November 24, 2008

Another Great Gift Idea

I was banging around the kitchen yesterday and, as I often do, I threw something on my food scale to see how large it was, only to realize that I'd forgotten to list the food scale on my list of useful gifts for people with diabetes.

The food scale is a wonderful, and very affordable, gift that would be appropriate for anyone with diabetes and anyone who is working on weight-related issues.

Here's the one I use: Escali Primo Digital Multifunctional Scale. I've used mine for three years and have had zero problems with it.

For someone who is trying to lose weight, the food scale might be the difference between endless stall and reaching goal. For someone who has been trying to make fast-acting insulin work at meal times, it might be the difference between unexpected highs or lows and normal blood sugars.

Why? Because diets and insulin only work properly when we count things. For the diet we count calories, grams of carbohydrate, or even [shudder] grams of fat. When we are trying to make fast acting insulin work we need to know how many grams of carbohydrates we are going to be covering with that insulin.

But before we can count a nutrient, we must know the size of the portion we are going to be eating. Nutritional counts are always based on a specific portion size. And here's where the problems arise, because estimating portion size turns out to be much tougher than it looks.

For example, if you look up the standard nutritional information for a "small blueberry muffin", you will learn that it contains 33 grams of carbohydrate" and 259 calories. What you might not have noticed is that this nutritional count is based on a portion size of 66 grams, which is slightly over 2 ounces.

There's only one problem. The smallest blueberry muffin I have ever seen at a bakery and brought home to weigh--the one labeled "mini-muffin"--clocks in at 4 ounces. That's 116 grams--twice the portion size given in the guides.

If you had relied on that nutritional information to figure out what was in that "small" muffin you ate without knowing how large that small muffin actually was, you'd have eaten twice as many calories and twice as much carbohydrate as you thought you were eating. If you were counting calories as part of a weight loss diet, that 259 calories you thought you had eaten were really 518. And if you were trying to cover that muffin with insulin, you'd have used half the insulin you really needed and would have ended up with a nasty high.

Make this kind of mistake a few times each day and there is no way you will lose weight or keep your blood sugars under control.

And that's just what happens when you eat a "small" muffin. If you thought, "I'll just have one little Dunkin Donuts muffin, just this once. How bad can that be?" The answer is, "Plenty bad." When I've weighted those muffins--and most other coffee shop muffins--on my scale I've found they clock in at 7+ ounces, or about 900 calories and almost 120 grams of carbohydrates. The "health food" muffins are even worse as they are denser and may weigh in at 8 ounces or 132 grams of carbohydrate!

All this changes when you buy a food scale that reads in grams and ounces and start weighing your food. You will start to understand what you have really been eating and learn why you've had the problems you've been having with weight and blood sugar control.

If you buy take out food and start weighing it, you'll also learn that the typical restaurant portion of just about anything is always four times what the guides consider a portion. A sterling example is pasta: Weigh out 2 ounces of pasta (Dreamfields will work for this) and cook it up. What you'll end up with is one fifth of what you get when you order a pasta dish at a restaurant.

If you are one of those people who have concluded that eating cheese stalls your low carb diet, weigh the cheese you eat and you may find that it wasn't anything special about cheese that stalled you, only the fact that cheese is so concentrated that you can easily add seven or eight hundred calories to your daily diet in the form of cheese and hardly notice it. After the first few weeks most people find that calories still count on a low carb diet, and cheese is the most concentrated form of calories available after pure oils and fats.

There are some expensive food scales on the market that include food databases, the idea being that you can skip having to go and look up the nutritional value for the food and let the scale work this out for you. But these kinds of scales are a waste of money because their databases are not extensive enough to be useful and, more importantly, you can't add your own recipes and favorite foods to them.

Still this brings up another important point: A food scale is only useful when you combine it with a reliable source of nutritional information, preferably one that can be customized. Many people use the online nutrition tracker http://fitday.com. It is free which is helpful. I personally like the LifeForm shareware product you can download and try from http://lifeform.com. The LifeForm software is a very old design, so it may look a bit clunky, but it gets the job done, the built-in nutritional database is excellent, it is very easy to customize with your own recipes, and most importantly, it is fast and intuitive.

There are other helpful nutritional resources online besides these, and for the computer-phobic, there is always the The Complete Book of Food Counts.

Books that contain nutritional information are particularly helpful for people who are new to dieting or counting carbs. That is because when you are just starting to learn about what is in the food you eat, you can leaf through the pages of a book and look for foods that have the amounts of nutrients that fit the specifications of your chosen diet. Software does not let you do this. After you've gotten a broad overview of what you can and cannot eat, software is more helpful for looking up individual food counts quickly.

While the food scale is a wonderful gift for someone who could use it, it is only appropriate for someone who would appreciate some help in improving their diet success or in making their insulin work better.

As is the case with all diet products, giving a diet-related item to someone who is in denial about a weight or blood sugar problem might end up offending them. The message you want to give with this kind of gift is "Here is something that will help you with a goal I know means a lot to you," NOT "You're so fat, why don't you go on a diet."

November 21, 2008

Chronicles of Evil: Documented Drug Company Malfeasance Puts You At Risk

An article published in the New York Times early last month documents the steps large drug companies have taken to suppress research showing their expensive new drugs to be worthless or dangerous, to suborn doctors, and to foist questionable studies on the spineless folk who supposedly "peer review" the research used to make drug policy decisions.

The article is: NYTimes: Experts Conclude Pfizer Manipulated Studies.

Citing testimony of experts involved in a trial involving Pfizer's mismarketing of Neurontin, the article reports,
Pfizer’s tactics included delaying the publication of studies that had found no evidence the drug worked for some other disorders, “spinning” negative data to place it in a more positive light, and bundling negative findings with positive studies to neutralize the results.
In making the case that Pfizer's behavior was part of a larger pattern of deception by drug companies, the articles cites the way that Schering-Plough delayed the release of the results of the study that ended up showing that its new moneymaker, Vytorin, did not slow the growth of plaque in arteries. Also reported is this:
In April ... a group of academic doctors questioned the validity of drug industry research after finding that Merck had hired ghostwriters to produce scientific articles about Vioxx, then recruited prestigious doctors to serve as their official authors.
In regards to Pfizer's handling of Neurontin, the article describes company emails discussing how to delay publication of research showing that Neurontin was ineffective for diabetic neuropathic pain. To see how effective the company's strategy was you have only to note that:
Dr. Dickersin, the Johns Hopkins expert, said that of 21 studies she reviewed, five were positive and 16 negative, meaning they did not prove the drug was effective. Of the five positive studies, four were published in full journal articles, yet only six of the negative studies were published and, of those, two were published in abbreviated form.
By now Neurontin has been exposed for what it is--an ineffective drug whose side effects included a heightened incidence of suicide among those who took it. But the strategies the big drug companies used to market Neurontin are no different from those they are using to market the rest of their moneymaking drugs.

Every time you see a new study touted in the press that "proves" some very expensive new drug has immense benefits, you have to wonder how many studies were not published that found the same drug to be ineffective.

Every time you see a prestigious doctor praising a new drug, you have to wonder how much he is being paid by the maker of that drug to influence him to sing its praises. Even though journals now require that doctors and researchers disclose whether they have taken drug company money, they do not require that they disclose how much. In the disclosures now pulished at the end of research studies, the academic researcher whose conference lunch was paid for by a drug company is indistiguishable from the "opinion leader" who received half a million dollars for "consulting fees" or for putting his name on research studies actually conducted and written up by drug company employees.

And once the drug related research makes it to the newspaper, even the paltry disclosure you find in journals goes by the wayside, so you have no way of knowing if the doctor you see quoted in the paper or speaking with authority on TV news is a paid spokesman for the drug.

If you think law suits like the one described in the NYTimes article might remedy the situation, think again.
There's a simple reason why drug companies will continue to pursue this kind of behavior. The original maker of Neurontin, Warner-Lambert, paid $430 Million in claims after some of its illegal marketing tricks came to light. But the drug had earned $3 billion a year until it lost patent protection. So that $430 million was just written off as part of the cost of doing business. The profits were large enough to leave room for many more law suit payments while this ineffective, dangerous drug still yielded the kinds of profits other companies can only dream about.

Which is why all new and highly profitable drugs are dangerous to you, the patient. Right now the drug that ranks number one for new prescriptions written for a non-psychiatric drug is Januvia. Januvia costs about $150 a month per person. Last year Merck was selling 100,000 prescriptions for Januvia a week. That's $60 million a month or $7.2 billion a year.

With that kind of profit piling up every year, and the certainty that it will be 5-10 years before any truly disturbing information comes to light about Januvia's real dangers (which I have written about about HERE)there's plenty of money to pay settlements to the hundreds of thousands of people who contracted unnecessary cancers. Dr. Goldstein estimates based on the number of prescriptions written and the published data about increased cancer incidence in people taking Januvia compared to placebo in the drug's approval trials that Januvia may be causing an additional 30,000 cancers a year.

But don't hold your breath waiting for research to discover this and other disturbing side effects of new drugs. The events of the past few years make it unlikely that such studies will ever be conducted. With what happened to Vioxx, Avandia and Vytorin after the companies who made them ran post-marketing studies intended to expand their use only to have these studies discover that the drugs were killing people or not doing what they claimed to do, no drug company executives is likely to commission large scale post-marketing studies again.

Instead, as is currently the case with how Merck is handling Januvia, they will simply point to the very small, short-term studies done as part of the effort of getting the drug approved and use the results from these studies--carefully spun--to support the argument that the drug is safe and effective.

If you don't study a highly profitable drug you won't find out anything bad about it that could damage its profitability. And since the only organizations funding large scale studies of drugs right now are drug companies, without their support, no large long-term large studies of the kind that uncover the real problems with these drugs will ever take place.

Bottom line: Over the past decades the drug companies have so polluted the environment surrounding the medical research about their drugs that it is very hard to know what the true benefits and dangerous side effects are for these drugs. The safest drugs are those that have been on the market long enough to have lost patent protection. Drug companies promoting new drugs will fund studies intended to find flaws with these older drugs so they can promote their newer drugs as alternatives.

====

UPDATE LATER THE SAME DAY: Wow, no sooner do I post this but the New York Times comes up with the news "An influential psychiatrist who served as the host of public radio’s popular “The Infinite Mind” program earned at least $1.3 million between 2000 and 2007 giving marketing lectures for drug makers, income not mentioned on the program."

NYTimes: Popular Radio Host Has Drug Company Ties

Sheesh. Doesen't it seem like when someone pays you $1.3 million to market its product and you keep it hidden, the appropriate word to describe the relationship isn't "ties," its "corruption."

Of the man who hired this drug pusher to host the radio show the NYTimes reports, " Mr. Lichtenstein said that he was unaware of Dr. Goodwin’s financial ties to drug makers and that he called Dr. Goodwin earlier this year 'and asked him point-blank if he was receiving funding from pharmaceutical companies, directly or indirectly, and the answer was, "No."'"

Not surprisingly, Dr. Frederick Goodwin, the psychiatrist in question, is reported to have heavily promoted the safety of psychiatric drugs for children though their safety is far from assured and they are widely believed by people NOT receiving millions from drug companies to be highly overprescribed.

The undisclosed financial relationship was uncovered by Senator Charles Grassley who has long been one of my favorite senators for his unrelenting work in unveiling drug company corruption.

So how much drug money has gone to Dr. Buse, Dr. Nathan, Dr. Nissen and the other high profile doctors who frequently comment on diabetes research? You won't know until Senator Grassley gets around to investigating and cross-checking their records.

November 19, 2008

Myth Busters: Gestational Diabetes is Indeed Real Diabetes

If you have had Gestational Diabetes you may be confused about whether this means you have "real diabetes." If your family doctor is like most you may have been told not to worry about it. Many doctors treat GD if it were nothing more than a complication of pregnancy which goes away when the pregnancy is over.

So while today's obstetricians are aggressive about helping their patients control their blood sugars through the pregnancy, as soon as the baby is delivered, they hand women with GD back to their primary care doctors whose attitude towards blood sugar control is far more relaxed, giving the woman with GD the message that their diabetes is "over."

Post-pregnancy screening, if it occurs at all may be nothing more than administering a single A1c test or, perhaps, a fasting glucose test. If these come back "Normal"--i.e. under 7% for the A1c and under 125 mg/dl (7.0 mmol/L) for the fasting glucose--the doctor will consider the case closed.

Unfortunately, it isn't closed, and the fact that you developed GD should be treated as a big red flashing warning. A new study published in the Journal of Clinical Endocrinology and Metabolism looked at the genetic make up of a group of women who had had Gestational Diabetes and compared it with a group of women who did not. They concluded "The prevalence in a prior GDM [gestational diabetes mellitus] group of several previously proven type 2 diabetes risk alleles equals the findings from association studies on type 2 diabetes. This supports the hypothesis that GDM and type 2 diabetes are two of the same entity." [emphasis mine]

This study found that the group of women who had experienced GD had a frequency of 11 different genes linked to diabetes that was very similar to that found in groups of people who have been diagnosed with Type 2 diabetes.

Common type 2 diabetes risk gene variants associate with gestational diabetes.
Jeannet Lauenborg et al. Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2008-1336

The only reason that your PCP doesn't think you have diabetes, is that he is using much laxer standards to diagnose than your gynecologist did.

We know that women tend to develop diabetes in a pattern where the post-meal control deteriorates many years before fasting control goes away. This is probably one reason why obstetricians screen for GD with the glucose tolerance test, NOT the fasting glucose test. But most PCPs still screen women for diabetes using only the fasting glucose test. Those who don't often rely on A1c test, a test which even the ultra-conservative ADA says should not be used for diagnosing diabetes.

Your blood sugars may be going into the diabetic range after meals but if your fasting blood sugar is only in the "impaired" range, your A1c may be somewhere between 5.9% and 6.3%. That is a value too many PCPs consider to be normal, though, in fact, it is linked by a lot of research with a much higher risk of heart disease. And even worse, blood sugars that go high after each meal make you more insulin resistant and more insulin resistance causes even higher blood sugars. They also may poison the rest of your remaining beta cells, via what is known as "glucose toxicity."

If you are a woman in the early stages of diabetes, the only test that can accurately tell you if you are diabetic is one that looks at your blood sugars after you eat a high carb meal or drink a glucose solution. The Glucose Tolerance Test is a good test. Or you can test yourself at home using the meal test described on this page: Am I Diabetic.

If you see a result over 200 mg/dl (11.1 mmol/L) after a meal two or three times make sure you have washed your hands before testing so you aren't getting sugar from your fingers on the test strip. If the reading is real, you should assume you have diabetes and get back to controlling your blood sugar the way you did when you were pregnant. The ADA's published criteria for diagnosing diabetes include two random glucose tests over 200 mg/dl (11.1 mmol/L) though many family doctors are ignorant of this fact.

Obstetricians train their patients to shoot for much lower blood sugars than do PCPs and most endocrinologists. This is because they have learned that normal blood sugars results in normal pregnancies. Unfortunately, family doctors have not gotten the message that diabetic complications can be prevented by maintaining normal blood sugars no matter what the diagnosis, so they are much less aggressive in helping people get their blood sugar back to the normal range.

Another major issue that many doctors ignore is the question of when, during your pregnancy, you developed gestational diabetes. Typically this happens towards the end of the pregnancy as women get larger and more insulin resistant.

But some of us, like, say, me, became diabetic much earlier in our pregnancy, and when this happens it may point to something different from insulin resistance being at fault. Early GD may be caused by insulin deficiency.

If you have a condition that causes beta cell dysfunction, as opposed to insulin resistance, pregnancy may unmask it. These conditions occur in in young, thin people who doctors don't think of as being at risk for diabetes, so doctors often don't notice these forms of diabetes until they have had years to ravage your body and finally cause serious symptoms. Despite my having had two diabetic pregnancies where I became diabetic very early in the pregnancy, it was more than a decade until my doctors finally thought of giving me a diabetes test that wasn't a fasting plasma glucose test.

Two forms of non-Type 2 diabetes which can cause Gestational Diabetes that arises early in the pregnancy are LADA, which is a slow-onset form of autoimmune diabetes which seems to becoming much more common over the past decade, and MODY, which is the term used to refer to a group of unrelated genetic forms of diabetes which have in common only that they are passed in dominant genes and that they limit the body's ability to control blood sugar.

You can read about LADA here: http://www.phlaunt.com/diabetes/18382053.php and about MODY here: http://www.phlaunt.com.diabetes/14047009.php.

MODY is much rarer than LADA, so if you have had GD when you were thin especially if it came on early in the pregnancy, and if you also have a family history of other autoimmune diseases, that would be the first diagnoses to have checked out.

In any case, the important thing is not what caused your gestational diabetes, so much as making sure that after you have your baby and your blood sugar seems to improve you do what it takes to keep it under control.

With that in mind, here is what I suggest you do. It is what I wish I had done after my GD pregnancies:

1. Every three months test your blood sugar after eating a high carb meal to see how your blood sugar is doing. If you see blood sugars that are over 140 mg/dl two hours after eating, test more often and work on getting your blood sugar down.

You should also put some effort into finding a doctor who will work with you to prevent your pre-diabetes from turning back into full-fledged diabetes.

There are a lot more things you can do at this "pre-diabetic" stage than there are once you've let high blood sugars kill off your beta cells. If your doctor does not take pre-diabetes seriously, find a younger, better trained doctor who will.

2. Go Easy on the Carbs!. Cut down as much as possible on the carbohydrates you eat. Don't drink high carbohydrate fruit juices, spritzers, or sodas, or eat side portions of starchy foods that will raise your blood sugar. You don't have to be obsessional about it, but before you eat something with carbs in it, stop and think: Is this carb really necessary? Some are. But most are not worth the spike they will cause in your blood sugar.

3. Start walking more and sitting less. If you are insulin resistant, exercise may help lower your insulin resistance. Walking is a lot less likely to cause injuries that put you out of commission for long periods of time than are trendier but more injury-provoking athletic pursuits. I learned this the VERY hard way, as I was too aggressive with exercise in my younger years and ended up with serious non-reparable orthopedic problems that now limit my ability to exercise. More walking and less weights and hours on the stair climber and rowing machine would have been smarter!

November 17, 2008

Myth Busting: Your Brain and That "Required" 130 Grams of Carbohydrate

My email has been filed this past week with emails from people with diabetes whose doctors or nutritionists have told them that it is dangerous to eat less than 130 grams of carbohydrates a day.

It isn't true. In fact, for most people with diabetes the opposite is true: eating more than 130 grams of carbs a day guarantees blood sugars that are so high they raise your risk of blindness, amputation, kidney failure and heart attack.

The old wives tale that you must eat 130 grams of carbohydrate a day has no basis in science. Is is one of those factoids that has been passed from teacher to student in the health profession for generations--long after anyone remembers where it originally came from. As it turns out, it came from two sources, one was ignorance of how the body works and the other a problem common 25 years ago that has been solved by medical progress.

Let's look at the origins of the damaging myth that you have to eat 130 grams of carbohydrate every day:

1. Though the brain requires carbs, you don't need to eat carbs to provide your brain with carbs.

The brain is unique among organs in its need for glucose. All your other organs can run on ketones or free fatty acids, both the byproducts of the metabolizing fat--but your brain does does require a certain amount of glucose to keep functioning--somewhere around 120 grams.

But before you rush off to eat a bagel for breakfast, you need to know while your brain needs glucose, you do not need to EAT glucose to provide your brain with the glucose that it needs. That is because your liver has the remarkable ability to transform the protein that you eat into glucose. This process is called "gluconeogenesis."

You liver can transform 58% of every gram of protein you eat into glucose, so any deficit created by eating less than 130 grams of carbohydrate can be made up by eating enough extra protein to supply the liver with the raw material to make some carbohydrate on its own.

But (as they say on the infomercials) that's not all! After a period of prolonged glucose "starvation" the brain's requirement for glucose drops. It becomes far more efficient and is able to run largely on the ketones produced by metabolizing fat. At that point, the brain's requirement drops to a mere 40 grams of glucose. If you ate no carbohydrate at all, you could can easily get that 40 grams of glucose from eating 69 grams of protein, or slightly over ten ounces of a protein-containing food like meat, cheese, or eggs. If, like most of us who limit our carbohydrates to control our blood sugars, you eat 45 to 100 grams a day, you will already be eating enough glucose to keep your brain happy.

This ability of the liver to make glucose from protein and its ability to adapt to burning ketones has been known for a long time. You can find it discussed in complex scientific language on pages 279 and 282 of the textbook, "Understanding the Brain and Its Development." Though the chapter assumes that a lowering of carbohydrate would be caused by "malnutrition" the same mechanisms occur when you lower carbohydrate and eat enough protein and fat to avoid malnutrition.

With this information, you can see that a person with diabetes who is eating 40-80 grams of carbohydrate a day can easily meet their brain's need for carbohydrates by eating a slightly higher protein intake for three weeks and then dropping it to a moderate amount--no more than 12 ounces a day for many people.

I have put together a calculator which will let you figure out exactly how much protein you need to eat to give your body both enough glucose to run your brain and additional protein to repair your muscles: Protein Need Calculator. Check out your current diet and see whether you are getting enough protein.

In case you might worry that your brain might still suffer if you make this adaptation to glucose "starvation" you might find it interesting to know that, far from it being dangerous, neurologists have found that eliminating all carbohydrates from the diet and providing high quality protein and fat often cures forms of childhood epilepsy that are otherwise untreatable with any drug or surgery, often permanently. Many parents also report improvements in their children's behavior when they are placed on these extreme low carb diets. (NOTE: The epilespy extreme low carb diet also severely limits fluids, which is not the case with the diabetes mildly lower carb diet.)

It is worth noting that the authors two of the best-regarded and bestselling books about diabetes, Dr. Bernstein and Gretchen Becker, both eat considerably less than 130 grams of carbohydrate a day. So, for that matter, do I. Perhaps another side effect of limiting carbohydrates is uncontrollable bibliographia*.

2. Low carb diets posed some danger to people using insulin and insulin-stimulating drugs before blood sugar meters came into use.

There is another reason why many doctors and nutritionists were trained to believe that a diet of less than 130-140 g of carbohydrate a day was dangerous. It is because, until the middle 1990s, few people with diabetes had access to blood sugar meters. At the same time, their diabetes was usually treated with sulfonylurea drugs that stimulate uncontrolled insulin production or with antique insulin regimens that involved taking one or two large shots of mixed insulins each day.

Because these people could not check their blood sugar in real time and had large, often unknown doses of insulin coursing through their bloodstream, there was always the fear that they might get too much insulin and have a life-threatening attack of hypoglycemia.

Back in these bad old days the only way people with diabetes could test their blood sugar at home was by dipping test strips in urine. These strips changed color when the concentration of glucose in the urine rose. Since most people don't spill glucose into urine until their blood sugar has been quite high for several hours, the lowest blood sugar that could be identified with these strip was one somewhere between 160 and 180 mg/dl (8.9 mmol/L and 10 mmol/L). If a person's blood sugar dropped below this level, it was impossible to tell what it was. It might be a normal 130 or a near-fatal 32 mg/dl (6.7 or 1.8 mmol/L). Not only that, but the "blood sugar" reading you saw on a urine test lagged several hours behind your blood sugar at the moment of testing so they told you what your blood sugar had been an hour or two before, not at the time of the test.

Given that situation, doctors and nutritionists urged people with diabetes to eat a lot of carbohydrate, enough to make sure they wouldn't suffer dangerous hypos no matter how much insulin was in their blood stream. To make it possible to check their blood sugar with urine test strips, many were urged to eat enough carbohydrate to keep their blood sugar above the 160 mg/dl level that showed up on urine test strips--which most people with diabetes can do if they eat at least 130 grams of carbohydrate a day.

But we have blood sugar meters now that can tell us exactly what our blood sugar is, any time we fear it might be dropping. We also have drugs for Type 2 diabetes that do not cause dangerous hypos, and much more controllable insulin regimens available to those of us who need to use insulin.

So for many of us hypos are not even an issue, and even for those of us using insulin, they are no where near the threat they used to be. That is why there is no longer any reason for anyone to ever eat a diet intended to push their blood sugar up over the high end of the normal range, which is 140 mg/dl (7.7 mmol/L). Doing so raises your likelihood of developing complications.


Bottom line: There is no reason to eat any set amount of carbohydrates. The best carbohydrate intake level is the one that keeps your blood sugar at a safe and normal level. This flyer will explain to you what that level is and how to reach those safe and normal blood sugar levels. http://bloodsugar101.com/flyer.pdf. If you live in a part of the world that uses the mmol/L measurements, download this version: http://www.bloodsugar101.com/flyer-mmol.pdf.

Even the American Diabetes Association--notorious for its hyper-conservative stance on diet--has stated in its 2008 practice recommendations that the low carb diet appears to be safe for people with diabetes.

If you are still battling a doctor or nutritionist whose last education about diet and diabetes took place decades ago, bring them some of the research studies proving the safety of low carb diets you'll find at HERE.

=======
Bibliographia: medical term for writing books.

November 14, 2008

Spread Diabetes Awareness


Go visit the World Diabetes Day web site and check out the activities.

This would be the perfect day to share one important fact about diabetes with your friends and coworkers who, like most people, are likely to be full of misinformation about diabetes. Keep your communication short and to the point, people close down after more than a sentence or two.

My favorite Diabetes Awareness fact is this: Despite what you read in the media Type 2 isn't caused by obesity. Eighty percent of the obese never develop diabetes. Diabetes has a genetic basis and the obesity associated with it is a result of the raving hunger that people experience as their blood sugar control deteriorates.

Obesity is a symptom, not the cause of Type 2 diabetes!

November 13, 2008

Holiday Gifts for People with Diabetes

It's almost that time again!

People with diabetes are bracing themselves to smile graciously as they unwrap boxes of diarrhea-producing, blood sugar-raising "Sugar Free" cookies and tuck into dinners filled with diet-ruining high carb/low fat items prepared with love by friends and relatives who don't understand diabetes.

There's still time to head off these kinds of disasters. If you are shopping for someone with diabetes, I hope this list of suggestions helps you choose an appropriate gift. If you are a person with diabetes, don't be shy about letting those who love you know what kinds gifts would be most appreciated--and what kinds of foods you can eat.

SUGGESTED GIFTS

1. A Pedometer. The "10,000 Steps" program might be a great way to start a gentle but effective exercise program and the pedometer is a fun way to motivate and measure improvement. Count how many steps you take each day, then set goals that gradually raise your daily step count to 10,000. This has been shown to make dramatic impacts on fitness.

2. A Heart Rate Monitor. The heart rate monitor makes it possible to fine-tune an aerobic regimen so that it strengthens the heart. This is only an appropriate gift for someone who already is involved in some form of aerobic exercise. Pair the monitor with a book that explains how to use the monitor to improve cardiac fitness.

3. A gym or pool membership. If you are looking for an expensive gift consider a gym membership, but consult the recipient as to which club they prefer before you buy the membership as it will be nonrefundable.

4. Three Bottles of Vitamin D. If you live in a wintry climate and can't afford to give the gym membership, give the gift of Sunlight. 1,000 IU of vitamin D are safe for any adult and supplementing Vitamin D improves mood and appears to have impressive health benefits. Go for the oil-based Vitamin D3 (Cholecalciferol).

5. Blood Sugar Test Strips. This can be a wonderful gift for someone who is working on improving their blood sugar control as strips are very expensive and many insurance plans limit the number of strips a person can get each month. Make sure you find out which brand of meter the person uses as strips only work with specific meters. Amazon has some very good deals on strips, but check the comments to make sure that the expiration dates are current.

Do NOT give a meter as a gift! The biggest expense in blood sugar testing is not the meter but the strips. A "nice" meter might require the giftee to spend more on strips than they can afford. Also, many insurance plans limit the brands of strips they will pay for or charge a much higher deductible for strips of certain brands.

Check beforehand to find out what meter your recipient uses and whether they would appreciate more strips. This gift may be especially useful for people on Medicare which limits the number of strips given out severely.

6. Pharmacy Gift Cards. Many insurance plans have very high copays. A pharmacy gift card could be very helpful to a person who needs to fill prescriptions every month.

7. Stick Me Design Meter/supplies fashion bag. These are a delightful treat for women who carry blood sugar testing supplies or injection supplies. I have one myself and love it.

8. Pumpwear. This company makes a range of fashion accessories for people who use insulin pumps including quite a few for children.

9. Low Carb Cookbooks. Lowering carbohydrate intake is the key to improving blood sugars, but it can be tough to know what to eat. Low carb cook books can help people with diabetes learn more about what foods will work best to improve blood sugar control.

10. Low carb cooking ingredients. Many people with diabetes would appreciate a gift of DaVinci Sugar Free Syrups. They are extremely useful for making low carb desserts. They contain Splenda, so don't give them to people who don't use this artificial sweetener.

Other low carb cooking ingredients that might be appreciated are Not Starch which is a extremely low carb thickener that can be used to replace flour in gravy.

Other useful low carb supplies include Almond Flourand Vanilla Whey Protein Powder

I welcome your gift suggestions in our comment section, but will be deleting comments which are obvious spam so please do not put in links to commercial web sites of dubious interest to people with diabetes.

UPDATE Nov 13, 3:14 PM: Be sure to read the comments. Visitors have posted some really great gift ideas!

November 10, 2008

Should You be Taking a Statin? What the Crestor Study Really Found.

A new study has been reported all over the media as proving that just about everyone should be taking Crestor because of the way it lowered the incidence of stroke and heart attack.

As usual, when we read the actual study, we find that it said something very different.

The entire study as published in The New England Journal of Medicine is available for free this month here:

Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein

Here is a brief summary of how the study was conducted.

The researchers found a group of men over 50 and women over 60 years old who had normal cholesterol but whose C-reactive protein was elevated. C-reactive protein believed to be a marker for inflammation, particularly inflammation in your arteries.

Take a look at this table to see the other characteristics of the participants in this study:

Baseline Characteristics of the Study Group

Several things leap out that were not made clear in the popular press reporting of this study.

First of all, they were older people. The median age was 66. Secondly, though they had normal cholesterol they had other significant risk factors for heart disease and stroke:

They were overweight. The median BMI was 28.3. That would translate into a weight of 165 lbs for the average 5' 4" woman or 192 lbs for the average 5' 9" male.

More importantly, they had higher than normal blood sugars. The median A1c was 5.7% which I have been told by an endocrinologist is high enough to suggest undiagnosed diabetes.

The interquartile range(a measure of the area in which most values concentrate) for this study group was 5.4% - 5.9%. These figures alone tell us that these people had a higher than normal risk of heart attack since several large studies have shown that the risk of heart attack rises in lock step with the rise of A1c as it goes over 4.7%. At 5.7% the risk is already significantly higher than at true normal.

Finally, These people had elevated blood pressure--which is another well known pointer to early heart disease. The median blood pressure was 134/80. Doctors now believe 120/80 is the upper bound of normal.

You need to also look at who was excluded from the study: Women taking hormone replacement therapy, people with any indicator of liver or kidney abnormality, people with high blood pressure, people with thyroid disease, people with autoimmune disease and people with a history of alcoholism or drug abuse. These people were excluded because, among other things, earlier studies have shown Crestor might be very dangerous for them.

The study participants were then put on Crestor, a newer and very expensive statin drug. Note that the study was run exclusively by people with strong financial links to the company that makes Crestor. (More about this at the bottom of this post.)

After two years the study was stopped because it found that people in this group taking Crestor had about half the risk of "end points" than people taking a placebo. These "end points" included were fatal and non fatal myocardial infarction [heart attack], fatal and nonfatal stroke, arterial revascularization [putting in a stent], hospitalization for unstable angina, or confirmed death from cardiovascular causes.

But lets look a bit closer at the statistics. When ever anyone uses the "Risk" statistic, you can be sure they are trying to amplify a very small statistic into a larger one. Here's what the actual statistics came up with:

There were a total of 393 "end points" reported among the 17,802 people involved in the study. There were a grand total of 109 more "end points" among the people taking placebo compared to those taking Crestor.

In this group of 17,802 people involved in the study, half of whom were taking Crestor, there were 99 heart attacks or 5 per 1,000. Of these 15 were fatal or 8 in 10,000. There were 97 strokes of which 9 were fatal, a rate of 5 in 10,000. These numbers are for the group as a whole.

The most frequent endpoint was getting a stent put in, which occurred in 202 cases or about 1% of the group. When considering this statistic, note that Dr. Davis the cardiologist who writes the Heart Scan Blog believes that this procedure is dramatically overused because there is a strong economic motivator involved: this kind of procedure is the primary way that cardiologists make a living.

It is also worth noting that the way these statistics were collected one person may be recorded as having several "end points" though in fact they had only one incident or hospitalization. In fact, it is worth noting that the way that these end points are reported is so confusing, with so much overlap that it is very hard to know exactly what is being reported. The total given for "primary end points" is much lower than the total of all the various end points listed.

So right away it is important to note that the actual likelihood of death or stroke in this group of middle aged people with clear cardiovascular risk factors, while regrettable, was quite small.

But no one wants to experience any of these "end points." So let's look more closely at what happened when people took 20 mg of Crestor every day for two years.

In fact, though the way the data was reported was carefully arranged to obscure this finding, it appears that while there were indeed slightly less than half as many heart attacks within the group taking Crestor, there were more fatal heart attacks in the group taking Crestor.

The way that this is reported is thus:

Nonfatal myocardial infarction: Crestor 22 Placebo 62
Any myocardial infarction: Crestor 31 Placebo 68

Subtract "Nonfatal myocardial infarctions" from "Any myocardial infarctions" and you get Fatal Myocardial infarctions, a statistic which is NOT reported in the list of "end points." But simple math gives us the information that there were 9 fatals in the Crestor group as opposed to 6 in the placebo group.

Okay, so it looks like taking Crestor cut down the incidence of heart attack by 37 cases, but did not cut down on the deaths from heart attack. In fact, the proportion of heart attacks that were fatal in the Crestor group was 29% compared to the 9% that were fatal in the placebo group. Why is this not noted by the authors of the study?

For stroke, there were 31 fewer strokes in the group taking Crestor and 3 fewer deaths. So Crestor looks a bit more helpful here.

In total there were 49 more deaths from any cause in the group taking placebo than in the group taking Crestor, though this statistic is not explained. But it is worth pointing out that the death rate for the study group as a whole (2.5%) was better than the death rate for this age group reported by census data and identical to the death rate for the age group being studied according to CDC statistics.

But here's the bad news buried in this study: Both A1c and the incidence of diagnosed diabetes rose in the group taking Crestor.

There were 54 more cases of diabetes diagnosed in the Crestor group than in the placebo group. This is brushed off as barely significant by the authors, though, in fact, it is greater than the difference in heart attack, stroke, etc.

You can examine the side effect statistics here.

http://content.nejm.org/cgi/content-nw/full/NEJMoa0807646v1/T4


So what does this study tell us about Crestor?

1. Crestor makes a small difference in the cardiovascular health of people with high CRP.

2. This study confirms the suspicion that cholesterol levels are a red herring and that the impact of statins, where they have an impact, is on lowering inflammation in the cardiovascular system.

3. Crestor is most effective against microvascular problems--most notably stroke, than heart attack death, which makes sense if the main thing they do is decrease inflammation in small arteries most likely to lead to stroke.

4. Crestor lowers the number of heart attacks, but not the number of heart attack deaths.

5. Crestor appears to raise the incidence of diabetes in those taking it. The mechanism of this is not known.

6. The study did not find an increase in muscle or liver problems, but it carfully screened out those who most likely to develop these problems. Crestor has been linked to severe muscle and liver damage. Read this FDA Advisory before you take Crestor and make sure your doctor does the same screening that this study group was given:

http://www.fda.gov/CDER/Drug/InfoSheets/patient/RosuvastatinPT.htm

7. The study did not investigate or report the incidence of cognitive decline in this group. Statins have been linked to cognitive decline (i.e. memory loss and other signs of dementia).

Some information about statins and memory loss can be found here:
http://www.spacedoc.net/662_cases_memory_loss

and here: Blood Sugar 101: Other Dangerous Drugs

8. This study did not look at the impact of a much cheaper generic statin on the same endpoints. It was run and reported by people with strong financial links to AstraZeneca, the company that makes the expensive, patented Crestor. It is very possible that the benefits found with Crestor may also be achieved by taking the inexpensive generic statin, Simvastatin (Zocor).

9. This study was run by people with very strong financial links to the manufacturers of Crestor and who have additional financial motives to promote CRP testing. The way that they obscured the heart attack death statistic should make you careful about trusting their conclusions. See the list of conflicts of interest reproduced below.

BOTTOM LINE:

1. Get your CRP tested before you let any doctor talk you into taking a statin. Your level of CRP is probably a much better indicator of heart disease than your cholesterol levels. If your CRP is dramatically high, Crestor or a much cheaper generic statin may be helpful, but balance the possible impact the statin may have on your blood sugar control and cognitive function against the modest benefits it may present.

2. Before you take Crestor or any other statin, insist your doctor run a full Liver Panel and repeat this test every few months.

3. Stop taking Crestor or any other statin if you experience muscle pain.

4. Do not take Crestor or any statin if you are over 65 and have a family history of dementia or any symptoms of early memory loss.

5. Given the very strong link between A1c and heart disease it is possible that you might achieve similar benefits by lowering your blood sugar via a lower carbohydrate diet and exercise. Checking your CRP after six months of adopting such a regimen might help you evaluate whether or not you need a statin.

WHY YOU NEED TO BE CAREFUL TRUSTING THIS STUDY

Here is the disclosure paragraph published with this study. The names listed are those of the study's authors:

Dr. Ridker reports receiving grant support from AstraZeneca, Novartis, Merck, Abbott, Roche, and Sanofi-Aventis; consulting fees or lecture fees or both from AstraZeneca, Novartis, Merck, Merck–Schering-Plough, Sanofi-Aventis, Isis, Dade Behring, and Vascular Biogenics; and is listed as a coinventor on patents held by Brigham and Women's Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease, including the use of high-sensitivity C-reactive protein in the evaluation of patients' risk of cardiovascular disease. These patents have been licensed to Dade Behring and AstraZeneca. Dr. Fonseca reports receiving research grants, lecture fees, and consulting fees from AstraZeneca, Pfizer, Schering-Plough, Sanofi-Aventis, and Merck; and Dr. Genest, lecture fees from AstraZeneca, Schering-Plough, Merck–Schering-Plough, Pfizer, Novartis, and Sanofi-Aventis and consulting fees from AstraZeneca, Merck, Merck Frosst, Schering-Plough, Pfizer, Novartis, Resverlogix, and Sanofi-Aventis. Dr. Gotto reports receiving consulting fees from Dupont, Novartis, Aegerion, Arisaph, Kowa, Merck, Merck–Schering-Plough, Pfizer, Genentech, Martek, and Reliant; serving as an expert witness; and receiving publication royalties. Dr. Kastelein reports receiving grant support from AstraZeneca, Pfizer, Roche, Novartis, Merck, Merck–Schering-Plough, Isis, Genzyme, and Sanofi-Aventis; lecture fees from AstraZeneca, GlaxoSmithKline, Pfizer, Novartis, Merck–Schering-Plough, Roche, Isis, and Boehringer Ingelheim; and consulting fees from AstraZeneca, Abbott, Pfizer, Isis, Genzyme, Roche, Novartis, Merck, Merck–Schering-Plough, and Sanofi-Aventis. Dr. Koenig reports receiving grant support from AstraZeneca, Roche, Anthera, Dade Behring and GlaxoSmithKline; lecture fees from AstraZeneca, Pfizer, Novartis, GlaxoSmithKline, DiaDexus, Roche, and Boehringer Ingelheim; and consulting fees from GlaxoSmithKline, Medlogix, Anthera, and Roche. Dr. Libby reports receiving lecture fees from Pfizer and lecture or consulting fees from AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Pfizer, Sanofi-Aventis, VIA Pharmaceuticals, Interleukin Genetics, Kowa Research Institute, Novartis, and Merck–Schering-Plough. Dr. Lorenzatti reports receiving grant support, lecture fees, and consulting fees from AstraZeneca, Takeda, and Novartis; Dr. Nordestgaard, lecture fees from AstraZeneca, Sanofi-Aventis, Pfizer, Boehringer Ingelheim, and Merck and consulting fees from AstraZeneca and BG Medicine; Dr. Shepherd, lecture fees from AstraZeneca, Pfizer, and Merck and consulting fees from AstraZeneca, Merck, Roche, GlaxoSmithKline, Pfizer, Nicox, and Oxford Biosciences; and Dr. Glynn, grant support from AstraZeneca and Bristol-Myers Squibb. No other potential conflict of interest relevant to this article was reported.

November 7, 2008

A Book You MUST Read: Hippocrates' Shadow

The only thing wrong with Hippocrates' Shadow: Secrets from the House of Medicine by David H. Newman, M.D. is its title, because it gives you no idea what this insightful book is about. That means a lot of people are going to walk by it who really need to read it.

The title of the book should be Fixing Medicine. The author is an emergency room doctor, someone who has learned to evaluate, diagnose, and treat patients who are minutes from death. In this book, he brings the same swift insight he uses in the ER to sorting out in a mere 214 pages what's wrong with medical practice.

The titles of his chapters say it all: "We Don't Know" discusses the gap between the all-knowing image doctors present to patients and the huge number of conditions they neither understand nor know how to treat.

"It Doesn't Work" describes how doctors continue to use diagnostic techniques and treatments that research has shown to be worthless.

"We Don't Agree" discusses how even well trained doctors can look at the same test results, EKG, or X-ray and come out with completely different diagnoses.

"We Don't Talk" and "We Prefer Tests" are self-explanatory.

The most powerful chapters in the book are the three that come near the end. "We Won't Unlearn" is a devastating look at the way that false "Truths" (he calls them Axioms) become embedded in practice and how doctors cling to them without any idea of where they came from, long after they are discredited by research. We see this all the time with doctors who insist that low fat diets prevent heart disease or nutritionists who tell us that our brains will stop functioning on a low carb diet.

Dr. Newman shows that medical practice is riddled with many more deeply held beliefs that harm patients, beliefs based on findings published in Journals fifty or sixty years ago which have been handed on from doctor to doctor as truth though they were based on flimsy or even made up evidence.

The chapter, "We're Missing the Meaning" explores the concept of placebo and shows how powerful the attitude communicated by a doctor can be in helping or hindering healing. If you don't think that your doctor's (erroneous) belief that you caused your diabetes by being a lazy glutton is having an actual, negative impact on the way your body works, this chapter will change your mind.

Finally, the chapter, "You're a Number" discusses the way that statistics are manipulated to give patients false ideas of risk and benefit. If you read nothing else in this book, you should read this chapter.

In it Dr. Newman explains in simple terms a vital concept:"number needed to treat" (NNT). The NNT is a statistical measure of the actual number of people who will benefit from a drug or treatment. If the NNT is 2 it means that one out of every two people who use the treatment will benefit. This is a very different statistic from "risk" which as he explains is used to magnify an otherwise unimpressive statistical result.

To see the power of this statistic, consider that with statins, if you are not a middle aged male who has already had a heart attack, the NNT is 250. That means one person who takes a statin will not have a heart attack they'd otherwise have had for every 250 people who take it. The other 249 people or their insurers are paying a lot of money for a treatment that will do nothing for them and which may cause devastating side effects.

If you have any interest in understanding the way medicine is currently practiced, you should read the whole book. It will make you better understand why the care you get is so unsatisfying, and in addition it will make you realize that your doctor isn't much happier than you are at having to practice in the current environment.

As I read through this book, I kept wishing that there was some way that well meaning physicians like Dr. Newman could connect with concerned, activist patients like the readers of this blog so we could work together to fix the medical system together. Will that happen? Probably not, but we can always dream.