Do you take insulin? Read on!

Could a plant-based diet ever be risky?

Very rarely, but this letter I received on the PBNSG website about diabetes perfectly illustrates a real risk:

After suffering two strokes in late January 2015, my husband and I went on a plant-based, no oil vegan diet. He has lost some weight (with more to lose), but is having a really, really hard time with continuing episodes of low blood sugar. These are daily - sometimes multiple times per day. Often he needs assistance to get the sugar to him, and will wake me up when it happens at night to help him. He has some other health issues as well, from a vehicle accident suffered a few years ago. Our primary doctor, while sympathetic to our plant based diet, mostly follows a Mediterranean diet, and just leaves my husband to figure out his own insulin dosage. His diabetic doc also knows we are following this diet, but pretty much just continues care as usual.

My question, since we are on the west side of the state (MI) is: can you refer us at all to someone who will help us monitor the draw down of needed insulin medications? These daily, repeated and severe low blood sugar reactions are scaring me a bit.
— Anonymous
Low blood sugar effects

Low blood sugar effects

The "side effects" of a plant based diet are good ones (weight loss, reversal of heart disease, etc.), except for this sort, when medication suddenly becomes too strong. Wise to be scared! Low blood sugar can be dangerous. It can cause confusion, or delayed reflexes - very dangerous, especially when driving - or weakness that can result in a fall. Frequent low blood sugars may cause memory problems, or loss of the warning signs that alert the person that blood sugar is falling. Severe low blood sugar can cause loss of consciousness, and requires emergency treatment with a glucagon injection (available by prescription) or by EMS.

When someone who takes insulin starts on a no-oil, whole foods, plant based diet, improvement in high blood sugar levels can come very quickly. Suddenly, someone who has never had a "low," finds they are low all the time. This is good news! But immediate action is required: continue with this healthy way of eating AND work with your health care provider to cut back on insulin! Some people may be able to eliminate the need for insulin shots and other medications completely.

Clinicians are guided in how to increase medications, but there is little guidance on how to reduce it.

Clinicians are guided in how to increase medications, but there is little guidance on how to reduce it.

Doctors, nurse practitioners (like me) and physicians assistants are taught a lot about how to adjust insulin doses to correct high blood sugar. After all, that is a frequent reason for medical office visits. Professional organizations such as the American Diabetes Association and the American Association of Clinical Endocrinologists publish guidelines on how to add medications or increase doses until clinical goals are met. Pharmaceutical reps provide handy charts on how to add a certain number of units at regular intervals until blood sugar hits a pre-determined target. However, I've never seen a guideline from these sources on how to reduce insulin. Neither, it seems, have the doctors responsible for the care of the spouse of this letter writer.

The writer did not ask me HOW to reduce the insulin, and since I'm not her husband's care provider, with his chart in front of me, I would not want to provide specific advice (Wish I could, but that is a limitation of this forum). There are lots of factors to consider in adjusting insulin doses: current blood sugar levels throughout the day, type(s) of insulin used, meal times, and meal content. I would want to know when the last A1c test was done, and the result. If it has been more than a few months, I'd repeat the A1c to get a baseline now. I would want to know if he takes other medications besides insulin that can cause low blood sugar, such as pills in a class called sulfonylureas, or any of the non-insulin injectables.

While I would ask a lot of questions, I would not hesitate for a second to cut down on the insulin dose if this patient was under my care
. In fact, I would rather err on the side of too little insulin than too much! Low blood sugar can cause immediate harm, whereas high blood sugar takes days, or often even weeks or months to cause problems. The insulin dose(s) should be reduced, and followed closely by the patient and clinician, as further corrections may be needed, especially with additional weight loss.

A plant-based diet for people with diabetes can be powerful medicine. So powerful in fact that medications can often be reduced, and perhaps even eliminated.

The other question that this letter raises is how do you handle a health care professioinal who does not seem supportive or knowledgeable about your no-oil, whole foods, plant-based diet? Suggestions? Please post them here.

Dr. Caroline

PBNSG Director - diabetes education 

P.S. For information on how to recognize and treat low blood sugar and low blood pressure in plant-basers who take medications for diabetes and/or hypertension, please go here and scroll down read 'IS IT HYPOGLYCEMIA (ALSO KNOWN AS LOW BLOOD SUGAR)?'

Hope for Diabetes

As a nursing student in the 1980s, diabetes always seemed overwhelming and hopeless to me. So much to know: so many parts of the body affected, so many potential acute complications, so much to teach patients about self-management. But my first job after graduation was working in a large teaching hospital with people with diabetes, and I loved becoming a specialist in a disease that many health care professionals found frustrating. Over the course of my career, new equipment and new medications came along. And for a while, I really thought that the secret to diabetes management was to get people on insulin, and aggressively adjust the doses to achieve good blood sugars.

Diabetes management is no longer my goal. Type 2 diabetes can be cured, and prevented from happening in the first place. People with type 1 diabetes can often reduce the total amount of insulin needed, and reduce wild swings in blood sugar and get on the road to good health.
— Dr. Trapp, PBNSG Director - Diabetes

As a nurse practitioner, I got really good at prescribing insulin, and helped a lot of people get good numbers. But it was disappointing, to say the least, to see that this did not always protect them from heart problems…

or nerve problems… 

or kidney problems, etc.

And, people on insulin usually gain weight, and have to worry about preventing and treating low blood sugar, and deal with the expense of insulin. Don’t get me wrong – insulin is an effective medication, and sometimes is necessary for type 2 diabetes, and always for type 1. But my patients had to deal with a lot of unwanted side effects and without any guarantee of good health or longer life – so it seemed to me that I had not yet really found the best way to help people.


Dr. Neal Barnard

Dr. Neal Barnard

In 2006, I was fortunate to stumble upon the work of Neal Barnard, MD, and research conducted by his team at the Physicians Committee for Responsible Medicine. He was kind to share with me data from a new study that was about to be published, which compared a low-fat vegan diet to a reduced-fat, restricted carbohydrate, portion-control diet based on the dietary recommendations of the American Diabetes Association at that time. His research showed that the people in the plant-based group lost twice as much weight if overweight, and their A1c (a blood test that measures diabetes control) dropped three times as much as those following the conventional diabetes dietary approach. Many people in the plant-based group were able to reduce or even eliminate some or all of their medications, and LDL cholesterol and kidney function also improved. And, after an initial period of adjustment, people liked the plant-based approach, and most found that they were able to stick with it.

So ok, this worked in a research study in Washington, D.C., but would my patients in Southfield be willing to go on a low-fat, vegan (plant-based) diet? Many of the physicians I worked with were pretty skeptical, understandably (“I can’t get my patients to go for a walk; you expect them to stop eating cheese burgers and Coney Dogs?”). But my husband Bill and I had been eating plant-based at that point for several months, and had seen our own health improvements, so it seemed to me that the right thing to do was to at least offer the option to the people who trusted me to help them manage their diabetes.

PCRM Power Plate

PCRM Power Plate

Fast forward 9 years. There are now many studies that support a plant-based dietary pattern for diabetes and the other chronic conditions that are epidemic in Michigan and across the U.S. The ADA now includes a plant-based diet in their clinical practice recommendations and provide some practical advice on their website – very encouraging! - and the USDA has identified a plant-based dietary pattern as among the best for all Americans. Most clinicians agree that this approach works, but many don’t think their patients can or will follow it. However, I’ve been offering this approach in my clinical practice for years, and time and time again, I’ve seen many are willing and able: people lose weight, people are able to reduce medications, other health problems resolve – it’s all good. To be sure, there is a learning curve, and it helps to have support of others. Over the months ahead, I’ll share some of the most important research studies with you, and allow you to peek into the lives of my patients (with their permission, of course) and share in their successes. We will explore the best-of-the-best tools and resources.

Diabetes management is no longer my goal. Type 2 diabetes can be cured, and prevented from happening in the first place. People with type 1 diabetes can often reduce the total amount of insulin needed, and reduce wild swings in blood sugar and get on the road to good health. 

Join me in this space to make it happen for you.

Dr. Caroline Trapp
PBNSG Director - Diabetes education