April 29, 2017

Diabetes and Your Teeth

There are many tips for reducing the teeth problems and four signs you may have a problem.

Diabetes puts you at risk for dental problems. It hurts your ability to fight bacteria in your mouth. Having high blood sugar encourages bacteria to grow and contributes to gum disease. You may have gum disease if you have:
  • Gums that are red, sore, bleeding, or swollen, or that pull away from your teeth
  • Loose teeth
  • Chronic bad breath
  • An irregular bite or dentures that don't fit well
Tips to help you have a healthy mouth:
Control Diabetes to Keep Your Smile - Well controlled diabetes will help you keep your mouth healthy. If you have poorly controlled or high blood glucose, you have a higher chance of dry mouth, gum disease, tooth loss, and fungal infections like thrush. Since infections can also make your blood glucose levels rise, your diabetes may become harder to control. Keeping your mouth healthy can help you manage your blood glucose.

See Your Dentist Regularly - People with diabetes are more likely to have oral infections. You should get dental checkups at least twice a year. Let your dentist know you have diabetes and what medicines you take. Regular checkups and professional cleanings can help keep a mouth healthy. Your dentist can teach you the best ways to care for your teeth and gums at home.

Keep Plaque at Bay - Sticky plaque -- food, saliva, and bacteria -- starts to form on your teeth after you eat, releasing acids that attack tooth enamel. Untreated plaque turns into tartar, which builds under gum lines and is hard to remove with flossing. The longer it stays on your teeth, the more harmful it is. Bacteria in plaque causes inflammation and leads to gum disease. High blood glucose can make gum disease worse.

Brush Daily, Brush Right - When you brush your teeth twice a day, it not only keeps your breath fresh, but it also helps rid your mouth of bacteria that makes up plaque and can lead to infections. To brush properly, point your bristles at a 45-degree angle against your gums. Use gentle back-and-forth strokes all over your teeth -- in front, in back, and on chewing surfaces -- for two minutes. If holding a toothbrush is hard for you, try an electric toothbrush. Also, brush your gums and tongue.

Floss Every Day - It helps control plaque. Floss can reach where a toothbrush can't, like between the teeth. Do it every day, and use floss and interdental cleaners that carry the American Dental Association (ADA) seal. Ask your dentist for tips if you're not sure how to floss. Like everything else, it gets easier with practice.

Rinse - Use an anti-bacterial mouthwash every day. It freshens your breath, gets debris out of your mouth, and helps ward off gum disease and plaque buildup. Talk to your doctor or dentist about the best rinse for you.

Take Care of Your Dentures - Loose-fitting or poorly maintained dentures can lead to gum irritation and infections. It's important to talk to your dentist about any changes in the fit of your dentures. When you have diabetes, you are at a higher risk of fungal infections like thrush. Poorly maintained dentures can contribute to thrush, too. Remove and clean your dentures daily to help lower your risk of infection.

Toss the Tobacco - Tobacco products -- cigarettes, cigars, smokeless tobacco, and pipes -- are bad for anyone's mouth. But if you have diabetes and you smoke, you have even higher odds of developing gum disease. Tobacco can damage tissue and cause receding gums. It can also speed up bone and tissue loss. Motivate yourself to quit. List your reasons for quitting, set a date, and get the support of family and friends.

Prepare for Oral Surgery - Well-controlled blood sugar reduces your chance of infection and speeds healing. If you need oral surgery, tell your dentist and surgeon you have diabetes beforehand. Your doctor may recommend that you wait to have surgery until your blood sugars are under control

4 Steps to Protect Your Health - The same steps that ensure a healthy mouth also help you manage your diabetes.
  • Eat a healthy diet.
  • Don't smoke.
  • Keep up with your diabetes medications.
  • See your dentist regularly to lower your of a serious problem.
Know the Warning Signs - Regular dental checkups are important because your dentist can spot gum disease even when you don't have any pain or symptoms. But you should examine your teeth and gums yourself for early signs of trouble. Infections can move fast. If you notice redness, swelling, bleeding, loose teeth, dry mouth, pain, or any other symptoms that worry you, talk to your dentist right away

April 28, 2017

Diabetes Organizations Contribute to Complications

Yes, I am making this accusation and it makes sense to me. Why else would people of importance in the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) speak so confidently about type 2 diabetes not needing to test regularly and to rely on their A1c results only.

Dr. Robert Ratner, past chief scientific and medical officer of the American Diabetes Association and Alan J. Garber, M.D., Ph.D., Professor of Medicine, Biochemistry & Molecular Biology, and Molecular & Cellular Biology at Baylor College of Medicine, Houston, Texas are both recipients of money from Big Pharma. I also have to wonder if they also receive large sums of money from Big Food, Big Agriculture, and Big Chemical. These two doctors and others within these organizations received big sums of money to limit what most patients can do. To date we have not heard from the new officers in the ADA or AACE.

This is why they insist that we do not test to make the complications happen. This in turn is a favor to the rest of the doctors to give them patients to treat. It is a shame that the insurance industry has to go along with the pronouncements of these doctors, but they are in the business of showing a profit. Therefore, their leaders are more than happy to limit testing supplies. What they do not realize is that the complications will cause greater expenses in the future than the test strips will cost now.

This is part of the reason I have such a dislike for the people in the ADA and the AACE that are in a position to influence guidelines and position statements. This in turn affects most of the actions of other healthcare professionals in the American Association of Diabetes Educators (AADE) and the Academy of Nutrition and Dietetics (AND). This is also the reason most of their members do not talk about testing or promote testing.

This leaves people with type 2 diabetes who cannot afford extra test strips, managing their diabetes in the dark without the means to use testing supplies that will aid them in more efficient diabetes management. These patients will not be able to determine the most reliable time to test postprandial and often find it impossible to test in pairs to help them decide how a meal affects their blood glucose levels. Those of us that have been able to do this have found that we are better able to manage our diabetes.

We have found that by reducing the number of carbohydrates consumed, we are better able to manage our diabetes. Yet both members of the AADE and AND continue to promote carbohydrates and reduced fat and this makes diabetes management more difficult for most people with diabetes. Yes, the ADA has opened the door for low carbohydrate consumption, but the members of these organizations have yet to put this into practice. Maybe the officers have accepted this, but the general membership still follows the old guidelines and the two organizations have not produced new position statements to affirm to the membership the acceptance of anything but the prior guidelines.

All of this creates an uphill battle for people with diabetes that desire to manage diabetes at a level to prevent complications. It is still possible, but takes more effort and education, which most with type 2 diabetes do not receive. Most are required to self-educate to be able to manage their diabetes.

April 27, 2017

Diabetes, Type 1 and 2 Confusion

Other bloggers are writing about this, and I am now writing about the topic – the ADA mess up in titling of the types of diabetes.

First:
  1. The ADA titles diabetes to blur the lines for the general population
  2. The ADA objective in the titles is to satisfy Big Pharma and Big Food
  3. The ADA aim is to obscure the real causes of the different diabetes types

The ADA mission:
  • is to secure donations to extend their employment
  • ingratiate themselves with their true “constituents” (#2 above)
  • is not to serve people with diabetes

Second:
The titles have gone through several different titles:
  • IDDM: Insulin dependent diabetes mellitus
  • NIDDM: Non-insulin dependent diabetes mellitus

The current titles include the following:
  • Type 1 diabetes
  • Type 2 diabetes
  • Pre-diabetes – while discussed it is not an official ADA classification
  • LADA - Latent autoimmune diabetes in adults – Generally discussed as a part of Type 1
  • MODY - Maturity-Onset Diabetes of the Young – Presently there are six or seven types of MODY based on the genetic location

Those with Type 2, as we know, typically over produce insulin for many years.
Why would someone who over-produces insulin, NEED insulin? For two reasons:
  1. The poor lifestyle advice that leads to the need for huge insulin production, leads to insulin resistance, leading to the need for even more insulin to do the same job. And,
  2. After years of this insulin over-production, the pancreas “wears out,” or insulin producing cells are destroyed. Therefore, insulin becomes necessary to be injected.

That is not all that is happening. People with Type 1 are often told from childhood to “eat like every other child and just cover with enough insulin.” Here is the thing…the diet for the average child in America is leading to obesity and Type 2 (previously never seen in children). Therefore, it’s not good for ANY child!! After years of following this poor dietary advice and using large doses of injectable insulin, those with Type 1 will begin to become overweight and insulin resistant.

What is at the heart of it? Poor dietary advice. The right dietary advice (if applied early enough) can often keep those with Type 2 from becoming insulin dependent. In fact, when adopting a healthy lifestyle, many people with Type 2 are able to manage their diabetes without medication. The right dietary advice will also keep those with Type 1 from becoming insulin resistant. It can help both Types to maintain a healthy weight.

I think there needs to be a reclassification of diabetes Types as well, but with emphasis on cause. If we identify diabetes Types by cause, the focus on treatment will be clear.
  • Type 1 diabetes should be classified as “autoimmune” diabetes (not reversible, yet), insulin needed.
  • Type 2 diabetes should be classified as a “lifestyle” diabetes (preventable AND reversible). In fact, the esteemed Dr. Robert Lustig, world renowned Pediatric Endocrinologist and obesity specialist, recently quipped that Type 2 should be called a “processed food disease.” If we classify Type 2 in this way, it would put the focus on using lifestyle to treat and reverse Type 2 diabetes. The majority of lifestyle management would be directed toward diet, with the other factors being things such as exercise, proper sleep, stress control, and balancing hormones.

Some might balk at calling Type 2 a “lifestyle” disorder, saying that it is strongly genetic. I feel your pain. I do find that I must work much harder than many of my healthy eating friends to keep my blood sugar and weight regulated. But, as the saying goes, “genetics loads the gun but environment pulls the trigger.” In other words, we can’t change what we have inherited. But we can do our best with what we have been handed…it doesn’t have to rule us or be our destiny. Through great effort, and by adopting a healthy lifestyle immediately upon diagnosis, many people have been able to achieve non-diabetic health markers for several years.

So why is the right dietary advice so elusive? As I have said before…diabetes is big business. And there are a lot of organizations and people in the business of diabetes. Unfortunately, there is much money to be made when people are sick.
Please, don’t line the pockets of organizations that are increasing their bank accounts on the very advice that increases your drug dependence and your waistline.

April 26, 2017

Metformin, Aging, and Comorbidities

According to the American Diabetes Association, over 29 million Americans have diabetes, with 11.8 million of the patient population being over the age of 65. Approximately 1.4 million Americans a year are diagnosed with diabetes, and those diagnosed with type 2 diabetes or prediabetes are likely to be started on first-line therapy with metformin. Although a concern of vitamin B12 deficiency is associated with metformin, it is still a choice drug due to its efficacy and limited side effects and may now have additional benefits for diabetes patients.

A study was recently released in the Journal of Diabetes and its Complications that aimed to “…assess the heterogeneity of metformin’s co-development of ARCs (age-related comorbidities) among healthy older adults with T2D” and focused on the prospect of the development of cardiovascular disease, cancer, depression, dementia, and frailty-related disease (FRD). The study population originated from the Veterans Administration Electronic records between the years of 2002-2012 and included men who were age 65 or older, had diagnosis of type 2 diabetes but were naïve to glucose-lowering medication treatment prior to 2003, had one or more outpatient visits per year, and were not diagnosed with any ARC at the beginning of the study period.

The study excluded patients with liver and kidney disease due to metformin’s contraindication in these disease states of increased risk of developing lactic acidosis. Glucose-lowering medications used in the study were: sulfonylureas (glipizide, glyburide, glimepiride, etc), biguanides (metformin), mheglitinides (repaglinide, nateglinide), and alpha-glucosidase inhibitors (acarbose, miglitol, vogilbose). Study subjects were further divided into metformin users (more than 180 days of a prescription for metformin) or non-metformin users who were on any of the other included study medications.

The analysis identified four advanced-related comorbidity trajectory classes that included both metformin and non-users. The majority of the study patients fell into the healthy class, meaning they had a lower chance of developing ARCs. After nine years of the study, metformin was found to have an absolute risk reduction of 2.5% in likelihood of cancer diagnosis (p= 0.02), 6.1% reduction in cardiovascular disease (p= less than 0.01), 5.0% reduction in FRD (p= less than 0.01), and 0.14% reduction in dementia (p= less than 0.01). Consequently, the patients who were classified as non-users of metformin had an approximate increase of 2.8% in likelihood of cancer diagnosis, 6.7% increase in cardiovascular disease, 6.2% increase in FRD, and a 1% increase in depression.

The second most populated class consisted of patients who had the highest risk of developing cardiovascular disease. Metformin non-users had an increase of 74.5% (p less than 0.01) in cardiovascular disease (up from 47.1% in year one of the study) as well as significant increases in likelihood of cancer diagnosis (p less than 0.01), depression (p less than 0.01), dementia (p less than<0 .01="" 0.01="" 1="" 23.6="" 40.1="" 44.4="" 45.5="" 48.2="" 48.6="" 64.7="" a="" above="" across="" all="" an="" and="" arcs="" as="" associated="" being="" both="" by="" cancer="" cardiovascular="" category="" class="" classes.="" classes="" compared="" consequently="" consisted="" decrease="" decreased="" decreases="" depression.="" developing="" diagnosis="" disease="" effect="" final="" followed="" four="" frd.="" frd="" from="" furthermore="" greatest="" had="" high="" highest="" impact="" in="" increase="" increased="" less="" likelihood="" metformin="" mortality="" most="" non-users="" occurrence="" of="" p="" patients="" rate="" reduction="" risk="" seen="" significant="" similarly="" spectrum="" than="" the="" third="" to="" trends="" up="" use="" users.="" users="" was="" well="" who="" with="" year="">

Metformin use was found to reduce the development of ARCs, with significant reduction in patients who are at risk for a particular condition. Limits of this study include the observational design that could lead to bias due to the possibility of unobserved events and confounders, the all-male cohort, and lack of data concerning other medications study participants were taking during the 9-year course observed. This study opens up further potential investigation to confirm the benefit of metformin in reduction of ARCs. Possible beneficial studies would include women as well as looking into the effects of long-term use of glucose-lowering medications used alone or in combination.

April 25, 2017

People with Diabetes Need Life Insurance

Because I have life insurance and have not needed to purchase more, I do not know a lot about life insurance. I do know that many of us with type 2 diabetes and even many with type 1 diabetes have a very difficult time obtaining life insurance. A good person, Matt L. Schmidt has given me information about life insurance.

While I firmly believe in term life; however, Matt has presented me information that makes me doubt my wisdom. In addition, I had purchased a Non-guaranteed Universal Life policy in the late 1980's that I became very unhappy with and thought to cancel, but then I talked with another agent for the same company and this agent was able to convert the policy to another type of policy.

Matt provided me some information on Guaranteed Universal Life Insurance which I find interesting. So I will quote from the information provided, as I could easily make a mess of the information. “Guaranteed Universal Life is often called “No Lapse” or “Secondary Guarantee Universal Life” in the insurance industry.

Let’s look at the Pros and Cons of this life insurance product:
Pros:
  1. Premiums can be level for lifetime. You can select the age they want the death benefit guaranteed to, whether it is age 90, 95, 100, 105, 115 or 121….
  2. The length of premium payments can be structured according to your preferences.
  3. Interest rate volatility does not affect premium payments.
  4. This product is inexpensive as a permanent life insurance product compared to other products, as the premium is calculated to maintain a level premium payment until death.
  5. Comparisons of this product among insurance carriers are relatively easy as there are not many components to the plan.

Cons:
  1. This product may not have any cash value, unlike alternative permanent life insurance products.
  2. Although premiums may be lower than whole life insurance or other permanent insurance products, they will generally be higher than term insurance.
  3. The greatest con of guaranteed universal life is that the timeliness of premium payments is critical to maintain the guaranteed level premium. Other policies that contain cash value can provide a source within the policy to cover the required premium to maintain the death benefit, however, a missed or late premium payment can jeopardize the guaranteed premium feature resulting in a policy without a guaranteed premium. An individual has to maintain timely payments, or the guarantees of the policy could be altered. Unquote

If you are like myself, age 60 or older, you’ve had term life insurance in the past, and it has since expired, or your term policy is getting ready to expire. If this is the situation you are in, you’ve probably received a notice that your rates are about to skyrocket. Your next policy should be your last policy, as it becomes increasingly difficult to re-qualify as you age and your health is not guaranteed to remain insurable

Despite the implication of its name, guaranteed universal life insurance (GUL) is not whole life insurance. But, it is designed to last your entire life. It does not build cash value, allowing you to keep your monthly payments low, and does not carry the expensive management fees of whole life. It is also much better than regular universal life in which the premium continues to rise and can become very expensive.

Term life insurance is the ideal solution for those in good health to secure coverage into their 80s. But, if you are in your late 60s or early 70s and still pondering whether or not to buy a term life policy or another term life policy, you are approaching a cutoff where term life will no longer be viable (or even accessible, for that matter).

Here’s why I'm suggesting a guaranteed universal life over a non-guaranteed universal life:
  • Your cost of insurance will not change, even as you get older or if your health changes.
  • Your coverage isn’t tied to an investment. You pay for the life insurance protection only, just like term life insurance.
  • You aren’t pouring extra money into your policy. Trust the financial experts on this–you’re better off putting your money into a savings, or perhaps paying down your mortgage.
  • You will pay less up front. Guaranteed universal life insurance is a fraction of the cost of non-guaranteed universal life.
  • You don’t run the risk of losing coverage from unfavorable investments or changes in the market.

I don't sell insurance, but if you are looking for life insurance, I suggest reading or looking at this http://www.diabeteslifesolutions.com .

April 24, 2017

Avocados May Help Treat Metabolic Syndrome

A new review of studies looking at the health effects of avocados finds that there is "satisfactory clinical evidence" that the fruit can help to treat metabolic syndrome.

Metabolic syndrome is defined as a cluster of risk factors that can raise the risk of other health conditions, such as type 2 diabetes, heart disease, and stroke.
Risk factors include abdominal obesity, low levels of high-density lipoprotein (HDL) cholesterol - or "good" cholesterol - high triglyceride levels, high blood pressure, and high fasting blood sugar.

The presence of at least three of these risk factors warrants a diagnosis of metabolic syndrome. According to the American Heart Association, metabolic syndrome affects around 23 percent of adults in the United States.

Adopting a healthful diet is considered one of the best ways to prevent or treat metabolic syndrome. The new review - recently published in the journal Phytotherapy Research - suggests that avocados should form a part of this diet.

Avocados are a fruit from the avocado tree, or Persea americana, which is native to Mexico and Central and South America.

A number of studies have documented the possible health benefits of avocado. A study reported by Medical News Today in 2014, for example, found that eating half an avocado with lunch may aid weight loss, while more recent research linked the fruit to reduced levels of low-density lipoprotein (LDL) cholesterol, known as "bad" cholesterol.

These benefits have been attributed to the bioactive components of avocados, which include carotenoids, fatty acids, minerals such as calcium, iron, and zinc, and vitamins A, B, C, and E.

For their review, co-author Hossein Hosseinzadeh, of Mashhad University of Medical Sciences in Iran, and colleagues set out to determine how these components might help to combat the risk factors of metabolic syndrome.

Avocado has strongest effect on cholesterol levels. To reach their findings, the researchers analyzed the results of various in vivo, in vitro, and clinical studies that investigated the effects of avocado on metabolic health.

Hosseinzadeh and colleagues found that the fruit has the strongest impact on lipid levels - that is, levels of HDL cholesterol, LDL cholesterol, total cholesterol, and triglycerides.

As an example, the team points to one study of 67 adults, of whom 30 had a healthy lipid profile and 37 had mild hypercholesterolemia. After adhering to an avocado-enriched diet for 1 week, both groups showed significant reductions in total and LDL cholesterol and triglyceride levels.

"The reported mechanism of this effect was regulating of the hydrolysis of certain lipoproteins and their selective uptake and metabolism by different tissues such as liver and pancreas," explain the authors.

"Another possible mechanism could be related to the marked proliferation of the liver smooth endoplasmic reticulum which is known to be associated with induction of enzymes involved in lipid biosynthesis."

An 'herbal dietary supplement' can help treat metabolic syndrome. The review also uncovered evidence that avocado is beneficial for weight loss. The researchers cite one study that found overweight or obese adults who ate one avocado every day for 6 weeks experienced significant decreases in body weight, body mass index (BMI), and the percentage of body fat.

Additionally, the team identified a number of studies associating avocado intake with reductions in blood pressure among patients with hypertension, and evidence suggests that the fruit might also help to reduce atherosclerosis - the narrowing or hardening of arteries caused by a buildup of plaque.

Notably, Hosseinzadeh and colleagues found that it is not just the flesh of the avocado that can benefit metabolic health - the peel, seed, and leaves of the fruit may also help.

One study published in 2014, for example, found that a daily dose of oil extracted from avocado leaves led to reductions in total and LDL cholesterol and blood pressure.

Overall, the researchers conclude that avocado may be effective for the treatment of risk factors associated with metabolic syndrome, though further research is warranted. They write: "In this review article, satisfactory clinical evidence suggested that avocado can be used as herbal dietary supplements for treatment of different components of [metabolic syndrome].

Although, avocado like other herbal products is safe and generally better tolerated than synthetic medications, there is limited scientific evidence to evaluate different side effects because of contaminants, or interactions with drugs. Besides, further studies need to be accomplished on the metabolic effects of different parts of avocado for other possible mechanisms."

April 23, 2017

Insulin Resistance May Cause Cognitive Decline

Many of us that have had insulin resistance and no longer have it because we are on medications or have adapted our lifestyles to overcome this are fortunate. While we may have some cognitive problems, we are likely not having continued cognitive decline.

Executive function, memory is particularly vulnerable to the effects of insulin resistance, researchers say. Insulin resistance, caused in part by obesity and physical inactivity, is also linked to a more rapid decline in cognitive performance, new research suggests.

A new Tel Aviv University study published in the Journal of Alzheimer's Disease finds that insulin resistance, caused in part by obesity and physical inactivity, is also linked to a more rapid decline in cognitive performance. According to the research, both diabetic and non-diabetic subjects with insulin resistance experienced accelerated cognitive decline in executive function and memory.

The study was led jointly by Prof. David Tanne and Prof. Uri Goldbourt and conducted by Dr. Miri Lutski, all of TAU's Sackler School of Medicine.

"These are exciting findings because they may help to identify a group of individuals at increased risk of cognitive decline and dementia in older age," says Prof. Tanne. "We know that insulin resistance can be prevented and treated by lifestyle changes and certain insulin-sensitizing drugs. Exercising, maintaining a balanced and healthy diet, and watching your weight will help you prevent insulin resistance and, as a result, protect your brain as you get older."

Insulin resistance is a condition in which cells fail to respond normally to the hormone insulin. The resistance prevents muscle, fat, and liver cells from easily absorbing glucose. As a result, the body requires higher levels of insulin to usher glucose into its cells. Without sufficient insulin, excess glucose builds up in the bloodstream, leading to prediabetes, diabetes, and other serious health disorders.

The scientists followed a group of nearly 500 patients with existing cardiovascular disease for more than two decades. They first assessed the patients' baseline insulin resistance using the homeostasis model assessment (HOMA), calculated using fasting blood glucose and fasting insulin levels. Cognitive functions were assessed with a computerized battery of tests that examined memory, executive function, visual spatial processing, and attention. The follow-up assessments were conducted 15 years after the start of the study, then again five years after that.

The study found that individuals who placed in the top quarter of the HOMA index were at an increased risk for poor cognitive performance and accelerated cognitive decline compared to those in the remaining three-quarters of the HOMA index. Adjusting for established cardiovascular risk factors and potentially confounding factors did not diminish these associations.

"This study lends support for more research to test the cognitive benefits of interventions such as exercise, diet, and medications that improve insulin resistance in order to prevent dementia," says Prof. Tanne. The team is currently studying the vascular and non-vascular mechanisms by which insulin resistance may affect cognition.

April 22, 2017

Low- or Gluten-free Diets Linked to Type 2 Diabetes

Gluten is a protein that is commonly found in wheat, rye and barley, which gives bread and other baked goods elasticity and a chewy texture. It is avoided in a small percentage of the population that cannot tolerate gluten due to Celiac disease or gluten sensitivity. Gluten-free foods often contain less dietary fiber and other micronutrients, such as, vitamins and minerals, thus making them less nutritious and they also tend to cost more. However, recent popularity of gluten-free diets has been trending even among people without any health problems.

A ‘Gluten-free’ diet has been interchangeably used to represent a ‘healthy diet.’ On the contrary, researchers have shown concern that it may actually lead to the development of type 2 diabetes (T2D) over a period of few decades. Although there is no scientific evidence that low-gluten will contribute to diabetes, the scientists are concerned about the long-term health benefits with the reduction in gluten consumption. An analysis of a large study of U.S. health professionals observed the effects of food on health in nearly 200,000 subjects. The study suggested that gluten intake might not exert significant adverse effects on the incidence of T2D or excess weight gain. Thus, limiting gluten from the diet is unlikely to facilitate T2D prevention and may lead to reduced consumption of cereal fiber or whole grains that help reduce diabetes risk. The purpose of the study was to determine if gluten consumption would affect health in people with no apparent medical reasons to avoid gluten.

A long-term observational study looked at the data from three big previously held studies that started 40 years ago with the Nurses’ Health Study (NHS) and continued with Nurses’ Health Study II (NHS II) and the Health Professionals Follow Up Study (HPFS) to observe the effect of nutrition on long-term health. The studies, NHS (n=69,276), NHSII (n=88,610), and the HPFS (n=41,908), estimated the gluten intake using a validated food-frequency questionnaire collected every 2 to 4 years and the T2D incident was defined as physician-diagnosed and confirmed diabetes with supplementary information. The major dietary sources were pastas, cereals, pizza, muffins, pretzels, and bread. The average daily gluten intake was 5.8 grams per day for NHS, 6.8 grams per day for NHSII, and 7.1 grams per day for HPFS.

The researchers found that most subjects consumed less than 12 grams gluten per day and surprisingly, within this range, the subjects who ate the most gluten had lower risk of T2D during 30 years of follow-up. However, subjects who ate less gluten consumed less cereal fiber that is a protective factor from progression of T2D. Moreover, participants in the highest 20% of gluten consumption had a 13% lower risk of developing T2D versus subjects with the lowest daily gluten consumption less than or equal to 4 grams per day. The mean gluten intake (± standard deviation) was 5.83±2.23, 6.77±2.50, and 7.06±2.76 grams/day in NHS, NHSII, and HPFS respectively, and strongly correlated with intakes of carbohydrate sources, especially refined grains, starch, and cereal fiber (Spearman correlation coefficients greater than 0.6).

During the prolonged 4.24 million years of follow-up from 1984-1990 to 2010-2013, 15,947 T2D cases were confirmed. An inverse association between gluten intake and T2D risk was observed in all three cohorts after multivariate adjustment and hazard ratio (HR) comparing extreme quintiles was 0.80 (0.76, 0.84; P less than 0.001). Further adjusting for cereal fiber resulted in slight attenuation in the association (HR [95%CI]= 0.87[0.81, 0.93]), but not other carbohydrate components. There was no significant association with weight gain in participants without major chronic diseases and aged less than 65 years with changes in gluten intake in multivariate adjusted model: 4-year weight change (95%CI, lb) was 0.08 (-0.06, 0.22; P=0.25) in NHS, -0.05(-0.18, 0.08; P=0.43) in NHSII, and 0.36 (-0.24, 0.96; P=0.24) HPFS for each 5-gram increase in gluten intake.

In conclusion, the study suggested that gluten intake might not exert significant adverse effects on the incidence of T2D or excess weight gain. In the conference media release, the author acknowledged that the study does not conclude the effects of gluten in the prevention of T2D, but limiting gluten from the diet may lead to reduced consumption of cereal fiber or whole grains that help reduce diabetes risk. The study suggested that if avoiding gluten is not clinically deemed necessary, then avoiding foods that have other benefits could be harmful unless replaced with healthy, naturally gluten-free grains, such as quinoa or buckwheat. Overall, although gluten-free diets have grown in popularity, evidence is lacking regarding gluten intake and long-term health, thus it is crucial to have a comprehensive understanding of diet and nutrition prior to making dramatic changes in the diet.

April 21, 2017

Why as We Age, Do Doctors Say Raise Your A1C

This seems to be the rule as I age and I have more doctors asking me to raise my HbA1c. When I ask to what level, currently, I am told between 8.0 and 9.0. I am guessing this is because I am on insulin as two others that are on metformin or another oral medication have not been told to raise their A1C.

Allen, who regularly has an A1C below 5.6 percent, has also been advised to raise his A1C, however, he continues to say it will be what it is and I can do no less. He continues to eat very low carb and eats the fats to his satisfaction.

I suspect my A1C will rise because of all the comfort food I have consumed while undergoing the radiation for my prostate cancer. I have not had a PSA test since completing the radiation, but I will have one shortly, as well as the A1c test.

I am beginning to feel better, but other things are creating stress and three good friends are also battling for their lives. These three occupy my thoughts and best wishes are going out to them. I have been reassured by all three that they are not experiencing a lot of pain and one of the three is in an Iowa hospital full time. His daughter is passing information to several of us as she can. The rest of his family is gathering and she says her father is happy to see them.

My friend in North Dakota is ready to be admitted in a hospital, but his family has encouraged him to go to the Memorial Sloan Kettering Cancer Center in New York City. He has resisted so far, but is now considering this as his son has said he will pay for the trip and the family will cover any expense insurance will not cover. They are making calls to Sloan Kettering to see if they will accept him.

Then today, a cousin notified me that another of our relatives has passed. He was killed in an auto accident and it has been proven that the other driver was under the influence and because this is the fourth accident caused by him, at least he is finally being charged and will stand trial.
Stress has been with me the last week as I thought I was healing well after the radiation, but then some of the lining has started to come loose and the pain factor is worse than the pain during radiation. This lasted for 24 hours and I did not get much sleep during this. Now a couple of days later, my system has finally relaxed and I have had two nights of 12 hours of sleep each night. Now to see how much sleep I get for the next two nights.

April 20, 2017

Dietary Advice That Caused a Catastrophe

It is becoming more acceptable to question dietary advice. Low fat is slowly losing support because of the obesity epidemic and as people are trying to solve this, they are also questioning other dietary advice.

Yes, there are still those that believe in low fat, but as others continue to consume medium to higher fat, now they are labeling meat as the culprit of heart disease. The majority of knowledgeable people are ignoring the change and are actually lowing the amount of carbohydrates they are consuming. Some are eating low carb/high fat and others are eating varying percentages of the three macronutrients.

Sensible people take no notice of expert advice about what they should or should not eat, secure in the knowledge that the latest fad will eventually be shown to be false. There is, however, one group for whom that advice, first promulgated exactly 35 years ago, has proved disastrous. Maturity onset (or Type 2) diabetes is, as all know, a condition of carbohydrate intolerance where either the pancreas produces insufficient insulin for the body’s needs, or the tissues are resistant to its action. Either way, the body’s metabolism can no longer utilize the sugars in carbohydrate-based foods, the levels of glucose in the blood rise and the unused energy laid down as fat.

Thus, historically, those with Type 2 were advised to restrict the amount of bread, pasta, potatoes etc consumed in favor of meat and dairy products. This dietary regime combined with weight loss was often sufficient to restore their blood sugar levels to normal. Then, back in 1982, an alliance of influential nutritionists and epidemiologists reversed this logical advice on the grounds that meat and dairy products contain wicked saturated fats that push up the cholesterol, causing tens of thousands of premature deaths from a heart attack.

It is the shame of the U.S. Department of Agriculture and the Department of Health and Human Services that they promoted the dietary fads of a few and grew the obesity epidemic and the fast increase of type 2 diabetes.

The above is the cause of the dietary catastrophe of the last three decades. Hopefully, the next few years will start to show that people are ignoring the dietary advice of the two departments promoting the poor dietary advice and people will be eating more real foods and slowly pushing highly processed foods out of the grocery stores.

April 19, 2017

Preventing DFU Has Cost Effectiveness

This is an important topic and I can understand the cost savings, as many people with type 2 diabetes are not aware of diabetic foot ulcers (DFU). Fortunately, the members of our support group do and great effort to prevent DFU is a continual thing with the members. Several members have had them discovered early and they were properly treated to prevent amputations.

Does an ounce of prevention beat a pound of cure? Our support group members believe this and have witnessed the successes of several of the members in avoiding amputations.

According to the ADA, treatment of diabetic foot ulcers (DFUs) along with associated infections, below the knee amputations, and surgeries to revascularize the lower limbs account for a significant portion of the costs incurred in the treatment of diabetes. Yet, with the frequency of occurrence of these complications, there are very few studies that drive the paradigm toward either primary prevention (avoiding DFUs entirely) or secondary/tertiary measures (efficient treatment of DFUs in those who are not aware [secondary]/are aware [tertiary] of diabetic ulcers), which are combined into a single term (secondary prevention) for purposes of the article.

Sadly, utilization of primary prevention of these complications is spotty in most health care systems, and implementation of secondary prevention is often delayed in patients with DFUs. It is speculated that one reason little attention is paid to these secondary measures may be the concern over a “small return on the investment” in trying to prevent amputations, an attitude that certainly appears to be both counter-intuitive and counterproductive. An attempt to show otherwise was made by N.R. Barshes et al. who utilized a Markov model demonstrating the probability of significant cost savings attributable to otherwise less costly preventive measures.

The idea of the Markov model allows prediction of transition from one condition to another, with the understanding that the probability of any transition is only dependent on the current condition, but not any past condition, and that these conditions exist over a continuum. A simple example would be the states of untreated, treated, and final outcomes (cure, amputation, or death, the latter two of which would be considered “inescapable” outcomes, where return to the state immediately prior is not possible). Barshes looked at 1,000 repeated simulations of 100,000 hypothetical diabetes patients with no current or historical DFU, over a period of five years in 1-month intervals. Each month, each “patient” would exist in one of six clinical states: no DFU, uninfected DFU, infected DFU, limb loss, healed DFU, and all-cause death. Based on available clinical data, the patients were stratified into low, moderate, and high risk, and transition probabilities for moving from state to state each month were assigned (for example, the chance of transitioning from no DFU to initial DFU event in moderate risk patients was 0.3%, while the chance of limb loss in undertreated DFU in high risk was 3.1%).

Each of the simulations was run with transitions occurring over five years (60 months/transitions), and the outcome probabilities were pooled. Each outcome was assigned a monthly cost estimate (for example, the median monthly cost of a healed DFU was $45, infected DFU $12,955, and major limb amputation such as BKA $38,934). Remember, each of these costs were per case, not the total population.

By applying costs of both primary and secondary preventive measures to all levels of risk-presenting patients (low to high), cost thresholds, at which at least 90% of simulations demonstrated savings, were established. An example was a measure that decreased the occurrence of DFU by 10% (0.90 RR), costing $50 per person and would have greater than a 90% probability of reducing amputations (at almost $39K) in diabetes patients at a cost that is equal or even lower than the standard of care, compared to no preventive care. The same 10% reduction in moderate- to high-risk patients from preventive care costs $125 per patient, with increases in cost as risk reduction also increases, yet said costs are considerably less than the outcome of amputation. For the purpose of this discussion, these results have been simplified.

The lack of programs designed to prevent/eliminate DFUs is troubling, this in spite of the known impact these DFUs have on amputation requirements, increasing healthcare costs, and overall quality of life. The paucity of such programs, even in larger academic healthcare centers, may be related to the perception of a clear lack of economic benefit. Studies have been few and far between, and prior Markov models have not demonstrated a potential for overall savings, where cost effectiveness has been shown. The difference in this study from past offerings is this one looked at differing degrees of effectiveness (risk reductions ranging from 5% to 25%), assigning costs to each and determining a likely cost threshold for determining the need for preventive measures.

One important limitation stated by the authors was separating low-risk from moderate- to high-risk patients, which may cause those higher risk populations to lose favor due to increased costs of prevention. An examination of the overall population as a whole would have been warranted to help support better utilization of prevention of diabetic foot ulcers and subsequent complications. If little else, there is certainly a need to encourage preventive programs as a means to reduce these high costs of care.

April 18, 2017

Are You Taking Too Many Pills?

Normally, I would not take a topic from the NY Times. However, since this is one of the better articles on polypharmacy, and covers the topic quite well, I will use it.

About one-third of adverse events in hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.

The above statement is very powerful, but most hospital administrators care less as long as they make their bonus. Many hospitalists send patients home on the same or more pills than they prescribed for them while in the hospital.

The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.

Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But, older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.

Some drugs are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.

Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.

For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)

Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.

Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.

Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it could reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.

So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.

The above paragraph shows the problems that doctors have and the possible influence of Big Pharma on their prescribing habits. Unfortunately the following paragraph is also true and adds to the problems.

Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.

To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.

Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”

Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.

April 17, 2017

Importance of A1C and Blood Glucose Readings

Which is more important: The A1C or blood glucose readings? In asking several type 2 friends, only one said you need both for good diabetes management. So, we will look at the two tests and their differences.

The A1C test: The A1C test measures the amount of glucose on your red blood cells and gives an average of your blood glucose control over a period of four months. This test is generally ordered by your healthcare provider every 3 to 6 months, depending on your blood glucose control and the type of diabetes you have.

The goal standard set by the American Diabetes Association is for you to keep your A1c percentage at 7.0 or below. The American Association of Clinical Endocrinologists prefers the percentage to be 6.5 or below. The American Geriatrics Society recommends A1c levels of 7 percent or lower for healthy adults and less stringent levels for less healthy adults of 8 percent or lower.

Many individuals with type 1 diabetes prefer readings above 5.5 and below 6.5 percent for the A1C. Individuals with type 2 diabetes prefer A1C readings below 6.5 percent to a low of 4.5 percent.

Blood glucose metering: Checking your blood glucose with your personal meter gives you immediate information and helps you make decisions for your diabetes management. Metering helps you determine how to dose your insulin, handle exercise and illness, and tell you if you're on track with your diabetes care.

Even if you're not on insulin, blood glucose metering even several times a week tells you how well you're doing, if you need to make lifestyle changes, or if you need to contact your healthcare provider for help.

The two tests together inform your provider of the long range control over the past 3 to 5 months and the meter reading tells the day to day control. I sometimes use the analogy; the A1c is the motion picture and the blood glucose meter readings are the camera snap shot picture.

What if the A1c and blood glucose meter readings don't match?
  • Measurement errors could result from the meter being off, an incorrect lab test, anemia, recent blood transfusion, nutrition deficiencies, iron or certain medications. This is rare.
  • If there is good A1c range but the blood glucose readings show wide swings from high to low, the doctor needs to assess treatment and management issues.
  • It's important to make sure there are enough readings to give a fair representation.
  • Blood glucose needs to be tested at the right times, post meal.

Meanwhile, Reuters Health recently reported that frequent blood sugar testing was strongly associated with better diabetes control in a large new study that concludes public and private insurers should not be limiting test strip supplies.

This last paragraph helps explain the problems for many type 2 diabetes patients on oral diabetes drugs and not on insulin. Some insurance companies even restrict the number of test strips for type 1 and type 2 patients on insulin.

April 16, 2017

New Model in Type 2 Treatment

Finally, a treatment plan to introduce insulin to people with type 2 diabetes that is showing promise of being successful.

A new model of healthcare that focuses on a stronger role for nurses in primary care has been associated with a higher uptake of insulin treatment among patients with type 2 diabetes, reports a study published in The BMJ.

By 2030, almost 600 million people will have type 2 diabetes; therefore, innovation in delivering effective clinical care to patients with type 2 diabetes is an urgent global priority.

Guidelines in the UK, US and Europe recommend early adoption of insulin treatment to improve long-term outcomes. However, insulin initiation is often delayed, particularly in primary care, because of barriers in clinical practice.

A team of researchers, led by John Furler from the University of Melbourne, assessed the outcomes of implementing "The Stepping Up" model of care that focuses on addressing some of the barriers seen in clinical practice, by enabling nurses to lead on insulin treatment initiation among patients within the practice as a part of routine care.

By focusing on an enhanced role for the practice nurse, who is trained and mentored by a registered nurse with diabetes educator credentials, the model uses existing resources within the practice in a bid to improve outcomes.

The study compared patients enrolled in an intervention group where they had consultations with the practice nurse as part of the Stepping Up Model, with a control group where patients received usual healthcare.

In total, 266 patients took part and were based across 74 practices in Australia.

Results show the model was associated with significantly higher rates of insulin initiation 105/151 (70%) patients starting insulin, compared with 25/115 (22%) in control practices.

After 12 months, patients had significantly better HbA1c levels (an important measure of glucose in the blood), which is associated with better long term outcomes, such as reduced rates of kidney and eye disease, compared to the control group.

The authors note the study may be subject to selection bias, and the patients in the study may not be representative of all people with diabetes.

Nevertheless, they say "our results indicate that, with appropriate support and redesign of the practice system, insulin initiation can become part of routine diabetes management in primary care, obviating the need to refer to specialist services with geographical, cost, and accessibility barriers."

"Our pragmatic, translational study has important implications for policymakers, funders, and practitioners seeking innovative ways to provide the best care for people with type 2 diabetes in primary care," they conclude.

I agree with the study and think a similar study in the USA could prove useful and could be an example for doctors to allow more activity for nurse practitioners and even registered nurses.

April 15, 2017

Are Doctors the Cause of Insulin Resistance?

At least Dr. Stephen A. Brunton, executive director of the Primary Care Metabolic Group, concedes that doctors may be the cause. Dr. Jay Shubrook, family physician and diabetologist at Touro University in California, is the doctor interviewing Dr. Brunton

Dr. Brunton says that doctors have always talked about insulin resistance being something that is the result of patient resistance. However, a lot of insulin resistance comes from practitioners. We resist using insulin for many reasons, and that has an impact on getting our patients to target.

Dr. Shubrook asks, what is clinician insulin resistance?

Then to quote Dr. Brunton, “Traditionally, we have been reticent to use insulin because of the impact it would have on slowing the flow in the office, and even in terms of our feelings of expertise. When the basal insulins came out, it made things so much easier—insulin could be initiated with 10 units daily. At that dose, there is a very low risk for hypoglycemia or any other problems. With the insulin pens, it became so much easier.

Part of it, however, is that we assume that our patients do not want to start insulin. Perhaps, in the past, we used insulin as a threat: "If you do not behave, you are going to get insulin." Now we have realized that it is the most effective regimen for getting patients under control. Part of the problem is that the patients may still have some of those other considerations that we may have originally laid upon them. It is our resistance to start patients on a very therapeutic regimen.

Part of the issue of complexity is that when patients come for the management of diabetes, many don't have only diabetes. They may have eight to 10 different comorbidities. We are so busy trying to manage all of that that we tend to put off starting insulin. We may have them on three or four oral antidiabetic drugs. So, we need to look at where our patients are and how we can get them to target.

Many studies show how long it takes us to make a change. It's therapeutic inertia. It has been shown that sometimes for years, the patient is out of control, and we will give them one more chance. We will add another oral agent, but it is not going to have a benefit, particularly when these patients have glucotoxicity.

We need to recognize that we have a broad base of different therapeutic options and that today's insulin is not your grandparents' insulin. We have better analog insulins. We have pens. We have very small needles, so patients are much more likely to accept insulin than we think. Insulin resistance is really our problem. Patients are not as frightened of needles as we think.

Patients may have misconceptions about what insulin means; for example, they might have heard, "I started insulin and my leg dropped off." That, as you and other clinicians know, is not why that person lost their leg, but the patient still holds onto that, and insulin becomes a big fear. It is up to us to help them overcome that.

Dr Shubrook says: You mentioned many things that make it easier for us to overcome our resistance—insulin pens, easy-to-titrate insulins, and algorithms for treatment. How do we address the clinician resistance to using insulin that remains?

Dr Brunton answers: The issue is to try to develop a system in the office so that you do not have to do everything yourself. Educate the staff to overcome some of the barriers to implementation in the office. Introduce insulin early on in the diagnosis. With people who have type 2 diabetes, insulin seems to be far in the future, and the thinking is, "Oh my God, I hope not." I say, "I have a natural therapy that eventually you might use." We recognize that diabetes is a progressive disease and eventually a significant proportion of patients are going to need insulin. I view this as a positive and say, "This natural therapy is insulin, and we will talk about that as it gets a little closer, but let me tell you a little bit about it." I explain the pathophysiology of diabetes and where insulin fits in. Then, I also have staff who can go over injection techniques and some of the algorithms, so that it is not all laying on my shoulders.

Dr Shubrook says: Those are important points, but I can still see some of my partners being resistant to the use of insulin. Maybe it's based on a bad experience they have had in the past, maybe it's just a lack of experience, or maybe it's the math. If I wanted to talk to one of my colleagues about starting insulin more frequently, what are some steps that they can follow?

Dr Brunton answers: First, try to understand the concerns. Sometimes it relates to misconceptions. Not only do we have an easier process now with basal insulin, but show them how to titrate it. A lot of patients will start on 10 units and if they stay on that, they are not going to get the benefits. The benefit of basal insulin comes with titration. One does not have to go from a basal all the way to a basal bolus with four injections a day. We can use the basal-plus approach where you provide some short-acting insulin for the main meal. That makes things a little easier. Now we also have GLP-1 agonists that we can use in concert with insulin. There are many ways that we can use insulin to help get our patients to goal.

Dr Shubrook commented: This is really still a very important topic because we know that most of our patients with type 2 diabetes and all of our patients with type 1 are going to need insulin. If clinicians are not comfortable, these patients are certainly not going to get the treatment they need.

What I have heard you say today is:
  1. Clinician insulin resistance is still an issue despite many advances, and sharing these advances with providers might be a first step;
  2. Get someone in your office who can help you so that it is not on the clinician alone to have to do this; and
  3. Trust some of these tools and get some positive experiences.

Dr Brunton: Yes. We have come a long way, Jay, and that is one of the exciting things about managing diabetes today. We have so many tools at our fingertips that can help our patients get to goal. We have been at a plateau—about 55% of patients are getting to goal and 45% are not. Now that clinicians have these tools, if they feel more comfortable with them, we can help our patients.

This discussion points out the problems many people new to diabetes have with doctors. This reinforces earlier blogs by David Mendosa and myself on February 24, 2017 about  starting insulin at diagnosis. Please take time to read both.

April 14, 2017

Effects of Sugar on Your Teeth

It’s common knowledge that sugar is bad for your teeth. As science has progressed, one thing is certain — sugar causes tooth decay. Sugar on its own is not the culprit. Rather, the chain of events that takes place afterward is to blame.

Many different types of bacteria live in your mouth. Some are beneficial to your dental health, but others are harmful. Yes, it is a battleground. Studies have shown that a select group of harmful bacteria produces acid in your mouth whenever they encounter and digest sugar. These acids remove minerals from the tooth enamel, which is the shiny, protective, outer layer of your tooth. This process is called demineralization.

The good news is that your saliva helps to constantly reverse this damage in a natural process called remineralization. The minerals in your saliva, such as calcium and phosphate and water, help the enamel repair itself by replacing minerals lost during an “acid attack.” This helps strengthen your teeth. However, the repeated cycle of acid attacks causes mineral loss in the enamel. Over time, this weakens and destroys the enamel, forming a cavity.
Simply put, a cavity is a hole in the tooth caused by tooth decay. It’s the result of harmful bacteria digesting the sugar in foods and producing acids. If left untreated, the cavity can spread into the deeper layers of the tooth, causing pain and possible tooth loss. The signs of tooth decay include a toothache, pain when chewing and sensitivity to sweet, hot or cold foods and drinks.

Sugar is like a magnet for bad bacteria. The two destructive bacteria found in the mouth are Streptococcus mutans and Streptococcus sorbrinus. Both of them feed on the sugar you eat and form dental plaque, which is a sticky, colorless film that forms on the surface of the teeth. If the plaque is not washed away by saliva or brushing, the bacteria convert it to acid. This creates an acidic environment inside the mouth. The pH scale measures how acidic or basic a solution is, with 7 being neutral. When the pH of plaque drops below normal, or less than 5.5, these acids start to dissolve minerals and destroy the tooth’s enamel. In the process, small holes or erosions will form. Over time, they will become larger, until one large hole or cavity appears.

A word to the wise - think before you reach for that sugary snack. Many studies have found that the frequent consumption of sweets and sugary drinks leads to cavities. Frequent snacking on foods high in sugar increases the amount of time your teeth are exposed to the dissolving effects of various acids, causing tooth decay.

One recent study among school children found that those who snacked on cookies and potato chips were four times more likely to develop cavities than children who did not.

The most common source of liquid sugar is sugary soft drinks, sports drinks, energy drinks and juices. In addition to sugar, these drinks have high levels of acids that can cause tooth decay.

In a large study in Finland, drinking 1–2 sugar-sweetened beverages a day was linked to a 31% higher risk of cavities. Also, an Australian study in children aged 5–16 found that the number of sugar-sweetened drinks consumed was directly correlated to the number of cavities found.

One study involving more than 20,000 adults showed that just one occasional sugary drink resulted in a 44% increase in the risk of losing 1–5 teeth, compared to those who did not drink any sugary drinks. This means that drinking a sugary drink more than twice daily nearly triples your risk of losing more than six teeth.
Fortunately, one study found that reducing your sugar intake to less than 10% of daily calories decreases your risk of tooth decay.

Just as you learn for diabetes, if you constantly sip sugary drinks throughout the day, it’s time to rethink that habit. Research has shown that the way you drink your beverages affects your risk of developing cavities. One study showed that holding sugar-sweetened beverages in your mouth for a prolonged time or constantly sipping on them increased the risk of cavities. The reason is because this exposes your teeth to sugar for a longer time, giving the harmful bacteria more opportunity to do their damage.

Research has found that these factors can hasten or slow the development of cavities. These include saliva, eating habits, oral hygiene, and overall diet.

Below are some ways you can fight tooth decay.

Make sure to eat a balanced diet of fresh fruits, vegetables and dairy products.
If you do eat sugary foods and sweetened or acidic beverages, have them with your meals, instead of between them.

Also, consider using a straw when drinking sugary and acidic beverages. This will give your teeth less exposure to the sugar and acid in the drinks. Add raw fruit or vegetables to your meals to increase the flow of saliva in your mouth.
Finally, do not allow infants to sleep with bottles containing sweetened liquids, fruit juices or formula milk.

Sugary and sticky foods should only be eaten occasionally.

If you do indulge in sweet treats, drink some water, preferably tap water that contains fluoride, to help rinse out your mouth and dilute the sugar that sticks to the tooth surface. Moreover, only drink soft drinks in moderation, if at all. If you do drink them, don’t sip them slowly over a long period of time. This exposes your teeth to sugar and acid attacks for longer. Instead, drink water. It contains no acid, sugar or calories.

Practicing good oral hygiene is one way to fight bad habits and the wrong food.
Brushing at least twice per day is an important step in preventing cavities and tooth decay. It is recommended to brush after each meal whenever possible and then again before you go to bed.

Additionally, stimulating saliva flow helps bathe the teeth in beneficial minerals.
Chewing sugar-free gum may also prevent plaque build-up by stimulating saliva production and remineralization.

Lastly, nothing ensures keeping your teeth and gums healthy like visiting your dentist every six months.

Just remember that whenever you eat or drink anything sugary, the bacteria inside your mouth work to break it down. They produce acid in the process. Acid destroys the tooth enamel, which results in tooth decay over time.

To fight this, keep your intake of high-sugar foods and beverages to a minimum, especially between meals and right before bedtime. Taking good care of your teeth and practicing a healthy lifestyle are the best ways to win the battle against tooth decay.

April 13, 2017

Early Treatment Can Improve Glycemic Control

Yes, better outcomes happen when doctors work with patients to intensify oral antidiabetic drugs (OADs). Again, another article claiming that type 2 diabetes is a progressive disease. The only time it is progressive is when the patients with their doctors', refuse to aggressively treat type 2 diabetes and let it get out of control. Treated aggressively, type 2 diabetes can be managed and prevented from becoming progressive.

According to guidelines, antidiabetic drugs (OADs) must be added three months after the failure of initial therapy with metformin monotherapy and lifestyle modifications in order to achieve glycemic goals. Many patients with T2D on OADs are deprived of timely treatment intensification, regardless of hemoglobin A1c (HbA1c) being above target range. The failure to intensify treatment in a timely manner has been termed ‘Clinical Inertia.’ According to Dr. H.J. Folse and colleagues, this delay is associated with an inability to achieve target HbA1c in a timely manner, increased risks of cardiovascular events, and amputations.

Previous studies have shown that poor glycemic control due to clinical inertia can be improved by earlier intensification with OADs. In a retrospective cohort, ‘the Inertia study,’ a large United States claims database was used to estimate time to intensification (TTI) with an additional OAD or injectable medication for adults with type 2 diabetes and poor glycemic control (HbA1c greater than or equal to 8%) after three or more months of therapy that included metformin (index date), and no history of injectable antidiabetic medications. The results showed that less than 48% of subjects had received treatment intensification within 12 months after the index date. However, not much is known about long-term consequences of clinical inertia. The primary outcome was the time from index date to treatment intensification, defined as patients filling a prescription for injectable or additional OADs. The purpose of the study was to use the Archimedes Model in a cohort of hypothetical patients with HbA1c greater than or equal to 48% on metformin with no history of insulin use to examine the consequences of delayed OAD treatment intensification on glycemic control and long-term outcomes at 5 and 20 years in patients with T2D.

Using real world data, the study used a cohort of hypothetical T2D patients with HbA1c greater than or equal to 8%, and greater than or equal to 18 years old, on metformin, with no history of insulin use. The cohort included three strata based on the number of OADs taken at baseline. Treatment intensification sequence included addition of a sulfonylurea, followed by a dipeptidyl peptidase-4 inhibitor, and a thiazolidinedione. Based on observed and extrapolated times to intensify the treatment, the result included either ‘No Delay’ or ‘Delay.’ Treatment failure was defined as HbA1c greater than or equal to 8% and patients were followed for one year following the index date and when patients filled a prescription for injectable or additional OADs. Subgroup analyses were based on metformin monotherapy, metformin with one other OAD, and metformin with two or more other OADs. Time to treatment intensification was grouped as early intensified (within 6 months), late intensified (6 to 12 months), or never intensified within 12 months.

The mean HbA1c at one year for patients intensifying without delay vs. with delay was 6.8% and 8.2%, respectively with an absolute reduction of 1.4%. Also, at five years for no Delay vs. Delay, reductions in the risks of major adverse cardiac events, myocardial infarction, heart failure, and amputations were seen at 18.0%, 25.0%, 13.7%, and 20.4%, respectively. The timing of intensification of OAD therapy per guideline recommendations steered greater reductions in HbA1c and lower risks of complications, but severe risk of hypoglycemia increased to 19% for the no Delay group in comparison to 12.5% for the Delay group. In general, the relative risk reduction (RRR) trend at five years was similar to the results at 20 years. At five years, the incidence of hypoglycemia was 51.7% higher and at 20 years, it was 18.0% higher in the No Delay groups versus the Delay group.

Some of the limitations in this study included lack of other adverse effects besides hypoglycemia, the effects of hypoglycemia on costs, quality of life, and cardiovascular risk. Also, the OAD add-ons selected were based on the U.S. OADs prescribing patterns observed in the retrospective Inertia study from 2009-2013. However, the addition of following medications in the treatment sequence was universally applied to everyone at an average dose for each treatment. Future studies should expand the treatment sequence with the addition of other classes of OADs.

In conclusion, this study supports the timing of intensification of OAD therapy per guideline recommendations, which leads to greater reductions in HbA1c and lower risks of complications, but increases the risks of hypoglycemia instead of delaying intensification. The differences in HbA1c between patients delaying and not delaying have important long-term consequences with substantial risk of complications of diabetes. HbA1c has been found to be a relatively important risk factor for the progression of diabetic retinopathy, but not so much for stroke and ESRD. Overall, the results emphasized the potential impact of timely treatment intensification on long-term outcomes.

  1. Intensifying OAD therapy at guideline-recommended time intervals results in greater reduction in HbA1c.
  2. Failure to intensify treatment in a timely manner results in a higher risk of complications, including adverse cardiac events, myocardial infarction, heart failure, and amputations.
  3. This study proves that intensifying OAD therapy results in a higher risk of hypoglycemia than delaying intensification.

April 12, 2017

Exercise and Why Some People Do Not Benefit

Regular physical activity is considered key for the prevention of obesity and associated health conditions, but some people reap greater rewards from exercise than others do. A new study may have shed light on why this is.

In a study of both mice and human subjects, researchers found that higher levels of selenoprotein P - a protein secreted by the liver - was associated with reduced exercise capacity and fewer exercise-related benefits.

Study co-author Hirofumi Misu, of the Kanazawa University Graduate School of Medical Sciences in Japan, and colleagues say that their findings indicate that selenoprotein P may be a driver of exercise resistance.

The researchers recently published their findings in the journal Nature Medicine.

According to current guidelines, adults should engage in around 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity each week in order to maintain good health.

However, responsiveness to exercise - in terms of both endurance and metabolic health - can vary widely from person to person. "In particular, some people show complete non-responsiveness to exercise training in terms of aerobic improvement. Similarly, 15-20 percent of patients with type 2 diabetes show a poor hypoglycemic effect to regular exercise therapy," the authors note.

"These findings indicate that some people suffer from exercise resistance and derive limited benefits from the health-promoting effects of physical exercise."
The precise mechanisms behind exercise resistance, however, have been unclear. Previous research has indicated that selenoprotein P might play a role, so Misu and colleagues set out to investigate this association further.

Firstly, the team assessed the effects of exercise training on two groups of mice: one that was deficient in selenoprotein P, and one group of wild-type mice (the controls).

Both groups ran on a treadmill for 30 minutes per day for 1 month. The researchers found that the selenoprotein P-deficient mice had double the exercise capacity of the wild-type mice.

Furthermore, at the end of the 1-month exercise training, the selenoprotein P-deficient mice demonstrated a larger reduction in blood glucose levels following an injection with the hormone insulin.

The researchers also administered selenoprotein P to wild-type mice prior to 1 month of exercise training. These mice showed a reduction in phosphorylation of the enzyme AMPK in their muscles. The researchers explain that AMPK phosphorylation is associated with a number of exercise benefits.

Additionally, the researchers found that mice lacking LRP1 - a selenoprotein P receptor in muscles - were unable to absorb selenoprotein P into their muscles. Furthermore, AMPK phosphorylation was not impacted by exercise training.

Next, Misu and team sought to determine the effects of selenoprotein P on exercise in humans. The researchers enrolled 31 women who were healthy but who did not engage in regular exercise. All women took part in 8 weeks of aerobic training, and their maximal oxygen intake was monitored throughout as a measure of exercise endurance.

The team found that women who had high levels of selenoprotein P in their blood prior to the 8-week exercise program demonstrated a lower maximal oxygen intake than those with lower levels of selenoprotein P.

Taken together, the researchers believe that their results indicate that selenoprotein P contributes to exercise resistance by targeting the LRP1 receptor in muscles.

Further research is needed in order to gain a more detailed understating of how selenoprotein P impacts physical activity, but the team believes that this current study may pave the way for drugs that reduce selenoprotein P production to improve exercise endurance.

Misu and colleagues write: "The current findings suggest that future screening for inhibitors of the [selenoprotein P]-LRP1 axis could identify exercise-enhancing drugs to treat physical-inactivity-associated diseases such as type 2 diabetes."