On 24 May 2010 my wife drove me to our family doctor’s surgery and told me not to emerge without a diagnosis. Over the previous two or so months I had started to feel increasingly thirsty, and I had not only started to drink water all day but I had also started to pee all day. And all night. I was losing weight, my muscles were wasting away with a strange ‘crackling’ ache, and I felt tired all the time. I even woke in the morning feeling tired. Clearly, my wife said, I had developed diabetes, and she was irritated by my assurances that if we ignored the symptoms they might go away. So it was she who made the appointment to see our doctor, and it was she who drove us to the surgery to ensure I kept it.
I told my doctor what was happening and, echoing my wife, he said it sounded a bit like diabetes. I was forced to agree. So he performed a spot urine test, and there it was – glucose in my urine (‘sugar in the water,’ as he put it). I was diabetic. He then sent a blood sample to the lab, which shortly revealed a fasting blood glucose level of 19.3 mmol/l (normal range 3.9 to 5.5) and an HbA1c of 13.3 per cent (normal range 4 to 5.9; see later). I was very diabetic indeed. Type 2.
My story should thereafter have been routine. Thanks to a good wife and a good doctor a correct diagnosis had been made, and I was surely on the road to recovery. But I was then told to eat breakfast.
The authorities: Diabetes UK is the major diabetic charity in Britain. It was founded in 1934 as the Diabetic Association by H.G. Wells, the author, and by Dr R.D. Lawrence, a prominent physician, both of whom were diabetic. In 2013 its membership exceeded 300,000 people and its income was £38.8 million.1 It is universally respected, both for its research and for its support for patients. Here is some dietary advice from its Eating Well With Type 2 Diabetes:
Eat three meals a day [in bold in the publication]. Avoid skipping meals and space out your breakfast, lunch and evening meal over the day. This will not only help control your appetite but will also help control your blood glucose levels.2
And in case we don’t get the message, Diabetes UK and the NHS have combined to reiterate, in red in the joint publication:
Don’t skip breakfast.3
The American Diabetes Association (ADA) is another impressive body. It has a membership of 441,000 and an annual turnover of $222 million,4 and it recommends an even more generous frequency of eating, suggesting that diabetics eat: ‘breakfast, lunch, dinner, and two snacks’.5
The diabetic charities certainly believe in frequent meals, and equally they believe in breakfast. So when, on diagnosing my diabetes, my doctor recommended I eat three meals a day including breakfast – as well as frequent snacks – he was only following the internationally agreed guidelines.
My glucometer: I might never have discovered how bizarre was that advice and those guidelines if our family doctor hadn’t also given me a personal glucose meter or glucometer. This is a hand-held device, not much larger than a mobile phone, that allows people to monitor their fingerprick blood glucose levels several times a day. Because it provides the patient with direct access to the mysteries of their own disease, the glucometer is the diabetic equivalent of the ninety-five theses Martin Luther reportedly hammered into the church door in Wittenberg: it allows the patient to bypass the doctor, the NHS and the diabetes charities as directly as Luther once bypassed the pope, so patients can test the official advice against their own blood glucose levels.
On using my glucometer I soon made an unexpected discovery. I found that my blood glucose levels were dismayingly high first thing in the morning, but – even worse – they would rise much further, indeed hazardously, if I ate breakfast. I didn’t feel ill with those elevated levels (glucose in high concentrations is a silent killer), but over time they would be killing me.
Yet if I skipped breakfast, my blood glucose levels would fall to normal over the morning. After lunch and dinner, of course, they would rise again, but noticeably less than after breakfast. Since high blood glucose levels are unsafe, I had discovered that, as a type 2 diabetic, breakfast was the most dangerous meal of my day. On reviewing the research journals, moreover, I found I hadn’t been the first person to make that discovery. One of the pioneers was Professor Jens Christiansen from the department of medicine at the University of Aarhus in Denmark.
Professor Christiansen’s experiment: Figure 1.1 shows the typical twenty-four-hour blood glucose profile of a group of healthy young people who eat three meals a day.6
As you can see, blood glucose levels between meals normally run at around 4–5 mmol/l. Within an hour of eating, however, those levels rise to well over 6. Yet within six hours of eating, those levels fall back to around 4–5.fn1
To see what happens in type 2 diabetes, Professor Christiansen and his colleagues monitored the blood glucose levels of thirteen adult patients. On some days he asked his thirteen patients to skip breakfast, whereas on others he asked them to eat it. To ensure that all other conditions were unchanged, he asked his patients on breakfast-free days to compensate by eating more for lunch and dinner, so their daily energy intake was the same. Figure 1.2A shows his patients’ blood glucose levels on the days they ate breakfast.7
FIGURE 1.1
Glucose levels in healthy people who eat three typical meals a day.
21 healthy subjects eating typical meals were studied and their results averaged. The arrows indicate that breakfast was served at 7.30, lunch at 12.15 and dinner at 18.00. The results are from interstitial fluid, which is similar to blood plasma and serum. (Less energy was ingested at breakfast than at the other two meals.)
As you can see, these diabetics start their days in a hazardous state: their overnight fasting blood glucose levels are not much short of 7.0 mmol/l. But look what happens after breakfast. When patients are fed a full breakfast of about 600 calories (between a quarter and a third of a day’s intake of energy) their blood glucose levels spike at around 10.5. These come down within four hours, but that spike will have done the patients no good because spikes in blood glucose levels will double a person’s chances of dying from heart attacks and strokes.8
Moreover, Professor Christiansen also showed that, over the rest of the day, the breakfast eaters’ blood glucose levels remain volatile; and such volatility not only adds a further risk of the two cardiovascular diseases of heart attacks and strokes, it also increases the risk of developing a gamut of diabetic complications including blindness, renal failure and the need for limb amputations.9
FIGURE 1.2A
Plasma glucose
