Diabetes Care Linked to PCP Volume

Primary care physicians (PCPs) with higher overall ambulatory volumes provided lower-quality care to patients with diabetes, whereas PCPs with higher diabetes-specific volume provided higher-quality care, a large cohort study suggests.

"Although a relationship between volume and quality has previously been demonstrated with procedural and hospital-based volumes, there has been less research demonstrating associations between outpatient volumes and quality of care in chronic disease management," the researchers write. "Our study provides evidence of such a relationship in the outpatient context."

Andrew Cheung, MD, from the Department of Medicine, McMaster University, Health Sciences Centre, Hamilton, Ontario, Canada, and colleagues reported their findings online December 13 in the Annals of Internal Medicine.

This is something that most of our support group members have discovered on their own. Many PCP's try to take our members off insulin and start them back on oral medications. Our members have learned when this happens, it is time to leave and not look back. Most of our insulin using members have found a doctor that they are satisfied with seeing and those on oral medications are always asking us questions about the doctor they should see, if and when they feel the need to move to insulin.

The researchers analyzed data from provincial healthcare administrative databases to examine the relationships between overall ambulatory volume and diabetes-specific volume for PCPs and quality of care among 1,018,647 patients with diabetes in Ontario, Canada.

They used six indicators to evaluate quality of care: eye examination, low-density lipoprotein (LDL) cholesterol testing, hemoglobin A1c testing, prescriptions for angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs), prescriptions for statins, and emergency department (ED) visits for hypoglycemia or hyperglycemia.

Patients of PCPs with the highest overall volume had lower rates of appropriate eye examination, hemoglobin A1c testing, and LDL cholesterol testing — findings that were indicative of lower quality of care. These patients were also less likely to fill prescriptions for ACEIs, ARBs, or statins compared with patients of physicians with the lowest overall volume.

These findings contrasted with those for patients of PCPs with higher diabetes-specific volume. Marginal rates of appropriate eye examinations, hemoglobin A1c testing, and LDL cholesterol testing were higher among these patients, as were rates of prescriptions for ACEIs or ARBs and statins.

In addition, marginal rates of ED visits for hypoglycemia and hyperglycemia were lower among patients of PCPs with increasing overall ambulatory volume, suggesting higher quality of care, but this trend was not statistically significant.

Rates of ED visits for hypoglycemia and hyperglycemia were also lower among patients of PCPs with higher diabetes-specific volume. Patients of PCPs with lower diabetes-specific volume were younger and were more likely to be referred to an internist or endocrinologist.

"Referral to a specialist substantially improved the likelihood that recommended process measures would be achieved; however, referred patients had 3 times the rate of ED visits," Kevin A. Peterson, MD, MPH, from the University of Minnesota, Minneapolis, explains in an accompanying editorial. "Clearly, better performance on process measures does not guarantee better clinical outcomes. The study also suggests an association between higher volume of patients with diabetes and better performance on diabetes process measures, although whether this association is causal remains unclear."

He continues, "Providing an isolated focus on a single disease-based performance measure tells only part of the story and can underestimate the effect of a PCP on the medical needs of a community. Pursuing modestly higher-quality care for substantially fewer people is not necessarily a step forward. The question remains of how many patients with and without diabetes should be empaneled with a PCP so that the dual goals of comprehensive, evidence-based primary care and a manageable physician workday can be achieved."

"These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care," the researchers conclude.

The authors and editorialist have disclosed no relevant financial relationships.

Unusual Actions of Some Diabetes Drugs

Scientists have found that some drugs from a group of anti-diabetic treatments may, in certain circumstances, act on glucagon receptors in the body, meaning that they could also potentially enable the release of sugar into the bloodstream.

Researchers behind the study say that while their results are speculative at this stage, they point to a lack of complete information about the potential impact of a group of treatments known as GLP-1 agonists, or incretin mimetics.

In particular, their survey found that one such treatment has the hitherto unrecognized potential to activate receptor sites for the hormone, glucagon. This can promote the release of sugars into the blood, which is a process that GLP-1 agonists are supposed to prevent.

The paper, which is published in TheJournal Of Biological Chemistry, stresses that these are only initial findings, and that more in-depth research will be needed before “definitive conclusions can be drawn” about the existing results.

The researchers also say that there is no evidence that existing GLP-1 agonists are in any way dangerous for patients, but they do call for a more comprehensive approach to testing new drugs of this type, before they are released on to the market.

The work was carried out by a team of researchers, led by academics from the University of Cambridge and the University of Warwick. Dr Graham Ladds, from the Department of Pharmacology and St John’s College, University of Cambridge, said: “What we have shown is that we need a more complete understanding of how anti-diabetic drugs interact with receptors in different parts of our bodies.”

“GLP-1 agonists clearly benefit many patients with Type 2 diabetes and there is no reason to presume that our findings outweigh those benefits. Nevertheless, we clearly lack a full picture of their potential impact. Understanding that picture, and being able to consider all the components of target cells for such treatments, is vital if we want to design drugs that have therapeutic benefits for diabetes patients, without any unwanted side effects.”

People affected by diabetes suffer from excessively high blood sugar levels and resulting complications, caused by the fact that their body does not produce enough insulin – the hormone that enables the uptake of sugar from food. According to the World Health Organization, about 347 million people worldwide have diabetes and it is likely to become the seventh leading cause of death in the world by the year 2030. Among adults, type 2 diabetes accounts for the vast majority of cases.

GLP-1 agonists are a group of injectable drugs, which are normally prescribed to patients who have not been able to bring their condition under control through lifestyle changes or with first-stage, tablet treatments.

They work by imitating the effects of a naturally-occurring hormone, called a Glucagon-like peptide (GLP-1). This regulates blood sugar levels both by stimulating the release of insulin, and also by inhibiting glucagon, another hormone which allows the liver to release stored sugar into the bloodstream.

In addition, both GLP-1 and GLP-1 agonists have a number of other potentially beneficial effects. These include telling the brain when a person is full, and clinical trials have shown that some GLP-1 agonists can promote weight loss.

Like other peptides, GLP-1 takes effect by binding to specific receptor sites in the cells of our bodies. GLP-1 agonists are synthetic molecules which are designed to bind to these receptors in the same way.

Building on previous research, however, the new study investigated the possibility that instead of activating these receptors, GLP-1, or treatments which mimic it, might bind to the receptor for glucagon instead. This belongs to the same general “family” of receptors, but activating it could cause an unwanted side-effect for people with diabetes because it can potentially enable the release of more sugar into the bloodstream.

Although a limited number of previous studies had suggested that this was not possible, the team’s lab-based tests discovered that in certain conditions, GLP-1 can bind to the glucagon receptor. Their initial experiments, carried out on yeast containing the receptor, found that it was activated not only by GLP-1, but also by a GLP-1 agonist, which was among three such drugs that the group tested. Further experiments were then carried out in a mammalian cell culture, with similar results.

The researchers found that the decisive element was another protein called a receptor activity-modifying protein (RAMP2). When RAMP2 was present, it prevented the peptides – including the diabetes treatments – from binding to the glucagon receptors. In its absence, however, binding became possible.

Little is currently known about RAMP2. Tests in mice have, however, shown that its levels vary in different parts of the body. In the liver, where glucagon receptors stimulate the release of sugar into the blood, levels of RAMP2 appear to be lower than in other parts of the body. As a result, it is possible that some GLP-1 agonists could activate these receptors and, potentially, promote the effects of glucagon, which they are supposed to inhibit.

“The work shows that, contrary to our previous assumptions, glucagon receptors can potentially be activated by anti-diabetic treatments,” Dr Ladds added. “To date, very little work has been done on RAMPs, but they clearly play an important part in the process of regulating blood sugar, which is core to helping people with diabetes. The study shows that there is a critical need to take this into account when designing new therapeutics.”

Saturated Fats May Be Healthy

A Norwegian study challenges the long-held idea that saturated fats are unhealthy

A new Norwegian diet intervention study (FATFUNC), performed by researchers at the KG Jebsen center for diabetes research at the University of Bergen, raises questions regarding the validity of a diet hypothesis that has dominated for more than half a century: that dietary fat and particularly saturated fat is unhealthy for most people.

The researchers found strikingly similar health effects of diets based on either lowly processed carbohydrates or fats. In the randomized controlled trial, 38 men with abdominal obesity followed a dietary pattern high in either carbohydrates or fat, of which about half was saturated. Fat mass in the abdominal region, liver and heart was measured with accurate analyses, along with a number of key risk factors for cardiovascular disease.

"The very high intake of total and saturated fat did not increase the calculated risk of cardiovascular diseases," says professor and cardiologist Ottar Nygård who contributed to the study.

"Participants on the very-high-fat diet also had substantial improvements in several important cardiometabolic risk factors, such as ectopic fat storage, blood pressure, blood lipids (triglycerides), insulin and blood sugar."

Both groups had similar intakes of energy, proteins, polyunsaturated fatty acids, the food types were the same and varied mainly in quantity, and intake of added sugar was minimized.

"We here looked at effects of total and saturated fat in the context of a healthy diet rich in fresh, lowly processed and nutritious foods, including high amounts of vegetables and rice instead of flour-based products," says PhD candidate Vivian Veum.

"The fat sources were also lowly processed, mainly butter, cream and cold-pressed oils."

Total energy intake was within the normal range. Even the participants who increased their energy intake during the study showed substantial reductions in fat stores and disease risk.

"Our findings indicate that the overriding principle of a healthy diet is not the quantity of fat or carbohydrates, but the quality of the foods we eat," says PhD candidate Johnny Laupsa-Borge.

Saturated fat increases the "good" cholesterol. Saturated fat has been thought to promote cardiovascular diseases by raising the "bad" LDL cholesterol in the blood. But even with a higher fat intake in the FATFUNC study compared to most comparable studies, the authors found no significant increase in LDL cholesterol.

Rather, the "good" cholesterol increased only on the very-high-fat diet.

"These results indicate that most healthy people probably tolerate a high intake of saturated fat well, as long as the fat quality is good and total energy intake is not too high. It may even be healthy," says Ottar Nygård.

"Future studies should examine which people or patients may need to limit their intake of saturated fat," assistant professor Simon Nitter Dankel points out, who led the study together with the director of the laboratory clinics, professor Gunnar Mellgren, at Haukeland university hospital in Bergen, Norway.

"But the alleged health risks of eating good-quality fats have been greatly exaggerated. It may be more important for public health to encourage reductions in processed flour-based products, highly processed fats and foods with added sugar," he says.

The Whole Patient Finally Considered

The American Diabetes Association's2017 Standards of Medical Care include a new focus on assessment of the social, psychological, and financial circumstances in patients' lives that affect their ability to self-manage their diabetes, with the emphasis being on helping those with the condition to live as normal lives as possible. This means caring for the whole patient and not just part of the situation that the patient encounters.

For 2017, the ADA advises assessment of nonmedical factors that influence patients' abilities to self-manage their diabetes, including issues around access to care, financial barriers, and food insecurity, along with psychological or psychiatric disorders.

A new chapter called "Promoting Health and Reducing Disparities in Populations" provides guidance for promoting patient-centered care aligned with the Chronic Care Model, team-based care, and referral to local community resources for further support.

"You need to be aware of issues that impact self-management.… It doesn't do the patient or clinician any good if the clinician writes a prescription for an expensive branded medication and the patient can't afford it," Dr Ratner noted.

New recommendations for psychosocial assessment and intervention were published in a separate document November 22 in Diabetes Care. We're not just managing glucose, we're managing a human being who's trying to live a normal life.

These include evaluation for symptoms of diabetes distress, depression, anxiety, and disordered eating and of cognitive capacities, using appropriate standardized tools at initial visits, periodic intervals, or if the patient experiences any changes that merit concern, with the inclusion of family members when appropriate. Any problems found should be addressed via follow-up visit or referral.

In particular, depression is extremely common in both type 1 and type 2 diabetes and doubles the cost of care if left untreated, Dr Ratner said. "The idea is that we're not just managing glucose, we're managing a human being who's trying to live a normal life, and it's hard.… Ultimately, the person with diabetes is their own primary caregiver, and we need to be able to support them in doing that very difficult job," he said.

This seems to be the first time that the ADA has advocated anything like this. I am not aware of anything in the last seven year, but this may have been partially advocated before and fallen out of practice.

This is a good practice and may have come at the right time.

Importance of Vitamin K

Vitamin K is a fat-soluble vitamin. Originally identified for its role in the process of blood clot formation ("K" is derived from the German word "koagulation"), vitamin K is essential for the functioning of several proteins involved in physiological processes that encompass, but are not limited to, the regulation of blood clotting (coagulation). Naturally, occurring forms of vitamin K include a number of vitamers known as vitamin K1 and vitamin K2. Vitamin K1 or phylloquinone is synthesized by plants and is the predominant form in the diet. Vitamin K2 includes a range of vitamin K forms collectively referred to as menaquinones. Most menaquinones are synthesized by human intestinal microbiota and found in fermented foods and in animal products. Menaquinones differ in length from 1 to 14 repeats of 5-carbon units in the side chain of the molecules. These forms of vitamin K are designated menaquinone-n (MK-n), where n stands for the number of 5-carbon units (MK-2 to MK-14). Widely used in animal husbandry, the synthetic compound known as menadione (vitamin K3) is a provitamin that needs to be converted to menaquinone-4 (MK-4) to be active.

Vitamin K functions as a cofactor for the enzyme, γ-glutamylcarboxylase (GGCX), which catalyzes the carboxylation of the amino acid glutamic acid (Glu) to γ-carboxyglutamic acid (Gla). Vitamin K-dependent γ-carboxylation that occurs only on specific glutamic acid residues in identified vitamin K-dependent proteins (VKDP) is critical for their ability to bind calcium.

Although vitamin K is a fat-soluble vitamin, the body stores very small amounts that are rapidly depleted without regular dietary intake. Perhaps because of its limited ability to store vitamin K, the body recycles it through a process called the vitamin K-epoxide cycle. The vitamin K cycle allows a small amount of vitamin K to be reused many times for protein carboxylation, thus decreasing the dietary requirement. Briefly, vitamin K hydroquinone (reduced form) is oxidized to vitamin K epoxide (oxidized form). The reaction enables γ-glutamylcarboxylase to carboxylate selective glutamic acid residues on vitamin K-dependent proteins. The recycling of vitamin K epoxide (oxidized form) to hydroquinone (reduced form) is carried out by two reactions that reduce vitamin K epoxide (KO) to vitamin K quinone and then to vitamin K hydroquinone (KH2). Additionally, the enzyme vitamin K oxidoreductase (VKOR) catalyzes the reduction of KO to vitamin K quinone and may be involved — as well as another yet-to-defined reductase — in the production of KH2 from vitamin K quinone. The anticoagulant drug warfarin acts as a vitamin K antagonist by inhibiting VKOR activity, hence preventing vitamin K recycling (see Coagulation).

The ability to bind calcium ions (Ca2+) is required for the activation of the several vitamin K-dependent clotting factors, or proteins, in the coagulation (clotting) cascade. The term, coagulation cascade, refers to a series of events, each dependent on the other, that stop bleeding through clot formation. Vitamin K-dependent γ-carboxylation of specific glutamic acid residues in those proteins makes it possible for them to bind calcium. Factors II (prothrombin), VII, IX, and X make up the core of the coagulation cascade. Protein Z appears to enhance the action of thrombin (the activated form of prothrombin) by promoting its association with phospholipids in cell membranes. Protein C and protein S are anticoagulant proteins that provide control and balance in the coagulation cascade; protein Z also has an anticoagulatory function. Control mechanisms for the coagulation cascade exist since uncontrolled clotting may be as life threatening as uncontrolled bleeding. Vitamin K-dependent coagulation factors are synthesized in the liver. Consequently, severe liver disease results in lower blood levels of vitamin K-dependent clotting factors and an increased risk for uncontrolled bleeding (hemorrhage).

In January 2001, the US Food and Nutrition Board (FNB) of the Institute of Medicine established the adequate intake (AI) level for vitamin K based on consumption levels in healthy individuals (Table 1). The AI for infants was based on estimated intake of vitamin K from breast milk (42).

Table 1. Adequate Intake (AI) for Vitamin K

Life Stage	Age	Males (μg/day)	Females (μg/day)
Infants	0-6 months	2.0	2.0
Infants	7-12 months	2.5	2.5
Children	1-3 years	30	30
Children	4-8 years	55	55
Children	9-13 years	60	60
Adolescents	14-18 years	75	75
Adults	19 years and older	120	90
Pregnancy	18 years and younger	-	75
Pregnancy	19 years and older	-	90
Breast-feeding	18 years and younger	-	75
Breast-feeding	19 years and older	-	90

Phylloquinone (vitamin K1) is the major dietary form of vitamin K in most diets. Green leafy vegetables and some plant oils (soybean, canola, olive, and cottonseed) are major contributors of dietary vitamin K. However, phylloquinone bioavailability from green vegetables is lower than in oil and supplements. Also, the phylloquinone content of green vegetables depends on their content in chlorophyll (green pigment), so that outer leaves have more phylloquinone than inner leaves. The efficiency of phylloquinone intestinal absorption varies among plant sources and is increased with the addition of a fat source to a meal. Finally, the hydrogenation of vegetable oils may decrease the absorption and biological effect of dietary phylloquinone. If you wish to check foods for their nutrient content, including phylloquinone, search the USDA food composition database. A number of phylloquinone-rich foods are listed in Table 2, with their content in phylloquinone expressed in micrograms (μg).

Table 2. Some Food Sources of Phylloquinone

Food	Serving	Phylloquinone (μg)
Kale, raw	1 cup (chopped)	472
Swiss chard, raw	1 cup	299
Parsley, raw	¼ cup	246
Broccoli, cooked	1 cup (chopped)	220
Spinach, raw	1 cup	145
Watercress, raw	1 cup (chopped)	85
Leaf lettuce (green), raw	1 cup (shredded)	46
Soybean oil	1 Tablespoon	25
Canola oil	1 Tablespoon	10
Olive oil	1 Tablespoon	8
Cottonseed oil	1 Tablespoon	3

Dietitians Being Called Out By Bloggers

More bloggers are becoming active in highlighting the faults of the different antics of dietitian organizations around the world. Most dietitian organization officers and staff are tools of Big Food and Big Beverage and in some countries, the dietitian members are the activists for the food and beverage companies.

Yes, I call them antics because they behave like the anointed and will not put up with any debate or discussion on the topic of dietetics. When there is discussion, they say that the patients do not understand and they must reteach them the importance of diet. They must follow their directions as to the number of carbohydrates they must consume and if they have diabetes, they inform the doctor that they need more medications or a higher dose of medications.

In some countries, they monitor what patients are told and expose other dietitians, doctors, and others and they are put on notice that the dietitian is no longer a dietitian. The doctor is often charged with not being authorized to practice nutrition and brought up on charges. Other people are charged with practicing nutrition without a license and this has happened in the State of North Carolina against Steve Cooksey. Fortunately, he was able to defeat the NC dietetic board.

This is one more reason we need to be watchful as the Academy of Nutrition and Dietetics (AND) is bringing more bills before more legislatures in more states to make them the only source of nutrition and dietary advice. Under the current president of the Certified Diabetes Educators, Hope Warshaw, who is also a registered dietitian, is also making more state legislatures receive bills to make the Registered Dietitians the only source of dietary advice. This makes two organizations pushing the same information at state legislatures.

Read this by Dr. Malcolm Kendrick about some of the other dietitian acts in other countries. Then read this by Eddie at Low Carb Diabetic for his take on dietitians. It could be very informative to follow these two bloggers for other activities of dietitians.

There are other bloggers that occasionally write about dietitians, myself included, but only when something is very obvious. Most are low carb bloggers and object to dietitians that push low fat and high carb diets.

Dietitian Controversy

Recently, November 21, Candice Choi of the Associated Press published a feature article on Kellogg's Breakfast Council of “independent experts”. These are industry efforts at corporate damage control. And in cases like these, public health always takes a bath.

At least this time, the Academy of Nutrition and Dietetics (AND) were caught with their hands in the money satchel. Yes, the AND continues to be in constant controversy and this time passing off food industry marketing as education. This is what the AND officers and headquarters staff are well qualified in doing and being caught while doing it.

What was not covered in the AP's article is any reaction from the members of AND. This makes Candice Choi's article less effective and makes me wonder if the members really care and maybe they support the actions of organization.

“Highlights:

• “On its website, Kellogg touted a distinguished-sounding “Breakfast Council” of “independent experts” who helped guide its nutritional efforts. Nowhere did it say this: The maker of Froot Loops and Frosted Flakes paid the experts and fed them talking points, according to a copy of a contract and emails obtained by The Associated Press.”

• “For Kellogg, the breakfast council — in existence between 2011 and this year — deftly blurred the lines between cereal promotion and impartial nutrition guidance. The company used the council to teach a continuing education class for dietitians, publish an academic paper on breakfast, and try to influence the government’s dietary guidelines.”

• “[Kellogg] told the AP it had been reviewing its nutrition work, and decided not to continue the council. The breakfast council page is no longer online.”

• “The breakfast council was also a way to patrol for naysayers. After an advocacy group issued a report criticizing sugary cereals, Sarah Woodside, a Kellogg employee, sent the council an email explaining why it was unfair and asked them to alert her if they noticed any discussions about it.”

• “Disclosures by the council could be confusing. When two of the experts taught a class for dietitians on the “science behind breakfast,” an introduction said they were members of Kellogg’s Breakfast Council, then said they had no conflicts of interest. It said Kellogg funded the class, but had no input into its content.”

• “Marion Nestle, a professor of nutrition at New York University, said health experts usually have good intentions when working with companies, and may not realize they’re being used for their credibility.”

• “One of the breakfast council’s most notable achievements was publishing a paper defining a “quality breakfast” in a nutrition journal. Kellogg touted the paper in its newsletter as being written by “our independent nutrition experts.” Dietitians could earn continuing education credits from the publisher for taking a quiz about the paper.”

• “Kellogg didn’t describe its own role in overseeing editing and providing feedback, such as asking for the removal of a line saying a recommendation that added sugar be limited to 25 percent of calories might be “too high.”

Canadians Physicians for Better Dietary Guidelines

Doctor Malcolm Kendrick blogged about this on the December 16 and thus alerted many people about what is happening in Canada. A petition signed by over two hundred Canadian doctors is asking the Health Minister to change the dietary guidelines for Canada. You can read more about it here https://www.facebook.com/photo.php?fbid=10103115611237481&set=a.10103115599810381.1073741857.58002911&type=3&theater

For the past 35 plus years, Canadians have been urged to follow the Canadian Dietary Guidelines. During this time, there has been a sharp increase in nutrition-related diseases, particularly obesity and diabetes.

I can only hope that the American doctors would do something like this, as there has been sharp increases in obesity and diabetes in the United States since 1980 as well. Every five years when the dietary guidelines are issued, people have complained about the lack of scientific evidence for many of the guidelines.

For more information on obesity in the United States, click on this link and then on Home and then go down the page about two thirds for the graph.

We are especially concerned with the dramatic increase in the rates of childhood obesity and diabetes. In 1980, 15% of Canadian school-aged children were overweight or obese. Remarkably, this number more than doubled to 31% in 2011; 12% of children met the criteria for obesity in the same reporting period. This has resulted in a population with a high burden of disease, causing both individual suffering, and resulting in health care systems, which are approaching their financial breaking points. The guidelines have not been based on the best and most current science, and significant change is needed.

We are a group of Canadian Physicians and Allied Health Care professionals who wish to see significant change to the dietary guidelines, and insist they be based on the best and current evidence.

They have put together a list of things that they believe should happen

Points for Change

The Canadian Dietary Guidelines should:

1. Clearly communicate to the public and health-care professionals that the low-fat diet is no longer supported, and can worsen heart-disease risk factors
2. Be created without influence from the food industry
3. Eliminate caps on saturated fats
4. Be nutritionally sufficient, and those nutrients should come from real foods, not from artificially fortified refined grains
5. Promote low-carb diets as at least one safe and effective intervention for people struggling with obesity, diabetes, and heart disease
6. Offer a true range of diets that respond to the diverse nutritional needs of our population
7. De-emphasize the role of aerobic exercise in controlling weight
8. Recognize the controversy on salt and cease the blanket “lower is better” recommendation
9. Stop using any language suggesting that sustainable weight control can simply be managed by creating a caloric deficit
10. Cease its advice to replace saturated fats with polyunsaturated vegetable oils to prevent cardiovascular disease
11. Stop steering people away from nutritious whole foods, such as whole-fat dairy and regular red meat
12. Include a cap on added sugar, in accordance with the updated WHO guidelines, ideally no greater than 5% of total calories
13. Be based on a complete, comprehensive review of the most rigorous (randomized, controlled clinical trial) data available; on subjects for which this more rigorous data is not available, the Guidelines should remain silent.

Quoting Dr. Kendrick - My sense of what is now happening is that the momentum against the very stupid and damaging nutritional guidelines that have dominated the Western World for the last forty years is reaching breaking point. This group even managed to throw ‘restricting salt intake’ into the dustbin.

Hypoglycemia and Diabetes – Part 2

Part 2 of 2 parts

When you have low blood glucose, first, eat or drink 15 grams of a fast-acting carbohydrate, such as:

• Three to four glucose tablets
• One tube of glucose gel
• Four to six pieces of hard candy (not sugar-free)
• 1/2 cup fruit juice
• 1 cup skim milk
• 1/2 cup soft drink (not sugar-free)
• 1 tablespoon honey (put it under your tongue so it gets absorbed into your bloodstream faster)

Fifteen minutes after you've eaten a food with sugar in it, check your blood glucose again. If your blood sugar is still less than 70 mg/dl, eat another serving of one of the foods listed above. Repeat these steps until your sugar becomes normal. These are important steps and should be followed.

Hypoglycemia may make you pass out. If so, you'll need someone to give you a glucagon injection. Glucagon is a prescription medicine that raises blood sugar, and you may need it if you develop severe hypoglycemia. It's important that your family members and friends know how to give the injection in case you have a low blood sugar reaction.

If you see someone having a severe hypoglycemic reaction, call 911, or take him or her to the nearest hospital for treatment. Do not try to give an unconscious person food or fluids as they may choke. Never give a person insulin if they are having an episode of hypoglycemia as this could kill them.

Do not drive when you have low blood glucose. It's very dangerous. If you're driving and you have hypoglycemia symptoms, pull off the road, check your blood sugar, and eat a sugary food. Wait at least 15 minutes, check your blood sugar, and repeat these steps if necessary. Eat a protein and carbohydrate source (such as peanut butter crackers or cheese and crackers) before you drive on. Be prepared – always keep a sugar source in your car at all times for emergencies.

If you have diabetes, ways you can prevent hypoglycemia include:

• Follow your meal plan.
• Eat at least three evenly spaced meals each day with between-meal snacks as prescribed if necessary.
• Plan your meals no more than 4 to 5 hours apart.
• Exercise 30 minutes to 1 hour after meals. Check your sugars before and after exercise, and discuss with your doctor what types of changes can be made.
• Double-check your insulin and dose of diabetes medicine before taking it.
• If you drink alcohol, be moderate and monitor your blood sugar levels.
• Know when your medicine is at its peak level.
• Test your blood sugar as often as directed by your doctor or what your experience has taught you.
• Carry an identification bracelet or other identification that says you have diabetes and specify the type of diabetes you have.

Always carry a list of the medications you are currently taking in your wallet, purse, or in what you carry daily. Always list your primary care doctor and the phone number for him/her so contact can be made if you are unable to communicate at the time.

Read this is WebMD.

Hypoglycemia and Diabetes – Part 1

Part 1 of 2 parts.

Hypoglycemia can be caused by diet, some medications and conditions, and exercise. This is one reason for testing as often as many of us do. If we don't have enough sugar (glucose) available in our bodies, low blood glucose or hypoglycemia can happen for those of us with diabetes.

If you develop hypoglycemia, please record the date and time when it happened and what you did. Share your record with your doctor, so he or she can look for a pattern and adjust your medications, if necessary. Call your doctor if you have more than one episode of unexplained hypoglycemia in a week.

While it is true that most people feel the symptoms of hypoglycemia when their blood glucose level falls below 70 milligrams per deciliter (mg/dl), you will need to learn what your symptoms are and act on them.

Most of the early symptoms include:

• Confusion
• Dizziness
• Feeling shaky
• Hunger
• Headaches
• Irritability
• Pounding heart; racing pulse
• Pale skin
• Sweating
• Trembling
• Weakness
• Anxiety

Without treatment, you might develop more severe symptoms, including:

• Poor coordination
• Poor concentration
• Numbness in mouth and tongue
• Passing out
• Nightmares or bad dreams
• Coma

If you have any doubts about the diabetes medications you are taking, be sure to ask your doctor if any of your medicines can cause hypoglycemia.

Insulin treatment can cause low blood sugar, and so can a type of diabetes medications called "sulfonylureas." Commonly used sulfonylureas include:

• Glimepiride (Amaryl)
• Glipizide (Glucotrol)
• Glibenclamide (Glyburide, Micronase)
• Gliclazide

Older, less common sulfonylureas tend to cause low blood sugar more often than some of the newer ones. Examples of older drugs include:

• chlorpropamide (Diabinese)
• nateglinide (Starlix)
• repaglinide (Prandin)
• tolazamide (Tolinase)
• tolbutamide (Orinase)

You can also get low blood glucose if you drink alcohol or take allopurinol (Zyloprim), aspirin, Benemid, probenecid (Probalan), or warfarin (Coumadin) with diabetes medications.

You shouldn't get hypoglycemia if you take alpha-glucosidase inhibitors, biguanides (such as metformin), and thiazolidinediones alone, but it can happen when you take them with sulfonylureas or insulin.

You can get low blood glucose if you take too much insulin for the amount of carbohydrates you eat or drink.

For instance, it can happen:

• After you eat a meal that has a lot of simple sugars
• If you miss a snack or don't eat a full meal
• If you eat later than usual
• If you drink alcohol without eating any food

Don't skip meals if you have diabetes, particularly if you're taking diabetes medications.

If you have diabetes and think you have hypoglycemia, check your blood sugar level. Do your levels often drop after meals that include a lot of sugars? Change your diet. Avoid sugary foods, and eat frequent small meals during the day.

If you get low blood sugar when you haven't eaten, have a snack before bedtime, such as a protein or a more complex carbohydrate.

Your doctor may find that you take too much insulin that peaks toward the evening-to-morning hours. In that case, she may lower your insulin dose or change the time when you get your last dose of it.

Yo-yo Dieting Causes Weight Gain

I think the timing of this article is on target. The holiday season is here and the food seems more carb or calorie laden than usual. Specialty breads, cakes, and other carb dense foods are everywhere you turn. As people with diabetes, you may want to think long and hard about the food you chose to eat. According to new research, if you diet for a period of time and then eat more for a few days, your brain interprets repeated dieting as short famines, prompting the body to store more fat for futures food shortages, resulting in weight gain.

The study, published in the journal Evolution, Medicine and Public Health, was led by Prof. Andrew Higginson, from the University of Exeter, and Prof. John McNamara, of the University of Bristol, both in the United Kingdom.

Keeping weight in check is a health benefit; compared with people of a healthy weight, people who are obese are at increased risk for many diseases. For instance, the risk of high blood pressure, type 2 diabetes, coronary heart disease, and stroke are all higher in the obese population. More than one-third of adults in the United States are obese, so keeping weight at a healthy level is a major priority from a public health perspective.

Although shedding holiday pounds may be a popular focus for many of us in January, the Centers for Disease Control and Prevention (CDC), say that people who lose weight gradually - about 1-2 pounds per week - are more successful at keeping the weight off.

Previous studies have investigated the negative health effects of yo-yo dieting. One study recently presented by the American Heart Association suggested that yo-yo dieting increases the risk of heart disease death.

For the latest study on yo-yo dieting, the researchers utilized a mathematical model of animals, such as birds, that know when food is in abundance or is scarce but do not know when the situation will change. The researchers note that animals respond to food shortages by storing energy and gaining weight.

Their model demonstrates that when food is in short supply, much like during a phase of dieting, an efficient animal will gain excess weight between periods of food shortage.

Prof. Higginson says, "Our model predicts that the average weight gain for dieters will actually be greater than those who never diet. This happens because non-dieters learn that the food supply is reliable so there is less need for the insurance of fat stores." Prof. McNamara adds that their model "shows that weight gain does not mean people's physiology is malfunctioning or that they are being overwhelmed by unnaturally sweet tastes." It could be that their brain is working normally, "but uncertainty about the food supply triggers the evolved response to gain weight," he adds.

The researchers say their model shows that the desire to eat increases as a diet continues and this desire will not go away as weight is gained. This is because the brain thinks that further famines are likely. The model may explain why many people get into a cycle of weight gain in the wake of increasingly restrictive diets; it only serves to communicate to the brain that it must store fat.

For those of us who over-indulge during the holiday season, however, what is the best way to lose weight? "The best thing for weight loss is to take it steady. Our work suggests that eating only slightly less than you should, all the time, and doing physical exercise is much more likely to help you reach a healthy weight than going on low-calorie diets," says Prof. Andrew Higginson, University of Exeter

The CDC offers some good advice for healthy weight loss. Because 1 pound equals 3,500 calories, they recommend reducing caloric intake by 500-1,000 calories per day to lose 1-2 pounds per week. Once a healthy weight is achieved, the CDC says to rely on healthful eating and physical activity most days of the week to keep the weight off over the long term.

Even a modest weight loss will confer health benefits, such as improvements in blood pressure, blood cholesterol, and blood sugars, the organization adds.

Preventing or Delaying Type 2

At least the American Diabetes Association is including information that has been published by others during the year relating to metformin and vitamin B12 deficiency.  

Now I will quote from the statements by the ADA:

“Recommendations

• Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI greater than or equal to 35 kg/m2, those aged less than 60 years, women with prior gestational diabetes mellitus, and/or those with rising A1C despite lifestyle intervention. A
• Long-term use of metformin may be associated with biochemical vitamin B12 deficiency, and periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy. B

Pharmacologic agents including metformin, α-glucosidase inhibitors, orlistat, glucagon-like peptide 1 (GLP-1) receptor agonists, and thiazolidinediones have each been shown to decrease incident diabetes to various degrees in those with prediabetes. Metformin has the strongest evidence base and demonstrated long-term safety as pharmacologic therapy for diabetes prevention (37). For other drugs, cost, side effects, and durable efficacy require consideration.

Metformin was less effective than lifestyle modification in the DPP and DPPOS but may be cost-saving over a 10-year period (34). It was as effective as lifestyle modification in participants with BMI greater than or equal to 35 kg/m2 but not significantly better than placebo in those over 60 years of age (17). In the DPP, for women with history of GDM, metformin and intensive lifestyle modification led to an equivalent 50% reduction in diabetes risk (38), and both interventions remained highly effective during a 10-year follow-up period (39). Metformin should be recommended as an option for high-risk individuals (e.g., those with a history of GDM, those who are very obese, and/or those with relatively more hyperglycemia) and/or those with rising A1C despite lifestyle intervention. Consider monitoring B12 levels in those taking metformin chronically to check for possible deficiency (see Section 8 “Pharmacologic Approaches to Glycemic Treatment” for more details). Unquote”

This is a very good statement by the ADA and tells us, at least on this topic, that they are at least concerned about vitamin B12 deficiency.

Several of our support group members have contacted me when I sent them an email about this and a link to the 2017 ADA Guidelines. Allen said that Barry, Ben, and he were happy this is in the guidelines and they thanked me for bringing this to their attention. They said they were forwarding my email and link to all of the members. I thanked them for that and said I appreciated them doing this.

Later, Brenda called and thanked me for the information and was thinking of using the guidelines for the topic. I told her I would help where I could and give the person chosen, any links necessary. She thanked me and said she would make the person aware of this.

Food Companies Like to Put Bias into Research

If you think there is bias inscientific research by Big Pharma and Big Food, you would be correct. I know as a reader, I normally start at or near the end of any article to find out who the funded the study and who the authors of the study are to discover who may have conflicts. If it is only an abstract, then it is at the start that I look for potential bias in the study.

Other keys that I look for is the organization of the study, if this is even specified. It can be interesting when the study is done at a university and I can obtain an email address for corresponding and requesting a copy of the study. This allows for an easier analysis and chance to discover conflicts.

Consumer choice is often guided by recommendations about what we should eat, and these recommendations also play a role in the food that’s available for us. Recommendations take the form of dietary guidelines, food companies’ health claims, and clinical advice. But there’s a problem. Recommendations are often conflicting and the source of advice not always transparent.

Governments issue national dietary guidelines to inform people’s food choices and the nation’s food policies. To be credible and scientifically sound, they should obviously be built on rigorous evidence. But often they are driven by other needs. In the United States, agriculture is a large driver and many studies show the bias of Big Agriculture. High fructose corn syrup is strongly promoted by the corn industry and other products are also promoted.

Public health dietary guidelines and policies are influenced by political, economic, and social factors. Bias in research is the systematic error or deviation from true results or inferences of a study. Pharmaceutical, tobacco or chemical industry funding of research biases human studies towards outcomes favorable to the sponsor.

Even when studies use similar rigorous methods – such as keeping study information away from participants (blinding) or removing selection bias between groups of patients (randomization) – studies sponsored by a drug’s manufacturer are more likely to find the drug is more effective or less harmful than a placebo or other drugs.

This bias in pharmaceutical industry sponsored studies is just like the sugar industry sponsored studies that downplayed sugar’s link to heart disease while putting the blame on fat.

Financial conflicts of interest between researchers and industry have also been associated with research outcomes that favor companies researchers are affiliated with.

So how does this happen? How can industry-funded studies use methods similar to non-industry funded studies but have different results? Because bias can be introduced in several ways, such as in the research agenda itself, the way research questions are asked, how the studies are conducted behind the scenes, and the publication of the studies.

Industry influences on these other sources of bias in research often remain hidden for decades.

It took over 40 years to show how the tobacco industry undermined the research agenda on the health effects of secondhand smoke.

It did this by funding “distracting” research through The Center for Indoor Air Research, which three tobacco companies created and funded. Throughout the 1990s, this center funded dozens of research projects that suggested components of indoor air, such as carpet off-gases or dirty air filters, were more harmful than tobacco. The center did not fund research on secondhand smoke.

There is a high risk of bias when the methodology of the study (how the study is designed) leads to an error when assessing the magnitude or direction of results. Clinical trials with a high risk of methodological bias (such as those lacking randomization or blinding) are more likely to exaggerate the efficacy of drugs and underestimate their harms.

Publication bias occurs when entire research studies are not published, or only selected results from the studies are published. It is a common myth publication bias comes about because scientific journal editors reject studies that don’t support the hypothesis or question the studies were asking. These are called negative or statistically non-significant studies. But negative research is as likely to be published as positive research. So, it’s not that.

Analysis of internal pharmaceutical industry documents from 1994 to 1998 shows the pharmaceutical industry had a deliberate strategy to suppress publication of sponsored research unfavorable to its products. Industry-funded investigators were not allowed to publish negative research that did not support the efficacy or safety of the drugs being tested.

This has contributed to a clinical literature dominated by studies demonstrating the efficacy or safety of drugs. The tobacco industry also has a history of stopping the publication of research it funded if the findings didn’t lean in favor of tobacco products.

Please read the full article here to further understand the different bias that is so unfavorable to many studies.

A Good Organization Gone Bad

I feel very sad as I write this. I dislike what is happening to the diabetes newsletter by “experts” at the Mayo Clinic. Apparently, funds are becoming shorter and many articles are being repeated on a regular basis. The real problem is the refusal of the staff posting the article to answer questions. Some of the questions are from people crying for help, and these most often are not answered.

Since our health with diabetes and even prediabetes is important, the Mayo Clinic turning their backs on these people is inexcusable and showing lack of respect for people needing help.

I am wondering if there are problems among the Mayo Clinic employees that are causing many of the problems. I am also concerned that what was a great newsletter may become a relic and no longer of any value to people new to diabetes and a nuisance for people that have had diabetes for several years. I have had thoughts about unsubscribing to the newsletter, but with the latest antics, felt that someone needs to be aware of what is happening and inform others about the weaknesses of the Mayo Clinic and their treatment of people with diabetes.

If you doubt the last sentence, one of our support group members did receive and keep an appointment with the diabetes department. He felt that the doctors for diabetes had no interest is helping him and showed it by writing prescriptions for three oral medications and increasing his dosage for the statin and blood pressure medication. When he asked why they were taking him off insulin, the answer was that this was what the ADA recommended. He stated he had been on insulin for five years and saw no reason to return to oral medications when insulin worked so well for keeping his blood glucose under control. Again, he was given the answer that the ADA recommended this.

He said if he was new to diabetes, he could agree, but having diabetes for almost 9 years and A1c's over 10 percent on oral medications, he could not understand why they would be so careless with his health. At that point, he said that doctor handed him the prescriptions and left the exam room.

Another problem I have with the diabetes newsletter is some of the questions that are argumentative more that true questions. Yet given the chance, why is the author or someone at the Mayo Clinic not presenting facts to answer the questions. Maybe they don't know the answers or worst yet, don't want people to know the correct information.

Type 2 Diabetes from Statins

I am somewhat surprised, but appreciative that Om Ganda, M.D., Director of the Lipid Clinic at Joslin Diabetes Center is not trying to hide the fact that statins have the side effect of causing type 2 diabetes.

He does seem to be blunting the side effect, and is saying that it may be the higher doses causing problems. If you’re like nearly one-third of Americans over age 40, you probably take a statin. These cholesterol-lowering drugs are used for reducing risk of stroke and heart attack. They work by lowering the amount of LDL cholesterol, the so-called “bad cholesterol” in the blood. Statins also reduce inflammation around plaque in the blood vessels.

Despite their benefits, some people stop taking them because of side effects. The latest example, which is shown in numerous studies suggest that taking statins could increase the risk of developing type 2 diabetes. “Nobody expected it,” says Dr. Ganda.

In response to this mounting evidence, Dr. Ganda carried out a comprehensive review of all available evidence examining the association between statins and type 2 diabetes. The new review showed largely consistent results across 33 randomized controlled trials and observational studies.

“There does seem to be a slight, but significant increase in the risk of new-onset diabetes in patients on statin therapy,” says Dr. Ganda.

Of the 33 studies included in the review, one study found that taking statins was linked to a 25 percent higher risk of diabetes. However, the other studies revealed either no increase or a much smaller increase (2 to 10 percent) with various statins.

Dr. Ganda says that it’s important to note that the increased risk is over and above the risk people already have, because diabetes and prediabetes are so common today.

The review also showed that the highest risks are associated with the most intensive statin therapy. It appears that those on high-dose statins, which have a greater effect at lowering cholesterol, are more likely to develop diabetes than those on moderate-dose statins.

“The risk of diabetes is dependent on the dose of the statin – that is, how strong it is — and the correlation seems to be significant,” says Dr. Ganda. “But still, more intensive therapy is indicated because of all the evidence that we have, particularly in patients who already have cardiovascular disease.”

The reason behind the statin-induced diabetes remains unclear. “The cumulative evidence does show that most people who get diabetes on statins already have prediabetes or features of metabolic syndrome, he explains. “This means that starting statin therapy just ushers it in.

What to Think About - If you’re concerned about preventing diabetes from happening, adopting a healthier lifestyle is the first step. If you’ve been diagnosed with prediabetes and have to go on statin therapy, talk to your doctor about doing whatever is necessary to control or reverse your prediabetes. In general, that means staying active, eating a heart-healthy diet and controlling your weight.

“People should be educated about their choices,” says Dr. Ganda. “The results from this review provides yet another reason for people to monitor their diet and get regular exercise.”

Should You Avoid Statins? Despite the slight increase in diabetes risk from using statin drugs, this alone is not enough to avoid taking them, Dr. Ganda points out. “It’s important for people with diabetes not to stop initial statin therapy, because it lowers the risk of cardiovascular disease.”

Instead, he explains, statin therapy should be intensified in order to get LDL as low as possible. As we get older, our LDL cholesterol usually rises, probably due to an increase in body fat. This harmful cholesterol is what produces atherosclerosis, the buildup of plaque in the inner linings of arteries that restricts blood flow. The goal should be an LDL level below 100, closer to 70 if you have heart disease “This benchmark is stricter than it used to be because many trials have shown that the lower you get LDL cholesterol the better,” he says.

When these studies first came out some experts said that statins should not be used in the diabetes population, but that is the wrong approach, he adds. “There is no reason to avoid statins out of fear of developing diabetes. And those who do develop diabetes on statin therapy are still protected against cardiovascular disease, even after developing diabetes.”

In addition, please read this article which says in one sentence the following - “The association of statins with the risk for incident diabetes is less well understood, but in an earlier study, previous meta-analysis of 13 clinical trials of statins featuring a total of 91,140 patients suggests that the risk for diabetes associated with these medications is real.”

Clinical Trial Results Not Published

Apparently, the United States isn't the only place that clinical trials never are published. January 6,2012, I blogged about NIH-funded trials not being published. Now Canada is having the same problem and it is among universities and research hospitals where they are having the biggest problems.

The CBC of Canada reports that every year, thousands of its citizens sign up to participate in clinical trials. Like the U.S., the results of many of these trials never are published.

And new online tool aims to put pressure on some of the companies and institutions behind the problem. TrialsTracker maintains a list of all the trials registered on the world's leading clinical trials database and tracks how many of them are updated with results.

Amid pharmaceutical companies and research bodies from around the world on ClinicalTrials.gov, maintained by the U.S. National Institutes of Health, nine Canadian universities and institutions rank in the top 100 organizations with the greatest proportion of registered trials without results.

"It's well documented that academic trialists routinely fail to share results," says Ben Goldacre, who was part of the team from the University of Oxford that developed TrialsTracker. "Often they think, misguidedly, that a 'negative' result is uninteresting — when, in fact, it is extremely useful."

The University of Toronto's David Henry says "publication bias," as it's called, is robbing the medical community and patients of important information.

"We've been deceived about the truth about treatments that we've used widely over a long period, in very large numbers of individuals, because of the selective publication of results that are favorable to the product," says Henry, a professor of health systems data at U of T's Institute for Health Policy Management and Evaluation.

But Henry adds that publication bias isn't the only reason results aren't being made public. He says many institutions haven't made it a priority.

"If you leave it to the trialists, they've often moved on to the next trial," he says. "At the end of the day, I don't think they give enough weight to it."

Please consider reading the full article here, as I only covered part of the full article.

Elderly Often Have Dehydration Problems

Dehydration in the elderly can be difficult for many doctors to correctly diagnose.

Often doctors become confused because of urinary tract infections (UTIs) and prescribe antibiotics heavily which can then lead to real UTI.

Dehydration means the body doesn’t have as much fluid within the cells and blood vessels as it should. Yes, the body can gain fluid through what we eat and drink. The body loses fluid by urination, sweating, and a host of other bodily functions. When we lose more fluid than we take in, we become dehydrated.

When a person starts to become dehydrated, the body is designed to signal thirst to the brain. Then the kidneys are supposed to start concentrating the urine to lessen the water loss in urine. However, as we age, the body's mechanisms that are meant to protect us from dehydration lose the ability to perform efficiently. The elderly often develop reduced thirst signals and become unable to concentrate their urine.

Other factors that put older adults at risk include:

1. Chronic problems with urinary continence, which can make older adults reluctant to drink a lot of fluids
2. Memory problems, which can cause older adults to forget to drink often, or forget to ask others for something to drink
3. Mobility problems, which can make it harder for older adults to get something to drink
4. Living in nursing homes, because access to fluids often depends on the availability and attentiveness of staff
5. Swallowing difficulties

Dehydration can also be brought on by an acute illness or other event. Vomiting, diarrhea, fever, and infection are all problems that can cause people to lose a lot of fluid and become dehydrated. The elderly are more likely to be taking medications that increase the risk of dehydration, such as diuretic medications, which are often prescribed to treat high blood pressure or heart failure.

In the elderly, the most accurate way to diagnose dehydration is through laboratory testing of the blood. Dehydration generally causes abnormal laboratory results such as:

1. Elevated plasma serum osmolality: this measurement relates to how concentrated certain particles are in the blood plasma
2. Elevated creatinine and blood urea nitrogen: these tests relate to kidney function
3. Electrolyte imbalances, such as abnormal levels of blood sodium
4. Low urine sodium concentration (unless the person is on diuretics)

Doctors often sub-classify dehydration based on whether blood sodium levels are high, normal, or low.

Dehydration can also cause increased concentration of the urine — this is measured as the “specific gravity” on a dipstick urine test. However, this is not an accurate way to test for dehydration in older adults, since we tend to lose the ability to concentrate urine as we get older.

Physical signs of dehydration may include:

• dry mouth and/or dry skin in the armpit
• high heart rate (usually over 100 beats per minute)
• low systolic blood pressure
• dizziness
• weakness
• delirium (new or worse-than-usual confusion)
• sunken eyes
• less frequent urination
• dark-colored urine

But as noted above: the presence or absence of these physical signs are not reliable ways to detect dehydration. The physical symptoms above can easily be caused by health problems other than dehydration.

So if you are concerned about clinically significant dehydration, or about the symptoms above, blood tests results may be needed. A medical evaluation for possible dehydration should also include an interview and a physical examination.

Please read the entire blog here and it explains much more about dehydration.

Eye Care for PWD

Yes, I used PWD for people or person with diabetes in the title and I am trying to use more acronyms to help people learn them and recognize them when other people use them in articles, blogs, or on social media. I have received emails asking the meaning of a few acronyms.

Yes, I have blogged about eye diseases and diabetes before, but I still receive emails asking if they should take eye diseases seriously. I always answer with the three blogs from January 21 to 23, 2014 and add this to their reading from January 4, 2014 and this blog from January 1, 2016.

I will always write about the same topics that I have written about before when I receive emails asking questions about a topic. I realize that new readers find my blogs and have questions.

To keep your vision sharp, you’ll want to take great care of your health so you can avoid problems related to diabetes. Over time, high blood sugar can damage the tiny blood vessels in your eyes. That can lead to a condition called diabetic retinopathy. High blood sugar can also lead to cataracts and glaucoma, which happen earlier and more often when you have diabetes.

Use these seven tips to take charge of your disease and protect your eyes:

1. Schedule appointments with your eye doctor at least once a year so she can spot any problem early and treat it. During your exam, your eye doctor will use special drops to widen (dilate) your pupils and check the blood vessels in your eyes for early signs of damage.
2. Keep your blood sugar under control. If you do that, you can slow any damage to the tiny blood vessels in your eyes. Several times a year, you should have an A1c blood test. It shows your blood sugar levels over the past 3 months. Your result should be around 6.5% or less.
3. High blood pressure alone can lead to eye disease, so keep it in check. If you have high blood pressure and diabetes, you need to be even more careful about your health. Ask your doctor to check your blood pressure at every visit. For most people with diabetes, it should be less than 140/80.
4. Check on your cholesterol levels. All it takes is a blood test to find out how much “bad” LDL and “good” HDL cholesterol you have. Too much LDL is linked to blood vessel damage.
5. Eat for wellness. Go for fruits, vegetables, and lean protein. If that’s a big change for you, you can get ideas and encouragement from a nutritionist. You can also ask your doctor’s advice about when you should eat and how much is OK if you take insulin.
6. If you smoke, quit. Lighting up causes problems with your blood vessels, which makes you more likely to end up with eye trouble. It’s not easy to kick the habit, so don’t hesitate to ask your doctor for help. Alternatively, go to a support group or quit-smoking program.
7. Move more, if you have no medical limitations. Exercise can have a big influence on blood sugar. If you use insulin or medication to lower your blood sugar, ask your doctor when you should check your levels before and during your workouts. Also ask what type of workout you should do.

There are more ideas and if you have them, do not be afraid to use them as well.

Mildly Excessive Body Iron Increases Risk of Type 2

I am thankful that The University of Eastern Finland developed this study and that Science Daily printed their information. Several of the post menopausal women in our support group were also happy when I sent them the link to this as they had been having several conversations with different doctors lately about anemia and this gave them another concern, but as Brenda told me, this is good to know. She sent the link to her daughter, as she wanted to let her know about this study.

Even mildly elevated body iron contributes to the prevalence and incidence of type 2 diabetes, according to research from the University of Eastern Finland. Excess body iron accumulation is a known risk factor of type 2 diabetes in hereditary hemochromatosis, but the results presented by Dr Alex O. Aregbesola in his doctoral thesis show that elevated iron is a risk factor in the general population as well, already at high levels within the normal range.

In addition, a gender difference was observed in the risk and prevalence of type 2 diabetes, to some extent due to different body iron accumulation between men and women. Men had 61% higher prevalence and 46% increased risk of developing type 2 diabetes when compared to women. At comparable age groups, men were found to accumulate more iron than women do, and iron explained about two-fifths and one-fifth of the gender difference in type 2 diabetes prevalence and incidence respectively.

Moderate iron stores are safer than depletion toward iron deficiency and possible anemia.

Body iron predicted the risk of type 2 diabetes. There was a slight variation in the risk of type 2 diabetes over a wide range of serum ferritin (sF) concentrations that reflect body iron stores, with a marked increase in the risk observed at high normal range of sF concentrations in men (>185 µg/L). However, iron depletion toward deficiency as reflected by serum-soluble transferrin receptor concentrations did not offer protection against type 2 diabetes; rather, there was a U-shaped type of association between iron stores and the risk of type 2 diabetes which showed that the risk was lowest on moderate levels.

"Hence, a safe range of body iron stores in men with regard to the risk of type 2 diabetes may be 30-200 µg/L of serum ferritin," Dr Aregbesola says. The association between body iron and impaired glucose metabolism was strongest among people in prediabetes states.

Abnormalities in glucose metabolism and type 2 diabetes are on the increase globally, and the prevalence of diabetes among adults is estimated at 642 million by 2040. Reduced quality of life and increased mortality due to type 2 diabetes and its complications are of great concern. Preventive measures targeted at established risk factors of type 2 diabetes, such as excess body weight or obesity, physical inactivity and poor nutrition need further exploration. This may be a key and signifies the need for further studies.

Unhealthy dietary habits associated with the surge of type 2 diabetes include excess dietary intake of iron and unregulated iron supplement use. Iron is a micronutrient that is required in the formation of some essential body proteins and enzymes, like hemoglobin, cytochromes and peroxidase. However, it is harmful when stored in excess in the body. It promotes the release of free radicals that damage the secretory capacity of beta cells of pancreas to produce insulin. It also decreases insulin sensitivity in peripheral tissues and organs involved in glucose metabolism.

The doctoral thesis is based on studies where the main aim was to examine the associations between body iron stores and glucose homeostasis and type 2 diabetes among middle-aged men and women representing the general population and living in the eastern part of Finland. The thesis investigated the risk of type 2 diabetes over a wide range of body iron stores, as well as whether iron depletion toward mild iron deficiency offers protection against type 2 diabetes risk. The types of associations between body iron stores and glucose homeostasis were examined in the three glycemic states ‒ normoglycemia, prediabetes and type 2 diabetes, using markers of insulin resistance and beta cell function. Gender differences and the contribution of body iron accumulation to any gender difference in type 2 diabetes were also investigated.

"This study provides a new body of evidence that mildly elevated body iron is an important risk factor of glucose metabolism derangement, which contributes to the increase in the prevalence and incidence of type 2 diabetes," Dr Aregbesola concludes.