Wil Dubois

Welcome back to our weekly diabetes advice column, Ask D’Mine — with your host veteran type 1, diabetes author and educator Wil Dubois. This week, Wil takes on a couple of question about low-carb, high-fat diets and some not-so-pleasant complications that just add more to the mixed health bag people with diabetes are already carrying. Read on to find out what might help…

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Bhassker, type 2 from India, writes: As a 22-year diabetic on insulin (both Humalog and Lantus) and a recent convert to LCHF (Low-Carb High-Fat diet), I would like your opinion on whether good control of blood sugars with a little help from insulins is better than a very tight control by diet alone. My HbA1c is 6.4 and I am aiming to go below 6.

Wil@Ask D’Mine answers: I think Omnes viae Romam ducunt. That’s Latin for “all roads lead to Rome.” It’s also my philosophy for diabetes control. There’s no one right, or better, or worse way to get to the destination of the city of control. Any road, any therapy, that gets you where you are going is a good one. The trick is to find the one that’s the easiest and most effective path for you.

But it’s funny you’re writing to me from India, not Italy, because it seems to me that with an A1C of 6.4 you’ve already arrived at your destination. That’s an enviable A1C that would make most people happy. Why do you want to be under 6?

My feeling is that under 6 puts you at risk of being six feet under.lchf

Especially for insulin users, most people with low A1Cs have a lot of hypos (the radical low-carb folks will disagree with me on that), and those buggers can kill you—the hypos that is, not the radical low-carb crowd. So I guess my opinion is that if you really want an A1C in the non-diabetic range, the onlysafe way to do it is with diet alone, not using any medications whatsoever that artificially lower blood sugar.

Now, as you state that you are a recent convert to the low-carb diet, I want to caution you that you might need to lower your insulin doses. You likely won’t need as much to cover the lower impact meals. Can you do away with them and still get even lower sugar? Not to rain on your Roman Road, but frankly, I’m skeptical that someone who requires two insulins now can get his A1C even lower using diet alone. But of course, that depends on how much insulin you’ve been using and how high-carb you were eating before. Your weight also comes into play. If you were rather… ah… hefty before and lose a bunch of weight on the LCHF diet, that will change your insulin resistance. So who knows?

Oh, but please keep an eye on your cholesterol, OK? It’s heart attacks that do in most type 2s. Heart attack risk is tied to cholesterol, and high-fat diets can increase cholesterol. Or, as my Grandpa was fond of saying, “If it’s not one damned thing, it’s another.”

Cary, type awesome from Nebraska, writes: My son was diagnosed with T1D in April of 2014 at age 23. He is able to control his blood sugars well (on Omnipod) and in fact his last A1C was 6.0. The bad news is that almost immediately upon diagnosis he began having severe foot pain and stomach issues. He is on 1800 mg of gabapentin daily and has just been diagnosed with abnormal gastric emptying. As if that weren’t enough, in September he was diagnosed with thyroid cancer and had it removed. Subsequently, he had to take a medical leave from law school, but he plans on returning in January. He continues to have foot pain, although it is somewhat better. Why is this happening at such an early stage? Is this what he has to look forward to forever?  

Wil@Ask D’Mine answers: Well, that sucks. You are correct that the diabetes should not have had time to mess up his stomach or to trigger neuropathy, which I infer he has from the max-dose gabapentin he’s taking for the foot pain. The common wisdom is that both of these kinds of complications take many years of elevated blood sugars to trigger. And while it’s not unusual to find neuropathy present at diagnosis in type 2s—because type 2 can go unrecognized for many years—in type 1s, we don’t normally see nerve damage until ten years or more after diagnosis. It also tends to creep up a little at a time, rather than coming on like a storm. So something unusual is going on with your son, for sure.

Two possibilities jump to mind, and you’re not going to like one of them even one little bit. Was your law school son a bit of bad boy when he was younger? Because there’s a type of neuropathy called toxic neuropathy that’s caused by exposure to toxic chemicals… and… umm… some recreational drugs. And we also see that methanol ingestion can poison the pancreas. Granted, it’s a stretch, but it could be that his problems share a root cause of some sort of toxic exposure, either accidental or as the result of misguided recreational forays into the world of dangerous chemicals, rather than from biological causes. I’m just sayin’….

The other possibility, that you’ll like better, is that the neuropathy (and the gastric issues, which are also nerve-related) might be tied to the cancer rather than to the diabetes. Did he have any chemo? Although thyroid cancer is usually treated without it, in some cases it’s advisable, and some chemo drugs do cause neuropathy, and D-folks with cancer seem to be at higher risk for this side effect. And even if he didn’t need chemo, I can’t help but wonder if the combination of both the cancer and the diabetes at the same time, and at the same age, might somehow be telling us something odd is going on that I’m not smart enough to figure out for you.

But what I am smart enough to know is that nothing is forever, and in this case that’s a good thing. Our bodies and our diseases are not carved into stone. They are dynamic, alive, ever changing—as are our tools and medications.fortune

I’ll not kid you; historically neuropathy has been regarded as a one-way street. In fact, your son’s gabapentin doesn’t treat the neuropathy; it’s palliative therapy, which means it just masks the pain, at least somewhat, but doesn’t address the issue at hand. But I believe that will change. Why?

Because there are over 20 million people in the USA who have one of the flavors of neuropathy (there are more than 100 sub-types). That makes neuropathy almost as big a deal as diabetes itself. I can smell the money, can’t you? And if we can, you can bet your boots so too can Pfizer, Novartis, Sanofi, Roche, Merck, GlaxoSmithKline, AstraZeneca, and the rest of the pack.

So, sorry, I don’t know why this happened to him as such a young age, and so soon after diagnosis. But I promise you, this is not what he has to look forward to forever. Today is the darkest time of the night. He has many dawns ahead.

Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

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This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.