I achieved a new goal with my diabetes control recently. My Blood Glucose Meter gives me an average for my readings over the last 7, 14 and 30 days. For the first time ever, all three averages are now sitting (just) at levels of less than 6mmol/l (110mg/dl).

Image:DAFNE - Tight Diabetes Control - Three FivesImage:DAFNE - Tight Diabetes Control - Three FivesImage:DAFNE - Tight Diabetes Control - Three Fives
Blood Glucose Averages: Three Fives

My averages have traditionally been above 7mmo/l (125mg/dl).

As the regular readers of my blog may know, eight months ago I did a course on Diabetes control called OZ DAFNE: Dose Adjustment for Normal Eating.

A Quick History Lesson

I was diagnosed with diabetes in 1976.

It was only in 1993 that a large scale study concluded that keeping blood glucose levels in normal ranges was important to ensuring that people with Type 1 diabetes didn't develop a range of complications.

The Diabetes Control and Complications Trial (DCCT) followed 1,441 diabetics over a period of about ten years. Half were given intensive control to keep their blood sugars as close to normal as was then thought feasible. The rate of diabetes complications in this group dropped by anywhere from 50 to 76% depending on the type of complication.

Subsequent studies have shown there's no threshold value for this improvement: the close you come to normal control the more the risk drops.

The intensive control consisted of:
  • four blood glucose tests per day,
  • four insulin injections or pump,
  • adjustment of insulin to match exercise and food,
  • a diet and exercise plan, monthly visits to a health care team with a physician, nurse educator, dietitian and behavioural therapist.)

The Australian Medical Journal said of this approach
  • "No Australian diabetes centre has been able to routinely offer this level of support to patients.", and
  • "Although bodies such as the American Diabetes Association recommend a glycated haemoglobin (HbA1c) target of < 7%, only around 20% of adults with type 1 diabetes under specialist supervision in Australian centres achieve this goal", and, more worryingly:
  • "Intensive treatment in the DCCT was accompanied by a threefold increase in severe hypoglycaemia and a 33% increase in the risk of becoming overweight."

(HbA1c tests are a measure of how good diabetes control has been over a period of up to three months. A normal (non-diabetic) reading is below 5%, and certainly below 6%.)

For about as long as I can remember, I've just scraped into the "Very Good" range for someone with diabetes: I've been somewhere between 6.8 % and  7%, with occasional readings up to 7.2%, and once I fluked a low reading of 6.6%.

But: studies show that people with readings of 6.8 to 7% are still developing complications well above the normal rate.  

Image:DAFNE - Tight Diabetes Control - Three Fives
Random Photograph: A bird I saw today in Melbourne's beautifully named "Pollution Control Pond Q" (I kid you not, the place name is real.)


There's a well recognised regime for diabetes control that improves average control that doesn't significantly increase the rate of hypos called DAFNE  See this summary of its relevance to Australia.

On average, people's HbA1c results drop by 1% following the completion of a five day DAFNE course.

It's often much easier to cut 1% from a "Poor" reading of (say) 9% than it is from a "Good" reading of 7.0%. 20% of people with Type 1 diabetes currently manage to get below 7.0%.  But in relation to achieving the "Normal" or "Reference" range of 4.0 - 6.0%, one comment seems to be repeated:
  • "A very few people manage to do it, but they have lots of hypos."

I plan to disagree.

The DAFNE course has given me a much greater understanding of my blood readings and my insulin. I thought I'd developed some good rules of thumb over the thirty years I have had diabetes, but many turned out to be grossly wrong.
I previously thought.... I now know....
A hypo probably doesn't need to be treated until I drop below 3 mmol/l (55 mg/dl) Treat every reading below 3.5 mmol/l (65 mg/dl) as if it's a hypo
If you are especially low, take even more glucose to get back to normal. Unless it's just before a meal, take some long acting carbohydrates as well. Treat every hypo consistently with 20g of glucose.
(I now sometimes take a little less than 20g on some occasions. But to start with, follow a simple rule: Below 3.5, take 20g.)
Take standard amounts of insulin with each meal, and then adjust it up or down at the rate of 1 unit for every 10g of carbohydrates. Insulin doses are calculated with ratios. Everybody's ratios will be different. Most importantly, mine are different at different times of the day. For lunch I have 1.5 units per 10g carbohydrate - eg 4 units with 30g of carbohydrates; for dinner I have 2.5 units per 10g carbohydrates - eg 8 units with 30g of carbos.)
I used to take 50 units of long acting insulin per day: 30 in the morning and 20 at night. I, along with most other people on my DAFNE course managed to drastically reduce the quantity of long acting insulin.
I now take a total of 27 units per day: 14 in the morning and 13 at night.
When looking at what has happened with blood glucose levels, think about what has happened over the last hour or so, and look forward to the next hour. Watch the curves of insulin and food responses over periods from 4 to 72 hours.
Short acting insulin will still be having some effect four hours after you take it.
It might take 3-6 hours for a meal to digest.
Exercise and alcohol can change things the next day.
Changes to long acting insulin doses will take at least 72 hours to settle down.

Low Carbohydrates

The quibble that I have with DAFNE is with the phrase "Normal Eating".

Fairly early on it became apparent that whilst DAFNE gave me good control, I was still having regular excursions into high levels in the three hours after a meal. This was especially true after some of my 'big' meals:
  • Indian takeaway with lots of Naan breads and rice
  • Large servings of pasta
  • Pizza
  • Anything with chips (french fries)
  • Japanese vegetarian pancakes (with a nice sweet sauce on top)

I could properly calculate insulin doses for these meals so that I ended up with a nice 4.5mmol/l (80mg/dl) four hours after the meal. But that hid the fact that I was rising to 16mmol/l (280mg/dl) or even more in the hours after the meal. In fact, at DAFNE we were discouraged from taking readings soon after meals on the basis that there wasn't much we could do to avoid those high readings.

But  I can avoid those readings. By avoiding those types of foods.

There are plenty of people who go onto modified diets. People with Coeliac's disease (who can't digest wheat) come to mind. If they can make major changes to their diet in the interests of their health, then I can reasonably make some (relatively minor) changes to my diet. It's worth it to reduce the risk of diabetes complications that include...
  • high blood pressure,
  • obesity,
  • elevated blood fats eg cholesterol,
  • cardiovascular disease, eg heart disease and stroke,
  • kidney disease,
  • foot ulcers,
  • amputations,
  • retinopathy (and other eye diseases),
  • neuropathy and peripheral nerve disease,
  • gastroparesis etc..

(I don't think that anybody has come up with any type of cancer that is caused by diabetes, but it starts to look like almost every other cause of death gets a little bit of encouragement from diabetes.)

What's the evidence for Low Carbohydrate eating?

Conventional advice is to have standard doses of carbohydrate and to lean towards slow acting carbohydrates (eg Those with a low Glycemic Index.) Like Pasta. Hmm.

To get a flavour of the discussion:

British Journal of General Practice letter by Katharine Morrison advocating low carbohydrate diets. She provides links to a number of articles on the topic.

Contrast the Response by A Lindsay Gibb and William Welfare stating "it is better to enable people with diabetes to live a normal life with good control than to promote a difficult-to-achieve, restrictive, expensive and potentially stigmatising diet, which has unclear long-term benefits."

That sounds to me a little like a doctor telling somebody with Coeliac's Disease to avoid that special wheat free bread because it's expensive and people might make fun of them in the school yard.

I think the profession is concerned about the consequences of extremely low carbohydrate diets, like those proposed by Dr Bernstein.

My diet used to consist of perhaps 260g of carbohydrates per day: 50 at breakfast, 30 for morning tea, 50 at lunch, 30 for afternoon tea, 80 (or more) for dinner and 20 for supper. I dropped a little lower than this in my late 30s after I had put on 12 extra kilograms, but I was still eating almost this much when I started DAFNE.

I've now dropped down to about 100-140g of carbohydrates per day... plus whatever extra I need when I drop below 3.5mmol/l (65mg/dl).

My current diet is a bit of a compromise: a dietitian would regard me a somebody who has changed from having a bit more carbohydrate than average to one who was having a bit less. They'd be happy with the increase in vegetables and fish.

I'm still well high of the extremely low levels (30g of carbohydrate per day) recommended by Dr Bernstein, the guru of low carb diets for diabetes.

I'll consider going that low if:
  • I can't get myself to the normal HbA1c range with my current approach, and/or
  • If a large study shows the benefit in a way that's independent of HbA1c goals

    Image:DAFNE - Tight Diabetes Control - Three Fives
    A secret forest: almost nobody knows where it is. Hint: it's within fairly easy walking distance of the centre of Melbourne.

Current Outcomes

In the meantime, my results are running as follows:
Date Result Approach
August 2007 HbA1c 7.0% Just prior to DAFNE training
Mid March 2008 HbA1c 6.5% Six months of DAFNE treatment with about two-three weeks of slightly reduced carbohydrates.
Start May 2008 Monthly Average Blood Glucose Result 5.9mmol/l (106mg/dl)

This may equate to an HbA1c of 5.2 - 5.8%
Reduced Carbohydrates, increased Blood Glucose testing frequency, tighter targets.
Mid June 2008 I will have another HbA1c test: three months after my last test and a bit before my 12 month DAFNE Review If I can maintain my current averages for another two months (a moderately big ask), then I'll get an HbA1c in the "Normal" or "Reference" range.

See my other postings on diabetes:

Comments (2)
Anthony Holmes May 4th, 2008 09:07:18 PM

1) DAFNE - Tight Diabetes Control - Three Fives
Frank 5/05/2008 9:56:26 AM

It sounds as if you're doing OK - well done!

You've got me stumped with the secret forest pic -- give me a hint.

2) Finding the Secret Forest
Anthony Holmes 5/05/2008 9:13:48 PM

The "Secret Forest" is near Pollution Control Pond Q.

Now, naturally, that's only a clue if you can work out where Pollution Control Pond Q is.

Since neither web searches nor the Melways reveal where PCP Q is, I'll give a further hint: PCP Q is managed by Melbourne Water and Citilink. The Secret Forest is on the pond's banks, or (arguably) slightly upstream of the pond.

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