People with Type 2 diabetes often end up taking many different medicines, and understandably are unhappy about it. First, they are concerned about side-effects; second, every time they take medication it’s a reminder of their Type 2 diabetes; third, the practicalities of getting enough supplies of medication are sometimes a hassle (renewing prescriptions, running out of medication, how to cope with long holidays – I needn’t go on); and finally, people with newly diagnosed Type 2 know friends and relatives who have ended up on increasing amounts of medication over the years.
Fortunately, we don’t need to be quite so concerned now about serious side-effects as a result of the regrettable history of Avandia (rosiglitazone), a drug introduced in the late 1990s. It reduced blood glucose levels effectively, but in long-term follow-up was linked with increased rates of heart attacks, bone fractures and anaemia. The USA Federal Drug Administration responded by requiring all new diabetes drugs to have long-term safety trials, focusing specifically on cardiovascular risks – that is, heart attacks and strokes. But these studies only need to start once the drug has been licensed for use, and they run for two to four years, so there is still a period after the introduction of drugs and before the final safety trials have reported during which there is a risk of new serious and previously unknown side-effects. We can be confident that all the new major groups of diabetes drugs have been through these trials (and semaglutide, a drug introduced in 2018, may have set a good example for the future: its cardiovascular safety trials were completed before the drug was launched, an extra reassurance). But no clinical trial, however huge and well conducted, can completely exclude the possibility of very long-term side effects, chief of which, of course, is cancer. Even with these new safety requirements successfully implemented, we must remain vigilant for side-effects that occur in individuals.
Key point: Regulations now make it more unlikely there will be serious unexpected side-effects from new drugs.
The frustration experienced by many people, especially when recently diagnosed, is that they feel they aren’t given the time, encouragement or education to help improve their diabetes without the help of medication, and that it’s a case of a brief introduction to lifestyle, followed in short order by a prescription for one or more tablets. They have an important point, though this scenario may be less common in places where all newly diagnosed people are encouraged to take part in a formal education programme (e.g. ‘DESMOND’ in the UK), and where people with diabetes have regular medication reviews, either with their diabetes team or, increasingly, by specialist pharmacists. A key question during these reviews is, or should be: is every item on a prescription list really necessary?
Despite these concerns, medication is valuable when used with care and consideration, with due regard for individuals and their concerns, and their medical and social circumstances. Also, although medication is only very rarely immediately life-saving in the context of Type 2 diabetes, it can surprisingly quickly reduce the risks of major complications. For example, if blood pressure is found to be very high (systolic pressure more than 160 mm), prompt treatment with two different medications started at the same time reduced the risk of a stroke or heart attack over the next one to two years. Most doctors would use the medication approach rather than the slower and more unpredictable benefits of lifestyle intervention for initial treatment of very high blood pressure. The same goes for patients whose diabetes presents with serious symptoms due to very high glucose levels (see Chapter 2). Tablets, sometimes even insulin, are needed so that people can rapidly get on with their lives, though once the emergency is over, these emergency drug treatments can often be reduced when lifestyle interventions have started working. But where there is no such urgency, we should aim to start with minimum medication and maximum lifestyle intervention.
Nevertheless, over the years many people do tend to become burdened with more and more medication. Understandably, this doesn’t do wonders for self-worth and can undermine motivation to self-manage. This is particularly the case for drugs to treat blood glucose levels, where progressive addition of tablets and injected treatments is a real concern.
During the 2000s, a major clinical trial (the ACCORD study) in people with about 10 years’ diabetes attempted to keep blood glucose levels super-low (between 5 and 7 mmol/l) in order to find out whether this reduced the risk of heart attacks and strokes (it barely had any effect, as it happens – see Chapter 5). At the end of the trial, which lasted just over three years, the intensively treated group was taking on average just over three drugs for blood glucose, while the less-intensively treated group was taking two drugs. And these were just the blood glucose-lowering ones. In the same study, but this time focusing on blood pressure control, most people allocated to a very low blood pressure target were taking three drugs, and nearly one in five were taking five. So, to control blood pressure and blood glucose levels, admittedly to very low values which didn’t help much to reduce long-term complications, many Type 2s might be taking five or six medications, and that’s without a statin for cholesterol-lowering and aspirin for blood thinning (plus any other medications for non-diabetes problems). This could mean eight or more different drugs – a common scenario.
Key point: Type 2s often end up taking many drugs. Although it’s unlikely you will be able to ditch all medication, healthcare professionals and patients can work closely together to minimise the burden.
Doctors often don’t help the situation, though it’s not entirely their fault. Every so often a group of experts issues ‘guidelines’ that – usually – urge us to aim for progressively lower blood glucose, blood pressure and cholesterol levels, and encourage us to use more complicated combinations of drugs, including newly introduced medications, to help achieve these lower targets. At the same time, other organisations tell doctors they aren’t sufficiently ‘proactive’ and, even worse, they are accused of ‘therapeutic inertia’, which is medical-speak for doctors who don’t act quickly enough to prescribe additional drugs to achieve the targets. Finally, once they’ve become more proactive and overcome their therapeutic inertia, they’re encouraged to be ‘aggressive’ in their use of drug treatment. I don’t much like the terms ‘proactive’ and ‘therapeutic inertia’, but ‘aggressive treatment’ seems to me a really unfortunate phrase in a supposedly caring profession. Of course, there’s no implication of physical violence (though if I were a patient and overheard a reference to ‘aggressive treatment’ I might get a little anxious), but the implication is that at the very first sign of blood glucose levels rising, more and more medication needs adding – and as soon as possible. On rare occasions this may be the right thing to do – for example, where blood glucose levels are so high that a hospital admission is looming. This scenario was mentioned at the beginning of the chapter. But apart from emergencies, this approach is almost never needed, and when it is used quite often causes unnecessary anxiety in people who have been told they urgently need treatment.
Let’s think about an approach that starts putting you more in control, so you can present information to your medical team that will convince them that, at the very least, you don’t need more medication – and in fact may be in a good position to start reducing it. We will look in turn at each of the three main areas of Type 2 medication – blood glucose control, hypertension and cholesterol reduction, and examine what you can do in each case.
Newly diagnosed Type 2s often ask whether they will always need some medication for blood glucose control, and the answer is: no, they may not – for the reasons outlined in earlier chapters. Type 2 is potentially reversible, especially in the first five or so years after diagnosis, and one of the criteria to judge whether diabetes has been reversed is that blood glucose comes under control without the need for medication. There is also a small but interesting group of Type 2 people who have never needed medication and probably never will. They may have a form of diabetes that for some reason progresses ultra-slowly, but it’s often because, right from the start, they were determined to minimise their tablet intake, and took the decision to substantially and permanently cut their calorie intake.
While most people are not in this fortunate situation, many can reduce their blood glucose-lowering medication, even if they can’t completely ditch it altogether. The dietary approach is discussed in Chapter 5, and everyone can start their own diet experiment – for example, by trying to reduce their food intake by about 400 kcal/day while continuing to take their usual medication. This should result in fasting blood glucose levels falling substantially, perhaps by 2 or 3 mmol/l, and once this has happened, then your practice nurse or GP will be much happier to support a gradual reduction in medication. But the whole thing is a complex business that needs to be done carefully and slowly, reducing one medication at a time, while, of course, maintaining your calorie reduction.
One glucose-lowering medication widely considered to be a must for nearly all people with Type 2 is metformin. It was probably the medication you first started, and it’s going to be the one that doctors will be most reluctant to let go. It is, in fairness, one of the oldest and most effective drugs (its active ingredient is derived from a plant extract – see Chapter 6, page 82), and the one that has never been shown to have any long-term adverse effects. In fact, a few years ago it was also thought to protect against some forms of cancers, but that enthusiasm has waned while we wait for the outcomes of large clinical trials. It doesn’t usually cause hypoglycaemia (low blood sugar levels), though this can happen in some people if they’re trying really hard with diet. Although metformin was supposed to cause significant weight loss, it’s more accurate to say that it minimises weight gain. But these two properties – lack of hypoglycaemia and not causing weight gain – are two definite points.
In one trial, the United Kingdom Prospective Diabetes Study (UKPDS) (see References, page 214), metformin in overweight Type 2s showed some benefit in reducing the risks of heart attack. Ever since then, it has been widely thought that metformin has beneficial effects on the heart, independent of its blood glucose-lowering effect (and in 2015 someone even touted it as an anti-ageing drug that could increase life-expectancy to 120). In fact, no modern trials have confirmed the UKPDS finding, so although metformin is a safe and valuable drug for reducing blood glucose levels, as far as we know there are no additional advantages in taking it. Several clinical trials are in progress, investigating the effects of metformin on brain ageing and cardiovascular disease.
You may have some difficulty in persuading most doctors to let you off the metformin hook, as many still believe it has ‘special’ qualities. If you’re taking metformin you could regard it as the only medication you need to continue in the long term. However, that is much better than taking an additional two or three drugs, with the prospect of another one being suggested every few years. But to get down to taking metformin alone often requires a good deal of determination, and nearly always major and permanent weight loss.
The sulfonylureas (in the UK gliclazide is the most widely prescribed of this group of drugs) haven’t had such a great press for a long time. There are no reports of major long-term side-effects but because they prod the pancreas into producing more insulin, and thereby reduce blood glucose levels, they can cause hypoglycaemia, particularly in people taking unaccustomed exercise or who miss meals. In addition, in the UKPDS, Type 2s taking older sulfonylureas that are no longer used gained weight and many people notice they stimulate the appetite. On the list of drugs that can be replaced by serious attention to weight loss, sulfonylureas are near the top. But they are quite powerful drugs for reducing blood glucose levels (they are often used at the time of diagnosis if blood glucose levels are very high), so after you and your diabetes team have decided to gradually decrease the dose of gliclazide, you need to maintain your enthusiasm for dieting and weight loss.
If you have successfully minimised or stopped a medication such as gliclazide by determined focusing on weight loss and diet, you are likely to want to go on and repeat the success story with other medications. But aiming to stop all your blood glucose medication for ever is very tough. The reality should be to minimise medication. As they say, the perfect must never be the enemy of the good. Nevertheless, whenever an additional medication is suggested, always consider whether it’s really necessary, if the simpler solution might be reducing your calorie intake.
Doctors are very reluctant to admit that, right from the start, some medications don’t work very well in some people. In addition, for a variety of reasons, all medications have a failure rate over time. Even metformin may become less effective with time, and the sulfonylureas are notable for their quite high rate of failure. In addition, there are some drugs which just aren’t as effective as others in reducing blood glucose levels, even when they’re working perfectly. The group of drugs whose names end in ‘-gliptin’ (for example, sitagliptin, saxagliptin, vildagliptin) are generally weaker than other medications, so if you are taking one of these it could be relatively easy to discontinue it with additional attention to weight loss and carbohydrate intake.
Key point: Sulfonylureas (for example, gliclazide) are the drugs most likely to cause hypoglycaemia, and they tend to increase weight and appetite. They would be a good focus in any medication-reducing programme.
Insulin is the one medication that people most dislike taking, but unfortunately it is by far the most difficult to reduce or discontinue through weight loss, and any attempts at changing doses must always be done with the support of your medical team. Although compared with 20 years ago I think a smaller proportion of Type 2s now take insulin, the numbers are still very high, around 25–30%. In the past, most insulin-treated Type 2s took just insulin, but now it’s usually combined with other medication, so perhaps they are taking fewer injections each day, a statistic that’s probably not of much consolation to individuals using insulin. It’s depressing that there are no studies on how to safely reduce insulin doses, or how successful it is: both these important omissions contribute to the understandable concern of patients that insulin treatment in Type 2 is always life long. However, it’s well known that people whose diabetes is effectively ‘cured’ by bariatric surgery generally no longer need insulin after the operation, so it’s important to recognise that the majority of insulin-taking Type 2 people are not ‘insulin dependent’. Insulin is similar to the sulfonylureas, only more so: it tends to increase weight and appetite, and there is an even higher risk of hypoglycaemia. Type 2s who take insulin are highly aware of all these risks, and understandably it makes them even more keen to reduce their doses.
You’ll first need agreement and support from your diabetes team. Abruptly discontinuing insulin, or reducing it by large amounts (for example, halving the dose) can result in rocketing blood glucose levels, and some hazard. There are many different kinds of insulin, and you would need a specific plan for the particular type and doses of insulin(s) you take. But we can use our new insight into Type 2 diabetes to make some educated judgements.
Remember the basic problem in Type 2 is the inability of the liver to control blood glucose levels overnight. That’s why most people starting insulin begin with a bedtime dose of long-acting insulin that helps control high fasting glucose levels first thing in the morning. In the UK, the most frequently used long-acting insulins are Lantus and Levemir. There’s also Abasaglar, Toujeo and Tresiba. The long-acting insulin is going to be the most difficult to reduce unless you lose the kind of weight seen in the Newcastle study (see Chapter 4, and page 213). In truth, most people taking one dose of long-acting insulin a day (usually at bedtime, but sometimes in the morning) don’t mind injecting it, at least from the practical point of view of taking an injection.
But you can start making inroads if you are taking faster-acting or mixed insulin before one or more meals. A list of mealtime insulin preparations in common use in Type 2 diabetes in the UK is shown below.
Fast-acting ‘analogue’ insulins, usually taken before each meal:
Biphasic insulins (mixed short- and medium-acting) usually taken twice-daily before breakfast and the evening meal, but sometimes three times daily (additional dose before lunch):
Mixed short-acting and long-acting:
Mealtime insulin limits the rise in blood glucose after eating that is mostly caused by the amount of carbohydrate you take. Regularly limit your carbohydrate intake and you are likely to need less insulin at mealtimes. But again, this needs careful discussion with your diabetes team, who will probably suggest you measure blood glucose levels even more frequently after meals before and during any dose reduction.
I’ll make one general point about different insulin preparations. In Type 2 diabetes there’s almost no difference between one long-acting insulin and another. The same goes for short-acting mealtime insulins, and the mixed (biphasic) insulins. Manufacturers of new insulin preparations are understandably keen to promote small differences in the way these insulins act, and differences in the risk of hypoglycaemia. The way the insulin is used, and the engagement of the person using insulin, are both much more important than tiny differences seen in clinical trials, and we know this from studies over the years in younger people with Type 1 diabetes. Your current insulin is very likely to be fine. Only very rarely is there any need to change one insulin for another that acts in broadly the same way, and most importantly you are in control of your insulin, not vice versa.
Key point: Don’t suddenly discontinue or radically reduce the dose of any medication, especially insulin. Slow, gradual decreases tied in with strict dietary control, especially of carbohydrates, is the approach that’s most likely to be successful.
People with diabetes are less concerned about taking several different treatments to control blood pressure than for blood glucose. There are several reasons for this. Blood pressure doesn’t have the same tendency as blood glucose to rise over the years, so you are less likely to be asked to take additional blood pressure medication. While blood pressure varies a little through the day (it’s usually highest in the early morning and lowest in the middle of the night), it doesn’t show the same dramatic swings as blood glucose, and doesn’t need to be measured nearly as often. Finally, all medications for blood pressure control have been around for ages (the last major group of drugs was introduced nearly 20 years ago), so there’s fortunately nothing new on the side-effect front that we haven’t been aware of for a long time. You won’t see headlines about either magic new drug treatments for blood pressure or shock-horror stuff about side-effects of older treatments (compare the seemingly never-ending statin saga; see Chapter 10). In short, blood pressure doesn’t figure as prominently as blood glucose in the lives of people with Type 2, and the risk is that we can consider it to be less important than glucose. But we need to rethink our priorities. Blood pressure control is extremely important in reducing nearly all complications of diabetes and some, for example stroke risk, respond much better to blood pressure than glucose control.
Can any non-drug intervention really help blood pressure and reduce the number of drugs you need to take? Yes. But the warning about blood glucose control applies even more to blood pressure. Never reduce or stop blood pressure medication yourself. Blood pressure can rise very quickly if medication doses are reduced or stopped completely without having a proper plan in place. Bear in mind again the strong relationship between high blood pressure levels and stroke risk.
Key point: Don’t reduce or discontinue any of your blood pressure medicines until you have a discussion with your healthcare team.
Before discussing non-drug interventions in more detail, the simplest option to reduce your medication might seem like a bit of a cheat, but it makes a lot of sense. Can you combine two of your blood pressure medicines in one pill? There are lots of these combined preparations around, they are always logical combinations, and haven’t been introduced just on a whim. (Combination blood glucose medications are also widely available, usually metformin together with another drug.) Some doctors are quite keen to help people combine medications in this way, because it helps the troublesome business of tablet numbers. Others, often of an older generation, were taught at medical school that these so-called ‘fixed-dose combinations’ were the product of the devil and ought to be banned from the face of the earth. I’m with the first group. Any reduction in tablet numbers is to be welcomed, and if doctors don’t support the use of combined medication it shows we don’t appreciate the burden of daily tablet taking.
Key point: If you are taking several medications for blood pressure, discuss with your medical team or pharmacist if two of them are available in a combined preparation.
As with blood glucose, you can safely experiment with lifestyle changes, because any further blood pressure reductions are likely to be of long-term value. Work through in detail the blood pressure portfolio described below, and measure your blood pressure about twice a week while continuing to take your usual medication. Write the results down, show them to your healthcare team, and discuss whether there is any room for reducing your blood pressure medication. As you’d expect, the nearer your systolic blood pressure is to target (130 to 140 mm) the easier it will be to substitute permanent lifestyle change for medication.
Many studies have looked at the impact of lifestyle measures on blood pressure, so at least we have a firm basis for recommending what is likely to work. Equally important, we have some idea of what doesn’t work, and chief among these is – surprisingly – weight loss by itself. Since being overweight is associated with high blood pressure, you’d expect weight loss itself to lower blood pressure. It doesn’t: we saw that 15 kg weight loss in the Newcastle study didn’t reduce blood pressure, and even huge weight loss, as much as 40 kg after bariatric surgery, only has a small effect on blood pressure.
However, when weight loss and exercise are combined – for example, in the Look AHEAD study (see Chapter 5, page 58) – blood pressure does fall, and the reduction can be quite impressive, similar to the effect of drugs in the ACCORD study (see page 101). In general, lifestyle intervention is more successful in very overweight people with a BMI greater than 30, while drug treatment seems to be better in the less overweight.
The DASH diet for hypertension (DASH stands for ‘Dietary Approaches to Stop Hypertension’) is now 20 years old, but was way ahead of its time. It emphasised fruits and vegetables, low-fat dairy products and encouraged low saturated fats and total fats, though it was before the era of encouraging ‘good’ fats – for example, the monounsaturated oils of nuts and olive oil; these, as we have seen (in Chapter 5), were the focus of the PREDIMED approach. Nevertheless, it was dramatically successful and reduced systolic blood pressure by 11 mm in hypertensive people, which is the equivalent effect of at least one, and in some people two, medications.
Too much salt causes fluid retention and increases blood pressure. The link was established years ago; conversely, reducing salt intake reduces blood pressure in many people. (An unseemly scientific quarrel lasting decades has blunted the impact of this ‘fact’, and as I write this, a USA research scientist is advocating eating any amount of salt that you feel is right.) There are concerns that the false controversy over salt intake and cardiovascular disease risk is in some ways similar to the climate change ‘debate’. We can never be 100% certain of the link, because we’ll never be able to do the experiment comparing life expectancy in a group forced to eat a high-salt and another a low-salt diet, but for the majority of scientists and doctors, the evidence is pretty compelling: too much salt is bad for everyone, but especially for people with high blood pressure.
The recommendation is to eat less than the equivalent of one teaspoonful of salt a day (2.3 g), and if you’re over 50 less than ½ teaspoonful (1.2 g). On average we eat hugely more than that. In a recent survey, most people take between 6 and 12 g a day – that is, between two and five times the recommended maximum. However, encouragingly, in the UK average daily salt intake fell from about 9.5 g a day in 2003 to 8 g in 2011 – still far too much, but heading in the right direction. This reduction itself may have been responsible for much of the reduction in strokes that occurred over the same period. In spite of nearly everyone claiming that they don’t add salt to their meals, most people are aware that pre-prepared food contains most of the salt we eat. Vegetarian foods are no lower in salt than non-veg foods. Some examples:
| Standard white bread | 0.7 g per slice | |
| Packet of salt and vinegar crisps | 1 g | |
| Shop-bought prawn sandwich | 0.8 g | |
| Pre-packed vegetarian sushi selection | 1.1 g | |
| 3 chocolate digestive biscuits | 0.6 g | |
| Half a can of tomato soup | 1.1 g | |
| Two slices of bacon | 0.3 g |
The best safeguard against eating too much salt is to do as much of your own cooking as possible, and minimise shop-bought snacks and sandwiches. (And point out to the smug people who proudly state they never add salt to their meals that a generous pinch of salt is only about 0.3 g, while a packet of crisps contains three times that amount.)
Key point: Reducing your salt intake can make meaningful inroads into blood pressure, up to 10 mm lower, similar to the DASH diet, and the equivalent of one or two different blood pressure medications.
Until recently I wasn’t aware that excess alcohol was associated with high blood pressure, but this is part of a recent reassessment of evidence on the impact of alcohol on general health. This takes into account the increased risk of cancer (including breast cancer), and possibly of Alzheimer-type dementia. In 2016 the recommended alcohol limit for both men and women was decreased to 14 units a week (for example, 7 pints of beer), compared with the previous guidance of 21 units or less for men, and 14 for women. On the more positive side, in Type 2 diabetes, moderate alcohol intake is linked to a lower risk of eye and kidney complications, but heavy alcohol drinking increases overall cardiovascular risk. Whether it is alcohol itself, or specifically red wine that is responsible for vascular benefits has never really been sorted out, because it’s difficult to find populations who drink only beer, or only white or red wine.
Focusing on blood pressure in people with Type 2, ⅓ of a bottle of red wine daily in women and about ½ bottle in men (3 to 5 units a day – well over the current recommended limit) had no impact on blood pressure or blood glucose levels. But the evidence on heavy alcohol intake is clear: it increases many risks, particularly strokes and heart attacks, and in very heavy alcohol users, a short period without alcohol reduced blood pressure by 8–13 mm, whether or not they were already hypertensive.
Key point: Limiting alcohol intake, for example up to the current recommended limit (14 units a week), may reduce the risk of cardiovascular events and eye and kidney complications. Risks of many diseases increase rapidly above this level of drinking.
Exercise doesn’t reduce weight (see Chapter 8), but it can really help blood pressure. Three times a week intensive treadmill exercise can reduce blood pressure by about 10 mm, and the same frequency of resistance training (weights) may also help.
There is a long list of nutraceuticals that may help hypertension. Where they have been studied, each reduces systolic blood pressure by a small amount, around 2 mm, but combined they are likely to have a more marked effect. Note the overlap here with many of the components of the Mediterranean diet. One, cocoa, has been of interest for a long time, especially because it contains flavanoid chemicals that relax blood vessels and help blood pressure, and chocolate regularly emerges as a ‘superfood’ (see Chapter 6, page 95).
Nutraceuticals potentially helpful for hypertension include:
Herbal suggestions include hawthorn and various traditional Chinese herbal medicine formulas. Meditation-based interventions, including Qi Gong and Tai Chi, reduce blood pressure in smaller controlled trials, but it seems as if regular exercise is the key factor here, not whether it is conventional or traditional. Biofeedback has been around for many years, but little positive support has emerged from clinical trials.
Key point: To help reduce blood pressure: minimise salt, keep alcohol intake to less than 14 units a week, exercise, and do your best with the Mediterranean/DASH diet.
Non-drug management of high cholesterol levels has been downgraded just as we encountered in hypertension. The reason is that statins are very safe, can reduce cholesterol levels by up to 50% (even more if combined with other medication) and, most important of all, reduce vascular risks by around 40% (see Chapter 10). Non-drug management of cholesterol can reduce blood levels – in trials quite substantially – but it’s unlikely that dietary portfolios could either be maintained in the long term or significantly reduce heart attack and stroke risk. However, several foods and nutraceuticals used in trials not surprisingly also figure in the lower-carbohydrate and Mediterranean approaches we discussed in Chapter 5.
There is a link between high saturated fat diets and blood cholesterol, but it’s a weak link. However, less red meat and processed meats is probably a good start – the latter also contain a lot of salt. Remember that very few foods contain cholesterol, and even when they do (for example, eggs) eating them doesn’t translate into higher blood cholesterol, and can even boost protective/good HDL levels. Zero-cholesterol foods won’t help your blood cholesterol levels, and they’re often packed with carbohydrates and sugars.
Specific nutraceuticals can reduce cholesterol levels. The most powerful are the plant stanols/sterols added to margarines and drinks (e.g. Benecol, Flora ProActiv, and various supermarket own-brand products). The most effective daily intake is about 2 g, which is contained in two tablespoonsful of margarine or a small individual drink. They consistently reduce LDL cholesterol, the portion of circulating cholesterol which causes most damage to arteries, by about 13%. This isn’t anywhere near the reduction needed in most Type 2s to get LDL to the recommended level of less than 3 mmol/l – around 30–50% – but it’s significant, and a non-statin drug, ezetimibe, that has about the same effect, reduced coronary events in a major clinical trial by about 10%. But you need to take your drink or margarine in the right amount, and every day. I’d suggest the drinks rather than the spread: you’d need several slices of bread to accommodate the two large spoonfuls of margarine, and that might not be so good for the lower-carbohydrate approach. Ensure that any drinks are low-calorie.
Foods that actively reduce cholesterol levels are individually much less effective than the plant stanols/sterols. Each can reduce cholesterol by about 2%, which is too small to detect on routine blood tests, but taken together as a portfolio they are likely to be more effective, and perhaps boost the effect of the plant stanols supplement by a few percentage points. But regardless of their cholesterol-lowering effects, we encountered several of them in the lower-carbohydrate and Mediterranean diets. See Table 7.1.
Table 7.1 A portfolio approach to non-drug reductions in cholesterol levels.
| Food/nutraceutical | Recommended amount | Comments |
| Soy protein (soy milk, tofu, soy ‘meat’ products) | 1½ ounces daily | Soy is an important high-protein food incorporated into south-east Asian cuisines. It’s much more interesting and varied than soy ‘milk’. Most of the clinical trials of soy protein haven’t shown a reduction in cholesterol levels. |
| Soluble fibre | Around ¾ ounce daily | Barley, oats, aubergine, okra (see Chapter 6). |
| Nuts | Around 1½ ounces daily | In the PREDIMED study this intake was associated with a reduction in heart attacks. |
| Plant sterols | Margarine (2 tablespoons) or 1 yoghurt drink daily | |
| General advice | Vegetables, eggs, whole-grain cereal, low-fat dairy, fruit; reduce red meat and snacks. |
Key point: A daily intake of 2 g of plant sterols/stanols (margarine, yoghurt drink) can reduce LDL cholesterol levels by about 13%. But you’ll still need a statin.
A very small proportion of people need no medication at all for their diabetes. These fortunate people will be Type 2s with only slightly high blood glucose that can be managed with diet alone, and whose blood pressure and cholesterol levels are naturally at target. Interestingly, this profile is often seen in young people with Type 1 diabetes. Later-onset Type 1 diabetes in people is being diagnosed more frequently and perhaps up to 20% of older people thought to have Type 2 diabetes, because they were diagnosed in their 30s, 40s and 50, may actually have Type 1. They tend not to be too overweight, and like the younger Type 1s have life-long naturally low blood pressure and a nice cholesterol profile. Type 2 patients from China and other south-east Asian countries also have these characteristics.
But these are small numbers, and there are almost no Type 2s not taking any medication. Strenuous attempts to stick to your lifestyle portfolios may allow you to cut your medication back to the following. It still looks like a lot of tablets, but it’s a lot less than eight or nine medications, which isn’t uncommon:
And as we’ve seen, if there is a ‘threat’ to increase your medication, a determined and focused effort using the considerable evidence that we now have on lifestyle changes may well result in a postponement of another pill to pop every day.
If you pay detailed attention to your diet, weight loss and activity you should, with support from your healthcare team, be able to reduce the amount of medication you take. This will improve your numbers (glucose, blood pressure and possibly cholesterol) and, combined with a broader approach to your diet, for example the Mediterranean, is likely to reduce your risk of diabetic complications in the longer term. But don’t reduce medication by yourself: always discuss it first with your diabetes team.