Learning from illness: diet dilemmas
Dr Katharine Morrison explains how her son's type 1 diabetes led her to question accepted dietary advice and adopt a
low-carb, high-fat approach
The moment of realisation hit me when the panel on the dipstick turned dark brown. My son Steven, then aged 12, had been intermittently incontinent over the previous two weeks and I was testing his urine to see if he had a UTI. I quickly realised it was more likely to be diabetes and a glucose tolerance test confirmed this.
That was two-and-a-half years ago. Since then Steven and the whole family have come a long way in dealing with Steven's condition. He is able to spend overnights with friends, enjoy all sorts of sporting and recreational activities and look after himself at school just like any other 14-year-old. What is different, however, is the amount of planning that goes into every day – meal planning, insulin regime and back-up plans.
The Atkins approach
At the time of Steven's diagnosis I felt from my own experience that the standard dietary advice given to diabetes patients was detrimental to them. I had been on the Atkins diet myself and had been impressed with how much better I felt on a low-carbohydrate diet. My HDL and triglyceride results, which are the most important lipid indicators for cardiovascular disease, became above the normal range for HDL and below the normal range for triglycerides. My IBS and hunger was eliminated and my nails were no longer breaking.
Dr Atkins' rationale made sense and my type 2 diabetes patients who followed it got a 2 to 3 per cent reduction in their HbA1c and similar improvements in their lipid patterns to mine. One man who had had a diabetic foot ulcer for 18 months was delighted to find his foot starting to heal after several days of normal blood sugars on this new diet. His foot completely healed within weeks and he has told me he will never go back to high-carbohydrate eating.
I started Steven off on a low-carbohydrate diet and for the first two years he was on up to 100g of carbohydrate a day. This is quite generous by some standards (see website link to Dr Bernstein's diet) but about one-third of what is usually recommended for patients with diabetes who attend NHS dieticians. His HbA1c was 4.8 per cent on this regime. But as his growth spurt ensued we were not able to keep up with his requirements for calories on the low-carb diet. Higher protein and fat diets fill you up for much longer than higher carbohydrate meals and this blunts the appetite considerably. At present Steven is on what I would describe as a moderate carbohydrate, moderate protein, high-fat diet.
With careful adjustments of diet and insulin I think it is possible to get much better control than the national average of 9.5 per cent to have an HbA1c of 5.9 per cent as Steven has now. The paediatric consultant was supportive of my plans to try a low-
carbohydrate approach but the adult diabetologist and team were against it. They even tried to stop me via clinical governance systems but this was not pursued after I submitted a 47-page dossier on the research evidence supporting low-carbohydrate diets and showing the adverse effects of high-
carbohydrate diets in people with glucose metabolism problems of all kinds and the general population.
Most diabetic clinics adjust medications on the basis of blood sugar results at six-month intervals. I have a much tighter feedback loop and adjust on the basis of 10-day blood sugar averages. I have coached Steven on how to do this and also taken him through my patient education programme. He has completed a comprehensive self-
assessment quiz, which is available to the general public on Dr Bernstein's forum site.
A typical day
A typical breakfast would be a piece of low-carb baking (see left) with double cream, sliced sausage, black pudding, bacon and a small quantity of fruit. Lunch is often school dinners such as chicken curry with rice. In the evening Steven will have a meat and vegetable-based dish with a small quantity of starch such as potatoes or rice. As much fat as possible is added to the meal to make it palatable, to improve vitamin absorption and to provide calories without the requirement for additional insulin. My interpretation of the evidence reassures me there is no need to limit saturated fat on health grounds. I use extra virgin olive oil freely on salads and use macadamia nut oil from Australia for frying.
I have found that up to 30g of carbohydrate in a meal can be covered in a linear way by insulin titration. For example, at lunch and dinner one unit of aspart (NovoRapid) will cover 12g of carbohydrate. Dr Bernstein has worked out this level based on thousands of patients but it is only accurate for those who do not have additional insulin resistance. But this level can vary. Steven's insulin sensitivity increases in hot weather considerably and decreases with even the mildest viral infection. Each individual needs to work these variations out for themselves. Gary Scheiner's book Think Like A Pancreas gives excellent coaching on how to do this.
The higher the blood sugar, the more insulin-resistant you become. After 30g of carbohydrate at one sitting an additional weighting dose of insulin needs to be given. For Steven I have found that this is an additional 0.5 units of NovoRapid per 10g extra of carbohydrate.
Insulin absorption irregularities can result in a 30 per cent variation on the effect on blood sugars. This can be minimised by sticking to no more than seven units of insulin per shot. Although this can mean that Steven will have up to 10 injections of insulin a day, I feel it gives far more predictability and safety. For people consuming smaller amounts of carbohydrate the number of injections are correspondingly less.
We've found that a lean piece of protein the size of a deck of cards needs two units of Actrapid to cover it. This can be given 15 minutes before the meal is started at the same time as the NovoRapid that covers the carbohydrate.
Snacks and exercise
We will give Steven snacks if exercise is anticipated or he has a hypoglycaemic episode. Otherwise giving additional food between meals leads to too much uncertainty about how much insulin is active in the body by the time the next meal comes.
Exercise is a great way to lower a high blood sugar and we have purchased a rowing machine to help with this. Simple aerobic exercise or cycling works just as well.
Blood sugar testing four to 10 times a day helps everyone know what is going on. Steven has eight to 12 insulin injections a day. He deals with this without complaint and just gets on with it. This approach
reduces hypos and improves HbA1c. Dr
Bernstein and Dr Vestig Nielsen have done studies to prove it.
I think it is regrettable that the NHS, in my opinion, does not provide adequate education for patients with diabetes. Fortunately, there are internet-based resources that can really help the patient who wishes to investigate alternative options. I believe diabetes patients of all types will get real improvements from a progressive reduction in the amount of refined carbohydrates and grains they are consuming, in favour of replacing these with non-starchy vegetables such as salad vegetables, broccoli and cauliflower. Fat found in dairy products such as butter and cheese, and limited quantities of nuts, can be added to the diet if additional calories are needed.
The DAFNE programme (dafne.uk.com), albeit restricted in its availability in that it is not available to under 18s and takes a week's commitment out from work, does produce improvement in HbA1c and the same level of feedback between insulin and blood sugars that Steven has been learning at home. But I feel that it gives diabetes patients the idea that they can eat unrestricted carbohydrate and stay healthy. This unfortunately is simply not true.
In brief, protein is the key to reducing hunger, carbohydrate limitation is the key to blood sugar control and fat intake can be adjusted for additional calorific requirements.
Katharine Morrison is a GP and police surgeon in Mauchline in Ayrshire
Competing interests None declared
Steven's moderate-carb, high-fat diet
• The mainstay is protein at every meal, aiming for 2-4oz every time
• Protein options include meat, eggs or fish
• Low-carbohydrate baking can be an unexpectedly good protein source
• Using whey protein powder, ground almonds and soya flour as flour substitutes with sweeteners can really get the carb count down
• Low-glycaemic index cakes, biscuits and desserts can be made using full-fat cream cheese, double cream and moderate amounts of fruit
• Steven's favourite desserts include vanilla cheesecake, key lime pie and blueberry tart
What I have learned
• No young person with a new diagnosis of type 1 diabetes need have a reduced life-expectancy or experience serious complications if they take advantage of the available technology and educate themselves about managing their blood sugars
• I believe a low-glycaemic, low-carbohydrate, moderate-protein and high-saturated-and-monounsaturated- fat diet is the key
• Strategies to avoid hypoglycaemia, post-meal hyperglycaemia and wide blood sugar swings reduce the complications of diabetes
• Learning from other patients and carers can often be much more relevant than studying textbooks