg source or non starchy vegetable. Usually the nutrients are present in much greater quantities too.

And there is no adverse effect on your blood sugars that often occurs with fruit, milk and wholegrains unless consumed in very small quantities, and preferably with a lot of fat added.

Sucrose and starches should be regarded by diabetics as poisonous until proven otherwise.  You can probably get away with eating small quantities of these infrequently. But you are kidding yourself if you think you can eat these as in a five year old’s birthday party and get away with it.

What the ADA and Diabetes UK say about sugar and starch is just plain wrong.  You may not want to believe this. It may be tough.

But do you know how much funding the food and drug industries give national diabetes associations such as the ADA every year? I’m not talking about the organic vegetable and free range chicken farms. I’m talking about sugar, confectionary, soft drink, breakfast cereal, bread , cake,  biscuit and other processed food suppliers give in donations and for endorsement of their products.

You can try to cover high carb/glycaemic items with insulin. Because of the 30-50% injection to injection variation in glycaemic effect you do put yourself at a rather high risk of overly low or overly high blood sugars. This is if your insulin matching and carb ratios are perfect.

Expert consensus about anything just means that a lot of people with common interests agree on something.   I call this “over the garden fence” opinions because they are just as scientifically valid.

They may be right. They may be wrong. But we just don’t know.

We don’t know what evidence they examined.
We don’t know what evaluation process they went through.
We don’t know what evidence they did look at.
We don’t know what evidence they didn’t look at.
We don’t know if they are bright or not.
We don’t know if they are going a bit batty-bat or not.
We don’t know if they took their medication that day or not.
We don’t know what they were offered for agreeing to someone else’s agenda or not.

We don’t know nuthin’ about that decision.

If you are happy to accept consensus decisions that is okay. Please give some tolerance to others who are a bit worried about accepting those decisions.

What is a typical NHS  dietary and insulin regime?

Your advised diet should you be a diabetic in Britain’s National Health Service is us usually something like this:

Consume plenty of starches at each meal.
Try to have wholegrain versions when possible.
Eat sugary foods in low to moderate amounts.
Eat at least 5 portions of fruit and vegetables a day.
Avoid diabetic products.
Drink diet versions of soft drinks.
Fruit juices may be consumed in moderate amounts.
Eat your usual amount of protein especially white meat such as chicken and fish.
You may eat eggs and red meat but only in small amounts.
Eat some oily fish each week.
Avoid saturated fat.
Avoid fried foods.
Avoid butter or lard. Use margarines instead.
Use olive oil in low to moderate amounts.
Drink alcoholic drinks sparingly.

A typical “healthy eating” day could be:

7.30 am

Breakfast cereal, semi skimmed milk.
Toast thinly spread with marmalade.
A glass of tropicana.
Tea.
A banana.

10.30 am

Small scone with small quantity of margarine and jam. (optional)
Coffee

1pm

Tinned cream of tomato soup.
Tuna sandwiches with margarine and wholegrain bread.
An apple.
Diet coke.

4pm

A small quantity of raisins and mixed nuts. (optional)
Coffee.

6.30 pm

Spaghetti Bolognese.
Tea.

9.30pm

Wholemeal toast and margarine.
A glass of semi skimmed milk.

The insulin regime to cover this could be:

Novorapid at breakfast, lunch and dinner and possibly before snacks.
Lantus at bedtime.

No carb counting is usually taught.

Dose adjustments are made on the trend in the blood sugars.

Blood sugars are preferred to be 4- 8 before meals and on rising.
Blood sugar is preferred to be over 5.0 at bedtime.
If blood sugar is 10 or over three days running at the same time of day the insulin to cover that period of time needs to be raised.

If 7.30 am bs is over 10 raise night Lantus.
If  1pm bs is over 10 raise breakfast insulin.
If  6.30pm bs is over 10 raise lunch insulin.
If  9.30 pm bs is over 10 raise evening meal insulin.

This sort of dietary and insulin regime is commonly used for type ones.

For insulin using type twos simple basal Lantus or other long acting insulin such as Levemir is commonly given on its own. No meal insulin is usually started unless the hbaics are over 8.

Twice daily mixed insulins such as Mixtard, Humalog Mix or Novomix may then be given.

Sometimes type 2s are given separate basal and rapid acting insulins to cover all meals.

The results of following this regime tend to be blood sugars set at a considerably higher points throughout the day and night. This is needed to reduce hypoglycaemia which can occur due to unpredictable absorption and action which is worsened by high amounts of insulin given at each injection.

The amount injected is whatever you have worked out works best and it is given in a single injection. When high carb diets are consumed high amounts of insulin are needed to cover this.

There is usually not enough fat consumed to reduce the speed of digestion of the carbohydrate. Snacking due to hunger results in a need for more insulin injections to cover the snacks. This can still be active when the next meal insulin is given.

This can increase the chances of hypoglycaemia.  Hypoglycaemia can often be overtreated and so blood sugars before the next meal are high.

No strategies such as correction doses, limiting the amount of insulin injected in one shot, using different types of  bolus insulin, timing the insulin injection so it is optimally effective are taught.

No wonder the results that insulin users get are so far away from what your pancreas would do if only it could.

Quick Quiz:
There is no quiz for this section.

Where to Next?
For type twos who don’t use insulin you may have mixed feelings now. The good news is that you have completed the course. Well done!

The more difficult news is that if your diabetes is not managed tightly enough or simply due to having the condition for a long time, you may need insulin in the future and have to come back and do the insulin users section that follows.

Its now time for type twos to start the course from the beginning again. I know. I’m a slave driver! This time you will be familiar with the sections most relevant to you. You can even take lots of time to browse the internet sites available.

Create a good action plan and be consistent and persistent.
We hope you reach your personal diabetes solution very soon.

For type ones and insulin using type twos its not over yet!

Insulin is a very dangerous hormone in overdosage. This is why there has been such an emphasis on waiting till you have completed the whole course and in a particular order before you low carb.

The sections ahead are very detailed. There aren’t many fun sections. It is very serious stuff. I’ll be really narky if I catch you laughing at anything.

Are you ready?  Got your meter steady?  Now Go to the How To: Keep Healthy with Type 1 Diabetes section.