Access Dr. Bernstein – diabetes control with low carb

Aside

Diabetes Solution

Diabetes Solution (Photo credit: Earthworm)

Every month the highly-respected Dr. Richard K Bernstein has a teleconference.

From the email I received:

“Ask Dr. Bernstein Webcast and Teleconference !!! – TONIGHT!  Wednesday, Oct 31, 2012 Special Topic Diabetes/cancer and CVID

Please Ask Dr. Bernstein Your Questions NOW! By emailing us at publisher@diabetesincontrol.com or by going to www.askdrbernstein.net
Join the Ask Dr. Bernstein Webcast and conference call on Monday Oct 31,2012 7PM CST, 8PM EST and 5PM West Coast Time. Dr. Bernstein will answer your questions

To attend, visit: http://cdset.c.topica.com/maapWXOacaxnobtVXqrbaeQyvr/
Or Primary dial in number: Phone number: (206) 402-0100 PIN Code: 900326#  “

(Note: for Canadian readers, this is definitely not the Dr. Bernstein of the diet clinic chain.)

Dr. Bernstein has endeavored over many decades to get out his message of blood glucose control to normal levels, and the essential role of low cab intake in that process.

Glucose Control Wins – Test!

A kit used by a woman with gestational diabetes.

A kit used by a woman with gestational diabetes. (Photo credit: Wikipedia)

Another week, another information packed newsletter from Diabetes in Control. If you have any reason to be interested in blood sugar control (that is, if you are alive and plan to be for a while), I highly recommend you sign up for their newsletter. I can’t highlight on this blog all that they publish that is important, or I would be posting little else.

There are many items in this week’s newsletter worth your attention. LINK  – this week’s newsletter is #649, if you need to search for it.

One is a report of a study, this time done in Sweden, that looked at 5 year outcomes among patients with inadequately controlled diabetes whose HgA1c improved versus those for whom it didn’t improve or worsened. It is important to note that this is a correlation study – there would be some other factors in the mix as to why some people’s HgA1c improved and others didn’t. Trouble is, we can’t do a causation study, as you can’t with-hold treatment from people

“Patients who had suboptimal glycemic control and reduced their HbA1c value by slightly less than 1% were 50% less likely to die within 5 years than were patients whose HbA1c did not improve….”

“After adjusting for baseline risk factors and treatment changes during the study period, patients whose HbA1c decreased were half as likely to develop cardiovascular or coronary heart disease as were those whose levels increased. They were also 33% less likely to experience fatal cardiovascular disease and 41% less likely to die from any cause than were those in the poorly controlled group. All of these differences were statistically significant.”

“We must make an effort to identify patients who don’t respond to diabetes medications earlier.”

Test, test and target. Even small improvements can mean big benefits. Do you know where your post-meal glucose values go? Blood glucose test kits are not expensive. Don’t wait for your fasting blood sugar to go up before you take action.

English: Illustration of the changes in blood ...

English: Illustration of the changes in blood glucose over time following a high and low GI carbohydrate. Designed and made Public Domain by Scott Dickinson (user: Studio34), Sydney, Australia. (Photo credit: Wikipedia)

Compare these results to the results from studies targeting how closely diabetic subjects followed the researcher’s versions of good lifestyle habits. What works is “the facts, ma’am” – test you glucose, set post-meal targets and keep tweaking and trying. The winning strategy is to find out what really works for you by watching your personal responses.

Consider the dismal outcome recently reported for the Look AHEAD trial, which went for 11 years and cost $220 million, which focused on achieving weight loss and found NO benefit in terms of reduction of heart attacks or strokes in people with diabetes.

Washington Post article on the results - LINK

Analysis of the results that is more informative – from Tom Naughton LINK

Extensive resources can be found on the web sites listed in the sidebar under “Blood Sugar Health”.

See also my post Restoring normal blood glucose levels associated with less progression to type 2 diabetes

Sunday Stories of Low Carb – June

Sunday Stories and 23 Jazz Concerts!

(1) Interview (about 13 minutes) on NEquals1Health.com among 2 couples regarding their experiences with the benefits of low-carb nutrition. LINK

(2) Gary Noreen, of Low Carb Review (lcreview.org), has written the story of his 19 years of controlling Type 2 diabetes with a low carb diet:

http://lcreview.org/main/my-story/

“They made the mistake of giving me a glucometer (blood glucose meter). I quickly found that eating cereal and skim milk for breakfast along with a banana made my glucose take off like a rocket. “Artery-clogging” eggs and bacon had no effect. This was bewildering.

Fortunately for me, the only Type 2 diabetes book in my local library was Diabetes Type II: Living a Long, Healthy Life Through Blood Sugar Normalization by Dr. Richard Bernstein, who recommended a very low carbohydrate diet (30 gm/day) and no restrictions on fat except no trans fats. Dr. Bernstein’s very low carb diet quickly brought my blood glucose under control and dramatically improved my lipid measurements. 19 years later, I have never needed to inject insulin, my most recent A1c measurement was 5.6%, I have no diabetes complications, and my lipids are excellent.”

His story is much longer than the quote above, and he includes his lab test results and details of his medications and how he manages his health.  Note that after 19 years since diagnosis, and with sky-high blood glucose at diagnosis, he reports “I have no diabetes complications”.

Sunday Music

The CBC (The Canadian Broadcasting Corporation) is Canada’s public broadcasting corporation and the radio is commercial-free. They maintain a very extensive website.

www.cbc.ca/radio

One of their features is CBC Music, with multiple genre streams and tons of “concert on demand” recordings.

This link is to a page featuring over 20 jazz concerts.  LINK

Lottttsss of Sunday Music!

Carpe Your Blood Sugar

What if the urgent public health issue of the day is less obesity itself and more about the elevated blood sugar (glucose) levels that occur in the majority of those with higher amounts of body fat?

What if the true cut-off level for concern is less than the target values now used for screening tests, diagnosis and for management targets in diabetes?

What if the urgency comes from the combination of two factors:

  • the fact that at last estimate about half (46%) of the adult population in the US (for example, but other countries are headed in the same direction) have pre-diabetes or diabetes, and
  • these elevated glucose levels are now optional for the majority of people, because a different approach to management can be used (at least, for those who have access to regular medical care and the personal resources to manage a care plan involving self-monitoring of blood glucose).

What if having similarly elevated blood glucose levels (including below the threshold for diagnosis of diabetes) means that people who are classed as ‘normal’ body weight face many of the most worrisome health issues that we have incorrectly been blaming on the total body fat itself?

What if swings in blood glucose are itself a major driver of weight gain and those swings can be eliminated?

Metabolic Syndrome is a term used for a cluster of related medical problems or health indicators that have at their core a reduced ability for the body to handle glucose.  The root causes for this have not yet been understood, so we can’t say that we have a way to treat or correct the source cause of the metabolic syndrome itself.  But we can succeed in keeping the blood glucose in the normal range, and thus largely interfere with the means by which the metabolic syndrome causes damage.

Among the experts in obesity, there is a sea change over the past few years moving towards the realization that the amount of extra fat itself is not the major driver of the degree of health impact of the obesity.  Yes, there are physical impacts of simply being a larger size, such as stress on the joints.  At very high levels of body fat, there can be other serious effects of the physical size, such as strain on the heart and fluid accumulation in the legs.  Certainly we must keep in mind and be very aware that there are emotional impacts, which are related to such factors as weight-based discrimination and (unfairly) feeling personally inadequate for not loosing weight when surrounded by the attitude that it should be so easy.  There are also economic impacts, including discrimination in the work place.

But there is an “illness” aspect that the obesity experts refer to.  Some people who are overweight or obese are actually quite healthy in their metabolism. It is thought that these are not the ones who are headed (at least, not any more than usual) for heart attack, stroke, cancer or the other “illness” consequences that we have come to consider to be caused by high body fat itself. Having a high amount of body fat is not a sole determiner for whether someone is more at risk of these outcomes than someone of “normal” body weight.

Metabolic syndrome is thought to be the major part of the difference, as well as some other factors, such as inflammatory molecules coming from body fat stores, most particularly those in the abdomen.  Control of blood glucose levels, it could be argued, is the most readily attainable change that can be implemented at this time.

Blood sugar levels respond very quickly, in a matter of days, weeks or, at most, months when a well-designed and individually adjusted program is instituted that focuses on reducing the intake of glucose-producing foods, adjusted to create an eating plan that the individual finds acceptable as a long-term aspect of their medical care.

My new web site and blog has been set up as a place to consider these ideas, the relevant research, the experiences of clinicians, the input of people affected by high blood glucose and the implications for individuals and for public health.

www.carpeyourbloodsugar.com

Still in infant form, please visit “Carpe your blood sugar”.

A blog reporting glucose impact of low-carb products

Aside

This site helps fill a need. Low Carb Review is a new site dedicated to reporting the results of one person’s test trials of low carb foods and products.  He reports the part that matters, which is the rise in blood sugar after eating.  His test subject is himself, but, being an engineer, he takes a very careful approach.

Each person’s blood sugar responses can be unpredictably different, but still this is helpful and a valiant contribution.

I think the pumpkin and ricotta cheese breakfast dish is tempting (he refers to this as pumpkin “cereal”).  You can click through from his site to the recipe, which he found on About.com Low Carb Diets.

Low Carb Review  lcreview.org

Impact of high blood glucose on vascular events and death

This study is just published.  When looking at this study, there are four key factors to consider:

  • This is a study that looks at correlation, it does not specifically test cause. People who had evidence of sustained exposure to higher blood glucose levels had worse outcomes, for whatever mix of reasons.
  • This study did not look at micro-vascular disease (such as nerve damage, kidney damage or eye damage) or rate of deterioration of glucose control, so the study does not say that there might not be health benefit from achieving a HgA1c of less than 6.5%
  • I’ll have to wait to see the full text of the study (and consider input from others who will doubtless publish commentary) to consider what further might be said of this study. For example, the fact that the results of the study did not suggest a protective effect from having HgA1C below 6.5% could be related to low numbers of the study group reaching such a relatively good level of control – although this was probably accounted for. Only further examination of the full study report will tell.
  • Also, HgA1C is only one way of looking at blood glucose levels.  It does not give information about aspects of blood glucose that vary between people, such as the degree of elevation of fasting glucose versus glucose spikes after meals.
Diabetologia. 2012 May 26.

Relationship between HbA(1c) levels and risk of cardiovascular adverse outcomes and all-cause mortality in overweight and obese cardiovascular high-risk women and men with type 2 diabetes.

Department of Cardiology, Gentofte University Hospital of Copenhagen, Niels Andersens vej 65, 2900, Hellerup, Denmark, ca@heart.dk.

Abstract

AIMS/HYPOTHESIS:

The optimal HbA(1c) concentration for prevention of macrovascular complications and deaths in obese cardiovascular high-risk patients with type 2 diabetes remains to be established and was therefore studied in this post hoc analysis of the Sibutramine Cardiovascular OUTcomes (SCOUT) trial, which enrolled overweight and obese patients with type 2 diabetes and/or cardiovascular disease.

METHODS:

HRs for meeting the primary endpoint (nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death) and all-cause mortality were analysed using Cox regression models.

RESULTS:

Of 8,252 patients with type 2 diabetes included in SCOUT, 7,479 had measurements of HbA(1c) available at baseline (i.e. study randomisation). Median age was 62 years (range 51-86 years), median BMI was 34.0 kg/m(2) (24.8-65.1 kg/m(2)) and 44% were women. The median HbA(1c) concentration was 7.2% (3.8-15.9%) (55 mmol/l [18-150 mmol/l]) and median diabetes duration was 7 years (0-57 years). For each 1 percentage point HbA(1c) increase, the adjusted HR for the primary endpoint was 1.17 (95% CI 1.11, 1.23); no differential sex effect was observed (p = 0.12 for interaction). In contrast, the risk of all-cause mortality was found to be greater in women than in men: HR 1.22 (1.10, 1.34) vs 1.12 (1.04, 1.20) for each 1 percentage point HbA(1c) increase (p = 0.02 for interaction). There was no evidence of increased risk associated with HbA(1c) ≤6.4% (≤46 mmol/l). Glucose-lowering treatment regimens, diabetes duration or a history of cardiovascular disease did not modify the associations.

CONCLUSIONS/INTERPRETATION:

In overweight, cardiovascular high-risk patients with type 2 diabetes, increasing HbA(1c) concentrations were associated with increasing risks of cardiovascular adverse outcomes and all-cause mortality.

PMID: 22638548

Do you know where your blood sugar climbs after eating?  BloodSugar101.com

A Sunday Morning in June

When “normal” blood sugar is not normal:

A great day to save life and limb …

On a Sunday morning, some reading that is all about taking charge of your health, getting results and protecting your future.

This is the introduction to the BloodSugar101.com website, it will open in a new window.

“A Very Brief Summary”

The focus of this particular article is controlling blood sugars when you have diabetes.

In her new book, Diet 101, Jenny provides the reasons why every person should be aware of their blood sugar health, even if they do not meet the lab test cut-off values that are used in the diagnosis of diabetes or pre-diabetes. She covers how to understand your blood glucose (“sugar”) test results and then what you can do to claim your health.

To encourage you to linger a while and learn about this vital aspect of protecting your health, here is some music to go along with your reading:

Michael Hedges, Aerial Boundaries

The Four Faces plus Black Box of Low Carb

Tailoring a Carb Control Plan Just for You, Today and Tomorrow, Requires Understanding Your Personal Health Needs:

Part One: The Four Faces Plus Black Box of Low Carb

Did you know there may be wonderful health benefits even if you do not follow the kind of very strict low carb diets you may have heard of or may have undertaken yourself in the past?

Don’t let the goal of perfection cause you to lose out on claiming and keeping your gold nugget to be found within a controlled carb eating lifestyle.

The key is to understand which benefits from carb control are important specifically for you. This will allow you to find the choices that bring the most benefit for the least “cost” in terms of changes you are willing to make.

Low carb eating is actually four medical interventions mixed together:

  • (1) it reduces the need for insulin, and thereby reduces the impact and expression of metabolic syndrome, which at its core is insulin resistance (with initially higher levels of insulin and later falling and inadequate levels of insulin) and inadequate control of blood glucose levels. Other aspects of metabolic syndrome include weight gain in the abdomen, a tendency to develop high blood pressure and changes in blood lipids, most specifically an increase in triglycerides and decrease in HDL
  • (2) it is a means to maintain abstinence for people who find that they have an addiction-like response to sweet or starchy foods OR to fatty or salty foods that are also sweet or starchy. They can learn that they do not need to eat any sweet or starchy foods and therefore abstinence is available as an option.
  • (3) it improves the ability to maintain a stable blood sugar within the healthy range by dietary means with or without the help of medications. It also can be used as a means to reduce the doses of medication needed, therefore reducing the risk of adverse effects.
  • (4) it allows a person to be in the metabolic state known as “nutritional ketosis“.

… and a black box:

Are there other basic mechanisms by which a low carb or controlled carb lifestyle can help your health?  Probably yes. There is a lot of discussion about other possible mechanisms of benefit.  Much is speculated and much more is unknown. The answers to many questions still lie in a black box that needs to be illuminated by research.

The biggest question is probably whether being on a very low carbohydrate diet with a resulting state of nutritional ketosis provides a “metabolic  advantage” in weight loss by leading to increased non-activity burning of calories.  There is some evidence that a low carb diet can lead to less systemic chronic inflammation.  The research on this is only in the early stages and it will be difficult to separate what effects are from the change in carbohydrate intake itself and what of the effects are from changes in adverse effects from specific food stuffs, like gluten.

By understanding your own health needs and responses, you can make plans you find to be worthwhile staying with long term and you can understand how to sensibly adjust your eating plans when needed.  This way, everything becomes about what you find worthwhile.  The more you understand about your options, and the more you understand about your individual needs, the better this will work out.

People are unpredictably different. This has to be kept in mind when listening to other people’s stories of how any particular thing they have tried has worked out for them.

This is especially true when hearing about other people’s experiences when they have decided to take control of the carbohydrate in their diet – whether by cutting back on sugar, or changing the type of carbohydrate foods they eat, or cutting down to a very low amount of total carbs.  The reason is that these kinds of changes in the diet can be beneficial in so many different ways.  For any one person who finds benefit from reducing or changing the carbs in their diet, any one of many different effects may be responsible for that benefit – or the benefit could come from many different factors acting together.  The story you are listening to may be the experience of someone whose health needs are not similar to yours.

Sources of Confusion Can Cloud the Picture

When people switch to controlled carb or low-carb eating, there are many things that occur that can affect symptoms and health that have nothing to do specifically with the change in carbohydrates themselves. For example, some of these could be:

  • the enthusiasm of starting something new
  • the breaking of old habits and patterns
  • change in meal times
  • an increase or, more often, a decrease in caffeine consumption, which can lead to various effects such as a severe withdrawal headache
  • starting to eat (or eat more of) some food the person has an adverse reaction to
  • more commonly, stopping eating (or eating much less of, at least for a time) some food that the person has an adverse reaction to. This can be very confusing and it is of great importance that such problems be actively sought out and identified (see my posts on the importance of recognizing gluten sensitivity even in those people committed to a low-carb and/or grain-free lifestyle).
  • a decrease in alcohol consumption, with various possible consequences up to withdrawal symptoms.

The list of things that can confuse the picture could go on and on.

What is meant by a “controlled carb” eating plan or lifestyle?

That term is used when a choice has been made to control the types and/or the amounts of carbohydrate-containing foods that are eaten.

“Controlled carb” can mean anything from:

  • “A” (what most would consider the first level of control – cutting back or eliminating liquids with sugar in them, such as soft drinks and fruit juice) but not trying to cut back on the total carbs in foods in a day, to
  • “Z” (a very low carb diet with less than 20 grams of carbs and only as much protein as needed for health)
  • and everything in between, which represents a vast array of choices.

This does not refer to choices made for reasons other than the amount or type or form of starch and/or sugar content of the food eaten.** For example, a person might decide to eliminate wheat due to concerns about immune reactions to gluten or concerns about other potential harmful effects from wheat (for example, the human digestive tract is not able to properly digest gliadin).  That wheat elimination would not be, in itself, a controlled carbohydrate program.  Many people who have decided to limit or control their carbs also have eliminated wheat with or without a full gluten elimination, but it is important to keep in mind the differences between metabolic effects (e.g. sugar), toxic effects and immune effects.  Because it is acting through the immune system, gluten can be an issue for people down to 20 parts per million, whereas it takes gram levels of sugar or starch to have an effect on metabolism.

An Aside: Keep in mind that no research studies can ever offer firm conclusions about what will be best for you personally. In the end, after all the research and information is looked at, it always comes down to three stepsFirst, the available choices must be considered in terms of their suitability for that particular person, in their particular circumstances and at that particular time.  Second, if an intervention (treatment or lifestyle change) is chosen and undertaken, it is always an individual trial-of-therapy and third, the results have to be assessed.  One can never take the expected results for granted.  Again, we are just so unpredictably different.

** Technically, the term “dietary carbohydrates” includes dietary fiber

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Diabetes – Not Just Type 1 and Type 2 Anymore

English: Diagram shows insulin release from th...

English: Diagram shows insulin release from the Pancreas and how this lowers blood sugar levels. (Photo credit: Wikipedia)

Need for Wider Recognition of Non-Classic Forms of Diabetes

Almost all discussion of diabetes revolves around what are called Type 1 diabetes and Type 2 diabetes.  Type 1 diabetes is the term used when there is a very low or absent production of insulin, due to destruction of the type of cells in the pancreas that make insulin.  Classically, this onsets in childhood and is the result of an immune attack on those cells.  The term is also used when those cells are destroyed by other processes.  An example would be repeated or severe bouts of pancreatitis (inflammation of the pancreas), which may bring a great deal of pancreatic tissue destruction.

Type 2 diabetes is the term used when the amount of insulin being produced is as much (or more) as would normally be needed to do its job, but the blood glucose is high because the signal of the insulin is not being recognised properly at the level of the cells – most prominently, in terms of blood sugar levels, the muscle cells and the liver.  The cells are “resistant to insulin”, and the person has “insulin resistance”.  The insulin production is higher than normal, but not high enough to keep blood glucose in the normal range, die to cells not responding properly to the insulin.

These two types can also get mixed up together.  A person with Type 1 diabetes (not able to produce enough or any insulin) can also becomes resistant to insulin, which would mean that they need higher amounts of insulin to keep their blood sugar controlled.  Someone with Type 2 diabetes can, over time, have a gradual destruction of their ability to make insulin, becoming more like a Type 1 diabetic.

It turns out there is more to the story.  There is also MODY and LADA.  It turns out that these need to be included more in our awareness.  The term “MODY” is an acronym for “Maturity Onset Diabetes of the Young” and “LADA” is an acronym for “Latent Autoimmune Diabetes of Adults”.

For an explanation of these, I refer you to Jenny Ruhl’s site, BloodSugar101.com.

Keep in mind as you read these two articles that our present understanding of both LADA and MODY is not well developed. More research will fill in gaps in our knowledge, so it is to be expected that the known facts and the concepts will develop over time.

From Diabetes in Control comes an article discussing new findings about LADA:

AACE: Latent Autoimmune Diabetes in Adults often Misdiagnosed

Almost half of nonobese adult with poorly controlled diabetes have latent autoimmune diabetes that has been misdiagnosed as type 2 diabetes….

Ankit Shrivastav, MD, from the Institute of Postgraduate Medical Education and Research in Kolkata, India, said that, “Young, nonobese, adult-onset diabetic patients with a negative family history, a rapid deterioration of glycemic control, and a rapid onset of complications should be screened for autoantibodies.”

Here is a recent article about MODY:

“Systematic Assessment of Etiology in Adults With a Clinical Diagnosis of Young-Onset Type 2 Diabetes Is a Successful Strategy for Identifying Maturity-Onset Diabetes of the Young”

It is time for these two other forms of diabetes, which had been thought of as uncommon, to be included more generally in our thinking and our approach.

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Sugar Damage and Related Research

For anyone interested in looking “behind the scenes” at the research that goes into development of medical knowledge, this is a link to what I have been doing this morning. (Note: it is not obvious, but there are 4 pages, you click at the top right.)

http://www.ncbi.nlm.nih.gov/sites/myncbi/collections/public/18SLu9dl8FbUgixFr7tzWyi/

I have spent the past couple of hours looking at research related to damage from high blood sugars and from molecules that have been damaged by sugar (glycation). Some of these molecules are called AGEs, which is Advanced Glycation End Products. In the body, these attach to receptors, which are thus called RAGEs, or Receptors for Advanced Glycation End Products. It gets confusing as AGEs aren’t the only damaging molecules from high blood sugars. On top of that, it is now known that RAGEs react to many other molecules that occur within the body, not just those related to sugar damage.

AGEs are produced in your body and they are also present in foods. The AGEs present in foods (bacon is, sadly, the source of the greatest amount of AGEs in the typical North American diet) have been shown in research to have damaging effects.

This list of published papers is in no way an attempt to be complete, just some interesting ones I have set aside in a list, published in the past few months, to pursue in more depth later. To be more complete, I would do other searches on PubMed  using related search terms or following the work of specific researchers. For example, the older citations on the list are because I followed backwards Dr. Ceriello’s work, for example:

Vascul Pharmacol. 2012 May 16. [Epub ahead of print]

The emerging challenge in diabetes: The “metabolic memory”

Ceriello A.

Abstract

Large randomized studies have established that early intensive glycemic control reduces the risk of diabetic complications, both micro and macrovascular. However, epidemiological and prospective data support a long-term influence of early metabolic control on clinical outcomes. This phenomenon has recently been defined as “metabolic memory.” Potential mechanisms for propagating this “memory” may be the production of reactive species unrelated to the presence of hyperglycemia, depending on the previous production of AGEs which can maintain RAGE over-expression, on the level of glycation of mitochondrial proteins and on the amount of mtDNA produced, all conditions able to induce an altered gene expression which may be persistent even when glycemia is normalized. Clinically, the emergence of this “metabolic memory” suggests the need for a very early aggressive treatment aiming to “normalize” the metabolic control and the addition of agents which reduce cellular reactive species and glycation in addition to normalizing glucose levels in diabetic patients in order to minimize long-term diabetic complications.

Copyright © 2012. Published by Elsevier Inc.  PMID:22609133

I generally will look at a thousand or so of these “abstracts” of published papers in a typical week, on many different health-related topics, but mostly regarding diet and nutrition.

The place to go online for information about AGEs is to the website The AGE-less Way, where you can learn about this subject and the very important work of Dr. Jaime Uribarri MD and Dr. Helen Vlassara MD.  There is much useful info on their site and they also have a book out, The AGE-less Way, available in print and on Kindle.  Dr. Uribarri was interviewed by Jimmy Moore in January 2012. http://www.thelivinlowcarbshow.com/shownotes/5670/532-dr-jaime-uribarri-warns-of-disease-making-advanced-glycation-end-products-ages/

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