Dietitians up to No Good

I don't know what else will be uncovered, but my respect for the Academy of Nutrition and Dietetics (AND) has reached a new low as it has for many of its members. They use the promotion of keeping us safe and being the only safe source for nutrition. If what they are doing now is any indication, they would be the last group I would want in charge of my nutrition.

All dietitian advice is brought to you by their sponsors and has been for a very long time. Now that it’s becoming more blatant, maybe the public will finally figure out that being a dietitian is akin to being a corporate big food representative. During the months of February and March, AND started promoting Kraft Singles, the individually wrapped slices of “cheese product” popular in school lunches. This is the first product to boast the AND’s new “Kids Eat Right” label. Kraft Singles are not cheese, but a combination of chemicals that represents fake cheese.

Then the Associated Press recently broke a story showing how dietitians were promoting small cans of Coca-Cola as a snack. Ben Sheidler, a Coca-Cola spokesman, compared the February posts to product placement deals a company might have with TV shows. "We have a network of dietitians we work with," said Sheidler, who declined to say how much the company pays experts. "Every big brand works with bloggers or has paid talent."

With the current atmosphere within AND, I don't see much success coming from a group called Dietitians for Professional Integrity. The group has called for sharper lines to be drawn between dietitians and companies. Andy Bellatti, one of its founders, said companies court dietitians because they help validate corporate messages. And without corporate money, AND will continue to function as it will have complete control in the messages it allows and the dissenting group will be banned from AND.

Other companies including Kellogg and General Mills have used strategies like providing continuing education classes for dietitians, funding studies that burnish the nutritional images of their products and offering newsletters for health experts. PepsiCo Inc. has also worked with dietitians who suggest its Frito-Lay and Tostito chips in local TV segments on healthy eating. Others use nutrition experts in sponsored content, the American Pistachio Growers has quoted a dietitian for the New England Patriots in a piece on healthy snacks and recipes and Nestle has quoted its own executive in a post about infant nutrition.

If you are looking for safe nutrition advice, do not look to the members of AND or the Academy for safe nutritional information. They are a tool of big food and have been for many years, even before the name change. Maybe they are becoming too self-confident and will continue to throw any good reputation they may have out the window. They are making themselves harder to ignore and people are beginning to doubt whether they are the organization to consider for sound or safe nutrition information.

Cinnamon May Not Be Good for You

Someone had to say it! This article in WebMD explains why people should not depend on cinnamon to lower blood glucose levels. It is okay to sprinkle cinnamon on oatmeal or to use it in baking when a recipe calls for it as it often improves the taste. Some people are claiming it will help you manage diabetes, but don't count on it.

I agree with the WebMD article when it says that it is not clear if cinnamon is good for diabetes. While it is true that research has produced mixed results, much of the research is limited by the lack of funds. Therefore, most of the studies are too short and too limited in the number of participants. This has caused the American Diabetes Association to reject cinnamon for use on diabetes treatment.

A few small studies have linked cinnamon to better blood glucose levels and a few studies have shown that is may help in lowering insulin resistance. In one study, volunteers ate from 1 to 6 grams of cinnamon for 40 days. (One gram of ground cinnamon is about half a teaspoon.) The researchers found that cinnamon cut cholesterol by about 18% and blood glucose levels by 24%. In other studies, the spice did not lower blood glucose levels or cholesterol levels.

Is cinnamon safe for people with diabetes? Generally, it is safe, but there are potential problems if you have liver damage. This means that you need to talk to your doctor and follow the doctor's instructions. If you have liver problems, such as fatty liver disease, be careful, because large amounts of cinnamon may exacerbate liver problems.

Talking to your doctor is even more important if you are taking other medications. This involves side effects and adverse reactions that may occur with some medications.

Then we have the complex interaction with herbs. Use caution if you also take other supplements that lower blood sugar levels, including:

• Alpha lipoic acid
• Bitter melon
• Chromium
• Devil's claw
• Fenugreek
• Garlic
• Horse chestnut
• Panax
• Siberian ginseng
• Psyllium

The same holds true with diabetes medications. If you and your doctor decide it's OK for you to try cinnamon, pay close attention to your blood sugar levels. Tell your doctor if your levels fall too low.

Taking cinnamon with drugs that affect the liver may make liver problems more likely.

Grapefruit, A Superfood or A Drug Nightmare?

This author creates hype for grapefruit by calling it a superfood. Then what she presents as being the new antioxidant found in the citrus – Naringenin. Naringenin is far from a proven antioxidant and the tests to date have all been performed on rats and mice. This is why I label what she says as hype.

The following is quoted from Wikipedia which is not known for being totally accurate.

"This substance, naringenin, has also been shown to reduce oxidative damage to DNA in vitro. Scientists exposed cells to 80 micromoles of naringenin per liter, for 24 hours, and found that the amount of hydroxyl damage to the DNA was reduced by 24% in that very short period of time.[citation needed]

Naringenin found in grapefruit juice has been shown to have an inhibitory effect on the human cytochrome P450 isoform CYP1A2, which can change pharmacokinetics in a human (or orthologous) host of several popular drugs in an adverse manner, even resulting in carcinogens of otherwise harmless substances.

Naringenin has also been shown to reduce hepatitis C virus production by infected hepatocytes (liver cells) in cell culture. This seems to be secondary to Naringenin's ability to inhibit the secretion of very-low-density lipoprotein by the cells. The antiviral effects of naringenin are currently under clinical investigation.

Naringenin seems to protect LDLR-deficient mice from the obesity effects of a high-fat diet.

Naringenin lowers the plasma and hepatic cholesterol concentrations by suppressing HMG-CoA reductase and ACAT in rats fed a high-cholesterol diet.

The National Research Institute of Chinese Medicine in Taiwan conducted experiments on the effects of the grapefruit flavanones naringin and neringenin on CYP450 enzyme expression. Naringenin proved to be a potent inhibitor of the benzo(a)pyrene metabolizing enzyme benzo(a)pyrene hydroxylase (AHH) in vitro experiments in mice. This suggests, but does not conclusively prove, that naringenin would elicit the same response when administered to humans. More research will be needed to determine if naringenin has any clinically significant effects (including medical applications) in human subjects." Unquote

Beverleigh H Piepers is the author of this article declaring grapefruit as being at “diabetic superfood.” What is not mentioned is that many of the people with diabetes cannot eat this superfood, especially if they are taking statins, some antibiotics, cancer drugs, and heart drugs. Most at risk are older people who use more prescriptions and buy more grapefruit.

The gist of the situation is the grapefruit, which contains furanocoumarins, blocks an enzyme that normally breaks down certain medications in the body. When this happens, medication levels in the body can become toxic.

I don't care how many concoctions for grapefruit she lists, grapefruit is not the diabetic superfood for many with diabetes. For me, grapefruit almost became a drug nightmare when my wife suggested I eat it. I did and became very sick. She then went to her drug book and discovered that grapefruit was contraindicated for the statin I was taking. At that point, I was handed a 12-ounce glass of water and told to drink it, followed by several more glasses of water. After five glasses, I could tell that I was flushing the toxin out and was starting to feel better.

This should tell you that if you are on the medications mentioned above, have a talk with your doctor about how grapefruit might affect you and interact with the medication.  Don't let grapefruit cause a nightmare for you.

Conclusion of Diabetes Complications and Related Topics

The last blog about polypharmacy concludes the blogs on diabetes complications and related topics. This does not mean that I will not write more blogs, as I find more information. Almost weekly, new information appears about a study that affects how a complication could be treated. Often it can take several months for the information to be accepted and put into practice or be rejected as unproven.

This happens because many studies become junk science as the researchers were attempting to salvage something for the money spent on the study. Sometimes the research itself was unreliable and a few of the researchers cherry pick results that they wanted. Other times, journals do not approve the study for publication and the researchers submit it to several journals with no success.

I will continue to look for more studies that will provide information on the diabetes complications and the related topics. I have several other topics coming about some of the natural substances that have been in the news lately that may not be safe when used with some of the prescription drugs. Some of them I have blogged about previously, but more are coming into the news because people are having problems by combining the natural substances with prescription drugs and creating toxic effects.

Two of the prior members were just released from the hospital this weekend from the toxic effects from a fruit and both were on statins. Jerry said he knew what was happening and called Tim and asked for a meeting of those that had helped him. Tim sent out emails and we met Monday evening for about an hour.

Jerry said he would be sending emails to the members that his wife had talked away from our group and warning them not to be eating certain natural substances. I asked Jerry to hold up, as there were several spices, fruits, and other substances that could be added to the list and we had better do our research before he sent out emails. Then I retracted that, and said to go ahead as the warning should be sent immediately and we could add information to another email.

Barry said he would search for more information as he thought he remembered where he had seen some information. Allen said he had a few items pulled into a word processor and he would send them to Jerry. I added that I would send copies of what would be posted and he could use what he needed from them.

Tim admitted he did not have the time, but would search when he could. A.J said he could search and with that, maybe we could stay ahead to the information being dispersed by the person.

With that, we ended the meeting and agreed we would stay in contact. Then A.J asked to follow me home with Jerry as he wanted to talk some more. When we arrive, A.J asked if the person would really do something this dangerous to these people. Jerry admitted that she could and felt that by putting out this information, we could prevent more of our prior members from being hospitalized.

A.J then suggested that he would send out emails to others of the group explaining what had happened and warning then about advice they might receive. First, he would talk to Tim, but he felt this would be a good way to warn everyone. Jerry agreed, as did I, and Jerry and A.J left.

Polypharmacy and Diabetes – Part 2

In the previous blog I used the following - other definitions have appeared in the medical literature that put the problem of polypharmacy in a broader perspective. One defines polypharmacy as the “prescription, administration, or use of more medications than are clinically indicated, or when a medical regimen includes at least one unnecessary medication.

I had wanted to say then that often the elderly are prescribed a statin because of slightly elevated cholesterol. Yet the doctors seldom do a benefits analysis to determine if it might be better to withhold statins. These doctors would rather prescribe statins which dramatically increase the risk of type 2 diabetes. I know this because I have a friend that was prescribed a statin at the age of 88 that did not have diabetes. Last month (at age 89) he was diagnosed with type 2 diabetes and Allen and I have been working with him to help him manage his diabetes. And I have personal experience because the doctor rushed to prescribe a statin for my wife about 22 months ago and now she has type 2 diabetes.

Another problem all of us face today is the direct-to-consumer advertising. It is blasted at us daily and a few of the side-effects which may be mild are rushed through and not actually spelled out. The medications are hyped as the latest and greatest. Then many patients and their families demand the medication. Even more problematic is that they then ignore warnings about why the drug may not be in the best interest if the patient.

The lay media frequently report outcomes of clinical trials, often before complete reports are available to physicians through the medical literature. Brief reports in the press may give false hopes or heightened expectations for the benefits of new therapies without adequate explanation of their inherent risks. This drives demand from patients or their families for additional treatment.

Multiple medications creates problems unknown in medicine and is often underestimated by the medical profession. By increasing the number of medications, doctors increase the risk of adverse reactions – remember in the elderly there is no research to say they are safe. The aging process, other chronic illnesses or diseases, and polypharmacy places the elderly at increased risk of adverse reactions.

Now with this in mind, polypharmacy has additional problems, including but not limited to:

• Risk of duplication of therapy (multiple agents in the same class and generic and brand name versions of the same medications)
• Risk of patients seeing multiple prescribers and no one conducting oversight of the drug regimen (read my blog on this here)

Medication adherence among patients with chronic conditions is disappointingly low according to doctors. Doctors seem inclined to overestimate the degree of medication adherence. Adherence rates are diminished by:

1. Complex drug regimens
2. Incomplete explanation of drug benefits and side effects
3. Lack of recognition of a patient's lifestyle
4. Cost of medications
5. Communication style with the patient
6. Avoidance of including the patient in the decision

Adherence to a course of therapy is more positive when a patient understands the reasons for taking a medication and is involved in the decision to prescribe. Patients are more likely to have confidence in the prescriber if they are given basic knowledge of potential adverse effects and advice about what to do if such effects occur. Increasingly, clinical practice guidelines are incorporating quality of life and patient preferences to increase adherence by both physicians and patients. Finally, when doctors suggest generics instead of the more expensive brand name drugs. Read my blog on what doctors are saying about patients being noncompliant.

Review of a patient's drug therapy should begin with assessing the patient's adherence, asking about problems with side effects, and determining whether the provider's drug list in the patient's record matches the patient's own drug list. Asking patients to bring all of their medication containers to routinely scheduled office visits can facilitate this effort. Doctors can also help patients recall the need for each of their medications by adding the purpose to the directions for use in their written prescriptions (i.e., “once daily for blood pressure” or “two times a day and take with meal for diabetes”).

The medication list should include all prescription medications, including those taken routinely and those used on an as-needed basis; over-the-counter medications; herbal products; and vitamins or nutritional supplements. Medication lists constructed from memory or even from written lists are notoriously misleading and incomplete compared to examination of the actual medication containers.

Polypharmacy and Diabetes – Part 1

Again, I am listing a few of my prior blogs on polypharmacy rather than rewrite them. I find this a very interesting topic and one that I am fighting at the same time, as I take more medications than I like.

http://bobsdiabetes.blogspot.com/2014/03/is-polypharmacy-in-your-future.html

http://bobsdiabetes.blogspot.com/2014/04/more-about-my-friend-on-polypharmacy.html

http://bobsdiabetes.blogspot.com/2014/04/polypharmacy-how-i-dislike-you.html

Polypharmacy is the shame of our doctors, the FDA, and Big Pharma. Polypharmacy is a problem all people, but especially for those of us with diabetes. Problems inherent in polypharmacy include:

• Half of the people with type 2 diabetes are over the age of 65
• No research is done to determine how diabetes medications affect the elderly
• Doctors stack oral medications on the elderly with no research verifying that they will benefit them
• Doctors then complain about the elderly and others of not taking their medications
• No research has been done to determine how other medications prescribed will affect diabetes medications
• Many of the elderly are over medicated excessively.

There is basically no research done on the elderly (for any medication) to determine if the medications prescribed will perform as intended or if the elderly will get the benefit.

The fact finding with the elderly can be problematic. Even if the elderly patient is coming to an office and has been instructed to bring all medications and supplements, there is often the doubt that you are seeing all of them. Even for home visits, medications are often hidden and not brought out. Therefore, some detective work must be done. Look for medications from more than one doctor or more than one pharmacy, as this may be a clue to more medications. Always record all information that is on the prescription container, Rx number, date filled, directions, medication name and dosage size, quantity, physician name, refills remaining, pharmacy, and prescription expiration date. Whether you are an educator, peer-to-peer worker, or a peer mentor, dealing with some elderly patients can be a delicate situation where even the best diplomacy may not yield the discovery of all prescriptions and supplements in use.

All conflicts in medication must be reported to the doctor as well as discrepancies like out of date medications, medications not refilled, especially other doctors and pharmacies discovered. Always be on the lookout for duplication of medications and medications that may conflict with other medications.

Polypharmacy is a risk factor in the treatment of type 2 diabetes. In normal use, polypharmacy means the concurrent use of multiple medications in the same patient. What is forgotten in most definitions is the potential for harm that polypharmacy may pose for the individual. Other definitions have appeared in the medical literature that put the problem of polypharmacy in a broader perspective. One defines polypharmacy as the “prescription, administration, or use of more medications than are clinically indicated, or when a medical regimen includes at least one unnecessary medication.

Having written the above, I will admit that polypharmacy may be unavoidable. This is because multiple drug therapy has become a standard of care in most chronic conditions. The comorbidities of diabetes commonly include hypertension (blood pressure), dyslipidemia (cholesterol), depression, and coagulopathies (any disorder of blood coagulation), each of which may require one or more drugs for adequate control. Then add to this other conditions that often accompany diabetes, such as hypothyroidism, heart failure, and osteoporosis, and the total number of possible medications needed becomes significant. Lastly, the fear that doctors have about hypoglycemia, and they add oral diabetes medications on top of oral diabetes medication, up to four different medications.

As people age, the chance for other chronic conditions increases. With the availability of multiple medications and the variety of “expert” guidelines for the treatment of these conditions, additional drug therapy is often indicated. Debate has emerged about how many conditions need to be treated.

The burden of polypharmacy falls especially hard on the elderly, who incur the highest incidence of chronic conditions coupled with reduced or fixed incomes and therefore inability to afford the cost of multiple medications. Treatment of elderly patients with diabetes requires special considerations, especially in how aggressively diabetes should be treated. Treatment decisions should consider age and life expectancy, comorbid conditions, cognitive status, living arrangements, and severity of vascular conditions.

The variety of “expert” panel recommendations, clinical practice guidelines, and other national standards for medical treatment has grown exponentially in the last decade. The National Guideline Clearinghouse listed greater than 1,650 active clinical practice guidelines in July 2005, 386 of which were devoted to diabetes alone. Many of these guidelines overlap, and sometimes they contradict each another.

Clinical practice guidelines rarely address the treatment of patients with three or more chronic diseases, and such patients make up half of the population greater than 65 years of age in the United States. When other aspects of chronic disease management (e.g., dietary or other lifestyle modifications, attending regular office visits, and laboratory monitoring) are added, the burden on elderly patients and their caregivers becomes onerous and, in many cases, unsustainable over time. Guidelines and quality assurance initiatives largely ignore the issue of marginal benefits of multiple medications as recommended by various sets of treatment guidelines.

The guidelines are all set up for people under 60 years of age with only one chronic condition. The elderly are discriminated because no research has been done to determine how to treat people with multiple chronic conditions. Yet, the so-called “experts” could care less about treating the elderly.

Statins Up the Risk for Type 2 Diabetes – Part 3

To relieve statin side effects, your doctor may recommend several options. Discuss the following steps with your doctor before trying them:

#1 Take a brief break from statin therapy. Sometimes it's hard to tell whether the muscle aches or other problems you're having are statin side effects or just part of the aging process. Taking a break of 10 to 14 days can give you some time to compare how you feel when you are and aren't taking a statin. This can help you determine whether your aches and pains are due to statins instead of something else.

#2 Switch to another statin drug. It's possible, although unlikely, that one particular statin may cause side effects for you while another statin won't. It's thought that simvastatin (Zocor) may be more likely to cause muscle pain as a side effect than other statins when it's taken at high doses. Newer statin drugs are being studied that may have may have fewer side effects.

#3 Change your dose. Lowering your dose may reduce some of your side effects, but it may also reduce some of the cholesterol-lowering benefits your medication has. It's also possible your doctor will suggest switching your medication to another statin that's equally effective but can be taken in a lower dose. For example, if you've successfully taken atorvastatin (Lipitor) for a long time at higher doses, your doctor may keep you at this level. However, higher doses aren't recommended if you're new to this medication.

Take it easy when exercising. It is possible exercise could make your muscle aches worse. Talk to your doctor about changing your exercise routine.

Consider other cholesterol-lowering medications. Taking ezetimibe (Zetia), a cholesterol absorption inhibitor medication, may help you avoid taking higher doses of statins. However, some researchers question the effectiveness of ezetimibe compared with statins in terms of its ability to lower your cholesterol.

Don't try over-the-counter (OTC) pain relievers. Muscle aches from statins can't be relieved with acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) the way other muscle aches are. Don't try an OTC pain reliever without asking your doctor first.

Try coenzyme Q10 supplements. Coenzyme Q10 supplements may help to prevent statin side effects in some people, though more studies are needed to determine any benefits of taking it. If you'd like to try adding coenzyme Q10 to your treatment, talk to your doctor first to make sure the supplement won't interact with any of your other medications. Some people need this supplement and do well when taking it.

Be careful and watch for drug interactions. Some of the following are extremely important. The first one I was not warned about and I have a very serious drug interaction. See my blog here.

Statins can have several potentially dangerous interactions with other medications and some foods. These interactions can make it more likely you'll have statin side effects. These include:

#1 All statins and grapefruit or grapefruit juice. Grapefruit juice contains a chemical that can interfere with the enzymes that break down (metabolize) the statins in your digestive system. This can be dangerous because it's uncertain what the effect would be on your total cholesterol. You should still be able to have some grapefruit or grapefruit juice, but talk to your doctor about limiting how much grapefruit you can have.

#2 Lovastatin (Mevacor, Altoprev) or simvastatin (Zocor) and amiodarone (Cordarone). People taking the statins lovastatin or simvastatin, either alone or in combination with amiodarone (Cordarone), a medication for irregular heart rhythms, are at a greater risk of severe statin side effects, such as rhabdomyolysis.

#3 All statins and gemfibrozil (Lopid). People who take both gemfibrozil (Lopid) and a statin may be at a greater risk of statin side effects.

#4 Mevacor (lovastatin) and HIV drugs. Medicines used to treat HIV (protease inhibitors) should never be taken with Mevacor.

#5 All statins and some antibiotic and antifungal medications. If you have a fungal or bacterial infection, be sure to tell your doctor if you take a statin.

#6 All statins and some antidepressant medications. It's possible that taking antidepressants, such as nefazodone, and a statin could make you more likely to have muscle aches.

#7 All statins and some immunosuppressant medications. If you take a medication to suppress your immune system, such as cyclosporine (Sandimmune), and a statin, you may be more likely to have muscle aches.

Weigh the risks and benefits

Although statin side effects can be annoying, consider the benefits of taking a statin before you decide to stop taking your medication. Remember that statin medications can reduce your risk of a heart attack or stroke, and the risk of life-threatening side effects from statins is very low.

Even if your side effects are frustrating, don't stop taking your statin medication for any period of time without talking to your doctor first. Your doctor may be able to come up with an alternative treatment plan that can help you lower your cholesterol without uncomfortable side effects.

Be careful because some doctors just will ignore taking you off statins (they don't wish to diminish the cash flow coming in). Other doctors do not honestly know how to a risk /benefits analysis.