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.