Wednesday, January 17, 2018

The Most Important Thing

People sometimes ask me, "What's the most important thing to do if you're diagnosed with type 2 diabetes?'


Well, actually, I don't usually shout, but I sometimes want to. If you're reading this, then I think you're taking this disease seriously, trying to learn as much as you can about it so you can control it.

But too many people don't. They want the doctor to give them a pill so they can go on exactly as they have in the past, eating too much, especially foods that make their blood glucose (BG) go up, and getting no exercise.

One problem in type 2 control is that the results of not controlling well aren't immediate. You won't break out in blue spots if you a big piece of chocolate cake with ice cream. Your hair won't turn pink if you eat a huge pile of mashed potatoes and gravy with Texas toast on the side. Some people feel bad when they have high BG levels. Others don't.

I was diagnosed with fasting levels in the 300s, and I went into the 400s after meals. But I felt fine.

No, the effects of high BG levels are insidious. The glucose gloms on to various substances in your body and eventually causes complications. The damage from the glucose can result in cataracts, retinopathy that can lead to blindness, neuropathy that can make your feet hurt all the time, vascular problems that lead to heart attacks, amputations, and impotence, kidney disease, and more.

None of these complications are pleasant. But if you take this disease seriously and control your BG to normal or near-normal levels, the chances that you'll get complications are low.

It's not easy.Watching your friends pig out at an ice cream stand while you drink a cup of black coffee, no sugar, isn't fun. Different people have different ways of dealing with this. Some can eat just a couple of spoonfuls of some treat and leave the rest. Others find it works best to avoid the treats altogether. I'm in the latter group. If I ate a couple of spoonfuls of some treat, I'd crave it all. When I haven't eaten bread, cake, and ice cream for years, I no longer want them, even if all around me are eating them.

This situation of not wanting the treats isn't instantaneous. It takes a while before you can deal with these situations easily. But persistence pays off.

Well, I'd rant on and on, but right now I'm craving a lamb chop with broccoli and butter, so I'd better go.

Thursday, December 21, 2017

Reactive Hypoglycemia: a cautionary tale

For many people, losing a lot of weight results in blood glucose (BG) levels at or close to normal, and your doctor may tell you that you're no longer diabetic. If this happens to you, first of all you should be congratulated for the difficult job of losing weight. That's wonderful.

But you should also be vigilant to make sure you don't get reactive hypoglycemia, which means very low BG levels after you've eaten a lot of carbohydrate. This can happen even when you're not diabetic.

I had reactive hypoglycemia about 20 years before I got the diabetes diagnosis. At the time, I was a night owl and hated getting up early in the morning. But occasionally, at the daily newspaper where I worked, I had to do the "wire desk," which meant arriving at 7 am. Because I hated it so much, I'd treat myself to a chocolate doughnut. Usually I didn't eat breakfast at all.

Then at almost exactly 4 hours after the doughnut and black coffee, I'd get the shakes and feel as if I'd die if I didn't eat something. In fact, I could almost set my watch by this phenomenon. "Oh. The shakes. It must be 11 o'clock." Then I'd eat a candy bar and feel fine for the rest of the day.

Why does this happen?

Insulin secretion is biphasic. When a nondiabetic eats a carbohydrate food, the pancreas quickly spurts out a pulse of insulin. This pulse doesn't last very long but it's enough to keep the  carbohydrate that reaches the intestine from going very high. It also suppresses the production and release of glucose from the liver. This is called the phase 1 or first phase insulin response.

Then insulin is secreted continuously as long as carbohydrate comes into the system in proportion to the amount of carbohydrate reaching the intestine. This is the phase 2 or second phase insulin response, and it lasts much longer than the first one.

The food that we eat, including carbohydrate, isn't dumped into the intestine all at once. Instead, the stomach releases only a certain amount at a time, usually containing about the same number of calories, so the insulin release is pretty steady. Liquids leave the stomach faster than solids.

Unfortunately, those of us with type 2 diabetes tend to lack a first phase insulin response and may have lacked it for a long time before we were diagnosed with diabetes. This means that when we eat carbohydrate, our BGs aren't knocked down by that first insulin pulse, so they go much higher than they would in a nondiabetic who ate the same amount of carbohydrate. Then the body sees these high numbers and assumes they're that high despite a first phase insulin response. So the second phase response is extra strong, and with all that extra insulin, we may go low. Some people call this "too much too late."

Now, no one really knows at what point in our life the first phase insulin response is eliminated, although there is evidence that first-degree relatives of people with diabetes have impaired first-phase insulin responses despite having normal BG levels.  We also don't know if or when the first phase is restored when people normalize BGs enough to be considered nondiabetic again.

I was in a clinical study in which they did an intravenous glucose tolerance test that measured both BG and insulin after a huge dose of glucose. I started with almost no phase 1 response. But after I was on the study drug (salsalate) for a couple of weeks, the phase 1 response was restored to about 70% of normal, which is consistent with the idea that the situation is reversible.

Weight loss alone may or may not restore the phase 1 response, but there's some evidence that phase 1 is restored after weight-loss surgery.

So if you've reversed your diabetes so that your BG levels are in normal ranges, you may still lack that phase 1 response and be sensitive enough to large carbohydrate loads that you'll have reactive hypoglycemia.

That happened to Joseph recently. He had lost a lot of weight after gastric bypass surgery, and his BG levels were usually normal, but he still watched his diet and didn't go overboard with the starches. Then one day he was at a football game, and it was very cold and his friends had a lot of tasty crackers with them, so he ate some. No, he ate a lot. A few hours later, he felt odd and tested his BG. It was 35. Luckily, he wasn't alone, and someone gave him some juice and he recovered.

I have no idea how low I was when I worked the wire desk and got the shakes after eating a doughnut with black coffee. But I do know it was very unpleasant. So if you're a recovered diabetic, be vigilant and don't let this happen to you. Avoid carbohydrate fests, especially on an empty stomach. And if you can't avoid them, make sure you have available some glucose tablets or other food that will raise BG quickly in case you do go low.

Reactive hypoglycemia is counterintuitive ("How could I be low when I just ate all those carbs?"), but it can be serious. You can outsmart it, though, if you're prepared.


Tuesday, December 5, 2017

Being Positive

Getting a diagnosis of diabetes can be pretty depressing. Then we're usually given a lot of admonitions about things we can't do. Don't eat this. Don't eat that. Don't eat too much of anything. Don't drive without testing first. Don't sit down and read a book when you could be walking on a treadmill. And the list goes on.

Thus it's a pleasant change when one comes across some diabetes information that is positive.

One such find is an article by type 1 blogger and author Riva Greenberg and Boudewijn Bertsch that describes their approach to diabetes treatment. They are currently traveling around the world teaching health care people how to implement their approach and report that they are getting a lot of interest.

"Last night in Almelo, the Netherlands, 62 doctors got it. And trust me, a Dutch crowd isn’t easy," Greenberg wrote on her Facebook page.

They call their approach the The Flourishing Treatment Approach, and it focuses on health rather than on disease, the positive rather than the negative.

The authors call traditional treatment a Coping Treatment Approach, in other words treating a disease and helping people cope with the difficulties caused by the disease.

Their Flourishing Treatment Approach, on the other hand, focuses on the causes of health instead of the pathogenesis of the disease. For example, rather than asking how the patient is coping with "dietary challenges," the health care person should focus on "dietary successes" and ask the patient to think of ways of increasing these successes.

I think many health care professionals (like many parents) want to improve their patients' (or children's) lives by pointing out their faults so they can correct them. If you have a stellar hemoglobin A1c, they won't mention that but will point out that you need to lose more weight. I've heard many patients complain about that and say it makes them depressed, because no matter how hard they work to improve their health, they get criticism rather than praise.

Focusing on the positive results should give patients an incentive to obtain more of them, and everyone should benefit.

The other source of a positive approach is Adam Brown's book Bright Spots & Landmines: The Diabetes Guide I Wish Someone Had Handed Me. Brown has type 1 diabetes. He is a senior editor at and leads Diabetes Technology & Digital Health at Close Concerns. He calls things that work and should be done more often Bright Spots, and things that don't work and should be done less often Landmines.

For example, Brown finds that eating breakfast foods high in protein, fat, and fiber is a Bright Spot for him. Other than eggs, one example is his chia seed pudding, which also includes nuts, seeds, coconut oil, and berries. The recipe is in the book. Eating white foods like bread, potatoes, rice, and so forth is a Landmine. He says that the Landmines should be done less often; he doesn't say you should never do them, which is more daunting.

The good thing is that Brown has put the Bright Spots ahead of the Landmines in his title. Like the Flourishing Treatment approach, this ordering tends to make the reader focus on the positive instead of sulking about the negative.

Sure, there's definitely a downside to having diabetes. But I think focusing on that just makes things worse. Let's focus on flourishing with Bright Spots and dietary successes instead.

Friday, November 10, 2017

It's the Patient's Fault: Not

A lot of doctors don't understand how difficult it is to make major lifestyle changes of the sort that most everyone agrees will help to control type 2 diabetes. "Lose weight!" they'll say, although you may have been trying to lose weight for most of your life and not succeeding. "Get more exercise!" they'll say, even if you've been going to the gym religiously every day.

But one doctor is trying to teach medical students how difficult it is to be a type 2 diabetes patient. In  an editorial in Clinical Diabetes, Stephen Brunton describes how he tried to train medical students by asking them to give up something they loved for just one month. Just one month! Only 2 of the 40 who took part were able to comply. That means 95% failed.

Yet physicians and other medical people routinely tell diabetes patients to give up certain foods or certain behaviors not for a month, but for the rest of their lives. Is it surprising that many don't succeed?

Of course, not everyone says to newly diagnosed patients that they'll never be able to eat a doughnut again, but it's implied when they are told to eat a turkey sandwich on whole-grain bread and an apple (the favorite of nutrition writers) instead of the burgers and fries and pie that they love.

Brunton's approach isn't going to make being a type 2 diabetes patient easy. But I think patients are more apt to work with health care people who understand the problems. "Lose weight" isn't useful. Better would be to suggest keeping a food log and then looking for ways to cut back on unhealthy foods.

I once met a health care worker from Missippi who was making a booklet designed to help overweight people lose weight. She had a "before" photo of a big burger and a big order of fries, the meal taking up the whole plate. Then the booklet had a photo of what the patient should eat instead: a tiny burger and three fries, most of the plate empty. But to anyone with a huge appetite who has always eaten huge meals, a tiny burger and three fries would seem like a punishment. And they'd still be hungry. She apparently didn't understand what it was like to live with a huge appetite.

I wondered if it would work better to show a big burger without the bun and a huge mound of green beans, or some other vegetable that the patient enjoyed. That way, the meal would still take up the whole plate and would also take up room in the stomach, helping to dampen hunger.

Whatever, I think if more physicians tried to look at the problems of living with diabetes from the point of view of the patient rather than just wondering why the patients didn't improve, we'd see more progress.

"She just won't lose weight." Maybe she can't. Maybe there's something wrong with her appetite control so she's ravenously hungry all the time. It's almost impossible to not eat when you're ravenously hungry.
"He doesn't exercise." Maybe he works two jobs and commutes for two hours and just doesn't have the time or energy for formal exercise.
"I doubt that he takes his meds." Maybe he can't afford them.

Feeling that your physician understood your struggles would help a lot more than just being told to do this and give up that. No one really understands how difficult it is to live with diabetes unless it happens to them, but at least Dr Brunton is trying. Let's hope his editorial motivates some physicians to change their approach.

Thursday, November 2, 2017

Whole Grain Spinning

It's interesting how news reports of nutritional studies can spin the results, probably without the authors realizing that's what they're doing.

Take a recent report titled "Several reasons why whole grains are healthy." Now, you see a headline like that and you're apt to think "Whole grains good" and you might eat more of them, increasing your carbohydrate consumption.

Yet the article might just as well have well been titled "Several reasons why processed grains are not healthy." In that case you would be apt to think, "Processed grains bad" and eat less of them. Instead,  you might eat more whole grains, or you might eat more fish or broccoli or beef or whatever. And if you have diabetes, the latter would be more beneficial for your blood glucose levels.

The study I cited took 50 adults at risk of cardiovascular disease or diabetes and had them substitute whole grains for the processed grains they usually ate. They found that doing so reduced the amount of inflammatory markers in these adults.

I have no problem with the study or the results. Just with the way it's spun.

Wednesday, October 18, 2017

Controlling Weight

Controlling weight is affected by so many physiological factors it's sometimes difficult to keep track. Before 1994, when leptin was discovered, people thought weight control was simply a matter of willpower. Now we know better.

Most of us know that leptin is secreted by fat cells when we have had enough to eat and the fat cells are full, and the leptin turns down our appetite. Children born without leptin have voracious appetites and become obese as toddlers; when given leptin, they slim down. People with no leptin are rare, but overweight people may have leptin resistance, just as people with type 2 diabetes have insulin resistance. In both cases, levels of the hormones can be high but the body doesn't respond to them properly.

On the other hand, the hormone ghrelin is produced by the stomach when we haven't eaten, and it makes us hungry.

Now a third hormone has been discovered that increases appetite during fasting and decreases it during feeding. It has been named neurosecretory protein GL, usually referred to simply as NPGL.
This hormone not only affects appetite, but it also increases the storage of fat, even on a low-calorie diet.

Another study found a gene with the snappy name GTRAP3-18 that helps to regulate both food intake and glucose levels. Mice without this gene were both lean and hypoglycemic, and this was due to neither less activity nor an increased metabolism, but rather to eating less. The authors suggested that the gene could be a target for drugs, saying, "Eating too much or too little could actually be a genetic problem," although we know that other factors such as emotions and the food environment can play a role as well.

A third study found yet-another protein with a snappy name, MKK6, that affects weight by stimulating the burning of fat to generate heat. Overweight people seem to have higher levels of MKK6, which hinders the conversion of white fat cells into brown fat cells. White fat cells store fat, and brown fat cells burn fat.

A fourth study described brain cells called tanycytes that detect nutrients and tell us when we've eaten enough. Foods high in certain amino acids (the building blocks of protein) activate the tanycytes and make us feel full sooner, which is consistent with the commonly stated fact that protein is satiating. Interestingly, the receptors in the tanycytes are the same as those in the tongue that detect the umami flavor of protein foods.

The two amino acids that react the most with the tanycytes are arginine and lysine. Foods rich in these amino acids include pork shoulder, beef sirloin, chicken, mackerel, plums, apricots, avocados, lentils and almonds.

Finally, a Swiss study showed that severely obese people release fewer satiety hormones than people of normal weight because they have fewer of the intestinal cells that produce the satiety hormones than normal-weight people. Weight-loss surgery seems to increase the number of these cells.

We all know that weight loss, and especially maintenance of weight loss, is difficult. One reason is that there are so many factors involved (and I'm sure even more will be found in the future), and different people may have deficits in different systems.

In fact, an Israeli study showed that the glycemic index of various foods could vary a lot between individuals. A food that was problematic for one person might be fine for another. And for some individuals, even white bread seems to be better for blood sugar levels than whole grain bread.

Even the bacteria in your gut may affect whether or not you will lose weight on a diet with a lot of fruits, vegetables, fiber, and whole grains, according to a Danish study. So if some recommended diet doesn't work for you, it may not be that you're "doing it wrong." It may be that the diet isn't the right one for you.

What this all means is that it's up to us to take charge and find out which diets are best for our personal physiology. It's a lot more work than simply following guidelines set by some "diet expert." But it's worth the effort.

And it's encouraging that so much research is going into what factors govern appetite and fat gain or loss. In the long run, this basic research should lead to real solutions. Let's hope funds for basic research aren't cut any more in a misguided effort to save money. In the long run, figuring out the best way for people to lose weight and keep it off will save even more money from health care expenses than the costs of the research.

Wednesday, August 30, 2017

Information overload

One of my favorite cartoons, which I have pasted on my desktop computer, shows a man with a little beach pail standing on a beach while a huge wave (which looks like the woodcut "Great Wave Of Kanagawa" by Katsushika Hokusa) is about to break over him. The man is saying, "Eureka! More information."

(I can't show the cartoon here because it's copyrighted. I was going to link to the author Ted Goff's page, but he's apparently updating his website and the links don't work for now.)

This cartoon illustrates how I feel about science news these days. I get about 150 Eurekalert science press releases every day, as well as the tables of contents from a lot of journals. And it seems as if just as some fact is generally accepted, a paper comes out refuting that fact.

Also, science research is getting much more technical these days. Unless a study is commissioned by some commercial group like the the California Walnut Commission, which funds a lot of studies showing the health benefits of walnuts when some of those benefits might be found by eating similar nuts, people no longer tend to publish simple studies saying that factor X increases or decreases diabetes symptom Y. Instead the authors (often 20 or more) drill down to the molecular level and try to show that factor X increases or decreases the level of numerous cell factors that govern gene expression or hormone activity.

Unless the reader has a background in biochemistry or molecular biology, I figure the reader probably wouldn't understand these studies (sometimes I don't either), so there's no point in discussing them.

Also,  unless I think there's a major flaw in the evidence, I see no need to link to a study that has been picked up by all the news media, something like "Eating pickles and figs will make you lose 10 pounds in a week." You'll most likely see that study on the TV news anyway.

All this is a way of explaining why I'm not blogging much at the moment. But I haven't disappeared. I continue to try to keep up with new research developments, and when something both interesting and comprehensible by the average reader comes out, I'll let you know.

Hang in there. I'm trying to.