Get Tough with Type 2 Diabetes

Master your diabetes

David Levy

• Publisher: Hammersmith Health Books
• Year: 2018
• Print ISBN:
  9781781611081
• eBook ISBN:
  9781781611098
• Topic: Medicine
• Subtopic: Diseases & Allergies

Get Tough with Type 2 Diabetes is a cutting-edge yet practical guide for newly-diagnosed and established type 2 diabetes patients and their families, by one of the UK's leading diabetes physicians. It discusses ideas that have emerged over the past 20 years about the fundamental problems that cause Type 2, many of which may be unfamiliar to non-specialist healthcare professionals as well as patients: The primary problem is not blood glucose but fat in the wrong organs (liver and pancreas) from starchy carb consumption; High blood glucose levels occur late in the course of Type 2 – the metabolic syndrome, with hypertension and abnormal cholesterol levels, often exists years before Type 2 diagnosis; The Newcastle-type ultra-low-calorie diet can re-set the metabolism and even reverse Type 2; The Mediterranean approach to diet can significantly reduce cardiovascular risk; Managing cholesterol and blood pressure problems is at least as important as blood glucose levels; Minimising medication while overcoming complications is desirable and possible; Diabetes is closely related to depression, and other psychological issues including 'diabetic distress' and 'diabetic burnout'. Armed with this new information and the results of important clinical trials, it is more possible than ever before to Get Tough with Type 2 without the need for progressively more and more blood glucose-lowering medication.

Chapter 1

Understanding Type 2

Key points

• Type 2 is defined as blood glucose levels above a particular level.
• High blood glucose is only the final outcome of a pathway that originates in a complex package of abnormalities in several organs.
• The main abnormalities are in the liver and pancreas.
• In Type 2 the liver overproduces glucose, especially overnight. Insulin, whose main job during the day is to reduce blood glucose levels after meals, isn’t produced in sufficient quantities from the pancreas.
• Type 2 diabetes has a strong genetic basis, and runs in families.
• Although over-nutrition is strongly associated with Type 2 diabetes, most people developing Type 2 aren’t obese.

Type 2 diabetes is complicated and still not fully understood, but we’re getting there. Until the late 1980s, we couldn’t even reliably make the distinction between the two major forms of diabetes – Type 1, which usually begins in childhood and requires permanent insulin treatment right from the start, and Type 2 – but it was known that all types of diabetes were characterised by high blood glucose levels. From the late 1980s it gradually became clear that having a high glucose level wasn’t the fundamental problem in Type 2. Much more important was a series of problems occurring in two organs – though these eventually led to high glucose levels.

• The liver, which in Type 2 diabetes was inefficient in processing glucose derived from absorption of food.
• The pancreas, the organ where insulin is produced. Insulin is the key hormone that reduces blood glucose levels when they rise – though, as we’ll see later and in Chapter 3, insulin is amazingly versatile and has countless actions that are completely separate from its effect on blood glucose.

New ideas on the cause of Type 2 diabetes

Evidence increasingly supports the idea that most cases of Type 2 diabetes are caused by stress on the liver and pancreas resulting from over-nutrition, which usually, but not always, leads to being overweight or obese. This nutritional stress occurs over a long time – many years in some cases – before people develop diabetes. This process is similar to stress on any mechanism – for example, mechanical or even electronic equipment – where small errors and defects accumulate over the years without there being any noticeable problem, but then there is a final stress, which may not be any bigger than the earlier ones, but which precipitates mechanical or electronic failure. In the case of Type 2 diabetes, continuing stress on critical organs, the liver and pancreas, results in the onset of diabetes diagnosed by ‘high’ glucose levels. But the original problem will have started many years earlier, certainly in childhood, and perhaps even earlier. Around the same time as this new idea about the real nature of Type 2 diabetes was being uncovered, it was becoming clear that over-nutrition during pregnancy – and under-nutrition too – were both linked to an increased risk of Type 2 when offspring grew up to be adults. In other words, Type 2 is now considered to be a very long-term condition indeed: not caused by eating too many chocolates as a middle-aged adult, as is popularly thought, but by a series of subtle but continuing stresses that have taken place over at least a generation, and perhaps even longer.

Metabolic stress caused by over-nutrition

Let’s describe in more detail the role of the liver and pancreas, how they become stressed by over-nutrition, and then how they respond to this stress.

In order to do this, and therefore to understand Type 2 diabetes, we need to appreciate that food is metabolised in a very complicated way, and we have to understand that if, for example, you eat sugar, it doesn’t just go straight into the blood and register as a high glucose value. Evolution is much cleverer and more subtle than that, for the simple reason that if sugar in the diet went straight into the circulation, a blow-out on a large amount of fruit, or a box of chocolates, could raise everyone’s blood glucose to dangerous levels. What occurs in the interval between eating and glucose appearing in the circulation is complicated, but it’s worthwhile trying to understand it because that leads to a better understanding of the treatment of Type 2 diabetes, especially non-drug options (see Chapters 5 and 7).

Key point: Overeating, but by no means always to the point of being obese, is the major cause of diabetes. Overeating stresses the function of the liver and pancreas, the two organs most involved in metabolising food.

The liver – a tough organ for tough tasks

Once food has been broken down in the intestine after eating, the products of this chemical breakdown are absorbed into the circulation and transferred to the liver for processing. If we eat a standard Western diet, most of the absorbed products (about 50–60% of the total) is glucose, which is derived from carbohydrates – primarily bread, pasta, rice and potatoes – but also ‘sugar’ in confectionery or sweets. This used to be sucrose, but is now mostly fructose in the form of high-fructose corn syrup and apple juice, which are ferociously sweet and found in almost every pre-prepared food. We eat smaller amounts of fats and protein, but they are also broken down into smaller chemical components and, like glucose, transferred to the liver, where they are eventually converted into glucose. Remember that not all food can be broken down, even in the chemically tough environment of the stomach and intestine. Of the non-absorbed components of food, fibre, especially soluble fibre, is highly relevant to the treatment of diabetes because it can slow down the absorption of food, and delay glucose appearing in the circulation (see Chapter 5).

The liver is the largest organ in the body, and one of the reasons it has to be so big is that it’s the immediate destination of the breakdown products of all food (think about the scale of the task it faces when confronted by an all-you-can-eat buffet or 24-hour eating when its owner is on a cruise). It also processes medications, and does its best to detoxify all kinds of potentially hazardous substances we eat or even absorb from the environment. Whatever you eat – carbohydrate, fat, protein – is transported in broken-down chemical form to the liver. Once there, it’s packaged up into different forms for storage. One form you’re likely to remember from GCSE biology is glycogen, a starch which has been reassembled from absorbed glucose molecules. Glycogen is an efficient storage chemical but it can’t be used directly to generate energy, so it has to be converted in the liver back to glucose – which is the chemical most organs need to generate energy and keep working. Both the storage of glucose as glycogen and its conversion back to glucose are performed by insulin.

High blood glucose levels first thing in the morning (that is, after fasting) are caused by an inefficient liver. Eating our daily meals causes glycogen from excess glucose to be stored in the liver. During the night when we’re not eating, stored glycogen has to be chemically broken down slowly and carefully, in order to prevent our brains being starved of glucose, and to keep up with the low metabolic demands of the sleeping body and generally resting organs. Insulin is the key to ensuring we have just enough glucose circulating during the night, and in people without Type 2 it exerts a gentle braking effect on the liver and prevents too much glucose being released. It doesn’t succeed in doing this in people with Type 2, in part because the liver becomes resistant to its effects, so there is a form of brake failure. The result is that too much glucose is released from the liver overnight, resulting in a high fasting glucose level if you measure it when you wake up.

Celebrating insulin

It’s worthwhile pausing here to pay a brief tribute to insulin. Natural insulin is produced by the beta-cells of the pancreas; it lowers blood glucose levels by ensuring glucose is transported with great efficiency into organs that need it, mostly muscle, but to nearly every other organ as well. But insulin is also the master regulator of nearly all metabolism, and continually changes its function according to which nutrient it is dealing with (carbohydrate, some fats, or protein), which organ it’s acting on, and the time of day – whether we have just finished eating or have been without food overnight. Insulin is without doubt the most versatile substance in the body, and whether naturally produced by the pancreas, or delivered from syringe or pen, deserves serious respect but not fear.

High fasting glucose levels are very common in Type 2 diabetes, and are one of the ways in which Type 2 is diagnosed – see Chapter 2. High blood glucose levels in the morning, after what is effectively a period of overnight fasting, often puzzles people with Type 2. They are understandably at pains to point out that they don’t raid the fridge in the dark hours. It isn’t Type 2s who are misbehaving (unless they really do launch fridge raids); it’s the liver, pancreas and your own insulin produced by the pancreas. I’ll mention this again in other chapters, but if you think that diabetes is caused by eating too much sugar (sucrose, the white stuff added to hot drinks and sweets and confectionery etc.), then a high blood glucose level after eight or more hours without food doesn’t stack up. This simple phenomenon tells us that Type 2 diabetes has very little to do with eating sweet sugary stuff.

Key point: People with Type 2 diabetes tend to have high blood glucose levels when they wake up. This indicates that the liver isn’t working properly.

The pancreas – the insulin factory

In contrast with the liver, the pancreas is less obviously impressive, much smaller and buried at the back of the abdomen. Altogether, 90% of the pancreas produces digestive juices, while only 10% produces insulin. Insulin-producing cells, also known as beta-cells, are grouped together in ‘islets’. The pancreas has important connections: it is the first stop for nutrients, especially glucose, absorbed from food in the gut. In response to these high glucose levels, in non-diabetic individuals insulin levels increase very quickly in order to lower blood glucose levels to normal.

High blood glucose levels after eating are caused by an inefficient pancreas. In people without diabetes, blood glucose levels are usually 4 or 5 mmol/l and even after eating rarely go higher than 7 or 8. If they do, they return to normal very quickly, usually within an hour. Within minutes of starting to eat (possibly even as we catch a glimpse of tempting food before we actually start eating), the pancreas is already starting to produce more insulin, which will keep blood glucose levels down. If you’re eating a high-carbohydrate meal (for example, a large burger meal complete with large fries and milk shake, or lots of pasta, rice or noodles) then the healthy pancreas will go into major overdrive to produce large quantities of insulin to ensure that blood glucose levels don’t rise.

It doesn’t matter what form of diabetes you have; the pancreas can’t produce enough insulin. In Type 1, it can’t produce any at all, because the beta-cells within the islets have been destroyed by an immune process, so Type 1 people always need insulin with each meal, and even with snacks. In Type 2, there is some insulin product...

Table of contents

• Cover
• Title Page
• Contents
• About the author
• Introduction
• How to use this book
• Chapter 1: Understanding Type 2
• Chapter 2: Diagnosing diabetes
• Chapter 3: Pre-diabetes and the metabolic syndrome
• Chapter 4: Is Type 2 potentially reversible?
• Chapter 5: Taking control of calories
• Chapter 6: ‘Superfoods’ and nutraceuticals
• Chapter 7: Keeping your medication to a minimum
• Chapter 8: Activity and exercise
• Chapter 9: Looking after your heart and arteries
• Chapter 10: Blood pressure and cholesterol
• Chapter 11: Avoiding eye, kidney and nerve complications
• Chapter 12: Diabetes and older people
• Chapter 13: Psychology and Type 2 diabetes
• Postscript: That wasn’t too tough, was it?
• References and further reading
• Index
• Copyright