My grandmother had type 2 diabetes since before I was born. We were all very aware of it because she controlled it mostly through her diet. We knew she couldn't eat sweetened foods or if she did it was a tiny bit as a treat; rarely more than a mouthful. As far as I'm aware, she never developed any of the bad complications that come with having diabetes and she didn't even start using any medication to treat it until at least well into her 70s, perhaps not even until her 80s when she went into a residential home. She died in 2002 at the age of 86 and maintained her physical health well until around 2000 when she went into the aged care home.
My grandmother on her wedding day
This was the lens I saw diabetics through, so it was puzzling to me when I encountered diabetics who would still eat sugary foods, maybe less than non diabetics, but still at much higher levels than seemed reasonable given their condition. They instead chose to rely more on medication to try and control their blood sugar levels and quickly began to develop the complications that are known to come with diabetes. Initially I thought that this was a decision they were making despite doctor's advice, but recently I've begun to wonder exactly what the advice is these days from doctors and diabetics associations and I have to say that the associations' guidelines are rather confusing at best.
Diabetes and it's causes
There are two main types of diabetes, type 1 is an autoimmune condition where the pancreas doesn't produce enough insulin. With type 2 diabetes insulin is produced, but the cells have become resistant to it and it struggle to take up glucose for fuel. This leads to high glucose in the blood, so the body produces even more insulin to force glucose into the cells which respond by becoming more insulin resistant.
With type 1 diabetes patients generally require exogenous (outside) insulin in order to survive. While the right diet for this type of diabetes can reduce the amount insulin needed to be taken and give better control over blood sugar levels, it's unlikely to allow you to reach a point where you can do so without exogenous insulin.
With type 2 diabetes, the right diet can actually put it into remission. If you can bring glucose levels down to a level where cells won't be overloaded with more than they can handle, then their resistance to insulin will decrease.
My grandmother ate a mostly vegetarian, wholefood diet, avoiding any added sugars and limiting carbohydrate rich foods to low GI ones as best she knew how. She'd always eaten mostly wholefood anyway, so I wondered what might have caused her to develop this type of diabetes. After all, it's prevalence today comes mostly from the highly processed, high sugar diets most of us in the western world are consuming. At first I thought it might be the stress of living through WW2 and this could certainly have contributed. However, after talking to my mum we think a more likely cause was the steroid medications she was put on for her asthma and eczema. So it wasn't even her diet that caused the diabetes, but she was still able to control it with diet.
Guidelines from doctors and diabetes associations
I suspect guidelines from my grandmother's day were more diet related, but then we seemed to go through a period when the emphasis was on just taking medication. There is an indication that this could be turning around again with at least the American Diabetes Association putting some emphasis back on diet to control it.
From Diabetes Australia we have this:
"Eating a healthy diet helps to keep your blood glucose levels within your target range, which reduces the risk of developing diabetes-related complications."
This seems like good guidance, although it's rather confusingly followed by:
"There is no such thing as a diabetic diet. People living with diabetes can enjoy the same foods as everybody else."
I suppose this is also accurate to a point. The odd little bit of high glucose causing food is not going to make you completely lose control of your blood sugar, but this isn't made particularly obvious. Most people want to know clear cut boundaries otherwise they will take this and run with it in the wrong direction, especially if they don't really want to make changes. A friend of mine was told he could have the occasional beer when he was early into his diabetes diagnosis, but basically interpreted that as being able to drink however much he wanted. It wasn't long before the doctor gave up on any hope of him controlling his condition with just diet and decided to put him on tablets for it. He's in his mid 50s now and has bad teeth (they deteriorated rapidly once he went onto medication), circulation issues and is prone to getting infections from injuries.
Perhaps a bigger problem is that people rarely get full disclosure as to the outcome of not changing the way you eat and using medication to try and control symptoms of high blood sugar instead. If your cells are already resistant to insulin then adding more will only force the body to do something with the excess glucose and that will basically be putting it into fat storage. The ongoing problems of glycation from the excess glucose aren't being addressed and inflammation and cell damage will continue. You will also continue to develop further insulin resistance requiring more and more insulin.
On the positive side insulin isn't usually the first medical intervention for type 2 diabetes, that would be a metformin medication, as long as you don't have other conditions that it could negatively affect. This medication makes your cells more responsive to insulin, decreases the amount of glucose absorbed from food and the amount of glucose made by your liver. While this is likely a much better approach than going straight to just putting more insulin into your body, it's not without its side effects and it's still not addressing the root cause, as indicated by the fact that people will eventually still graduate to insulin if diet isn't addressed.
Was the historical approach better?
For decades before medical interventions were found, type 2 diabetics had good success with ketogenic diets and even today people who choose to go that route seem to do well with putting it into remission. There are those who don't find this dietary approach appealing for a whole host of reasons, however, and I think my grandmother was a good example that other dietary approaches work too.
That said, our modern food landscape is far removed from what it was 100+ years ago as is our way of life. We're flooded with an ultra processed, sugar filled plethora of offerings which are hard to resist and even when we think we're making healthy choices there are often hidden sugars we don't expect. We regularly don't have time to cook from scratch and it's just so much easier to grab takeout or heat something up after a long day at work. But if we knew just how severe the complications of diabetes were, would it help motivate us to navigate this minefield better and make the time to eat better?
Looking up diabetes complications can give you an idea of what you'd face in the future if you didn't control your diabetes, but just reading them doesn't really hit home. The way most sites list them you can convince yourself that they are possible rather than certain complications and you might not get them. However, the reality is that one of them will get you, it's just a matter of which ones. I recently watched a documentary about a chef who got a type 2 diabetes diagnosis and he went to visit some later stage diabetics in hospital who each had warnings for him not to take it lightly. At least one was having a leg amputation and one had lost his sight. The chef said that actually seeing the complications and how they affected people did more to hit home than just being told or reading about them.
I'd actually love to hear from diabetics what the current advice is. Is healthcare heading in the right direction or are they just throwing medication at it?