April 23, 2016

Diabetes and Blood Glucose Levels

I have not been asked this question - Can You Have Diabetes If Your Blood Glucose is Normal? Fortunately, Kelley Pounds has a blog that answers this question. According to her, the answer is yes! Elevated blood glucose is a LATE sign of Type 2 diabetes. In fact, when your diabetes has advanced to the point when your blood glucose levels are elevated, you have already sustained significant damage. It has been estimated that at the diagnosis of pre-diabetes, as much as 50% of beta cell destruction has already occurred. And, at diagnosis of Type 2, as much as 80% destruction has already occurred. So, when did diabetes really start, at diagnosis, or 10-15 years earlier? I think we all know the answer to that question. Any physician can attest to the fact that by the time a diagnosis of Type 2 diabetes is made, the patient is often in severe metabolic dysfunction, often with many of the elements of metabolic syndrome already present (insulin resistance, abdominal obesity, hypertension and dyslipidemia).

Fortunately, the book she refers to was available to me and I was able to read it.
The cover of the book is below and I will be reading it a second time, as the information is important. Kelley Pounds says I know I have mentioned this before, but this is one of the most important books to read about the prevention of diabetes. Diabetes starts long before diagnosis. Diabetes pathology starts long before your blood sugars are elevated.

In fact, if you have any of the diseases or conditions listed below, even with normal blood glucose, you already have diabetes pathology, even if undiagnosed with diabetes. One of the best methods for detecting early diabetes pathology is the oral glucose tolerance test with insulin assay. Remember, Type 2 is not primarily a disease of blood glucose disregulation, but insulin disregulation. Dr. Kraft spent years performing these tests upon thousands of patients and developed profiles that can help us to identify the earliest stages of diabetes.

Notice what Dr. Kraft says about diabetes in the presence of normal blood sugar: “If you have any of the pathologies of diabetes (athero-arteriosclerosis, cardiovascular disease, cerebral vascular disease, hypertension, nephropathy, retinopathy, peripheral and central neuropathy, and penile erectile dysfunction) you are diabetic irrespective of your glucose status! In the undiagnosed with any of the clinical pathologies noted above, especially those with normal fasting blood sugars, the insulin assay with oral glucose tolerance will confirm the diabetes diagnosis. The pathology of diabetes mellitus occurs in those with normal blood sugars.”

This is so important to understand. It is the very reason that if we have any risk factors for Type 2 (family history, overweight, belly fat despite being normal weight, high blood pressure, low HDL cholesterol, high triglycerides, PCOS, gestational diabetes, age/race/gender) that we must live a lifestyle, as if we already have diabetes, because, given the right test, it would be revealed that we already do!

April 22, 2016

Bariatric Surgeons Don't Do Nutrition

Bariatric surgeons are finding out that they have problems in many patients that they have operated on and this is the high risk of vitamin D deficiency and insufficiency among bariatric surgery patients. Both referring physicians and bariatric specialists need to take a greater role in personalizing vitamin D supplementation regimens in these patients.

Even most referring physicians aren't aware of the importance of early vitamin D intervention or may not be addressing the issue in the most effective manner. Even with the latest medical research, doctors specializing in bariatric surgery do not yet know the best vitamin D supplementation regimen for these patients. As a result, the referring physicians and bariatric specialists should be working together to closely monitor and tailor an individualized supplement regimen for each patient.

The best method of treating vitamin D malnutrition pre- and post-bariatric surgery is to deliver a higher daily dose of vitamin D and then adjust to the appropriate blood 25(OH)D readings, which will require personalized medicine and treatment from both referring physicians and bariatric specialists. Personalized vitamin D supplementation will prevent both under- and overtreatment in bariatric surgery patients and is likely also important for many other patient populations who are at risk for vitamin D deficiency, including people who have obesity or in those who are overweight.

Until recently, vitamin D deficiency after bariatric surgery was thought to be due to side effects of the procedure, i.e., poor absorption of fat-soluble nutrients. It has been determined now that vitamin D deficiency stems of pre-surgery malnutrition with up to 98 percent of bariatric surgery candidates having vitamin D deficiency. This malnutrition persists after surgery despite supplementation and weight loss, which theoretically releases vitamin D stored in the fat.

The primary concern over vitamin D deficiency is that the risk of deficiency is even greater after bariatric surgery when these patients may be less able to absorb vitamin D, and, thus, treatment before surgery may be more effective. Improving vitamin D status before surgery may also improve healing and shorten the length of stay in the hospital following bariatric surgery.

What is an optimized vitamin D level in a patient before or following bariatric surgery? According to the 2013 American Society for Metabolic and Bariatric Surgery guidelines, physicians should bring blood concentrations to greater than 30 ng/mL of 25-hydroxyvitamin D, the circulating form of vitamin D. The society recommends achieving these readings by delivering the standard daily dose of at least 3,000 IU, test the patient's blood, adjust the dose, test again and repeat until the patient's vitamin D readings are optimized. A physician may consider giving high doses of vitamin D -- 50,000 IU one to three times weekly or even daily -- if necessary for patients following surgery. The recommendations from the society sound like a ringing endorsement for personalized medicine.

A key consideration in vitamin D supplementation that physicians need to be aware of is the form of vitamin D given. Vitamin D3 is made in the skin during sun exposure and is found in over-the-counter supplements, whereas vitamin D2 is uncommon in the diet and found in high-dose prescription vitamin D supplements. In a meta-analysis of 57 studies, patients given vitamin D3 had an 8.08-ng/mL larger improvement in 25(OH)D readings over the same dose of vitamin D2 -- meaning vitamin D3 proved more effective. Despite this, many doctors inadvertently prescribe vitamin D2 to their bariatric surgery patients. Many doctors do not realize that writing a prescription for vitamin D will likely yield vitamin D2, and many also do not know the difference in effectiveness between these two forms. I recently showed that 87% of our bariatric surgery candidates prescribed high-dose vitamin D were given vitamin D2, despite that many patients only get a short window for preoperative treatment.

As for the appropriate dosing regimen, of 25 separate studies testing different regimens, none of these studies reported consistently optimized vitamin D readings in patients. These studies ranged from a daily multivitamin to high doses of vitamin D (50,000 IU monthly or weekly) and various combinations of daily and high doses. These findings from my recent review echo the society's recommendations, yet no studies giving dosages up to 5,000 IU daily reached optimized vitamin D readings universally. However, some patients did reach blood concentrations over the recommended 30 ng/mL. Would the best course of treatment really be to increase the standard dose for all, or should we only increase the dosage for those patients who are still below the recommended concentration?

With this discussion, I also have to wonder if the other vitamins and minerals are monitored and kept at the correct levels as I have seen other studies reporting deficiencies in other vitamins as well.

April 21, 2016

Disagreeing with Another Writer

I seldom find myself in complete disagreement with other writers, but except for a few points, I find myself disagreeing with most of what Nancy Finn has in her latest blog. Her subtitle “The New Era in Healthcare,” leaves much to be desired as while many physicians and hospitals have moved from hand written records to computer records, these records do not communicate with each other and do not communicate with other record systems across the country.

The good news according to the Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services, is that more than 75% of all physicians now use some type of electronic record system, up from 18% in 2001.

Over 65% of American doctors also “routinely” send patient prescriptions electronically to the pharmacy and more than half use digital tools for basic clinical tasks, such as receiving alerts, and sending and receiving electronic lab reports to and from their medical record systems.

In a report sent to Congress in 2015, the Department of Health and Human Services stated that hospital adoption of at least a basic electronic record system has markedly increased to 59% of all hospitals.

The sad news is in this new era of digitizing patient records so they can be accessed in real-time by multiple health care providers, patients and caretakers has finally arrived is false. I know this for a fact as in the area where I live, going to the hospital emergency department in my home town does mean that my doctors in the other town cannot access these under any circumstances, even if I authorize this. In order to have my records available to my doctors, I must go the to the local hospital and request in written form the specific records that my primary care doctor needs. After a few days, I can generally pick up the paper copies and maybe a DVD of images to take to my PCP. This is hardly what I would call real-time. These digital records put our health information in one place, but cannot be shared in real-time, searched, or parsed out. So, if I have my doctors in another community, hand written requests must be made by me for the records needed by any of my doctors. This does not mean that wherever I go, the full information is available – only what I request copies of to hand carry with me.

Nancy says, “Our dialogue with our clinicians has changed as well. We are demanding, and getting, our visit notes so that we can check their accuracy and participate fully in our care.” We are still in the dark ages where I live – no copies of our visit notes are available, they are still hidden from us and while we can obtain copies of our lab results, no more is available. Errors cannot be corrected, but we don't know what the errors are unless the doctors thinks to ask us about something. I can participate in my care up to a point and then the doctor takes over and if I disagree – my records are marked as non-compliant.

Apparently, Ms. Finn lives in an ideal world as we still only use office visits only, I do have a secure portal to answer surveys about the visit and office cleanliness, but nothing else, no email, skype, or other advantages of digital communications. If I don't have any questions written out, my questions will not be answered.

There is little or no coordination of care and if I travel, I would need to take copies of certain information as no other information would be available if I was hospitalized or needed to see another doctor.

In this day and age, we can only hope that what Ms. Finn describes was available, but in essence, we are still back in the prior century in having access to our medical records if traveling. If we have caregivers, they are kept in the dark and would not be given access to our medical records, even with a limited power of attorney. Even my own wife can only receive information if she is with me at my doctor appointments. Much of the time she is discouraged from being in the exam room with me.

If you are interested, you may read Nancy Finn's full blog here.

April 20, 2016

Do You Have Food Cravings? - Part 2

Continued from the previous blog,

#7) Nutrient Deficiencies. I sometimes see claims made that when people aren't eating a nutrient-dense diet they may crave more food than they need, the idea being that the body is still trying to get what it needs. There is very little scientific evidence for this, but it's not impossible, and certainly eating a nutrient-dense diet is a good idea.

#8) Menstrual Cycle. It is well documented that for women, the menstrual cycle can affect the desire for different amounts and types of foods.

How to Combat Cravings
The best overall strategy to combat cravings is to construct a set of very clear specific guidelines for your eating based on what you have learned about what triggers your cravings. Examples:
  • "I don't eat sugar."
  • "I don't eat processed grains."
  • "My snacks always include protein and fiber."
It may help you to think of these guidelines as "rules" you follow. Eventually, these rules become "just the way you eat," you don't think about them, and you don't have to exercise "willpower". It may surprise you how quickly this happens.

If you have rules about unhealthy foods you crave but you don't want to eat, it helps some people to "demonize" those foods: think of them in some negative light: "harmful", "poisonous", or even (as I do) "not real food".
(If it seems too onerous to say, "I never eat ___", try including a specific exception. A friend had a rule, "Fridays are Fries Days", which worked for him until he didn't need it any more. Now he hardly ever eats fries.)

So, these are overall strategies. Besides repeating your rules and guidelines, what can you do if you're in the middle of a craving?

20 Methods to Stop Cravings in 5 Minutes or Less
Cravings are mainly happening in your head, whether from habit or from a trigger food. The idea is to get your brain and body onto a totally different track. First, drink a glass of water and take three deep breaths. Then try one of the following. Over time, you'll figure out what types of things work best for you.
1) Go outside: take a quick walk, enjoy the fresh air, sniff the breeze, or pull some weeds.
2) Exercise for 5 minutes: Walk up and down the stairs, stand up from your chair ten times, do jumping jacks, sit ups or push ups.
3) Dance! If you have kids, dance with them, or play tag.
4) Note of Appreciation: Write a quick email or note thanking someone for something he/she has done for you, or what you appreciate about him or her.
5) Say something nice to someone in person!
6) Write down 5 things you're grateful for.
7) Do some stretches, or if you do yoga -- strike a pose you enjoy.
8) Sit, close your eyes, and remember something nice that happened recently, in as much detail as you can.
9) Take a nap - sometimes we reach for food as a pick-me-up, when what we really need is sleep. A 5 to 10 minute power nap can work wonders.
10) Check off something on your to-do list that doesn't take much time. Make the appointment, pay a few bills, clear the trash out of your car, or clean out your purse.
11) Laugh! Read, watch, or listen to something funny.
12) Pray or meditate for a few minutes.
13) Focus on something beautiful: Smell some flowers, look at a favorite painting, watch the sunset, or light a candle and admire its scent and glow.
14) Listen to an uplifting song -- better yet, sing one!
15) Spend 5 minutes de-cluttering.
16) Plan something fun to do with a friend or partner.
17) Drink something warm -- a cup of tea, or bouillon with a little olive oil in it (there is recent research showing that olive oil contains a substance that may suppress appetite).
18) Hug someone, or cuddle with a pet. Physically contact with other living things is de-stressing.
19) Write in your journal. If you don't have one, it's as close as opening a file on your computer.
20) Cut up some vegetables to make prep for the next meal easier.

Of course, make sure you have food in your home that is on your eating plan!

April 19, 2016

Do You Have Food Cravings? - Part 1

Do you have food cravings or hunger pangs or is your stomach saying I'm hungry, feed me? How can we keep this from ruining a healthy food plan?

Yes, the term “Craving” is not well defined. Many use the term when craving certain foods, or certain types of foods. Others say this is the impulse to eat in the absence of hunger. Cravings can be for specific foods, or heading for the refrigerator for no good reason.

Differentiating between hunger and cravings is not always easy, and there is possibly some overlap. Food-specific cravings can often occur at the same time as hunger, and hunger can manifest itself in different ways. For example, if you've just eaten a satisfying amount of food and you still feel like eating, this is most probably what we are calling a craving. On the other hand, people who have gone with insufficient calories for an extended period, as in an extended dieting, will also report a sensation of wanting more food even when they are full.

Some have suggested that one way to differentiate between cravings and
hunger is to think about a plain but satisfying food, such as a steak. If eating a steak sounds like a great idea, it's probably hunger.

What can cause cravings? From my reading and experience, the following causes of cravings are my suggestions.

#1) Too much carbohydrate in the diet. A very common reaction to a low-carb diet is a dramatic reduction in cravings. People frequently talk about "feeling normal around food" or not feeling like eating between meals. This is actually the most-mentioned "favorite thing" about low-carb eating.

Of course, the same people will usually find to their dismay that adding too much carbohydrate back into the diet brings the return of those urges to eat when not hungry.

The obvious remedy is to find out how much carbohydrate is best for you, and stick to it. It generally takes about 5-14 days to rid yourself of the cravings (tips for getting through that time). However, this won't help in the moment when you're having the craving! Near the end of this blog, (part 2), I will have strategies for that.

#2) Eating processed, "hyper-palatable" foods. In recent decades, the food industry has perfected the art of creating foods that leave you wanting more of them. As documented by writers that have written about how these foods work in our brains to create yearnings.

These brain circuits actually have some commonality with responses and addictions to opioid drugs. The remedy for this is to not let the food companies get away with this: don't purchase and eat these foods.

#3) Sweet foods. Even apart from highly processed foods, sweet foods can be a problem for many people, for very similar reasons. Obviously, you don't need to buy highly processed sweet foods; you can make them yourself, and this can cause problems. This is why even artificial sweeteners should be used in moderation. Sweet foods can be an occasional treat for some, but others find that eating any sweet foods make them want to eat more.

#4) Other trigger foods. If you are eliminating sweet foods and processed foods, and are eating the right amount of carbohydrate for you, there aren't many trigger foods left. But, there are people who, for example, do fine on a moderate amount of carbohydrate, but find that potatoes or some other specific food trigger unwanted eating.

#5) Emotional eating. People do eat for emotional reasons: sadness, boredom, etc. However, before jumping to the conclusion that you are doing this, I urge you to carefully check out numbers 1-4, because many, many people have found that their "compulsive emotional eating" vanishes when they figure out the way of eating that works best for them. I was one of these people. I spent several years trying to figure out why I was overeating. Turned out it was simply "too much carbohydrate".

#6) Habits. If we get in the habit of having certain foods at certain times or in certain settings, we'll often find ourselves wanting that food whether or not we are hungry.

April 18, 2016

Animal Fats Healthier Than Vegetable Oils

The science behind the recommended change to vegetable oils about 50 years ago appears to be very faulty and even the trail itself was not that great. The research suggests that the switch from animal to vegetable (corn) fats may be not only unnecessary, but it may misguided. Studies have arrived at similar findings before, but the new one, which looks at the heart health of people eating animal fats vs. corn oil, suggests that people who use the latter may actually be at an increased heart risk.

The team looked at data from a study that started in the late 60s, using 9,400 residents from several mental hospitals and one nursing home (the participants coming from these two communities may be a problem in itself). It wasn’t published until 1989, for reasons that aren’t very clear, and it reported that switching from animal fats to corn oil was beneficial for cholesterol; it did not report that the switch had any effect on heart disease.

A team at the NIH, the University of North Carolina and several other universities uncovered the entire data set and ran the stats again, because some had been omitted. The reconsidered results were strange: People who ate vegetable oils had lower cholesterol, but also had a significantly higher risk of heart attack.

Though the research authors would not say this, it looks like the previous researchers were cherry picking data to arrive at the conclusion desired at the time. “Altogether, this research leads us to conclude that incomplete publication of important data has contributed to the overestimation of benefits–and the underestimation of potential risks of replacing saturated fat with vegetable oils rich in linoleic acid,” said Daisy Zamora.

The omega-6 fatty acid linoleic acid (LA) is known to have some major health drawbacks. “An odd thing about this is the outdated substitution of linoleic acid for unspecified saturated fat,” says David L. Katz, founder of the Yale Prevention Research Center. “Linoleic acid is an omega-6, and it’s clear now that there are many problems associated with excessive omega-6, notably interference with the production of long-chain omega-3s.”

The two types of fats need to be consumed into the body in balance, otherwise omega-6s usurp the machinery needed to make omega-3s. But researchers have been aware of this danger for some time. Omega-6 has also been linked to increasing, rather than decreasing, inflammation.

Sunflower oil in the US was ‘upgraded’ through selective breeding to produce a high-oleic-acid variety (high monounsaturated fatty acid) that now prevails, and avoids the potential harms noted in this paper. The same thing is now being done to soybean oil, and the high monounsaturated fatty acid version of that will soon replace the old variety.”

So the new study may simply underline that swapping animals fat for corn oil may lead to more health problems than it solves. And as Katz points out, no one today would think that making the swap the study made is terribly informative.

The evidence that replacing saturated fat in general with a balanced portfolio of unsaturated fats from a variety of foods is still questionable. The Dietary Guidelines advise, oils from whole foods: nuts, seeds, avocado, fish. These do not provide the excess of omega-6 likely in this case. Different varieties of imbalance tend to represent different ways of eating badly. The body needs, and responds well to, balance.”

For possible clarification of the unnamed studies and more information, please read this blog by Dr. Malcolm Kendrick. He does name the studies and makes the discussion clearer.

April 17, 2016

Testing to Manage Your Diabetes

If you have diabetes (any type), testing your blood glucose should be a part of your life. The test results will tell you and your doctor if your diabetes is well managed or not. The fallacy of this is that most doctors do not even look at your test results, but instead rely only on the HbA1c test they take.

This means that many people with type 2 diabetes especially, will need to learn how to interpret their test results and obtain copies of their lab results for comparison purposes. The WebMD article states that you and your doctors will work closely together to find the answers that will keep you healthy. For people with type 1 diabetes, this is probably true, but for people with type 2 diabetes, most doctors follow the ADA. They won't even prescribe the testing tools as they have been taught by the ADA that you are supposed to rely on the A1c results and not test.

This means that people with type 2 diabetes are operating in the dark about care for their diabetes and are not able to learn what foods or types of food raise their blood glucose levels dramatically and need to be eliminated from their food plan.

In goal setting, you’re aiming for an A1c level of 6.5% or less, which equals an average glucose (or eAG) of 140 mg/dl. Your doctor will give you an A1c test every 3-6 months.

When you should test and what goals you’re aiming for depend on:
  • Your personal preferences – but testing should be before and after meals for 3 to 4 months after diagnosis – called testing in pairs.
  • How long you’ve had diabetes.
  • If you’re pregnant.
  • Your age.
  • Other health problems you may have.
  • Medication(s) you’re taking.
  • If you have complications like retinopathy or neuropathy.
  • If you have low blood sugar (your doctor may call this hypoglycemia) without warning signs.
As mentioned above, testing times after diagnosis are important to help you establish a food plan and track what the different foods do to your blood glucose levels. You will also need to check the components of lifestyle change in my blog here, to determine the lifestyle changes you need to make.

A fasting blood glucose level, taken in the morning before you eat or drink anything, is the go-to test for many. Another test at bedtime is common. But what about other times? Testing 1 to 2 hours after breakfast or before lunch gives a more complete picture of what’s going on, says Pamela Allweiss, MD, of the CDC.

“Testing is really important, particularly if you take insulin or medicine that can cause hypoglycemia,” says David Goldstein MD, professor at the University of Missouri School of Medicine. And measuring both before and after meals is important in understanding what your blood-sugar patterns are and what to do about them.

This switch is part of a move away from a kind of one-size-fits-all thinking and toward more individualized care. Why? The old mantra was that better control led to fewer complications, Allweiss says. And that works OK for people who are healthy despite the diabetes.

In addition to understanding why you are testing, the following is important. All this testing means nothing if you don’t keep track of the results. Many glucose meters now do that for you. You should also keep a log. A full lifestyle diary that includes your eating and exercise habits, and how you feel at different times of the day, can also be a big help.

There’s lots to self-monitoring of blood glucose and lots to learn. Your self-testing is a big part of it. One number doesn’t tell the story. Looking for trends is also important.

A number by itself is just a number, Allweiss says. “We want to look at a pattern.” The steps to take after testing, of course, are simple enough. Talk to other people with type 2 diabetes and learn what all those numbers mean, and figure out how you can meet your blood glucose goals.

Diabetes requires a lot of education. It isn’t like taking a pill and seeing a doctor twice a year. You have to be engaged,” Goldstein says. We have great tools now, and we need to teach people how to use them. People have to know what to do -- and then they have to do it.”