Tag Archives: diabetes

Is the Hemoglobin A1c Test Always Accurate?

From 97 to 90 mg/dl

Not the only way to assess glucose control

Can you believe I’ve had patients show me a week’s worth of home glucose tests showing great numbers, tell me they’ve been that good for the last three months, and then I find a sky high Hemoglobin A1c test? How can that be?

Hemglobin A1c (or HgbA1c) is a standard measure of glucose control, or lack thereof, over the three months preceding the blood test.

It’s also used for diagnosis of diabetes and prediabetes. Levels between 5.7 and 6.4% suggest prediabetes. Levels of 6.5% of higher indicate diabetes.

Hemoglobin is the oxygen-carrying protein in red blood cells. HgbA1c tells us if many sugar molecules are stuck to the hemoglobin, a process called glycosylation. HgbA1c is sometimes referred to as glycated hemoglobin. About half of the HgbA1c value is determined by blood sugar levels in the month before the blood draw.

But the HgbA1c test is not always an accurate reflection of blood sugar levels.

Many factors unrelated to serum glucose (sugar) levels can alter the HgbA1c value. Here they are:

Pregnancy

Pregnant women tend to have lower than average HgbA1c.

 

Certain Types of Anemia

Iron-deficiency anemia may yield falsely low or high HgbA1c, depending on whether it’s being treated or not.

Acute bleeding and hemolytic anemia give falsely low HbA1c values.

The unifying feature here is that young red blood cells, called reticulocytes, take some time to get glycosylated.

Lack of a Spleen 

HgbA1c will be falsely high. Your spleen removes old red blood cells. Not having a spleen increases the life span of red blood cells, so they can accumulate more glucose molecules.

Various Hemoglobin Types or Congenital Abnormalities

Hemoglobin S and hemoglobin C may lead to deceptively low HgbA1c. Hemoglobin F tends to overestimate.

Blood Transfusions

Recent red blood cell transfusions will lower the HgbA1c if it was elevated to begin with, especially if lots of blood is transfused.

Renal Failure

It’s complicated; talk to your kidney specialist.

Chronic Disease

HgbA1c values can be unreliable in chronic alcoholism, chronic narcotic users, severely high triglyceride or bilirubin levels, kidney failure, vitamin and mineral deficiencies (particularly the vitamins and minerals needed to make red blood cells).

Race

Hispanics, Asians, and Blacks tend to have higher HgbA1c’s than Whites who have the same blood sugar levels. The difference is about 0.3% (absolute, not relative.

Wild Glycemic Excursions

What’s this? You might call it labile diabetes: dramatic swings between sugars too low and way too high. For example, this patient may have daily glucose swings between 40 and 210 mg/dl (2.2  and 11.7 mmol/l). His HgbA1c may turn out near normal or acceptable, but many experts worry that the wild oscillations may contribute to diabetic microvascular complications like eye and kidney disease.

Are There Alternatives to HgbA1c?

Yes. If you think the HgbA1c test is inaccurate, consider other tests such as continuous glucose monitoring, fructosamine, glycated albumin, 1,5-anhydroglucitol, and more frequent home glucose monitoring.

Steve Parker, M.D.

Reference: Bazerbachi, F., et al. Is hemoglobin A1c an accurate measure of glycemic control in all diabetic patients? Cleveland Clinic Journal of Medicine, vol. 81, #3, March 2014: 146-149

Which Diet for a 41-Year-Old Asian Indian With Prediabetes?

The CulinaryRx blogger at MedPageToday asked two physicians what diet modifications they’d recommend for a 41-year-old Asian-Indian man with prediabetes. (To read the article you may need to do a free sign-up.)

The moderator asked his experts twice whether carbohydrate restriction is important, and never got a straight answer. These experts must not think it’s important since they push legumes, lentils, fruits, and whole grains. Dr. Nadeau said he believes there is no specific diet for folks with diabetes. I almost fell off my chair when I read one comment recommending cookies and sweets, because they’re traditional. They also recommend low glycemic load, nuts, higher protein consumption, vegetables, and “good oils” like olive oil (ghee not even  mentioned).

Read this blog post for prior comments that include advice from possible clinicians.

I’m confident that Dr. Ronesh Sinha in Silicon Valley, California, would disagree with the advice of MedPageToday’s experts. Dr. Sinha would likely recommend limiting digestible carbohydrates to 50–150 grams/day as the most important dietary step.

I’m still looking for clinical studies of various diets for South Asians with prediabetes and diabetes.

Steve Parker, M.D.

Getting Bariatric Surgery to Improve Your Type 2 Diabetes? RYGB May Beat LAGB

An article at Diabetes Care suggests that insulin-treated T2 diabetics getting bariatric surgery were almost twice as likely to get off insulin if they had roux-en-Y gastric bypass rather than laparoscopic adjustable gastric banding. The former procedure is also generally more effective for weight loss.

If you think bariatric surgery is a sure-fire cure for type 2 diabetes, it’s not. I would go as far as I could with diet and exercise before going under the knife.

Steve Parker, M.D.

Even Mild Elevations of Fasting Blood Sugar Are Linked to Pancreatic Cancer

The pancreas produces digestive enzymes, insulin, and other hormones

The pancreas produces digestive enzymes, insulin, and other hormones

A recent meta-analysis found that elevated fasting blood glucose levels, even in the prediabetic range, are associated with higher risk of developing pancreatic cancer. This is important because you can take action today to lower your fasting blood sugar level, which may lower your risk of pancreatic cancer over the long-term. The researchers conclude that…

“Every 0.56 mmol/L [10 mg/dl] increase in fasting blood glucose is associated with a 14% increase in the rate of pancreatic cancer.”

In the developed world, your risk of getting an invasive cancer is roughly one in four. Pancreatic cancer is the most lethal. Surgery is the way to cure it, but at the time of diagnosis only two in 10 patients are candidates for surgery because the cancer has already spread. Pancreatic cancer is the fourth leading cause of cancer death in the USA and the fifth in the UK. Nevertheless, pancreas cancer is not terribly common; the US has 50,000 new cases annually. As a hospitalist, I run across one or two new cases of pancreas cancer annually.

We’ve known for years that type 2 diabetes is linked to pancreatic cancer, with diabetics having twice the risk of nondiabetics.

What if you have elevated fasting blood sugars? There’s no proof that reducing them to the normal range will reduce your risk of pancreatic cancer. But if it were me, that’s what I’d shoot for.

Other that type 2 diabetes and prediabetes, some other risk factors for pancreas cancer are:

  • heredity
  • smoking
  • sedentary lifestyle
  • body mass index over 30 (obesity in other words)

You can alter most of those risk factors. Why not get started today?

Steve Parker, M.D.

PS: If you’re not sure if your fasting blood sugar’s elevated, click here.

Paleobetic Diet Book Now Available

Paleobetic Diet-FrontCover_300dpi_RGB_5.5x8.5

 

 

 

I started this blog four years ago as an exploration of the Paleolithic diet as a therapeutic option in diabetes and prediabetes. Scientific studies from Ryberg (2013), Mellberg (2014), Boers (2014), and Masharani (2015) have convinced me that the paleo diet indeed has true potential to improve these conditions.

A couple years ago I published a bare-bones preliminary version of the Paleobetic Diet. Here’s an outline. I just finished a comprehensive fleshed-out version in book format.

The central idea is to control blood sugars and eliminate or reduce diabetes drugs by working with Nature, not against her. This is the first-ever Paleolithic-style diet created specifically for people with diabetes and prediabetes.

Also known as the caveman, Stone Age, paleo, or ancestral diet, the Paleolithic diet provides the foods our bodies were originally designed to thrive on. You’ll not find the foods that cause modern diseases of civilization, such as concentrated refined sugars and grains, industrial seed oils, and over-processed Franken-foods. Our ancestors just five generations ago wouldn’t recognize many of the everyday foods that are harming us now. On the Paleolithic diet, you’ll enjoy a great variety of food, including nuts and seeds, vegetables, fruit, meat, seafood, and eggs.

In the book you’ll find one week of meal plans to get you started, plus additional special recipes. Meals are quick and easy to prepare with common ingredients. You’ll find detailed nutritional analysis of each meal, including carbohydrate grams.

All measurements are given in both U.S. customary and metric units. Blood glucose values are provided as both mmol/l and mg/dl. Also included is information and advice on exercise, weight loss, all 12 classes of diabetes drugs, management of hypoglycemia, and recommended drug dose adjustments. All recipes are gluten-free.

 

Availability and Formats

You’ll find Paleobetic Diet at all major online bookstores. For example, Amazon (290-page paperback book in U.S.), Kindle ebook, and multiple ebook formats at Smashwords.

If you have diabetes or prediabetes, please give this program careful consideration. Help me spread the word if you know someone else who might benefit. Thank you.

Steve Parker, M.D.

Theoretical Support for the Healthfulness of the Paleo Diet

See modern man walking off that cliff?

See modern man walking off that cliff?

Aren’t people healthier now, thanks to the Agricultural and Industrial Revolutions?

As a marker for health, we can look at life span and longevity. Humans started to see dramatic increases in longevity probably around 30,000 years ago, before the revolutions. Nevertheless, Kuipers, Joordens, and Muskiet note that average life expectancy after the start of the Agricultural Revolution 10,000 years ago fell from about 40 to around 20 years.

Other researchers report that average height in the Nile River Valley at the time of the transition fell by 4 inches (10 cm). The Agricultural Revolution allowed for rapid expansion of human populations through more births, but those folks still didn’t live very long. As before the revolution, infections and high infant/child mortality rates were devastating killers, dragging down average life spans. If you survived childhood, you had a shot at hitting 50 or 60.

At the dawn of the Industrial Revolution, life expectancy at birth was only 35–40 years, even in then-sophisticated cultures like Switzerland. Consider Thomas Jefferson, the principal author of the U.S. Declaration of Independence and the third U.S. president, who lived between 1743 and 1826 (he died on July 4, Independence Day). He and his wife Martha had six children; only two survived to adulthood, and only one past the age of 25. Martha died at age 33. This mortality picture was typical for the times.

Since 1800, life expectancy has doubled in industrialized countries, but it’s mostly due to public health measures and economic prosperity. Other than smallpox vaccination, it wasn’t until the mid-20th century that medical care advances contributed in a major way to longevity.

Overview: Conflict Between Our Paleolithic Genes and Modern Life

A number of diseases or conditions may result from the mismatch of our Paleolithic genes and modern lifestyle. If not caused by the mismatch, they’re aggravated by it. These are the so-called “diseases of civilization”:

  • type 2 diabetes
  • high blood pressure
  • overweigh and obesity
  • dental caries (tooth decay or cavities)
  • osteoporosis
  • fertility problems (polycystic ovary syndrome)
  • pregnancy complications (pre-eclampsia, gestational diabetes)
  • some cancers (colon, breast, prostate)
  • heart disease (such as coronary artery disease)
  • major and postpartum depression
  • autism
  • schizophrenia
  • some neurodegenerative diseases (Parkinsons disease, Alzheimer’s disease)
  • constipation
  • hemorrhoids
  • diverticulosis
"I ate well over 70 grams of fiber daily!"

“I ate well over 70 grams of fiber daily!”

Overweight and Obesity

The Paleolithic diet is lower in total carbohydrate calories compared to the standard American diet: 30-35% versus 50-55% of calories. The higher consumption today, especially of highly processed refined carbohydrates, contributes to overweight and obesity, diabetes, gallbladder disease, heart disease, and possibly dementia. Ian Spreadbury hypothesizes that carbohydrate density of modern foods may be the cause of obesity. Refined sugars and grains—types of acellular carbohydrates—are particularly bad offenders. These acellular carbs may alter our gut microorganisms, leading to systemic inflammation and leptin resistance, etc. Our Paleolithic ancestors had little access to acellular carbohydrates. Here’s how Spreadbury explains acellular: “Tubers, fruits, or functional plant parts such as leaves and stems store their carbohydrates in organelles as part of fiber-walled living cells. These are thought to remain largely intact during cooking, which instead mostly breaks cell-to-cell adhesion. This cellular storage appears to mandate a maximum density of around 23% non-fibrous carbohydrate by mass, the bulk of the cellular weight being made up of water. The acellular carbohydrates of flour, sugar, and processed plant-starch products are considerably more dense. Grains themselves are also highly dense, dry stores of starch designed for rapid macroscopic enzymic mobilization during germination. Whereas foods with living cells will have their low carbohydrate density “locked in” until their cell walls are breached by digestive processes, the chyme produced after consumption of acellular flour and sugar-based foods is thus suggested to have a higher carbohydrate concentration than almost anything the microbiota of the upper GI tract from mouth to small bowel would have encountered during our coevolution.” (Reference: “Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity,” in Diabetes, Metabolic Syndrome, and Obesity: Targets and Therapy. 2012; vol 5: 175–189. doi: 10.2147/DMSO.S33473 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402009/)

Added sugar provides 17 % of total energy in modern societies, contributing to overweight, obesity, tooth decay, and diabetes. Modern diets provide 15–20% of calories from protein, compared to 25–30% in the Paleolithic diet. To the extent that high protein consumption is satiating, lower consumption may cause over-eating of carbohydrates and fats, then overweight and obesity and all their associated medical conditions.

Heart Disease

I written elsewhere on the blog that the much lower omega-6 to omega-3 fatty acid ratio in the Paleolithic diet. There’s some evidence that today’s high ratio may contribute to systemic inflammation and chronic disease, heart disease in particular. Today’s ratio is quite high due to our consumption of industrial seed oils, such as those derived from soybeans, peanuts, corn, and safflower. And we don’t eat enough cold-water fatty fish, which are major sources of omega-3 fatty acids. Two long-chain polyunsaturated fatty acids, EPA and DHA, are essential fatty acids. That means our bodies cannot make them. We have to get them from diet. DHA and EPA are also cardioprotective omega-3 fatty acids.

High Blood Pressure

Most modern diets have much more sodium and much less potassium than the Paleolithic diet, perhaps contributing to high blood pressure, which in turn contributes to heart attacks, strokes, and possibly premature death. The higher magnesium content of the paleo diet may also help prevent high blood pressure.

Gastrointestinal Problems

We eat much less fiber these days, contributing to constipation, hemorrhoids, and diverticulosis. Some experts believe low fiber consumption adversely effects development of palate bones, jaws, and tooth placement.

Osteoporosis

Our lower vitamin D levels these days may cause osteoporosis (thin fragile bones) and raise the risk of diabetes and cancer. Our prehistoric ancestors spent more time in the sun, allowing their bodies to make vitamin D.

Type 2 Diabetes

Robert Lustig and associates looked at sugar consumption and diabetes rates in 175 countries and found a strong link between sugar and type 2 diabetes. It’s not proof of causation, just suggestive. From the scientific article abstract: “Duration and degree of sugar exposure correlated significantly with diabetes prevalence in a dose-dependent manner, while declines in sugar exposure correlated with significant subsequent declines in diabetes rates independently of other socioeconomic, dietary and obesity prevalence changes. Differences in sugar availability statistically explain variations in diabetes prevalence rates at a population level that are not explained by physical activity, overweight or obesity.” (Reference: Basu S, Yoffe P, Hills N, Lustig RH (2013) The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data. PLoS ONE 8(2): e57873. doi:10.1371/journal.pone.0057873)

A major diet change from Stone Age to modern diets is a reduction in magnesium consumption. This could be one reason type 2 diabetes is a problem today. A 2013 article at Diabetes Care suggests that higher magnesium consumption in modern populations may protect against type 2 diabetes (Reference: http://care.diabetesjournals.org/content/early/2013/09/23/dc13-1397.abstract.html?papetoc).

Dental Problems

Dentist John Sorrentino wrote at his blog in 2012: “The truth is that tooth decay is a relatively new phenomenon. Until the rise of agriculture roughly 10,000 years ago, THERE WAS NO TOOTH DECAY IN HUMANS. Let that sink in for a moment. Humanity is 2,500,000 years old. For the first 2,490,000 years no one ever had a cavity. If we understand that tooth decay started when people started farming instead of hunting and gathering for a living clearly you realize that tooth decay is a disease or mismatch between what you are eating and what your body expects you to eat. If we examine the past as prologue it becomes clear that the path to proper health starts in the mouth and the answers are so simple that not only did a Cave Man do it. They perfected it.” (Reference: http://www.sorrentinodental.com/blog.html?entry=why-teeth-decay-i)

To be fair and balanced, a research report from 2014 found a very high incidence of caries (cavities) in a Stone Age population living in what is now Morocco. The authors attributed the cavities to heavy consumption of acorns, which are rich in carbohydrates and sticky, to boot.

Orthodontist Mike Mew, BDS, MSc, made a presentation at the 2012 Ancestral Health Symposium titled “Craniofacial Dystrophy—Modern Melting Faces.” Dr. Mew says 30% of folks in Western populations have crooked teeth and/or malocclusion, and the mainstream orthodontic community doesn’t know why. But they’ve got expensive treatment for it! Dr. Mew thinks he knows the cause and he shared it at the symposium. The simple cure is “Teeth together. Lips together. Tongue on the roof of your mouth.” And eat hard food that requires lots of chewing, like our ancestors did, ideally in childhood before age 9. Older people also benefit, he says.

NPR (National Public Radio) in February, 2013, ran an article called “Ancient Choppers Were Healthier Than Ours,” by Audrey Carlsen. An excerpt: “Hunter-gatherers had really good teeth,” says Alan Cooper, director of the Australian Centre for Ancient DNA. “[But] as soon as you get to farming populations, you see this massive change. Huge amounts of gum disease. And cavities start cropping up.” And thousands of years later, we’re still waging, and often losing, our war against oral disease. Our changing diets are largely to blame. In a study published in the Nature Genetics, Cooper and his research team looked at calcified plaque on ancient teeth from 34 prehistoric human skeletons. What they found was that as our diets changed over time — shifting from meat, vegetables and nuts to carbohydrates and sugar — so too did the composition of bacteria in our mouths. Not all oral bacteria are bad. In fact, many of these microbes help us by protecting against more dangerous pathogens. (Reference: http://www.npr.org/blogs/health/2013/02/24/172688806/ancient-chompers-were-healthier-than-ours)

Dentist Mark Burhenne wrote the following at Huffington Post – Canada: “It is generally well accepted that tooth decay, in the modern sense, is a relatively new phenomena. Until the rise of agriculture roughly 10,000 years ago, there was nearly no tooth decay in the human race. Cavities became endemic in the 17th century but became an epidemic in the middle of the 20th century (1950). If we understand that tooth decay started when people started farming, rather than hunting and gathering, it’s clear that tooth decay is the result of a mismatch between what we’re eating and what our bodies are expecting us to eat based on how they evolved….The recent changes in our lifestyle create a “mismatch” for the mouth, which evolved under vastly different environments than what our mouths are exposed to these days. Our mouths evolved to be chewing tough meats and fibrous vegetables. Sugar laden fruit was a rare and special treat for our paleolithic ancestors. Now, our diets are filled with heavily processed foods that take hardly any energy to chew — smoothies, coffees, and sodas high in sugar, white bread, and crackers to name just a few.” (Reference: http://www.huffingtonpost.ca/mark-burhenne/paleo-diet-oral-health_b_4041350.html)

Shrinking Brains

Since the end of the Stone Age, human brain size has been shrinking. That’s not good, is it? Anthropologist John Hawks has noted that over the past 20,000 years, the average volume of the human male brain has decreased from 1,500 cubic centimeters to 1,350 cc, losing a chunk the size of a lemon. The female brain has shrunk proportionately. Anthropologists don’t know why. Is it modern nutrition? The experts aren’t sure what it means for our future. As for me, I think the answer is in Mike Judge’s movie, “Idiocracy.”

His brain was bigger than yours

His brain was bigger than yours

Death By Sugar

Sugar-sweetened beverages kill almost 200,000 worldwide annually, according to a Gitanjali Singh, Ph.D., a postdoctoral research fellow at the Harvard School of Public Health. How could that be? Sugar-sweetened beverages contribute to obesity, which in turn leads to diabetes, cardiovascular disease, and some cancers. (Reference: Singh, GM, et al “Mortality due to sugar-sweetened beverage consumption: A global, regional, and national comparative risk assessment,” American Heart Association Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions, Abstract EPI-13-A-879-AHA.) Reducing consumption of sugar-sweetened beverages was one of the major points in the American Heart Association’s 2010 guidelines for reducing heart disease.

Elderly Cognitive Impairment

Diets high in sugar and other carbohydrates raise the risk of elderly cognitive impairment, according to recent research by the Mayo Clinic. Mild cognitive impairment is often a precursor to incurable dementia. (Most authorities think dementia develops more often in people with diabetes, although some studies refute the linkage.) Researchers followed 940 patients with normal baseline cognitive functioning over the course of four years. Diet was assessed via questionnaire. Study participants were ages 70 to 89. As the years passed, 200 of them developed mild cognitive impairment. Compared with those eating the lowest amount of sugar, those eating the most sugar were 1.5 times more likely to develop cognitive impairment. Looking at total carbohydrate consumption, those eating at the highest levels of carbohydrate consumption were almost twice as likely to develop mild cognitive impairment. The scientists note that those eating lower on the carbohydrate continuum were eating more fats and proteins. (Reference: Mayo Clinic website, published October 16, 2012 http://www.mayoclinic.org/news2012-rst/7128.html)

Is a Paleolithic-Style Diet the Healthiest Way to Eat?

Certified paleo-compliant, plus high omega-3 fatty acids

Certified paleo-compliant, plus high omega-3 fatty acids

The jury’s still out on that one! My strong sense is that it’s definitely more healthful than the Standard American Diet. Maybe the traditional Mediterranean diet or DASH diet is even healthier. Don’t hold your breath waiting for the randomized controlled trials that would answer the question definitively.

If the paleo diet is the healthiest, which version is best? That’s a question for another day (or year).

The most healthful diet for you depends on your genetic make-up and any medical conditions you have.

Steve Parker, M.D.

If You Have Diabetes, You Need to Know About Glucagon

I couldn't find a pertinent picture

I couldn’t find a pertinent picture

Everybody knows that insulin is the key hormone gone haywire in diabetes, right? Did you know it’s not the only one out of whack? Roger Unger and Alan Cherrington in The Journal of Clinical Investigation point out that another hormone—glucagon—is also very important in regulation of blood sugar in both types of diabetes.

Insulin has a variety of actions the ultimately keep blood sugar levels from rising dangerously high. Glucagon, on the other hand, keeps blood sugar from dropping too low. For instance, when you stop eating food, as in an overnight or longer fast, glucagon stimulates glucose (sugar) production by your liver so you don’t go into a hypoglycemic coma and die. It does the same when you exercise, as your muscles soak up glucose from your blood stream.

Glucagon works so well to raise blood sugar that we inject it into diabetics who are hypoglycemic but comatose or otherwise unable to swallow carbohydrates.

Glucagon also has effects on fatty acid metabolism, ketone production, and liver protein metabolism, but this post is already complicated enough.

So where does glucagon come from? The islets of Langherhans, for one. You already know the healthy pancreas has beta cells that produce insulin. The pancreas has other cells—alpha or α cells—that produce glucagon. Furthermore, the stomach and duodenum (the first part of the small intestine) also have glucagon-producing alpha cells. The insulin and glucagon work together to keep blood sugar in an fairly narrow range. Insulin lowers blood sugar, glucagon raises it. It’s sort of like aiming for a hot bath by running a mix of cold and very hot water.

Update: I just licensed this from Shutterstock.com

Update: I just licensed this from Shutterstock.com

Ungar and Cherrington say that one reason it’s so hard to tightly control blood sugars in type 1 diabetes is because we don’t address the high levels of glucagon. The bath water’s not right because we’re fiddling with just one of the faucets. Maybe we’ll call this the Goldilocks Theory of Diabetes.

When you eat carbohydrates, your blood sugar starts to rise. Beta cells in the healthy pancreas start secreting insulin to keep a lid on the blood sugar rise. This is not the time you want uncontrolled release of glucagon from the alpha cells, which would work to raise blood sugars further. Within the pancreas, beta and alpha cells are in close proximity. Insulin from the beta cells directly affects the nearby alpha cells to suppress glucagon release. This localized hormone effect is referred to as “paracrine guidance” in the quote below, and it takes very little insulin to suppress glucagon.

From the Ungar and Cherrington article:

Here, we review evidence that the insulinocentric view of metabolic homeostasis is incomplete and that glucagon is indeed a key regulator of normal fuel metabolism, albeit under insulin’s paracrine guidance and control. Most importantly, we emphasize that, whenever paracrine control by insulin is lacking, as in T1DM, the resulting unbridled hyperglucagonemia is the proximal cause of the deadly consequences of uncontrolled diabetes and the glycemic volatility of even “well-controlled” patients.

*  *  *

All in all, it would seem that conventional monotherapy with insulin is incomplete because it can provide paracrine suppression of glucagon secretion only by seriously overdosing the extrapancreatic tissues.

So What?

Elucidation of diabetes’ disease mechanisms (pathophysiology) can lead to new drugs or other therapies that improve the lives of diabetics. A potential drug candidate is leptin, known to suppress glucagon hyper secretion in rodents with type 1 diabetes.

RTWT.

Steve Parker, M.D.

PS: Amylin is yet another hormone involved in blood sugar regulation, but I’ll save that for another day. If you can’t wait, read about it here in my review of pramlintide, a drug for type 1 diabetes.

Fruit Smoothie #1

 

A 12 fl oz serving

A 12 fl oz serving

My wife began experimenting with smoothies last year after seeing a Vitamix demonstration at Costco. Most Americans should probably eat more fruit; smoothies are one way to do that. Today’s recipe is one she concocted. Note the trendy chia seeds and kale. Smoothies are a great substitute for junk food desserts.

We’re using a Vitamix mixer. Other devices may be able to get the job done. The mixing speeds our device range from one to 10. (Tip for a competitor: make one that goes to 11.) We love our Vitamix and have no regrets about the purchase, although it was expensive (over $500 USD). It is hard to hear anything else when it’s running at top speed.

Since I provide nutritional analysis below, most diabetics can fit this smoothie into their diets without guessing the carb grams. Twelve fl oz or 350 ml provides 32 digestible carb grams. Most diabetics should probably reduce the serving size by a third, down to 8 fl oz (240 ml) and 11 digestible carb grams.

One potential advantage of blending these fruits is that one fruit may provide nutrients that the others lack

One potential advantage of blending these fruits is that one fruit may provide nutrients that the others lack

Ingredients

1 cup (240 ml) grapes, green seedless

1 mandarin orange, peeled, halved

1 banana (7 inches or 18 cm), peeled, cut into 3–4 pieces

1 pear, medium-size, cored, quartered (ok to leave peel on)

1/2 tbsp (7 g) chia seeds

1 cup (50 g) raw kale

Instructions

First put the water in the Vitamix, then grapes, pear, orange, banana, chia seeds, kale, and finally ice. Ice is always last. Then blend on variable speed 1 and gradually go up to high level (10). Total spin time is about 45 seconds.

Full speed ahead!

Full speed ahead!

Number of Servings: 2.5 consisting of 12 fl oz (350 ml) each.

Advanced Mediterranean Diet boxes: 2 fruits

Nutritional Analysis per Serving:

7% fat

88% carbohydrate

5% protein

160 calories

38 g carbohydrate

6 g fiber

32 g digestible carbohydrate

15 mg sodium

520 mg potassium

Prominent features: Good source of vitamin C, fair amount of fiber, miniscule sodium.

Steve Parker, M.D.

 

 

What About Vegetarian Diets for Diabetes?

low-carb diet, spaghetti squash, paleobetic diet, diabetic diet

The spaghetti squash at top is related to pumpkins and zucchini

I was surprised to learn that well-known diabetes writer David Mendosa (Type 2 DM) has switched from a very low-carb diet to a low-carb vegetarian diet, eating no more than 50 grams/day of carbohydrate. Why?

For me the issue is that I don’t want to be responsible for harming sentient beings as much as I can avoid it while still following a healthy diet.

I can respect that. I’m sure he’s monitoring the effects of the diet on his blood sugars and weight. Probably his blood lipids, too.

It sounds like all David had to do was drop fish from his prior diet. He still eats eggs (whites only?), cheese, and full-fat yogurt, so I’d call him a lacto-ovo-vegetarian.

If you’re already convinced that the Paleolithic diet is the best one for people with diabetes, read no further.

What Is a Vegetarian Diet?

From UpToDate.com:

Vegetarian diets vary considerably depending on the degree of dietary restrictions. According to the strictest definition, a vegetarian diet consists primarily of cereals, fruits, vegetables, legumes, and nuts; animal foods, including milk, dairy products, and eggs generally are excluded. Several less restrictive vegetarian diets may include eggs and dairy products. Some vegetarian diets may be grouped as follows:

●Macrobiotic — Vegetables, fruits, legumes, and seaweeds are included in the diet, while whole grains, especially brown rice, are also emphasized. Locally-grown fruits are recommended. Animal foods limited to white meat or white-meat fish may be included in the diet once or twice a week.
●Semi-vegetarian — Meat occasionally is included in the diet. Some people who follow such a diet may not eat red meat but may eat fish and perhaps chicken.
●Lacto-ovovegetarian — Eggs, milk, and milk products (lacto = dairy; ovo = eggs) are included, but no meat is consumed.
●Lactovegetarian — Milk and milk products are included in the diet, but no eggs or meat are consumed.
●Vegan — All animal products, including eggs, milk, and milk products, are excluded from the diet. Some vegans do not use honey and may refrain from using animal products such as leather or wool. They also may avoid foods that are processed or not organically grown.

A 2012 poll in the U.S. estimated that 7% of adults eat at least one meal a week that does not include meat, fish or poultry, 4% do not eat meat, fish, or poultry, and 1–2% do not eat meat, fish, poultry, dairy products, or eggs. Roughly 5% of individuals in the UK, Germany, and Australia describe themselves as vegetarian.

Switching to the paleo diet often leads to increased vegetable and fruit consumption

A low-carb diet can still have plenty of vegetables

Are Vegetarian Diets Safe?

Vegetarians need to be careful to get enough high-quality protein, iron, vitamin B12, vitamin D, and perhaps calcium. B12 comes only from animal products, as far as I know. You can make vitamin D by exposing your skin to sufficient sunlight. Some vegetarians will need to consult a dietitian to ensure adequate nutrition. (BTW, all my comment about vegetarian diets apply to adults only—I don’t treat children, so I’m not up-to-date on their nutritional needs.)

I’ve written about vegetarian diets for diabetes before: here and here. Dr. Michael Greger couldn’t convince Dr. Harriet Hall (or me) that we should avoid eating all animal products.

The Grashow Question

Someone claiming to be Charles Grashow left a comment on one of my blogs recently:

As I’ve posted before, this [vegetarian macrobiotic diet] took Insulin Dependent T2D [patients] OFF MEDS within 21 days!

Seems much better – but then again this diet is vegan not paleo!

http://www.hoajonline.com/internalmedicine/2052-6954/2/3
Ma-Pi 2 macrobiotic diet intervention during 21 days in adults with type 2 diabetes mellitus, Ghana 2011

http://www.nutritionandmetabolism.com/content/11/1/39
The effect of the macrobiotic Ma-Pi 2 diet vs. the recommended diet in the management of type 2 diabetes: the randomized controlled MADIAB trial

http://www.hindawi.com/journals/jnme/2012/856342/
Medium- and Short-Term Interventions with Ma-Pi 2 Macrobiotic Diet in Type 2 Diabetic Adults of Bauta, Havana

SO – my question is this. Why do you not recommend this type of diet instead? Or does it not fit into your paradigm?

I responded:

Charles, that macrobiotic Ma-Pi 2 diet looks like it has significant potential. I quickly scanned your first link only. For those not familiar with the diet, here’s a description form your first link:

“Vegetarian Ma-Pi 2 macrobiotic diet, designed especially by Mario Pianesi for treating diabetic patients. Total volume of the Ma-Pi 2 diet consisted of 40-50% whole grains (rice, millet and barley), 35-40% vegetables (carrots, savoy cabbage, cabbage, chicory, onions, red radish, parsley), and 8% legumes (adzuki beans, chickpeas, lentils, black beans). As a complement we used gomasio (roasted ground sesame seeds with unrefined sea salt), fermented products (miso, tamari, umeboshi) and seaweeds (kombu, wakame, nori). Bancha tea (theine-free green tea) was the main liquid diet.”

“The assayed Ma-Pi 2 diet is lower in energy than the traditional one recommended for diabetic patients, but safe, with adequate satiating effect due to the high fiber content, adequate in protein (12% of the total energy), with an acceptable amino acid score, low in fat (15% of the total energy), and high in complex carbohydrates (73%). The diet has a high antioxidant capacity and a high content of bioactive compounds with recognized functional properties (Table 2). Foods were elaborated by culinary macrobiotic specialists from UPM, Italy, and offered at the hospital during breakfast, lunch, dinner and snacks. Unfortunately, the variety of vegetables was restricted because of limited availability.”

I wonder if that would be deficient in vitamin B12.

It looks like it would be worth a try for a type 2 diabetic under medical supervision (risk of hypoglycemia). I’d like to try a few meals with those ingredients, some of which I’ve never heard of, prepared by someone who knows what they’re doing. Unless I missed it in the link, it might be hard for the average person to replicate that study diet. If I understood correctly, the study participants stayed in a hospital for three weeks and meals were prepared for them.

I don’t have time to hit the other links right now.

-Steve

My Current Stance on Vegetarian Diets For Diabetes

I say “current stance” because I’ll change my mind based on scientific evidence as it becomes available.

I’m not convinced that any of the vegetarian diets is clearly superior to the other available “diabetic diets” in terms of quality of life, longevity, and avoidance of diabetes complications.

We have some evidence that some vegetarian diets may help control diabetic blood sugars and help reduce the need for diabetes medications, at least short-term.

If my diabetic patients want to try a vegetarian diet, I have no objections as long as these criteria are met:

  • it’s a well-designed diet that provides adequate nutrition (which may require a dietitian consultation)
  • blood sugars, hemoglobin A1c, body weight, and blood lipids are monitored periodically
  • the patient is able and willing to self-monitor blood sugars fairly frequently
  • physician oversight, especially for those taking diabetes drugs

Vegetarian diets can be very high in carbohydrate content, which potentially could wreck blood sugar control. If that happens, consider a vegetarian diet with fewer starches and sugars.

Steve Parker, M.D.

Would You Believe Four in Ten U.S. Adults Will Develop Diabetes?

Like type 1 diabetics, many type 2's need insulin shots

Like type 1 diabetics, many type 2’s need insulin shots

Researchers affiliated with the U.S. Centers for Disease Control estimate that 40% of American adults will develop diabetes, mostly type 2. The CDC’s prior estimate was the one of every three Americans born in 2000 would develop diabetes. Some snippets from the article abstract:

On the basis of 2000—11 data, lifetime risk of diagnosed diabetes from age 20 years was 40·2% for men and 39·6% for women, representing increases of 20 percentage points and 13 percentage points, respectively, since 1985—89.

The number of life-years lost to diabetes when diagnosed at age 40 years decreased from 7·7 years in 1990—99 to 5·8 years in 2000—11 in men, and from 8·7 years to 6·8 years in women over the same period.

Years spent with diabetes increased by 156% in men and 70% in women.

The good news is that you can decrease your odds of type 2 diabetes via diet and exercise. The single most important issue in preventing type 2 diabetes is avoiding obesity.

Steve Parker, M.D.