Access Dr. Bernstein – diabetes control with low carb

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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

Sleep Link to Cravings

Just out is a study of sleep apnea in people with diabetes.  This is a small study, but worth noting.  LINK to report of study in Medical News Today.

They report:

“They found that in a small sample of clinic patients, the risk for sleep apnea was high among diabetics compared with non-diabetics, and that sleep apnea appeared to be associated with carbohydrate craving.”

The researcher comments:

“Previous studies have shown that sleep deprivation may lead to changes in hormones that regulate appetite and hunger,” Siddique said. “These hormonal changes can lead to significant craving for high-calorie carbohydrates such as cookies, candy, breads, rice and potatoes. The current study supports previous findings by validating this in a community sample of diabetics.”

Have a look at the article to get a better understanding of what was found and what it means.

Reference:

American Academy of Sleep Medicine. (2012, June 15). “Link Between Sleep Apnea And Increased Risk For Carbohydrate Craving Among Diabetics.” Medical News Today. Retrieved from http://www.medicalnewstoday.com/releases/246563.php.
Addendum June 16th, in response to the comment below regarding observational studies:
The many limitations of observational studies are well known and always important to keep in mind.  They do provide a useful role in suggesting directions to look when trying to figure out actual cause and effect.  For many of the questions we need answers for, studies that could validly test for cause and effect are hard to come by or even in practice not going to be done, due to issues of study size, study costs, or simply what would have to be done to the human subjects in the process of testing for cause and effect.
In the case of this study, you get some insight into the motivation to conduct the research when you look towards the end of the article:
“The management of patients with diabetes and or metabolic syndrome based solely on pharmacotherapy, exercise and nutritional modifications without taking into account the risk of sleep apnea may not lead to optimal outcomes for patients suffering from these chronic diseases.”
It seems they are looking to build a case for more attention to the problem of sleep apnea in the era of managed care and protocol-driven medicine. Notice they do not claim any proof of causation and they are not trying to use the study results found in order to justify an intervention of any sort (medication, lifestyle or otherwise), just to justify more awareness of the need to explore for possible sleep apnea in people with diabetes.  Obviously, the well-known “big neck” rule is not succeeding in getting the job done, leaving people suffering from sleep apnea undiagnosed.
Here is a post which links to a discussion between 2 couples regarding their experiences with low-carb, real foods living. Part of the conversation is about sleep apnea.  LINK

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”.

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

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.

Short Link for this article http://wp.me/p2jTRh-9Z

Review: Diet 101 by Jenny Ruhl

Diet 101: The Truth About Low Carb Diets (Kindle Edition)
This book is a natural continuation on from the author’s on-line interactions and blogging that led to her remarkable contribution Blood Sugar 101. There has been a perception that the main value of choosing to change the amount or type of carbohydrates (sugars and starches) in your diet is as a weight loss diet. Also, there has been a perception that this strategy is only valuable if applied very strictly – and this strict application then means that many people find it too difficult to keep up over time.

In Diet 101, Jenny Ruhl emphasises the fact that the greatest value from controlling carbs is in keeping blood sugars within the normal, non-damaging range. What if you’re not diabetic? Many people who do not meet the cut-off blood sugar test levels to be diagnosed with diabetes have blood sugar levels, at least for parts of the day, that are associated with slowly-accumulating harm to health. This problem is very widespread in our society.

What to do? This damage can be avoided, or at least lessened, by changing your intake of carbohydrate foods – by just as much as you need to and/or are able to. Even changes less than targeting perfection can bring benefits you might really value.

Jenny Ruhl explains all this in her new book in a clear, easy to understand manner, with all the back-up science also available for those who are interested. Also, she ties the excess swings in blood sugar to excess hunger drive and the tendency to gain weight. To be useful, this needs to be practical day-to-day, which is an important goal and strength of the book.

My review on Amazon of Jenny Ruhl’s new book.

Update: Please see my blog “Carpe Your Blood Sugar” inspired by the work of Jenny Ruhl and Dr. Richard K. Bernstein.  Links on the Resources page there to 3 interviews with Jenny.  www.carpeyourbloodsugar.com

(This post short link http://wp.me/p2jTRh-6F).

Sunday Stories

Sunday is a good day for stories of hope and inspiration.

Personal stories of benefit from low-carb/controlled-carb nutrition:

Jenny Ruhl, diagnosed with diabetes in 1998

Personal stories on Dr. Andreas Eenfeldt’s blog

Dr. Jay Wortman’s personal story

If you would like to inspire others with your personal story, but don’t want to do this on a blog, Tumblr, etc, a good option is Ancestral Weight Loss Registry (listed under LINKS).

A comment by Dr. Richard Feinman on another site, quoted in full:

RIchard Feinman · Professor of Cell Biology (Biochemistry) at State University of New York Downstate Medical Center

“People need to do what works for them.”  How do you find out what works best for you. Diabetes is a disease of carbohydrate restriction. The first thing to try is to keep carbohydrates as low as possible. If that doesn’t work, you might want to try something else but it is always good to start with the science. As Dr. Eric Westman put it: At the end of our clinic day, we go home thinking, “The clinical improvements are so large and obvious, why don’t other doctors understand?” Carbohydrate restriction is easily grasped by patients: because carbohydrates in the diet raise the blood glucose, and as diabetes is defined by high blood glucose, it makes sense to lower the carbohydrate in the diet. By reducing the carbohydrate in the diet, we have been able to taper patients off as much as 150 units of insulin per day in 8 days, with marked improvement in glycemic control-even normalization of glycemic parameters. Read more at http://www.inquisitr.com/193759/diabetes-a-growing-threat-with-no-single-dietary-answer/#Hk7Sl0wpw3xtP5Eh.99.
(I believe he meant to say “Diabetes is a disease of carbohydrate intolerance”).