Balancing diet and diabetes medications
- High blood glucose levels (glucose toxicity) and high insulin levels (hyperinsulinemia) are both bad news for your health.
- The highest priority in the treatment of diabetes should be to reduce foods that require large amounts of insulin.
- Over reliance on medications can lead to ‘learned helplessness’, meaning that people do not use a dietary intervention to what is primary a dietary disease.
- Periods of fasting and intense exercise also improve insulin sensitivity.
- A lower insulin load diet and improved insulin sensitivity will enable you to reduce and possibly eliminate medications.
when do you need insulin?
Last year I was tracking my blood sugars. I was concerned with what I saw.
Based on my average sugars of about 6.2mmol/L my HbA1c would have been about 5.5%. I wasn’t happy because I knew it was still well away from ideal.  I knew that improving my blood sugars was likely the key to losing the weight that I had been struggling with.
In an odd sort of way I was jealous of my wife who has type 1 diabetes. She could manipulate her blood glucose levels manually with her insulin pump, but I wasn’t sure what to do to bring my blood glucose levels down to more healthy levels.
Given that doctors will typically not give insulin until your HbA1c is greater than 7.0%  there was no way a doctor was going to prescribe me with insulin. My doctor told me to lose some weight to combat the developing signs of fatty liver in my blood tests.
In January 2015 I found Jason’s Fung’s videos  and kicked myself in the butt. Intermittent fasting seemed to do the trick to break the insulin resistance even though I had been following a lower carb paleo approach for a while. I was able to get my blood sugars back down to an average of 5.4mmol/L to give me an estimated HbA1c of about 4.8% and in the process of actively trying to manage my blood glucose levels I lost ten kilograms.
Fasting and improving insulin sensitivity
Dr Jason Fung  has recently increased the focus on fasting and dietary intervention and discourages an over-reliance on insulin to manage diabetes.
Jason says that focussing on medicating the symptoms of diabetes rather than addressing the root cause of insulin resistance can lead to a ‘learned helplessness’ where people do not pursue a dietary solution to what is largely a dietary problem.
Addressing diabetes by giving insulin to address the symptom of high blood glucose levels is like giving an alcoholic alcohol to relieve the symptoms of their alcohol withdrawal.
Meanwhile, Dr Richard Bernstein says that most of his type 2 diabetics need to remain on small doses of insulin in addition to minimising carbohydrate in order to achieve ‘normal blood sugars’.
In this video Dr Bernstein however notes a number of negative consequences of taking exogenous insulin including:
- it can make you fat if you eat a lot of carbohydrate, and
- it can cause hypoglycaemia (i.e. low blood glucose levels).
the balance between diet and medication
So how do we find the optimal balance between an over-reliance on exogenous insulin and medication while still achieving normal blood sugars?
Dr Ted Naiman of BurnFatNotSugar.com says that when he sees a new diabetic patient he checks their fasting insulin and C-peptide levels to understand whether they are still producing insulin or if their pancreas is already burned out.
If you don’t have access to these tests another option is to test your ketones and blood glucose levels to establish the ratio of glucose to ketones, which can also help you estimate your insulin levels (see the glucose : ketone index).
High insulin and high blood glucose means that you are insulin resistant (i.e. hyperinsulinemia).
Low insulin and high blood glucose means that you are insulin deficient and your pancreas is not producing enough insulin (i.e. type 1.5 diabetes, LADA).
Dr Naiman (pictured below – he practices what he preaches!) says he “avoids insulin like the plague” if at all possible, preferring to focus on diet, fasting and exercise.
Ted says that if you are still producing insulin but have high blood glucose levels the urgent need is to reduce the insulin load of the diet, start an exercise routine to improve insulin sensitivity, and ideally commence intermittent fasting ASAP! If you continue to consume a diet with a high insulin load you risk burning out the beta cells of your pancreas at which point you will require insulin.
Ted has produced an excellent summary of intermittent fasting and the various ways to put it into practice that you can download here. For more detail you also can check out Brad Pilon’s Eat Stop Eat or Jason Fung’s series on the topic.
the dangers of glucose toxicity
As discussed in the Diabetes 102 article there are a range of well-established risk factors for high blood sugars including accelerated brain shrinkage, cancer, obesity, heart disease and stroke.
This article from Jenny Ruhl’s Blood Sugar 101 lists a number of other complications related to high blood sugars including nerve damage, beta cell destruction, heart disease, diabetic retinopathy, and kidney disease.
Just in case you weren’t already aware… elevated blood glucose levels are very bad news!
If you want to be healthy, feel good, look good and live a long life, then your number one priority should be to do whatever it takes to achieve excellent blood sugars.
the dangers of insulin toxicity
I was interested to hear Professor Tim Noakes tell Robb Wolf in episode 273 of the Paleo Solution Podcast
You really want to keep your control through diet and minimal medication and never use insulin.
What I take this to mean is not that insulin is forbidden for people who need it, but rather that you should do whatever you can to not get to the point that you need to be injecting insulin to control your blood glucose levels.
Dr Fung points to the ACCORD Study along with the ADVANCE, VADT and ORIGIN studies which showed worse outcomes for people with type 1 diabetes who targeted a lower HbA1c of 6.0% rather than a more typical 7.5%.
The figure below from the ACCORD study shows the reduction in HbA1c with intensive therapy (i.e. more insulin) to “successfully” reduce blood sugar levels. What they found however was that the people in the intensive therapy group were 22% more likely to die (i.e. all-cause mortality) in spite of having ‘better’ blood glucose levels!
This may sound contradictory, because at the same time we know that reduced HbA1c levels actually lead to better health outcomes in the general population. So what’s the difference? Why are these studies suggesting that trying to normalise blood glucose levels are dangerous? Is there something about people with diabetes that makes it unhealthy for them to have lower blood sugars?
There is plenty of debate on what these studies really mean,    however Dr Fung says it is the use of medication in the absence of dietary intervention that is making the difference. Simply applying more insulin or other medications without addressing the diet is not only illogical it’s very dangerous!
This aligns with the data shown below which shows that reducing HbA1c is highly beneficial when it comes to heart attack and stroke risk, however doing it through the use of antidiabetic medication does not help.
Ivor Cummings does a great job on his blog of highlighting a wide range of studies that demonstrate that insulin resistance is by far the dominant risk factor for heart disease.      All we do when we medicate a high carbohydrate diet with insulin is to exacerbate the insulin resistance.
So is insulin all bad? Not necessarily. Insulin is important for a range of bodily functions including growth. However, high levels of insulin to cover high levels of dietary carbohydrate is a recipe for metabolic disaster.
Rather than relying on insulin, Dr Fung recommends a low insulin load diet combined with periods of fasting to improve insulin sensitivity and reduce insulin and blood sugar levels. Dr Fung told me that people need to “reduce both blood glucose and insulin to reduce glucotoxicity and insulin toxicity.” He says a HbA1c of less than “6.0% is defined as normal, although the lower you get, the better. However, this only applies if you are using diet rather than medications.” 
two sides of the same coin?
Both Dr Fung and Dr Bernstein focus primarily on non-medical interventions which include:
- A low carbohydrate / low glucose load / low insulinogenic diet. I suggest you focus on foods from this list and meals from here to bring your blood sugars under control.
- Exercise will improve your insulin sensitivity and help to remove excess glucose from your system. High intensity short duration exercise is ideal along with regular movement through the day. Rather than forcing yourself to exercise out of guilt you may find once you balance your blood sugars with diet rather than medication you have more energy and want to move more.
- Fasting is a great way to restore insulin sensitivity and reduce blood glucose levels naturally. It might be considered by some to be extreme, however it’s the most aggressive and effective approach to move the metabolic needle in the right direction. And it’s not that hard, particularly if you’ve got a lot of weight to lose and you’re looking down the barrel of major health complications.
Bob Briggs does a great job of putting this into simple terms that are easy to understand and apply.
refining insulin levels for type 1 diabetics
For someone with type 1 diabetes balancing dietary insulin load with exogenous insulin is an ongoing process of fine tuning.
Getting the basal insulin dose is important, particularly if you’re following a reduced carbohydrate approach, as it can represent up to 80% of the daily insulin dose. Unless you’re fasting you are unlikely to have a higher basal : bolus ratio than this. Covering too much of your food with basal insulin can be dangerous if you need to skip or delay a meal for any reason (e.g. sleeping in on the weekend).
The scatter plot of blood glucose readings below shows my wife Monica’s blood glucose readings. We use this data to review and refine her basal insulin rates (80% of her insulin dose) every couple of weeks.
While we are still on a journey, her blood glucose levels are the best they’ve been in her adult life and we’ve seen massive improvements since switching to a more nutrient dense low insulin load diet.
If her blood sugars drift up in a particular period of the day she will increase the basal rate on her pump in the two hours leading up to the point where the blood glucose levels are high. Conversely, if there are a cluster of hypos (lows) at a particular point in time she will drop back the basal insulin leading up to that time. Ideally we try to keep the high / low bars on the top chart on the red line, but not below it.
Her basal rates (shown below) are lower over night with a higher dose in the morning to cover the ‘dawn phenomenon’ which is the body’s way of supplying glucagon and adrenaline in preparation for the day ahead.
We’ve experimented with reducing basal insulin rates and running higher blood glucose levels to avoid lows and to reduce the overall insulin load. However this hasn’t really worked as Moni just doesn’t feel good with higher blood glucose levels.
It’s a delicate balancing act between blood glucose levels and insulin load. Your mileage may vary. You’ll need to refine things based on how you feel and with what you are comfortable with.
It’s also a good idea to look at the data over a longer period to make sure you’re not just reacting to recent events. Diet, hormones, stress, sickness and exhaustion all influence blood sugars and insulin requirements.
Knee jerk reactions to recent events can throw everything out of whack. We’ve found it better to make small refinements rather than large changes.
Some female diabetics also refine their basal rates around their monthly cycle as insulin resistance typically increases by around 15% in the four days leading up to their period. It’s worth tracking this and being ready to adjust insulin dosage.
the law of small numbers
The most important thing to know is that managing the insulin load of your diet is the most important thing you can do to improve blood glucose control. If you have a high degree of variability in your blood glucose from hour to hour due to a highly insulinogenic diet you’ll never be able to bring blood glucose levels down without risking going too low.
Most endocrinologists will recommend against targeting optimal blood glucose levels due to the risk of hypoglycaemia (low glucose levels). However reducing the insulin load of the diet will mean that the amplitude of the blood glucose swings are smaller, which will enable you to bring the overall average blood glucose level down using the basal insulin and smaller food bolus and correcting insulin doses.
Bernstein talks about the ‘law of small numbers’. If you are consuming a high carbohydrate diet then you will need ‘industrial doses’ of insulin and there is no way to calculate the insulin dose perfectly, so the errors compound and the resulting blood sugar swings are out of control. It’s the severe blood glucose swings that make you feel really bad, even more so than high or the low blood sugars alone.
adjusting insulin doses for type 2 diabetics
For the most part the observations from people with type 1 diabetes also apply to those with type 2 diabetes. A type 2 diabetic can balance their dietary insulin load with the insulin produced by their own pancreas supplemented with insulin sensitising drugs such as Metformin or injected insulin.
The first priority when transitioning to a low carbohydrate diet is to avoid driving your blood sugars low with too much medication. Rather than going low all the time it’s better to reduce your medications to a point where higher blood glucose levels will remind you that you need to manage blood glucose by controlling your diet.
If your medications are too high you will likely end up having to eat extra food to treat low blood glucose levels all the time. So not only do you have more insulin than you want (which will stop you using stored body fat for energy) you have to eat more than you need because of excess medication (which will also get stored as fat).
It’s hard to give an exact target blood sugar range, however the following guidelines may be useful:
- Blood glucose levels less than 4.0mmol/L (73mg/dL) are typically considered low (unless you are young and / or have high ketone levels). If you are seeing these blood glucose levels you should decrease your diabetes medications.
- Post meal blood sugars should be less than 6.7mmol/L (120mg/dL). If you’re seeing higher blood glucose levels than this after meals then you shouldn’t eat what you just ate again.
- A fasting blood sugar of less than 5.0mmol/L (90mg/dL) and an average blood sugar of less than 5.4mmol/L (100mg/dL) is ideal.
Once you reduce your dietary insulin load (i.e. by reducing carbohydrates, moderating your protein and maximising high fibre foods) you will not require as much medication and may need to reduce your medications to prevent hypos (low blood sugars).
If your dietary insulin load reduces further you will be able to reduce, and possibly eliminate, your diabetes medications as your own pancreas is able to keep up with your decreased insulin requirements.
If you are able to further reduce your insulin load your blood sugars will come closer to normal levels. With reduced insulin you will be able to use your body fat stores for fuel and ideally lose weight.
Depending on your goals and level of dedication (or OCD), you might get to a point where injecting small amounts of insulin is no longer worth the hassle. This is something that you should work through with your doctor who prescribed the insulin and / or medications.