I admit I have built up tension.
There are big gaps between what I have come to believe in regarding both sound diabetes management and general good health and what I see in public policy, diabetes care guidelines, and clinical practice. This is a big topic, and I do not want to get into it right now. I've already done that today, but I will give examples.
The Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada states in Appendix 3 p197
Example A: Basal insulin (Humulin-N, Lantus, Levemir, Novolin ge NPH) added to
oral antihyperglycemic agents
• Insulin should be titrated to achieve target fasting BG levels of 4.0 to 7.0 mmol/L.
• Individuals can be taught self-titration, or titration may be done in conjunction with a healthcare provider.
• Suggested starting dose is 10 units once daily at bedtime.
• Suggested titration is 1 unit per day until target is reached.
• A lower starting dose, slower titration and higher targets may be considered for elderly or normalweight
• In order to safely titrate insulin, patients must perform SMBG at least once a day fasting.
• Insulin dose should not be increased if the individual experiences 2 episodes of hypoglycemia
(BG <4.0 mmol/L) in 1 week or any episode of nocturnal hypoglycemia.
• For BG levels consistently <5.5 mmol/L, a reduction of 1 to 2 units of insulin may be considered
to avoid nocturnal hypoglycemia.
• Oral antihyperglycemic agents (especially secretagogues) may need to be reduced if daytime
Maybe this makes perfect sense to many, but it severely pissed me off! Why? Because this nearly killed me. I'm nearly blind because of bad management. If you want good control, you have to match insulin to your need, and your need follows patterns. No exceptions. But our patterns are all different, and many do approximate basal insulin action. But there's a large number that need better basal matching.
DYSLIPIDEMIA IN DIABETES
Diabetes is associated with a high risk of vascular disease
(2- to 4-fold greater than that of individuals without diabetes),
with cardiovascular disease (CVD) being the primary
cause of death among people with type 1 or type 2 diabetes
(1-3). Aggressive management of all CV risk factors, including
dyslipidemia, is therefore generally necessary (4). The
most common lipid pattern in people with type 2 diabetes
consists of hypertriglyceridemia (hyper-TG), low high-density
lipoprotein cholesterol (HDL-C) and normal plasma concentrations
of low-density lipoprotein cholesterol (LDL-C).
However, in the presence of even mild hyper-TG, LDL-C
particles are typically small and dense and may be more susceptible
to oxidation. In addition, chronic hyperglycemia promotes
the glycation of LDL-C, and both these processes are
believed to increase the atherogenicity of LDL-C. In those
with type 1 diabetes, plasma lipid and lipoprotein concentrations
may be normal, but there may be oxidation and glycation
of the lipoproteins, which may impair their function
and/or enhance their atherogenicity.
This basically agrees with my beliefs: TGs indicate danger. The danger comes from sugar! Sugar decreases LDL-C particle size [and causes inflammation]. Basic stuff supported by science. Yea!
However, the document then says
As well, an energy-restricted, wellbalanced
diet that is low in dietary cholesterol, saturated fats,
trans fatty acids and refined carbohydrates is essential.
However, in a “real-world” setting, only
one-third of individuals were able to adhere to this diet over
a 1-year period of time (9).
Don't reduce carbs, just their refinement.
This involves consuming a variety
of foods from the 4 food groups (vegetables and fruits; grain
products; milk and alternatives; meat and alternatives).
Grain is by definition a refined carb. We can't eat them whole. Grains are their own food group in Canada.
The acceptable macronutrient distribution range, or
percentage of total daily energy associated with reduced risk
of chronic disease for adults, is as follows: carbohydrate intake
of no less than 45% (in part to prevent high intakes of fat); and
fat intake of a maximum of 35% (26). Diets that provide
>60% of total daily energy from low-glycemic-index and
high-fibre carbohydrates improve glycemic and lipid control
in adults with type 2 diabetes (27).
These passages really push me. I want to take a baseball bat to a few heads, or better yet kneecaps. Their heads are worthless.
If you can't see why I'm angry, their argument goes like this:
"Sugar is the real problem here people. It causes increased triglycerides, and as sugar increases TGs it reduces your LDL particle sizes to dangerous levels. You have small, atherogenic LDL particles. This nasty sugar is also glycates and oxydizes these small LDLs. It's a double whammy. You are going to die young from CHD! "
The obvious solution here is to cut out sugar as much as possible. Present the problem to 1000 kindergarteners and you will get 1000 children no longer wanting to eat sugar.
"We don't want you to reduce sugar. We want you to package it with fibre to make its effects slower, and we want to package it with antioxidants to make it not oxydyze. Whatever you do, don't touch those bad fats though. We can't tell you why, but the Americans think they are bad."
Chemically sugar is sugar. Carbohydrates are all sugar. There's no such thing as a carbohydrate that isn't sugar. Got it yet? It doesn't matter that it's wrapped in fibre. It still goes into your bloodstream and your body recognizes it as sugar. You might not get as big a spike, but it's still creating TGs, small LDLs, and it's oxydizing away. Packaged antioxidants as found is fruits and veggies certainly help with the oxydization though. BTW there's no antioxidants to speak of in refined grains, rice, or potatoes.
Side note: potatoes used to be rich in vitamin E. Due to selective breeding, they have virtually none today.
So I wrote a letter about all this stuff and more. It was to a doctor on the committee that sets this stuff. He's a fairly well known Canadian diabetologist. I've met him before, and we've emailed before, briefly . He replied
Thanks for your email. I will read it over with interest.
Best wishes on your continued journey striving for good health.
Pissing in the wind, I know.