CHAPTER 5 – How a Type 1 diabetic doctor runs half marathons on a ketogenic diet

National guidelines currently cling onto the belief that a healthy, balanced diet must contain a lot of carbohydrate and not a lot of fat. But the evidence is suggesting that this is not the case at all. The reverse is likely to be true, more fats from real food sources and restricted carbohydrates.

Slightly more troubling is the notion that the high carbohydrate model can be extended to diabetes, which is a condition of carbohydrate intolerance. If you have a carbohydrate intolerant body, why on earth would you feed it carbohydrates? Most of the old school would reply with ‘because it is a major food group and is essential’ (which of course it isn’t) as if it was as obvious as the fact that the sun goes round the earth. But now there is new thinking on this which is getting good results. A paradigm shift is imminent. But the old paradigm has dug its heels in. Big time. Some influential scientists have made the age-old mistake of seeing their speciality as a fact, not a current best-fit, and have become high priests of their own quasi-religions. Business has of course moved in to exploit an opportunity. As long as the old paradigm can be propped up, that will be the case. But in the end the new paradigm will replace the old one. It is the order of things.

Unless they have diabetes, or are close to someone who has, clinicians would find it difficult to imagine what us diabetics go through on a daily basis. For example: forgetting if we have taken our insulin doses; running out of supplies; eating out and forgetting insulin, or worse, injecting early and the food arrives late; feeling hypo and having no glucose; just not feeling right and wondering if it is due to glucose or not; being drunk and not knowing if the morning after is a hypo or hangover; re-using needles or injecting through clothes to be discrete. Life as a diabetic is a constant struggle, trying to master the almost impossible dark art of carbohydrate counting and medication balance. Mini-hypos are not uncommon, but dangerous ones are rare. I have had hypos regularly for 20 years, but I’ve only been caught out twice, when I needed help, and both were due to my stupidity.

However, despite some of the best medical care in the world, I was not doing as well as I would have liked. My HbA1c was creeping up and my insulin doses were increasing. The thing was though, it really was not lack of effort. But the nuancing of the advice in my medical consultation made me think it might be. Was I simply not trying hard enough, (or was that just my paranoia)?

Extract from Chapter 5 – Diabetes Unpacked, by Dr Ian Lake

CHAPTER 4 – Who gets Type 2 diabetes?

Only two groups of people get Type 2 diabetes (T2DM): drug addicts and performance athletes.

It is neither the addict nor the athlete’s fault for becoming diabetic. Remission is possible, but the burdensome responsibility of remission lies solely in the hands of the diabetic and can occur only once they understand why they became diabetic in the first place. I cannot help diabetics to become non-diabetic, but I can help diabetics to help themselves to become so.

Carbohydrates are an endorphin releasing drug, not a hunger satisfying food.

You cannot have T2DM if you do not consume carbohydrates. And just as with alcohol, opioids and nicotine, it matters not how the drug enters your face – whether as a simple sugar or as a complex starch, nor how fast it enters. What matters is how much and how often. Irrespective of the form it takes at entry into your mouth, by the time it enters your bloodstream, it can only be glucose, galactose or fructose.

Because treatment is usually based on glycemic index principles, almost all T1DM have an additional Type 2 component added into the complexity of their disease. There is no reason a T1DM patient should not be managed according to carbohydrate abstinence principles. In our experience, this approach achieves the most sustained degree of tight glycemic control and the most effective way to stabilise medications at very basal levels.

Typically a person with T2DM consumes more than 75-90% of their total daily calories in the form of carbohydrates. The pattern of consumption is more like smoking than real meals. Not only is the total fraction of carbohydrate calories excessive, the pattern of consumption follows endorphin needs rather than somatic nutritional needs. Diabetics typically have more than 15-20 consumptive events per day, mostly in the form of carbohydrate snacks or drinks that pattern daily endorphin activation requirements. A snack is always an emotional event, never a nutritional event, and “hunger” is the need for an endorphin release through eating or drinking rather than a need to consume nutrients based on a somatic nutrient deficit.

Extract from Chapter 4 – Diabetes Unpacked, by Dr Robert Cywes

CHAPTER 3 – What causes Type 2 diabetes?

High blood glucose is the most obvious clinical feature of the Type 2 Diabetes Mellitus (T2DM), but it is only a symptom of disease and not the disease itself. So, what is T2DM? What causes it? What is the etiology of T2DM?

This is a crucial question. Without understanding the cause, it is impossible to devise a rational treatment. T2DM is accepted as a disease of excessive insulin resistance, which causes the high blood glucose readings that characterise the disease. This immediately suggests an important conundrum. If the problem is high insulin resistance, then why is treatment entirely directed towards correcting the high blood glucose?

It is far more logical and effective to treat the insulin resistance. To do so, we must understand what causes insulin resistance.

Over a period of years, you move from pre-diabetes, to diabetes taking a single medication, then two then three and then finally large doses of insulin. Here’s the thing. If you are taking more and more medications to keep your blood sugars at the same level, your diabetes is getting worse!

The blood sugars got better with insulin, but the diabetes got worse. This unfortunately happens to virtually every patient. The higher dose of medications only hides the blood sugar by cramming it into the engorged body. The diabetes looks better, but actually is getting worse.

What happens over ten or twenty years? Every single part of the body just starts to rot.

This is precisely why T2DM, unlike virtually any other disease, affects every single part of the body. Every organ suffers the long- term effects of the excessive sugar load. Your eyes rot – and you go blind. Your kidneys rot – and you need dialysis. You heart rots – and you get heart attacks and heart failure. Your brain rots – and you get Alzheimer’s disease. Your liver rots – and you get fatty liver disease and cirrhosis. Your legs rot – and you get diabetic foot ulcers. Your nerves rot – and you get diabetic neuropathy. No part of your body is spared.

Medications and insulin do nothing to slow down the progression of this organ damage, because they do not eliminate the toxic sugar load. We’ve known this rather inconvenient fact since 2008. No less than 7 multinational, multi-centre, randomised controlled trials of tight blood glucose control with medications (ACCORD, ADVANCE, VADT, ORIGIN, ELIXA, TECOS and SAVOR) have all failed to demonstrate reductions in heart disease, the major killer of diabetic patients. We pretended that using medications to lower blood sugar makes people healthier. But it’s only been a lie. All because we’ve overlooked a singular truth. You can’t use drugs to cure a dietary disease.

Extract from Chapter 3 – Diabetes Unpacked, by Dr Jason Fung

Chapter 2 – What is diabetes? (treatment)

As you might expect almost all of the treatments for diabetes focus on increasing insulin levels, or trying to overcome the build-up of resistance to the effects of insulin in two organs, the liver and skeletal muscle (what you or I would call muscle). For these are the only two parts of the body where a problem, if it can be called a problem, exists.

Muscles can store glucose, about one thousand calories in an average sized person. Glucose is stored as glycogen (lots of glucose molecules stuck together as a ‘polymer’). This reduces the amount of water needed to surround each glucose molecule. The liver can store about five hundred calories, also as glycogen.

So, three mars bars and your sugar/glycogen stores are full. Once this happens the liver switches on a different system, known as lipogenesis (the creation of fat). Thus, after a high carbohydrate meal, if your glycogen stores are full, the liver will start producing fat, from glucose. It will then send this excess fat out, wrapped up in triglycerides (also known as very low density lipoproteins VLDL) – as these lose fat, they shrink down to become LDL (low density lipoproteins a.k.a. ‘bad’ cholesterol).

Anyway, with regard to the drugs used to treat diabetes, we have metformin – the most commonly used. This helps to reduce release/ formation of glucose, from glycogen, from the liver (gluconeogenesis), and increases insulin sensitivity in the muscles. We also have sulphonylureas, there are many of these, which flog the beta-cells to produce more insulin. We have pioglitazone, which is supposed to increase insulin sensitivity in muscle and does something beneficial in the liver.
We have acarbose, which stops the body digesting carbohydrates (which are all turned to sugar in the gut). We have other new drugs that increase hormones produced in the gut which stimulate insulin production after eating – in various ways. The most recent drugs are those that prevent the kidneys from reabsorbing sugar, so more sugar is lost in the urine. Hmmmm.

As you can see these are all focussed on insulin, and sugar, and nothing much else. Finally, of course, we have insulin itself. More and more people with T2DM are put on insulin to keep the blood sugar down. Of course, people are also told to lose weight and exercise more. People have been told to do this for the last forty years. Obesity and diabetes have both exploded in the past forty years. So this advice has been splendidly effective.

Extract from Chapter 2 – Diabetes Unpacked, by Dr Malcolm Kendrick

Chapter 1 – What is the scale of the problem?

Diabetes is a particularly nasty long-term condition because of the complications associated with it. However, these can often be avoided if the disease is managed well, and people living with diabetes can often lead long and healthy lives. If managed poorly though, that’s when complications occur. These are often traumatic – diabetes is the most common cause of leg amputations across the world, for instance, with more than 1 million people losing a leg every year. That’s one lost leg every thirty seconds.

The prevalence of diabetes has increased enormously since the 1980s. The following tables provide a breakdown of how numbers have grown over the last 35 years for different countries. As you can see, this is not a disease exclusive to western developed nations, but a truly global problem.

The increased incidence of diabetes by continent between 1980 and 2014.

The authors of this study went one step further by evaluating the age-adjusted increase in diabetes prevalence. This is an important calculation because T2DM is strongly associated with age, so you would naturally expect the number of people with diabetes to increase with an aging population. Age-adjusted calculations take this in account, and show the net change in diabetes prevalence. The authors calculated that global age-standardised diabetes prevalence between 1980 and 2014 increased from 4·3% to 9·0% in men, and from 5·0% to 7·9% in women, which leads us to infer that a number of factors about our modern lifestyles are responsible beyond age alone. Diet, exercise, sleep, and stress management all play their role. If current trends continue, over 700 million adults across the planet will be living with diabetes by 2025.

Extract from Chapter 1 – Diabetes Unpacked, by Mike Gibbs, CEO, OurPath.co.uk

The Noakes Foundation

At The Noakes Foundation, we raise funds to support research, but also to support the approximately 46.5 million South Africans who are not on private medical aid and are thus not able to get the world class care that less than 18 percent of our country affords in the privatised system. It is these people who are worst off; with little or no support and insufficient regular medical advice, diabetes is an ever-growing burden and dynamite that has now taken over HIV deaths in our country. It is a bomb that has already gone off. There is not a second to waste to make the change, cut the sugars and to start asking why we got here and how we can fix things for future generations. Many people need to wake up, even the ones who are not diabetic or sick and are managing on the current diet, but still feeding their children endless refined carbs and sugars and thinking ‘it won’t happen to us’.

The truth of this situation is so dire that in order to effect change, we need help from everyone: the academics and scientists and their extraordinary minds and problem-solving abilities; the doctors and specialists who are on the ground addressing the daily realities of chronic disease and fighting up-hill battles; the nurses and dieticians. Mostly, it’s going to take every single person to change things, cut the sugar and carbs and generate industry demand to change. It’s going to take every mother’s purse, both in South Africa and the world, to change the situation form the bottom up.

Extract from Introduction to Diabetes Unpacked, by Jayne Bullen, CEO, The Noakes Foundation