High Fructose Corn Syrup Again In the News

Now that the Food and Drug administration has declared trans fat unsafe, consumer groups already have their next target in the cross hair for elimination, or tighter regulation. This target is high fructose corn syrup (HFCS) and there is a lot of anticipation that there will be success. Those of us with diabetes won't feel hurt if they are successful in removing it from foods.

#1. It is a highly processed ingredient shrouded in secrecy.

#2. It causes damage to the liver and spikes the blood glucose for people with diabetes.

#3. The corn processors spend millions on lobbyists, TV ads, and highly paid advocates in an attempt to convince consumers that their product is safe.

#4. As health concerns escalate, food companies, supermarkets, and restaurants will voluntarily remove this ingredient.

#5. Some communities are banning or restricting HFCS to halt the ever-increasing medical costs associated with HFCS.

#6. When lawsuits start multiplying and claiming HFCS causes serious health damage, the product will become less prevalent.

As clinical evidence against HFCS mounts, independent researchers are going on record to alert consumers about its health risks. This includes Dr. Robert H. Lustig, Dr. Mark Hyman, Chairman of the Institute for Functional Medicine, and Dr. Michael Goran, Director of the Childhood Obesity Research Center.

Citizens for Health has filed a petition asking the FDA to take action against food and beverage manufacturers that use HFCS concentrations above approved limits, and to require accurate HFCS labeling information. This is the one area I feel will be the greatest help and reducing the amount of HFCS in our foods.

Depression May Be Linked to Low Zinc Levels

Because soils in the United States are generally low in levels of zinc, this may well be factual and part of the depression problem. Granted this is the determination of a meta-analysis and not a large controlled study. In addition, the authors list some weaknesses of the studies they used. Association studies cannot determine the direction of causation, a causal association between zinc status and depression is biologically plausible.

Zinc does have antioxidant properties, it helps to maintain endocrine homeostasis and immune function, and zinc plays multiple roles in regulating the hippocampal and cortical glutamatergic circuits that sub serve regulation and cognitive function. Thus, changes in zinc homeostasis might compromise neuroplasticity and contribute to long-term neuropsychological and psychiatric decline. Homeostasis is the tendency of a system, especially the physiological system of higher animals, to maintain internal stability, owing to the coordinated response of its parts to any situation or stimulus that would tend to disturb its normal condition or function.

People who are depressed were found to have lower concentrations of zinc in their peripheral blood compared with nondepressed individuals, a meta-analysis suggests.  The pathophysiological relationships between zinc status and depression, and the potential benefits of zinc supplementation in depressed patients, does warrant further investigation. This is the conclusion of author Walter Swardfager, PhD, from the Sunnybrook Research Institute, University of Toronto, Canada, and colleagues. Their findings were published in the December 15 issue of Biological Psychiatry.

The analysis included 17 studies that measured peripheral blood–zinc concentrations in 1643 depressed patients and 804 control participants. Ten of these studies reported on psychiatric inpatients, and seven reported on community samples. Of the participants, 34.4% were male; the mean age was 37.7 years.

I found no mention in the study about whether the following vitamins, B12 and B6, which can also influence depression were even considered. From my research, I know that vitamin B12 and vitamin B6 can influence depression. From the Oregon State University the following is quoted from depression - “Because a key enzyme in the synthesis of the neurotransmitters serotonin and norepinephrine is PLP-dependent, it has been suggested that vitamin B6 deficiency may lead to depression. However, clinical trials have not provided convincing evidence that vitamin B6 supplementation is an effective treatment for depression, though vitamin B6 may have therapeutic efficacy in premenopausal women.”

Also from the Oregon State University, this is quoted from the vitamin B12 - “Observational studies have found as many as 30% of patients hospitalized for depression are deficient in vitamin B12. A cross-sectional study of 700 community-living, physically disabled women over the age of 65 found that vitamin B12 deficient women were twice as likely to be severely depressed as non-deficient women. A population-based study in 3,884 elderly men and women with depressive disorders found that those with vitamin B12 deficiency were almost 70% more likely to experience depression than those with normal vitamin B12 status.”

Rather than purchasing and taking zinc supplements, I would suggest that you talk this over with your doctor and have the doctor test for serum zinc deficiency. Be careful, as many doctors will declare that this is “all in your head.” A member of our support group had a relative with depression and this was the answer she received. The doctor also said the same for B12 and B6 and refused to test for them.

We are thankful that our local doctor, Dr. Tom, as we have nicknamed him, that knows our group fairly well now, did the tests for Sue's relative and discovered she was severely deficient for zinc, iron, and vitamin B12. He gave a series of shots for the B12 and started her on iron supplements immediately. He said because iron could prevent the uptake of zinc, he wanted her iron levels in the normal range before she took any zinc supplements. Sue's relative recovered from her depression before she started on the zinc supplement. There were other vitamins that the doctor discovered she was in the low range for and they started tackling them with food to start, and when one still tested low, he prescribed a supplement for it.

We have invited him to speak to a joint meeting of his support group and our group in January. He has accepted this.

AADE Membership Numbers and Industry Sponsors

Apparently, I have ignored some of the activities of the American Association of Diabetes Educators (AADE) for too long. The membership has decreased from a reported 13,000 members per the AADE 2012 Fact Sheet to the latest number of 12,000, as shown in the AADE Career Opportunities. Why is this happening? There is no indication on the website and at least they are no longer claiming that their membership is growing as I questioned in my blog here.

I suspect that many have left the organization or discontinued their membership, but I have no proof, as they are very secretive about what compromises their membership. Because I have been critical of their organization, I cannot get anyone to answer an email for further information.

Further exploration of the AADE website confirms that they are continuing to ignore the National Standards for Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS) adopted by the ADA and written by members of the AADE and ADA. Another article calls these the Ten Gold Standards for Diabetes Self-Management Education.

These ten National Standards for Diabetes Self-Management Education is designed to define the quality of education and support for diabetics and pre-diabetics. A diverse group of health care providers reviews and revises the standards every five years. There are ten standards that diabetes educators and programs should follow in order to provide optimal care. The fact that the AADE has not adopted them or shown them in their Position Statements for 2013 or their 2013 Practice Advisories says they are not adopting them. Fact is they show no Position Statements for 2013. The AADE is still adhering to their standards for Diabetes Self-Management Education (DSME) and Training (DSMT).

In their Scope and Standards section they do have reference to the fact that the AADE collaborated with the American Diabetes Association to develop the 2012 National Standards for Diabetes Self-Management Education and Support. This is just the PDF file that is a copy of the ADA publication. There is no statement that they are adopted or if they are to be part of the AADE guidelines. I have blogged about the National Standards starting here.

The surprising find on the AADE website is their conflict of interest area in which they list the Industry Allies Council of the diabetes supplies manufacturers and pharmaceuticals manufacturers. The list is more inclusive that I had imagined and explains why certain medications are being heavily promoted by CDEs. This list can be read here.

In the past, I have wondered why the AADE would not establish a classification for lay people to help with diabetes education, especially for people with type 2 diabetes, but now, I will not encourage this with the conflict of interest being known. Instead, I will move my encouragement to organizations already making this happen and encourage medical schools to develop these activities and other higher educational institutions that have developed lay programs in the past.

Finding the Veterans Affairs Office in Your State

If you have served in the military, either on active duty or in the reserves or National Guard that were called into active duty, you should check with your Veterans Affairs office to determine if you are eligible for medical benefits. You do have to be honorably discharged and there are some active duty lengths of service to be met.

One of our group, Allen worked with me in pulling information together for this blog. We were able to find the websites for every state, but a couple was difficult to find. Most of the time by typing in the state followed by "department of veterans affairs" in a search engine, we were successful – example: iowa department of veterans affairs. For a couple of states we needed to use this site, which does list every state and territory. Find your state and by clicking on your state, or territory, it will take you to the website.

Each state seems to handle their website differently and to find a local Veterans Affairs office requires some work. We feel fortunate that our state – Iowa – makes it fairly easy to find the office of the county in which you reside. The county map can be found here.

The remainder of this blog is for veterans living in Iowa. There is not enough space in a blog to do all states or the interest for two Iowa natives. We have learned about the Veterans Affairs offices in Iowa and are comfortable with locating information for each of the 99 counties. The information for each county is different as you click on different counties and there is no consistency from one county to the next. Some also maintain county Facebook pages with minimal information on the county site. While checking out each of the 99 counties, we came across several county sites that were down.

We were able to contact one of the counties, they will be up by the middle of the month, and another county site was down for the holidays. One county even had information on their site that they were down until a new Veterans Affairs officer was hired and then the site would be back with the new information in place. This has to be expected with retirements and others being replaced when the local VA commissioners are not satisfied with the performance of a current VA officer.

If you are a reader of this blog and a former United States military veteran, Allen and I strongly urge you to become familiar with the county website where you reside. You should take time to become familiar with where the office is located in your county. Then take the time to stop by the office and check out what benefits you are eligible for and when.

Poor SMBG Studies Lead to Wrong Conclusions

When participants that know something about self-monitoring of blood glucose (SMBG) are excluded from studies, when participants are given only testing supplies and not education, and when the study is too short, it is not surprising that a meta-analysis of SMBG studies arrives at an incorrect conclusion.

What is even more shameful is that the Centers for Medicare and Medicaid Services (CMS) also believes the incorrect conclusions and is penalizing the elderly by forcing many to rely on unreliable blood glucose meters and test strips. This is on top of the limited number of test strips they will be reimbursed for in a period for testing. What this does is force many Medicare members to pay for their own testing supplies, especially among those that know the value of blood glucose testing and do not want to manage their diabetes in the blind.

The value of self-monitoring of blood glucose is established in patients with type 1 and type 2 diabetes taking insulin. Yet, discrimination is the password for type 2 people with diabetes on oral medications. A working hypothesis has been developed that self-monitoring in these patients could prompt them to adjust their diet and lifestyle based on the immediate feedback and this would improve glycemic control.

A meta-analysis published in the Cochrane Library this year has concluded that this hypothesis is false. The meta-analysis included 12 randomized controlled trials with 3259 patients with type 2 diabetes and not on insulin. The primary outcomes were HbA1c, health-related quality of life, well-being, and patient satisfaction. Secondary outcomes were fasting plasma glucose level, hypoglycemic events, morbidity, adverse effects, and costs.

The trials of self-monitoring was shown to provide a small, statistically significant improvement in HbA1c at 6 months and at 12 months, the benefit was not statistically significant and was even smaller. The authors concluded that the overall benefit of self-monitoring in these patients is minimal at 6 months and disappears at 12 months. Patients in this part of the analysis had diabetes for at least 1 year. The study authors claim the results are consistent with those published in 2010 study of 10 trials comparing self-monitoring with no self-monitoring.

The information not explained may be more important than the meta-analysis of 12 studies. How long were the studies that were used in the meta-analysis? This is carefully left out of the analysis data. Also missing was any statements of whether education was given any of the participants. Unknown is the amount of testing supplies furnished the participants or for how long. If the testing supplies were furnished for the first six months and stopped, it is reasonable that the next six months might not show any significant improvement.

This is why they can claim that the working hypothesis is false by not making information available to the reader. I don't believe the meta-analysis was correctly done because of the missing information and this is represented in late 2013 when the original was published in March 2012.

Goals for People with Type 2 Diabetes

As a subscriber to a few American Diabetes Association newsletters, I received the following information. Granted it was written about New Year's resolutions, but since I don't believe in making them once a year and breaking them in the same month, I have them as goals to do every day, every year. As you achieve a goal, redefine the goal and then work to achieve the new goal.

Now remember, if you make a mistake, and we all do, shake it off and get back to working on the goal. Once a resolution is broken, you need to wait until the beginning of a New Year to restart – not so with goals. Learn to set achievable goals at the start and then when you achieve them, set additional goals. Just don't set a goal that is too difficult, make the goal realistic.

Sometimes it is easier to start out with small steps to be able to make great strides. The following are just some of the things to consider in setting goals.

#1. A1c – This will often depend on your doctor and the medication you are taking. Many doctors only see diabetes patients twice a year if they have well managed and on oral medications. Now if you are not managing your diabetes, your doctor may be seeing you four times a year. If you are certain medications like sulfonylureas, DPP-4 inhibitors, or insulin, you may automatically be seeing your doctor four times per year. Other medications may also have an effect on how often you doctor wishes to see you, such as blood pressure medications, statins, certain antacids, and others. Your A1c approved range should be part of the results. Do not rely on the doctor to supply the appropriate range for you unless you are very elderly and in poor health. Many doctors automatically raise this the older you become. Because I am over 70, my doctor wants mine to be between 7.0 and 7.5. I am tired of being scolded for having one below 7%.

#2. Most doctors do take your blood pressure at every appointment. This is standard for all offices, clinics, and hospitals. It is also important because diabetes and high blood pressure are closely linked therefore it is important the have you blood pressure checked at every visit.

#3. Have you feet examined at every appointment. This is a little premature, but still important. If you are seeing a foot doctor or podiatrist, not every doctor you see will need to examine your feet at every appointment. A foot exam is important because diabetes may damage the nerves and blood vessels in your feet. This can mean that small cuts and blisters can be impossible to feel and slow to heal. This is why you should also check you feet on a daily basis.

#4. Annual eye exam is important to discover early any possible diabetes related damage to the retina. You should see an optometrist or ophthalmologist once a year for a dilated eye exam. If you didn't read my blog on January 4, please do, as many people can't seem to get this right.

#5. Having an annual physical exam once a year. Most people with diabetes see their physicians more than once a year. Make sure at least one of these visits includes an annual physical exam.

The following were not part of the newsletter.

#1. Have a dental exam on an annual basis. The health of your teeth is affected by diabetes and can become infected by periodontal disease (gum disease).

#2. Keep the results of your blood glucose readings recorded. This record may help solve problems when you obtain results that don't seem right. Granted if your results of your A1c are fairly consistent your doctor may not ask to see the results, but these may be handy if you are going up and down from one appointment to the next.

Diabetes, Type 1 and Type 2 an Over Simplification

Ever wonder why there is so much confusion about whether some people are first a type 2 and then later are reclassed as a type 1 person with diabetes. Even people diagnosed with type 2 later in life do not fit into the mold as true type 2 diabetes. Some persons with type 2 diabetes actually don't fit the symptoms of type 2 because of how they became people with diabetes. Back in March 2013, I became aware of the over simplification when I wrote this blog.

Then in August, September, and October of 2013, further information came to light in three more articles that I blogged about. Now, in December 2103, even more researchers and physicians are declaring that there is more involved in the diagnosis of diabetes. “The current subdivision of cases into type 1 or type 2 'is a gross simplification, and poorly describes the true range of diabetes,' wrote Leif Groop, MD, PhD, of Lund University in Sweden, and his co-authors online Dec. 4 in The Lancet.”

Yet, in the United States, doctors are becoming even more close-minded and want everything simplified so they don't have to think. They refuse to accept that diabetes can develop from several overlapping mechanisms that can be modified by both genetic and environmental factors. I will not go so far as to say this could be the reason they are abandoning support for diabetes, but their over simplification could be a large part of their treatment and greater desire to not support patient needs for education and methods of treatment to help manage the different subgroups of people with diabetes.

No one is yet positive that the growing obesity epidemic is some areas of the world is the total cause, yet doctors in the United States declare that type 2 diabetes is a lifestyle disease and that it is progressive. Most doctors still want to blame poor nutrition and sedentary lifestyles totally for obesity.

When we read books by Dr. William Davis about the effects of wheat on the body, many bloggers about low carb, high fat nutrition and the results that are positive in reducing obesity, we know that what we are being told by the U.S. Department of Agriculture (USDA), registered dietitians, and doctors is not correct.

Many patients with diabetes present with features of two or more types. While this used to be young adults between the ages of 20 and 40, recently more confusion was added by youth presenting with forms of type 2 diabetes. Previously, most youth were correctly diagnosed with type 1 diabetes. Now we have many youth presenting with type 2 diabetes and even some with a monogenic subset, maturity-onset of diabetes in the young (MODY).

Most doctors are confused by this and not even aware of the changes happening. They do not know how to test for the variances in our youth and up into the later ages of adults. Many doctors have thrown up their hands in defeat because they cannot keep up with the changing and complex research required by diabetes. This may be another reason for the medical community turning against people with diabetes as I covered in my blog here.

Obesity used to be a clue for the presence of type 2 diabetes. Now with the rise in obesity and the number of people who are not obese being classified with type 2 diabetes, this characteristic is less helpful as a diagnostic tool.

Other subtypes of diabetes in adults include ketosis-prone diabetes in adults, a hybrid form of the disease in which patients have features of both type 1 and type 2 diabetes. Then we come to latent autoimmune diabetes of adults (LADA), in with patients tend to be younger, secrete less insulin than those with type 2, have less evidence of metabolic syndrome, and have faster progression to insulin dependency than antibody-negative patients.

Don't expect the American Diabetes Association to do anything about this as their classifications have not changed in the 2014 guidelines. They will use a foreign study when it suits them, but the study has to fit their needs.

Another Impromptu Meeting Asked by Our Local Doctor

Early this afternoon, I received an email asking if I would attend an impromptu meeting to discuss what needed to be done as a doctor would not test for Vitamin B12 or any vitamin or mineral deficiencies. One additional comment was included asking a few of us to research what the American Diabetes Association (ADA) said about this in their guidelines.

Since I have been studying the new 2014 guidelines since I discovered them on December 31, 2013, I knew there was nothing to be found. I went to the American Association of Clinical Endocrinologist (AACE) site to see if there was anything that I hadn't read before, but again nothing about testing for deficiencies. I knew there would be articles in Medscape and other places, so I called on my search engine to help me find them.

Success! I even located one reference on the ADA site, but not part of the guidelines.

The percentage of people with type 2 diabetes taking metformin and developing vitamin B12 deficiency varies from 6 to 52 percent depending on the study. I quickly sent off the URLs to Tim since he would have his laptop at the meeting. Then I copied and printed several points to have at the ready from the ADA and included the following - “Several researchers have made recommendations to screen those with type 2 diabetes on metformin for serum B12 levels. However, no formal recommendations have been provided by the medical community or the U.S. Prevention Services Task Force.”

Ten of our members were present and talking before the doctor arrived. He was upset and we could tell this. He apologized to Allen and stated that this meeting should not have been necessary. He had thought that he had been convincing enough in his presentation to the doctor Allen had trouble with about vitamin B12 deficiency. The doctor then explained that at noon, he had received a call and was told that the ADA did not have anything in the new guidelines about testing for vitamin B12 deficiency and as such, he was not going to test. He did not feel the cost, though small was worth the small percent of people that would be deficient.

Tim took over and said that he had several good articles and that I had a handout from the ADA site for another article not part of the ADA guidelines. I handed out my print out and pointed out the information I have in red above. Allen was surprised at this, and asked why no one would take responsibility for testing. The doctor said he was and that some other doctors would be testing. He asked if Tim could put up the article from ADA and Tim said it would be shortly.

After Tim had the article up, he scrolled down to this. “Although classical B12 deficiency presents with clinical symptoms such as anemia, peripheral neuropathy, depression, and cognitive impairment, these symptoms are usually absent in those with biochemical B12 deficiency.” The doctor had to ask how many knew about this and 7 of those present put their hands up. He said it is no wonder you people do research. He said he was aware of anemia, depression and cognitive impairment, but not the other two symptoms. He added this is the reason he asked for the impromptu meeting as even he could learn.

Allen spoke up and said the individual he brought in was complaining about neuropathy and that is why he thought he could be B12 deficient. He said that was also the reason he had been taken to see the endocrinologist. He was also anemic at the time. Tim stated that we try to inform our members about this and make sure, if they are on metformin for any length of time, that they are tested.

After more discussion, Tim pulled up the article from WebMD and this generated even more discussion. The doctor commented that with these two articles, he wonders why the ADA will not take a position about testing for B12 deficiency. He said he now appreciates our group even more with this meeting and the information we were able to provide. He asked one final question about whether he should consider testing the elderly, above the age of 65 for B12 and vitamin D. Several of the group answered yes, but he noticed I had not answered so he turned to me.

I said that was a difficult question. I would answer yes for anyone with diabetes, but this would be a judgmental call on his part for people without diabetes. He said if he started at age 70, would I change my answer. I said that first he should asked the patient if he/she was taking separate vitamin B12 and D supplements. If they were, he would need to ask questions about neuropathy and he would probably need to explain what neuropathy or peripheral neuropathy was. He would also need to ask if any other doctor had tested for these.

I said if this was also part of the annual exam, then the tests could be done as part of this and then only annually if they were in the lower part of the accepted range. I said that if cognitive impairment or any of the other symptoms were suspected, then yes, do the tests.

The doctor then thanked everyone for attending and asked if there were any questions. Receiving none, he asked Tim to send an email with the URLs and a copy of the summary of the meeting to him. With that, the meeting ended.