From the perspective of this Substack, the interesting thing is the metabolic impact of the hormone treatment. As of this week I am 11kg (24.25lbs) heavier than before the hormone treatment began in October 2025. My HbA1c, though, is largely unchanged (33mmol/mol last October, 34mmol/mol now, or 5.2% and 5.3% respectively.) That’s a good result.

The other primary impact has been on strength/fatigue. I try to get to the gym a couple of times a week for resistance training using a routine suggested by a specialist at Prostate Scotland but there are days when it just isn’t going to happen.

My current feeling is that sticking to my usual diet, keeping up the gym work and letting the hormone impact fade away should mean that by the end of this year I will be back in at least some of the shirts and trousers that were a bit baggy last year but are currently too tight.

The bigger win is that I seem to have come through this with both the cancer and the type-2 diabetes in remission. Yay!

A reminder that I had no symptoms and the cancer was found largely by chance and the thoroughness of a specialist checking all the possibilities. I invite all men reading this (or those with men as significant others in their life) to consider asking their doctor for a PSA test.

I said that I wouldn’t turn this into a cancer blog and I haven’t, but I want to return to the physical impacts of the treatment as they relate - possibly - to my T2D experiences.

As I’ve written before, my T2D is coded as ‘in remission.’ I got there by virtue of a number of things, one of which was losing a great deal of weight. Thanks to the hormone implants I have put on around 7kg (say 15lbs) in 4 1/2 months without making any significant lifestyle changes; I walk a lot most days and I have done at least some resistance work with dumbbells at home. The medical team assure me that this weight gain is common; despite it, I’m still wearing the same jeans and mostly the same shirts.

What strikes me is that, while the early entries here were to do with changes that I made to my lifestyle to achieve a particular goal, the cancer treatment indicates that you can do the ‘right’ things but still be frustrated by externally induced metabolic change.

The hormones cut off the making and distribution of testosterone which in turn starves the cancer. As I understand it, the physical impacts of fluid retention, especially around the tummy, and also loss of muscle mass combine to drive the weight gain. Although I understand this, and my daughter rightly chides me that my priority is getting rid of the cancer, nevertheless I can’t help but be frustrated by the weight gain and also to worry about my HbA1c and other indicators going in the wrong direction. I’ll find out more about that over the next three months or so.

I also have to say that daily visits to radiotherapy and the people I met and chatted to there and also in Maggie’s Centre put a lot into perspective: many are dealing with far more difficult and challenging circumstances than me and are doing so with cheerfulness and stoicism.

In any event, my focus now is on dealing with that muscle loss, and getting back to where I was as recently as October 2025.

At my lowest recent weight I was running a lot. I’ve since had to stop running regularly because of knee problems and my weight stabilised in a range I was content with. However it has been creeping up recently. My first reaction to the creeping weight gain was to berate myself for letting my diet go, even though I haven’t actually changed my diet, and I fell into the trap of writing in my health journal about self-control.

Incidentally, I think one of the key motivators in my remission was keeping a journal and tracking progress to self-imposed, practical targets - such as the waist size of my trousers.

However, it struck me yesterday that one very obvious change has been a hormone implant as part of my prostate cancer treatment, so I checked the known side effects of the hormone, Leuprolelin (also know as Prostap, Staladex and Lupron). As well as night sweats and tiredness which I have experienced, there is also weight gain, especially around the waist, caused by

• increased appetite and

• fluid retention

This reminded me of the two things that are the point of this post, the morals of the story: first, the importance of systems thinking, which is to say not thinking in terms of cause and effect but rather about correlations within the metabolic system; secondly, it is not about will power or self-discipline per se, which are likely to yield to external factors, like hormone implants.

Courage mon braves.

The numbers themselves also generated discussion, particularly around LDL and thus statins. My experience of doctors in discussions about these has been mixed, not in the sense of some doctors being in some way ‘better’ than others but because clinical opinion varies within a range without a single consensus point of view. For example, one of my doctors, now retired, did not pay much attention to the numbers themselves but to the ratios of several of them to each other (and my ratios are generally good to optimal); others have looked at the LDL/Total Cholesterol numbers and said ‘too high’ regardless of the ratios.

In my case, HDL and tri-glycerides are where they should be but my LDL rose unexpectedly a couple of years ago and stayed there.

My doctor yesterday said he wasn’t too bothered by my numbers given my age and general health and, moreover, attention was shifting away from the numbers per se and towards the mechanisms of how LDL binds. Unfortunately I didn’t get a reference for that and will have to hunt it out.

As expected, we then got into the subject of statins. Again he surprised me by saying that he didn’t have strong views on the prescription of statins but thought there were benefits. He then sent me a set of slides from NICE [https://www.nice.org.uk/] and suggested I think about it and make up my own mind.

The slides (PDF here) make interesting reading. They set out quite clearly the benefits of statins for different QRISK scores. In my case, I fall between two of the examples, but when you look at the numbers you see that for every hundred people with my risk score:

• 65-70% will not have heart disease or a stroke in the next ten years regardless of whether or not they take statins;

• 19-22% will have heart disease or a stroke in the next ten years regardless of whether or not they take statins;

• 11-13% will be protected from heart disease or stroke because of statins.

The inflexion point for the decision is therefore whether or not I might be in that 11-13% or, put another way, if I’m in the 87-89% of the population for whom statins make no difference with my calculated risk score (which is in part based on my T2D which is ‘in remission’).

Unless I’m missing something.

My most recent annual blood test - yesterday - produced exactly the result I wanted: HbA1c 33mmol/mol or 5.2%. That means that it is 2.5 years since my doctor told me my Type-2 Diabetes was officially in remission. Remission has a technical meaning of HbA1c <48mmol/mol, sustained for a year and achieved without resort to any medication.

The only blip in the numbers is that my total cholesterol remains higher than recommended which means I’ll need to have the statin chat with the doctor again. The total cholesterol number is entirely driven by LDL - my HDL and triglyceride numbers remain good. My ratios are generally fine as well.

Earlier this year I took a look at research on what dietary factors tend to increase LDL and compared it to my actual diet. The only two things that seemed associated were solid fats (in the form of my fondness for Stilton) and non-filter coffee prepared using an Italian coffee pot. As an experiment I cut both from my diet; since my LDL is only marginally down on last year, I conclude that they were not the primary changes of my otherwise unexplained LDL rise which therefore must be, in some loose sense, metabolic.

To date I have resisted statins because I’m not wholly convinced by the evidence for them as protective agents, however there is some research on their preventative effects regarding advanced prostate cancer. I do not have advanced prostate cancer, I have early-stage (type T2C) prostate cancer for which I am about to begin treatment, but obviously I want to take every means available to me to ensure that the treatment is a success.

So I think that when I see my GP to talk all of this through in a week or so, I will agree to statins, so long as they fit within the treatment regime for the cancer, which will be hormones plus radiotherapy.

Meanwhile, I am happy that I can continue with my current low-carb diet with the occasional treat, and my general lifestyle without having to worry about a recurrence in T2D. I am even still in the 30” waist Levis I bought a couple of years ago.

For clarity, my dietary approach generally is:

• no free sugars, though plenty of fresh fruit;

• minimal to no potatoes, pasta or rice and a preference for home-baked or sourdough bread (because the carbs ferment to CO2 and alcohol);

• A salad rather than fries with a meal if eating out;

• no snacking between around 18.30 and 08.00;

• cooking from fresh most of the time;

• No ultra-processed foods

• Plenty of walking since I have been unable to run for a while.

• No guilt about treats, so long as they truly are treats.

It seems that I have prostate cancer. It has been caught early, is localised and is eminently treatable, but somehow the T2D is a less pressing thing on my mind.

I do not intend to turn this into a cancer diary, that’s not what you happy few signed up for, but I am keeping a cancer diary of sorts on my main blog. You’ll find it here if you are interested: https://www.cosmicsurfer.co.uk/category/cancer/

But, to reiterate, I’m fine, I just need a wee bit of treatment in the near term.

Ian.

This is a low frequency Substack because, in the general run of things, there is not much that changes with Type-2 Diabetes in short spaces of time except, in my case, in the first 4 months after diagnosis in which I went cold turkey on carbs and dropped my HbA1c into the normal range, where it remains. I’m sure that there are people who could parlay this into weekly posts and maybe even a podcast too, but I am not one of those people.

Since my last post in September 2024, my only health scare was a UTI that got serious very quickly and landed me in hospital on a drip overnight in late November. That had its consequences, but not related to the focus of this Substack. My time mainly has been spent revising, polishing and proofing my next book, my second collection of off-kilter vampire tales, The Butcher Bird, due out early this year (if you like vampires and Hermann Hesse, this will be the book for you; buy my books, etc.)

However, I have had two things on my mind that are related to my theme here. The first is the notion that my diabetes is in remission. At what point does ‘in remission’ become ‘not diabetic?' There is a lurking presumption there that T2D is permanent state that subsists beyond the annual numbers in the blood test. I wonder if this will change in the general rethinking of T2D that has been going on. It would certainly help with the cost of travel insurance if it did.

The second thing is something that jumped out to me when I was journaling on my experience so far and setting myself some targets for this year - my weight has been slowly creeping up and I want to get it back down, although I’m still in 30” waist Levis, which is good. My doctor occasionally calls for the statins conversation, pointing to my age, the precautionary principle, and my cholesterol numbers; so far I have resisted the call. Aside from my general scepticism about statins and the precautionary principle, I noticed that my LDL/non-HDL cholesterol rose over six months in 2023 when my weight was falling and I was running a lot. I have no idea why it rose and I’m interested that it did. Something happened and I don’t know what, though I suspect it was metabolic rather than dietary. My HDL and Triglycerides were steady and my ratios were fine.

As with a lot of this field, there is always re-evaluation underway of the importance of LDL/HDL/total cholesterol on a number of things. There is an argument that it is not the absolute numbers of LDL/HDL/total cholesterol/triglycerides that matter so much as the ratios of each to the other.

In any event, my next check up is not until August/September 2025 and I want to get my weight back down to where it was two years ago, which means losing 5kg (11lbs). Since my diet remains very-low carb, this generally means eating smaller portions; however, as an experiment, I am also going to cut solid fats (ie fats solid at room temperature, mainly cheese) and revert to filter rather than non-filter coffee (see Schoeneck and Iggman at either https://pubmed.ncbi.nlm.nih.gov/33762150 or https://www.nmcd-journal.com/article/S0939-4753(21)00002-8/fulltext), although I tend towards tea most of the time. My aim is to see if it shifts the LDL number.

Also, after a year on the sidelines, it is time to find out if my knee problems have healed enough to let me take up running again, even if only on a treadmill.

More as I get it, but probably not until Autumn, by which time I hope to be well into writing my third novel.

Nearly 3 years ago, in late October 2021, my doctor called to say that my fasting HbA1c had passed into the diabetic range – 54mmol/ml (7.1%). By February 2022 I had lost 18kg (40lb) and my HbA1c was 37mmol/ml (5.5%).  In April 2023 I had lost a further 10 kg (22lb) and my HbA1c was 31mmol/ml (5%).

At no time during that period or subsequently have I taken any medication for diabetes or weight loss. My type-2 diabetes meets the definition of being ‘in remission’ and that’s what is on my medical record. I am now in my second/third year of remission depending how you count it. I have no foot or retinopathy issues.

A year ago I would have said (and did say here) that the principal cause of the change was a low-carb diet. That is what I thought I was doing when I decided to address the issue by not putting sugars, especially refined sugars, into my body. Now I would take a more nuanced view. It is certainly true that I adopted a low-carb diet, though not a full keto diet, but I also cooked almost everything from fresh and reduced my portion sizes. I did not snack or, if I did, it was on nuts or fruit. I did not, and do not, eat between around 18.30 in the evening and 08.30 the following morning. In time I increased the amount of exercise I do. I also cut out most alcohol for several months.

I paid attention to the glycaemic index and glycaemic load of the carbs that I did eat.

I did one other thing that I now suspect was the single most important thing of them all: I kept a journal and set myself simple targets, notably to get from 38” waist jeans to 28” waist jeans (I failed, I’ve been in 30” waist jeans since October 2022, though I did have to punch new holes in my belt as I slimmed down.)

All of the above approaches are becoming received wisdom, but they were not when I started. And it is true that whatever it was I did worked. But I’m hesitant now to ascribe a single cause and effect; I now think it was the combination of things that pushed my diabetes into remission.

Now, three years on, I’m not trying to beat a diabetes diagnosis, I’m trying to maintain the state of remission. I allow some carbs in my diet, though I still avoid potatoes, pasta and rice, and I’m more relaxed about eating a desert at a restaurant, for example.

To be clear, none of this is advice, just a statement of what worked for me. I am a white man in my 60s in Scotland; what I did may not work for people with different metabolisms or medical conditions, though there is growing evidence that the approach I took works for an awful lot of people. My diabetes went away without any medication by making changes to what I ate. There are issues with that, especially economic and social inequality issues regarding access to whole foods, and I’m lucky to be in Europe where there is not so much crap in the processed food if you have no alternative but to eat it.

These days, I wonder about other things that are likely to crop up here in future. For example,

• I avoid rice but there are cultures built on rice as a staple which did not have any historical issues with diabetes. Perhaps it isn’t the rice but the quantity of rice? My experience visiting China was that rice was not served in the quantity it is here. Or perhaps it is the refined nature of the rice usually found here in the west?

• One of the problems with supermarket bread and baked goods in the UK is that they are heavily processed. In particular, the industrial bread baking process does not allow enough time for yeast to work on the carbohydrates in the flour and convert them. When I make bread myself I use flour, water and yeast with a dash of salt and olive oil. I allow a long rise to maximise contact between yeast and carbs/sugars. There are no vegetable oils or emulsifiers or other chemical additives. Maybe it isn’t bread as such but industrial bread that’s the problem?

• Why does so much low-carb/keto advice sound like evangelism bordering on cultic behaviour?

• Diabetes is identified and tracked through blood glucose, but that is a symptom rather than a cause, I think; diabetes is a symptom of an insulin problem. Diabetes is, or appears to be, an outcome of activity in the metabolic system and thus a systems-thinking approach should dominate rather than naïve cause and effect model.

• Glycaemic Index and Glycaemic Load were useful guides when I was dealing with the diagnosis, but in retrospect I’m not sure how useful they really are. This is because they reduce foods to a single chemical constituent and do not give any regard to, for example, fibre content or the physiological responses to the act of eating itself, beginning with the action of saliva and chewing.

And so forth.

This is not a high frequency substack and it will remain free. My aim continues to be to publish the occasional post when I think I might have something to say. Feel free to tell your friends about me if they might be interested.

My liver and kidney functions are fine. My total cholesterol is up but ratios are more or less where they should be. In particular my triglyceride/HDL ratio is 1 (where ‘ideal’ is defined as a ratio of 2 or less.)

I’m happy with that. The trick, as always, is to maintain it.

The one major difference between this year and last is a knee problem that has stopped me running since February. In 2023 I was running two or three 5Ks per week with a 10k most weekends. I’ve been to the swimming pool and the gym this year, but the physiological impacts aren’t the same as running. I have managed some short jogs on a treadmill without reaction, but I’m not ready for outdoors and harder surfaces yet.

Another difference this year, though maybe not so significant, is that I’ve relaxed my diet a little. I don’t mean that I’ve gone crazy, just that I’m not so strict on myself as I was when pushing the t2d into remission. As I’ve written here previously, having got to this position it’s now about maintenance. Having said that, I continue to avoid potatoes, pasta and rice, only having them very occasionally in, for example, restaurants. I’m just a bit more relaxed about the occasional LiDL almond croissant.

My weight has crept up though, so I’ve set myself a target to get back to last year’s average over the next couple of months.

***

This week, I saw a video in Tiktok (I know) that referenced a study on t2d and consumption of fruit and vegetables. I normally scroll past that stuff but in this case the creator was a doctor in the UK. The thrust of the video, per the on-screen captions, was that certain fruit and vegetables were ‘preventative’ or ‘causative’ of t2d. For reasons that will become clear, I’m not linking to the Tiktok.

It was immediately apparent from a screenshot of the study that it was not about cause and effect at all but about association and therefore correlation. To that extent the video, even though it was by a doctor, was misleading. So I did what I often do: I went and read the study which is available online (links to an online pdf).

It's fair to say that the study, a metanalysis, was not written with a lay audience in mind and I skipped the denser statistical analysis.

The key finding was that intake of (i) fruit and vegetables and (ii) fruit alone is associated with a 7% reduction in t2d risk. There was also suggestive evidence that some of these foods were more associated with risk reduction than others while some were associated with increased risk. Note, it’s about risk not cause. I think the doctor on Tiktok should have explained this a lot better rather than jumping to the clickbait.

The specific fruits associated with reduced risk were apples, apples and pears together, blueberries, grapes and raisins.

The specific fruits and vegetables associated with increased risk were cantaloupe, fruit drinks, fruit juice, potatoes, brussels sprouts and cauliflower.

Note, the results were based on eating the foods at least three times per week.

A number of products had no significant statistical significance either way, including bananas.

The authors of the paper note a number of possible confounding variables that could skew the results. That being said, the general finding was a message to increase fruit consumption with a bias towards certain fruits, subject to further research.

I haven’t taken the time to do all the calculations, but I was immediately struck that, in the case of raisins and bananas, the results seem independent of their glycaemic load, which is to say their supposed impact on blood sugar (glycaemic load is the glycaemic index of the product as a percentage of total carbohydrate in it.) If that is accurate – and it is only an ‘if,’ then it raises questions about the proper understanding and use of glycaemic index and glycaemic load, both things that I paid attention to when putting my t2d into remission.

That would also resonate with Chris van Tulliken’s argument that, iirc, the method of delivery of sugars and nutrients into the body is as important as the chemical composition. There is, he says, something about the act of eating and the body’s physiological response to eating that is important and overlooked.

Now, to be clear, I’m not reaching any conclusions here except to be sceptical of doctors on Tiktok. But it lends weight to my general view that it is probably foolhardy to look for simple cause and effect in the operation of the metabolic system. Instead, it is about systems thinking in which outcomes depend on the interaction of several variables.

I don’t think that contradicts my view that we should all eat and cook from fresh ingredients as often as possible, have sensible portion sizes and avoid refined sugars and ultra-processed foods.

The thing is, though, eating fresh food as a staple is more than a nutritional issue: it is also economically dependent and specifically is deeply rooted in inequality (not to mention the impact of global heating.)

Access to affordable fresh food is a political issue, and so is type-2 diabetes.

One of my targets was the waist size of my trousers, allowing for differences between manufacturers. Starting from a 38” waist I targeted 28” as an ideal endpoint. I didn’t make 28” but have been stable at 30” since October 2022. I still have my belt buckled at the same notch.

What has been variable is my weight. At present I’m 5kg heavier than I was this time last year, although I have been in the same broad range for most of the last 4 months. This is despite all my efforts to repeat my earlier processes and knock a couple of kilos off my average weight. My diet is broadly the same as it has been for the past two years. The only real change is that I have been unable to run because of a knee injury, though I have been going to the gym and substituting the rowing machine as my cardio exercise.

This has got me thinking about the relationship between weight, food and exercise. I eat well and sensibly and I exercise more than many and I keep my eye on what I eat. I can see little causal relationship between what I eat and fluctuations in weight for the most part - the one that does impact is anything meat-heavy, I think because of the time it takes to digest. Hydration has an impact as well.

I haven’t reached any firm conclusions, but do have some provisional thoughts. The first is that, all things being equal, there is no obvious causal relationship between calories in and calories out, or at least to any noticeable extent. I rarely overeat, but over the course of the average week, things tend to even out anyway.

In a similar vein, 3 visits to the gym per week with a focus on free weights and resistance with some cardio in the mix doesn’t make a lot of obvious difference even where my Garmin watch suggests a higher than usual calorie burn. The main difference in exercise has been the switch away from running to weights and resistance.

The place I’m coming to is that we are not dealing with linear causation but a non-linear relationship: that the causality is multi-factorial and depends on a number of factors within the metabolic system of the individual. I’m approaching metaphor here (I’m thinking of something like the classic Lorenz Attractor as an illustration), and won’t be able to test this until I can run again, but I hypothesise that I’m currently in one equilibrium state and will switch to another if and when I can run again, because there is something about that particular exercise that impacts my body in a particular way. Swimming might trigger it too.

If that’s true, and I have a lot of journal entries tracking this, then a headline indicator like marginal weight variation, is not something to worry about if all the other indicators, whether ratios or proxies such as waist bands, are fine. (Which also says a lot about the context in which we should interpret derivative measures like BMI.) I also note that my weight varies over any two-week period and that it is the median rather than absolute number that is the one to keep an eye on. I don’t think this is a rationalisation.

I’ll let you know when I test the hypothesis (though I have a family wedding to deal with first.)

***

When I first received my t2d diagnosis, rather than prescribe any medication, my doctor suggested I read one of Michael Mosely’s books. It is no exaggeration to say that it changed my life. I was sorry to read of his death two weeks ago. RIP

Some other medical routines have yielded some data, though, which will do until a full maintenance check is forthcoming. The main one is that in mid-April 2024 my HbA1c was 33mmol/ml (5.2% for Americans) and so I remain in remission and a member of what I have only just found out has been called the 5% club. My triglycerides (in February) were 1.1 mmol/ml and my ratios were all either ‘good’ or ‘ideal,’ although that hasn’t stopped my doctor recommending statins ‘just in case’ (I’ve declined the invitation.)

It isn’t all sweetness and roses - I’m about 2.5kg heavier than I was this time last year and I’ve had to stop running until wear and tear on the meniscus on my left knee heals, but both of these are issues that anyone my age has to deal with - the important one is no diabetes.

The principal reason I remain in remission is because I’ve largely stuck to the eating regime I implemented in 2021/22 - relatively low carb and almost entirely UPF-free because I prepare most things fresh. I continue to fast completely between supper (around 18.00) and breakfast (around 08.00) and have a minimal lunch, if any. Portion sizes have gone up a bit though, which is where the weight gain is happening I suspect, although I remain in 30” waist trousers from most suppliers.

It’s important to say that this approach is no hardship - I continue to eat well and enjoyably with plenty of variety. Many recipes I found in the early stages of my dealing with diabetes are now regulars at family meals with no complaints. I am not a stranger to red wine or the occasional beer or malt whisky.

However, in terms of remission, I think it is also important that I continue to read around the subject and keep a regular journal, noting weight and any other issues that crop up, including any random dietary fluctuations. The discipline of doing that helps keep a focus, even if it is low-level from time to time. It is because I keep a note of things that I know that my weight has crept up even as my HbA1c has remained low.

One thing I find myself noting is just how much of what is said and written about t2d is in the context of the America and not only assumes the background of the US health ‘system’ and its promiscuous love of pharmaceutical solutions to everything - including problems caused by the promiscuous use of pharmaceuticals, but also the nature of food production in and for the US market. My experience from visiting the US regularly is that it is a lot easier - usually - for me to find out what is in a product that I buy from a shop in the UK and Europe and just as important what is not in it. And why do so many US low-carb/keto recipes use UPF sweeteners that taste horrible?

There is more to be written about this US/Europe split, and I plan to write it, hopefully sooner rather than later now that I have my account back.

These are big changes and I celebrate them as often as I can. Since being formally in remission, I’ve relaxed my diet a little, but not in any fundamental way. I’m still pretty low-carb and, importantly in my view, the bulk of what I eat is home-cooked from fresh produce or at best minimally processed. I eat more bread now, but it’s generally bread that I’ve made from spelt flour and fresh live yeast or sourdough from a local baker and only rarely supermarket-bought.

By low-carb I mean the avoidance of processed sugars and starches in pre-packaged foods and cutting out completely free sugars, and choosing foods on the basis of their glycaemic index and, later, their calculated glycaemic load.

As I indicated in my last post here (Correlations and Causations, 23^rd June), my thinking about what I did that was successful has changed and continues to change. When asked during 2022 and early this year, I would have said that it was my switch to a low-carb diet that was the primary driver of change. I did not follow a keto diet but I did take my cues and some recipes from it, some of which I still use when cooking for the family.

But I did not simply go low-carb, I did other things as well, and as I wrote in that earlier post, I came to the view that it was probably a combination of those factors that was key, perhaps particularly cooking with fresh produce and my deliberate avoidance of what is now known as Ultra-Processed Food (‘UPF’). It struck me last night that approaches based on low-carb and avoidance of UPF at worst have a substantial area of overlap and at best approach identity. They are, I now think, two sides of the same coin. That point has also been made by Dr Kevin D Hall and Dr Chris van Tulleken.

Exercise also had an impact, firstly to assist in ‘burning off’ stored energy, secondly for all round health benefits and thirdly for general body tone, although an unexpected outcome is that my resting heart rate is frequently in the 40 - 50 bpm range and this throws off blood pressure monitors.

The question that is always on my mind, of course, is what to do now to maintain the state I’ve reached? Drs Hall and van Tulleken have both raised a number of issues about, in essence, ‘what works?’ That rather begs the question of what works for what purpose?

I did what I did for a specific purpose, which was to take my HbA1c reading to below the threshold for type-2 diabetes, and in that it was a complete success. The situation is somewhat different today; I’m not now pushing for substantial change, I want now to maintain the change and stay within the bounds of what is - or ought to be - normal for a 64-year old white man in the UK.

I think that focusing on a fresh-food/home-cooked diet and continuing to run (and swim) are the basis of that.

On a broader point, something that I’ve noticed is that the ground appears to be shifting in interesting ways, even over the two years since my diagnosis. For example, there is a growing appreciation that PM25 air pollution appears to be associated with rising hypertension. As a layman, I have no idea how robust that hypothesis is or how far the ground will shift again in the next two years, but I raise it as an example of movement away from purely medicalised accounts of metabolic issues. A shift away from medicalised accounts of cause and correlation may well lead to a shift away from medicalised – for which read pharmacological – ideas of ‘cure.’

My references to Chris van Tulleken are principally to his book Ultra-Processed People, but I also enjoyed a recent lecture currently on YouTube -

I also enjoyed, albeit as a layman, this by Dr Hall -

I’ve been thinking about beer and bread in the context of carbohydrates and type-2 diabetes.

From the beginning of my dance with diabetes, I uncritically accepted the notion that beer has a high carb content and can/should be considered a bad thing from the perspective of managing diabetes. But it occurred to me a few days ago that, although the original content of a beer wort is high in carbohydrates, it should ferment out to alcohol in the brewing process to leave a low-carb end result.

It's similar with bread: there is carbohydrate content in flour of course, but when bread is traditionally made the carbs are converted out through fermentation into alcohol (which cooks off in baking) and the gas that causes the dough to rise.

What both products have in common is that they are based on grain and are products of fermentation through the action of yeast. Also in common, discussion of both beer and bread focuses on the glycaemic index of their raw materials without much (or often any) consideration of the effect of fermentation. This is important because even if you can calculate a relatively high GI for beer, that doesn’t matter if the actual carbohydrate content in the consumed product is low. Glycaemic load is calculated by (carbs x GI/100) and so when available carbs are low the GL must also be low. On this line of thought, bread and beer may have limited impact on the sugariness of one’s blood.

It’s more complex than that, of course. In the case of beer, some carbs are resistant to the common strands of brewer’s yeast and so there will always be some carbs in a glass of beer. I don’t have figures for commercial beers (including pilsners that are usually ‘unadulterated’) but in the case of homebrew beer, where the brewer has control of the contents of the drink, the yeast converts somewhere between 65 and 80% of the carbs to alcohol depending on the recipe and the yeast used. That doesn’t sound great, but the bulk of those carbs that survive are - I believe - dextrins which are slow-release carbs. The rest pass through the system and *may* act as prebiotics without impacting blood sugar.

Just to be clear, I’m not talking about industrially-processed commercial beers or supermarket breads, I’m talking about the ‘real’ products produced from grain, water and yeast (plus hops in beer and optional salt in the case of bread). Nor am I talking about going out for a night on the bevvy or stuffing my face with bread.

I follow a generally low-carb diet and run regularly. Does an occasional bottle of beer with a high-protein evening meal, or a slice or two of homemade bread during the day make much difference? (And yes, before you ask, I really do mean a slice or two.) I rather suspect not. I could check if I had a continuous glucose monitor, but I can’t afford one and, given that my T2D is in remission, I’m unlikely to be prescribed one.

My provisional conclusion is that neither good beer nor good bread should automatically be on the low-carb shit list. By happy chance, that conclusion happens to coincide with my predisposition and so I have to be suspicious of it. I daresay I’m missing something obvious and I am still researching, although I found this paper from 2005 persuasive on its face regarding beer.

CW Bamforth, Beer, Carbohydrates and Diet

This newsletter has a relatively low circulation at present, but as I wrote at the top I raise the subject here because I think received wisdom is always worth questioning; as someone used to say to me, what is well-known is rarely known well. In that spirit, I’m happy for informed comment on the science of this.

I must add that my research to date has led me to simply loads of websites infested with the kind of prissy puritanism that wags a prim finger of disapproval at the very idea that alcohol might be enjoyed in any quantity at any time for any reason. Not all of those sites were American. Also, every site took time out to warn of the dangers of alcohol taken in excess, which isn’t the subject under discussion but seems to be de rigueur. One of the things I’m coming to dislike a lot about this whole field is the dogmatic prohibitionism of so many commenters, especially those with things to sell.

When I reversed my type—2 diabetes I did several things:

• Cut out free sugars

• Shifted to a low-carb diet focused on low-GI carbs (later, I refined this to think about low-GL carbs rather than low-GI.)

• Ate smaller (child-sized) portions

• Practiced a form of intermittent fasting

• Avoided processed foods

• Cooked from fresh as often as possible

• Increased my exercise levels

The end result was remission of my T2D, improvement in average blood pressure, loss of significant weight and improvements in my triglyceride and cholesterol levels. What I did worked for me, but I’m reluctant to attach a causal explanation to any single one of those things. This is because I think it was the cumulative impact of all of those things that had the effects, that this is all about the interaction of a number of elements in the metabolic system.

My personal experience, naturally enough, informs how I react to news items and comment pieces. I like to think that I’m conscious of my priors and am open to re-examining them when faced with contrary opinions, but I’m only human. The systems-thinking approach conditions, for example, my response to the hard-core reductionist approaches touted on the internet that assume single-factor causality and, in essence, promote the idea that if only you do x then y will necessarily be the outcome.

With that in mind, I read an article in this morning’s Guardian with interest. The article, written by health editor Andrew Gregory, reports on studies published in The Lancet and is here: More than 1.3bn adults will have diabetes by 2050, study predicts.

The Lancet material is here: Global inequity in diabetes.

The Lancet studies look at the role of structural racism and geographical inequity in diabetes outcomes, international progress on interventions to address global inequity in diabetes, and disparities in diabetes prevalence and management by race and ethnicity in the USA. There is also an accompanying editorial piece identifying diabetes (overwhelmingly T2D) as a ‘defining disease of the 21st century.

I should be clear at the outset that I do not for one moment have a problem with any of the issues raised in the papers. Nor, as I hope I’ve made clear in previous posts here, do I think that there is any single ‘cause’ of T2D – people are different and the condition arises from several factors. Demographic and social elements in the prevalence and impact of T2D are obviously important, and I’ve written here previously about the relative costs of good fresh food as against processed/ultra-processed food and thus the impact of income inequality. I thought that the Lancet study on T2D disparities by race and ethnicity in the US was particularly good on identifying the multiple factors involved including a ‘non-linear’ relationship between weight and T2D in at least some ethnicities.

The Lancet editorial piece rightly draws attention to increasing pharmaceutical spend at the expense of other factors in T2D prevention and treatment, but none of the papers have their focus on other systemic issues or, except in passing, on other rising health problems – eg non-alcoholic fatty liver disease and heart disease – and none (as far as I could see) think about the global rise in obesity, T2D, non-alcoholic fatty liver disease, etc. as symptomatic of linked metabolic systemic issues.

The obvious absence from the discussions, except by inference, is diet.

I’m neither a doctor nor an expert, just a bloke on the internet whose priors are based on personal experience as a white British man in his sixties. I may very well be barking up the wrong tree. But the work by, amongst many others, Drs David and Jen Unwin and Dr Chris van Tulleken, suggests to me that there is a lot more going on here. As a layman, it seems to me that the global rise in a number of metabolic conditions correlates to large-scale urbanisation and the spread of a ‘western*’ diet – for example in the US, Mexico, India and China. Correlations can be, and often are, spurious, but they also suggest avenues for critical analysis and I reckon this is one such occasion.

*By ‘western’ diet I mean in general terms one rich in highly-processed foods and sugary drinks and snacks.

***

I had an interesting interaction with a couple of people on the internet recently. I have been looking at questions of nutrition for distance running after remission of T2D and thus aiming to avoid carbs. I contacted two people, who will remain nameless. One was a respected senior clinician in the field of the metabolic system and diabetes (who is also a runner) and the second was someone in the US who blogs about running and diet.

The senior clinician replied wrote back quickly offering a few friendly tips as to what they have found works for them - exactly what I was looking for. The American blogger declined to say anything at all to avoid liability issues – unless I paid them up to $200 for a personalised consultation and plan.

·         Improve blood pressure

·         Get my weight into an average range with 84.5kg as the lowest boundary

·         Get into 28” waist trousers.

Well, 2 out of 3 ain’t bad. The results were

·         Average blood pressure (mean and median) dropped from 130/86 to 128/77

·         5-day mean and median weight this morning was 84kg (lowest boundary 83.2)

·         No 28” trousers yet, although this may have something to do with variable sizing between manufacturers.

I also completed 5k and a 6k runs in the past four days. More on that later.

This whole thing is bedevilled by correlation and causality issues, but by any standards this was a successful experiment. The challenge now, of course, is to maintain the benefits. However, for all this was only eight weeks and the benefits are self-reported, there were one or two things I noticed along the way that made me think.

I stuck to the very low-carb diet quite closely for most of the period. Sometimes I was in mild ketosis (according to the usual pee sticks) and sometimes I wasn’t. There were noticeable, if temporary, effects when I came off the wagon – for example when entertaining visitors and friends – even if I was generally careful with what I ate. The biggest single impact was alcohol, but not on weight or blood pressure. I didn’t drink a great deal, but on the occasion I did – a street party for the coronation (remember that?) – I worked through a bottle of red over seven hours or so. My resting heart rate doubled and stayed high for at least two days.

Although the key driver of the change was diet, the impact of exercise was to reinforce and lock in the benefits. The two main exercises I did were swimming and jogging, as well as walking.

I was struck by the variability of blood pressure readings. As I mentioned in my previous post, although the figures fell quickly (within two weeks) and the benefits were consistent, there were some days when my BP was elevated and stayed that way with no obvious cause or correlation. That’s why I tracked averages. Also, my resting heart rate is in the range 45-52bpm after the consistent aerobic exercise. My impression is that the home blood pressure monitor really does not like it when the resting heart rate is in the 40s and goes off searching for a reading, over-inflating the cuff and distorting the readings.

Still on the subject of blood pressure, my preferred future is one with reduced BP medication. There are underlying drivers of my BP to do with aldosterone, but the average readings clearly responded to a low-carb diet. I suspect that systems thinking is the way to consider this - inter-relationships within the metabolic system rather than any single causative factor, but I’m no expert. My current view is that the experiment did not indicate a reduction in medication is on the cards but does show that diet+exercise+current medication means my BP is much better controlled (relative to my age).

More generally, I did not stick as rigidly to the diet as some would suggest I ought, but I was pretty close. I think the notionally perfect is the enemy of the good enough. Looking back a year, I reduced my HbA1c to sub-diabetic levels within 4 months of the diagnosis. Elements of the diet I adopted then were not as optimal as they might have been, but it still worked. For me at least, heroic self-sacrifice was not needed, just stubborn determination to follow a course of action and to enjoy it as I did it.

And that’s the lesson for people in the situation I was in when I had my diagnosis in late 2021 – don’t sweat being perfect as defined by internet and social media gurus, just aim for doing what is good enough for you in your circumstances to get results; like me, you can refine it as you go.

What now?

Now that my self-imposed eight week period is done, I don’t intend to relax things too much. For family reasons, I expect the next couple of weeks to be tricky from a diet management point of view, but I intend to stick with the programme to the extent that I can. At the very least, I’ve successfully avoided potatoes, pasta, rice and bread for eight weeks and plan to keep doing exactly that, with the possible exception of making home-made bread from time to time.

The bigger picture is that I’m focusing now on exercise planning to complement the diet. Two sessions a week in the local swimming pool have made a major impact on my general fitness, including cardio fitness, and they will remain in my schedule. More than that, and despite what I’ve written here previously, now that my jogging has reached 5k fitness again, I aim to be at 10k fitness by autumn. I could probably get there quicker but I’m wary of ever-doing it and risking injury given that I’m in my sixties; again, the heroic perfect is the enemy of the good enough.

And I’m thinking of a half marathon in 2024. I last ran one in 2009, so time to give it another shot, assuming that aging knees can cope. If anyone reads this who has experience of low-carb running in their sixties, both in terms of training and nutrition, I’d very much welcome contact as I sort out my plans. One of the things about all this, as others have mentioned, is that a lot of us are figuring it all out for ourselves and part of the point of this substack (and others, such as Tom Watson’s) is to share experience and end the isolation.

1   I came across this piece of recent research on exercise. It is here:

https://noisereduction.substack.com/p/whens-the-best-time-to-get-some-exercise

150 minutes per week is the conclusion. Currently I swim about 80 minutes (2x40 minute sessions) per week. and it takes about 30 minutes each way to walk to the pool. That is already 200 minutes per week before anything else. What else? I don’t drive which means I walk pretty much everywhere. No marathons or gym visits required.

2   I mentioned in my first piece here that the first thing you notice when you go low-carb and zero free sugars is that your face gets thinner. Sorry to inflict selfies on you, but the first two of these photos were taken seven months apart. The first was August 2021, a couple of months before my type-2 diabetes diagnosis, the second March 2022. The third is April 2023.

4   I also mentioned in that first post that I was doing an eight-week experiment on myself, going back to low carb to address creeping weight gain and to see what it did to my blood pressure. The experiment still has a couple of weeks to run, but after six weeks my five-day median weight is down by 4.1kg (9lbs).

My blood pressure has certainly responded: my median weekly average is down – significantly so for diastolic pressure. One thing I have noticed – and I’ll write more about this when I have researched it some more – is that there are days or sequences of two or three days when my BP is elevated for no obvious reason. On the one hand that’s why I’m looking at mean and median figures – as is standard for GPs here in the UK; on the other hand, this tells against the notion – more common in the US, I think – of treating BP as an absolute without much allowance for natural variation.

I once spent nineteen hours in a US hospital. A nurse wanted to give me beta blockers because my BP was high, and didn’t seem to get that having to attend hospital at short notice in a foreign country with my fingers crossed that my employer’s insurance would cover it and that I would catch my flight home might have something to do with that. As might sharing a room with an elderly Italian-American who talked to his imaginary friend whenever medical staff left the room, but that’s another story.

Not only the US, of course. An NHS website asked me what my BP is. I wanted to answer: do you mean average BP? Or taken in the morning? Or taken in the evening? Or … well, you get the idea.

5   More when I have it ready. I keep getting flashes of panic when I think I ought to be providing more content whereas my inclination is only to post something when I have something to say. In any event, this is, and will remain, free, even if Substack pesters you to subscribe or pledge or whatever. If you really do want to support me, whatever that means, you could do worse than consider buying some of my fiction. An Amazon link is here. Kindle editions cost less than most Substack subscriptions 😊

But Ian, you might say, surely all the supermarkets are doing the same thing. Well yes they are, but – and it’s an important but – only Tesco is a current corporate sponsor of Diabetes UK.

***

I had some interesting comments on my last piece, both here and elsewhere. Over on Facebook, a friend wrote:

Two comments 1) It misses the "opportunity cost" in time, possibly fuel, etc, of going round several supermarkets in order to get the best deal 2) It's a very "middle class" list of ingredients. I mean olives, courgettes, spinach, broccoli.  The glaring omission (and a crucial one) is the price of pasta which has almost doubled in the last year.

It's interesting. I live in a poor area, a two-bed terraced house in decent condition is under £100,000 yet my food choices are superb. Within five minutes’ walk there are two greengrocers, two butchers, a baker, two chemists, a very good off licence, several shops from ethnic based backgrounds (African, Caribbean, Eastern Europe) and "Heron" which specialises in frozen food and near Best Before Date offers and manufacturers over-runs (or goods not called off by supermarkets). That ignores the supermarket "local" branches and Lidl also in easy walking distance. In many respects I have more choice here than if I lived in a more affluent area and that's not counting the multitude of cafes, bars, and other eateries within the same radius.

I think that’s right, and there are parts of Edinburgh where this is true also, but not everywhere and not commonly.

Broadening the theme out, I was interested in this snippet from Politico - Brexit red tape to send UK food prices soaring even higher. The UK imports 30% of its food. Ironically, the piece is illustrated with a photo of the kind of market that barely exists now in the UK.

More strategically, we’ve just seen more extreme temperatures around the Mediterranean and must expect things to get worse. Even where our supermarkets have managed to source relatively fresh produce, it is largely imported. Quite aside from the carbon footprint and the impact on our own food producers, there must now be a strategic risk to food supplies. I thought this at the start of the pandemic in March 2020 and was wrong – or perhaps just premature.

Later, in August 2021, I wrote on my blog that,

In any event, even without catastrophising, it’s bad enough. As I write, we have monstrous fires in Siberia, record temperatures in the Mediterranean with fires in Turkey and Greece, and we’ll soon be getting round to this year’s catastrophic fires in the southern hemisphere. We’ve had major floods in Germany, Belgium and Luxembourg. Looking to the US, I would say the west coast and Pacific North-West are already on course to be uninhabitable at current population levels within twenty years, partly because of the direct effect of the heat and fires, and partly because of the water shortages that are already happening and certain to increase (the balance of probabilities globally is, broadly, that areas that are already dry will get drier while areas that are already wet will get wetter).

And that’s all before the impacts of sea-level rise, which is on course to become obvious after 2030. Anyway, I jotted down some headline areas to think about/worry about on a scrap of paper and came up with:

• Water rights

• Refugees

• International travel

• Transport

• Infrastructure,

• Food

• Energy

• Supply Chain/Logistics

• Nationalism/Border skirmishes

• Wealth inequalities

• Housing

I think that list, written well before Russia invaded Ukraine, remains valid, and all of the issues are substantive international political problems. In the limited context of this Substack, taken altogether they mean that we need to get serious about domestic food production, including the type and quality of food produced and the means of production and distribution.

As a simple example, I like fruit and yogurt and aim for fruit with a low glycaemic load, such as raspberries and blueberries. I also like walnuts and almonds. All of these are imported and all of them impose burdens on the places they are grown and the footprint of transporting them to Scotland. I also like mackerel as my oily fish of choice and note that it has just gone onto the amber warning list because of over-fishing.

***

I had a really odd exchange last week on Twitter with someone whose views I normally respect. It was to do with our government’s ideas about addressing the ‘obesity epidemic’ with medication.

My default position is that if I find myself taking an opposite view to someone for whom I have respect, it’s right that I look again at my own assumptions. In this case, I think I’m right. I’m not naming the person here because this is not about the person but about the argument. The conversation went like this (my posts in italics):

Obesity is a serious chronic disease affecting one in four adult and one in ten child in the UK. Drugs that can alleviate the problem would be great for peoples' health, wellbeing and happiness. They would further reduce pressure on healthcare and save everyone a lot of money made out of diabetes type 2, hypertension, statins and whatnot drugs.

My type 2 diabetes is in remission without any medication, because I stopped eating free sugars and minimised starchy carbohydrates. My average BP is down and I've lost 4 stones (30kg) as well. The 'problem' is more complex than a simple pharmaceutical solution.

I'm not claiming obesity drugs will be miraculous, but they have a major role to play, and their arrival is the only piece of good news in a while on the 'obesity epidemic' front. Not everyone can control their diet and spend enough time exercising to stay fit.

My main problem with the pharma approach is not that some people might need it, but that for a lot of people the real problem is sugar, and that is a problem we should tackle socially. I don't think we have an obesity epidemic, I think we have a sugar epidemic.

Sugar is highly addictive. It's a drug in effect. Given our dismal track record with 'wars on drugs', I welcome the possibility of pharmaceutical interventions.

Your first sentence = QED, I think :-) The 'real' issue for many is diet, access to fresh food at a good price, and knowledge of how to prepare it. BTW, my kidney and liver functions improved too. There is a complex metabolic issue in play that requires a more nuanced solution.

My interlocutor later subtweeted (in effect) that not everyone had opportunity to run marathons or live on specialised diets (I paraphrase.) You will note that I did not at any point mention exercise, he did. I would also say that the argument from the ‘wars on drugs’ is at best weak. My view is that my interlocutor should check his priors.

***

Congratulations on making it to the end. Here’s a book recommendation as a reward.

I kept an online diary right through the pandemic and was quite pleased with myself. Stu Hennigan also kept a diary, but he was delivering food packages in deprived areas of Leeds and turned his diary into a devastating book. It’s one that I have to read a chapter at a time as he encounters depths of poverty, deprivation and disenfranchisement that shook him to the core. Ghost Signs: Stu Hennigan.

The costed material that’s mentioned in a reply to me is here: PHC Real Food Booklets.

On a whim, I took a look this afternoon at the costings and searched for the same basket of goods on the websites of Sainsbury’s, Tesco and ASDA. I would have done LiDL and ALDI too, but their sites aren’t so easily searched. The results are in the handy table below (prices in GB£.)

Method - I searched each website on the afternoon of Saturday 22 April 2023 and selected the cheapest instance of the item that I could find - usually supermarket own brands. I didn’t count loyalty card offers because they come and go.

I have a number of comments on the numbers and on the text of the PHC booklet. I must add that I am supportive of PHC and the work that they do. What I write is critical, but, I hope, written as a critical friend.

First, the costings given are an average price per portion. That’s all very well as a comparator, but the average price per portion is an arithmetical artefact and is not the same as the purse price. For example, to get the price I did for lamb shoulder meant buying a much larger joint than 200g. I like lamb shoulder, but I don’t buy it very often because it is relatively expensive.

Second, looking at the text of the leaflet, I have the following comments (in bold italics):

Top Tips For Real Food On A Real Budget

1. Buy meat and fish from the counters at supermarkets, it's usually cheaper than straight from the fridges. If you can though, go to your local butcher and fish monger as they can be even cheaper. Supermarkets are closing their in-store counters. If you’re tight for cash, you may well not choose the big supermarket chains as your source anyway. Most peripheral estates do not have butchers or fishmongers anymore; I live in a middle-class part of Edinburgh and there isn’t a fishmonger near me either. Two items on the list - whole mackerel and whole sardine - are not available in supermarkets, at least online.

2. Buy loose fruit and vegetables, it's usually cheaper than prepackaged fruit and veg but sometimes frozen veg can be cheaper. This is often true so long as there aren’t supply-chain issues and inflation running at 10%. Inflation is a net impact on all shops, but supply chain issues and the industrial/commercial practices of the supermarkets exacerbate the issue.

3. Also, buy “wonky” vegetables at the supermarket, as they are even cheaper. If you can though, go direct to your local greengrocer or farm shop as they can be even cheaper. I don’t always see any wonky veg. at my local supermarkets. We have no local greengrocer, they’ve all gone since the supermarkets moved in more than two decades ago, and I’m in a middle-class area. Asian shops are usually good for fresh veg, but it’s a 2-3 mile walk to my nearest Asian shop. Farm shop - really?

4. Cook in bulk with dishes such as stews and soups, then store in containers for freezing and heating up quickly the next time. Good advice – so long as you have a big enough freezer and aren’t on a prepaid electricity meter. I have a decent pension, but we don’t have a chest freezer in our house as we have nowhere to put one.

5. Before going shopping, compare foods online for the best prices by looking at how much they cost per kilogram. This presumes online access and computer literacy. Also, searches are skewed towards the supermarkets who have eCommerce websites. If there are local stores or the mythical farm shops in your area, they are unlikely to have either a website or, if they do, one that gives that day’s prices. Some numeracy is required too - to get the comparators in the table above, I had to do quite a lot of calculations to make sure I was comparing like with like.

Underlying all of the above is a concern that a lot of commentary on this skews to the middle classes. The UK is increasingly beset by poverty and even apparently well-to-do areas conceal people having real difficulties. The unhealthiest people in our society are generally also the poorest, and good food for them, even if available, is expensive compared to highly processed frozen and tinned food full of carbs and sugars. That’s why Jack Monroe shot to prominence and why her work is, unfortunately, still relevant.

I’m working on another post for a future date about some of this but need to do more research. When I was growing up in the 1960s we had several local greengrocers offering local, seasonal produce, and at least two substantial open air markets. Now we have supermarkets and community shops for various ethnicities. The latter are the closest to what I had growing up.

What it boils down to is that we have a societal problem with food, and that problem is just one manifestation of major systemic issues.

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In October/November 2021 I was diagnosed with Type-2 Diabetes (T2D hereafter). It wasn’t a total surprise, but it forced change on me. When I mentioned my diagnosis on Twitter and my blog, my North American friends immediately told me about their experiences with medication; by contrast, my doctor here in Edinburgh, Scotland, said we should look first at ‘lifestyle issues.’ In passing, she said I could do worse than have a look at one of Dr Michael Mosley’s books.

I didn’t follow the programmes that Dr Mosley recommends, but from his book I got a much better understanding of what T2D is and determined to do two things:

• stop putting sugars into my body

• deal with the sugars already in my blood and stored as fat.

It worked.

On diagnosis, my HbA1c reading was 54 mmol/mol) (7.1%) - diabetes is diagnosed when the reading is above 48 (6.5%). Four months later, in February/March 2022, my HbA1c was 37 (5.5%), below the diabetic threshold. I had dropped two trouser sizes, lost 20kg (44lbs) and both my HDL cholesterol and triglycerides had improved.

One year later, the reading was 31 (5%). I’ve dropped another two trouser sizes and lost a further 10kg (22lbs) My HDL and triglycerides have improved even more, as has my creatinine.

The definition of remission in the case of T2D is an HbA1c reading below 48 sustained for 3 months without medication. My T2D is therefore in remission and this Substack is about how I plan to keep it that way.

How did I achieve remission without medication? I treated refined sugar as poison, ate a low-carb diet, avoided processed food, cooked from fresh whenever possible and, once I’d lost substantial weight from the diet alone, I went swimming and completed a couch-to-5K programme. I go into a bit more detail over on my blog.

So why start a Substack?

Because after that initial suggestion that I read Michael Mosley, I was more or less on my own to figure it out. That isn’t a criticism of my doctors because the practice has been under immense and sustained pressure like every other GP practice across the country. I’m still figuring it out, and I want to share what I’m doing, what works, what doesn’t, and other thoughts here. I could, and will, keep posting stuff on my blog, but I think Substack is likely more discoverable, especially if network effects kick in.

That’s my story so far; what more is there to say? Quite a lot.

Shortly after my doctor confirmed that I am in remission, an article appeared in the Observer about the work of Dr David Unwin. You’ll find the article here. Intrigued by the similarity with what I had managed, I watched several of Dr Unwin’s talks on YouTube and was introduced to some of the things that I hadn’t figured out for myself. Chief amongst these was the notion of Glycaemic Load (or GL).

I was aware of GL but didn’t grasp it’s significance. When figuring things out for myself, I reckoned that if I restricted carb intake and selected predominantly those with a low Glycaemic Index (GI) score I wouldn’t go far wrong. I’d tried to stick with that all through 2022 and the results speak for themselves. But I didn’t understand why my median weight before breakfast this year had risen 2-3kg (4.4-6.6 lbs) above where it was in August 2022, nor why my blood pressure was creeping up from where it was when I was in ketosis in early 2022.

GL is a measure of the impact of any particular food on your blood sugar level. It is conventionally expressed as a multiple of the effect of one gram of glucose. Unfortunately, we don’t think in terms of grams of glucose. More helpful is that a teaspoon of refined sugar has a GL of 2.73. That means that you can think about foods as the equivalent number of teaspoons of sugar.

In my case, I like to have fruit and nuts with Greek yoghurt. Great! and I get my five-a-day. But hang on, that banana has the equivalent impact of 5 to 6 teaspoons of sugar? I make my own bread and am quite good at it. I felt really pleased that I was using low-GI grains, without thinking of the glycaemic load each slice delivered.

So while I thought I was doing the right thing, and had excellent results, it looks like I’d got complacent and more carbs than I thought had crept back into my diet.

How can I be sure? I’m not yet, but I’m testing it. For the next eight weeks I’m going back into ketosis to see what happens to my weight and my blood pressure. Today is day six of the experiment. I’ve lost 1.3kg (2.86lb) so far. It’s too early to draw any conclusions about blood pressure, but at present my average systolic pressure is down by one point and diastolic down by 2.

Oh, and I forgot to mention. I currently buy jeans with a UK 30” waist (down from 38”). By the end of this experiment, I hope to be in a 28” waist, something I haven’t been since the early 1980s.

Finally, this Substack is and will remain free. I had to figure this stuff out for myself and I’m passing it along to whoever might find it helpful. However, please note that I am not a doctor and you shouldn’t treat what I write as being in any way medical advice. My body and circumstances are not your body and circumstances.

Having said that, I reckon that, for most of us, sugar is metabolic poison and should be treated as the enemy. The UK government is currently prescribing national medication in the face of what they see as an ‘obesity epidemic’ (and running into trouble). They are wrong; we don’t have an obesity epidemic, we have a sugar epidemic. In future posts, I hope to set out some of my reasoning for that, go into more detail on my thinking when I set out to do something about my T2D and quite likely have a rant or two about the unhelpfulness of food labelling.

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