February 13, 2016

Dietitians Harm and Maim People Legally

If you have a rudimentary knowledge of nutrition, as a person with diabetes, you should consider what a registered dietitian teaches for dietary advice as ludicrous. Some would say it is criminal. I find it unlikely that a person with diabetes following a diet prescribed by a dietitian would ever have reliable and safe management of their blood glucose numbers. Long-term elevated blood glucose numbers will bring on diabetes complications.

Yet, this is what most dietitians recommend and then tell doctors to increase the dose of medication or add more medications. This is a global occurrence and the U.S. is just part of the global problem. Diet organizations around the globe promote low fat, high carbohydrate diets and for the last 45 years have promoted this. Year after year approximately 93% of type 1 diabetics and approximately 50% of type 2 diabetics fail to get to a safe HbA1c number.

If you have gotten this far, you may well have another question for me. How would you reduce the damage, how would you improve the lot of all diabetics? This has an easy answer and involves both completely fresh food and eliminating almost all sugar, high starch foods, and highly processed carbohydrates.

I know there is resistance to a low carb, high fat way of eating (LCHF) (some use the term natural fat instead of high fat), but this is to be expected. Most of the resistance is by the professional experts who do not approve of LCHF way of eating. The reasons are many, but here are three of the reasons.

1. Most dietary organizations have become corrupted by junk food companies and big pharma. Many high profile dietitians are in receipt of payment from at best dubious companies. Check out some of the largest organizations advising Governments on diet, and what I call conflicts of interests
are paying the bills and pulling the strings. So corrupt and tainted has the situation got in the US, that a group of dietitians has broken away from the Academy of Nutrition and Dietetics, the equivalent of the British Dietetic Association and formed Dietitians for Professional Integrity.

2. So many doctors and dietitians have become so entrenched in what they like to call "evidenced based" science. It is now becoming clear, that much of the so-called evidence has become out-dated, and never was based on true and honest science.

3. A great quote sums up the situation for many healthcare professionals “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Upton Sinclair.

Changes have to be made, and are being made. The number of informed and clear thinking doctors, scientists and dietitians grows by the day, who have become converts to the low carb cause. Not only for their patients, but also for themselves. Money and corruption has played a big hand in the epidemics of obesity, and the often linked type two diabetes. Ironically, money, or more accurately the lack of money will end the madness. Health systems all over the world are being bankrupted by the aforementioned epidemics, the financial cost grows by the day. The cost in human misery is incalculable.

February 12, 2016

The Problems of Hypertrophy

People using multiple daily injections of insulin often develop hypertrophy. Many people are not aware of hypertrophy. This is the enlargement of the areas that has received too many insulin injections. This enlargement is often the result of scar tissue, which causes insulin to pool in this area, and this can increase the enlargement and the scar tissue can trap the insulin and prevent it from getting into the blood stream.

This means that they often have serious blood glucose issues and are difficult to manage. To avoid this problem, many people are not taught about the areas that are useful and can be used to inject insulin. See the diagram below from BD Diabetes.

Rotating among these sites may reduce the risk of lypodystrophy, lumps of fat that develop under the skin from injecting in the same spot repeatedly. Lypodystrophy is not found in any medical dictionary I have, but the BD website uses the term.

For most of us, the stomach area works the best and the area on the arms is second best. The biggest problem many people using insulin is injecting the fast acting insulin in an area too close the long acting insulin. If you want an episode of hypoglycemia (low blood glucose below 70 mg/dl), this is how you do it. I don't recommend this, as it is dangerous and unsafe. This is the reason I use a different area for long acting insulin than I am using for fast acting insulin.

Please understand the hypertrophy is serious and can upset the best management plan. Do not inject insulin in the same spot day after day to prevent this and rotate in the selected areas. I use the different areas on a regular basis and after twelve years and four months, I have a few areas of hypertrophy. I also realize that at my age, the areas of hypertrophy may not heal as quickly so I have to be very careful.

February 11, 2016

Guidelines for Diabetes Care in LTC Facilities

The new American Diabetes Association(ADA) guidelines for diabetes management in long-term care (LTC) and skilled nursing facilities (SNF) is needed and may be a good start. For now the emphasis is on treatment simplification, avoidance of hypoglycemia, and the need to reassess therapeutic goals for patients near the end of life.

The guidelines were published in the February issue of Diabetes Care by Medha N Munshi, MD, director of the Joslin Geriatric Diabetes Program, Boston, Massachusetts, and colleagues. The ADA has not addressed this topic in prior guidelines, just the care for the elderly in community settings and diabetes care among hospitalized patients.

Dr. Munshi said, "We've developed great protocols for looking at the numbers in managing diabetes. My fight in geriatric diabetes is we need to look at what the patient needs."

Most of the guidelines are written for doctors and nursing home directors, nurses, clinical pharmacologists, and others whose work centers on the elderly population. The guidelines provide additional information about the special considerations in institutionalized elderly patients. They did not forget the core of caring for the elderly, the assessment of functional capacity and common comorbidities that may interfere with diabetes care and strategies for simplifying treatment regimens and not adding more medications.

Dr Munshi commented, "As a geriatrician, I see a lot of inappropriate care and things done to patients at the end of life, not because people aren't trying to help or aren't paying attention, but simply because they don't know what to do. When you have to withdraw something, it makes people very uncomfortable. We are hoping this will help [clinicians] to understand that it is okay to back off of some of these things."

The document provides detailed diabetes-specific information and guidance, including minimization of hypoglycemia by replacing sliding-scale insulin-dosing regimens, and a medication roundup. "It's not enough to just say the A1c needs to be different, but how you get to that A1c needs to be different. [Otherwise], you get a lot of hypoglycemia or complex regimens that can decrease quality of life," Dr Munshi noted.

I like the next discussion, careful evaluation of comorbidities that can affect diabetes management is advised prior to developing treatment goals and strategies. Examples include cognitive dysfunction, depression, skin problems including infections and foot ulcers, hearing/vision problems, and oral health issues that may interfere with eating. These are all listed in a chart, along with their potential impact and possible strategies to manage diabetes in those situations.

The risk of hypoglycemia, Dr Munshi and colleagues write, "is the most important factor in determining glycemic goals due to the catastrophic consequences in this population." Increasing evidence points to the risks of hypoglycemia in the elderly, while there is little to support the use of intensive glycemic control for that population.

Even less severe hypoglycemia can be "catastrophic" in the elderly, such as in patients with poor vision, neuropathy with unsteady gait, and those taking other medications. "Even if they just drop to 60 (mg/dl), that can add enough to cause a fall or mental confusion. You really have to be careful."

To that end, the guidelines advise simplified treatment regimens and avoidance of "sliding-scale" regimens that base insulin doses solely on current blood glucose levels without consideration for food or exercise. Such regimens have been shown to induce wide swings in blood glucose levels. Other guidelines have advised against sliding-scale regimens in hospital and long-term care settings, but this is the first that Dr Munshi is aware of that provides specific instructions for replacing them with alternative regimens, depending on the patient's current routine and clinical circumstances.

If you are nearing this point in life or your parents are at this point, carefully read the guidelines at the link above to be aware of them and discuss them with the care facility.

February 10, 2016

Type 2 Diabetes Tips as You Age

Reasonable tips on maintaining good diabetes management as you age are difficult to find. Yes, there are some tips that are on the Internet, but they are few and mixed with many poor tips. Do I have all the answers – no I don't and the few I will mention in this blog will only scratch the surface.

Some of the tips I will use come from the newsletter Type 2 Diabetes. My biggest complaint is the one-size-fits-all approach many writers use. The first tip I will mention is - “As you age it is important to stay up to date with health maintenance.” This is important and deserves attention.

Here is a list of some tests/screenings and how frequently they should be done if you have diabetes:
  • Dilated Eye Exam: Yearly (I disagree as this must be as frequent as the eye doctor specifies.) Your eyesight is too important to ignore and if the eye doctor says twice a year, see him twice a year, or more often if needed.
  • Urine Test for Microalbumin (tests for kidney disease): Yearly (Again follow what the doctor orders and kidney disease can happen and needs to be taken care of when it happens.)
  • Lipid profile: Yearly (Many doctors suggest twice a year and some do this quarterly. Do not ignore doctor's orders.)
  • A1c test: 2-4 times/year (Again, this will depend on how well you are managing your diabetes and some see their doctor as often as six times per year or more.)

Another tip: Those with diabetes are at greater risk for bone fracture than the general population. Getting adequate exercise as well as sufficient calcium and vitamin D are just a few factors that may reduce your risk. Carefully follow your doctor's instructions about calcium. Many people overdue it with calcium and take too much and cause damage to their blood vessels and kidneys.

Managing type 2 diabetes can become more difficult over time. With age, it’s typical that vision deteriorates, additionally; complications from diabetes can lead to diabetic retinopathy, which can result in a loss of vision. It’s important to keep up with your eye exams and to alert your doctor if you notice any new or concerning changes to your vision. Failing vision can make it difficult to read medication labels, so be sure to allow yourself extra time to ask for clarification from your doctor or pharmacist and, if it will help you, ask for large print instructions to take home with you.  Please do not forget about cataracts.

Many people struggle with fine motor skills as they age, often made worse by arthritis. This can make daily tasks more difficult from food preparation to dosing and administering medications or injections. Don’t be afraid to ask for help. Talk to your diabetes medical team about finding simple, easy to use, devices. Think large, easy-to-see print, less buttons and less special functions, as these may be more confusing than helpful. Consider asking a family member, friend or caregiver to preload your insulin syringes or help with meal preparation.

Find a good podiatrist or consider a trusted caregiver to trim your nails and toenails for you. Decreased flexibility can make that task challenging and diabetic neuropathy means you may not be able to feel it if you accidentally trim too close to the skin. A podiatrist will examine your feet, while trimming your toenails, for other problems and foot ulcers so that they can be treated early and thus prevent amputations.

February 9, 2016

Grapefruit Can Interfere with Prescription Medications

First, here is some positive information about grapefruit. It’s delicious when broiled with a bit of brown sugar. It’s packed with vitamin C, dietary fiber, and potassium. It’s good for the immune system, skeletal system, and the cardiovascular system!

Yes, grapefruit has some good points and is generally healthy for you. However, grapefruit has a bad side and many people fall victim to the worse side of grapefruit. Grapefruit has earned the ire of some for its potential to cause harmful drug interactions and is known as the grapefruit effect. But, why is it specifically grapefruit and grapefruit juice that’s singled out?

Even though the harmful drug interactions have been known for several decades, many doctors still do not warn patients when they prescribe a drug known to be on the list. To begin with, the chemical in grapefruit that we’re going to talk about is called furanocoumarin. It’s a toxic chemical found in many plants that functions as a line of defense against would be eaters through a bitter flavor and by causing potential stomach issues.

It’s that exact line of defense that causes the drug interaction. Furanocoumarin is also found in most other citrus; but sour oranges, some mandarins, and tangelos have higher concentrations, though not as high as grapefruit.

The chemical doesn’t interact directly with medications, but instead binds itself to an enzyme found in the liver and intestinal tract. The enzyme in question is known as CYP3A4. This enzyme helps regulate how much of a drug may enter your bloodstream.

Essentially, furanocoumarin puts CYP3A4 into a headlock; as a result, it can’t do its job, so a medication seeps into your bloodstream at an increased rate. Certain drugs show different effects. Men taking Viagra may see the drug hit harder and faster, which may sound good but likely, this may come along with headaches, dizziness or even vomiting. None of which will help sexify the mood.

The FDA notes that cholesterol lowering drugs known as statins often have harmful interactions with grapefruit juice. These can include dizziness, harm to the liver and kidneys, and muscle breakdown. In one Mayo Clinic study, some people even showed signs of memory loss.

Some psychiatric and anxiety medications have also displayed signs of the grapefruit effect, including upset stomach, digestive issues, and exhaustion.

If you’re unsure of what drugs interact with grapefruit juice you can see a partial list here. I have more in this blog and this blog.

February 8, 2016

Insulin Resistance Discussion

The cause of insulin resistance is not well understood. Everyone knows that insulin is a hormone that acts like a key to unlock your cells and let glucose into the cells. Insulin resistance causes the lock and key not to work, even when your body produces more insulin when glucose levels rise in your blood.

Often you will not experience symptoms for varying lengths of time. You will not know that you have insulin resistance. People with severe insulin resistance sometimes develop dark patches of skin on their necks, elbows, hands, and armpits. Your chances of becoming insulin resistant go up if you're overweight, don't get enough exercise, have high blood pressure, or you smoke.

Your blood system may also increase the chances of having insulin resistance, including low HDL (good) cholesterol, high levels of triglycerides in your blood, heart disease, and blood vessel disease in your neck or legs. People with an African American, Hispanic/Latino, Native American, Asian American, or a Pacific Islander heritage are more likely to become resistant to insulin. If your parent, brother, or sister has type 2 diabetes, your risk is higher. If your mother had diabetes while she was pregnant with you (gestational diabetes), your risk also goes up as does the risk for your mother.

The test for insulin resistance is complicated and uncomfortable, so instead, your doctor will probably test you for prediabetes (blood glucose levels that's higher than it should be, 100 to 125 mg/dl). A lab can check the level of glucose in your blood after you haven't eaten for a while, or find an "average" blood sugar level for the past few months. Numbers that are higher than normal suggest you're insulin resistant.

It's hard on your pancreas to keep cranking out extra insulin to try to get glucose into your body's cells. Eventually, the cells that make insulin can burn out, leading to prediabetes and type 2 diabetes. If you catch insulin resistance early and make changes to your lifestyle, you may stop that from happening.

Cut back on sweets, refined grains, and have lots of low carb vegetables and fruits. That kind of eating plan will help you get to and stay at a healthy weight. It also helps your cells use insulin better. The low carb, high fat (LCHF) way of eating, for people with high blood pressure, is a good example. It helps to reduce salt amounts, too. It can lower insulin resistance, especially if you slim down and become more active while you're at it. Studies have also shown a link between low vitamin D and your body not using insulin well.

Physical activity goes a long way toward fighting insulin resistance. Like a healthy way of eating, it helps you lose weight. Exercise also helps your cells use insulin, especially in your muscles. Aim for at least 30 minutes of activity a day, most days of the week. Your heart should beat faster, and you should breathe a little harder.

Lifestyle changes are the best treatment for insulin resistance. But, if you have the condition and are very likely to get type 2 diabetes, your doctor may also want you to try the drug metformin. It can prevent or delay type 2 for younger, heavier people with a very high chance of getting it. Metformin may also help hold off type 2 for women who've had gestational diabetes.

Insulin resistance is part , but not all, of this condition. People with metabolic syndrome have at least three of these traits: a large waist, high triglycerides, low HDL cholesterol, high blood pressure, and blood glucose that is higher than normal. It raises your chances for diabetes, heart disease, and stroke.

I will not go into the technical side of insulin resistance, as a LCHF way of eating can really help in raising HDL, lowering triglycerides, lowering blood pressure, and improving health.

February 7, 2016

The Importance of Ketosis

There is terminology that is often confused and often not for the right reason. Ketosis, ketones, ketoacidosis, and ketogenic are often misunderstood and confused.

A lot of people are confused by the term "ketosis." You may read that it is a 'dangerous state' for the body, and it does sound abnormal to be "in ketosis." But, ketosis merely means that our bodies are using fat for energy. Ketones (also called ketone bodies) are molecules generated during fat metabolism, whether from the fat in the guacamole, you just ate or fat you were carrying around your middle. When people eat less carbohydrate, their bodies turn to fat for energy, so it makes sense that more ketones are generated.

Many people eat fewer carbohydrates to put their bodies into 'ketosis' to burn fat for energy. Some of those ketones (acetoacetate and ß-hydroxybutyrate) are used for energy; the heart muscle and kidneys, for example, prefer ketones to glucose. Most cells, including the brain cells, are able to use ketones for at least part of their energy. But there is one type of ketone molecule, called acetone, that cannot be used and is excreted as waste, mostly in the urine and breath (sometimes causing a distinct breath odor).

If we have enough acetone is in our urine, it can be detected using a dipstick commonly called by the brand name Ketostix (though there are other brands, they are still often called Ketostix). Even though everyone is generating ketones continuously, this detection in the urine is what is commonly called "ketosis." (Less commonly, but more accurately blood ketones can also be measured.) The higher the concentration of ketones in the urine, the more purple the sticks will turn.

The Atkins Diet in particular advises people to monitor ketosis as an indication of fat burning. Other reduced-carbohydrate diets don't pay as much attention to this, or aren't low enough in carbs to make much of an impression on the sticks. The latter type of diet is sometimes called a "nonketogenic" low-carb diet, and there are many benefits to be had from low-carb diets, even if they are not ketogenic.

Why do some people think ketosis is a bad thing?
There are several reasons people point to as proving that ketosis is a state to be avoided.

#1) Not enough glucose. There is an assumption among some advice-givers, especially registered dietitians, that if a body is burning a lot of fat for energy, it must not be getting "enough" glucose. However, there is no indication, from studying people on reduced-carbohydrate diets, that this is the case. Although it's true that our bodies can't break fat down into glucose (though, interestingly, they easily use extra glucose/carbohydrate to make fat, and not the good kind), our bodies can convert some of the protein we eat into glucose. Indeed, this works well for people who don't tolerate a lot of sugar, because this conversion happens slowly so it doesn't spike blood glucose.

#2) Negative symptoms at first. Another thing that people often point to as a negative thing about ketosis is that people can suffer symptoms such as headaches and dizziness in the first few days of a ketogenic diet. Also, athletic performance can suffer until the body adapts to using fat for energy instead of glucose. This is called keto-adaptation. These symptoms are temporary, but they are often used as "proof" that it's bad to eat a very low-carb diet, as if people are likely to have to tolerate headaches for the rest of their lives if they eat a low-carb diet. In fact, people often find that they have better mental function after keto-adaptation than they did when they were eating a lot of carbohydrates. This is the reason registered dietitians say you need carbohydrates for brain fuel and many CDEs follow the same logic.

#3) Confusion: Ketosis vs. Ketoacidosis. A dangerous condition called ketoacidosis can develop in those with type 1 diabetes, and it is sometimes confused with normal ketosis. The body usually avoids this state by producing insulin, but people with type 1 diabetes are unable to produce insulin. Even most people with type 2 diabetes who inject insulin usually produce enough insulin of their own to prevent ketoacidosis.