Healthcare professionals support patients to manage insulin resistance and/or their type 2 diabetes, by balancing the pros and cons of different approaches with the individual. Reading about the imminent new oral GLP-1 has provoked consideration of this balance. It is important that prior to recommending initiation or titration of expensive medication for diabetes that all other options have been considered.
Diet
Insulin resistance increases greatly in obese patients and those who have large amounts of fat around the waist. Locally, nationally and internationally a low carbohydrate diet has demonstrated notable success in reducing obesity and healthcare professionals have observed that this approach can put type 2 diabetes into drug-free remission. Dr David Unwin's sugar charts (Public Health Collaboration, 2020) are hugely beneficial for practice. Patients can relate to the clear information demonstrating the glucose content of common foods and an approximation of how they may affect blood sugar. Surprised exclamations such as: ‘I didn't realise how much sugar is in rice’ can be heard frequently from patients and staff when viewing laminated charts on display.
Omitting sugar and carbohydrate is not new, and may be a sideways step from the National Institute for Health and Care Excellence recommendations of a ‘balanced diet’ and the age old familiar ‘eat well plate’. Clinicians observe patients with insulin resistance and type 2 diabetes, who when on low carbohydrate diet lose weight, subsequently reduce medication and improve their mental health by enjoying the ability to be more active. Witnessing their newly found confidence when they see their improved blood results is very satisfying. As time goes by the evidence is mounting that this approach with support is maintainable and leads to improved control and potential remission of type 2 diabetes.
Expense
It is the responsibility of the prescriber, when signing repeat prescriptions, that medication is tolerated and adhered to. Add on therapy for diabetes is expensive, for example: the new oral GLP-1 is approximately £78.40 per month. Waste was found as a concern following interviews in a study on ‘deprescribing in chronic disease: perspectives of nurse prescribers’ (Crowe, 2020), with patients often ordering and collecting medication that they did not take, for a variety of reasons, including fear of disappointing their clinician. As a professional deprescribing medication for patients who have lost weight by addressing their lifestyle (weighing up what works for them) and being able to reduce costs for the NHS is satisfying. Unfortunately, deprescribing is not financially beneficial for the pharmaceutical industry or as yet individual clinicians and therefore has little education and publicity.
Side effects
Observing the beautiful garden outside the Royal College of Physicians displaying over 1 000 medicinal plants is a reminder of how many medicines are derived from poisonous plants.
As polypharmacy increases so do side effects and risks of interactions. Patients symptoms may not be disease related, but due to their complex medication regimes. Before considering initiation or titration of medication, it is necessary to ensure that patients are tolerating any current medication and ensure they are aware that modifying lifestyle may be a preferable alternative.
Addressing balance
Respecting different tastes, beliefs and priorities is necessary when helping patients make decisions. A patients' interpretation of a balanced lifestyle can be quite different to their healthcare professional and so understanding the patients' perspective is important but can be challenging. Building trust and continuity of care is necessary and ensuring appropriate timing of intervention is key.
Instead of concentrating on the negativity of restrictions and what is not allowed during lockdown, providing positive advice to reduce risks of complications with COVID-19 would be beneficial for vulnerable patients. Insulin resistance can be completely reversed by changing lifestyle and it may only be one of the below areas that needs attention to reset the balance and improve results:
- Exercise improves insulin sensitivity
- Lose tummy fat
- Stop smoking – tobacco can cause insulin resistance
- Reduce sugar/carbohydrate intake – especially potatoes, rice, bread, pasta
- Eat well – focus on delicious whole, unprocessed foods, nuts and oily fish (mackerel, salmon, sardines)
- Sleep – poor sleep causes insulin resistance so improving sleep quality is important
- Reduce stress
- Intermittent fasting – try to eat within a ten-hour period every day (for example: 8 am to 6 pm and nothing after).
In these challenging times of COVID-19 and risks to patients with insulin resistance and type 2 diabetes, it is important to support our patients to address balance and this may not be always by initiating or titrating up medication.