Intensive Diabetes Intervention May Halt Disease

This is good news in a different way. A cure is not completely promised, but it puts other options into play and means that bariatric surgery has competition. This is great because bariatric surgery has been touted as the cure-all for type 2 diabetes. Gastric bypass has not lived up to its promise as surgeons had promised. Yes, we now know that is not true and more studies are proving this. Diabetes is returning in larger percentages than previously realized and patients are unhappy. Weight is also coming back because of lack of education and lifestyle changes that are not stressed and educated about by the money hungry surgeons.

Now we have another alternative to bariatric and gastric bypass surgery. This is intensive diabetes intervention. This is also something that needs to be viewed with skepticism; however, this is better planned and education is part of the process. What is not talked about is maintaining the enthusiasm for the process and the rate of weight loss. This needs to be a part of the education and part of the continuing education. The biggest advantage is there are no surgery and other invasive medical procedures.

I always become skeptical when researchers claim total remission. When a patient returns to previous bad habits, the diabetes will return. The study here is only for a four-year period. Unless these studies continue, we cannot be sure of the outcome. The article sounds impressive and offers hope of non-surgical success. Sometimes it takes intensive intervention to start things, and I hope that these people get the complete education package they need to succeed.

“Remission rates were much higher among:

1. People who lost a great deal of weight

2. People who became considerably fitter

3. People with shorter duration of extant diabetes (those who had not had diabetes for long)

4. People with lower HbA1c at entry and not using insulin”

These points from the study are important. The third and fourth points are probably discouraging for many, but I can understand the why and know that the longer you have diabetes, the less likely remission will be. At least this study shows promise for extending the activity of preventing diabetes into the early stages of diabetes.

Interview with Adele Hite

I came across Adele's blog shortly after the March 1, 2012 post and I have been reading it ever since. Yes, when I had a computer crash, I missed a couple of weeks while converting to a backup computer and getting everything functioning to keep my blog moving. Then her October 9, 2012 blog reached out and finally let me know what I was reading and that it was not the standard nutrition blog. Yes, I had ideas before that, but this one really made me sit up and take notice. Now I am rereading many of her blogs with a new insight and understanding. Keep up the good work Adele!

It is with enthusiasm that I am happy to have an interview with Adele Hite and a person that does understand the needs of people with type 2 diabetes.

Bob: Please tell us whom Adele Hite is that we cannot find on your websites.

Adele: Interesting question. The Adele that is more difficult to find on the web is the one that is truly and deeply outraged at what is going on in our food-health system. I mean really angry. I try to be more calm and circumspect in my writing and in my talks, because there is a whole big food-health establishment that needs to change and diplomacy is important. But in person I can get really upset about the issue, especially when it comes to diabetes, because that hits home for me. My father was diagnosed as prediabetic a number of years ago; his doctor was “old school” enough to give him the options of either eliminating sugars and starches or starting medication (which is a reminder that the way everyone treated diabetes before the widespread use of insulin was to have patients reduce the sugars and starches in their diet). My dad chose the former and enlisted my help. I gave him a glucometer and some basic nutrition biochemistry information. That was all he needed to figure out a diet that keeps his blood sugars in check and his HbA1c normal (not “diabetes-normal,” but truly normal). The diet he settled upon is not one that the American Diabetes Association or the Academy of Nutrition and Dietetics would recommend, although in every respect it is very nutritious, filled with lots of veggies and adequate protein with natural fat at every meal.

When I did my hospital internship, I was horrified to see so many people with diabetes who were losing their bodies bit by bit—a few toes here, a foot there, eventually a lower leg, then the whole leg—with failing kidneys, failing eyesight, and lives that were defined almost entirely by their disease state. They weren’t near death but they were dying, quite literally, piece by piece, It was like some awful science fiction movie; it felt as if we were keeping these folks alive just enough to keep a steady supply of them coming into the hospital, dialysis center, and wound clinic where, as health professionals, we could make a show of treating them and get paid well for doing that—but we weren’t going to give them the opportunity to stop the progress of the disease by being willing to let them eat (gasp!) eggs or steak. Every day, as I saw these folks hooked up to wound suction machines or dialysis, I was profoundly grateful for my dad’s doctor (the now-retired Dr. Ronald Moore of New Bern, NC) and for the opportunities I had to learn that there was a different way. I am just as profoundly angered that we, as health care professionals and public health policymakers, give these patients and their families no other choice. I look at my dad and I know that there is a different ending to his story with diabetes that is not such a happy one. I could be losing him a little bit at a time, watching him suffer for years and years. I could be watching him have toes and feet become black with infection and then chopped off. He could be blind and crippled and enduring the painful process of dialysis multiple times a week. But he had a choice. And I am sickened by the knowledge that there are sons and daughters that have no other choice than to stand by helplessly and watch as those things happen to a mother or father that they love.

Whew. When I’m not outraged and angry, I’m a mom with three dangerously smart and funny children who forbid me to talk about nutrition in front of them, which is fine with me. I do have other interests! I have been teaching yoga for about a dozen years now, although my students teach me far more than I teach them. I also write songs with my husband, who is not only 100% supportive of my work, but who makes sure I have a life away from nutrition. He’s an incredibly talented musician who plays guitar and sings in multiple bands. Sitting in an audience watching people dance to a song I wrote or hearing them sing along is just about the coolest thing ever. I love being outdoors. I walk trails nearby with my husband and friends at least once a week. We go to the beach or to the mountains in NC frequently. I love camping by myself and cross-country skiing with my family. These things keep me sane and calm (most of the time) and help me to maintain perspective. I don’t want the food-health issue to be all I do because I look forward to the day when everyone has the choices my dad had and my efforts are no longer needed.

Bob: What drew you to nutrition and making this a career?

Adele: I’ve always been interested in food. My mom was a terrible cook (sorry, mom) and my brothers and sister and I learned to cook, as we say, in self-defense. I liked cooking and became interested in the nutrition aspects of food when the low-fat, vegetarian agenda took hold of the nation in the 1980s. Embarrassingly enough, I climbed on that bandwagon with little skepticism at the time. It worked fine when I was younger, but as I got older and had kids, I found myself in a constant battle with my weight. At 60+ pounds over my normal weight and officially “obese,” I was valiantly trying to get my weight under control, but the harder I tried, the harder it was to lose. Finally, I was eating about 1200 calories and exercising 2 hours a day—and not losing any more weight. What was worse is that I was miserable. I was hungry and exhausted. My hair was falling out. When I went to my family physician for help because I was sure I had some kind of weird metabolic condition, he told me I was fine but that I needed to lose some weight because my blood pressure and blood sugar numbers were going up. He suggested I eat less and exercise more. To my everlasting credit, I did not kill him on the spot.

Instead, I gave up dieting and exercising and took up research in my local Health Sciences Library, which turned out to be a much more productive way to lose weight! When I finally figured out that I needed more protein and fat and fewer carbohydrates, I did lose weight and I’ve kept my weight in a normal range for over a decade now. But that’s not why I made nutrition a career.

Because Dr. Eric Westman of the Duke Lifestyle Medicine Clinic knew that I’d lost weight using the same type of diet he was using to treat patients in his clinic (our kids went to the same school and we’d been in the PTA together), he asked me to join him in his work. I ended up as the Patient Educator, helping patients learn how to adapt their shopping, eating, and cooking habits to a reduced-carbohydrate diet.

As I got to know these wonderful folks who were struggling with overweight, obesity, and diabetes, I kept hearing the same story over and over again. It was very familiar because it was my story too. They had tried to lose weight by lowering fat and calories and exercising, but it didn’t work very well, or very long—or, for some folks, at all. After finding success with the clinic’s diet, the patients kept asking the same questions. Why were we told that eggs and meat are bad for us and bread and cereal is good for us when we feel so much better on this diet? Most of all, they wanted to know: Why weren’t we given this choice before? I didn’t have an answer, but their own outrage about how this option was never presented to them convinced me to go back to school to try to figure it out what was going on in nutrition and health care.

Bob: Is there a difference between nutrition and dietetics and is this important?

Adele: Yes and no. Both fields are centered around finding or maintaining health through food. But the scope of nutrition is much wider than dietetics, and there are many ways to study or practice nutrition in addition to being a dietitian; you could say that dietetics is a subset of nutrition. Almost by definition, if you are in dietetics, your training and education has been dictated by the Academy of Nutrition and Dietetics (AND) which has a particular agenda shaped by its close association with food and pharmaceutical manufacturers and with the USDA.

The difference between nutrition and dietetics is important because the AND has been leveraging its financial backing to lobby state by state for restrictive licensure laws that allow only Registered Dietitians to practice nutrition. This is a bad thing for the consumer because it would further restrict our already-restricted choices about nutrition information. People deserve the option of hearing a perspective on nutrition that is not influenced by one particular organization. I am fully committed to the idea that dietitians and other nutritionists should be held to high professional standards, but other nutrition professionals actually have higher educational standards than RDs. You can become an RD with only a 4-year Bachelor’s degree plus internship hours, as compared to a Certified Nutrition Specialist which requires Master’s or PhD level training. I also believe that nutrition professionals should be at the forefront of preventive medicine and health care reform—but dietitians cannot be the only nutrition professionals allowed to practice. 

Unfortunately, as long as the AND is chained to USDA guidelines, food manufacturers, and pharmaceutical companies, the interventions and advice of dietitians will be ineffective at best, damaging at worst.  And, as result, dietitians will be poorly paid, our motivations will be suspect, our advice will be (as it should be) disregarded, and as professionals we will be marginalized.  We will remain on the sidelines, as we saw when RDs were denied Medicare/Medicaid coverage for intensive treatment of obesity. If we want to be active players in healthcare, dietitians will have to raise their own standards, and we will have to disengage ourselves from industry influence. We will also have stop treating the policy guidelines that emanate from the USDA as if they are actually science, since they aren’t.

Bob: Is there hope for people with type 2 diabetes that listen to members of the Academy of Nutrition and Dietetics (AND)?

Adele: Well, yes, depending on who those members are! All RDs are not necessarily members of the AND (just as all MDs are not members of the AMA), and even those who are may have progressive, science-based views on nutrition. At the North Caroline Dietetics Association (an affiliate state-level organization of the AND) conference, I heard a colleague discuss the merits of carbohydrate-restricted diets at a question & answer session—and no one contradicted her! Times are changing and those RDs are out there. But you are right that the AND “party line” is probably not the best choice for those with type 2 diabetes. During my training, I was appalled at how much RDs and other diabetes educators rely on educational materials from insulin companies to teach patients about living with diabetes. These are not materials that are going to help patients minimize their insulin consumption, which—along with overall blood sugar control—should be a goal of treating diabetes.

Bob: In rereading your first two blogs (often these set the parameters of things to come), you have spelled out an agenda and I think rightly or correctly laid the groundwork for the blogs that follow. Have you changed any thoughts since?

Adele: Your question prompted me to re-read those blog posts. I will readily admit that I shift my position on matters of food and health all the time, but I still feel pretty good about those posts. The primary shift that has occurred is that, every day, I become increasingly oriented towards looking at the whole food-health system and its dysfunction as an extension of social, cultural and economic trends that have been with us as long as the Guidelines have. Although I would stand by the assertion that the Dietary Guidelines are very much at the center of that dysfunction, in some ways they may be—like obesity—more of a manifestation of other trends than a cause in and of themselves.

Bob: You have two statements that have intrigued me.

The first one is this - “Frequently those arguments (leptin insulin ghrelin, oh my!) boil down to a collection of snapshots from experimental data that may or may not create a physiologically significant or practically useful collage.” What is the significance of these three hormones in the discussion?

Adele: One of the effects of the intense amount of funding and attention that has been poured into obesity research is that we have been learning, as they say, more and more about less and less when it comes to obesity. I love biochemistry, but in nutritional biochemistry, our knowledge level sometimes becomes so detailed that we forget to climb back up the ladder and put all the pieces together. This may be what is happening with some of our investigations into hormones having to do with appetite, like leptin and ghrelin. Investigations into hormones that regulate appetite is, underneath it all, predicated on the assumption that people who are obese eat more than people who aren’t, or at the very least, eat more than they “should”—whatever that means. The fact that we don’t actually know whether or not this is true (or when it is true and when it isn’t)—there is plenty of evidence that people with obesity often do not consume more calories than others—means that this has turned our attention away from trying to figure out why some people utilize the same number of calories differently than others; some store those calories as fat, while others burn them for fuel or use them to build and repair the body.

Leptin is the hormone that is supposed to regulate appetite by telling the brain how much stored energy we have. It was theorized that a leptin deficiency is what prevented appetite from being “turned off” in people with obesity, who by definition have large amounts of stored energy. When we discovered that people with obesity had the same levels of leptin as people with normal body fat levels, we had to start looking at the problem in a different way. Dr. Robert Lustig has been doing a great deal of work with regard to leptin in human subjects, so I would check out his new book, Fat Chance, for a thorough discussion of this hormone.

Ghrelin is a hormone that stimulates hunger, but is also involved in regulating growth, learning, and memory. It is usually talked about as the counterpart to leptin, and like leptin, is linked strongly with insulin activity.

Insulin is very much at the center of our current concerns about health, but you’d be surprised at how little we know about it—and what we do know we seem to have forgotten. Insulin is a master hormone whose effects are felt throughout many metabolic pathways, but it has three very basic functions: 1) to clear glucose from the bloodstream by ushering it into cells where, if it isn’t used as energy, it is eventually stored as fat; 2) to “turn off” glucose production by the liver; and 3) to “turn off” the process that allows body fat to be used as energy. This last function is frequently forgotten in our haste to treat people with diabetes. A Duke endocrinologist who was mystified by the fact that her patients on insulin kept gaining weight—even though she told them to eat less and exercise more--couldn’t even dredge up the fact that preventing “fat-burning” is a primary role of insulin!

Although it is hard to make any sweeping generalizations about people with obesity and our investigations into leptin and ghrelin have shed little light on the issue, we do know one thing about people who are obese: their insulin levels have been elevated. We don’t know how often, or to what extent, or in what fashion, or even why. But we do know that much. Insulin, ghrelin, and leptin are strongly linked physiologically and we are just beginning to untangle those relationships, but at this point I would say that it is rare to have leptin or ghrelin dysregulation without the upstream effects of insulin dysregulation.

We also know that the effects of elevated insulin are not limited to increased fat storage. There is also increased inflammation which may help explain the fact that insulin levels are a strong independent predictor of heart disease. But we haven’t really investigated that relationship because we haven’t developed the tools to do that. The scientific developments that allowed researchers to easily measure serum cholesterol levels drove the investigations into the relationships between diet, serum cholesterol and heart disease—which turned out to be a rather fruitless path until we could start to further break down cholesterol measures into sub-particles. Because of its central role as a “master hormone,” unpacking the relationships between diet, insulin activity, and disease should be, in my opinion, the primary focus of nutrition science. But since we do not currently have a convenient and consistent way of measuring or even talking about insulin, this has not happened. I’m hoping that a breakthrough in insulin measurement will drive research in a long-overdue direction. I know a couple of gentlemen who are working on that now.

Bob: The second is this, “Note that I am not saying “Everything in moderation.” I am saying “Everything in context.”” Is this a key in the way food should be studied and whether a particular food is good for our health at our time and period in life?

Adele: Absolutely. If I ate the way my son eats, I would store a lot of body fat; if he ate the way I eat, he’d be very hungry. Our activity levels are about the same (I would even argue that I’m quite a bit more active than he is, as his favorite form of exercise is to lay on the couch). But I’m a peri-menopausal female, and he is an adolescent male. We have very different internal environments, metabolic and hormonal settings, and diet histories. There is no single dietary approach that would make sense for both of us, unless we are talking about focusing simply on acquiring essential nutrition—and even then, there are likely to be some significant variations between his needs and mine. As a result, it makes little sense to say this food or group of foods is “bad” and another is “good.” A dietary pattern that leads to good health for one person may not lead to good health for another, or even for that same person at a different point in his/her life.

As I see it, the biggest problem in nutrition right now is that we think we know—for all Americans regardless of race, gender, or age—what foods are (and are not) going to lead to good health. Not only do we not know (which makes us out of line when we tell people we do know), but it causes us not to question the effectiveness of any diet that we’ve already determined is a “healthy” one. When this happens, we stop listening to the messages our bodies send us about our health. It doesn’t matter what kind of diet it is, if it does not lead to you waking up in the morning and experiencing a day where you feel healthy—whatever your definition of that is—it isn’t a healthy diet for you. It is the height of presumption for public health leaders to think they know better than your body does what kind of diet that might be.

This assumption means that we have not paid attention to bioindividuality and how that intersects with public health policy. The truth is we don’t know what kind of diet—other than one that provides essential nutrition and helps you maintain a weight that is appropriate for you—will lead to good health for you this year, much less 30-40 years from now.

Bob: What advice can you share for those of us with type 2 diabetes whether they are taking oral medications or using insulin?

Adele: I think the most important thing to remember is that type 2 diabetes does not manifest itself the same way in every person. People have different levels and varieties of insulin production and insulin resistance that contribute to an elevation in blood sugar, which is the metabolic situation that results in a type 2 diabetes diagnosis. Although everyone with type 2 diabetes has low insulin production, just how low can vary significantly. Everyone can reduce the work the pancreas has to do by reducing dietary carbohydrate. But people whose pancreases still make some insulin can reduce or eliminate medication this way, while others with less insulin production cannot.

Insulin resistance occurs throughout the body, but can specifically affect the liver’s ability to “turn off” the production of glucose. If there is insulin resistance in the liver and the liver continually produces more glucose than the body needs, lowering dietary carbohydrate will only get you so far and some sort of medical intervention is almost always necessary.

That said, there is no known physiological need for dietary carbohydrate in the presence of adequate intakes of protein and fat, and dietary carbohydrate is the food group with the most significant impact on blood glucose levels. We also know that there is no known relationship between foods we’ve been told to avoid—meat, eggs, butter, and cheese—and any chronic diseases. At this point, we need to put the burden of proof where it belongs: public health policymakers and advocacy groups need to prove that these nutritious, whole foods are truly as dangerous to our health as we’ve been told before they tell us to avoid them. Whether you are on oral medications, insulin, or controlling your diabetes through diet alone, your overall health will be best served by feeding your body the nutrition it needs, and there is a lot of nutrition to be found in foods we’ve been told not to eat.

Bob: Have you followed the activities and the websites for Gary Taubes and Peter Attia and will they be a help for you, that is, the Nutrition Science Initiative (NuSI)?

Adele: I do follow the activities of Gary and Peter, and I’m thrilled about the developments at NuSI. The work that NuSI is doing will, I believe, support the changes that need to occur in public health nutrition policy. At the same time, science is only part of the problem. The Dietary Guidelines came into existence—and have remained virtually unchanged for 30+ years—due not only to theories being promoted by some in the scientific community, but to political, economic, and social pressures. If this were really all about science, well, the science is inconclusive on most matters of nutrition. If the Dietary Guidelines had been based primarily on science in the first place, they would say two things: 1) get your essential nutrition and 2) maintain a weight that is healthy for you. That’s all we really knew in 1980 when the first Dietary Guidelines were created, and that’s all we really know now. But the Dietary Guidelines are not based on solely on science, and it will take more than science to address the changes needed in our food-health system. However, the efforts of NuSI will certainly help to make the case that the one-size-fits-all dietary paradigm that we’ve been using since 1977 is inappropriate, which it most certainly is.

Bob: I like your last paragraph of your first blog and hope that all of us can do our part. “At the same time, I’m not here to wring my hands in anguish. I’m actively trying to figure out what to do about this mess we’re in. I’d love all the feedback and help and ideas I can get from anyone with enough time on their hands to wade through my musings. Let’s save the world & have fun doing it.”

Adele: Thanks! The work you do educating people with diabetes about their options is essential to the changes we want to make in reforming the system. The current approach to nutrition in treating people with diabetes is probably the weakest link in the chains holding back progress. Your efforts will surely help to break that link.

Bob: Thank you, Adele! It is a pleasure to publish this and there is a wealth of information that needs to be digested and expanded upon.

Her blog is here. Then with Adrienne Larocque they founded Healthy Nation Coalition

and that website is here.  Adele asked me to list an important person, Pam Schoenfeld, another founder and without whom the site would not exist.

A Positive Blog Site You Should Read

Are you having a downer of a day? Are you kicking yourself for doing something in your diabetes management that did not give you the result you were anticipating? If you need to have your confidence uplifted or an idea for a pat on the back, take time to read many of the blogs by Will Ryan at joyfuldiabetic. Here are three links you should enjoy – link 1, link 2, and link 3. Please take time to read these, and then come back. I'll wait for your return.

Now don't you feel better? This is what had me coming back to read this blogs. I can get down or disappointed and I go reading (actually rereading) some of his blogs. Then I feel more positive and ready to tackle a task that has been haunting me for several days. We can try to stay positive, but there are times when we need to have this reinforced and Will's blogs can do this for me.

You will not find long technical blogs. What you will find can be inspirational and uplifting and there are times when we need this. As primarily a speaker, Will has mastered the skill of being concise. You don't become a Toastmaster without this. I wish some of this would rub off on me. Take time to explore his site. Will usually blogs two times per week, on Sundays and Wednesdays, but life sometimes causes him to vary a day or two.

Medication Problems from Duplication

This is one feature from Diabetes Clinical Mastery that I enjoy. This does not always give me ideas for blogs, but occasionally there is a brief article that speaks volumes and points out some of the problems within our medical system. This article is not an exception and shows what happens when patients do not fill their prescriptions at one pharmacy, or provide their pharmacy of a complete list of medications they are taking,

This is one reason that more doctors are asking patients to being in all their medications in the containers in which they were received. Even then, some patients try to avoid doing this – to the point of endangering their health. The patient in this article did as she was asked and this may have saved her life. The author found two prescriptions for lisinopril. One prescription was for 20 mg and one for 40 mg, each to be taken daily.

She explained that the 20 mg was for her kidney and the 40 mg was for her hypertension. When the labels were examined, that was the case and each had been filled at different pharmacies. This explained why she had complained of being dizzy and afraid of falling when she rose from her chair. The doctor had her stop the 20 mg and her problems cleared.

The lesson learned by the author is that the same medication may be prescribed to a patient for different reasons and patients are most likely unfamiliar with the reasons for the medication. At least this author recognizes the fact that patient education is necessary to prevent the patient from either discontinuing the medication or like this example overdosing on a medication.

Even though this is listed as one lesson learned, the author did not forget that patients need to be encouraged to fill all prescriptions at one pharmacy. By doing this, the pharmacist should have recognized the problem and advised the different doctors at least or advised the patient of the problem.

There are other lessons to be learned from this example. First, every doctor should be aware of other doctors treating the patient and for what. This I make sure of and have the cooperation of all doctors concerned. I also provide at their request all medications I am taking, the dosage, when I am taking each, and who is prescribing the medication. The doctors do confer and I have only two doctors renewing my prescriptions. When a new one is needed, the conflicts are determined and the prescription issued if there are no conflicts. If the prescription if for the short-term, which all recently have been, the doctor concerned does the prescribing.

Another lesson is that patients often do not tell their doctor about supplements they are taking. Since many may conflict with medications, this always needs investigation. The last lesson is that some patients will not fill prescriptions at the same pharmacy for reasons only they are aware of. Others do not want one pharmacist to know all the medications they may be taking. Still others are receiving prescriptions that they in turn are selling for money. These are major problems within out current medical system.

Starting Small Is Good for Diabetes Prevention

This author knows how to push the wrong buttons and even though the message in general is a great idea, her delivery leaves a lot to be desired. The overarching message is for people that are hesitant about changing habits and ways of doing things is to start small and slowly develop good eating habits and other habits. Why the author could not have emphasized the positive side of this is a mystery to me. Instead, she uses scare tactics that people with diabetes do not appreciate hearing. Yes, I know, writing style and all that, but when introducing this to people that may not have diabetes yet, there has to be a better introduction.

Then in the suggestions area for a food plan, the author uses the National Institute of Health (NIH) recommendations. This means the USDA food plan of high carbohydrate /low fat. As many of us with diabetes are well aware, this is the formula for failure. Low carbohydrate/high fat is more successful over time and is the food plan of choice. Yet every time we are on the topic of potential aids for stopping or reducing the effects of diabetes, we hear the same plan for high carbohydrate/low fat mantra of the USDA, the American Diabetes Association (ADA), and other organizations.

Other than the suggestion of starting small to have initial successes, which may work well for some individuals, we are left with scare tactics and the wrong food plan. The idea of starting out slowly does work for people that are hesitant to make changes. Having early successes by setting short-term goals is good for many people. In the area of exercise, this is always good to start out slowly. However, even this author does not understand the importance of discussing an exercise plan with their doctor. The doctor should understand your current health and know if there are obstacles to an exercise regimen you have planned. Your doctor may find it necessary to do some tests to determine if there may be some limitations to your regimen. Once the doctor knows that there are not limitations, he may have suggestions, which will assist you in developing a more effective exercise regimen. It is wise not to leave the doctor out of the plan and encounter problems later.

Yes, we would like to see the current increase in diabetes stop, but until people are willing to start making dietary changes, start an exercise program, and develop other changes in their habits, this will not happen. Starting with small changes and having success is good, but getting people motivated is and should be the goal of physicians to begin converting people out of the sedentary lifestyle.

Hearing Loss Now Linked to Diabetes

Since I have type 2 diabetes, this is not news to me, but from discussions I have had with a few type 2 people with diabetes, I know many are not aware of the possibility of hearing loss. A key to understanding this is this statement from the study authors, “high blood glucose levels can damage vessels in the stria vascularis and nerves diminishing the ability to hear.” Stria vascularis is the upper portion of the spiral ligament that contains numerous capillary loops and small blood vessels, and is termed the stria vascularis. It produces endolymph for the scala media, one of the three fluid-filled compartments of the cochlea.

Like vision loss, it is the small blood vessels that are damaged by extended high blood glucose levels; therefore, hearing loss develops. Yet even this is controversial as most studies are inconsistent in results, that is, they have faults in research protocols so that the results are always inconsistent. It is still believed that over time, high blood glucose levels can cause damage and diminish the ability to hear. A study by the University of Japan found that people with diabetes have more than two times higher prevalence of hearing impairment than those without diabetes.

One of the strongest critics of the study states that the study is an observational association and additional studies are needed to clarify the relationship between diabetes and hearing loss. When researchers compare diabetics with non-diabetics, these observational studies cannot prove a cause-and-effect relationship, only a correlation between diabetes and hearing problems.

The connection between hearing loss and diabetes was stronger among people who were 60 years of age or younger rather than among older adults. The likelihood of having hearing impairment in this group was 2.6 times higher. Comments agreed and said this is consistent with the idea of poor blood glucose management, which damages blood vessels and nerves throughout the body and not simply old age.

It is important to be proactive in your care. If you notice any hearing loss, report this to your doctor. According the American Diabetes Association almost 26 million people have diabetes. More than 34 million Americans have some type of hearing loss and this number is rising as the baby boom generation ages.

Nutrients - Vitamin D

Vitamin D

Overview

Many of us are deficient in certain nutrients and our doctors do not test us as we age. Some of us do have sufficient quantities in our diets and then take supplements, which may give us an oversupply. Your doctor should test for all of these (that have testing available) before you run out and buy supplements. You may not need them as part of your diet because you are already obtaining sufficient intake from your diet.

I would be remiss if I did not give you a warning about not overcompensating and ingesting too much of some of these nutrients as there are some medical concerns with toxicity and conflicts with certain prescription medications. More is often not better and can be fatal with some supplements and herbal supplements.

Vitamin D is one large misnomer as it is a hormone, but this is now commonly accepted and will likely never be changed. It is the one that most people will have a difficult time in overdosing, but it has happened.

Tests

This is to inform you that the newer Vitamin D blood tests are over 40 percent unreliable and you need to make sure that the tests are not used. Please read this article in WebMD. Older testing procedures are the better bet.

Recommended Daily Allowance

The current RDA for vitamin D is being revised, and some experts suggest that adults should take at least 2000 IU of vitamin D daily. I personally use 3000 IU of Vitamin D3 daily and some that I know take as high as 10,000 IU.

Recommended dietary allowances currently for vitamin D are listed below. Seniors and people who don't get exposed too much sunlight may need to take supplements. Seniors may be at risk of developing vitamin D deficiency because, as we age, the body does not make as much vitamin D from sunlight, and it has a harder time converting vitamin D into a form it can use.

If you are concerned about your vitamin D levels, ask your doctor whether you should take a supplement, and how much.

Pediatric

1. Infants birth to 12 months: 400 IU (adequate intake)

2. Children 1 - 18 years: 600 IU (recommended dietary allowance)

Note: The American Academy of Pediatrics (AAP) recommends 400 IU of vitamin D daily for breastfed infants until they are weaned and drinking at least 1 liter of whole milk or formula fortified with vitamin D. The AAP also recommends that children and teens who drink less than 1 liter of milk a day take 400 IU of vitamin D.

Ask your doctor before giving a vitamin D supplement to a child.

Adult

1. 19 - 50 years: 600 IU (recommended dietary allowance)

2. 70 years and older: 800 IU (recommended dietary allowance)

3. Pregnant and breastfeeding females: 600 IU (recommended dietary allowance)

Food Sources

There are two dietary forms of vitamin D:

1. Cholecalciferol - D3

2. Ergocalciferol - D2

These are naturally found in foods and are added to milk. Not all yogurt and cheese are fortified with vitamin D. Food sources of vitamin D include:

1. Cod liver oil (best source). Cod liver oil often contains very high levels of vitamin A, which can be toxic over time. Ask your health care provider about this source of vitamin D.

2. Fatty fish such as salmon, mackerel, tuna, sardines, herring

3. Vitamin D-fortified milk and cereal

4. Eggs

Functions

Taking the proper amount of vitamin D may help prevent several serious health conditions. These conditions include:

1. Osteoporosis - Vitamin D helps your body absorb and use calcium, which you need for strong bones. Getting enough vitamin D throughout your life is important, since most bone is formed when you are young. For post-menopausal women who are at higher risk of osteoporosis, taking vitamin D along with calcium supplements can reduce the rate of bone loss, help prevent osteoporosis, and may reduce the risk of fractures.

2. Other Bone Disorders - Vitamin D protects against rickets and osteomalacia, softening of the bones in adults. Seniors who live in northern areas and people who do not get direct sunlight for at least 45 minutes per week should make sure they get enough vitamin D through fortified milk and dairy products. Or, they can take a vitamin D supplement or a multivitamin with vitamin D.

3. Prevention of Falls - People who have low levels of vitamin D are at greater risk of falling, and studies have found that taking a vitamin D supplement (700 - 1000 IU daily) may reduce that risk. In seniors, vitamin D may reduce falls by 22%.

4. Parathyroid Problems - The four parathyroid glands are located in the neck. They make parathyroid hormone (PTH), which helps the body store and use calcium and phosphorus. Vitamin D is often used to treat disorders of the parathyroid gland.

5. High Blood Pressure (Hypertension) - People with low levels of vitamin D seem to have a high risk of developing high blood pressure than those with higher levels of vitamin D. However, there's no proof that low levels of vitamin D cause high blood pressure in healthy people. Evidence about vitamin D and blood pressure has been mixed.

6. Cancer - There is some evidence that getting enough vitamin D may lower your risk of certain cancers, especially of the colon, breast, prostate, skin, and pancreas. This evidence is based mostly on studies of large groups of people, population studies, and doesn't prove a connection between taking vitamin D and lowering your cancer risk. Some research suggests that postmenopausal women who take calcium and vitamin D supplements may have a lower risk of developing cancer of any kind compared to those who don' t take these supplements.

7. Seasonal Affective Disorder (SAD) - SAD is a type of depression that happens during the winter months, when there's not much sunlight. It's often treated with photo (light) therapy. A few studies suggest that the mood of people with SAD improves when they take vitamin D. Talk to your doctor about whether vitamin D might help your treatment for SAD.

8. Diabetes - Studies find that people who have lower levels of vitamin D are more likely to develop type 2 diabetes than people who have higher levels of vitamin D. But there is no evidence that taking vitamin D can help prevent or treat type 2 diabetes. One study found that giving infants doses of 2,000 IU per day of vitamin D during the first year of life may help protect them from developing type 1 diabetes when they are older.

9. Heart Disease - Studies suggest that people with low levels of vitamin D have a greater risk of developing heart disease, including heart attack, stroke, and heart failure compared to people with higher levels of vitamin D. Low levels of vitamin D may increase the risk of calcium build-up in the arteries. Calcium build-up is part of the plaque that forms in arteries when you have atherosclerosis and can lead to a heart attack or stroke.

10. Multiple Sclerosis (MS) - Studies have found that women who take at least 400 IU of vitamin D daily lower their risk of developing MS. And higher levels of vitamin D in the blood seem to be associated with a lower risk of developing MS in white men and women, although the same may not be true of African American and Hispanic men and women. However, this does not mean that vitamin D supplements will help prevent or treat MS in people.

11. Obesity - Studies have found that people who have lower levels of vitamin D are more likely to be obese compared to people with higher levels of vitamin D. One high-quality study also found that postmenopausal women who took 400 IU vitamin D plus 1,000 mg calcium daily for 3 years were less likely to gain weight than those who took placebo, although the weight difference was small. Women who were not getting enough calcium to start with (less than 1,200 mg per day) saw the most benefit.

12. Overall Mortality - Studies suggest that people with lower levels of vitamin D have a higher risk of dying from any cause.

Precautions

Because of the potential for side effects and interactions with medications, you should take dietary supplements only under the supervision of a knowledgeable health care provider.

Taking too much vitamin D can cause several side effects. However, scientists don' t all agree on how much is too much. The National Institutes of Health has set the maximum tolerable upper limit at 1,000 IU daily for infants 0 - 6 months, 1,500 IU daily for infants 6 months to one year, 2,500 IU daily for children 1 - 3 years, 3,000 IU daily for children 4 - 8 years, and 4,000 IU daily for anyone over 9. Ask your doctor to determine the right dose for you or your child.

Side effects may include:

• Being very thirsty
• Metal taste in mouth
• Poor appetite
• Weight loss
• Bone pain
• Tiredness
• Sore eyes
• Itchy skin
• Vomiting
• Diarrhea
• Constipation
• A frequent need to urinate
• Muscle problems

You cannot get too much vitamin D from sunlight, and it would be very hard to get too much from food. Generally, too much vitamin D is a result of taking supplements in too high a dose.

People with the following conditions should be careful when considering taking vitamin D supplements:

 High blood calcium or phosphorus levels

 Heart problems

 Kidney disease

 Sarcoidosis

 Tuberculosis

Possible Interactions

If you are currently being treated with any of the following medications, you should not use vitamin D supplements without first talking to your health care provider.

Atorvastatin (Lipitor) -- Taking vitamin D may reduce the amount of Lipitor absorbed by the body, making it less effective. If you take Lipitor or any statin (drugs used to lower cholesterol), ask your doctor before taking vitamin D.

Calcipotriene (Dovonex) -- It's possible that taking vitamin D supplements and using calcipotriene, a medication applied to the skin for psoriasis, could cause calcium levels to get dangerously high in the blood.

Calcium channel blockers -- Vitamin D may interfere with these medications, used to treat high blood pressure and heart conditions. If you take any of these medications, do not take vitamin D without first asking your doctor. Calcium channel blockers include:

 Nifedipine (Procardia)

 Verapamil (Calan)

 Nicardipine (Cardene)

 DiltiaZem (Cardizem, Dilacor)

 Amlodipine (Norvasc)

Corticosteroids (prednisone) -- Taking corticosteroids long-term can cause bone loss, leading to osteoporosis. Supplements of calcium and vitamin D can help maintain bone strength. If you take corticosteroids for 6 months or more, ask your doctor about taking a calcium and vitamin D supplement.

Digoxin (Lanoxin) -- a medication used to treat irregular heart rhythms. Taking vitamin D if you take digoxin may cause levels of calcium to get dangerously high in the blood.

These drugs may raise the amount of vitamin D in the blood:

Estrogen -- Hormone replacement therapy with estrogen seems to raise vitamin D levels in the blood, which may have a positive effect on calcium and bone strength. In addition, taking vitamin D supplements along with estrogen replacement therapy (ERT) increases bone mass more than ERT alone. However, that may not be true if you also take progesterone.

Isoniazid (INH) -- a medication used to treat tuberculosis.

Thiazide -- A diuretic or water pill that helps your body get rid of too much fluid. It can increase vitamin D activity and lead to high calcium levels in the blood.

Vitamin D levels may be lowered by the following medications. If you take any of these medications, ask your doctor if you need more vitamin D:

Antacids -- Taking certain antacids for long periods of time may alter the levels, metabolism, and availability of vitamin D.

Anti-seizure medications -- these medications include:

 Phenobarbital

 Phenytoin (Dilantin)

 Primidone (Mysoline)

 Valproic acid (Depakote)

Bile acid sequestrants -- used to lower cholesterol. These medications include:

 Cholestyramine (Questran, Prevalite)

 Cholestipol (Colestid)

Rifampin -- used to treat tuberculosis

Mineral oil -- Mineral oil also interferes with absorption of vitamin D.

Orlistat (Alli) -- a medication used for weight loss that prevents your body for absorbing fat. Because of how it works, orlistat may also prevent the absorption of fat-soluble vitamins such as vitamin D. Doctors who prescribe orlistat tell their patients to take a multivitamin with fat-soluble vitamins.

Points to Consider About Food

The glycemic index (GI) and the glycemic load (GL) are two of the more meaningful terms in understanding the value of food and how each affects our blood glucose levels. This is a topic everyone with diabetes needs to be aware of and learn the general principles.

Everyone also needs to be aware that to some this is a religion, and therefore they can endanger their health. I will warn that this topic and the principles behind this should be used as a guide, but not as a bible. First, the glycemic values were determined using healthy people and not patients that were obese or that had any diseases. Therefore, we cannot be positive that the tables are exactly right for us. We do need a starting point, so I accept the tables as a starting point.

I will direct your reading to several people that have influenced my thinking about the glycemic index and glycemic load. The first was this book - The New Glucose Revolution, New York, Marlow & Company, 349 pages, by Dr. Jenny Brand-Miller, et al. I currently have the third edition.

Computing the glycemic load is fairly easy and will help in determining whether you are safe in eating the particular food, or will have high blood glucose levels briefly or for a longer period. Using the example from a blog by Dr. William Davis, we have the following: (quoting) “GL = (GI x amount of carbohydrate) / 100.

GL is therefore the GI that incorporates the glycemic potential of the food of interest. GI does not vary with portion size; GL varies with portion size.

Let’s take whole-wheat pasta, a food regarded by most people as a healthy choice. Whole-wheat pasta has a GI of 55–fairly low–and a GL of 29. A serving of 180 g (approximately 6 oz cooked) provides 50 g carbohydrates.” So using the formula above the GI of 55 X 50 g carbohydrates = 2750 divided by 100 = 27.5 for GL – not the 29 that Dr. Davis has. In either case when you look at the graph from David Mendosa's web site, you will see that the GI of 55 is the top end of the low range and the GL is well into the high range. This means that the whole-wheat pasta will raise blood glucose for a long period. This will depend on your body chemistry so actual time is difficult to measure. This is a good reason to avoid whole-wheat pasta.

Doctor Davis also has another blog on the glycemic index. By entering “glycemic index” in the search box on David's site, it will return many more articles by David and many that you may wish to read. Here and here are two of the articles.

If you have more interest in blogs on glycemic index go to this site and subscribe for a monthly newsletter.