Dr John Gedney qualified from the University of Nottingham in 1979 and from 1984 worked as a GP in Northumberland with a special interest in mental health, rheumatic diseases and diabetes. Now retired from clinical work he has an ongoing interest in the challenges posed by people being overweight and the pandemic of type 2 diabetes, particularly in the context of the food environment and the evolving science of metabolic syndrome.

Pamela Myles-Hooton worked as an accredited cognitive behavioural therapist for over twenty years and is an honorary fellow of the British Association for Behavioural and Cognitive Psychotherapies (BABCP). She wrote How to Beat Agoraphobia and co-wrote The CBT Handbook. She spent over eleven years training others in delivering evidence-based psychological interventions at the University of Reading, and later worked with NHS Education for Scotland to develop a training programme for mental health staff who help people experiencing anxiety and depression.

Living Well self-help guides use clinically proven techniques to treat long-standing and disabling conditions, both psychological and physical.

Series Editors: Professor Kate Harvey and Emeritus Professor Peter Cooper

Books in the Living Well series

Living Well Through the Menopause

Living Well with Tinnitus

LIVING WELL WITH
TYPE 2 DIABETES

John Gedney, Pamela Myles-Hooton

Copyright

Published by Robinson

ISBN: 978-1-47214-600-7

Copyright © John Gedney and Pamela Myles-Hooton, 2024

The moral right of the author has been asserted.

Illustrations by Liane Payne, unless stated otherwise

Important Note

This book is not intended as a substitute for medical advice or treatment. Any person with a condition requiring medical attention should consult a qualified medical practitioner or suitable therapist.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of the publisher.

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Introduction: about type 2 diabetes

‘I was in my late thirties when I went to see my doctor. I was absolutely exhausted, utterly lacking energy. I didn’t feel ill but neither did I feel well. I’m not sure what I was expecting – everyone says they are tired these days, don’t they? I was convinced I was lacking something. We talked about my steady weight gain since having our daughter Chloe, then aged six. The doctor examined me and then said it was a good idea to do some simple blood tests. He could see that I’d had pregnancy diabetes when I was carrying Chloe, and I was embarrassed to say I’d not followed up the reminders about getting it regularly checked. We agreed it was a good idea to test for that too.’

Suzanne, 47

Suzanne’s tests showed that she was not lacking anything but that she was ‘at risk’ of type 2 diabetes (T2D). A few months later, after losing weight, her test results were back to normal. She later developed type 2 diabetes during a stressful time in her life and we’ll follow some of her journey throughout the book. Her story demonstrates so many of the features of T2D and how they get caught up with the twists and turns of life.

Suzanne was at risk of T2D partly because her mother had the disease and pregnancy had then simply highlighted that additional risk. After the pregnancy came lasting weight gain, eventually tipping her into T2D. On the earlier occasion, when deemed at risk of T2D, then later when she developed the disease, she managed to lose weight and reverse the changes of T2D. By keeping her weight stable, she was then able to continue in remission – free of T2D.

Research suggests that up to 50 per cent of people diagnosed with T2D can put their condition into remission by changing the way they live – especially the way they eat. Even without getting T2D into full-on ‘reverse gear’, similar lifestyle changes can still improve the condition, making better health – and perhaps less medication – within the reach of many more people. It requires a determined mindset and hard work to get back your health, but it can be done, and many have achieved it.

There are three principles that thread their way through this book:

• The first is that you need relevant and up-to-date knowledge to tackle T2D.

• The second is that you will need to find and hold on to your innermost motivation to achieve the changes to help you manage your T2D.

• And the third is – with help – to find those ways of living, especially around eating, that work for you.

This book is about giving you that knowledge and encouraging that determined mindset but also being realistic about the hard work which will be needed long-term to stay well.

A diagnosis of T2D may have come as a surprise or even a shock to you, and is likely to be impacting your daily life. You may sense an impending change in your life or be worried that something bad may happen. Some of your fears may be realistic, but of course human nature is often to imagine the worst, which can make starting to fight back that bit harder – at least to begin with. This book will help you to understand T2D, avoid it if you are at risk and, if you have it, to try to understand why it may have happened to you. We will set out how best to live well with T2D and possibly even ‘reverse’ it. The fact that you have opened the book is an important first step in managing your fears, learning about T2D, and about what you can do to reclaim your life.

Who the book is for

This book is mainly intended for people with T2D, and their families or carers. It is highly relevant to people who are most at risk of being diagnosed with T2D, which would be any near relatives, such as a sibling or a child of an affected person. It is also for anyone in follow-up for a previously raised blood glucose reading, including women who have experienced diabetes in pregnancy.

It may also be of interest to healthcare professionals who deal with T2D, including those who work in mental health services.

T2D is becoming much more common and around half of all people in the world are overweight and/or have conditions which relate to T2D, so we could argue that most people could benefit from thinking about the issues we raise in the book!

Why ‘self-help’ is vital

Self-help is so important in many long-term medical conditions; most gains in health come from what we do for ourselves and with T2D this feels even more vital since we know that:

• As Suzanne demonstrated, T2D can be reversed and put into remission, or substantially improved, by changing the way we eat, and live.

• Equally importantly, T2D can be prevented in much the same way.

• Medical management can, to a degree, reduce the risks from having T2D but does not treat the actual underlying disease, which goes on regardless.

• Standard nutritional advice has made little, if any, difference to the growing number of people with T2D and we need to understand why.

If you have T2D or are at risk of developing it, healthcare will support and help, but what you do to help yourself will ultimately make a far bigger difference – with the biggest gains of all if you can put your T2D into remission.

What’s inside?

First of all, before we look at what’s inside, we should introduce ourselves and explain a bit about who we are and why we have written this book.

John

I qualified in medicine from the University of Nottingham in 1979, before early professional training in both general practice and hospital medicine. During a thirty-four-year career as a GP I developed a special interest in long-term medical conditions, notably in the fields of rheumatology and diabetes, serving on national working groups in both. I was also involved in developing general practice-based mental health service provision.

Through the middle and later stages of my career, diabetes became my main focus; I wanted to know why type 2 diabetes was becoming so much more common, and why we had assumed it to be a milder form of diabetes, when it was clearly not.

People say it’s hard to fix a problem if you don’t know what the problem is, and until the last decade, we could say this applied to type 2 diabetes. Though I am now retired from clinical work, my curiosity and commitment to understanding the disease continue undiminished.

Pam

Originally from Scotland, I am author/co-author of several educational texts, academic publications and self-help books, including The CBT Handbook and How to Beat Agoraphobia. I contributed to Health Education England’s curriculum for low-intensity practitioners working with people with long-term physical health conditions. I sit on the NHS Talking Therapies for Anxiety and Depression Expert Advisory Group.

For over twenty years I worked as a cognitive behavioural therapist, mainly in the NHS. Overlapping with this work, I led the development and delivery of cognitive behavioural therapy training programmes at the University of Reading for eleven years. More recently I worked with NHS Education for Scotland to develop a training programme for mental health staff who help people experiencing anxiety and depression. In 2020, I became one of three directors of Bespoke Mental Health, which provides online training in evidence-based psychological treatments for mental health practitioners and operates as not-for-profit for the NHS and charities.

We will begin with a brief outline of T2D, and the experience of being diagnosed with the condition.

Section I (Chapters 1–4) is all about preparing you for the challenge of T2D, first by helping you to understand just what the disease is all about – and showing how far our thinking has moved on in the last decade. We’ll see why it’s important to become – and stay – physically active, and why good sleep matters in preventing and managing T2D. We will look at how different people approach T2D after being diagnosed, and the value of motivation and an effective mindset in tackling it.

Section II (Chapters 5 and 6) is mainly about food and the way we eat. We’ll be covering the current ‘hot topic’ of reversing T2D and the equally important subject of how best to eat long-term for T2D. Robust scientific evidence is gathering around reversal, but that’s quite new, and we don’t have the experience yet of how best to follow up on reversal and hold the disease in long-term remission. We do, however, have good evidence for a small number of dietary approaches which improve T2D and these will be the focus of what we call ‘eating for the long haul’ – that is, for life.

In Section III (Chapters 7, 8 and 9), we’ll look at the risks of T2D and how to reduce them by being more in control, using knowledge, self-monitoring and self-management to improve T2D. Self-monitoring of blood glucose helps a proportion of people, but we think it could help more, with better understanding and more support from healthcare teams.

Almost everyone should monitor their own blood pressure, and we will make a case too for purposeful monitoring of any problem area – whether it be around eating, or tracking sleep, mood or exercise. Self-monitoring helps us to stay engaged and more in control of our body – and almost certainly helps us to improve our health.

In Chapter 9, we’ll take a look at T2D and pregnancy. Reproduction is nature’s way of passing on the best of us, but with a disease like T2D, some not-so-good things can be passed on too. Both T2D and (the related) pregnancy or gestational diabetes are now the commonest forms of diabetes in pregnancy, reflecting the surge in T2D in younger people all around the world.

It’s beginning to look like genetics is more complex than any of us could have realised. Being at risk of T2D carries not only increased risks to mother and infant during the pregnancy, but also additional and enduring risks to children even well into adult life. Transmission of disease across generations may underpin some of the rapid growth in T2D generally and we’ll try to explain why this is an issue for all adults, not just for pregnant women.

When we look at how the body works, and how T2D develops, we can see that all the systems of the body are involved – things connect. If the brain is involved then the mind is too, and T2D demonstrates just how joined up mind and body really are.

In Section IV (Chapters 10 and 11), we will explore how psychological issues, mental health problems and T2D can interact – and what you can do to help yourself.

We will close, then, with a summary of key points from the book and an update on the onward journeys of our T2D case examples, introduced below and in Chapter 1.

How to use the book

Read the book however you wish, as the chapter titles and short summary notes at the end of each chapter can help you navigate around. However, we would recommend reading Section I first, where we start by getting a feel for T2D and how things work; current science might just challenge some of your thinking about this disease.

Case examples

Our case examples, introduced fully in Chapter 1, will illustrate some of the common experiences and feelings people have at the outset with T2D. Though experiences are real, names and identifying features have, of course, been changed or removed.

We will revisit these people throughout the book. You have briefly met Suzanne, and will soon get to know others such as Mustafa, who developed T2D when working night shifts; Margaret, whose journey started with a visit to her optician; Ted, who had high blood pressure; and Nandita, whose T2D was diagnosed after developing odd sensations in her hands. What they all have in common is T2D and some of their experiences may be relevant to you.

Signposting

The world of T2D is a big one and it overlaps particularly with body weight and nutrition. We have already said that most of the good that gets done is by people themselves, not by professionals and healthcare teams. We’ll put more emphasis, therefore, on exploring behaviours and choices.

And if you want to know more, we will signpost to other materials in the appendices at the end of the book. There are some great sources and inspirational stories out there!

References, terminology, other resources such as diaries, and further reading suggestions can be found at the end of the book.

About T2D

We associate diabetes with the pancreas – where insulin is made – and with too much glucose in the blood, which is the hallmark of diabetes generally. With T2D however, the disease is not caused simply by a lack of insulin (as happens in type 1 diabetes). Indeed, for the most part the body is producing more insulin than usual. ‘Behind the scenes’ of T2D lies a fault in the way the body is storing and using its two main fuels – glucose and fat. This problem involves not just the pancreas but the two main organs of energy control within the body, the brain and liver, and the way insulin itself is working. A better understanding of what has been going wrong with insulin takes us to the very heart of T2D.

Doctors have typically concentrated on lowering blood glucose, and we have long had the tools (medications) to do this. We also know that lowering glucose lowers the risks from T2D – at least up to a point. It is no surprise then that the medical focus has been on glucose itself. But this approach does not address the reason for blood glucose going up in the first place, nor correct other harmful and important changes in the body’s chemistry which also define T2D, and probably even more of its risks.

Addressing these things is where you come in!

Science can now explain much more about how T2D comes about, and although not everything is within our control, some important things are, especially what and how we choose to eat. If we can really change the way we fuel our body, it is possible to improve or restore normal insulin function. And if we can do that we will see weight loss, and more importantly normal blood glucose, and the restoration of health. This is the main treatment of T2D itself.

For sure, being healthy is about more than just food, but we can say that living well with T2D is mainly about eating well for T2D.

There are now around half a billion people with T2D in the world. It affects one in fifteen people and has undergone a fivefold increase over forty years. It is associated with being overweight, but T2D is increasing proportionately faster than are the rates of being overweight or obese – alarming though they are. In Europe and North America, between 5 and 10 per cent of people are affected, and in lower- and middle-income countries the figures are even higher. Between a quarter and a third of all people affected by T2D live in China, where little more than a generation ago the disease was almost unknown.

Wherever you live, you probably know someone with T2D.

We want to help reduce the number of people with T2D, and the number of people who suffer a serious problem as a result of having T2D – starting with you.

1

Introducing type 2 diabetes

Colin, 62, carpenter

Colin has recently been in hospital after a heart attack. He had been surprised at how little it had affected him, and had started to think himself lucky until the hospital doctor told him that he had T2D – and his blood pressure was higher than it should be. He had been feeling low, worrying about possible redundancies at work, and had been sleeping badly for months. He was constantly tired. He and his wife talked a lot about ‘stress’.

Colin was seeing his local healthcare team for follow-up checks and next-step planning. He’d felt thoroughly miserable since leaving hospital – all he could think about were money worries and now, with uncertain future health, he wondered ‘what the point of it all was’. He would later recall that this was an all-time low. His wife had worked very hard to get him to his appointment. She thought his stress and low mood had ‘brought everything on’. She was anxious about the future too.

In the last few decades, fewer people smoking and better, quicker treatment of heart attacks has meant fewer people dying from heart disease. But like the fairground whack-a-mole game, just as you think you are getting one problem down, another pops up in its place!

A significant proportion of people admitted to hospital with a heart attack are found to have one or more features of metabolic syndrome, which include hypertension (high blood pressure) and T2D. As we move through the first section of the book, we’ll see how T2D is not just about too much glucose in the blood but involves a range of changes in metabolism, which impact health much more.

Colin has T2D and he has metabolic syndrome – a term used by doctors and scientists to describe how T2D sits within a wider cluster of related health conditions.

What is diabetes?

Diabetes is short for diabetes mellitus (DM) – a mixture of Greek and Latin words. Diabetes means ‘syphon’ – the movement of fluid or water – because a classic diabetes symptom is peeing a lot. Mellitus means ‘honeyed’ or ‘sweet’ – referring to the characteristic sweetness of the urine in diabetes. In ancient times, physicians really would diagnose diabetes by tasting their patients’ urine (no dipsticks!). To have too much glucose in the urine, a person has too much glucose in the bloodstream, which then spills over into the urine when blood is filtered by the kidneys. So behind some of the typical symptoms of diabetes is an abnormally high level of glucose in the bloodstream – hyperglycaemia is the medical term.

What actually is T2D?

The two most common reasons for persisting hyperglycaemia are type 1 diabetes (T1D) and T2D. In spite of the hyperglycaemia which gives each its name they have less in common than you might imagine!

In the first half of the last century, there was still no official separation of the types of diabetes – though doctors noticed that their older patients tended to carry more weight, and when insulin was introduced in the 1920s, they showed little or no response to the new treatment which was keeping their younger, slimmer patients alive. Later, when it became possible to measure insulin levels in the blood, it was clear that people with T2D did not always lack insulin – indeed many had elevated levels.

T1D and T2D are different and separate conditions

The legacy of calling all instances of raised blood glucose diabetes is that we tend to see them as more alike than they really are. T1D and T2D don’t have the same cause, or behave in the same way, and outcomes – though similar – are not the same. They really are different diseases, which happen to overlap because of hyperglycaemia.

A common question is, ‘I have type 2 diabetes, but am now on insulin – does this mean I now have type 1 diabetes?’ No! T2D is a different disease, whether treated with insulin or not. Using insulin to lower blood glucose says nothing about the underlying nature of the condition. Everyone with T1D uses insulin because they need it to stay alive; insulin is lost quite quickly and permanently – injections replace the missing natural insulin. Until the late stages of the disease, lack of insulin is not the problem in T2D, which develops against a backdrop of higher than usual insulin levels. But although insulin is present, the way that it regulates blood glucose has become defective, a state generally called insulin resistance. In Chapter 2 we will see how this problem plays a key role in bringing about T2D. With T1D, insulin is absent and with T2D, insulin is often present but not working as it should.

Although increasing numbers of young people are being diagnosed with T2D, it is still a disease which is more likely to appear in mid-life and beyond. By contrast, the average age of onset of T1D is around thirteen years. T2D also evolves more slowly, typically taking years or even decades to fully surface. A person with T2D is usually less visibly ill, that is unless you are a ‘Colin’ and suffer a heart attack before you even realised you had T2D. T1D presents with weight loss – often profound – whereas with T2D there is nearly always weight gain.

The conundrum of T2D is that it has always looked mild – indeed people called it ‘mild diabetes’ – but now we can see that it is far from mild. T2D affects older people because the impact of insulin resistance is slow. It is also what makes a person susceptible to high blood pressure, heart attacks, stroke and poor (limb) circulation. They are not so much complications of T2D but part of its very nature.

Around 95 per cent of people with ongoing diabetes have T2D.

Figure 1.1: T1D and T2D overlap - but less than you might think

T1D and T2D look different because they are different.

How does T2D show itself?

T2D is a complex condition that evolves slowly, usually over years. To begin with many people have no symptoms, or changes are so gradual that they are not experienced as abnormal. Eventually most people do experience noticeable symptoms – broadly of two kinds:

Those of hyperglycaemia

• Peeing a lot, thirst, and genital soreness and itching from recurring fungal infections – both sexes; this is glucose ‘overspill’ into the urine.

• Blurred vision – caused by a changing glucose concentration in the eye fluids, which in turn affects focusing. It disappears when glucose levels settle.

And those of the wider effects of T2D

• Tiredness – a real lack of energy affects nearly everyone in T2D; the body has plenty of energy on board but problems with insulin make that energy difficult to use.

• Hunger is common in T2D, and is caused by disturbances in the hormones – including insulin – which regulate appetite.

• Weight gain is almost ever-present in T2D, and the gain is usually long-term, over years.

Surprisingly perhaps, slimmer people can also develop T2D – though their weight gain is typically less.

Hyperglycaemia is usually less pronounced in T2D than in T1D, so those connected ‘classical’ diabetes symptoms may be mild, barely noticeable or even absent.

T2D can come to attention at any point, and detected early it’s often when a person is having a check-up for another problem such as high blood pressure. Following up previous borderline glucose values, routine medical checks, such as those related to employment or insurance issues, can also reveal early T2D.

Suggestive symptoms or the investigation of a problem, like Colin’s heart attack, may also reveal underlying T2D.

Here’s how T2D came into the lives of some of the people we know:

Ted, 78, retired

Ted was seeing the nurse for a review of his blood pressure and mentioned that he had been peeing a bit more, getting up two or three times at night rather than his usual once. He had put it down to age or his prostate. He felt fine otherwise. It had not crossed his mind that he could have diabetes. Diagnosis of T2D over the age of seventy-five does not pose the same problems and risks as it would if it appeared earlier in life. If managed sensibly, it may impact little on quality or length of life.

T2D coming on later in life can feel ‘mild’.

Cassie, 56, estate agent

Cassie had been progressively unwell for several months when she was diagnosed with T2D. Something of a lifelong exerciser, with a lean athletic build, she had been running and swimming regularly until a dramatic loss of energy brought her to a standstill. She was passing urine much more than usual and suffered repeated infections. She was no one’s idea of a candidate for T2D and the diagnosis was a big shock to those that knew her and to Cassie herself.

T2D can occur in slim, previously fit people.

Suzanne, 47, secretary

Suzanne visited her doctor at the age of thirty-eight reporting tiredness and mild diarrhoea. She had slowly gained weight following the birth of her daughter six years before. Her mum had T2D. Her blood tests showed mildly abnormal liver function and that she herself was at risk of T2D.

After a few months of substantial weight loss, she no longer felt tired, and her blood tests returned to normal. Planned check-ups for one reason or another did not happen and after two years, the family moved away because of her husband’s job.

The house move did not go especially well and Suzanne felt isolated, using alcohol to help mask her anxiety and to sleep. Later, her symptoms and weight gain returned, and she was diagnosed with T2D five years after the first borderline test results. She regretted not seeking further help in the interim but just lacked the motivation, saying she had ‘put her head in the sand’.

We will see later (Chapter 9) how family issues motivated Suzanne to enable her to regain control of her health.

T2D can develop when life gets in the way of us looking after ourselves.

Mustafa, 54, factory worker

Mustafa, originally from Iraq, works in a car factory in the UK. He developed raised blood pressure in his forties and was in annual medical review. Nearing fifty, he began to work a rotating shift pattern at work. Soon after, he began to feel excessively tired, experiencing both weight gain and difficulty controlling his blood pressure. His regular checks revealed that he had developed T2D.

Within five years of being diagnosed he had needed insulin treatment to achieve reasonable blood glucose control, along with multiple medications for his blood pressure.

We will come back to Mustafa in Chapter 4 when we look at the impact of disturbed sleep on how the body works, and how this might worsen a person’s T2D journey. We will also use his experience of navigating Ramadan, on insulin, to illustrate the value of self-monitoring of blood glucose (Chapter 8).

Disturbed sleep, whatever its cause, can affect metabolism and potentially worsen or even cause T2D.

Margaret, 62, carer

Apart from developing what she called a ‘weak bladder’, Margaret felt in good health. But then she developed blurred vision. Her optician was unable to explain her symptoms but her practice nurse found her blood pressure to be elevated. Routine blood tests subsequently revealed T2D.

Margaret had a positive disposition and, whilst disappointed by the news, she was not unduly worried. Her elderly aunt had T2D and had been well enough so far, she reasoned. Margaret felt herself fortunate to be diagnosed before any serious problem had developed. She initially managed dietary reversal of her T2D but struggled to hold on to it, and we’ll look at her efforts in Chapters 5 and 6. Margaret’s vision and her ‘weak bladder’ returned to normal when her glucose level improved.

Blurred vision may be explained not by an eye problem, but by a change in a person’s blood glucose level.

Benjamin, 55, air traffic controller

Regular work medicals had shown moderate weight gain over a decade before Benjamin was diagnosed with raised blood pressure (hypertension). At the age of fifty-one, he was diagnosed with T2D with no suggestive symptoms other than getting out of bed to pee more often.

Benjamin was born of Jamaican parents, neither of whom had T2D, though both had hypertension; T2D is significantly more common in the Black Caribbean population. He worked in air traffic control, and was anxious about the impact of diabetes on his job – particularly as he would not be allowed to work as a controller if on insulin.

He lost a reasonable amount of weight and had fairly good control of his blood glucose on oral medication. His main ongoing problem was a difficulty adjusting psychologically to his T2D, and ongoing worry about job security.

In some people the impact of T2D can be more psychological.

Nandita, 60, retired teacher

Nandita, whose family were from India, was born in the UK. She was a music teacher but retired early due to neuropathy (pains and loss of feeling in her hands and feet) which interfered with her work. She had always been an anxious person, and this became a problem in itself after she developed T2D with its complications.

Persistent tingling in her hands had taken her to see a doctor, not long after the age of fifty. Slowly rising weight, urinary symptoms and fatigue suggested that Nandita’s T2D had probably been smouldering for a decade, and within five years of diagnosis, she was on insulin. T2D and mental health problems can be so bound up that it’s hard to see, looking back, which is the ‘chicken’ and which is the ‘egg’ – and this was the case with Nandita.

Enduring anxiety drives the stress hormone system of the body which in turn can contribute to the onset and course of T2D.

Colin

We have already introduced Colin. He suffered the double whammy of experiencing a heart attack and the diagnosis of T2D at the same time. He had been feeling low for about a year and getting physically unwell had put him in a very bad place. It took a long time for him to adjust and eventually get on top of his health problems. Parts of his journey appear throughout the book.

T2D can smoulder on in the background before coming to light through a major complication.

Here are two people without T2D but with a relevant associated problem:

Chloe, 15, school student

Chloe is Suzanne’s daughter. She has not been diagnosed with T2D, but her strong family history (mother and grandmother have T2D) puts her at risk. She herself became overweight in her teens, and was diagnosed with PCOS – polycystic ovary syndrome, which can affect menstrual periods, fertility and body weight, and can cause acne, which affected Chloe quite badly. PCOS is considered to be part of the metabolic syndrome mentioned earlier, and so is linked to T2D. We will explain more about the link and what happened with Chloe in Chapter 9.

We can be at risk of T2D through the complexity of inheritance.

Alan, 42, police officer

Alan, a police inspector, found his weight rising slowly in spite of being active, including jogging up to twenty miles a week. His annual medical check at work showed his blood pressure to be up a little, and his liver function blood test was mildly abnormal. He was found to have a fatty liver (NAFLD – non-alcoholic fatty liver disease), which is strongly connected to T2D.

Alan believed that exercise would keep him fit and healthy, regardless of his dietary and social habits (he liked his beer!), but his rising weight and his liver problem challenged that belief.

We can be at risk of T2D if we follow our beliefs and ignore the facts.

Pause for thought: Your story with T2D

How was your T2D diagnosed? Are there similarities with any of our cases? What have you done so far to help tackle the problem? How successful has that been? Make a note of ongoing problems and, as you work your way through the book, check the advice to see how you might try to tackle them.

Measuring blood glucose, and making sense of HbA1c

Hyperglycaemia – Other than defining diabetes and causing its most recognisable symptoms, a raised blood glucose level has also been our benchmark for judging the severity of T2D and, historically, how to manage it. It’s helpful, therefore, to understand how blood glucose is measured and to get a feel for what the numbers mean. You will hopefully get to know your way around glucose testing as we go through the book, and if you are new to T2D, your healthcare team will probably have given you a good start. But we know that even when people have had T2D for a long time, the tests can still confuse, and some basic revision might be useful – especially on HbA1c (more on that later).

Glucose – There are two main ways to assess blood glucose. The first is to simply measure it! If John were to test a sample of Pam’s blood at, say 9.45 a.m., he would discover her glucose reading at the time the test was taken. When interpreting the result he would need to know that she ate some porridge and toast at 8 a.m. Blood glucose is an ‘in-the-moment’ test and to interpret it we need more information, especially the time and content of the last meal. To know what the reading is later in the day, after the next meal or after a walk, etc., would need multiple tests.

Glucose, like most chemicals in the body, is a variable – it changes, and what’s more, it changes continuously, so any test result is a snapshot from the bigger, moving picture of what’s actually happening. The same applies to most other tests or measurements. For example, cholesterol, weight, kidney function and blood pressure all change by the moment, and throughout a day. Some things don’t change much during a twenty-four-hour period, or the variation matters less. The variation with blood glucose, however, matters a lot; knowing its level on waking (when it’s usually lowest) and two hours after eating (when at its highest) tells us how T2D is doing. Multiple tests were once the only way of gauging T2D. Then along came the second way of assessing blood glucose, which is HbA1c.

HbA1c – This test transformed the monitoring of T2D when it came into widespread use in the 1980s. Measuring HbA1c gives a reliable estimation of average blood glucose and is the test most often used to assess or even to diagnose T2D. For most people, most of the time, it is the only test they and their healthcare teams use to monitor T2D. Everyone gets used to HbA1c (eventually), but to begin with it can be hard to grasp what it’s measuring and what it means. The abbreviation stands for haemoglobin A1c, also sometimes called glycated haemoglobin. Glycation is the word for the chemical attachment of a sugar – in this case glucose, to (usually) a protein – and here it’s haemoglobin.

Haemoglobin (Hb) is the important oxygen-carrying protein in all of our red blood cells. We measure Hb to assess the health of the blood generally – a normal Hb level tells you that you are not anaemic.

Measuring glycated Hb – HbA1c – in the laboratory gives an indication of how much glucose has been in contact with the red blood cell (and the haemoglobin inside it) during the lifespan of the cell, which is roughly three or four months. The more glucose in the blood, the more it attaches to the Hb, and the higher the HbA1c reading becomes. The HbA1c level therefore reflects indirectly, but accurately, the average level of glucose in the bloodstream over a three- to four-month period.

Figure 1.2: The making of haemoglobin A1c (HbA1c)

In summary, the two tests of blood glucose in regular use are glucose itself – a snapshot test giving a direct measure of the glucose level at a specific time – and HbA1c, an indirect reflection of average blood glucose over the previous three months – with the variability of individual glucose readings smoothed out.

Here’s how these tests can be used when answering the key questions:

Do I have T2D? – Both blood glucose and HbA1c can be used for diagnosing T2D. A blood glucose test would need to be performed in the morning after an overnight fast. Doing both tests is common practice and helps make the diagnosis more secure, though neither is infallible.

How’s my blood glucose doing? – Either just in general, or for example since making a change such as cutting back on food after Christmas. These ‘How are things going generally?’ questions need a HbA1c test. A single – or even a few – blood glucose readings would not be enough. HbA1c checked every 4–6 months, or 3–4 months after making a lifestyle/diet change is a standard and reliable way of tracking blood glucose indirectly in T2D.

What happens to my blood glucose when I eat a loaded bagel? – This is a different, more ‘here-and-now’ sort of question. To answer this, you would want to measure your blood glucose before and after eating the bagel. HbA1c would not help you here – the impact of the bagel, even several bagels, on your HbA1c would be too small and feedback too slow to be useful.

People who self-monitor (see Chapter 8) use HbA1c to track their T2D path overall, and use blood glucose readings to assess the day-to-day impact of treatments, particularly insulin, and of illness. Assessing the impact of lifestyle changes – taking up a new exercise, changing a shift-work pattern or the impact of bagels! – can be done over a few days tracking blood glucose, and over weeks or months with HbA1c.

Don’t worry if HbA1c confuses you. Many people struggle with it, but it is the main test in assessing T2D and it’s worth spending time on. A link to an audio-visual explanation of HbA1c is in Appendix 2: Terminology (for Chapter 1). There’s more on the subject in Chapter 8 too.

The units for expressing blood glucose and HbA1c

Apologies, this is dull but might be useful!

Blood glucose is expressed in mmol/L (millimoles per litre) – this is the modern standard, used for example in Canada, the UK, China, Australasia and half of Europe.

Or mg/dL (milligrams per decilitre), used in the US, South America, India/southern Asia and the other half of Europe!

HbA1c can be expressed in mmol/mol (millimoles per mole). Again, the modern standard and generally used where glucose is expressed in mmol/L units.

Or as a percentage (the proportion of Hb that has glucose attached). Mainly used in the US.

Confusingly, some countries use old units for glucose and newer units for HbA1c, or even both at the same time!

The numbers themselves (old and new units) relating to a diagnosis of T2D

If you have been diagnosed with T2D, you will have had a fasting glucose reading of at least 7mmol/L (126mg/dL). Normal levels are usually around 4–6mmol/L (72–108mg/dL). If you have been diagnosed with T2D following a HbA1c test, the result will have been 48mmol/mol (6.5%) or higher, ideally done more than once.

You only need to become familiar with the units in your own country – and remember that glucose and HbA1c, while connected, are not the same thing; their units are different and the range of numbers is different. Be mindful of the unit differences if reading guidance or articles from other countries online.

Pause for thought

Can you remember your HbA1c reading at diagnosis? How has it changed since?

Here are the first HbA1c readings for some of our case examples:

HbA1c – mmol/mol (%)

Colin

64 (8.0%)

Margaret

60 (7.6%)

Suzanne

52 (6.9%)

Cassie

104 (11.7%)

Ted

56 (7.3%)

Mustafa

50 (6.7%)

Benjamin

55 (7.2%)

Nandita

60 (7.6%)

They all had mild symptoms except Cassie, who was really very unwell; a HbA1c of 104 (11.7%) meant that her average blood glucose would have been around three times the normal!

Colin suffered a heart attack before he knew he had T2D, so you might be surprised that his HbA1c was only 64 (8%). It’s still worth bearing in mind that, although this sounds like a modest elevation of HbA1c, it correlates with an average blood glucose which is twice normal.

In Chapter 8 we’ll look more at how the values of blood glucose and HbA1c connect with each other.

Figure 1.3: What on earth has happened with T2D?

Though based on UK data, the graph in Figure 1.3 would look similar in most countries. The slope might be either a little flatter or steeper, or be a year or two in front or behind, but it would still be there.

The rise in T2D since the 1980s is unprecedented for a non-infectious disease. T1D has increased a little during this period, but the vast majority of the rise in numbers has been from T2D. We have become so used to the reported numbers about T2D (and rising obesity) that it can feel that we are becoming resistant to an appropriate, more urgent response.

Many people, including doctors, feel intuitively that we now ‘overindulge’ and don’t take good care of ourselves – that we ourselves are to blame. However, modern lifestyles are complex and challenging, and the food environment clearly makes staying healthy difficult. One of the main messages in this book, we hope, is that we have not been in full control of our food choices in particular, which have been driven during this period by a combination of politics, medicine and the food industry. T2D is most definitely our problem, but not, it seems, necessarily our fault.

Something happened around 1980, at least somewhere around that year. We don’t mean just that hair got shorter and popular music became ‘electronic’ – our species started to physically change. We can see that from our T2D graph. Body weight was changing by 1980, though it might have taken another decade for alarm bells to sound. Look at archive photographs, maybe your own, and compare people of the 1970s with those in 2020. In less than two generations – what happened?

Figure 1.4: Rising weight

All countries show rises in T2D and weight in the last forty years or so, but the variation is wide. Some have seen a modest increase in average weight but a big rise in T2D, and others the opposite – a bigger rise in weight and a smaller rise in T2D.

Big variations between weight and T2D growth around the world suggest that although being overweight links with T2D, it cannot be a direct cause; in any event, at least 15 per cent of people with T2D are lean like Cassie. There are also many very obese people who do not have – and probably will never get – T2D.

Weight gain on its own cannot explain the global pandemic of T2D

We now know that changes in weight and T2D in populations are seeded in the same soil, but they are not the same plant – and their paths are growing apart. Some of us are susceptible to becoming overweight and some are destined to be at risk from T2D. What drives becoming overweight can drive T2D too, but neither is inevitable, if we can find the safe nutritional path. This is good news – it gives us something to work on, as we cannot change our genes!

Overall, about one in three people in the world is overweight (BMI >25), but in some countries one in three people, or even more, is actually obese (BMI>30). BMI (body mass index) is explained in Appendix 2: Terminology.

People just about everywhere are getting heavier on average – we’ve all noticed how clothing manufacturers have adapted their sizes – and, worryingly, children are quickly catching up. According to the World Health Organization (WHO), worldwide more than one in five children and young people aged between five and nineteen are overweight. In some countries, such as the US and the UK, around one in five children are actually classed as obese. Even more concerning is that these figures are still rising.

Rising weight in children should be a major wake-up call for everyone. Children are programmed to grow, mainly by lengthening rather than fattening, and overweight children often turn into overweight adults, with all of the consequences of that. The rise in T2D will just keep accelerating if the current childhood obesity pandemic is not addressed.

There are more people now with too much energy stored in their bodies than too little. Both are forms of malnutrition.

Liver disease – the rise and rise of NAFLD

Non-alcoholic fatty liver disease, or NAFLD (most folk say ‘naff-led’) was on very few radars until about 1980. A liver disease, unconnected with either alcohol or infection, emerged after doctors started to see increasing numbers of abnormal liver function blood tests – up to around a quarter of routine tests during the 1990s.

Liver scans of those with abnormal tests nearly always showed a single abnormality – the presence of excess fat. Initially regarded as a harmless manifestation of fat generally, over time we started to see inflammation of the liver, even cirrhosis (scarring of the liver caused by long-term liver damage), as with alcohol. It was most definitely not harmless. We then learned that NAFLD was more common in people with T2D, and people affected by NAFLD were more prone to the same artery diseases as people with T2D. As you will see shortly, excess liver fat is one of the clearest markers of metabolism under stress. Excess liver fat is present in T2D, and both NAFLD and T2D get better if we can eat in a way that helps to clear that fat.

Of our cases, Suzanne, Cassie and Colin all had abnormal liver tests, which became normal when their diets were changed. A diagnosis of ‘fatty liver’ (as with Alan) means that your liver is making or storing (or both) too much fat, and your body overall is storing too much energy. Excess liver fat impedes the action of insulin – a key step in how T2D starts (see the next chapter).

NAFLD has become the most common liver disease globally, and appeared at roughly the same time as the escalations in obesity and T2D around 1980. Science can now better explain just how connected these things are.

Insulin resistance and weight gain

This expanding family of conditions also includes high blood pressure and high blood triglyceride (fat) levels, both of which are seen in T2D. It is called metabolic syndrome – metabolic meaning to do with metabolism or energy, and syndrome meaning things which occur together. Metabolic syndrome conditions share the common thread of insulin resistance. The simplest visible clue to its presence is fat around the tummy, which can signal fat inside the abdomen or, worse, inside organs like the liver.

When we gain weight, accumulated fat is mainly generalised – spread around the outside of the body under the skin (subcutaneous fat). You can see it and you can feel it! This is the normal and healthy way to store spare energy. Excess fat in organs like the liver is not normal or healthy, and is a major contributor to insulin resistance, and to diseases like T2D.

Nowadays, it’s said that on average adults are gaining half a kilogram (just over one pound) every year from the age of twenty onwards. It seems likely that the weight we gain as an individual over a period of years contributes to our risk of getting T2D, especially if we have the ‘wrong’ genes. If you have gained at this rate or more and do not have T2D, it might still show up in the future, or you may be fortunate and are not at risk. If you have good fat storage capacity under the skin, little liver fat and are not susceptible to T2D, you could gain, in theory, a huge amount of weight and stay healthy – think of a sumo wrestler!

To date, we don’t have any easy way of knowing our safe fat storage capacity, nor our true genetic predisposition for T2D, so avoiding weight gain is the safe option.

Table 1.1: Previous weight gains over an estimated timescale of our case examples at the time they were diagnosed (TBW = total body weight)

Their actual weight gains were fairly similar apart from Cassie’s, although her percentage weight gain was similar. BMI increases of 3–5 were seen across all cases. It’s worth noting that Cassie’s weight gain was the smallest, occurred over the shortest time, and she was the most unwell.

EXERCISE

Have you gained weight? If so, how much, and over what timescale?

See if you can pull together a sense of how your weight might have changed over the years. What was your recollection of your weight aged around twenty? Then go up by the decades, using life events, like weddings, births or big holidays (or look at photos) to jog your memory.

Gaining 10–15 per cent of your total body weight, or 10–15kg (20–30lb+ or more) – which can be more than 15 per cent – is quite significant. If you have T2D, a weight loss of the same may be enough to get you started on the road to recovery (see Chapter 5).

Final thoughts on the 1980s

Changes in eating patterns across many countries started in the 1970s when concerns around cholesterol and dietary fat started to make their impact. Comprehensive dietary guidelines – a new departure for governments – appeared in the US in 1977, and in Europe a few years later. This nutritional advice almost certainly accelerated the reduction in dietary fat, which was already under way, with a consequent increase in average carbohydrate intake. Many experts believe that further rises in weight and T2D were linked to these dietary changes, with slowly rising insulin levels being the main driver. The 1980s brought rising weight, T2D, NAFLD and metabolic syndrome.

Before we leave this opening chapter, we want to say a little more about the experience of T2D and what we believe most people need to tackle the disease. We will do that with Cassie, Margaret and Colin, comparing and contrasting their reactions and how they started out.

Cassie

Cassie was super fit and a keen runner for twenty years. At the age of fifty-three, she began to feel unusually tired and running became hard work. She started to get irritating infections and soreness in the skin around her toenails after running. She began to pee a lot and, thinking she had cystitis, made several unproductive visits to the pharmacist. Her energy finally ‘switched off’ and she had to stop running. She had never been ‘properly’ ill, so just what was wrong with her? Cancer was on her mind.

What was wrong with her was that she had T2D with a HbA1c of 104mmol/mol or 11.7% (normal <42/6.0%), and her blood glucose level was three times its normal value. There were problems too with her liver blood tests and blood pressure.

Cassie was dumbfounded by the diagnosis of T2D which had not crossed her mind for a moment. How could this have happened to someone as fit as she had been? She felt sad for what had happened to the body she thought she had looked after so well, now broken seemingly for good.

She felt angry at the world, including her friends, some of whom smoked or drank to excess. She thought to herself, Why me? After some very difficult early days, Cassie read that it might be possible to reverse T2D and maybe get her life back again. The start of her fightback was simply that knowledge – it triggered her determination to find a way back to health. Those who knew her would say, ‘If anyone can do it, Cassie can.’ The determination which drove her to run would now be harnessed to making her well again.

Margaret

Margaret was surprised and disappointed to be diagnosed with T2D, but in truth not shocked. She had always been in good health, but her work as a carer meant that she had seen many people with T2D, and she had an elderly aunt with the disease who seemed to manage well. It felt to her that it was one of those things that people got – a person was lucky not to have it at her age! She knew that her weight needed to be tackled and if she had to take medication then so be it. People would help, and she would do as the doctor and nurse advised.

Margaret was the hub of her family, and did so much for other people that she had rarely thought of doing things for herself. The nurse advising her about eating well and looking after herself was the first time she had really thought about her health since she was last pregnant over thirty years before! Margaret’s best friend had nagged her constantly to go to an exercise class with her at the local leisure centre, and she’d always said she hadn’t the time, but maybe she should make time now. It’s never too late to get a bit fitter and, after all, she was only sixty-two. She wanted to stay fit for her grandchildren and needed to work for a few more years for the family finances.

Margaret had a sunny disposition which gave no room for glum thoughts, and this would prove invaluable to her in the months and years ahead. She would do well with her T2D but not without some twists and turns, which started not long after she was diagnosed when, sadly, her aunt had a stroke and needed to go into care.

Colin

Colin had such a difficult start to T2D, diagnosed in the immediate aftermath of a heart attack. At the time, it had felt to him like rubbing salt into a wound. It was only much later when he understood that his heart attack had not caused any serious or lasting damage and life had started to look up, that he realised that maybe the heart problem had been a blessing in disguise; he reasoned that it gave him the chance to get control of his T2D before something worse happened.

At the time he was diagnosed, Colin had been depressed for months. His life had been on hold for some time, a redundancy threatened, and he could see no way at his age that he would be able to find another job that paid a decent wage. He had lost interest in everything, rarely went out and was seeing less of his friends. His wife tried hard to galvanise him, but to no avail. If he lost his job, he felt that life would not be worth living.

Colin’s depression had taken over his life. The heart attack and T2D together had pushed him even lower, if that were possible. He simply could not take it all in. He had lost all his drive. His wife had to work very hard to get him to see his doctor.

Colin could not engage with his new physical health problems – that would have to be done by his wife and his healthcare team. He received psychological help for his depression, and in time was able to take over control of his T2D, which he came to understand also helped, in turn, his heart and his mood.

The toolkit

Every job has its toolkit, and looking after T2D is no exception. Now that you have a little knowledge – and there is much to come – you can start to think about what you need to know or do, and share that with a partner or friend and your nurse or doctor. Some of us can do lots for ourselves and some of us need more help, but that’s OK and we can all get to the same place eventually. Here are our ideas of what might be in a T2D toolkit, and you can think of your own additions.

Knowledge – you have opened this book and there are many other ways to get knowledge that we’ll signpost for you. Knowledge helps us to understand things, to predict or answer our questions, and can focus our whole approach and trigger us into action. It is important to know that you can, with guidance, put T2D into remission by changing the way you eat, and that medical treatment can help too, though that can’t get rid of the T2D itself. Knowledge also helps you to keep a sense of perspective – this is a serious disease but there are worse, and you can live well with it.

People help – those attempting to reverse and hold T2D in remission have emphasised the importance of ongoing support from people around them: their healthcare team and, especially, their friends and family. T2D can be a complex experience and your care team will ideally have a diabetes-trained professional who can provide up-to-date technical care but also personal continuity of care. Working with professionals who come to know you as a person enables the shared decision-making which is the heart of good care.

Taking control – ideally with a long-term health condition, try to be in charge; what you do yourself will have much more impact than things that medical people do. Believe that. Don’t be afraid to experiment – safely. Be guided by what you read but also by your healthcare team. T2D is impacted differently by different approaches in different people; this is especially true for how you eat. Go with what works rather than what should work!

Persistence – keep going! Even if you do perfect self-help, receive perfect healthcare and hit the perfect dietary notes with T2D, it can take a long time to get better. It took Cassie almost a year to feel anywhere near normal, and that was just the beginning. Staying well is a lifelong task but doable. The rewards are definitely worth the effort!

Mindset – is something that could describe us, or part of us, as we can have more than one. It’s about attitude and can determine how we approach something and our disposition to act (or not). Being open-minded and wanting to learn is one kind of mindset. Determination and wanting to stay in control of your health are others, and all are really helpful when dealing with T2D.

Motivation − underpinning a determined mindset is motivation, one of the cornerstones of self-help. It’s fundamentally how we encourage ourselves to achieve things – to make changes like living healthily. In T2D, lifestyle changes can feel tough, and tougher still to maintain. At times, even the most determined mindset can need refuelling. A person’s deepest innermost motivation can provide that fuel. Margaret, for example, felt motivated to stay as healthy as possible, to see her grandchildren grow up.

Pause for thought

If you have recently been diagnosed with T2D, what would you like to happen next (other than a magic spell to remove it!)? What motivates you to change? What else might you need in your toolkit?

Mental health – it can be tricky, if not downright impossible, to manage T2D well with a significant mental health issue hovering. Mental health problems nearly always need to be tackled first, while ‘holding’ T2D as safely as possible, which is what happened with Colin. They are both common and will often overlap. The challenge of managing them both will be looked at later in the book. Our minds are intertwined with our bodies so it is not possible to receive a life-changing diagnosis without there being an emotional reaction.

This does not mean that you also now have a diagnosis of a mental health problem, but it is normal to feel a range of emotions – from sadness, anger and anxiety to difficulty accepting the diagnosis. Depression and anxiety are common in people with T2D and should not be ignored. There may be a sense of grief about aspects of life that seem lost. Typical thoughts can be: ‘It’s not fair.’ ‘Why do bad things always happen to me?’ ‘My life can never be as good again.’ ‘It’s all my fault.’ ‘I should have been able to stop this from happening’, etc. These experiences are completely normal. In Chapters 10 and 11, we will consider ways of looking after your mental wellbeing when you are adjusting to the diagnosis and also for along the way when things don’t go to plan, and how to pick yourself up again. We’ll look at ways you can help yourself and also ways of accessing help if needed.

Pause for thought

What was the main emotion you felt when you were diagnosed with T2D? What thoughts went through your mind? Do you still experience the same emotions and thoughts? If not, how have they changed?

Introducing FAST

When a person fasts, they stop eating for a certain period of time. Fasting is generally a healthy thing to do and can be very helpful in T2D; we are going to talk about fasting in the food chapters, 5 and 6. We would like to introduce you now to another kind of fast – one using each letter of the word to make a T2D health check reminder:

FAST stands for Food, Activity, Sleep, Tension. By activity we also mean exercise, and by tension we mean persisting stress or worry of any kind. We judged FAST to be easier and more useful than FESS!

You have four prongs on your weapon or, if you prefer, four routes of attack to hit back at T2D: eating as well as you can; being as active as possible; getting your best sleep; dealing with your stresses and tensions to the best of your ability. It’s likely that the cause of your T2D lies within these areas – it might be one or more – so addressing them all gives you the best chance of putting your T2D right, or at least of making things a good deal better.

Though we will refer to F-A-S-T throughout the book, the F chapters are 5 and 6, the A chapter is 3, the S chapter is 4, and the T chapters are 10 and 11. You can think about FAST at every annual or anniversary T2D check-up or every clinic check with your diabetes healthcare team; once a month, every week or even every day, just in your own way! Use it as you go, or when a problem arises, or when managing T2D gets tough, which happens.

It’s a quick and easy reminder that four things matter with T2D – not just one. You can think about FAST as often or as seldom as you like – or use something similar of your own creation – whatever works for you.

Key points from Chapter 1

• T2D comes on slowly, possibly over years, and presents in a variety of ways. Most people don’t feel especially ill early on.

• An elevated blood glucose level (hyperglycaemia) is only a part of T2D.

• A diagnosis of T2D can be based on a raised glucose (fasting blood sample) or raised HbA1c test. The tests are related but not the same.

• T2D is significantly different to T1D and are not connected in the same person – you don’t get both!

• Weight gain and insulin resistance are the hallmarks of T2D.

• Some 15 per cent or more of people with T2D are of normal weight (lean).

• Average weight and T2D have risen dramatically during the last forty years or so.

• T2D is part of a metabolic syndrome of related conditions, which also includes fatty liver disease (NAFLD) and high blood pressure (hypertension).

• T2D is not ‘mild’ diabetes.

• A diagnosis of T2D can provoke a wide variety of emotional, but mainly normal, responses.

• FAST is a reminder to think widely about the causes of T2D, and the ways to address it.