HomeAnswersEndocrinologytype 2 diabetes mellitusMy 70-year-old father is a diabetic. Despite the treatment, his sugar levels are not coming down. Please suggest.

How to manage type 2 diabetes?

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

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Published At October 17, 2023
Reviewed AtOctober 17, 2023

Patient's Query

Hello doctor,

My father is 70 years old and has had diabetes type 2 for around 20 years, but I guess now he officially turned to diabetes type 1 because his body is not secreting insulin anymore.

The Problem:

Recently we have been unable to control his blood sugar, so his doctor suggested increasing his insulin dosage, without further investigation into the causes of why his blood sugar is increasing and why we need to increase the insulin dosage. To be straightforward, we need a 'Human' first and a doctor second, who can listen carefully to my father's case, check his medical history, and his eating routine, and suggest a good lifestyle or correct insulin dosages. I have searched a lot on the internet and found out that you are the best. If you think it is possible, we need you to be my father's diabetes doctor and follow his case. We are ready to send you whatever information you need. I hope that you can offer us the help we need. I am attaching now the following:

1. The medications that my father currently takes.

2. His last blood test report.

3. The insulin shots that he takes.

About his insulin dosages:

1. NovoRapid Flexpen: he used to take 10 points before lunch, now the doctor increased it to 14 points. (Photo attached)

2. Ryzodeg: 19 points before breakfast and 15 points before dinner (before the doctor decided to increase the dosage, it was 15 points before breakfast and 15 points before dinner )

Other medications:

1. Vascor- for cholesterol

2. Micardis- for blood pressure

3. Aspirin protects 100 mg- to dilute the blood.

I would need your suggestions for the following:

1. Why is the blood sugar spiking up to 250-300, two hours after breakfast, although his breakfast is composed of things like:

  • Cauliflower.

  • Zucchini.

  • Egg.

  • Mozzarella.

  • Corn bread.

  • Yogurt.

  • Sesame

2. Can you recommend a book, with clear recipes for diabetes 1 patients? Or a known diet that he can follow?

As I expressed earlier, we are ready to follow up with you for as much as needed, as long as you give us clear directions that will help my father, and hopefully, lower his insulin shots. Kindly give your suggestions.

Thank you.

Answered by Dr. Zulfiqar Ahmed

Hello,

Welcome to icliniq.com.

I have read your query and understand your concern. I will try my best to provide you with the best of the available treatment. I have seen his medications and the test reports (attachments removed to protect the patient's identity) you have sent me. His sugars are really up and it is for months it seems as if his HBA1c is over 10. Target HBA1c for him should be near seven. Diabetes has many complications so it is not just to bring down the numbers but to monitor and treat complications associated with diabetes Check his eyes for retinopathy by an eye doctor at least it should be baseline and then at least yearly. Kidneys should be monitored at baseline with urine albumin creatinine ratio which is a urine test. Check his feet for any ulcers wounds or callous sensations which can decrease diabetes and can later lead to diabetic foot. At least an ECG (Electrocardiogram) should be done and depending on his symptoms other tests may be needed to rule out any cardiovascular issues which may come with long-term diabetes with his age. Does he have any chest discomfort, breathing issues, or palpitations? How is his lifestyle? Is he active in his life? How is his daily routine from morning to evening? What he eats and likes to eat from breakfast to dinner? By knowing these I will be in a better position to know him and accordingly suggest lifestyle modifications to control his diabetes. Lifestyle is much more important than the medications only. Lifestyle modifications are the best treatment of diabetes. Generally, I suggest the following things but we can modify it if I know him by his daily routine.

  1. Low carbohydrate diet and no added sugar.

  2. No sugary juices.

  3. No bread, rice, pasta, and potatoes. If you cannot stop, at least take as little as possible. More vegetables, salads, and fibers. Fruits only as a sweet dish.

  4. Do not take mangoes, grapes, and bananas. Apple not more than one piece. Strawberries and other berries are fine along with peaches, apricots, and small amounts of plums. Intermittent fasting will also help you control your diabetes.

  5. You can fast for 16 hours like taking your dinner at 7 pm and not eating anything after that then the next day you can take breakfast at 11 am. During fasting just drink water and green tea without sugar. You can extend fasting to 24 hours then 36 hours as your body adapts.

  6. You can do fasting two times a week or as you feel comfortable it will control your sugar. Drink more water at least 0.6 gallons a day. Sleep well at least six to seven hours a day and the best time to sleep is from 9:30 to 10 pm because during this time a sleep hormone melatonin is released which gives the best sleep.

  7. Exercise at least walk 45 minutes daily or above 7000 steps. The more he practices these things the better will be his control. Check his sugar frequently at least after fasting sugar and after eating.

  8. Anything you want to add to your meals first time check sugar before taking it and then after two hours of eating to see how much it increases your sugar. Anything which increases sugar 20 to 30 mmHg is fine. And he can eat it frequently but if it increases sugar over 30 to 40 mmHg take it less frequently. Your fasting target should be 90 to130 mmHg, two hours after eating 150 to160 mmHg, and HBA1c should be less than 7.

    Coming to your questions: As the duration increases, the pancreas which makes insulin gets tired and cells die, and insulin requirements increase. There can be many reasons that suddenly his requirements increase. It can be any infection, change in diet, mental stress, loss of proper sleep, and physical activity decreased. When using insulin it should not be taken at any one point, the place of insulin should be changed on the body frequently. It may lead to lumps on the body where insulin is given frequently at one point. Does he have any? Insulin should be kept at a proper temperature less than 25. Can you please tell me from what time he is on insulin? What were the last oral medications he was taking and then what was his HBA1c? His weight is also a bit above the range. If you have a list of his sugar values for the last week please send me so I can see at what times of the day his sugars are high. About the book for recipes you can check on the internet- Dr Berg’s recipes. It is a nice book that will give you low-carbohydrate diet recipes for diabetes and another recipe book for low-carb diet by intermittent fasting. You can search for yourself as well, the recipe book which will be according to your culture and eating habits. The principle is that a diet should have carbohydrates less than 20% and it should have good carbohydrates like more vegetables which have more fiber. Potatoes should be consumed at the minimum. Low-carb foods include lean meats, such as sirloin, chicken breast, or pork, fish, eggs, leafy green vegetables, cauliflower and broccoli, nuts and seeds, including nut butter oils, such as coconut oil, olive oil, and rapeseed oil some fruit, such as apples, blueberries, and strawberries, unsweetened dairy products including plain whole milk and plain Greek yogurt too. Know the carb counts and serving sizes of foods. Most low-carb diets only allow for 0.7 to 1.7 ounces (oz) of carbohydrates per day. Because of this, it is essential that people following low-carb diets choose foods that have a lower carb count but a high nutritional value per serving. The foods in the quantities listed below all contain approximately 0.4 oz of carbs: one tennis ball-sized apple or orange, one cup of berries, one cup of melon cubes, half medium banana, two tablespoons of raisins, eight ounces of milk, six ounces of plain yogurt, half cup corn, half cup peas, half cup beans or legumes, one small baked potato, one slice of bread, 1/3 cup of cooked rice. While the foods listed above all contain roughly equal amounts of carbohydrates, they are not all nutritionally equivalent. The dairy products on the list contain protein and vital nutrients, such as Vitamin D and calcium in addition to the carbohydrate content. The fruit and vegetables also contain essential vitamins and minerals. Choosing whole-grain varieties of bread and rice will provide more nutrients than white varieties, even though the carb content is similar.

    In my discussion above, I talked about intermittent fasting. I want to give you some details about it. You can look into it and see if it appeals to you. It is one of the options for controlling your dad’s sugar. But still, it depends upon him if he is willing to do it. There is nothing to force but my job will be to give you the options and then after discussion, we can make a proper plan for his sugars to be controlled appropriately. Fasting may be the oldest and most powerful dietary intervention we know. Weight loss is the most obvious health benefit. Other physical benefits of intermittent fasting include:

    • Weight and body fat loss.

    • Increased fat burning.

    • Lowered blood insulin and sugar levels.

    • Reduction in HbA1C.

    • Improved mental clarity and concentration.

    • Increased energy.

    • Increased growth hormone.

      How do I get Started? Fasts vary-

      1. Only water is allowed during fasting usually but coffee and green tea with sweetener but without milk can be taken as well.

      2. Fast 16/8, 24 hours, 36 hours or extended fasting

      3. You need to check how much your body is ready to do this. Once you decide on your fasting regimen, then it is time to implement your plan.

      When we eat, food is converted to either glucose from carbohydrates, amino acids from proteins, and fatty acids from fats. Sugar is stored as glycogen in the liver. This energy store is easy to access but limited in storage capacity. Dietary glucose and protein in excess of glycogen storage capacity are turned into fat for storage by the liver in a process called de-novo lipogenesis (literally, making new fat). This form of energy storage is more complicated, but there is virtually no limit to storage capacity. These two food energy storage systems complement each other. Glycogen is easily accessible but has limited storage space. Body fat is more difficult to access but has unlimited storage space. When we do not eat, insulin levels fall, telling the body to start burning the stored energy, glycogen, and body fat. Glycogen is used first once glycogen stores are depleted, the body will start breaking down body fat for energy. If feeding and fasting are balanced, then there should be no net weight change. You do not gain weight and lose weight. If feeding (insulin high) predominates, then we gain weight. If we start eating the minute we roll out of bed and do not stop until we go to sleep, we spend all our time in the fed state. Over time, we will gain weight because our body spends insufficient time in the fasted state, where it burns that stored food energy. If we want to lose weight, then we simply need to increase the amount of time spent burning food energy. That is intermittent fasting. It essentially allows the body to use its stored energy. After all, that is what we stored it for. It is a completely natural process. Type 2 diabetes (DMII) is fundamentally a disease of too much sugar in the body. When we eat glucose, insulin allows it to be used by all the cells of our body for energy, and to store the excess. Over time, if all our cells and storage system becomes overloaded, the remaining glucose spills over into the blood. Those high blood glucose levels are measured resulting in the diagnosis of type 2 diabetes. Our body is like a sugar bowl. It starts off empty. Over time, if we are continually putting a little more sugar in than we take out, it becomes full, just like the cells of our body. Now, if we put in a little more sugar, it spills out into the blood with high blood sugar leading to type 2 diabetes. If the core issue is glucose overfilling the cells, then the solution is obvious: get that glucose out of the cell. There are really only two ways of getting the toxic glucose overload out:

      1. Stop putting glucose in. Low carbohydrates reduce the amount of dietary glucose. Fasting also eliminates carbohydrates – and all other foods, for that matter.

      2. Burn off the excess glucose. Your body requires a certain amount of energy every day to survive.

      The heart, brain, kidneys, liver, etc. all require energy even if you are lying in bed. If you do not eat food (fasting), then the body must burn its stored energy. The first place it will get that energy from is the glucose in the blood. As you continue fasting, your body will start to burn body fat. As you lose body fat, the type 2 diabetes will start to reverse. Indeed, more and more research is showing that intermittent fasting has the potential to reverse type 2 diabetes without medications, surgery, or even cost. Both fasting and exercise significantly increase the beneficial BDNF (brain-derived neurotrophic factor) effects in several parts of the brain. In human studies, a 30% reduction in calories significantly improved memory significantly and synaptic electrical activity in the brain. Lower insulin levels are correlated to better memory. Further, a higher body mass index is linked to a decline in mental abilities and decreased blood flow to those areas of the brain involved in attention, focus, reasoning, and more complex, abstract thought. Autophagy is a form of cellular cleansing: it is a regulated, orderly process of breaking down and recycling cell components when there’s not enough energy to sustain them.

      Once all the diseased or broken-down cell parts have been cleansed, the body can start the process of renewal. Autophagy keeps our bodies running well. Our diet, especially protein intake stops this process of cleansing. When we eat food, our bodies detect it through nutrient sensors like insulin. Constant snacking reduces autophagy. When we fast, the body senses the absence of nutrients and worries there won’t be enough food to feed the whole body. It must prioritize which cell parts to keep. The oldest and most worn-out cell parts get discarded. At the same time, fasting also stimulates growth hormones. When we eat again, this signals the production of new cell parts, giving our bodies a complete renovation. Since it triggers both the breakdown of old cellular parts in the creation of new ones, Fasting may be considered one of the most potent anti-aging methods in existence. Along with intermittent fasting, a low carbohydrate diet is great for controlling diabetes and even in some cases, it can reverse it if it is newly diagnosed diabetes. I hope you find this helpful.

      Thank you.

Patient's Query

Hello doctor,

It is true that his HBA1c has been increasing for months if not years, and now it has reached around 10.

Tests:

We got all the tests you suggested:

1. Eye test to check for retinopathy (report attached).

2. Urine test to check for albumin creatinine ratio (report attached).

3. Diabetic foot test: he got his foot checked, he has a healthy foot.

4. ECG (report attached).

5. Does he have any chest discomfort, breathing issues or palpitations? - No signs of chest discomfort or respiratory issues.

Daily food plan- I have attached his daily food meals for the last week, in addition to his fasting sugar and the sugar values two hours after meals.

Daily routine: My father has an average of 20 to 30 minutes of walking per day, recently after our first consultation he tried to increase this time.

I have attached a file with five questions, thanks in advance for your patience with us. And of course, we are waiting for your suggestions regarding the attached tests.

Answered by Dr. Zulfiqar Ahmed

Hello,

Welcome back to icliniq.com.

Thanks for your feedback. I have seen the reports (attachment removed to protect patient's identity) which show blood sugars are in the target range except one morning after breakfast is 210. His fasting sugars are in a good range. I am happy with the sugar readings that you have sent me. All grains have carbohydrates but millet is better than others. He can use it in moderate amounts like bread of 0.8 ounces once a day three to four times a week. Corn flour is not suggested. He should repeat HBA1c after two months of the last HBA1c. Smoking Sheesha itself does not increase or decrease sugar but definitely it has bad effects on the lungs and heart so it would be better if he could stop. Usually, intermittent fasting is useful when it is at least 16 hours. So if he takes his dinner at 6 PM he should eat his breakfast at 10 AM the next day but if he finds it harder he can start with a fasting time of 12 hours and slowly increase as his body adapts. He can drink water black coffee and green tea during these fasting hours without sugar and milk. His current plan is quite good but you can check those recipes I suggested as well.

Whenever you want to add anything new to your meal plan check his sugars before eating it and check it after two hours. If it does not increase sugar over 20 to 25 mmHg he can use it frequently, for something that increases near 30 to 35 mmHg use it rarely and for anything more than 40 try not to use it. It is nice to know he is currently not having any serious complications of diabetes and his ECG (electrocardiogram), eye exam, and urine is fine. His sugar levels are satisfactory right now. I think he can continue the same regimen right now. But he needs frequent monitoring of his sugar levels

Thank you.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Zulfiqar Ahmed
Dr. Zulfiqar Ahmed

Diabetology

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