Is the Glycemic Index Useful for People with Diabetes?

This is an interesting short article from a doctor at the Mayo Clinic. M. Regina Castro, MD is the doctor and I can appreciate some of her comments about the glycemic index.

Some people with diabetes use the glycemic index (GI) as a guide in selecting foods for meal planning. Other people won't use it as a guide, but as the food bible in selecting the foods they consume. The glycemic index classifies carbohydrate-containing foods according to their potential to raise your blood glucose level. Foods with a high glycemic index value tend to raise your blood glucose higher than do foods with a lower value.

There are a few benefits in using the glycemic index, but be careful not to slip into some of the common traps. Some of the traps include:

• Single food items, rather than combinations of foods, can impact blood glucose differently
• Doesn't consider all variables that affect blood glucose, such as how food is prepared or how much is eaten
• Only includes foods that contain carbohydrates
• Doesn't rank foods based on nutrient content — foods with a low GI ranking may be high in calories, sugar or saturated fat

Why the doctor is concerned about saturated fat tells me that she still believes the low fat high carbohydrate way of eating and cannot accept the low carbohydrate high fat way of eating.

It can be difficult to follow the glycemic index. For one thing, there is no standard for what is considered low, moderate and high glycemic foods. Packaged foods don't list their GI ranking on the label, and it can be hard to estimate what it might be. The doctor also misses the glycemic load (GL), which can be useful in determining some foods that are good for you. To begin with, packaged foods need to be avoided by people with diabetes because they will raise your blood glucose levels higher and faster than other foods.

Basic principles of healthy eating, portion control and counting carbohydrates are all ways to help you better manage and control your blood sugar. If you're interested in learning more, talk to a registered dietitian. Warning! Be very careful as most registered dietitians will only push carbohydrates and not be concerned about the glycemic index. Instead of helping you make wise food choices or help with your eating habits, they will mandate whole grains and other foods that will require larger doses of medications. Don't worry, they will be happy to advise your doctor that you need this or additional medications.

A Death from Type 2 Secrecy

This afternoon, June 16, Brenda sent out several emails that the woman she and Sue were working with, had passed. Even the husband was not aware of what had happened and the children had found her and the oldest had called 911, but the emergency medical people with the ambulance could not revive her. The oldest daughter called Brenda to come over after calling 911. Sue was there as well now and the husband had gone directly to the hospital.

Brenda said that the husband had called her after he found out what had happened and was very despondent. She said the doctor was counseling him and would not let him leave until they knew he would be okay. Brenda said that the two girls were crying and were wondering what they could have done. She said Sue had talked to the doctor and the doctor would be sending someone to help explain to the children that there was nothing they did wrong. He had asked the husband how much insulin his wife had that morning and he said he had seen eight vials and the EMT had reported only six vials and had found none in the waste baskets they had checked.

Sue said she had gone completely through the house and had found an empty vial in the upstairs bathroom. Brenda said she had found a second empty vial in the kitchen garbage and called the doctor to report what had been found. She said the doctor had guessed the cause of death was from hypoglycemia, but they would wait for the autopsy to be completed.

The husband then called to ask Brenda if she could take a few of the girls clothes and keep them overnight and not send them to school the next day. He had just found out that his wife had been told about her breast cancer that morning and he was not aware that no one had been with her when she found out. She had not gone back to work and everyone figured she had gone home. Even he was not aware of her seeing the doctor.

Brenda said the husband would be staying with his folks for the night and her parents would be there in the early evening. The doctor had approved this and was happy that he would have his family around him, as his sister would be there also. Brenda said she would put out another email when things were more definite.

This has several members of our support group upset and wondering why this happened.  Suicide was not on our minds and we are all wondering what we can do.  Many are thinking about talking to her parents and seeing if this can help,  We will be talking to the doctor first, to ask if we need to delay things or if we need to talk among ourselves and no one else.  Tim has scheduled us to talk with a pastor on Monday.

More on Polypharmacy

I had expected one or two emails after writing this blog on the unbelievable pile of pills, but I am now over a dozen emails. Many had parents that they had checked on and were surprised at the number of potential deadly medication conflicts in their possession. Two of the emails said they needed to take a parent to the pharmacist to prove to them the danger they were going to have. Another three could not believe even themselves what their parent was doing on statins and the amount of grapefruit the parent(s) were eating. One needed to take a parent to the hospital because of this.

Most of the parents would not believe the son or daughter because the vitamins, minerals, and grapefruit are considered natural. This required accompanying the parent to a doctor appointment and even then, the parent would not believe the doctor. How could something natural conflict with a prescription medication? Heart medications and statins were the two most problematic medications.

Other problems discovered were many pharmacies being used to prevent discovery of opioid use. This was a real surprise for a couple of children. One son was told to get out their house and never come back. Several phone calls were needed to notify the emergency room, two doctors and several pharmacies to let them know of the parent's addiction.

This is the reason I blog and will continue to blog about polypharmacy and other problems that people with diabetes can face. Polypharmacy has scared me the most and in talking this over with my pharmacist, she stated that this is more common than many people even want to know. She said she tells people quite often that the vitamins, minerals, and over the counter drugs will cause problems with the prescription they have just filled, yet they ignore what she says.

I told her that I still remember what she told one individual that ignored her and ended up dead two days later. I said I have known others that come in here to fill one prescription and travel to another town to fill another prescription of opioids. She said that the state is starting to step up prescription checks on opioid prescriptions and she now has several that she gets alerts on to not fill prescriptions.

She then asked about the Gabapentin that I have filled about every 90 days. I said that I have been moved up and down in my dosage and that two per day were for the neuropathy pain and one was for a muscle pain until that cleared up and now the third one is for arthritis pain in the lower spine. I said that the neuropathy pain was only blunted somewhat, but that I did not want a stronger pain medication until it became worse. The arthritis pain was more of an aggravation and only really bothered me when I was doing a lot of bending over.

She said good as there were several more levels of medication that would help if the pain became worse. I said I know and Lyrica would be one of them for the neuropathy, but I don't want that until I need it. She said it could help, but if I didn't want it, that was good. I said I don't know everything about the arthritis yet, but I hope that I don't need anything more for quite a while. With that she had a customer she needed to help and I left.

Mixed Results in a Small Trial on Diabetes Alert Dogs

This is a small trial only using eight dogs and is presented before being published in a peer-reviewed journal. There are several possible biases that are self-evident causing this to be junk science. Either the article was poorly written by an author not understanding the subject, or the authors of the study presented this in a poor manner,

The first statement that I question is this - “the first sign of hypoglycemia was the continuous glucose monitoring, followed by the dog, followed by a patient's symptoms.”

This is the first controlled study of the reliability of diabetes alert dogs to hypoglycemia in their diabetic companions under real-life conditions, Los said. Evan Los, MD, of Oregon Health & Science University in Portland is the lead author. His group examined eight patients (the youngest was 4-years-old) who had both a diabetes alert dog and a blinded CGM. Dog alerts were recorded in a diary and those were compared to capillary blood glucose (CBG) and CGM downloads.

Diabetes alert dogs undergo rigorous training, starting with obedience and socialization, as well as scent training. For the latter, they are trained based on a cotton swab of sweat from a human companion during a hypoglycemic event. The training takes 6-24 months to complete, but there is no universal competence test for dogs.

The first bias is using a 4-year-old child that can do little or no continuous training to the dog. A child this young generally indicates that the parents may have abdicated their responsibility of caring for their child. This is common and occurs more often than it should.

The second bias is the length of training. Six months means the dog is generally unfit for duty as a diabetes service dog. Most excellent trainers would prefer the 24 months or up to 30 months for the dog to be trained and the owner of the service dog to be trained on how to continue the training to reinforce prior training.

While there is no universal competence test for hypoglycemia alert training, there is a test given by the American Kennel Club for a dog to become a good citizen when out in the public and every diabetes service dog needs to have this training and pass this test.

I can concede that there will be some false positives with any dog, but the level in this study does require that the study needs to be redone with properly trained dogs and not include children that have no knowledge in refresher training to prevent the large number of false positives.

Only using eight dogs of unknown training is a serious weakness of this controlled study and makes me doubt that the proper criteria were established before the trial began. No information is given about the original trainers, which can also affect the outcome of the study as some trainers can talk the talk, but not walk the walk.

Study limitations included the small sample size, short duration of the study, and the fact that the dogs were different breeds and different ages, and from different trainers. The most reliable dog in the sample had completed 24 months of dog training, suggesting that dog skills diminish over time and may require re-training. 

The last sentence above shows the ignorance of the person making this statement, as the owner of the diabetes service dog also needs to be trained in how to refresh the dog's training on a continuous basis.  Dogs do get lazy and suffer from poor use.

AACE/ACE Position Statement on SGLT2 Inhibitors

In spite of the FDA warning a year ago, the American association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) has taken a strong position in opposition to the FDA warning.

This position paper represents the official position of the AACE and ACE and is meant to provide guidance. It is not to be considered prescriptive for any individual patient and cannot replace the judgment of a clinician.

The FDA warning in May 2015 that SGLT-2 inhibitors may lead to ketoacidosis, generated considerable attention. Now, AACE/ACE have issued a joint position statement concluding that the incidence of diabetic ketoacidosis in patients with type 2 diabetes taking an SGLT-2 inhibitor is no greater than the low levels occurring in the general diabetes population. While this is true, the cases are not considered similar to what develops in those with type 1 diabetes. The AACE/ACE concluded that the risk of DKA when using inhibitors is infrequent and the risk-benefit ratio favors continued use.

In an interview with Endocrine Today, study co-author Zachary T. Bloomgarden, MD, MACE, stated that “There is no definite evidence that these agents are associated with DKA in type 2 diabetes, and some reports have actually described patients with ketosis, or even just ketonuria, which likely are not clinically significant. The DKA cases that have been reported generally involve patients with type 1 diabetes, although reports in atypical diabetes (such as that with pancreatic disease) and in patients with longstanding type 2 diabetes who require multiple-dose insulin treatment similar to that used in type 1 diabetes suggests that a necessary mediator of DKA is marked insulin deficiency.”

The consensus group reviewed over 82 DKA cases from the literature, including those involving SGLT-2 inhibition and those cases occurring before SGLT-2 inhibitor therapy was available. In patients taking an SGLT-2 inhibitor, DKA occurred most often in insulin-deficient individuals, including those with longstanding type 2 diabetes, type 1 diabetes or latent autoimmune diabetes in adults. SGLT-2 inhibitors are not FDA approved for patients with type 1 diabetes, and 7 out of 9 patients in the American case series that prompted the FDA safety warning had type 1 diabetes, the authors wrote.

Nonetheless, the authors urge further study of SGLT-2 inhibitors in type 1 diabetes because initial studies have shown promise in glycemic regulation for patients with type 1. For future T1D trials, lower SGLT-2 inhibitor doses should be considered and insulin doses should not routinely be reduced when SGLT-2 inhibitors are begun, but adjusted based on the individual response.

Further, the position statement notes that almost all cases of SGLT-2 inhibitor-associated DKA occurred in patients challenged with metabolically stressful events, which acted as precipitants of DKA, such as surgery, extensive exercise, myocardial infarction, stroke, severe infections, prolonged fasting, and other stressful physical and medical conditions.

The statement recommends that SGLT-2 inhibitors be stopped at least 24 hours before planned stressful events, such as surgery, or very intensive exercise, such as running a marathon. Patients prescribed SGLT-2 inhibitor therapy should also avoid excess alcohol intake and very low carbohydrate diets, both of which are potentially ketogenic, the researchers wrote.

Once diagnosis of DKA is suspected, the SGLT-2 inhibitor should be stopped immediately and a DKA protocol initiated, including fluids, insulin and other standard interventions.

DKA diagnosis may be missed or delayed due to atypical presentation involving lower-than-anticipated glucose levels or other misleading laboratory values. This presentation has been seen with SGLT-2 inhibitors, but has also been observed for decades before the introduction of these agents. Gaps in understanding call for more studies of the mechanisms behind the metabolic effect of SGLT-2 inhibitors as well as more healthcare professional education focused on the proper diagnosis and treatment of DKA.

Hospitals Need to Test More for Diabetes

Hospitals are being urged to test people for diabetes while in the hospital. Patients with high blood sugar and no known history of diabetes were five times more likely to leave the hospital with a diagnosis if given a standard test. Researchers say the high rate of hospital patients with high blood sugar diagnosed with diabetes who had no known history of the condition suggests increased screening is necessary to catch these patients.

Researchers at Touro University and Ohio University found a high rate of missed diabetes diagnoses were caught in the hospital, which they say suggests changes to hospital protocol and increased screening for the condition is necessary. The HbA1C test is used to measure average blood glucose level over the previous 8 to 12 weeks (The test actually measures blood glucose levels for the previous 16 weeks or four months). Often, it detects hyperglycemia, or high blood sugar, which can be ascribed to physiologic stress, illness or medications.

Hyperglycemia is often detected in hospital patients during treatment for conditions such as sepsis or heart attack, and the recent study showing a high proportion of these patients having diabetes or prediabetes suggests there is more doctors can do.

Dr. Jay Shubrook, a researcher at Touro University California, in a press release said, "We are missing opportunities to detect diabetes and initiate treatment for those patients to help manage that disease, which can reduce their long-term cost of care and disease burden."

For the study, published in the Journal of the American Osteopathic Association, the researchers reviewed medical records for 348 hospital patients with hyperglycemia in the hospital.

"From the osteopathic perspective of early detection equals better outcomes, it's easy to make a case for hospital protocols to trigger an HbA1C test when hyperglycemia is detected to distinguish between transient hyperglycemia and chronic disease," Shubrook said.

Corporate Scams Define Breakfast Today

While I love my breakfasts, I have never considered doing otherwise. For a time, I did eat cereal, but only because my first wife was not doing well in her battle with cancer and I needed to be careful in being available until people came in to attend her for the day. Once they were available, I would head off for work.

Have you ever stopped to question that well-worn adage, “breakfast is the most important meal of the day”? I have, but never considered going without a healthy breakfast to get me through the day. I am unlike the author of this article who claims to have gone without breakfast many days.

Aaron E. Carroll, a professor of pediatrics at Indiana University School of Medicine, argues that common myths around the importance of breakfast stem from “misinterpreted research and biased studies.” He cites a 2013 paper published in the Journal of Circulation that offered evidence tying skipped breakfasts to coronary heart disease and another to obesity. “But, like almost all studies of breakfast,” notes Carroll, “this is an association, not causation.”

Carroll continues to illustrate the numerous confirmation biases inherent in research that supports this commonly held belief. Prime among these tactics, writes Carroll, are “causal language” and improper citation of results that convince people “skipping breakfast is bad.”

As for the rationale behind this manipulative “observational research”? Carroll writes:

1. Many of the studies are funded by the food industry, which has a clear bias. Kellogg funded a highly cited article that found that cereal for breakfast is associated with being thinner. The Quaker Oats Center of Excellence (part of PepsiCo) financed a trial that showed that eating oatmeal or frosted cornflakes reduces weight and cholesterol (if you eat it in a highly controlled setting each weekday for four weeks).
2. Like so many issues tied to corporate-interest research, the problem comes down to a lack of “randomized controlled trials.” That’s not to say they don’t exist. But as Carroll points out, even those that draw no definitive connection between breakfast and the state of one’s health suffer from methodological weakness.

Writing for AlterNet in an essay on the corporate breakfast myth, Anneli Rufus reported:

1. Seeking to provide sanitarium patients with meatless anti-aphrodisiac breakfasts in 1894, Michigan Seventh-Day Adventist surgeon and anti-masturbation activist John Kellogg developed the process of flaking cooked grains. Hence Corn Flakes. Hence Rice Krispies. Hence a rift between Kellogg and his business partner/brother, who wanted to sweeten Kellogg's cereals in hopes of selling more. Guess who won.
2. In pre-Corn Flakes America, breakfast wasn't cold or sweet. It was hot, hearty and lardy, and it had about 4,000 calories.
3. “Breakfast was the biggest meal of the day. Eaten before you headed out to do a whole day of farm chores, it had to keep you going until dinner," says food historian Andrew F. Smith, author of Eating History: Thirty Turning Points in the Making of American Cuisine (Columbia University Press, 2009). Pre-industrial Americans loaded up on protein-rich eggs, sausages, ham and American-style belly-fat bacon along with ancient carb classics: mush, pancakes, bread.
4. The Great Cereal Shift mirrored -- and triggered -- other shifts: Farm to factory. Manual to mechanical. Cowpuncher to consumer. Snake-oil superstition to science. Biggest of all was food's transition from home-grown/home-butchered to store-bought.
5. "Cold cereals are an invention of vegetarians and the health-food industry, first through Kellogg's and then through C.W. Post, which steals all of Kellogg's ideas," Smith explains.
6. "These companies realized early on that people like sugar, and kids really like sugar -- so they shifted their sales target from adults concerned about health to kids who love sugar. It's a thoroughly American invention."
7. As is orange juice, another breakfast contrivance marketed as healthy for kids. Media buzz about vitamin C and advances in pasteurization spawned the orange-juice industry in the 1930s, turning an obscure luxury into a household necessity.
8. "Orange juice has come to symbolize purity in a glass," writes agriculture expert Alissa Hamilton in Squeezed: What You Don't Know About Orange Juice (Yale University Press, 2009). Her research reveals a highly processed product whose use of cheaply grown foreign fruit now mandates a massive carbon footprint.
9. "Orange juice marketers have succeeded in creating an aura of golden goodness around the product. The idea that orange juice is 'an essential part of a balanced breakfast' is familiar and for the most part unchallenged."
10. Hamilton is outraged that commercial orange juice is "advertised as pure, fresh, and additive-free. Those who buy orange juice buy the stories that the industry tells."

Sorry for the long quote, but I felt it was important enough to tell the whole story as even I can agree that many of us, and I include myself, have been hoodwinked by the messages from Big Food. Even reading this from 2011 should be interesting.