Bolus advisor masterclass part 1: Counting fat and protein

Seville, November 2016

It's been a few weeks since I attended this course, and it's time to assemble my thoughts and learning points. It was a terrific day and I certainly learned quite a lot, most of it very relevant to my work with people with Type 1 diabetes. In fact, two days after the course I was passing on some of the information to the group I was teaching at the time.

It is important to note that the day was hosted by one particular pump manufacturer, Roche, so there is a likelihood of bias. Having said that, I think the majority of information supplied was correct - it would be fairly straightforward to check, although I haven't done so. The first topic covered in the day was a comparison between the specifications and capabilities of the different insulin pumps on the market. Then we focussed on the algorithm that each manufacturer uses to guide the user in the amount of insulin to give in various circumstances: for exercise, for high fat and protein meals, and to correct high blood glucose levels after a meal or snack.

Exercise

The guidance around exercise wasn't very different from what we already advise - if you're exercising within 90-120 minutes after a meal you could give less insulin for the meal; if not then you'll probably have to eat or drink some carbohydrate to prevent blood glucose dropping, and if you're using an insulin pump you've also got the option of reducing background (basal) insulin. I've written extensively and comprehensively on the knotty topic of exercise and Type 1 diabetes. It's a challenging area, and management.is very individual. All the pumps work in a similar way, although the Roche handset has some features that help with the mathematics of percentage reductions.

High fat and protein meals

OK, this is going to start getting technical (although nowhere near as nerdy as the section on post-prandial correction doses in part 2).

For people with Type 1 diabetes, the evidence suggests that best management of blood glucose levels, and therefore long-term health and freedom from diabetes-related complications, comes from matching insulin injected and carbohydrates consumed. (Just for contrast, the approach for people with Type 2 diabetes in the first instance is weight loss).

The first point that hit home during the course was that although we focus on counting the carbohydrate in a meal, there is a contribution to blood glucose that comes from the protein and the fat in a meal. When we focus on carb counting, there is an unspoken (and for me until now, unrecognised) assumption that the meal is constituted of a 'normal' proportion of carbs, fat and protein. I actually know this to be true, because we have found when someone with Type 1 goes on a very low carb diet they need more rapid insulin with meals than the carbohydrate content would suggest.

Fat and protein have another effect alongside their contribution to blood glucose levels - they also slow down the digestion of carbohydrates. The action profile of insulin can't be adjusted to suit the meal composition - rapid insulin has a fixed onset, peak and acting time that doesn't change, so giving insulin in the standard way before a meal when it's a high fat/protein meal doesn't work very well, and post-prandial blood glucose often ends up way higher than one would like.

Up to now, conventional wisdom suggested that for a high fat meal carbs should be counted as usual, but the matching insulin dose should be delayed and/or split (if on injections) or spread over a longer time period (if on a pump), to account for the delay in digestion and later peak in post-prandial blood glucose. This course not only suggested that more insulin is needed because of the greater contribution of fat and protein to blood glucose, but gave some useful guidelines on how much more is needed, and how it should be delivered.

Six different high fat/protein meals were listed: fish and chips, Indian and Chinese takeaway, pizza, pasta with creamy sauce and fast food (McDonalds, KFC etc).  The following procedure was recommended separately for each.

As a first attempt, you should give 25% more insulin than you need for the carbs and deliver 50% at the start of the meal, and 50% an hour later (if on injections) or over 2.5 hours (if on a pump). Then, to see if these percentages are right, you should monitor blood glucose at 2.5 hours and 6 hours without having any more food or insulin. This will work best if your blood glucose level is within the normal range before the meal.

The 2.5 hour test is to find out whether the 50/50 percentage split is right. If blood glucose at this stage is more than 4 mmol/L higher than it was before the meal, then more insulin is needed up front - they suggest increasing by 20% at a time (i.e. switching to a 70/30 split next time). Conversely, if blood glucose is lower at this point than before the meal, the split should be changed to 30/70.

The 6 hour test is to find out whether the 25% extra insulin is right. If blood glucose at this stage is between 2 and 6 mmol/L higher than before the meal, next time add on another 10% - instead of 25% extra, add 35%. If at 6 hours blood glucose is more than 6 mmol/L higher than before the meal, next time add on 20% (to 45% extra). Conversely, if blood glucose is lower at this point, then next time knock the percentage down by 10% to 15% extra.

Multiple experiments may be needed to get the best results! Apparently parents are often taken aback when their Type 1 children come home from a carb counting course and assert that they've been given homework that requires them to eat fish and chips, takeaways and fast food.

Coming soon: Part 2 will contain even more technical stuff about how to manage post-prandial correction of high blood glucose levels.

Gestational Diabetes

Cardiff castle, May 2013

I started writing this post some considerable time ago, which is a little ironic. Not many posts have needed incubation.

Every week, I see a few patients who have just been diagnosed with Gestational Diabetes Mellitus (GDM). And when I say 'just diagnosed', sometimes it's been in the last hour or two. Some have had it before, some take it in their stride, and some are completely freaked out.

For each of these women, I aim to give them basic dietary information in 30 minutes, and then they can have lots more input the following week if they need it when they come back for a scan and a full check-up. When I started writing this post, the shortest time I had managed was about 40 minutes, and when I first started in the job it was more like an hour. Now I've got it down to a well-practised routine.

The diagnosis is made by screening women who have one of several risk factors, including pre-pregnancy BMI over 30 kg/m², a previous baby that weighed 4.5 kg or more, previous gestational diabetes, a first degree relative who has diabetes, or one of several ethnic backgrounds that have a high prevalence of diabetes. Screening is usually done at around 26 weeks into the pregnancy. The fasting blood glucose is measured, then they are given a measured dose of glucose to drink, and after two hours their blood glucose is measured again. In our Trust, if the fasting level is greater than 5.4 mmol/L or the 2-hour level is greater than 7.7 mmol/L, then bingo - the diagnosis is Gestational Diabetes. Even if the fasting level is 5.5 or the 2-hour level is 7.8 mmol/L.

For most of the time when I see people in the general diabetes clinics, I have to respond to what the individual brings to the consultation. It could be anyone, with any type of problem, or no problem at all. For this ante-natal clinic, it's always a woman, it's always gestational diabetes, and the advice is always the same at this initial stage. So it's an opportunity for me to hone things over the weeks, to get the right messages delivered as well as I can do it.

My first inclination was to do a bit of research, to make sure that my advice is based on the best available evidence. Two documents were the obvious starting point: the NICE guidelines, and a Diabetes UK document, both from 2008. I also found a couple of academic papers.

There are two main reasons that diabetes in pregnancy needs to be addressed. High maternal blood glucose means that the baby will receive more glucose than necessary via the placenta, and will secrete higher levels of insulin to compensate. Any energy that isn't needed for growth will be laid down as fat, generally around the middle and the shoulders. This can complicate delivery, with a higher risk of the baby getting stuck (shoulder dystocia) and trauma to the mother. The other issue is that after the baby is born, its blood glucose will drop to normal levels, but it may still be producing a lot of insulin. Hence there is a risk of post-natal hypoglycaemia, to the extent that the baby might need a glucose drip for a day or two until it sorts itself out.

After delivery of their baby, mothers are offered a six-week follow up glucose tolerance test, and the good news is that for most mothers the diabetes will have gone away. According to the US National Diabetes Education Program, however, 5 to 10% are found to have diabetes at this point, usually Type 2. Those who don't have diabetes at this stage still have a seven times higher risk of developing Type 2 later in life than if they hadn't had GDM.

I work with a specialist midwife in the clinic, and we take it in turns to deliver our messages. She covers the clinical information, and provides a meter so that the mother can test her blood glucose seven times a day: before each meal, one hour after meals and once before bedtime. Seven times a day, every day until the end of the pregnancy. Some women have had to do this before, some women take it in their stride, some women... well, you can imagine.

So what is my dietary input? In 30 minutes, I cover the following:

• An explanation of Gestational Diabetes, and how food affects blood glucose.
• Reassurance that they haven't developed GDM through eating too much sugar or too many pies.
• The treatments available (diet, tablets, insulin, in that order) and that if you progress to tablets and insulin it's not necessarily because you're doing anything wrong, but this is a progressive condition.
• What is their 'normal' or 'typical' diet? [I love a good diet history, you find out such interesting things]
• Foods that don't significantly affect blood glucose (protein, fat, vegetables/salad, diet drinks, sweeteners, vinegar, herbs, spices) and those that do (sugary and starchy carbohydrates, including fruit, milk and yogurt).
• The difference between sugary and starchy carbohydrate in terms of their effect on blood glucose, and the difference between a lot and a little carbohydrate.
• What a reasonable portion size of carbohydrate should be.
• Check that they are aware of advice on food safety and hygiene, avoiding liver, pate, uncooked shellfish and eggs, blue, soft and unpasteurised cheese, limiting intake of certain fish (swordfish, marlin, tuna), and the suggested restriction on caffeine.
• The benefit of activity on general health and particularly blood glucose control.
• And... any questions, at which point I have an eye on the clock and hope that they are completely overwhelmed with the information so far and will keep their questions for another day.

One of the reasons for clock-watching so closely is that the only time the midwives can run this clinic is on a Friday afternoon, when up to four women are scheduled. Run over a few minutes on each, and we're not going home on time. I can fill an A4 sheet with drawings, graphs and lists of food in clear handwriting faster than you can imagine.

The evidence behind the dietary advice for GDM principally supports a focus on a healthy balanced diet containing low glycaemic index carbohydrate food that is digested quite slowly. I often use the analogy of a sink with a blocked drain, where the level of water in the sink is the blood glucose level. Turn the tap on full blast and the sink overflows; put in the same amount of water (carbs) at a slow trickle and the level will only rise a little. It is all meant to limit the period of time when blood glucose is above the optimum level.

Women often ask how much carbohydrate is enough, or whether cereal A or B is better. I can give a generic answer based on population studies and determination of glycaemic index and glycaemic load (which is the index multiplied by the amount of food). The easiest way to address this question, however, is to point out that they will be testing their blood glucose before and after meals, and after just a few days they will know what 'too much' looks like. 

My dietetic advice differs slightly from the usual 'healthy eating' messages, because short-term glycaemic control is much more important than long-term cholesterol levels, for example. So a high protein, low carb cooked breakfast isn't such a bad thing for the few final weeks of pregnancy, because eggs, bacon, sausage, mushrooms, tomatoes and baked beans hardly contain any carbs at all. Crisps are a comparatively good choice of snack compared with sweets, cake or chocolate, but nuts are even better (as long as there is no history of nut allergy in the family). Reduced fat houmous with vegetables is probably the best choice for a snack that I can think of - low in fat, high in fibre with minimal effect on blood glucose.

Follow up in clinic consists of reviewing the blood glucose numbers recorded, and seeing a) if there are any above the target levels and b) whether these are occasional and random or frequent and showing a pattern. The woman may want advice on better choices for a particular meal, or she may have been experimenting to find the best type and amount of cereal for breakfast. There has been only one woman I can remember who seemed to deliberately ignore dietary advice and who changed nothing. Most are prepared to put up with everything because it's usually for only three months, and it's clearly worth it for an easy delivery and a healthy baby.

A tough week

Victoria Park, Leamington Spa, April 2013

My feet have hardly touched the ground for a week. Getting back from holiday led to a concentrated effort to get some of the more pressing jobs done around the house on Sunday, although there is plenty left to do. I was also anticipating a very full work schedule for this week, and copious amounts of preparation did seem to calm my frayed nerves, which enabled me to deal with everything.

Monday

I managed to navigate successfully to a Community Centre in the city to deliver the first session of my first Structured Education course. Structured Education describes evidence-based courses for groups of people with diabetes, delivering curriculum-led content designed to empower people to manage their diabetes more effectively. It is an intervention that, according to NICE, should be offered to anyone with diabetes, on the basis that the evidence suggests they those completing the course will be healthier, will need less time and resources, and therefore cost the NHS less money.

There are a number of different, validated Structured Education courses, and I guarantee I will be writing more about them in future. They are invariably known by an acronym or abbreviation: DAFNE, JUGGLE, BERT1E, EDWARD, T2ONIC, DESMOND and X-PERT - and there are more. Some are licensed nationally (and internationally), some have been developed by one diabetes centre in order to avoid paying licensing fees. In order to qualify for delivery within NICE guidelines, they must collect and collate evidence to demonstrate that they do in fact deliver positive results in terms of better diabetes management.

We deliver the course in pairs - one Diabetes Specialist Dietitian and one Diabetes Specialist Nurse. I was also being observed by my team leader to make sure I followed the teaching plan as documented (some of the other courses are very much more rigorous in their educator qualifications and peer review). Nine participants plus three carers were expected, and I was daunted by the prospect of such a large group, but as for all events of this sort, not everyone turned up. It went well, and I would almost go as far as to say that I enjoyed it.

Tuesday

On a different university campus I attended a preliminary meeting that introduced several Dietitians and Fitness Instructors to a European research project. It is a multi-centre, multi-national, 3-year project with the primary objective of discovering how two different dietary interventions affect the progression of people in a pre-diabetic state (with Impaired Fasting Glucose and Impaired Glucose Tolerance) to Type 2 diabetes. Secondary end points, no less important, incorporate two different exercise programmes alongside the dietary interventions, and also include assessing weight loss, CHD risk factors, quality of life and more.

The dietary interventions involve two diets that have previously been studied in other European projects (Diabetes Prevention Study and DioGenes): high protein and low glycaemic index (GI) compared with moderate protein and moderate GI. The hypotheses to be proved or disproved are a) that a high protein, high GI diet will be superior in preventing Type 2 diabetes compared with moderate protein, moderate GI diet, and b) that high intensity physical activity will be better than moderate intensity. I have provisionally put myself forward to conduct the dietetic aspect of the group sessions required within the project, but there are many barriers to my involvement, not least being that I am working full time at the moment, and I may be moving away from the region before the three years of the project are up.

Wednesday

The regular ante-natal clinic. I didn't have a great deal to do this time, but I was pleased that my thoughts about the treatment for one person I saw turned out to be supported by the more experienced members of the MDT. If blood glucose readings show high fasting levels first thing in the morning, this suggests adjustment to medication - if your blood glucose is on target when you go to bed but high in the morning, there isn't a lot of scope for fixing things with dietary intake.

I also went to see the convener of the Masters module. The date is approaching when the case study has to be handed in and I'm rather suffering from the pressure of it. It doesn't help that I can't do a great deal on my work PC because it uses such old technology and has various restrictions that prevent effective academic work, and I haven't had any Internet access at home all week because of some fault that can't be rectified easily because the landlord rather than the tenants has the contract with the ISP. I did get some very useful advice on where to focus my efforts with the case study, and with only two weeks to go before the deadline the pain will soon be over.

I also took a trip to the Islet Research Laboratory in Worcester in the evening, but I'm saving that report for a separate post.

Thursday

I attended a 'cross-site' dietetic meeting where Dietitians from the four corners of the Trust gathered to discuss various matters of import, and some other stuff. While we all sit under the umbrella of Dietetics, different disciplines are scattered in many places: Dietitians dealing with inpatients, home enteral feeding, paediatrics, hospital catering and diabetes all reside in different areas as well as being separated over the two hospital sites.

Some of the meeting was useful and interesting; some was not. The most interesting part was a discussion about Prescribing. At present, Dietitians are not legally able to prescribe Prescription Only Medicines (POMs), although we can prescribe nutritional supplements and tube feeding products which come under the heading of 'Borderline Substances.' Following a long drawn out process, Physiotherapists and Podiatrists have achieved a change in the law to allow them to prescribe (after a suitable Masters-level qualification has been awarded), and the BDA is following in their footsteps to try to bring about the same change for Dietitians.

If/when this comes about, it will make a great deal of difference in many dietetic settings. Most pressing is parenteral (intravenous) nutrition, where Dietitians make all the decisions about what should go into the parenteral feed and at what rate and for how long it should be administered, but have to find a doctor or a pharmacist to sign and take responsibility for the prescription, despite knowing nothing about its import. There are many other inpatient situations where it would make a big difference for the timeliness and efficiency of treatment if the Dietitian were able to prescribe, but in my line of work it would mean that a Dietitian could initiate and modify diabetes treatment. This would include tablets, injectable medications and insulin.

At present, it would be illegal for me to make or even to recommend any changes to the administration of a patient's insulin. We get round this by making sure that all I do is discuss what might be done and suggest that the patient decides whether to make a change or not. For example, repeated low blood glucose levels in the early hours of the morning in the absence of other factors might suggest that the basal rate of insulin overnight is too high. I could ask the patient what they thought they might do about that. Decrease the basal rate? That sounds like a good idea.

There are four defined levels of prescribing rights, starting at a Patient Specific Direction which allows a non-prescriber to supply and administer a specific dose of a named drug via a specified route for a named patient. Next up is the Patient Group Direction (PGD), which allows for a wider range of options to supply and administer specific drugs to classes of patients. The diabetes service in my Trust is working to draw up a PGD - it isn't entirely straightforward. What we hope to gain in future is firstly 'Supplementary Prescribing', which is fairly limited but allows prescribing of POMs according to a clinical management plan agreed by doctor, patient and prescriber. The end goal is to become 'Independent Prescribers', where no permission is needed from anyone.

Both supplementary and independent prescribing allow for complete access to the entire formulary of medicines available for prescription in the UK. It is not surprising, therefore, that there is significant work to be done to elicit approval of prescribing rights for Dietitians, including the amendment of an Act of Parliament. It is a worthy goal, but even if achieved it would only be available to a very few of the most senior Dietitians, not least because of the cost and difficulty of the Prescribing qualification, and the burden of such serious responsibility.

Friday

A much easier day ends a week in which my weekday house suffered the breakdown of the fridge freezer (it was replaced but all my frozen food was lost) and no Internet access. I have had to spend significant time after work and in the Medical Library during the week in order to research my case study and do all the other online tasks that are essential in this modern world. I am not optimistic that home Internet service will be resumed next week, but you never know.

Gastroparesis (part 2)

Groombridge Place, June 2013

In part 1, I described the symptoms of gastroparesis, what might be causing it in someone with diabetes, and the problems that arise - gastrointestinal symptoms, poor glycaemic control, malnutrition and weight loss, and depression. Now I'm going to write about possible treatments.

Nerve damage, if that's what is causing the problem, is irreversible. We can't (yet) mend nerves: once they're gone, they're gone. There doesn't seem to be an option to fix the faulty pacemaker cells either. But it is always useful to run through a list of things that will definitely not be helping. For example, opiate drugs are known for their constipating effects, and should be replaced with alternative painkillers if pain relief is necessary. Cigarette smoking has been shown to delay the gastric emptying of solids. Unfortunately, high blood sugar has also been shown to significantly delay gastric emptying, which is of no comfort to the person with diabetes who has been trying unsuccessfully to manage wild swings in blood sugar in the face of unyielding opposition from the gastroparesis itself. So I wouldn't bother opening that particular can of worms.

There are three methods used to help improve gastric emptying: pharmacotherapy (i.e. drugs), diet and surgical approaches. Two types of drugs can help with symptoms: prokinetics, which help to speed the intestinal contents on their way, and anti-emetics, which are used to prevent nausea and vomiting. These are routinely used, but changes to diet can be more effective than the medicines.

The Glycaemic Index (GI) is often used to assist with blood glucose control and weight management, and describes the speed at which carbohydrates are digested. High GI foods e.g. foods containing large proportions of monosaccharides and disaccharides (sugars) are digested quickly, and their glucose payload can reach the bloodstream before subcutaneous insulin has had time to get there, causing blood glucose to rise beyond the desired range. Low GI foods (complex starchy carbohydrates) such as oats and pulses are digested more slowly, and therefore deliver glucose to the blood slowly and more controllably, and keep you feeling fuller for longer. Unlike the majority of people with diabetes, high GI foods may help someone with diagnosed gastroparesis. These foods tend to contain simple sugars or processed carbohydrate and little fat and fibre - sweets, white bread, mashed potato.

Another good reason to avoid fibre, apart from its role in slowing gastric emptying, is that as it hangs around in the stomach it can contribute to the formation of unwanted fibrous masses called bezoars. The disadvantage of avoiding fat, however, is that someone with chronic gastroparesis is at risk of malnutrition, and could do with the calories supplied by energy-dense fatty food.

The diabetologist who referred the patient with gastroparesis to me suggested that a low carbohydrate diet might help reduce the volatility in blood glucose levels. The problem with this approach is that taking out the carbs leaves an energy deficit that can either be filled by protein or fat. Protein increases feelings of satiety, which is certainly not what we want, and fat slows gastric emptying. Blood glucose levels may be better managed with a greater proportion of high GI carbohydrate, which might actually be released from the stomach in a more predictable manner.

Research suggests other dietary recommendations, both to relieve symptoms and to maintain nutritional status. Small frequent meals are digested better than three large meals a day, and 'particle size' makes a difference - food should be chewed well, and liquids seem to leave the stomach more easily than solids. A patient might be prescribed three liquid supplements a day, adding a much needed 900 calories. Positioning during a meal, and sitting up and/or walking post-meal can promote gastric emptying; alcohol and carbonated drinks tend to exacerbate symptoms of bloating.

Placing a feeding tube below the stomach and pylorus in the jejunum (upper small intestine) allows nutrition to bypass the problem area, but brings with it the risk of infections and the inconvenience of having to be hooked up to a feed pump for hours at a time - jejunal feeding has to be much slower than feeding into the stomach. If nutritional status continues to decline, intravenous (parenteral) feeding is a possibility, but brings a whole new range of potential complications.

As well as addressing symptoms and nutrition, there are those pesky blood sugars to consider as well. Eating a meal containing carbohydrate requires a matching dose of insulin in order to maintain blood glucose within the desirable range, but we have seen that giving the insulin at the usual time (before, during or immediately after the meal) doesn't work if the glucose hits the bloodstream over a period greater than the lifetime of the insulin. So we could try splitting the insulin dose, perhaps giving 30% of the total dose just after eating, and the remaining 70% after an hour, or two, or whenever we think blood glucose is rising.

If you don't want to end up as a pincushion, this type of insulin regimen can be managed much more comfortably and conveniently with an insulin pump, which can be programmed to deliver insulin at whatever rate you desire. Delivering 6 units of insulin at one-tenth of a unit every five minutes over five hours can't be done with conventional insulin injection devices, but is a piece of cake with a pump.

Unfortunately the NHS doesn't fund Continuous Glucose Monitoring (CGM) systems, which have a subcutaneous sensor that samples interstitial fluid every five minutes linked to a device that translates the reading into an estimated blood glucose level. We lend these systems to patients to wear for just seven days at a time when we can't work out what their blood glucose is doing. Otherwise, users have to buy the kit and consumables themselves, which works out rather expensive. Although not mentioned in the research papers I have read about this condition, I think that CGM in combination with an insulin pump would be a valuable and effective approach to managing blood glucose with gastroparesis.

Finally, there are more technical and innovative options to try.

• Gastric electrical stimulation (GES) was approved in 2000 in the USA. Similar to a heart pacemaker, the GES device is implanted next to the stomach and mimics the role of the gastric pacemaker cells, stimulating and enhancing vagal function and muscle tone. 
• Botox (Clostridium botulinum toxin) is a muscle relaxant used cosmetically to reduce facial wrinkles, but will relax muscles elsewhere to therapeutic effect. Injecting Botox into the pyloric sphincter may cause it to relax sufficiently to allow better gastric emptying, but trials have shown this effect to be short-lived. 
• In future, that universally-cited panacea 'stem cell therapy' may be relevant, providing a way to replace or rejuvenate those faulty pacemaker cells of Cajal.

Another local meeting

Durnstein, October 2012

I continue to attend meetings of the grumpiest Diabetes UK local group, purely because of the occasional useful speaker. This time they had advertised a talk about 'The D-Diet', so I arrived nice and cynical, with my Diabetes Dietitian hat on, ready to do battle with some nutter with a passion for some crazy diet or other.

In fact I couldn't argue with the lecture in terms of nutrition. The speaker was from an animal welfare charity, which had clearly done their research and realised that their target audience could include people with diabetes as well as animal lovers - the diet for diabetics being advocated was vegan. And not just vegan food, but low-fat vegan food. And not just low-fat vegan food, but low-fat, low-glycaemic index (GI) vegan food.

It's usually possible to sustain a healthy vegan diet, forsaking all animal products including meat, dairy, eggs and even honey. A vegan diet is by definition low in saturated fat, and generally high in fibre, so low-fat and low-GI aren't too hard to achieve unless you go crazy with veggie burgers and banana fritters. The main nutritional risks are likely to be deficiency in vitamin B12, iodine, vitamin D and omega-3 essential fatty acids.

• B12 is only found naturally in animal products, although there are some fortified foods like marmite, so supplements are often needed. 
• Iodine is mainly in seafood - salt used to be fortified, but nowadays in the UK it isn't, so many people are deficient in iodine, and not just vegans. Green leafy vegetables and seaweeds like kelp are recommended vegan sources.
• Vitamin D is a hot topic for all of us, because the cancer campaigners have been so successful in persuading us to cover up, stay out of the sun and use high factor sun blocking products. This has helped no end in reducing the incidence of skin cancer, but the main source of vitamin D is from sunlight, so deficiency isn't just a vegan problem. A bit of safe exposure to sun, plus fortified foods and supplements are the answer.
• The omega 3 essential fatty acids are mainly found in fish, but also seeds and nuts and some marine algae - I'm not sure whether vegans consider algae to be animals or not.

I'm sure that a low-fat, low-GI vegan diet would be beneficial in terms of blood glucose control and cardiovascular health for most people, whether Type 1, Type 2, or not diabetic at all. With my cynical hat on, however, I think the main benefits would arise from weight loss due to the difficulty of working out what on earth to have for dinner, and then packing enough calories into a diet of wholewheat grains and high-fibre pulses, vegetables and fruit (but only low-GI vegetables and fruit). It would challenge a committed animal lover who had an active interest in food. The idea of anyone in this audience, mostly aged 60 and upwards, changing their diet to beans, tofu and kelp - with a sprinkling of hemp and linseeds on their natural oat cereal, then tucking into their Quorn and bean dinner and soya dessert - well, let's just say it seems very unlikely.

I think the audience probably agreed with me, because the questions at the end weren't really questions. One lady said she'd been a vegetarian nearly all her life, and she had still developed Type 1 diabetes, although she acknowledged that maybe it had arrived later in her life than it might have. Another man advised the speaker to read New Scientist magazine, because there were much more helpful developments towards curing diabetes in that publication. A third claimed that Type 2 diabetes had much more to do with genetics than lifestyle, and told someone else in the audience to 'shut up' when they tried to interrupt. They really are an unattractive bunch. And still nobody has voluntarily talked to me, or asked me my name or what I do for a living.

The group committee are going to ask the members for feedback about how we find the meetings, and what kind of activities or speakers are wanted. I haven't yet decided what I might say.