diet

Low-carbohydrate nutrition and metabolism

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Eric C Westman, Richard D Feinman, John C Mavropoulos, Mary C Vernon, Jeff S Volek, James A Wortman, William S Yancy, and Stephen D Phinney

ABSTRACT

The persistence of an epidemic of obesity and type 2 diabetes sug- gests that new nutritional strategies are needed if the epidemic is to be overcome. A promising nutritional approach suggested by this thematic review is carbohydrate restriction. Recent studies show that, under conditions of carbohydrate restriction, fuel sources shift from glucose and fatty acids to fatty acids and ketones, and that ad libitum–fed carbohydrate-restricted diets lead to appetite reduction, weight loss, and improvement in surrogate markers of cardiovascular disease.  Am J Clin Nutr 2007;86:276–84.

DOWNLOAD: Low-carbohydrate nutrition and metabolism Westman Feinman et al Am J Clin Nutr 2007

How To: Find Information Online

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We now come to a sad part of the course.  It’s time to say goodbye to those who are simply overweight and who have or are at risk of metabolic syndrome.

Your first run through is really to familiarise yourself with the information.

Your second run through is where you are starting to consider what options are right for you.

Your third run through is to form a definite action plan.

How will your eating change at each meal? What recipes are you going to try? Will you buy a new pair of trainers? Will you go to that class? Would any of your friends like to join you in your new activities?

On your fourth run through we want to hear from you. How are you doing? Have you discovered any other helpful sites, books or dvds? Would you like to contribute one of your own recipies to the site?

To our type twos and type one diabetics who are breathless with anticipation about what I’ve got in store for you next here it is:

For all type twos and any type ones who KNOW they have insulin resistance please now to to  How To: Look after yourself.

For all type ones with no known insulin resistance please proceed to  How To: “Eat to Meter”

 

This is a collection of websites that may help you to improve your low carb know how, cookery skills, exercise routine and knowledge about glucose metabolism disorders and diabetes.

Glucose metabolism disorders and diabetes

www.diabetes-normalsugars.com *meet the Bernies at the forum*

www.dsolve.com * the Bernie’s sister site*

www.nmsociety.org/

www.iddtinternational.org

www.bcchildrens.ca/Services/SpecialisedPediatrics/EndocrinologyDiabetesUnit/ForF amilies

www.care.diabetesjournals.org/cgi/content/full/diacare; 27/9/2266

www.mercola.com

www.second-opinions.co.uk

www.joslin.org

http://www.phlaunt.com/lowcarb/bio.php

 

Low carb cooking

D-solve free to download  300+ pages of Recipes 

http://www.lowcarb.ca/low-carb-recipes.html

www.carb-lite.au.com  * my favourite*

www.genaw.com/lowcarb/index.html

www.recipegoldmine.com *go to low carb recipies on list*

www.solitarydancer.wordpress.com

ww.steviva.com/steviva.recipies.html

www.lowcarbluxury.com

www.lowcarbcafe.com

www.wilstar.net/lowcarbpavilion

www.holdthetoast.com

www.lowcarbrecipies.com

www.lowcarbresearch.org

www.lowcarbmegastore.com

www.lowcarbdiets.about.com

http://www.holdthetoast.com/

http://genaw.com/lowcarb/

http://cookingwithstevia.com/

 

Carb counting

www.calorieking.com

www.nal.usda.gov/fnic

www.carbs-information.com/carbs-in-flour-baking-ingredients

www.dietfacts.com/fastfood.asp

http://www.nutritiondata.com/

Exercise

www.amazon.co.uk *dvd rental and books*

www.lowcarbmuscle.com

www.crossfit.com

www.exrx.net

www.diabetes.ca/files/Riddell-Final.pdf * for type ones*

Blogs

http://weightoftheevidence.blogspot.com/

http://livinlavidalocarb.blogspot.com/

http://diabetesupdate.blogspot.com/

http://hike2health.blogspot.com/

http://solitarydancer.wordpress.com/

http://www.diabetesamerica.org/diabetesamerica.html

 

Where to Next?
To our type twos and type one diabetics who are breathless with anticipation about what I’ve got in store for you next here it is:

For all type twos and any type ones who KNOW they have insulin resistance please now to to How To: Look after yourself with Type 2 diabetes.

For all type ones with no known insulin resistance please proceed to How To: 'Eat to Meter'

 

 

How To: Eat from a Hospital Menu

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This section is for everyone. It could happen to you!

Ironically one of the most risky places for a diabetic to eat is as an inpatient in a hospital.

Because you are a diabetic you will be told by nursing and dietetic staff that you must choose from the “Healthy Eating” section of the menu. This “Healthy Eating” section is specifically designed to be high in carbs, lowish in protein and very low in fat. I’m not at all sure what kind of metabolism is suitable for this sort of diet but it it’s certainly not a good idea if you have the sort of metabolism that cannot handle sugar and starch.  This is the situation for all those people with glucose intolerance or diabetes. Yes. You!

It is necessary for you and your relatives to be very firm at the outset that you must be able to choose from the whole menu, be able to choose large or small portions as you desire and to bring in supplementary food items if necessary.  This could include olive oil and vinegar to dress your salads, fresh temperate grown fruits, cheese, cooked meats, oatcakes and diet drinks.

For breakfast ignore the toast and cereals and porridge and go for the cooked breakfast and eggs in a large portion. Supplement this with a small portion of fresh fruit. Grapefruit and mandarin orange segments are often offered on hospital menus but they are usually tinned and sweetened with sugar so are best avoided.

Instead of digestive biscuits as a midmorning and midafternoon snack try some cheese and oatcake with butter.  Many hospitals routinely offer diabetics snacks as this used to be necessary with twice daily insulin regimes. You may not really need  a snack however. If you are hungry at a snack time you may not have eaten as much protein and fat as you really needed to at the previous meal. If you are insulin dependent you will need to have lucozade or gatorade or snacks available for low blood sugar treatment. A longer acting carb and some protein can work well provided you are not too low.

For lunch and dinner pick large portions of meat, fish, poultry, cheese and egg dishes with vegetables or salad. Ignore any potatoes, chips, rice, pasta or bread items. Avoid deep fried battered food if possible due to the high hydrogenated fat content and carb content of the batter.

Before bedtime toast and biscuits are about the only thing that is offered in hospital. These are likely to be too high glycaemic for you and cheese and cold meat or cheese and oatcakes usually work better to prevent a blood sugar spike or nightime lows.

Despite the difficulties in getting fed properly in hospital it is well worth the effort  to keep your sugars normal. Your infection rate is decreased and your recovery will be faster.

 

Quick Quiz:
1. Maintaining normal blood sugars by following a low carb diet in hospital results in three of these. What won’t happen?
a Less post operative infection.
b More chance of surviving a life threatening illness.
c Faster discharge from hospital.
d Getting on the dietetic staff’s Christmas card list.

 

2. In hospital suitable breakfasts for a diabetic are…
a Whatever the nurse thinks looks good from the healty eating section of the menu.
b Porridge, skimmed milk, fresh orange juice with cholesterol lowering margarine.
c Toast, butter, boiled eggs, tinned grapefruit and mandarin oranges.
d Bacon, scrambled eggs, tomato, half a grapefruit.

3. The most risky eating situation for a diabetic is…
a As an inpatient in hospital.
b As a passenger in an aeroplane.
c From a roadside snack shack.
d As a guest at a dinner party that includes Miss Marple, Hercule Poirot, Ellery Queen, Lord Peter Whimsey and Detective Columbo.

Have you got it?
1. ABC have been proven to result from good glycaemic control in hospital. Sadly D is something that is not as likely from low carbing in hospital. Well there is a first time for everything and sooner or later dieticians will come on board. If you are the first patient to get a card in these circumstances we MUST hear about it!

2. D is correct. The others are too high in sugar and starch. At least with option C you could eat the boiled eggs. Unfortunately the “Healthy Eating Menu in hospitals usually entails LOW FAT. The sugar content is usually high and the protein content is usually low. Most hospital dieticians and nurses will automatically dragoon you into choosing from this menu unless you make it very clear that you object.

3. These are all very risky eating situations. How do you choose between them? In hospitals and aeroplanes you have a very restricted choice of meal. Snack shacks may not be as hygeinic as you would wish. And someone always get poisoned when these super sleuths are near. The only way to deal with these risky situations is to plan ahead and that often means bringing your own meal.

Reference Info:
Acknowlegements for this section to John Gibson the first of my patients who stood up up to the dietetic staff in the hospital I work in. I am also grateful to hospital administrative staff who did their absolute best to bully me into backing down. I would never have believed what was necessary to secure a guarantee of freedom from the “Healthy Eating Plan.” To cut to the chase YOU MUST THREATEN TO SUE THEM. If they don’t back down. It’s okay. Call your lawyer and sue the pants off them.

Where to Next?
All of you need to know about the next topic. March this way to the How To: Take Care of Your Feet section.

How To: Know How Proteins, Fats, and Carbs Affect My Blood Sugar

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This section is for everyone.  The information is somewhat more applicable to type one diabetics but type twos need to know some of this as well.

You have read a lot about how carbohydrate affects your blood sugar but what is less known is the effect that protein has on your sugar levels.

About a third of the energy from protein is made into sugar. This process is slower than for carbohydrates and can take 2 or 3 hours or more. Delayed blood sugar rises are likely to happen if your meal has a significant amount of protein in it. By this I mean over 3- 4 oz of lean cooked meat, chicken, fish or 3 eggs.

A ready reckoner is to compare the size of the meat you intend to eat to a  pack of cards.  If you have steak the size of a woman’s hand or a deck of cards this is about 3 – 4 oz.  Chicken to the size of your palm plus the first finger joints or fish the size of a woman’s whole palm is about the same. When you have this amount you must give yourself extra insulin one way or another to cover it or you will go higher than you expect after the meal.

These are the average to small portion sizes such as you would be served in a hospital canteen. Restaurant servings can be a lot bigger. When looking at omlettes, quiches and scrambled egg you need to imagine how many eggs may be in there.  Three or more need extra insulin coverage. One egg is equivalent to about one ounce of protein. Big hamburgers eg quarter pounders are easier to recognise and also need extra insulin coverage.

Immediately delivered insulin which covers high and medium glycaemic carbohydrate dishes is no good for covering the much more slowly digested protein. The extended bolus and split bolus techniques familiar to pump users works well however. Using two or more rapid acting insulin boluses can work well and so can using meal insulins with longer action such as regular insulins.

In the UK actrapid is the regular insulin available.  It can be in pen form only from Wockhardt in the form of soluble pork or beef insulin. This is being exported now to several countries and can be used in the Owen Mumford Autopen Classic.  This pen comes in one unit or two unit increments. Genetically Modified Human Actrapid from Novonordisk is still available in vial and syringe form.  Sadly they discontinued their pen actrapid which could be delivered in half unit increments. Pens tend to be easier to carry and syringes can give more versatility over dosage.  It all comes down to personal preference.

These insulin delivery techniques and much more is discussed in Gary Scheiner’s excellent book, “Think Like a Pancreas”.  Gary was diagnosed as a type one diabetic at the age of 18. He became an exercise physiologist and diabetes educator and is particularly enthusiastic about pump therapy.  His book covers important details regarding insulin use that are not always covered in much depth in diabetic clinics. For anyone on insulin I recommend this book so you can get the best out of your current insulin regime and consider other helpful strategies to optimise control of your blood sugars. This book usually gives several different options regarding problem solving.  It goes into more depth about insulin than Dr Bernstein’s book regarding insulin use and takes a neutral stance on dietary aspects.

Meals that have a high glycaemic index or load will usually need a standard food bolus such as supplied by novorapid/novolog and humalog as the food is quickly converted into sugar in the blood stream.     Examples of these are bread, cereals, potatoes, parsnips, cooked carrots, rice, biscuits, cakes, tropical fruits and sweets.

Meals that have a very low glycaemic index / load may require a method to lengthen out the insulin delivery time just like meat.  Examples of these sorts of foods are pasta, especially with creamy or cheesey sauces like lasagne or spaghetti carbonara. Very high breakfast cereals eg all bran.  Curries made with lots of fat eg kormas. Battered fish and chips. Chocolate, most dairy food and nuts.

A major difficulty with the glycaemic index is that it gives artificial categories of supposed blood sugar rises for a given amounts of carbohydrate containing foods.  One problem is that these tests were done on healthy non diabetics who still have a phase one insulin response. Both type ones and type twos do not have this capacity to immediately release stored insulin. The rate of absorption is also dependent on the temperature of the food, bite size and what it is eaten with and in what order.

To really know what is going on in your body you need to do extensive testing to get the best results for each meal you eat.  This involves testing every 30 minutes or so for three or more hours after each meal  you eat.

You can only test a food accurately if your baseline blood sugar is normal. Even then insulin sensitivity can vary throughout the day. Typically you are quite insulin resistant at breakfast and are at your most insulin sensitive in the afternoon.

Although this sounds a terrible chore most people only eat about 20 different meals on a regular basis and some a lot less.  Please don’t ask me what to do if you are a type one restaurant critic!

To give smooth protein curves it is best to eat some of the protein and fat before you eat the carbohydrates.

If you are having a high glycaemic item leave it till the end of the meal if possible.  Can you add some fat to it?  This will reduce the rate of absorption. Eg fruit and cheese, potatoes with butter and cream, cake and cream.

Lots of fat in the diet improves the taste, fullness after meals, vitamin absorption and slows down carbohydrate induced sugar spikes.

Other Food Tips

If you are going to have a snack consider low glycaemic carbohydrates, protein and fat so you are fuller for longer and sugar spikes are minimised. Eg full fat yoghurt, crackers and peanut butter, toasted cheese with butter on thin sliced wholemeal bread.

In a restaurant you can take your regular insulin once the waiter has taken your order as long as there is bread on the table. You only eat this in an emergency however!

If you take rapid acting insulins take it with the starter if you have a normal blood sugar, your main meal if you are low and when the waiter takes your order if you are high.

Tell the waiter you are diabetic and need food right away if you have been waiting for a time or feel low.

It is best to let toddlers eat and then gave them rapid acting insulin to cover what they actually ate.

Quick Quiz:
1. Three of the following make food digest more slowly. Which one does not?
a A lot of sugar or starch in the meal.
b A lot of fat in the meal.
c A lot of protein in the meal.
d Delayed stomach emptying also called gastroparesis.

Have you got it?
1.A is correct. Protein and fat make meals digest more slowly. Sugar and starch are digested quickly. Gastroparesis is when stomach emptying is delayed or erratic due to nerve damage from chronically high blood sugars. Like foot neuropathy it can develop after around five years of having poorly controlled blood sugars.

Acknowledgements & Reference Info:

Where to Next?
Please continue to the How To: Know What Oral Medications I May Be Offered for Diabetes section.

How To: Do the Atkins Diet

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This section is for everyone. Even those of you who may have done the Atkins or lived with someone who has.

The easy way to do the Atkins diet is to buy one of Dr Robert Atkins books and do it.

The book I would particularly recommend is Atkins for Life the Next Level.

This is a simple introduction to low carbing and it covers all the basics you should know about.  The book discusses the research information, the relative importance of protein, fat and carbohydrate in the diet and gives you various meal plans and recipies that you can incorporate into various total daily carb plans.

What I like about it is its versatility between carb plans from 20-120g of carb a day.  Compared to the Zone diet it is more versatile about the amount of carb that may suit you and compared to the South Beach diet there is no unnecessary restriction on saturated fat.

When you do a traditional Atkins diet you start at 20g of carb a day and gradually increase your carbs as far as you can till your weight loss levels out.  For many people who are just plain fat and who are not on any medication that could affect their blood sugar this is usually fine.

For anyone who is on insulin or blood sugar lowering medication  such as sulphonureas which includes gliclazide or metaglinides this would not be such a good idea. In fact such a drastic reduction could be dangerous.

But the Atkins diet has in my opinion still a great deal to offer. For those people who have pre-existing heart disease or are otherwise at greater than average cardiac risk, or who are on medication or who perhaps are getting on a bit – over 45 – for instance why not do Atkins in REVERSE?

What I am proposing is to take things nice and slow.  If you have any glucose metabolism problem you are going to have to restrict your carb intake for the good of your long term health sooner or later. You have to face this sometime.

From my previous discussions about how to measure the carbohydrates you eat you can surely find some way that suits you to find out how much carb you are currently consuming.

Whatever this is you need to start here.

That’s right.

Start wherever you are and start to cut down.

Week on week. Day by day. Meal by meal. Carb by carb.

If you are over 120g a day that is okay. If you are already on say 90g a day that is okay too. Simply look at the weight loss and blood sugar goals you want to achieve for your future health and start right away.

Many people will get what they need at the higher ends of the Atkins range such as those following the Zone or perhaps Dr Lois Jovanovich’s guidelines at about 120g of carb a day.

Some will want to drop their carbs further such as those people who are following the Drs Eades Protein Power plan or the diet advocated by Dr Allen and Dr Lutz or Dr Jorgen Vestig-Nielsen or Barry Groves at around 70g a day.

Others will not get to what they want until they get to Dr Bernstein’s diet of between 30-42g of carb per day.

You decide.

What do you want to achieve?

What amount of carb restriction is likely to be necessary to acheive this?

How slowly must you go down for safety?

Whatever the answers are for you, I hope this internet course can help you get what you want with safety  and with the knowledge of companionship along the way.

Quick Quiz:
There is no Quiz in this section. All the questions in this section have been ones to ask of yourself.

Where to Next?
The last few sections may have been a lot tougher than you were expecting. Have you got an idea of the amount of food recording and sums that you are going to be doing from now on?

I think it’s time for a little change of scene.

It’s back to Home Economics 101 for your lessons on How To: Cook and Bake the Low Carb Way.

Even if you’ve never boiled an egg your life, the quality of food you will soon be able to serve to yourself your family and friends will greatly improve when you’ve taken the plunge.

 

How To: “Eat to Meter”

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This section contains the core information on which your future health depends. It covers the essential points about monitoring your blood sugars whether you are an insulin user or not.

The more normal your blood sugars are through the day and night and during and after meals the better able you are to prevent or delay complications.

“Eat to meter” is a shortened way to say that you eat whatever you like, whenever you like AS LONG AS YOUR BLOOD SUGARS STAY WITHIN THE NORMAL RANGE.

This is perfectly easy if you don’t have metabolic syndrome or diabetes but causes considerable difficulty for people with glucose metabolism problems.

Many diabetologists genuinely believe that diabetics cannot realistically acheive normal blood sugars. They hope that the best they can do is to monitor your inevitable decline in health that high blood sugars produce long term and sort out the worst of your complications with drugs, lasers and surgery.

There is no doubt that achieving normal blood sugars most of the time requires a lot of personal education, self experimentation, time and effort. Whether this is worth it or not is a decision that is only your own. It is after all your eyes, kidneys, feet and heart that are at risk.

Unfortunately the NHS and many other international health care systems do not currently provide an available, affordable and appropriate educational package to help you achieve normal blood sugars.  Helping you get the degree of control you want is the purpose of this site. It is essential that you become an expert in your own type of diabetes and its management. This site has lots of ideas, book and internet based resources to help you. Joining a diabetes forum like the “Bernies” can be a good way to get specific answers to your questions, get emotional support and encouragement and even make friends.

Before you start to change your diet or other management it is essential that you consult a doctor or diabetic specialist nurse so that any changes can be done in a planned, step wise and consistent way that will not have an adverse effect on your overall health. People on oral hypoglycaemic drugs and particularly insulin are likely to see a dramatic reduction in their dosage requirements and any change of diet will require close supervision and blood sugar monitoring so that dangerous and potentially fatal low blood sugars do not occur.

Normal fasting and between meal blood sugars for a fit young adult are 4.7. Blood sugars should not usually go below 4.0 even if a fit young person has not been eating or has been exercising vigorously.  A healthy young person can expect to have a hbaic of less than 5.0 although the laboratory range takes the older and not so fit or slim population into consideration and often gives an upper limit of 6.0.

Pancreatic beta cells start to die off at blood sugar levels of only 6.1 and irreversible damage to nerve cells starts at sugar levels of 7.8.  The blood sugar levels we therefore recommend that you aim for are therefore:

Fasting or before a meal assuming 3 spaced meals a day:

Ideal:  4.7
Type Ones  5.0
or at least below 6.1

One hour after your meal has been finished  a maximum blood sugar of 7.8

Two hours after your meal has been finished a maximum blood sugar of 6.5

In order to achieve these most people will have to go on a pretty strict low carb diet. As well as this you will need to understand about how other physiological events and exercise affect your blood sugars.   Remember that you are making long term decisions about your health every time you eat. Very tight control may not be for everyone. Have a look at the next section which is applicable to type ones as well to decide what you are aiming for.

This section is summarised from Gary Schiener’s excellent book for insulin users, “Think Like a Pancreas.” and “Pumping Insulin” by John Walsh and Ruth Roberts.

Extremely tight control
Ideal for pregnant women or women who are planning a pregnancy. This reduces maternal and baby complications to almost non diabetic levels. In the USA some centres put these women on insulin pumps 9 months prior to a planned conception to help acheive this. Their blood sugar targets are much lower than in the UK. The use of continuous blood glucose monitoring devices are used to detect night time lows and warn of pump failure. A diet with no more than 40% calories from carbohydrate (which is still quite high) is given and high glycaemic foods are banned.

Hbaic target 4.8%
Premeals and bedtime 3.6-5.2
one hour after starting to eat 7.2
2am-6am 3.6-5.2

If these targets are not met the high or low blood sugars can cause damage to the mother and baby. A pregnancy may be lost. These targets are aimed to mimic what goes on in a non diabetic pregnancy and the closer to target the less risk their is of damage.  If permanent damage from high blood sugars can manifest itself and be crudely countable in the form of miscarriages, foetal deformity and birth complications after 9 months, what do you think goes on in your body over say ten years or more?

Unfortunately the  will and infrastructure is not geared in the UK to offer this sort of support to pregnant women yet and in the USA it remains very expensive.

The plus point is that if you are willing to reduce your dietary carbohydrate sufficiently it is certainly possible to meet these targets and with less hypoglycaemia risk whether you are a type one or type two, male or female, pregnant or not, youthful or not so youthful.

Tight Control
For older children. They are going to have diabetes for a long time.
For those in honeymoon. This phase can be prolonged with tight control.
Experienced insulin pumpers. You have the technology to achieve this.
Low carbers. You will find it easier than most to achieve this.

hbaic is 5-6%
premeal target range 3.3-7.8
one hour post meal range less than 8.9
specific premeal target 5.6

The majority of the Bernies achieve this level of control according to a recent poll. Of course some are at normal “non diabetic” blood sugar levels and others are much higher but working their way down gradually.

Typical Control
Ideal for drivers who wish to avoid hypoglycaemia.
Most adults.
New insulin pump users.
Whenever you are switching to a new insulin or delivery method.

hbaic range 6-7%
premeal target range 3.9-8.9
one hour post meal target less than 10
specific premeal target 6.7

These blood levels would have most diabetologists and endocrinologists cartwheeling down their hospital corridors with glee. These levels are great to get to when you have been struggling so hard with a high carb/low fat diet on insulin or perhaps are quite insulin resistant.  Please be aware however that you will be delaying rather than preventing complications at these levels.  I don’t want to take the wind out of anyone’s sails but when you have been low carbing for a while it does get progressively easier to hit these targets. If this is you do you think you could go a little lower?

Looser control
Ideal for babies and toddlers and young children whose food intake and activity is unpredictable. Youngsters also tend to me more mentally affected by recurrent or severe hypoglycaemia.

Adolescents may have great trouble keeping their levels other than this because of the great hormonal changes that are occurring. Control will become easier in your twenties so just do the best you can do.

Older diabetics and particularly those who live alone. Because diabetic complications develop slowly over several to many years you may be able to be more relaxed.

hbaic range 7-8%
premeal target 4.4-10
post one hour target 11
specific premeal target 7.8

To get good control you need to have the appropriate tools and help from your medical support team.  You will need to test your blood sugars quite frequently and you will need to know something about carbohydrate counting.

Good records help a lot because you can see patterns in your control. Frequent high or low blood sugars at certain times of the day indicate that a change may be needed.

It is always best to sort out any low blood sugar problems first before you try to sort out the highs.  Sort out baseline blood sugars before dealing with meal issues. Sort out problems that occur early in the day before tackling the problems that are going on later.  More detailed advice on how to do this for insulin users is given in the type one section.

Keeping your diabetes in control is what enables you to enjoy your life and fulfil your other obligations. People who are consistent with their diet, avoiding unnecessary or frequent snacks tend to achieve much better blood sugar control.

Because you and your and the doctor will be making decisions based on your blood sugar levels you can improve accuracy by:

1. Washing and drying your hands.

2. Apply a sufficient amount of blood to the test strip (apply a sufficient amount of blood to the test strip at the first go–don’t “milk” the blood spot as this gives artificially high blood sugar readings).

3. Code your meter accurately.

4. Keep your meter with you or perhaps have one on your person and one in the house or car.

5. Have a regular checking system so you don’t run out of batteries, strips or lancets.

6. Record your findings at the time or before you go to bed for the night.

7. Remember your record book when you visit the medical team.

8. Do averages of several readings at the same times of the day to look for patterns in control. Between 3 to 14 days works well for many people depending on how stable your diabetes is and how many changes around exercise, meals and medications you are making.

9. Patterns may vary with shift work, work or weekends, monthy cycles, weather conditions and seasons.

10. Consider computer based logs that can produce graphs and charts to make this more visual and interesting.

Quite long Quiz:
1. Who is responsible for your diabetes management?
a I am responsible for my own diabetes management.
b The Consultant Diabetologist or Endocrinologist is responsible.
c The Diabetes Nurse.
d My family.

2. Three of these body parts are affected by long term high blood sugars. Which one is not?
a Heart.
b Eyes.
c Cartilage.
d Feet.

3. Damage to nerves starts at a blood sugar over which level? (The first number given is the UK, Canada and Australia measurements in mmol/l and the US figure follows. The US figure is the UK figure x 18)
a 4/72
b 8/144
c 12/216
d 16/88

4. What foods cause a rapidly high blood sugar level?
a Starch such as bread and potatoes.
b Meat such as fish and burgers.
c Vegetables such as cauliflower and broccoli.
d Fat such as butter and cheese.

5. Your hbaic test is …
a A test of whether you are anemic or not.
b A test of your blood sugar over the last week.
c A test of your blood sugar over the last 2-3 months.
d A test of your blood sugar over the last year.

6. A normal blood sugar after fasting and between meals is…
a 15/270
b 10/180
c 4.7/85
d 2.5/45

7. A normal blood sugar two hours after meals is…
a 20/360
b 10/180
c 8/144
d 6/108

8. Your blood sugar is starting to be too low when it is..
a 1.9/35
b 2.9/52
c 3.9/70
d 4.9/88

9. A normal hbaic for a healthy non diabetic person is..
a 7.5%
b 6.5%
c 5.5%
d 4.5%

Have you got it?
1. For most people taking this course the answer will be ME. If you are a child or have special needs eg visual problems you may need to rely more on your family.

2. Cartilage is not affected by high blood sugars but other tissues certainly are.

3. Levels of 8/144 or over are toxic to neurones. This is a frightening ly low level but did you know that pancreatic beta cells are affected adversely by levels of just 6.1/110 or over?

4. Starchy foods release sugar quickly. Mashed potatoes for instance release glucose faster than the table sugar some people put in their coffee. Not you of course!

5. The hbaic test reflects the past 2-3 months blood sugars with a stronger emphasis in the last two weeks. High blood sugar spikes affect it more than low blood sugar dips.

6. 4.7/85 is normal for healthy young people. This is why it is advisable for diabetics to aim for 4.7/85. Insulin users need to aim slightly higher at 5.0/90 to give a margin of error in order to avoid hypoglycaemia.

7. D 6/108 and this can be lower for fit young folk. Many diabetic organisations give much higher targets ranging between 7.8/140 and 10/180. Gary Scheiner has found that 9 out of 10 USA kids had higher blood sugars than this when tested one hour after finishing their meals. These target levels may be considered as good as you can get for those on high carbohydrate diets but are not a reflection of what goes on in non diabetic healthy people. Normal blood sugars for diabetics is the aim of Dr Bernstein’s programme.

8. 3.9/70 is getting too low. Below this you could be starting to be impaired for such things as driving. Most drivers wouldn’t realise they were impaired even at much lower sugar levels than this!

9. A normal hbaic for a healthy young non diabetic person is 4.5%

Reference Info:

Where to go Next?
The next section is quite intensive too. If you need to take a break now. When you are ready please move onto the How To: Count Carbohydrates section.

How To: Cover a Strict Low Carb, Moderate Low Carb, and High Carb Diet with Insulin

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This section is for everyone.

HOW DO I COVER A STRICT LOW CARB REGIME WITH INSULIN?

Dr  Richard Bernstein, Dr Annika Dalquhist’s, and  Dr Atkins diet have been described in previous sections. They can all take you to the strict low carbing end of things amounting to about 30-42g a day of carbohydrate.
I have chosen this level of carb for your meals to differentiate a strict low carb diet from a typical low carb diet. All of these diets in this strict  range  will give you the possibility of entirely normal blood sugars.

Dr Bernstein’s diet is more specific about what sorts of macronutrients you eat and in what amounts. For simplicity of eating and insulin regime combined with effectiveness it is my opinion that this is the “Gold Standard.”

If you are eating faster digesting carbs even within the  12g total carb limit you would need to experiment to see if a single insulin type covers your meals to entirely normal blood sugar standards or not.  The levels you may be aiming for have been described previously. If you get what you want this is perfect and if you don’t you may wish to try the specific insulin regime for the typical section which follows.

Dr Bernstein recommends using regular insulin to cover meals. These are of no more than 12g of non starchy vegetables three times a day with 6g allowed for breakfast because of the effect the dawn phenomenon has on insulin resistance at this time of day.

The regular insulin is best injected 45 minutes before eating. Because you are having such small amounts of carb and therefore insulin at each meal you don’t really need a separate insulin for the carb and protein. Just a little more regular  such as actrapid to cover your protein.  The usual formula for most people is 2 units regular insulin to cover 3oz lean protein or meat the size of a deck of cards.

The protein amount and consistency depends on your goals concerning weight gain or loss.  For people with delayed gastric emptying they may be on quite small portions of protein at their evening meal such as 2oz.  With guess and test you will quickly learn what works best for you.

Rapid acting insulin analogues are used for correction doses.

HOW DO I COVER A TYPICAL LOW CARB REGIME WITH INSULIN?

I have chosen Dr Jovanovich’s carbohydrate limits as the border between what could still be considered low carb and what is out with that range.  Dr Atkins and Drs Allen and Lutz diet’s have been described previously and fall in this range.  If you are  on another diet such as Protein Power, South Beach or Barry Groves “Eat fat and Stay Slim” diet you are in this range.

Once you get to higher carbohydrate levels of 13-30 g a meal of carb you increasingly need a bit more oomph with your insulin to deal with more rapidly rising  blood sugar levels.  At the same time protein continues to digest slowly so you need techniques to deal with that.

The most accurate technique that I know of was perfected by Dave (Iceman) from Alaska.  Sadly he died of cardiovascular complications of his longstanding diabetes. For all our benefits he passed his method throught the Bernie forum onto Adam (Adam DMer) who graciously passed it onto me. It is a beautifully simple technique that can also be used at lower and higher carb levels than I am describing in this section if desired.

Use rapid acting analogues to cover carb. This can be done according to your individual carb sensitivity for that time of day.

Use regular insulin to cover protein. This is to the tune of 2 units of regular insulin for each portion of lean protein which is a deck of card in size.

Both are optimally injected 15 minutes before eating.

HOW DO I COVER A HIGHER CARB REGIME WITH INSULIN?

The higher carb your meals the harder it is to get perfect  or even acceptable blood sugar control.  You can usually get an improvement from what you have been getting however,from the techniques I will be describing.

Although I much prefer to eat a typical low carb diet myself I was aware that my son Steven did miss the occasional treat. What was more important was that the meals provided at school emphasised high carb /low fat dishes in keeping with the ubiquitous “healthy eating” guidelines. The odd high sugar due to either of these reasons didn’t bother us at first because it was so infrequent.

For almost 18 months from diagnosis Steven did excellently on a typical low carb diet and twice daily mixtard combinations. Due to his lower carb diet and lengthy honeymoon his hbaic was 4.8.

Then his growth spurt and reduction in endogenous insulin became obvious. We continued mixtard but started on novorapid for lunch coverage in a half unit increment pen.

After 4 months on this we started an intensive insulin regime on levemir and novorapid.  By this time he was growing faster than our high fat/mod/protein/ low carb diet could sustain and his bmi was just under 16.  This is the bmi of eg Liz Hurley the actress who is indeed slim.

The dietician and diabetologist started threatening me. “Feed your kid a high carb/low fat diet and he will fatten up. Or else.” Presumably child protection procedures.

They did have a point.  Indeed I had never seen a skinny diabetic  on a high carb/ low fat diet.  It did seem to work like magic to fatten people up.

The problem was that Steven was just not hungry.  Effectively reducing hunger is  a major reason for the success of low carb diets in weight loss . But it is a disadvantage if you are hitting adolescent growth spurts.

I increased the carb in his diet knowing that he needed to have more carb for weight gain but also knowing that this would play havoc with his beautiful blood sugar pattern.

I decided to go for it and fatten him up like a goose destined for pate de fois gras. “Have what you like Steven. We have to learn how to control whatever effect it has on your bloods sugars. You could eat a bit more bread and potatoes than that couldn’t you? Please.”

I started this intensive fattening regime while on holiday abroad when we had almost unrestricted access to foods of all types and while I could monitor his sugars day and night.

To start with it seemed quite fun to Steven. “You mean I can eat a whopper with fries?”

“You certainly can. You must.”

Soon the wildly fluctuating blood sugars and blurred vision got us both down. “Please mum. Can’t I go back to low carbing? ”

“Please, Steven. Just keep going with this a bit longer. I am getting nearer and nearer to perfecting the carb weighting figures.”

We had a three month period of hellish sugars.  We did loads of blood sugar measurements including most nights between 2-4 am.  I could hardly sleep with anxiety.

This is what your average mother with an average kid with type one diabetes goes through all the time. It was bloody awful. I had no idea how bloody awful till I did it myself.

Fortunately I had some ideas about why Dr Bernstein strongly advised limiting carbs. The reason is to stop any spikes after meals that normal people don’t have.

And why does Dr Jovanovich limit a meal to 30g of carb? The reason I figured out is that linear doses of insulin based on reliable carb insulin sensitivities become increasingly unreliable above this level.

The more carb you eat the higher your blood sugar goes.

The higher your blood sugar goes the more insulin resistant you become.

The more insulin resistant you become the more insulin you need.

There is no longer a linear relationship between carb and insulin dosage after 30g.

There is an exponential curve.

Figuring out the sweep of that curve will vary from person to person.

To do this you MUST do extensive self experimentation.

Your carb counting skills must be well developed.

You must increase your carb counts above 30g in a progressive way.

You must keep meticulous records.

Give yourself a break every so often.  It is best only to do these experiments when you have help around and you are able to monitor day and night.

Unless you absolutely have to, you are much, much better off on a typical and preferably strict low carb regime. Low carbing is extremely efficient at curbing your appetite. This is a major benefit for most diabetics but I can see where it can be a problem for skinny toddlers and teenagers. If you need to resume a higher carb diet I hope our experiences and learning of techniques can help you through this process.

I know that for many diabetics the hectic blood sugar patterns that they simply accept as the package deal that comes with diabetes is actually due to the high carb diet.

I found the high carbing process extremely traumatic.  Steven was unhappy. I was unhappy. Yet, no matter how much fat I added to his diet I could not fatten him up. He is not as much as a carnivore as me and carb seemed the only answer. The high carb diet has worked and now Steven has a healthy bmi at 18. Teenagers have lower bmis than adults but your dietician won’t know this. They don’t know a lot about a lot of things you no doubt are finding out.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowledgements to Dr Bernstein, Dave (Iceman) and Adam (AdamDMer) from the Bernstein Forum and my son Steven.

Where to Next?
Please continue onto the How To: Do Dr. Morrison's Carb Weighting System section.

How To: Follow Dr. Bernstein’s Dietary Plan

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This section is for everyone.

Dr Bernstein’s dietary plan is at the strict end of the low carb dietary scale. The diet consists of planned, carefully measured, prepared and consistent amounts of protein foods and non starchy vegetables. In addition double cream, cheese and soya products are allowed. You can have some low carbohydrate sweeteners and beverages.

He aims to give suitable and small amounts of carbohydrate required for good health with the trade off that minimal amounts of insulin with then be required from the pancreas in type twos and by injection for type ones.

The exact monitoring system and ways to trouble shoot problems that crop up along the way are described in detail with a full account of the rationale. The reasoning is impeccable, the results are impressive. The difficulty is that it is a tough plan for most of us who love eating fruit, grains and starches.

The food is pleasant to eat as tasty fats, spices and herbs are used to give a wide variety of flavour.  The Bernie forum members have experimented with ingredients so you can eat cakes, biscuits, bread as well as main course and starter dishes. I would say that the difficulty lies in the daily planning and meal preparation that is needed. It is the consistency in doing this day after day that can be particularly hard to do.

You do need motivation to follow Dr Bernsteins diet for long periods of time. If you are on insulin however you do need to be highly consistent with your meals for control and safety in any event.

If you already have the complications of diabetes and can see that you are steadily getting worse you may now be at the point that you will do what it takes. If you are a type two diabetic who is really keen to avoid insulin injections now or in the future this plan offers real help. Although diabetes is still an incurable chronic disease it is very treatable and the long term complications are almost fully preventable.

You will get the best results from reading Dr Bernstein’s book “Diabetes Solution” particularly if you are insulin dependent.  Those not on insulin could read “Diabetes Diet.” You may also find listening to his podcasts and CDs and joining the forum on his website to be of interest and informative. It can help to chat on line to people who have similar difficulties to you.

When you change your eating pattern so radically it can help if you live with someone who can help you with your diabetes and food preparation.  The transition phase is the most risky for insulin dependants having hypos. Although Dr Bernstein himself advocates a rapid transition to meals of 6 and 12 g of carb at a time, he can do this because he is very experienced and keeps a daily check on his patients till they are stable.  Outside of this situation I would always advocate a planned and stepwise reduction in carbohydrate intake.  You can read more about this in the “Atkins in Reverse”  chapters in the type 2 section.

You will need to monitor your sugars much more closely in the transition phase and adjust your insulins downwards with care and in response to your blood sugar readings. This does take considerably longer to get stability than if you were one of Dr Bernstein’s patients, and your carb cravings will continue for longer, but it is the only way to do this in safety without the direct supervision of an experienced health professional.

Due to the high level of consistency required and more time and effort into sorting out your diabetes than you have probably ever done before,  I do not recommend you start this plan until you have overcome any major outstanding personal or domestic issues. You can do this plan even if you don’t have much money, but if your life is chaotic and you don’t have support I suspect it would be just too hard.

Dr Bernstein’s entire plan is well worth reading for the detailed information he provides about all aspects of diabetes management that is not easily found in one place. I see his plan as an ideal to aim for if you are looking for optimal control over your blood sugars. The most helpful part I have found is that I don’t have to worry about hypos when my son goes to bed at night.

Even if you do not follow the plan to the letter you are very likely to get much better control than you are already getting now by a planned adoption of the aspects of the plan that you CAN achieve consistently. YOU have to find out how to get the best sugars you can for YOU with the food you are happy to eat day in and day out.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Dr. Bernstein’s Diabetes Solution

Where to Next?
Please continue to How To: Use Insulin to the Best Effect section.

How To: Decide What To Eat When Using Insulin

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This section is for everyone.

The two dietary plans I wish to discuss in this section are Dr Bernstein’s and Dr Jovanovich’s plans.  Both of these diets call for a restricted amount of carbohydrate at each meal. Both doctors are type one diabetics themselves.

Dr Lois Jovanovich works in Santa Barbara California. She treats all kinds of diabetics but has a particular interest in improving the outcomes in pregnancy for type one, type 2  and gestational diabetic women.

Lois advocates a ceiling of 30 g of carb for each meal. If a snack is necessary it should be no more than 15g.

She admits pregnant patients for stabilisation of their diabetes as soon as a pregnancy is known about. By careful diet, exercise and insulin treatment her aim is to achieve non diabetic blood sugar levels. By this method she has greatly improved the outcome of these pregnancies for both mother and especially the babies.

It is imporant to note that the carbohydrate values she gives are limits not targets. The goal is to achieve as normal blood sugars as possible. If you can get there at 30g of carb a meal that’s okay but if you don’t you go lower.

Dr Richard Bernstein works in Marmaroneck New York State and has spent the last 25 years in practice dealing with diabetic and prediabetic patients. Richard was diagnosed with insulin deficient diabetes when he was 12. He followed standard dietary advice but by his 30s had severe and life threatening complications affecting his blood vessels, eyes, kidneys, heart and joints.

There were three factors that turned his life around. He was an engineer who was used to solving problems. His wife was a physician who helped him buy the first portable blood sugar meter that was only sold to physicians. He knew his life was on the line and this made him determined to beat diabetes.

After considerable research he found that the way to stop the painful and debilitating complications of diabetes was to maintain normal blood sugars as much of the time as possible.

“The Law of Small Numbers”  is the core of his method of controlling blood sugars.  There are many things about diabetes you cannot reliably control but the ones you can – you do.

Regarding diet you can predict what rise in blood sugar you are likely to have simply by eating foods that will affect your blood sugar in a small way. Even if you were to measure foods accurately there can be as much as 20% error allowed to the manufacturer when listing ingredients. If you stick to low levels of slow acting nutritious carbohydrates such as vegetables the results will be more predictable than large amounts of rapid acting carbohydrates such as bread, rice, potatoes or sugar.

Covering carbohydrates with insulin is a task full of uncertainty. There is about a 30-50% variation between the effects of the same insulin amount injected from jag to jag. This can be minimised by reducing the amount in any one injection to 7 units or less and keeping the carb count low with the gradual release of sugar that comes from vegetables high in cellulose.

For type one diabetics three meals a day is best. This minimises insulin injections and gives opportunities three or four times a day to correct the blood sugar to normal levels.

By careful experimentation Richard discovered what factors made his sugars stay normal and what factors made them go too high or too low. Many of his complications started to reverse including the kidney disease, neuropathy, heart and eye disease.

To his surprise and eventual dismay Richard  found that the medical profession of the time were not interested in his results, his method or his meter. So he decided he would need to become a doctor himself in order to let patients know of his success and he entered medical school at the age of 45.

Dr Richard Bernstein’s publications contain comprehensive and detailed advice that is based on what works for diabetics. In particular he emphasises the benefits of a very low glycaemic / carbohydrate diet. Much of what he says is still in conflict with the advice that is given out by The American Diabetes Association, Diabetes UK and most NHS dieticians and diabetologists. Unlike these people and organisations however he is absolutely rigorous in letting the reader know the scientific fact that underpins his advice.

The reason you are reading how to look after you diabetes on the web instead of from your local diabetes team is that the medical establishment are thoroughly entrenched in their high carb / low fat ways.

Unfortunately if you eat the way many diabetic clinics tell you to you will make it unnecessarily hard to control your blood sugars and this will make the development of diabetic complications inevitable.

This low carb diabetic course has been compiled by myself with the generous help of other diabetics, their carers and interested doctors and researchers. It takes a lot of nerve to do something very different from what a diabetic specialist or dietician tells you. My son Steven developed type one diabetes at the age of 12.  I am absolutely determined that he will have the same chance to enjoy a full and long life as his non diabetic brother. Fortunately many other people have the same aims for their relatives, friends and for themselves.  We have joined resources on Dr Bernstein’s forum to help you have normal sugars and prevent and reverse diabetic complications.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowlegements to Dr Lois Jovanovich’s many web published articles and lectures and Dr Richard Bernstein whose masterpiece “Diabetes Solution.” could be regarded as the core text of this course.

Where to Next?
Please all continue to How To: Follow Dr. Bernstein's Dietary Plan.

How To: Know the Truth About Fats

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This section is for everyone.

What the supposed “healthy eating” guidelines say:

Saturated fat is the main dietary determinant of LDL “bad”cholesterol.

Intake of saturated fat in most European countries is above the 10% limit recommended.

Diabetics appear to be more sensitive to dietary cholesterol than the rest of the population. Eggs, offal and shellfish are particularly high in cholesterol.

Trans-unsaturated fatty acids (often found in manufactured confectionery products and some margarine) and N-6-polyunsaturated fatty acids raise plasma LDL cholesterol.  Trans fatty acids also lower HDL “good” cholesterol.

Diets low in saturated fat and high in carbohydrate or enriched in mono-unsaturated fatty acids with a cis-configuration lower serum LDL. eg cashew nuts, hazelnuts, almonds, herring, salmon, pilchards, mullet, peanut butter, olive oil, rapeseed oil, goose fat and avocado.

N-3-polyunsaturated fatty acids are found in foods such as oil-rich fish such as mackerel, herring, sardines, pilchards, trout, and mullet. N-3-polyunsaturated fatty acid supplements have been shown to lower plasma triglyceride levels in type 2 diabetics but they raise serum LDL levels.

Reduced fat diets  when maintained over the long term, can help to bring about a modest weight loss and an improvement in dyslipidaemia.

Regular use of foods with fat replacers or substitutes is safe and may help to reduce saturated fat and cholesterol intake, but will not reduce total energy intake or weight.

Less than 10% of energy should be from saturated fats. If the serum LDL is greater than 2.60 mmol/litre this should be reduced to less than 7%. If weight loss is desirable or replaced with either carbohydrate or mono-unsaturated fat if weight is to be maintained.

Dietary cholesterol intake should be less than 300mg/day. If the serum LDL is greater than 2.60 this should be reduced to less than 200mg/day.

The intake of trans-unsaturated fatty acids and N-6-polyunsaturated acids should be minimised.

What they should say:

Well they got one thing completely right.  Trans and N-6 polyunsaturated fats should be minimised.  Well done!

Trans, hydrogenated, partially hydrogenated, refined vegetable oils and margarine should not be used for cooking and baking. You can use lard, butter, macadamia nut oil and extra virgin olive oil instead.

As correctly stated these oils are extensively used in processed food products. They are cheap, taste bland and prolong the shelf life of food.  In baked goods they also give a lighter texture than butter and lard for instance. The safest way to avoid them is to make your own food from ingredients that you know are safe.

Hydrogenated oils have been found to increase inflammation in the body and are one of several causative factors in metabolic syndrome and the development of diabetes, heart disease and cancers.

The most important lipid markers for the development of cardiovascular disease are having low HDL, high fasting triglycerides and a high amount of very low density lipoprotein.

It is true that high saturated fat intake increases LDL but it is the most dense particles of this that are the problem as they are easily oxidised. This is the process that is involved in atheroma formation in blood vessels.  Just plain LDL levels are irrelevant to the formation of atheroma.

High saturated fat intakes are associated with higher HDL levels.  This is the protective “good” cholesterol.

Saturated fats also promote the absorption of vitamins from vegetables and fruit which are natural anti-oxidants. Saturated fats themselves are chemically stable and are  not prone to oxidation.

The formation of superoxides is one of the major contributors to the aging of blood vessels and thus the complications of diabetes. High blood sugars, wide blood sugar swings,  free radicals given off from heated polyunsaturates, overheated monounsaturates and hydrogenated / ttrans fats are major causes of superoxide production. Superoxides cause direct cell damage, weaken cellular repair functions and cause vasoconstriction.

Saturated fat seems to act like a natural antidepressant.  It is a source of the vitamins A, D, E and K in its own right.
Some low carbers feel best with saturated fat intakes as high as 80%.  About 50% of calories from fat which is mainly from saturated and animal sources is common in a “typical” low carbohydrate diet as described. Some of the healthiest people in the world are the Masai Mara tribes in Kenya. They drink cow’s milk mixed with cow’s blood and a small amount of beef. Cardiovascular disease is almost unheard of.

High fat/moderate protein/ low carb diets are adhered to better than low fat/low protein/ high carb diets.  Weight loss from fat stores tends to be better in low carb /high fat than in high carb/low fat diets.  Low carb diets have a greater effect on fat loss from the spare tire area in the abdomen than high carb diets.  This is the metabolically active fat that drives insulin resistance.  In addition the low carb diets improve lipids levels, inflammatory markers and blood pressure independent of weight loss.

Diabetics are particularly sensitive to dietary carbohydrate because both types one and two have do not have a type one insulin response to deal with the rapidly high blood sugars from digested sugars and starches.  Diabetics either lack insulin or the insulin they do make is much less effective than in non diabetics.  90% of ingested carbohydrate becomes sugar in the blood starting at 15 minutes and peaking  anything from 30 to 70 minutes.

Quick Quiz:
There is no quiz for this section.

Reference Info and Acknowlegements:

  • Anthony Colpo’s The Great Cholesterol Con is a good source of the published but rarely promoted research that has been done on the fats, cholesterol and cardiovascular risk issues.
  • Malcolm Kendrick has recently published a book of the same name, The Great Cholesterol Con.  This deals with similar issues. I have not read it and would be pleased to have your opinion on it if you have.
  • A free online book by Uffe Ravnskov is also available The Cholesterol Myths – Uffe Ravnskov

Where to Next?
Please all continue to the  How To: Know the Truth About Carbohydrates section.