N=1 or Your Life Is The Trial.
Have you ever walked out of a medical practitioner's office and found that their guidance has not been accurate?
Have you ever followed a state-run guideline only to find that your health didn't improve, and may have even deteriorated?
Have you ever tried a 'diet' that made you sick or after you stopped following it your weight crept back up?
We are besieged by a torrent of health guidance from various sources ranging from governments, big pharma, doctors, food companies, health and fitness businesses, and influencers. Do they have our best interests at heart? - unlikely. Do they want to flog their products and services without hardly any due diligence into the consequences to their customers? - more likely.
That's not to say there aren't good eggs, but we are now living in a society whereby we must be very careful when following guidelines or advice, and we have to be fastidious in our assessment of these information sources (including this one).
A good example of this is the recommendations around fat. Many state guidelines around the world have used the 'diet heart hypothesis' as the driver of information around fat intake for the past 50 years. This suggested a correlation between saturated fat, cholesterol and increased incidence of cardiovascular disease. In the 1960's Ancel Keys, an American physiologist suggested a low-fat diet and this was taken by the American Heart Association (AHA) who recommended lower levels of saturated fat consumption. They noted, however,
It must be emphasised that there is as yet no final proof that heart attacks or strokes will be prevented by such measures.
There is still no evidence.
In science, we have a number of ways in which we can essentially make better-informed decisions, and that is with trials and research. These can range from simple ideas and editorials to cohort studies, randomised control trials (RCT) and meta-analysis. To view a comprehensive review of the different types of studies, click HERE.
A common problem with trials is that they are very expensive and the organisations that can afford them typically are biased toward a specific outcome (think big pharma).
The diabetes community is not immune from this bias and agenda as we constantly face conflicting information on diet, exercise, and medical needs. An underlying theme amongst the diabetes community is that we are all different in our needs and management of this disease and even if we were to follow exactly the same daily routine, we would still have distinct variabilities in our blood glucose levels and health outcomes. This is profoundly true, but there are also definite similarities between us all of which can’t be overlooked.
Before exogenous insulin was invented back in 1922, all diabetics were told to eat a very low carbohydrate diet with periods of extensive fasting to prolong their life. People were dying from chronically high blood sugars (hyperglycemia), and it's many complications.
We now have the ability to cover food with insulin to slow down this process, and with a combination of new insulin and technology, It’s easier than ever to keep our blood sugars in target range and for long periods. But is it?
Studies still show that our ability to keep normal blood sugars is poor at best, with 5% able to sustain an HbA1c under 7% (www.lowcarbdownunder.com).
So what’s wrong and what can we do to improve outcomes?
Universally, our guidance on diet is conflicting and this is, without question, a major source of confusion and contention. Carbohydrates are at the top of this list of disputed ingredients, and it seems almost impossible to get any kind of unanimous professional opinion on them for the benefit of a diabetic. Therefore, we are forced to take the matter into our own hands and test on ourselves.
Here are a few other pointers:
1) Utilise the medical profession as much as possible, but don’t necessarily follow their guidance to the letter. - Understanding the basics of diabetes management is integral. Perfecting your insulin regimen, carb counting, access to new glucose management technology, and sick day management is all something your medical team can help you get your head around. However, diet, exercise and other factors that impact blood sugars is also a game of trial and error. Have the confidence to change your insulin and test on yourself to perfect your blood sugar management.
2) Ingratiate yourself with online communities and learn from people with decades of experience.
- There is a wealth of knowledge at the click of a button. Not all will be sound and accurate so check everything but many social media groups are run and administered well, so ask questions and learn as much as possible.
3) Never stop testing.
- As mentioned, there are commonalities and stark differences between all diabetics, but we must always be testing the impact of food, diets, exercise, stress, sickness, alcohol, insulin amounts, even needle length. Diabetes is in a constant state of flux with every day giving us different readings, so never rest on your laurels and remain adaptable to a changing landscape.
4) Become a ’plastic’ dietician
- Your diet is the one thing you can control over everything else. Test your blood sugars before and after everything you eat and drink. If a particular food choice adversely affects your glucose levels then you know it's not good for you, regardless of whether you're told it is beneficial to your health or not. The impact on your body of elevated blood sugars is far more detrimental than missing or replacing a food.
5) Exercise, directly and indirectly, benefits your blood glucose management.
- We all know the extensive benefits of regular exercise, but for people with diabetes, it helps us lower our blood sugar levels and keep them low. It also improves insulin sensitivity and stimulates Autophagy.
How to test... everything.
Despite the onslaught of agendas, biased trials, and research, there is a way in which you can always take control of your disease, and importantly, give yourself confidence in your ability to manage your blood sugars.
Never stop testing on yourself.
Becoming an expert on all things diabetes will take the rest of your life - but we have that time - and the more you test, the more you learn, and the more you learn, the better control you’ll have.
If people disagree with you on how you manage something, simply show them your blood sugars. Having strict glycemic control is a skill in which you can refine and help others along the way.
There will always be cases whereby two people have different approaches to managing the same thing - MDI (multiple daily injections) and Insulin pump, low-carb and high carb, meat or vegetarian - if both have non-diabetic blood glucose levels and optimum metabolic health, there is no right or wrong way. As medicine becomes more individualised, so must our management of diabetes.
When I test and what I test
On the Believe the hypo website you can now download a logbook and input your daily routine - to access it click HERE.
If you're new to diabetes or your blood glucose levels are consistently higher than 6 mmol (106 mg/dl), then it's a good idea to keep a logbook for a couple of weeks to check on your diabetes management.
When to check your blood sugars:
1) Upon waking up.
2) 15 mins before and 2 hours after eating (depending on food choices, you should check 3 hours after high protein meals and after 1 hour if you're eating a high carb meal - particularly refined carbs like cereal and bread). If in doubt, check every hour for 4 hours after your meal. 3) Before, during and straight after exercise. 4) Before going to sleep. 5) During sleep (3 am) - if you don’t have a CGM - not every night, just once or twice.
What to log:
1) Blood glucose levels throughout the day, as above.
2) Insulin doses - times and amounts of basal and bolus.
3) Types and times of food, inc macronutrients, grams of carbohydrate and protein.
4) Sleep (hours) - try sleep trackers like 'sleep cycle'.
The more you test your blood sugars and log your activity the better. You want as much information as possible to then dissect and evaluate.
Why is this important?
Understanding what is contributing to fluctuations in your blood sugars is the cornerstone of diabetes management. The more you understand these factors, the better equipped you are at managing them (or avoiding them).
Putting it all together
Sit down and thoroughly digest your routine after completing the logbook. Read it aloud to your partner of family. Get them to read it to you. Share it with diabetic friends and finally, take it with you when you visit your Diabetic Educator and Endocrinologist.
You may see trends that immediately scream at you and you're able to make changes to improve your management, but there may well be more subtle things going on in the background that a medical professional could help you see and control.
Keeping a logbook once or twice a year will help you stay in control and adaptable to the changes that are inevitable with diabetes.
The point is that this is absolutely and infinitely more useful than reading a trial, research or an article such as this if you want/need control over your disease.
Don't listen to me - prove to yourself what works.