Category Archives: Diabetes Complications

Eat Nuts to Reduce Cardiovascular Risk and Improve Type 2 Diabetic Blood Sugars

Paleobetic diet

Macadamia nuts on the tree

Most of the diets I recommend to my patients include nuts because they’re so often linked to improved cardiovascular health in scientific studies. Walnuts are associated with reduced risk of type 2 diabetes in women, and established type 2 diabetics see improved blood sugar control and lower cholesterols when adding nuts to their diets.

paleobetic diet, diabetic diet, low-carb diet

Apples, pecans, and blueberries: So simple even a redneck can make it (I are a redneck)

Nut consumption lowers total and LDL cholesterol levels, and if triglycerides are elevated, nuts lower them, too. Those changes would tend to reduce heart disease.

Conner Middelmann-Whitney has a good nutty article at Psychology Today.

Steve Parker, M.D.

Reference: Joan Sabaté, MD, DrPH; Keiji Oda, MA, MPH; Emilio Ros, MD, PhD. Nut Consumption and Blood Lipid Levels: A Pooled Analysis of 25 Intervention Trials. Archives of Internal Medicine, 2010, Vol. 170 No. 9, pp 821-827. Abstract:

Background  Epidemiological studies have consistently associated nut consumption with reduced risk for coronary heart disease. Subsequently, many dietary intervention trials investigated the effects of nut consumption on blood lipid levels. The objectives of this study were to estimate the effects of nut consumption on blood lipid levels and to examine whether different factors modify the effects.

Methods:  We pooled individual primary data from 25 nut consumption trials conducted in 7 countries among 583 men and women with normolipidemia and hypercholesterolemia who were not taking lipid-lowering medications. In a pooled analysis, we used mixed linear models to assess the effects of nut consumption and the potential interactions.

Results:  With a mean daily consumption of 67 g of nuts [about 2 ounces or 2 palms-ful], the following estimated mean reductions were achieved: total cholesterol concentration (10.9 mg/dL [5.1% change]), low-density lipoprotein cholesterol concentration (LDL-C) (10.2 mg/dL [7.4% change]), ratio of LDL-C to high-density lipoprotein cholesterol concentration (HDL-C) (0.22 [8.3% change]), and ratio of total cholesterol concentration to HDL-C (0.24 [5.6% change]) (P < .001 for all) (to convert all cholesterol concentrations to millimoles per liter, multiply by 0.0259). Triglyceride levels were reduced by 20.6 mg/dL (10.2%) in subjects with blood triglyceride levels of at least 150 mg/dL (P < .05) but not in those with lower levels (to convert triglyceride level to millimoles per liter, multiply by 0.0113). The effects of nut consumption were dose related, and different types of nuts had similar effects on blood lipid levels. The effects of nut consumption were significantly modified by LDL-C, body mass index, and diet type: the lipid-lowering effects of nut consumption were greatest among subjects with high baseline LDL-C and with low body mass index and among those consuming Western diets.

Conclusion:  Nut consumption improves blood lipid levels in a dose-related manner, particularly among subjects with higher LDL-C or with lower BMI.

Exercise and the PWD (Person With Diabetes)

hypoglycemia, woman, rock-climbing

Hypoglycemia now would be a tad inconvenient

People with diabetes may have specific issues that need to be taken into account when exercising.

DIABETIC RETINOPATHY

Retinopathy, an eye disease caused by diabetes, increases risk of retinal detachment and bleeding into the eyeball called vitreous hemorrhage. These can cause blindness. Vigorous aerobic or resistance training may increase the odds of these serious eye complications. Patients with retinopathy may not be able to safely participate. If you have any degree of retinopathy, avoid the straining and breath-holding that is so often done during weightlifting or other forms of resistance exercise. Vigorous aerobic exercise may also pose a risk. By all means, check with your ophthalmologist first. You don’t want to experiment with your eyes.

DIABETIC FEET AND PERIPHERAL NEUROPATHY

Diabetics are prone to foot ulcers, infections, and ingrown toenails, especially if peripheral neuropathy (numbness or loss of sensation) is present. Proper foot care, including frequent inspection, is more important than usual if a diabetic exercises with her feet. Daily inspection should include the soles and in-between the toes, looking for blisters, redness, calluses, cracks, scrapes, or breaks in the skin. See your physician or podiatrist for any abnormalities. Proper footwear is important (for example, don’t crowd your toes). Dry feet should be treated with a moisturizer regularly. In cases of severe peripheral neuropathy, non-weight-bearing exercise (e.g., swimming or cycling) may be preferable. Discuss with your physician or podiatrist.

HYPOGLYCEMIA

Low blood sugars are a risk during exercise if you take diabetic medications in the following classes: insulins, sulfonylureas, meglitinides, and possibly thiazolidinediones and bromocriptine.

Hypoglycemia is very uncommon with thiazolidinediones. Bromocriptine is so new (for diabetes) that we have little experience with it; hypoglycemia is probably rare or non-existent. Diabetics treated with diet alone or other medications rarely have trouble with hypoglycemia during exercise.

Always check your blood sugar before an exercise session if you are at risk for hypoglycemia. Always have glucose tablets, such as Dextrotabs, available if you are at risk for hypoglycemia. Hold off on your exercise if your blood sugar is over 200 mg/dl (11.1 mmol/l) and you don’t feel well, because exercise has the potential to raise blood sugar even further early in the course of an exercise session.

As an exercise session continues, active muscles may soak up bloodstream glucose as an energy source, leaving less circulating glucose available for other tissues such as your brain. Vigorous exercise can reduce blood sugar levels below 60 mg/dl (3.33 mmol/l), although it’s rarely a problem in non-diabetics.

The degree of glucose removal from the bloodstream by exercising muscles depends on how much muscle is working, and how hard. Vigorous exercise by several large muscles will remove more glucose. Compare a long rowing race to a slow stroll around in the neighborhood. The rower is strenuously using large muscles in the legs, arms, and back. The rower will pull much more glucose out of circulation. Of course, other metabolic processes are working to put more glucose into circulation as exercising muscles remove it. Carbohydrate consumption and diabetic medications are going to affect this balance one way or the other.

If you are at risk for hypoglycemia, check your blood sugar before your exercise session. If under 90 mg/dl (5.0 mmol/l), eat a meal or chew some glucose tablets to prevent exercise-induced hypoglycemia. Re-test your blood sugar 30–60 minutes later, before you exercise, to be sure it’s over 90 mg/dl (5.0 mmol/l). The peak effect of the glucose tablets will be 30–60 minutes later. If the exercise session is long or strenuous, you may need to chew glucose tablets every 15–30 minutes. If you don’t have glucose tablets, keep a carbohydrate source with you or nearby in case you develop hypoglycemia during exercise.

Re-check your blood sugar 30–60 minutes after exercise since it may tend to go too low.

If you are at risk of hypoglycemia and performing moderately vigorous or strenuous exercise, you may need to check your blood sugar every 15–30 minutes during exercise sessions until you have established a predictable pattern. Reduce the frequency once you’re convinced that hypoglycemia won’t occur. Return to frequent blood sugar checks when your diet or exercise routine changes.

These general guidelines don’t apply across the board to each and every diabetic. Our metabolisms are all different. The best way to see what effect diet and exercise will have on your glucose levels is to monitor them with your home glucose measuring device, especially if you are new to exercise or you work out vigorously. You can pause during your exercise routine and check a glucose level, particularly if you don’t feel well. Carbohydrate or calorie restriction combined with a moderately strenuous or vigorous exercise program may necessitate a 50 percent or more reduction in your insulin, sulfonylurea, or meglitinide. Or the dosage may need to be reduced only on days of heavy workouts. Again, enlist the help of your personal physician, dietitian, diabetes nurse educator, and home glucose monitor.

Finally, insulin users should be aware that insulin injected over muscles that are about to be exercised may get faster absorption into the bloodstream. Blood sugar may then fall rapidly and too low. For example, injecting into the thigh and then going for a run may cause a more pronounced insulin effect compared to injection into the abdomen or arm.

medical clearance, treadmill stress test

This treadmill stress test is looking for hidden heart disease

AUTONOMIC NEUROPATHY

This issue is pretty technical and pertains to function of automatic, unconscious body functions controlled by nerves. These reflexes can be abnormal, particularly in someone who’s had diabetes for many years, and are called autonomic neuropathy. Take your heart rate, for example. It’s there all the time, you don’t have to think about it. If you run to catch a bus or climb two flights of stairs, your heart rate increases automatically to supply more blood to exercising muscles. If that automatic reflex doesn’t work properly, exercise is more dangerous, possibly leading to passing out, dizziness, and poor exercise tolerance. Other automatic nerve systems control our body temperature regulation (exercise may overheat you), stomach emptying (your blood sugar may go too low), and blood pressure (it could drop too low). Only your doctor can tell for sure if you have autonomic neuropathy.

Steve Parker, M.D.

Do High Insulin Levels Cause Memory Loss and Dementia?

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

Don’t wait to take action until it’s too late

Insulin resistance and high blood insulin levels promote age-related degeneration of the brain, leading to memory loss and dementia according to Robert Krikorian, Ph.D. He’s a professor in the Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati Academic Health Center.  He has an article in a recent issue of Current Psychiatry – Online.

Proper insulin signaling in the brain is important for healthy functioning of our brains’ memory centers.  This signaling breaks down in the setting of insulin resistance and the associated high insulin levels.  Dr. Krikorian makes much of the fact that high insulin levels and insulin resistance are closely tied to obesity.  He writes that:

Waist circumference of ≥100 cm (39 inches) is a sensitive, specific, and independent predictor of hyperinsulinemia for men and women and a stronger predictor than body mass index, waist-to-hip ratio, and other measures of body fat.

Take-Home Points

Dr. Krikorian thinks that dietary approaches to the prevention of dementia are effective yet underutilized.  He mentions reduction of insulin levels by restricting calories or a ketogenic diet: they’ve been linked with improved memory in middle-aged and older adults. His theory is also consistent with the commonly seen association of type 2 diabetes with dementia: overweight and obese type 2’s quite often have high insulin levels, at least in the early years.

Dr. K suggests the following measures to prevent dementia and memory loss:

  • eliminate high-glycemic foods like processed carbohydrates and sweets
  • replace high-glycemic foods with fruits and vegetables (the higher polyphenol intake may help by itself)
  • certain polyphenols, such as those found in berries, may be particularly helpful in improving brain metabolic function
  • keep your waist size under 39 inches (99 cm), or aim for that if you’re higher and overweight

Nearly all popular versions of the paleo diet would qualify as being low glycemic index.

I must mention that many dementia experts, probably most, are not as confident  as Dr. Krikorian that these dietary changes are effective.  I think they are, to a degree.

The Mediterranean diet is high in fruits and vegetables and relatively low-glycemic.  It’s usually mentioned by experts as the diet that may prevent dementia and slow its progression.

Read the full article.

I’ve written before about how blood sugars in the upper normal range are linked to brain degeneration.  Dr. Krikorian’s recommendations would tend to keep blood sugar levels in the lower end of the normal range.

Steve Parker, M.D.

PS: Speaking of dementia and ketogenic, have you ever heard of the Ketogenic Mediterranean Diet?  (Free condensed version here.)

Long-Term Maintenance for People With Diabetes

Contemplative Senior ManAs a diabetic or prediabetic trying to get and stay healthy, you need at least two other players on your healthcare team: a physician and a registered dietitian. Additionally, diabetes nurse educators can be quite helpful in teaching you to manage your condition. Other care team members may include physician assistants, nurse practitioners, pharmacists, and nutritionists.

Dietitians are particularly helpful consultants when diabetes is first diagnosed and periodically thereafter to answer food questions, check on compliance with diet recommendations, and to review new dietary guidelines. Unfortunately, a majority of dietitians still believe the out-dated idea that high-carbohydate eating is healthy for diabetics and others who have demonstrable difficulty processing carbs. Be sure the dietitian you choose supports a carbohydrate-restricted and paleo-friendly way of eating.

Many primary care physicians such as family physicians and internists are well-trained to co-manage diabetes with you. I chose the word “co-manage” carefully. It’s not like you have appendicitis and can turn over all management to a surgeon. With diabetes, you have to do more work than your physician. Your doctor will review your home glucose records, adjust medications, periodically examine you, and check blood work. You need a doctor who will support, or at least tolerate, your low-carb paleo way of eating.

An endocrinologist can be an invaluable team member, either as your main treating physician or as a consultant to your primary care physician. You should definitely see one if you are not close to the standard treatment goals after working with your primary care physician.

PERIODIC TESTS, TREATMENTS, AND GOALS

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with type 2 diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.) ADA guidelines with supporting documentation are available free on the Internet (search for “Standards of Medical Care in Diabetes—2013”):

  • Lipid profile (every two years if results are fine and stable)
  • Comprehensive foot exam
  • Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense
  • Serum creatinine and estimate of glomerular filtration rate
  • Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
  • Comprehensive eye exam by an ophthalmologist (if exam is normal, every two or three years is acceptable)
  • Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
  • Flu shots

Additionally, the ADA guidelines recommend:

  • Pneumococcal vaccination. “A one time re-vaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
  • Weight loss for all overweight diabetics. “For weight loss, either low-carbohydrate [under 130 g/day], low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).” For those on low-carb diets, monitor lipids, kidney function, and protein consumption, and adjust diabetic drugs as needed. “The optimal macronutrient composition of weight loss diets has not been established.” (Macronutrients are carbohydrates, proteins, and fats.)
  • Limit alcohol to one (women) or two (men) drinks a day.
  • Limit saturated fat to less than seven percent of calories.
  • During initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
  • In the early stages of diabetic chronic kidney disease, reduce protein intake to 0.8-1.0 grams per kilogram of body weight. In later stages, reduce to 0.8 grams per kilogram of body weight.
  • Those at risk for diabetes, including prediabetics, should aim for a) moderate weight loss (about seven percent of body weight) if overweight, through low-fat/reduced-calorie eating, b) exercise: 150 minutes per week of moderate-intensity aerobic activity.

Some of my dietary recommendations you’ve read on my blogs conflict with ADA guidelines. The experts assembled by the ADA to compose guidelines were well-intentioned, intelligent, and hard-working. The guidelines are supported by over 350 scientific journal references. I greatly appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

GENERAL TREATMENT GOALS

The ADA suggests general therapeutic goals for adult non-pregnant type 2 diabetics:

  • Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
  • Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
  • Hemoglobin A1C: under 7%
  • Blood pressure: under 130/80 mmHg
  • LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular disease: <70 mg/dl or 1.8 mmol/l.)
  • HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
  • Triglycerides: under 150 mg/dl (1.7 mmol/l)

The American Association of Clinical Endocrinologists (AACE) in 2007 proposed somewhat “tighter” goals:

  • Fasting blood glucoses: under 110 mg/dl (6.11 mmol/l)
  • Peak glucoses 2 hours after start of meals: under 140 mg/dl (7.78 mmol/l)
  • Hemoglobin A1C: under 6.5%

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely. For instance, there’s not much reason to aim for blood sugars of 100 mg/dl (5.56 mmol/l) in a 79-year-old expected to die of lung cancer in four months. The goal is comfort and symptom relief, even if sugars are 220 mg/dl (12.2 mmol/l).

Admittedly, the aforementioned goals are difficult for many diabetics to achieve, but they are worth your effort in terms of avoiding long-term complications of diabetes. You will need to see your doctor every three to six months, and more often if your glucoses are not well-controlled or you have other medical issues.

Steve Parker, M.D.

Diabetic Hypoglycemia and the Paleo Diet: Recognition and Management

Healthy non-diabetics making the switch to the paleo diet rarely, if ever, experience hypoglycemia.  That’s not true for diabetics, especially if they’re on certain medications.

hypoglycemia, woman, rock-climbing

Hypoglycemia now would be a tad inconvenient

Hypoglycemia means an abnormally low blood sugar (under 60–70 mg/dl or 3.33–3.89 mmol/l) associated with symptoms such as weakness, malaise, anxiety, irritability, shaking, sweating, hunger, fast heart rate, blurry vision, difficulty concentrating, or dizziness. Symptoms often start suddenly and without obvious explanation. If not recognized and treated, hypoglycemia can lead to incoordination, altered mental status (fuzzy thinking, disorientation, confusion, odd behavior, lethargy), loss of consciousness, seizures, and even death (rare).

You can imagine the consequences if you develop fuzzy thinking or lose consciousness while driving a car, operating dangerous machinery, or scuba diving.

Do not assume your sugar is low every time you feel a little hungry, weak, or anxious. Use your home glucose monitor for confirmation when able.

Why Would the Paleo Diet Cause Hypoglycemia?

Carbohydrates are the the primary source of blood glucose (blood sugar).  Paleo diets typically derive anywhere from 20 to 40% of total calories from carbohydrate, with 30% being about average.  This compares with 50-60% of calories coming from carbs in the usual American diet.  Additionally, the overall glycemic index of paleo diet carbs is likely to be lower than an average American diet since there are no refined starches and sugars.  A lower glycemic index tends to limit blood sugar spikes in response to a meal.  So any diabetic switching to a paleo diet could see significant drops in blood sugar,  including hypoglycemia.

How Is Hypoglycemia Treated?

If you have diabetes, your personal physician and other healthcare team members should teach you how to recognize and manage hypoglycemia. Immediate early stage treatment involves ingestion of glucose as the preferred treatment—15 to 20 grams. You can get glucose tablets or paste at your local pharmacy without a prescription. Other carbohydrates will also work: six fl oz (180 ml) sweetened fruit juice, 12 fl oz (360 ml) milk, four tsp (20 ml) table sugar mixed in water, four fl oz (120 ml) soda pop, candy, etc. Fifteen to 30 grams of glucose or other carbohydrate should do the trick. Hypoglycemic symptoms respond within 20 minutes.

hypoglycemia, candy

Lady, fruit juice would raise your blood sugar much quicker

If level of consciousness is diminished such that the person cannot safely swallow, he’ll need a glucagon injection. Non-medical people can be trained to give the injection under the skin or into a muscle. Ask your doctor if you’re at risk for severe hypoglycemia. If so, ask him for a prescription so you can get an emergency glucagon kit from a pharmacy.

Hypoglycemia Unawareness

Some people with diabetes, particularly after having the condition for many years, lose the ability to detect hypoglycemia just by the way they feel. This “hypoglycemia unawareness” is obviously more dangerous than being able to detect and treat hypoglycemia early on. Blood sugar levels may continue to fall and reach a life-threatening degree. Hypoglycemia unawareness can be caused by impairment of the nervous system (autonomic neuropathy) or by beta blocker drugs prescribed for high blood pressure or heart disease. People with hypoglycemia unawareness need to check blood sugars more frequently, particularly if driving a car or operating dangerous machinery.

OK, the Acute Crisis Is Over — What Next?

If you do experience hypoglycemia, discuss management options with your doctor: downward medication adjustment, shifting meal quantities or times, adjustment of exercise routine, eating more carbohydrates, etc. If you’re trying to lose weight or control high blood sugars, reducing certain diabetic drugs makes more sense than eating more carbs. Eating at regular intervals three or four times daily may help prevent hypoglycemia. Spreading carbohydrate consumption evenly throughout the day may help. Someone most active during daylight hours as opposed to nighttime will generally do better eating carbs at breakfast and lunch rather than concentrating them at bedtime.

DRUG  ADJUSTMENTS  TO  AVOID  HYPOGLYCEMIA

Hypoglycemia is a great risk for diabetics taking certain diabetic drugs while on a low-carb paleo diet. This is dangerous territory.

Remember, drugs have both generic and brand names. The names vary from country to country, as well as by manufacturer. You’ve got to know what class of drug you’re taking.  If you have any doubt about whether your diabetic drug has the potential to cause hypoglycemia, ask your physician or pharmacist.

hypoglycemia, fruit juice, orange juice

That’s the ticket

DRUGS THAT CAUSE HYPOGLYCEMIA

Regardless of diet, diabetics are at risk for hypoglycemia if they use the following drug classes. Also listed are a few of the individual drugs in some classes:

  • insulin
  • sulfonylureas: glipizide, glyburide, glimiperide, chlorpropamide, acetohexamide, tolbutamide
  • meglitinides: repaglinide, nateglinide
  • pramlintide plus insulin
  • exenatide plus sulfonylurea
  • possibly thiazolidinediones: pioglitazone, rosiglitazone
  • possibly bromocriptine

DRUGS THAT RARELY, IF EVER, CAUSE HYPOGLYCEMIA

Diabetics not being treated with pills or insulin rarely need to worry about hypoglycemia.  That’s true also for prediabetics.

Similarly, diabetics treated only with diet, metformin, colesevalam, and/or an alpha-glucosidase inhibitor (acarbose, miglitol) should not have much, if any, trouble with hypoglycemia. The DPP4-inhibitors (sitagliptan and saxagliptin) do not seem to cause low glucose levels, whether used alone or combined with metformin or a thiazoladinedione.

Thiazolidinediones by themselves cause hypoglycemia in only 1 to 3% of users, but might cause a higher percentage in people on a reduced calorie diet. Bromocriptine may slightly increase the risk of hypoglycemia.

DRUG ADJUSTMENTS TO AVOID HYPOGLYCEMIA

Diabetics considering or following a carbohydrate-restricted diet must work closely with their personal physician, dietitian, or certified diabetes educator, especially to avoid hypoglycemia caused by the aforementioned classes of diabetic drugs.

Clinical experience with thousands of patients has led to generally accepted guidelines that help avoid hypoglycemia in diabetics on medications.

Common strategies for diabetics on hypoglycemia-inducing drugs and starting a low-carb diet include:

  • reduce the insulin dose by a quarter or half
  • change short-acting insulin to long-acting (such as glargine)
  • stop the sulfonylurea, or reduce dose by a quarter or half
  • reduce the thiazolidinedione by up to a half
  • stop the meglitinide, or reduce the dose by up to a half
  • monitor blood sugars frequently, such as four times daily, at least until a stable pattern is established
  • spread carbohydrate consumption evenly throughout the day

Management also includes frequent monitoring of glucose levels with a home glucose monitor, often four to six times daily. Common measurement times are before meals and at bedtime. It may be helpful to occasionally wake at 3 AM and check a sugar level. To see the effect of a particular food or meal on glucose level, check it one or two hours after eating. Keep a record. When eating patterns are stable, and blood sugar levels are reasonable and stable, monitoring can be done less often. When food consumption or exercise habits change significantly, check sugar levels more often.

No One Cares About Your Health As Much As You

I recommend you become the expert on the diabetic drugs you take. Don’t depend solely on your physician. Do research at reliable sources and keep written notes. With a little effort, you could quickly surpass your doctor’s knowledge of your specific drugs. What are the side effects? How common are they? How soon do they work? Any interactions with other drugs? What’s the right dose, and how often can it be changed? Do you need blood tests to monitor for toxicity? How often? Who absolutely should not take this drug? Along with everything else your doctor has to keep up with, he prescribes about a hundred drugs on a regular basis. You only have to learn about two or three. It could save your life.

If you’re thinking that many diabetics on low-carb diets use fewer diabetic medications, you’re right. That’s probably a good thing since the long-term side effects of many of the drugs we use are unknown. Remember Rezulin (troglitazone)? Introduced in 1997, it was pulled off the U.S. market in 2001 because of fatal liver toxicity.  In 2010, rosiglitazone was heavily restricted in the U.S. out of concern for heart toxicity.

Steve Parker, M.D.

It’s the Best Time Ever to Have Diabetes

Here’s a quote from a recent Diabetes Care:

Improved therapeutics and health care delivery have brought remarkable declines in the incidence of … complications, with a 50% reduction in amputations from their peak in 1997 and ∼35% reduction in the incidence of end-stage renal disease. Similarly, 10-year coronary heart disease risk dropped from 21% in 2000 to 16% in 2008.

Left, right, or straight ahead (the road less travelled)?

Left, right, or straight ahead (the road less travelled)?

Nevertheless, diabetes remains the leading cause of blindness, renal failure, non-traumatic lower-limb amputation, in adults 18 to 65 years of age.

Diabetes is expensive, too.   We spent $174 billion (USD) on diabetes in 2007 in the U.S.

The companion essay by Dr. Robert Ratner also notes 79 million Americans with prediabetes.

In addition to lower rates of major diabetes complications, we now have 11 classes of drugs for treating diabetes, compared with just three or four a generation ago.

I’m hopeful that future research will point to dietary changes that can help control or prevent diabetes on a wide scale.  The paleo diet and low-carb eating are two possible avenues.

—Steve

Diabetic Life Expectancy

Exercise helps postpone death

Exercise helps postpone death

Type 1 diabetics diagnosed in childhood and born between 1965 and 1980 have an average life expectancy of 68.8 years.  That compares to a lifespan average of 53.4 years for those born earlier, between 1950 and 1964.  The figures are based on Pittsburgh, PA, residents and published in a recent issue of Diabetes.

Elizabeth Hughes, one of the very first users of insulin injections, lived to be 73.  She started on insulin around 1922.

Average overall life expectancy in the U.S. is 78.2 years—roughly 76 for men and 81 for women.

Don’t be too discouraged if you have diabetes: you have roughly a 50:50 chance of beating the averages, and medical advances will continue to lengthen lifespan.

Steve Parker, M.D.

Type 2 Diabetes: Scope of the Problem

97 mg/dl. Yippee!

Type 2 diabetes is the most important public health problem in the U.S. and most of the developed world. The U.S. Centers for Disease Control and Prevention predicts that one of every three Americans born in the year 2000 will develop diabetes.

The most common form of diabetes by far is type 2, which describes at least 85% of cases. It’s less serious than type 1 diabetes. Type 1 diabetics have an immune system abnormality that destroys the pancreas’s ability to make insulin. Type 1’s will not last long without insulin injections. On the other hand, many type 2 diabetics live well without insulin shots.

The epidemic of diabetes in the U.S. and the developed world overwhelmingly involves type 2, not type 1.

“Prediabetes” is what you’d expect: a precursor that may become full-blown type 2 diabetes over time. Blood sugar levels are above average, but not yet into the diabetic range. One in four people with prediabetes develops type 2 diabetes over the course of three to five years. Researchers estimate that 35% of the adult U.S. population had prediabetes in 2008. That’s one out of every three adults, or 79 million. Only 7% of them (less than one in 10) were aware they had it.

In the U.S. as of 2010, 26 million folks have diabetes. That includes 11% of all adults.

The rise of diabetes parallels the increase in overweight and obesity, which in turn mirrors the prominence of refined sugars and starches throughout our food supply. These trends are intimately related. Public health authorities 40 years ago convinced us to cut down our fat consumption in a mistaken effort to help our hearts. We replaced fats with body-fattening carbohydrates that test the limits of our pancreas to handle them. Diabetics and prediabetics fail that test.

Dr. Richard K. Bernstein, notable diabetologist, wrote that, “Americans are fat largely because of sugar, starches, and other high-carbohydrate foods.”

We’re even starting to see type 2 diabetes in children, which was quite rare just thirty years ago. It’s undoubtedly related to overweight and obesity. Childhood obesity in the U.S. tripled from the early 1980s to 2000, ending with a 17% obesity rate.  Overweight and obesity together describe 32% of U.S. children.

Diabetes is important because it has the potential to damage many different organ systems, deteriorating quality of life. It can damage nerves (neuropathy), eyes (retinopathy), kidneys (nephropathy),  and stomach function (gastroparesis), just to name a few.

Just as important, diabetes can cut life short. Compared to those who are free of diabetes, having diabetes at age 50 more than doubles the risk of developing cardiovascular disease—heart attacks, strokes, and high blood pressure. Compared to those without diabetes, having both cardiovascular disease and diabetes approximately doubles the risk of dying. Compared to those without diabetes, women and men with diabetes at age 50 die seven or eight years earlier, on average.

Diabetic complications and survival rates will improve over the coming decades as we learn how to better treat this ancient disease.

Steve Parker, M.D.

Annual Hospital Care Cost of Diabetes in U.S. Is $83 Billion (USD)

“Let’s hope this thiazolidinedione doesn’t give you bladder cancer.”

At least according to the Agency for Healthcare Research and Quality.

-Steve

PS: The article above says diabetes is the fifth leading cause of death in the U.S.  Not so, according to the Centers for Disease Control and Prevention, which lists diabetes in seventh place.  I suspect it’s not even as high as that.  I fill out my share of death certificates, and I rarely list diabetes as the primary cause of death.

Aggressive Blood Sugar Control Prevents or Delays Neuropathy in Type 1 Diabetes

I couldn’t find a “neuropathy” picture so enjoy this

Aggressive efforts to control blood sugar either prevent or delay clinical neuropathy in patients with type 1 diabetes, according to the Cochrane Collaboraton as reported in MedPage Today.  Type 2 diabetics showed a strong trend in the same direction, but did not quite reach statistical significance (p=0.06, which is darn close to significant).  Be aware, however, that tight control of diabetes is often at the cost of more frequent episodes of hypoglycemia.

Intensive blood sugar control is also a treatment for established neuropathy.

One in ten diabetics has neuropathy at the time of diagnosis.  After 10 years, four or five of every 10 have it.  The pain of neuropathy is worse than the numbness.

The medical community is still debating how aggressively blood sugars should be managed.

Steve Parker, M.D.

PS: I don’t know what the Cochrane reviewers consider “tight control” because the article is behind a paywall, and the MedPage Today article didn’t address that either.

Reference: Callaghan BC, et al “Enhanced glucose control for preventing and treating diabetic neuropathy” Cochrane Database Syst Rev 2012; DOI:10.1002/14651858.CD007543.pub2.