Physician Organizations Fight Over How Aggressively to Treat Diabetes

If you’re a patient, you probably don’t like to hear this. You like to think that doctors have looked carefully at the appropriate scientific studies, understand  the underlying pathophysiology in detail, then reach a consensus on treatment. Sorry, but not in the case of diabetes. NPR has the story. For example:

A major medical association today suggested that doctors who treat people with Type 2 diabetes can set less aggressive blood sugar targets. But medical groups that specialize in diabetes sharply disagree.

Half a dozen medical groups have looked carefully at the best treatment guidelines for the 29 million Americans who have Type 2 diabetes and have come up with somewhat differing guidelines.

The American College of Physicians has reviewed those guidelines to provide its own recommendations, published in the Annals of Internal Medicine. It has decided that less stringent goals are appropriate for the key blood sugar test, called the A1C.

“There are harms associated with overzealous treatment or inappropriate treatment focused on A1C targets,” says Dr. Jack Ende, president of the ACP. “And for that reason, this is not the kind of situation where the college could just sit back and ignore things.”

The ACP, which represents internists, recommends that doctors aim for an A1C in the range of 7 to 8 percent, not the lower levels that other groups recommend.

Source: The American College of Physicians Recommends A1C Levels Between 7 And 8 Percent : Shots – Health News : NPR

I come down in favor of the lower HgbA1c values.

Even short bursts of exercise can reduce risk of disease and death

Steve Parker MD

Bouts of 5 minutes may be enough

From ABC News:

The old benchmark of 150 minutes per week of moderate activity (or 75 minutes of vigorous activity) originated in 1995. The “rules”: Each time you exercise, it should be for at least 10 minutes.

“For about 30 years, guidelines have suggested that moderate-to-vigorous activity could provide health benefits, but only if you sustained the activity for 10 minutes or more,” an author of the research, William E. Kraus, M.D., of the Duke University School of Medicine, said in a press release. “That flies in the face of public health recommendations, like taking the stairs instead of the elevator, and parking farther from your destination. Those don’t take 10 minutes, so why were they recommended?

“The new study finds that the length of each bout or episode of exercise is unrelated to the benefit seen in living longer. Five minutes of jogging, researchers said, “counts” toward better health.

Source: Even short bursts of exercise can reduce Americans’ risk of disease and death, study says – ABC News

Do You Know Anything About Nutritics?

I’m thinking about using Nutritics for my nutrient analysis, rather than some of the free options like SparkPeople or FitDay. NutritionData still seems to be very popular, too, but they don’t keep up with new versions of the USDA database (currently on Release 28). The fine print at NutritionData shows they use Release 21. FitDay doesn’t say.

I looked up two cups of broccoli florets at FitDay and NutritionData, and was surprised to see zero grams of fiber. How could that be correct? Nutritics shows 3.3 grams, as does the USDA Nutrient Database. I believe Nutritics and USDA on this one. The free nutrient analysis tools you find on the internet all use some version of the USDA database as far as I know.

Click the link below to see Nutritics’ report.

https://www.nutritics.com/app/rec/4b82cb50b2

In that report you’ll see “%RI”, which I assume is short for  percentage of Dietary Reference Intake. The National Health Institutes defines DRI or Dietary Reference Intake:

DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and gender, include:

  • Recommended Dietary Allowance (RDA): average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%-98%) healthy people.

  • Adequate Intake (AI): established when evidence is insufficient to develop an RDA and is set at a level assumed to ensure nutritional adequacy.

  • Tolerable Upper Intake Level (UL): maximum daily intake unlikely to cause adverse health effects.

So what does Nutritics mean by %RI? I don’t know yet.

And by the way, Nutritics isn’t free like the other sources I mentioned above.

Any comments on Nutritics, or your source for nutritional analysis?

Steve Parker, M.D.

Which Foods Cause Obesity?

At my Advanced Mediterranean Diet website a few years ago I asked visitors to answer a poll question. 2,367 responded thusly:

What single food category makes you gain the most fat weight?

Fatty foods like bacon, butter, oils, nuts:
5%
Protein-rich foods: meat, eggs, fish:
0%
Sugary sweet items:
23%
Starches: bread, potatoes, peas, corn:
16%
Carbohydrates:
30%
Pastries, cake, pie, cookies:
25%
Other:
1%

Total Votes: 2367

Yes, I know it’s not a scientific poll, but it’s something. I’m not surprised at the results. I’m wishing I’d offered nuts as a choice since there are at least a few folks who gain weight on nuts, perhaps not realizing that nut calories are mostly from fat. To participate in the poll, click the link above.

Steve Parker, M.D.

Book Review: “Fit With Diabetes” by Christel Oerum

Front cover

Ginger Vieira introduced me recently to Christel Oerum via email. I was pleased to hear about Christel’s brand new e-book, “Fit With Diabetes.”

*  *  *

Physical fitness is a major determinant of longevity. It’s truly our only fountain of youth, and it’s available to most everybody. The only way to get and stay physically fit is through regular exercise. Some studies document shorter life spans for PWDs (persons with diabetes). So it’s particularly important for them to maintain a good level of fitness.

I like this e-book and highly recommend it to adults taking insulin for diabetes who need a great physical activity program but don’t know how to go about it. Use of insulin, whether in type 1 or 2 diabetes, significantly complicates exercise due to sometimes mysterious effects on blood sugar. Christel de-mystifies the issue in a clear and science-based manner.

The most dangerous interaction between insulin and exercise is hypoglycemia, although the opposite can be a problem, too. Much of the book is about avoiding dramatic swings in blood sugar, particularly hypoglycemia. Christel teaches the reader how to balance insulin, food, and exercise to keep sugars on an even keel. Aerobic exercise tends to cause hypoglycemia, whereas anaerobic exercise tends to cause high sugar spikes. But your own reaction may be a little different, if not a lot. As you might imagine, monitoring and record-keeping are critical, and Christel shares her own downloadable log.

Trust me, most primary care physicians and many endocrinologists are not going to be much help in the exercise advice department. I only remember one thing my first-ever accountant told me 30 years ago: “No one cares about your money as much as you do.” Likewise, no one cares about your health as much as you do. You’ll have to become your own expert.

The author is like a trusted old friend who’s “been there, done that,” and is sharing freely with you.

Christel has had type 1 diabetes for 21 years and is a diabetes coach. She’s been an avid exerciser since 2010. At that time there were very few resources that addressed vigorous exercise in the setting of T1 diabetes. Learn from her clients’ experience and her own N=1 experimentation so you don’t have to make the same trial-and-error mistakes.

The author works out five days a week. That doesn’t mean you have to. I suspect you can achieve 80–90% of the maximal longevity and other health benefits with just three days a week, maybe two. (Note: I am contradicting several authoritative medical panels!) If you’re sedentary now, two or three days a week should definitely improve your fitness. But you have to exercise right.

Early on, the author talks about how to get motivated for exercise. I like her SMART goal setting-checklist: Goals must be Specific, Measurable, Achievable, Relevant, and Time-bound.

She recommends a combination of aerobic exercise (“cardio”) and weight training. (I wouldn’t be surprised if we find out one day that the right weight-training program alone is good enough.) Christel tells exactly how to get started and maintain both types of exercise. She outlines both home-based and gym-based training programs.

Dietary calories for adults in the U.S. come 16% from protein, 48% from carbohydrates, and 34% from fats. Alternatively, the author recommends dietary calories come 40% from protein, 30% from carbohydrates, and 30% from fats. So 150 carb grams/day if eating 2000 calories, limiting meal carbs to 30 grams. I wonder if most folks will end up closer to 30% protein and 40% fat, especially for those not doing as much exercise as Christel. (Protein is important for muscle building and maintenance.) Many of my patients do well with additional carbohydrate restriction, but most don’t exercise as much as Christel despite my encouragement.

You can easily track your macronutrients and calories at MyFitnessPal.com.

The author shares some recipes and tells you how to get started on the all-important meal-planning and coming up with your own recipes. There’s even a helpful and realistic chapter on loss of excess weight.

As a reviewer, I always feel like I have to pick a few nits, so here it is. Christel says cardio exercise is great for losing weight. That probably true if you’re competing for $250,000 on TV’s Biggest Loser show. But usually exercise contributes at most 10% to a successful weight-loss program. Diet’s is critical. Exercise does help with prevention of weight regain and has many other benefits.

Again, I like this e-book and highly recommend it to adults taking insulin for diabetes who need a great physical activity program but don’t know how to go about it. Get the e-book here.

Of course, get the blessings of your personal healthcare provider before making any changes to your diet, exercise program, or medications.

Steve Parker, M.D.

PS: Disclosure: Christel kindly gave me a copy of the e-book. Otherwise there was not, and will not be, any remuneration for this review.

 

Why Are We in the U.S. Fat?

Your average Americans

There’s no shortage of speculation as to why 70% of us in the U.S. are overweight or obese. A few possibilities include:

  • we’re too sedentary
  • we eat too many carbohydrates
  • we eat too much fat
  • our foods are over-processed
  • we eat away from home too often
  • we eat too many industrial seed oils
  • our water and food are contaminated with persistent organic pollutants that disrupt our endocrine systems

I was reading an article at Nutrition Today and came across this graph of calorie consumption change from 1971 to 2004 (or 2000?):

A verbal summary is from this article cited by the the Nutrition Today authors: “During 1971—2000, a statistically significant increase in average energy intake occurred. For men, average energy intake increased from 2,450 kcals to 2,618 kcals, and for women, from 1,542 kcals to 1,877 kcals.”

So men’s daily calorie intake went up by 168, and women’s by 335.

The original article I read states, alternatively, that men’s daily caloric consumption rose from 2450 to 2693, a gain of 243. I can’t explain the discrepancy between 243 and 168, nor why 2004 is in the graph instead of 2000.

Maybe you don’t think an extra 168 calories a day is much. If you believe in the validity of the Energy Balance Equation, those 168 daily calories will turn into  17.5 pounds of fat in a year unless you “burn them off” somehow. If you weigh 150 lb (68 kg), you can burn those 168 calories by doing a daily 15-minute jog at 5.5 mph (8.9 km/hr). But you ain’t gonna do that. (I’m not getting into a debate about validity of the equation now; for another perspective, read Lyle McDonald.)

But year 2000 was a long time ago. How much are Americans eating now? According to a 2016 report from Pew Research Center:

Broadly speaking, we eat a lot more than we used to: The average American consumed 2,481 calories a day in 2010, about 23% more than in 1970. That’s more than most adults need to maintain their current weight, according to the Mayo Clinic’s calorie calculator. (A 40-year-old man of average height and weight who’s moderately active, for instance, needs 2,400 calories; a 40-year-old woman with corresponding characteristics needs 1,850 calories.)

Bottom line? We’re eating more than we did in 1970. Which could explain why we’re fat. Unless we’re burning more calories than we did in 1970, which I doubt.

Steve Parker, M.D.

PS: In scientific literature, “kcal” is what everybody else calls a calorie.

PPS: Why we’re over-eating is a whole ‘nuther can o’ worms.

Book Review: P.D. Mangan’s “Best Supplements for Men”

Death in a bottle?

Best Supplements for Men: for more muscle, higher testosterone, longer life, and better looks was published in 2017 so should still be up to date. I have the paperback but it’s also available as a Kindle e-book. Per Amazon.com’s rating system, I give it five stars (I love it).

*  *  *

My favorite sentence in this book is, “If you don’t eat, exercise, and sleep right, the health effects of adding any supplement may be minimal to non-existent.” That sets an honest tone. Also in favor of integrity is that the author doesn’t offer Mangan-branded supplements for sale.

I like this book and learned a lot from it. I’ve benefited by reading the author’s tweets and blog (Rogue Health and Fitness) for several years. He’s smart and, I believe, honest.

The author supports his assertions with numerous scientific references, organized by chapter at the back of the book. If he cites a study done in mice, he tells you. Human studies admittedly carry more weight.

Have you wondered if protein supplements and creatine are good for muscle strength and energy? Does magnesium increase testosterone levels? Does berberine have beneficial health effects? The answers are here.

The author gives good advice regarding calcium supplements that even most physicians don’t know about.

Great recommendations on food.

No book is perfect, and this one is no different. It has no index. So if you’re curious about turmeric or supplements that control diabetes, you have to scan the whole book. My copy didn’t include references for chapter 11. Page numbers for chapters in the index didn’t match the actual chapter starts. My least favorite sentence in the book was something about Dr. Joseph Mercola being a trustworthy source of health information; he is not (search “mercola” at ScienceBasedMedicine.org).

Again, I like this book, learned much from it, and recommend it to men. If you’re taking lots of supplements now, read this book to find out if they help, harm, or are only good for making expensive urine.

Steve Parker, M.D.

PS: Some personal notes from my reading. Many of the cited studies are “association”-type evidence  rather causation. Berberine may help reduce blood sugars in diabetics just as well as metformin. Creatine: Yes, for muscle growth and strength. Magnesium 700 mg/day increases testosterone. Mag oxide may be worthless due to poor absorption. Mangan likes mag citrate but Lexicomp says it’s no better than oxide; absorption “up to 30%.” Citrulline: Yes, for ED, and may help with HTN. DHEA 50 mg/day increases testosterone in men by 50%, but only in men over 70. During fat weight loss, whey protein helps prevent muscle loss. MCT oil may also help (e.g., cook with coconut oil). ASA 81 mg/day seems to prevent some cancers in folks over 55, especially colorectal cancer.

Paleo Theory: The sedentary (r)evolution: Have we lost our metabolic flexibility?

Gotcha!

If you can’t easily go over four hours without eating something, you’ve lost your metabolic flexibility. Or something.

European authors in F1000Research (?!) suggest we consider our hunter-gatherer roots for clues to prevention of diseases of modern civilization. Here’s the abstract to whet your appetite:

During the course of evolution, up until the agricultural revolution, environmental fluctuations forced the human species to develop a flexible metabolism in order to adapt its energy needs to various climate, seasonal and vegetation conditions. Metabolic flexibility safeguarded human survival independent of food availability. In modern times, humans switched their primal lifestyle towards a constant availability of energy-dense, yet often nutrient-deficient, foods, persistent psycho-emotional stressors and a lack of exercise. As a result, humans progressively gain metabolic disorders, such as the metabolic syndrome, type 2 diabetes, non-alcoholic fatty liver disease, certain types of cancer, cardiovascular disease and Alzheimer´s disease, wherever the sedentary lifestyle spreads in the world. For more than 2.5 million years, our capability to store fat for times of food shortage was an outstanding survival advantage. Nowadays, the same survival strategy in a completely altered surrounding is responsible for a constant accumulation of body fat. In this article, we argue that the metabolic disease epidemic is largely based on a deficit in metabolic flexibility. We hypothesize that the modern energetic inflexibility, typically displayed by symptoms of neuroglycopenia, can be reversed by re-cultivating suppressed metabolic programs, which became obsolete in an affluent environment, particularly the ability to easily switch to ketone body and fat oxidation. In a simplified model, the basic metabolic programs of humans’ primal hunter-gatherer lifestyle are opposed to the current sedentary lifestyle. Those metabolic programs, which are chronically neglected in modern surroundings, are identified and conclusions for the prevention of chronic metabolic diseases are drawn.

Source: The sedentary (r)evolution: Have we lost our metabolic flexibility?

For Overweight Type 2 Diabetics on a Paleo Diet, What’s the Effect of Adding an Exercise Program?

You better have good cardiovascular fitness if battling this big guy

Swedish researchers wondered if adding an exercise program to the Paleo diet in overweight type 2 diabetics would improve blood sugars or insulin sensitivity. Surprisingly, it did not. Exercise did, however, improve cardiovascular fitness.

How Was the Research Done?

Study participants in northern Sweden had been diagnosed with diabetes within the last 8 years and were either taking metformin (about 2/3 of them) or were using lifestyle modification (primarily diet, I presume) to treat diabetes. Folks on additional diabetes drugs were excluded. Baseline BMI was between 25 and 40, with and average of 31.5. (For example, a 5-ft, 9-inch person weighing 206 lb has a BMI of 30.4.) Men were 30–70 years old; women were post-menopausal or up to age 70 (no explanation given for excluding younger women). A third of participants were women. All were sedentary at the time of enrollment. Baseline hemoglobin A1c’s were between 6.5 and 10.8% (average of 7.2%).

Participants were divided into two groups (14 or 15 in each):

  1. Paleolithic diet (PD)
  2. Paleolithic diet plus thrice weekly supervised exercise (PD-EX)

The exercise regimen was included both aerobic and resistance training. Click the reference link below for details. It looks like a vigorous and reasonable program to me.

The study lasted for 12 weeks.

Here’s their Paleo diet: “…lean meat, fish, seafood, eggs, vegetables, fruits, berries, and nuts. Cereals, dairy products, legumes, refined fats, refined sugars, and salt were excluded with the exception of canned fish and cold cuts like ham. The diet was consumed ad libitum [i.e., they could eat as much as they wanted], with restrictions of the following: eggs (1–2/day but a maximum of 5/week, potatoes (1 medium sized/day), dried fruit (130 g/day), and nuts (60 g/day). Rapeseed or olive oil (maximum 15 g/day) and small amounts of honey and vinegar were allowed as flavoring in cooking. Participants were instructed to drink mainly still water. Coffee and tea were restricted to a maximum of 300 g/day, and red wine to a maximum of one glass/week.

Who could stand to eat this junk for 12 weeks?

What Did They Find?

  • Both groups had and average individual weight loss of 7.1 kg (15.4 lb).
  • Both groups lost fat mass (measured by DEXA). The males in the PD-EX group retained more lean mass (e.g., muscle) than the other males.
  • Insulin sensitivity and blood sugar control improved in both groups to a comparable degree.
  • Hemoglobin A1c dropped about 1% in both groups.
  • VO2max (a measure of cardiovascular fitness) increased only in the PD-EX group, from 22.5 to 25.8 mL/kg/min.
  • Both groups dropped both systolic and diastolic blood pressures by 10%.
  • Both groups cut their leptin levels by about half. Leptin causes inflammation and is linked to cardiovascular events (heart attacks, strokes).

So What?

This study adds to the relatively few previous ones proving that the Paleo diet is effective in diabetes (overweight and obese type 2 diabetes in this case).

Fifteen-pound weight loss over 12 weeks while eating as much as you want is amazing.

The 1% absolute drop in Hemoglobin A1c is also quite welcome, comparable to or better than the reductions we see with many of our diabetes drugs. The authors remind us that “The UK prospective diabetes study (UKPDS) stated that a 1% unit improvement of HbA1c reduces microvascular complications by 37% and reduces diabetes-related death by 21%.”

The exercise program didn’t add to the weight loss. No surprise there. Unless you’re a contestant on The Biggest Loser show, 90% of weight loss depends on diet.

Unlike other studies, the exercisers didn’t see extra improvement in insulin resistance or blood sugar control. I can’t explain it.

The 10% blood pressure reduction by this Paleo diet could be quite beneficial for an individual with high blood pressure, allowing drug avoidance or dose reduction. Systolic pressure of 150 mmHg is often treated with drugs; a 10% reduction gets you down to 135, which doesn’t require drug therapy.

Note the 3.3 mL/kg/min increase in VO2max from this exercise program, which could be an 18% in all-cause mortality if sustained over time. The investigators cite a cohort study that found a VO2max increase of 1.44 mL/kg/min reduced overall mortality by 7.9%.

Steve Parker, M.D.

Reference: Otten, et al. (including Ryberg and Olsson). Effects of a Paleolithic diet with and without supervised exercise on fat mass, insulin sensitivity, and glycemic control: a randomized controlled trial in individuals with type 2 diabetes. Diabetes/Metabolism Research and Reviews, 2017; 33(1): doi: 10.1002/dmrr.2828   Published online in 2016.

Paleo Diet Improves Lipid Profile Better Than AHA’s Grain-Based Hearth-Healthy Diet in Adults With High Cholesterol

He’s not worried about his lipids

Abstract from the journal Nutrition Research:

Recent research suggests that traditional grain-based heart-healthy diet recommendations, which replace dietary saturated fat with carbohydrate and reduce total fat intake, may result in unfavorable plasma lipid ratios, with reduced high-density lipoprotein (HDL) and an elevation of low-density lipoprotein (LDL) and triacylglycerols (TG). The current study tested the hypothesis that a grain-free Paleolithic diet would induce weight loss and improve plasma total cholesterol, HDL, LDL, and TG concentrations in nondiabetic adults with hyperlipidemia to a greater extent than a grain-based heart-healthy diet, based on the recommendations of the American Heart Association. Twenty volunteers (10 male and 10 female) aged 40 to 62 years were selected based on diagnosis of hypercholesterolemia. Volunteers were not taking any cholesterol-lowering medications and adhered to a traditional heart-healthy diet for 4 months, followed by a Paleolithic diet for 4 months. Regression analysis was used to determine whether change in body weight contributed to observed changes in plasma lipid concentrations. Differences in dietary intakes and plasma lipid measures were assessed using repeated-measures analysis of variance. Four months of Paleolithic nutrition significantly lowered (P < .001) mean total cholesterol, LDL, and TG and increased (P < .001) HDL, independent of changes in body weight, relative to both baseline and the traditional heart-healthy diet. Paleolithic nutrition offers promising potential for nutritional management of hyperlipidemia in adults whose lipid profiles have not improved after following more traditional heart-healthy dietary recommendations.

PMID: 26003334 DOI: 10.1016/j.nutres.2015.05.002

Source: Paleolithic nutrition improves plasma lipid concentrations of hypercholesterolemic adults to a greater extent than traditional heart-healthy dietar… – PubMed – NCBI

Authors are Pastore RL, Brooks JT, and Carbone JW