Recovering from Holiday Diet Mayhem

A quick scan of various diabetes support boards shows that people have either stopped posting completely, or they're posting messages along the lines of, "I can't believe I ate the whole thing!"

Yup. It's holiday time again.

Personally, I believe it is dangerous to be too perfect with any diet, because when people are utterly perfect, and never eat a single uncounted gram of carbohydrate, when they eventually DO crash off their diet plan, they tend to go off massively and end up harming their health and their weight. One day off plan won't do terrible things to your health, nor, for that matter, three days But if you're still eating your head off three weeks after Christmas, yes. You are in a world of hurt.

It's long been my belief that if you go off plan every so often you will learn how to get back on track, so you'll be more likely to handle times of excess like the holidays when temptations and the weight of family traditions make it extremely difficult to avoid diabetes-related food craziness.

There isn't any way around it. Unless you are one of those lucky people who have no emotional issues around food and could live happily on Purina People Chow, at times like Christmas, you either don't eat the special foods that have decades worth of warm associations and end up feeling like the Little Match Girl, standing in the cold, peering through the window at the more fortunate people enjoying the glorious family feast. Or you pig out and end up feeling like crap, because your body can't handle the carb-load and then spend the next week hiding from your diabetic friends out of embarrassment--hence the quietness on the diabetes discussion boards.

Fortunately, the official Diet Season starts January 2, and we can all stop thinking about party food until the Diet Season's Official End, which is of course, Super Bowl Sunday. Don't you love the irony of the way the supermarkets fill the "seasonal" shelves with diet food January 2, and then, 3 weeks later, replace them with Cheese filled Cheese Doodles and nacho sauce?

Meanwhile, for those of you who are relatively new to cutting back on carbohydrates, who did over do it on Christmas, here's a page I put together some years ago which helps you understand some of the physiological effects that can make you very hungry and feeling crazy when you try to get back to good dietary control. If you find yourself in a non-stop binge, reading this page may help you get back on track.

Crashing Off Your Low Carb Diet

Me, I'm going on a diet next week, until, of course, Super Bowl Sunday.

The Formulas equating HbA1c to Average Glucose Level Don't Work with Near Normal Blood sugars?

NOTE: Important New Information Added to this post in OCT 2007. Please scroll to bottom to read!

I got my new A1c result yesterday, the first in six months.

It was 5.5%.

During this period, my blood sugars have been significantly better than they had been for years. My fasting blood sugars have dropped about 20 mg/dl and my post-meal values have dropped by about 30 mg/dl. These changes have been measured many times using reference meals with known blood sugar outcomes.

In the past, my A1cs were almost always 5.7%.

The drop in A1c doesn't seem to capture the significant lowering of my blood sugars over this period.

The usual formula to estimate the relationship between A1c and mean plasma glucose was derived from the DCCT study.

That formula is:

Mean Blood Glucose = (A1c * 35.6) - 77.3

Applying this formula, an A1c of 5.5% is supposed to correspond to a mean plasma glucose of 118.5 mg/dl and an A1c of 5.7% is supposed to correspond to a mean plasma glucose of 125.6 mg/dl.

Neither of these values correspond to anything I have ever seen in my testing, and I test a lot and at many different times of day. My 30 day meter average, based on 150 measurements, has ranged between 98 and 103 during this period.

There is another, less cited formula that works better, at least for me. It is called "The Nathan Formula" it is:

Mean Plasma Glucose = (A1c * 33.3) -86

This formula yields a mean plasma glucose value of 97 mg/dl, which comes much closer to what my meter's 30 day average has looked like throughout this period.

Here's a calculator that will give you the Nathan Formula A1c/Mean Plasma Glucose equivalents:
A1c Calculator

However, I think the most important point is this: despite doctors' reliance on A1c it is not a particularly accurate measurement of what your blood sugars have been over the past three months. And not only that, the DCCT formula seem to work a lot better in people with very high blood sugars which is the group from which it was derived than they do those of us with near normal ones.

Here's a study published in the Journal of Family Practice that looked at the evidence connecting observed glucose measurements and A1c.

Does daily monitoring of blood glucose predict hemoglobin A1c levels?

The conclusions of this review include the following statements:

The relationship between HbA1c and blood glucose levels is such that blood glucose levels from the preceding 30 days determine about 50% of the total HbA1c. (10) This relationship may be altered by uremia, intake of vitamins C or E, and conditions that affect erythrocyte turnover. (11)

It remains unclear whether management strategies that focus on minimizing HbA1c levels are optimal for prevention of diabetic complications.

Although HbA1c levels correlate with the risk of some complications, aspects of glycemia not reflected in the HbA1c level, such as the heights of glycemic "excursions" from the mean, may independently affect the risk of complications of diabetes. (12) If so, quantitative analysis of day-to-day blood glucose levels might yield a better estimation of the risk of diabetic complications than HbA1c levels.


So what this means is this. The improvement I've made in my blood sugar by keeping my "excursions" (i.e. post meal values) around 110 instead of 140, is probably a lot more significant, healthwise, than the measily .2% improvement in A1c.

Keep this in mind if your A1c results don't match your observed daily testing results, and trust what you see on your meter not a cheering (or baffling) A1c.

UPDATE OCT 31, 2007

The American Association of Diabetes Glucose Trials has come up with a new and improved equation to relate A1c to mean glucose developed using "hundreds of thousands of readings" and CGMS data.

It is the A1C-Derived Average Glucose (ADAG) formula:

Measured in MMOL/L: Average Glucose = 1.583 * A1c - 2.52

Measured in mg/dl: Average Glucose = (1.583 * A1c - 2.52)*18.05

Using this formula:
4% = 69 mg/dl
5% = 97 mg/dl
6% = 126 mg/dl
7% = 155 mg/dl
8% = 182 mg/dl
9% = 211 mg/dl
10% = 239 mg/dl

In short, 1% of A1c equates to a difference in mean glucose of 29 mg/dl.

UPDATE: 4/23/2008.

I've put together a calculator that will convert A1c and average blood glucose using the new ADAG formula.

You'll find it at http://bloodsugar101.com/A1Ccalc.php

ADOPT - Avandia "Wins" If You Ignore the Doubled Bone Fractures

Following the publication of the results of the ADOPT study, GlaxoKlineSmith, the makers of Avandia have been touting the finding that Avandia delayed the progression from "Monotherapy" i.e. taking one drug to taking additional drugs better than Metformin.

In the diabetes oral drug sweepstakes, they'd have you believe that Avandia is the "winner." What was missed in this interpretation was that this same study also found that women taking Avandia had twice as many bone fractures as those taking Metformin and three times as many as those taking glyburide.

Here's an excerpt from the story as it ran on several news sites. This one is from Yahoo News.

"After the five-year period of study, commonly reported adverse events across the treatment groups were oedema (rosiglitazone 14.1 percent; glyburide 8.5 percent; metformin 7.2 percent); weight gain (rosiglitazone 6.9 percent; glyburide 3.3 percent; metformin 1.2 percent); gastrointestinal side effects (metformin 38.3 percent; rosiglitazone 23.0 percent; glyburide 21.9 percent); and hypoglycaemia (glyburide 38.7 percent; metformin 11.6 percent; rosiglitazone 9.8 percent).1

[emphasis mine] Recent further analysis showed a lower rate of fractures reported as adverse events in women taking glyburide or metformin versus rosiglitazone (glyburide 3.5 percent; metformin 5.1 percent; rosiglitazone 9.3 percent), most commonly involving fractures of the foot and upper limb bones.1 There was no observed difference among treatment groups in the number of fractures reported in men.1"

This says that women on Avandia (rosiglitazone) had twice as many fractures as those on Metformin and almost 3 times as many as those on Amaryl (glyburide.)

The total number of fractures was not huge, but this finding takes on more importance when linked to a previous study, published in November that also found that Avandia and Actos increased the incidence bone fractures in older women in nursing homes who had been taking it.

Here is a report of that study, as reported in the Diabetes in Control newsletter: TZD’s Can Increase Bone Loss in Type 2 Women

The reason why this might be happening as reported in the nursing home study was that Avandia apparently disrupts the parathyroid hormone that regulates calcium.

This is very disturbing because it may mean that in people who are taking Avandia, it is very slowly and without anyone observing it causing bone to be remodeled in a way that will not become obvious for years to come but will eventually ruin lives.

By the time the bone changes do become obvious, the old ladies who have taken Avandia for a decade will begin to break their hips and die, but it will be too late. Their bones will have already been weakened.

That the drug manufacturer completely fails to mention this new, and dangerous side effects in its hail of advertising to physicians and its press releases to the public is very troubling.

If nothing else, if you have been taking Avandia for any length of time, insist on having your doctor order a bone scan and have it repeated every couple years to be sure that that you aren't developing early signs of osteoporosis that won't otherwise be detectable for many more years. Osteoporosis causes fractures in older people that lead to death in 25% of all cases in people over age 50 and more in the more elderly.

Some Inspiring Stories

I answered a newbie on another board who had just been diagnosed, mentioning that I knew many people who had been diagnosed with blood sugars far worse than hers who had been able to get completely normal blood sugars.

The lady wrote back that reading that message had made her burst into tears which had not happened even when she'd gotten her diagnosis.

Only when she could believe it wasn't a sentence of death, or blindness, or amputation, could she begin to think about this huge change in her life!

With that in mind, I spent the day combing through 5 years of newsgroup messages, looking for inspirational tales. I've extracted excerpts from postings where people have reported that they have managed to get back to normal blood sugars often from very high initial numbers. (Normal in this case is defined as having an A1c of under 6%, or what people in the alt.support.diabetes newsgroup used to call "The 5% Club.")

The people quoted in these messages have used a variety of techniques to get to normal numbers, cutting carbs, testing blood sugar after meals, medications, exercise, and insulin. What they have in common is that they got there.

Here's the link to some of these stories. If you've been needed some inspiration I hope you'll find it here. And if you have an inspiring story of your own, please let me hear it!
http://www.phlaunt.com/diabetes/16535158.php - The Five Percent Club

Metformin vs Metformin ER

I'm seeing quite a few posts on BBSes from people who are having problems with metformin because of side effects that could be eliminated if they were taking the extended release form of this drug.

For some reason, many family doctors don't seem to be aware that there is a ER version of this drug that has such benefits. This is probably because metformin is a cheap generic and isn't promoted by herds of beautiful ex-cheerleaders turned drug company salespushers who "educate" doctors about far more expensive--and less effective--newer drugs.

Here are the facts: Metformin (also sold under the brand name Glucophage) comes in a regular version which is taken at meal time, three times a day, and an extended release form (marketed as ER or XR) which is taken once a day.

Almost always, when people report diarrhea or intense heartburn with metformin, they are taking regular version. I experienced the heartburn on the regular drug. It was very disturbing because the pain was localized over my heart and felt just like the description of a heart attack you read in articles. My doctor assured me it was coming from the metformin, but that didn't make it any easier to live with because I kept wondering how, if I were having a real heart attack, I'd know it wasn't a pain from the drug?

The ER version releases the drug more slowly and this usually eliminates the gastrointestinal problems.

The trade off with taking the ER form is that the amount of blood sugar lowering you see might be a bit less than with the regular form as the drug acts in a slower smoother fashion rather than hitting all at once. But if you can't take the regular at all drug because of the side effects, the slight weakening in effect is a reasonable trade off. Plus, you only have to remember to take one dose rather than three. For me, this is not a trivial benefit. Even remembering to take one dose a day is sometimes a challenge!

One important point that my doctor missed when prescribing the ER version of metformin is this: The maximum dose of Metformin ER is LOWER than the maximum dose of regular Metformin.

According to the prescribing information, the maximum dose of the ER is 2000 mg a day. That of the regular is 2550 mg/day. Don't count on a pharmacist to catch the error if your doctor prescribes too much. Mine didn't, but I felt distinctly unwell on the high dose, and a quick look at the prescribing information online showed me the error.

Fortunately, a metformin overdose appears to be surprisingly benign. People have survived suicide attempts where they swallowed as much as 85 grams of the stuff at once. (They did develop lactic acidosis, which can be fatal, but survived.)

The dose at which metformin is supposed to be effective for most people is 1500 mg per day, though I know some smaller people who find a dose of 1000 mg effective. Your body weight will make a difference here, so if you are very large, you may need the maximum dose. In any event, don't conclude that metformin doesn't work until you have tested the dose up to the maximum.

It also takes up to two weeks for the full effect of metformin to become evident. While I will see an increase in my blood sugars if I forget a single day's dose, if I stop the drug for two weeks I see a slow rise in blood sugars through this period. My guess is that this two stage effect is because metformin works both on the liver (where it reduces the release of glucose) and the muscle (where it tricks the tissue into thinking it has just exercised and thus ramps up its burning of glucose). Whatever the explanation, give the drug a few weeks to see what it really does.

Also, many people who experience gas after taking metformin find that cutting way back on their intake of starchy carbohydrates helps eliminate the problem.

Because you only take metformin ER once a day you might wonder what happens if you take it a few hours earlier than usual. Will this cause a dangerous overlap? My experience has been that this isn't a problem. I suspect that the drug does not release evenly over the 24 hours it is supposed to act, and by 20 hours it is pretty much done, so there is no need to be obsessive about taking it at exactly the same time each day.

If I completely space out and don't remember to take the drug for 5 or 6 hours, though, I usually only take half my dose because that way when I take the normal dose at the usual time I don't have too much overlap to worry about.

I have found that there can be significant differences in how the different manufacturers' versions of generic metformin affect my blood sugar. The version I'm taking now, the 750 mg ER pill manufactured by Teva, does not seem to be quite as slow in releasing the drug as other brands are, so I get a much stronger effect during the day, but it wears off by the next morning. Other brands last better through the night, but I don't get anywhere near as good post-prandial numbers at lunch and dinner.

Not so coincidentally, the Teva version of metformin ER comes in a compact, flecked pink pill, while the other versions are pillowy white pills that appear to involve an indigestible matrix in which the drug is embedded. I suspect that the pillowy stuff works a bit better at slowing the digestion of the drug which makes the Teva version sort of a semi ER/semi regular version. That works for me.

I've tried splitting the dose to even out the response, however, I find that if I take Metformin in the evening I end up having to get up to pee at night more than usual. Since this is already a problem for me, I prefer to take it in the morning.

Finally, both Metformin and Metformin ER are currently available for a $4 copay at Wal-mart pharmacies offering the $4 copays on selected generics.

Converting Blood Sugar Measurements from mg/dl to mmol/L

It's easy to convert blood sugar measurements reported using the U.S. style of blood sugar measurements using mg/dl to the kind used in the rest of the world that use mmol/L.

Just multiply the mmol/L measurement by 18.05 to get the US measurement.

Divide the U.S. measurement by 18.05 to get the measurement used in the rest of the world.

If you don't have a calculator handy, forget the fraction and use 18. It's close enough.

Here's a handy online calculator that does the conversions for you:
http://www.childrenwithdiabetes.com/bs_conv.htm

Novolog works for me!

If you've been following my Adventures with Insulin you might have read about how I gave up trying to make Humalog work for me. No matter how I tried to use it, I'd see surprising highs and surprising lows. The more I took it the worse it got. I concluded it either wasn't matching up with my food properly or it was sparking the growth of antibodies which were blocking its effect for an hour or so.

What a nice surprise to discover that Novolog, in contrast, does exactly what it is advertised to do. It starts to work within 5 minutes of injection, peaks between 1 hour and 1.5 hours (when my food peaks) and is mostly gone by 3 hours.

This means I can now eat a a restaurant and NOT have to inject until I see the waitress bringing the food. No more chugging smarties while no food appears and I wonder if they'll ever sober up the cook enough to get out my dinner!

For example, last week I brought some along when I went to a new restaurant that had advertised Jamaican Patties, something I adore. If I was using R I would have had to inject almost an hour before eating and if I didn't eat the patty I'd have to come up with 15-20 grams of carbs fast.

With the Novolog, I was able to order my patty and take a look at what I got before injecting. After it was served I had grave doubts about whether I would want to eat it. One bite confirmed that the crust was disgusting. Since I had no insulin in me, I could just pick out the filling (all meat), throw away the crust, and not worry about having a couple units of insulin flying around my blood stream. Three cheers for Novolog!

Though the Novolog is perfect for eating out, I still prefer R insulin for those meals that I make myself where I know what to expect and can inject 45 minutes before the food comes out of the oven.

What I like about R insulin is that I don't usually eat big meals, I like to kind of nibble at this and that through the evening. R's slower pattern of absorption lets me browse my food over a couple hours rather than eat all at once.

The other thing I like about R insulin is that it is just slow enough that a dinnertime shot will get my blood sugar to a good place when I'm done with my evening nibbling. The way my blood sugar works, if it is good at night when I stop eating, it is good first thing in the morning, too. This is a characteristic of the kind of MODY diabetes I have. This means that if I use R insulin I don't have to fool with basal insulin.

Does Red Meat Cause Cancer - or Meat & Potatoes?

The latest report from the Nurses Study claims to have found that, based on reports by study participants recalling what they ate, those who say they ate more than one serving of "red meat" a day were more likely to develop breast cancer.

My immediate thought here was this: is the problem something in red meat, which does not as far as anyone knows contain anything that would promote breast cancer, or is the problem that "red meat" mostly means hamburgers on carb-laden buns with piles of fries consumed at a fast food joint, or steak and potatoes, perhaps with a killer carb "Death by Chocolate" dessert, elsewhere?

Why is this significant? Because we ALREADY KNOW THAT THE HIGH BLOOD SUGAR CREATED BY A HIGH CARBOHYDRATE INTAKE PROMOTES CANCER GROWTH. Cancer cells grow much faster than normal cells and they need a lot of glucose to do that growing.

So it is quite reasonable to conclude that people who eat a lot of bread and potatoes along with their "meat" along with the supersized Coke that comes almost for free with the burger and fries special, would be much more likely to have the high blood sugars that feed baby cancer cells.

So what happens when people eat red meat WITHOUT the high carb sides? Do they get cancer? We'll never know because the researchers didn't ask.

Because, once again, researchers were blinded by religiously held beliefs--"red meat is bad for you, carbohydrates are good" rather true science which looks past belief to find explanations, the researchers did not tease out the meat from the potatoes, buns and sodas. So we'll never really know if it is meat or the many very high carbohydrate foods people usually eat ALONG with meat that promoted these cancers.

A Perfect Example of a Completely Flawed Study

Soy Yogurt Could Help Control Diabetes

An alert reader sent me this saying that this study proved fruit yogurt may control Type 2 diabetes.

A more perfect example of flawed research would be tough to find.

1. The study concludes that blueberry soy yogurt "controls" diabetes because it has more of a phytochemical which inhibits the enzymes that break down sugars than the other fruit yogurts it was compared to.

In this study one fruit yogurt (full of sugar, of course!) is only compared to other fruit yogurts with even more sugar as far as how much phytochemical it contains.

Note also that a pharmacetuical drug that completely inhibits the same enzymes has at best a very weak affect on blood sugar and only in people with very mild blood sugar abnormalities--the drug Precose. This drug and its drawbacks is discussed at Acarbose the Real Starch Blocker The tiny amounts of phytochemicals found in this yogurt, of course, would have a far weaker effect.

2. The researchers drew all their conclusions about "controlling diabetes" from the presence of these phytochemicals in the food. They did not observe the effect of the sugary fruit-filled yogurts on blood sugar. Fruit yogurt is full of sugar--usually 23 grams per serving, often more. That is enough to propel most of us into dangerous blood sugar territory.

3. The researchers claimed that soy fruit yogurt lowered ACE, a hormone involved with the regulation blood pressure, more than other yogurts. I imagine it also lowered it more than Milky Ways and chocolate cake. This does NOT make it a drug in food form.
Furthermore, they extended this finding about the effect on ACE to make the claim that their sugary fruit yogurt lowers blood pressure. That was not actually examined in this study. Again, the powerful pharmaceutical drugs that suppress ACE only work for people with diabetes in relatively large doses, probably hundreds of times higher than the amount of the phytochemicals found in the sugary yogurt.

4.One major company that makes soy yogurt, LightLife, coincidentally happens to have headquarters located near the UMASS lab. (In Turners Falls, two miles from my house. So I know what I'm talking about.) Lightlife was recently purchased by Conagra, a huge conglomerate that grows soy for the plastic industry and is always looking for ways to sell the excess soybeans. The article does not disclose whether LightLife/Conagra funded this study or others being done at this nutrition lab. Wanna guess if they were?

Finally, THE STUDY DID NOT MENTION THAT SOY IS POISONOUS TO THYROIDS AND PEOPLE WITH TYPE 2 HAVE A VERY HIGH INCIDENCE OF THYROID DISEASE!

The article concludes that, of course, everyone knows that a diet high in fruit and whole grains is what diabetics need.

Would someone send this lab a blood sugar meter and ask them to observe the effect on blood sugar of their fruit and sugar-laden yogurts compared with, say, a nice piece of chicken breast with cheese?

If I'm Dreaming, Don't Wake Me Up!

I picked up my local newspaper this morning and there on the front page were three headlines so wonderful I had to pinch myself to make sure I wasn't still sound asleep dreaming up a complete fantasy fulfillment!

Here are the headlines from our front page:

1. Dems control Congress!

2. Rumsfeld resigns!

and--Drum roll please . . .

3. Low-carb OK'd for women: new study shows diets high in fat and low in carbohydrates do not pose added risk of heart disease to women

If this keeps up, my blood sugar is going to be dropping just from a lack of things to get infuriated about!

What is a Normal Blood Sugar

Over the past year I've been tracking the searches that bring people to my web site What They Don't Tell You About Diabetes and have found that the single most popular search that brings in visitors is "What is a normal blood sugar?"

Much of my web site is devoted to answering that question with references to dozens of laboratory studies published in top peer reviewed journals which address various aspects of this question. If you want the details, that's the place to find them.

If you just want a quick answer to "What is a normal blood sugar?", here it is:

1. A normal fasting blood sugar (also the blood sugar you'd see before a meal) is 83 mg/dl (4.6 mmol/L) or less. Many normal people have fasting blood sugars in the mid and high 70 mg/dl (3.9 mmol/L) range.

2. A normal person eating the high carb typical American diet does not go over 120 mg/dl (6.6 mmol/L), ever, and many never go over 100 mg/dl (5.5 mmol/L).

3. A normal A1c is 4.6% or less. Heart attack risk starts to rise in a straight line fashion as soon as A1c goes over 4.6% and for each 1% of rise it is 2.3 times MORE frequent. That means that at a 5.7% A1c you have two and a third times more risk of a heart attack than a person has with an A1c of 4.6%

4. The reason that your doctor or lab might consider much higher numbers as "normal" is because there is a huge pool of people with undiagnosed diabetes and pre-diabetes in the "normal category" used by researchers in most studies because they used an arbitrarily chosen fasting plasma glucose of less than 110 mg/dl to define normal. An excellent study found that having a fasting blood sugar in the 90s was a very good predictor of diabetes 10 years or more down the road. So it is hard to defend it being truly normal.

5. People with diabetes CAN attain these normal blood sugar numbers. It takes the following to do it:

a. Education. You must learn how many grams of carb there are in every thing you eat, which includes weighing portions until you know what the "portion" listed in a Nutritional Information listing really looks like. Hint: It's MUCH smaller than you think. You need to learn in detail about what various drugs can and cannot do, and if you use insulin you must spend a lot of time reading about how to make it work. Bulletin boards and newsgroups are a good place to find people who have done this. Only take advice about how to get control from people with diabetes who have normal and near-normal blood sugars.

b. Cutting carbs. Carbs are what raise your blood sugar. Unless you are using insulin and are a genius at making it work, you are not going to be able to eat 100 grams of carbs a meal and control blood sugar. Somewhere between 12 and 30 grams a meal is the level most people with diabetes eat who maintain normal blood sugars.

c. Exercise. Some people find this helps greatly with blood sugar control. Others find it has no impact. It has a lot to do with what has made you diabetic. If it is mostly insulin resistance, exercise can usually help a lot. If it is insulin insufficiency, exercise is beneficial but won't necessarily normalize blood sugars on its own.

d. Meds. If you can't do it with carb restriction and exercise alone, it's time to check out drugs that lower insulin resistance, most notably Metformin.

3. Insulin. If diet and metformin don't do it, use insulin. Post-meal insulin works a LOT better for many of us than just Lantus, because Lantus can't bring down meal values to normal levels for most people. If you stress your beta cells at every meal, you are going to end up with non-normal blood sugars. It takes a lot of work and study to get insulin to where it gives you normal numbers. Most doctors can't be bothered and settle for numbers that won't keep you from developing complications. Read "Dr. Bernstein's Diabetes Solution" by Dr. Richard K. Bernstein to learn more about how to tailor insulin regimens so that they give you normal blood sugars.

That's it in a nutshell. Now get out there and get NORMAL!

The Earliest Complication?

I've kept my blood sugar as close to normal as possible for the last eight years, with A1cs almost always in the 5% range. As a result, my eyes and kidneys test out great and I have no neuropathy in my feet except for the nerve damage caused by my ruptured disc (which is distinguished from diabetic neuropathy in that it is only on one side, not symmetrical).

But I have developed one, to me, serious complication which my researches have found few doctors, except for the diabetes expert, Dr. Richard K. Bernstein, recognize as being a diabetic complication.

That complication is tendon damage.

Tendon damage can manifest many different ways. The most frequently detected is carpal tunnel syndrome. This recent study found that people who had been diagnosed with carpal tunnel syndrome were 36% more likely to later be diagnosed with diabetes, regardless of other diabetes risk factors.

One reason for this may be that just slightly higher than normal blood sugars cause tendons to grow abnormally thick. A study that linked tendon thickening to high blood sugars was published in Diabetes Care

Thickness of the Supraspinatus and Biceps Tendons in Diabetic Patients
Mujde Akturk, MD, Selma Karaahmetoglu, MD, Mahmut Kacar, MD and Osman Muftuoglu, MD.

Another diabetes-related form of tendon damage results in frozen shoulder. Frozen shoulder is known to be common among people with diabetes, though it occurs in people who have not been diagnosed with diabetes, too. My guess is that careful examination of post-prandial blood sugars in "non-diabetic" people with frozen shoulders not originating from sports injuries or other known traumatic events might show that the "non-diabetic" people with frozen shoulders have significantly elevated postprandial blood sugars.

Dr. Bernstein describes "piriformis syndrome" as another diabetic-related tendon problem in his article Some Long-Term Sequelae of Poorly Controlled Diabetes that are Frequently Undiagnosed, Misdiagnosed or Mistreated

I myself have yet another constellation of tendon problems that manifests in my feet. It is called "tarsal tunnel syndrome" and is the foot equivalent of carpal tunnel, resulting in painful shooting pains, first when walking up stairs, and later when it worsens, just plain walking.

Why are tendon problems often the Sentinel Complication--the first warning that something is seriously amiss? Because tendons in their normal state don't have much of a blood supply, so anything that compromises the blood supply to muscles, even slightly, will deprive the tendons of the nutrients they need to keep healthy. This mild failure of circulation starts happening even at the "mildly impaired" blood sugar levels most doctors dismiss as "pre-diabetic" and, all too often, ignore. Hence a failing tendon can be the first sign of microvascular problems.

MRIs show that it is possible to have tears in your tendons without any pain or other symptoms. You can read more about one kind of tear related to frozen shoulder HERE.

But if you are unlucky, as I have been, the tears will be in places that impinge on nerves and the pain can limit your mobility (a medical euphemism that translates into "making everything you do hurt like hell so that you mostly want to stay home, curled up in a fetal ball.")

Dr. Bernstein makes the point that just lowering blood sugars will not reverse these tendon problems which take a while to heal, and may respond to time and trigger point therapy, though he suggests normalizing blood sugars may stop new ones from starting.

My own experience has been that my tendon problems have gotten significantly worse after I have made major efforts to lower my blood sugars. My first frozen shoulder occurred after I dropped my A1c to 5.2% from the mid 6% range after diagnosis. Since starting insulin and bringing my fasting blood sugar down to truly normal (for the first time in my life) I've had tendon problems in my foot, my knee, and most painfully, my shoulder ,which is acting like it has a seriously torn rotator cuff.

Why this should be is a mystery, but since other complications initially get worse--or more painful--with improvement of blood sugars, like neuropathy and retinopathy, it is possible that there is some reasonable explanation.

If you've had problems with tendons, I'd love to hear from you about how they resolved and whether better blood sugar control made them better or worse.

New Pages on "What They Don't Tell You About Diabetes"

I created new "Complications" section on What They Don't Tell You About Diabetes. I'll be adding more pages and revising these new pages as time goes on.

The most important information is probably on the "retinopathy" page where I link to a good review of what is known about the worsening of diabetic retinopathy with improved control. The short version is that it happens, especially with people taking insulin, but long-term even if you experience temporary worsening as you get better control, over time you'll end up in MUCH better shape. And gradually improving blood sugar, rather than doing it fast doesn't appear to prevent the short-term retinopathy worsening that occasionally occurs.

I've also started a FAQ page which you can find limked from the main page of the site. I respond there to some of the common questions visitors write to me.

Januvia?

UPDATE (April 2, 2013): Before you take Byetta, Victoza, Onglyza, or Januvia please read about the new research that shows that they, and probably all incretin drugs, cause severely abnormal cell growth in the pancreas and precancerous tumors. You'll find that information HERE.

Januvia UPDATE -- POSTED NOV 15, 2006

A study linked from todays Diabetes in Control Newsletter reports that the DPP-4 drugs (including Januvia) slightly improve fasting blood sugar but have NO EFFECT on post-meal blood sugars. Since it is the post-meal blood sugars that destroy your organs, this looks to me like another reason to save your pennies and spend them on something that actually can lower your post-prandial blood sugars. That might be Byetta for some of you. For the rest of us, it probably is post-prandial insulin.

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ORIGINAL POST

Januvia is a new DPP-4 enzyme drug which inhibits the destruction of the incretin hormone GLP-1, the hormone another drug, Byetta, imitates. It has just been released with great fanfare.

Reviewing the study data that the manufacturer supplies with the press releases makes it clear that it produces very little improvement in blood sugar, despite its cost of almost $5 a day.

In people whose A1c was 8%, Januvia decreased the A1c by a measly .6%--bringing it to a level significantly higher than even the dangerously high 7% recommended by the ADA. Added to Metformin or Avandia, it got only about half of patients near 7%.

This is simply not good enough to justify the $150/month price tag. Especially when Byetta does a better job.

Unfortunately, because Januvia is a pill, doctors are going to be much more likely to prescribe it to patients than they are Byetta, even though it is far less effective in lowering blood sugar.

The real problem here is that current FDA practice requires drug manufacturers to do studies that compare their drug to placebo, NOT to other currently approved effective treatments. So while Januvia is better than placebo (i.e. nothing) it isn't better than insulin + Metformin or insulin + avandamet, which are both much cheaper than this new drug. Nor is it better than Byetta which is more expensive but more efficacious.

The drug is also being promoted as being weight-neutral (i.e. not causing weight gain) based on two studies, one of which showed a slight gain of weight in those taking the drug. This contrasts poorly with Byetta which, when it works, causes weight loss.

Finally, the manufacturer's information suggests that Januvia may be hard on the kidneys. Since most type 2s at diagnosis already have some decrease of kidney function (as shown on the microalbumin test) the wisdom of taking a drug that may be hard on the kidneys is tough to defend.

For the time being, it looks like Byetta would be a much better choice for an incretin hormone-based treatment because based on a lot of user reports when it works, it really works.

Getting Personal

After 3 1/2 weeks on the new metformin I'm back to experiencing the Reactive Hypoglycemia I last experienced in my 30s! I took my R insulin along with me on vacation and indulged in quite a lot of starchy and sugary food. At 90 minutes after eating, I kept finding myself in the 70s, and once even in the 60s. I'd chug some more carbs and still be in the 70s an hour later. I saw a couple highs, but none of them lasted more than 40 minutes. So between the insulin and the Teva Metformin ER, my blood sugar seems to be back to where it was when I was a lot younger.

Why this might be is up for grabs. It might be because the new metformin is more potent. Or because the many months of post-meal insulin has given my beta cells a chance to catch their breath.

But there is another possibility. I've been having almost non-stop pain from my shoulder. (The Physical Therapist thinks I might have a significant tear in my rotator cuff, but I can't see the orthopedic surgeon who specializes in shoulders until November 9.) I'm wondering if constant pain might burn out the body's ability to launch a counterregulatory response--the fight or flight thing that pushes blood sugars up when they go low. Up until the past couple weeks--which is when the shoulder went from occasionally twingy to permanently throbbing--when I would get anywhere near the 70s I'd get a sudden burst of counterregulation that would send my blood sugar back up, but that has completely stopped happening.

I'd always heard that stress pushed blood sugars up, but that certainly isn't what I going on here. I'll probably never know what the total explanation is. But for now I'll keep taking the Teva Metformin, though I'd happily give up the continual pain as soon as possible. It's REALLY getting old.

Vacation Time!

I'm off to spend a week at the beach with my daughter. Maybe I'll check my email. Maybe I won't. Talk to you all when I get back next Weds.

Not all Generic Metformin is The Same!

I've been taking Metformin ER for more than 3 years. When I got them at Stop & Shop's pharmacy, they always gave me big puffy white pills from one of two manufacturers. I noticed one brand seemed to cause a bit of digestive uproar the first day or two I tried it, but didn't notice anything significant in how they affected my blood sugar.

Well this past month I filled my prescription at Walgreens and they gave me a dark pink, dense pill from a manufacturer named Teva. They looked so different from the pills I'd been taking, that I went and looked them up online to make sure that they were, in fact, metformin ER. Based on the numbers on the pills, they checked out as being Metformin ER.

Within two days of starting the new pills, I started seeing dramatically lower blood sugar numbers. Suddenly I was in in the 80s after meals even when I didn't use any insulin (after a low carb breakfast and lunch). I cut back on my insulin at dinner to 2 units max and started seeing 80s and low 90s by 9 PM and fasting blood sugars from 80-89 the next morning every day even with hefty portions of carb at dinner.

When I called the pharmacy the pharmacist insisted that all the generic drugs had to perform the same to be approved, but when I went in, in person, another pharmacist told me that he had another patient who found one brand of regular metformin worked much better for him, too, though the pharmacist didn't say which brand.

To test out whether it wasn't something else causing the drop in my blood sugars, I cut back on the metformin, dropping back to one pill. Immediately my blood sugars went back up about 20 mg/dl. So it looks like it is because of the pink Metformin ER.

I take all 1500 mg at once, around 10:00 in the morning because if I take them at night I find it makes me have to wake up more to pee. My guess is that this particular generic formulation releases the medication more quickly so I'm getting more metformin in my system at once.

OTOH, I didn't see better numbers last year when I was prescribed 2500 mg of Met ER (an overdose, it turns out). That would make me wonder why a higher dose would have that effect. But I was taking that high dose back before I started insulin when my system was really burnt out from trying to normalize blood sugars with not enough insulin being secreted. After almost a year of supplementing with insulin daily perhaps my beta cells have perked up some.

Whatever it is, I'm asking for this stuff next month, too! If you've tried this pink stuff (750 mg Metformin ER) and experienced anything similar, let me hear from you. I'm intrigued!

What Can YOU Do to Help People With Type 2 Diabetes?

We all know the feeling, that combination of helplessness and fury we feel when we watch someone we know who has Type 2 diabetes eating the "healthy" meal their doctor has recommended to them that we know is robbing them of health.

For me, the defining moment was when I watched a diabetic friend shovel down a pile of pasta with a drizzle of low fat tomato sauce followed by an apple-laden dessert, only to hear her tell the waitress, "No sugar in the coffee, please, I'm diabetic!"

So what can we do?

I've given this a lot of thought and have come up with what I hope might be a solution. It's a simple support group format that combines methods from two very successful support formats I've been involved in over the years.

The first element in this approach is to teach participants the approach you'll find on Jennifer's Advice for Newbies (The Jennifer who wrote this piece of brilliance is NOT me, BTW!)

It works brilliantly, and even better, because it respects that each person is different and that the diet that works for each person will be different it appeals to people who are put off by any suggestion that they follow any particular diet.

The other element I've drawn on is the support group format pioneered by LaLeche League, a group which has taught women how to breastfeed successfully ever since the days when doctors and hospitals actively discouraged breastfeeding by promoting institutional practices which made it fail. LaLache League pioneered a technique that contradicts what doctors tell their patients without sparking conflict and which appeals to people who don't see themselves as radicals.

LaLeche's technique is to run a cycling sequence of four meetings each one of which puts across a single topic and which leaves room for plenty of interaction between the experienced participants and those who are new to the group. Participants are exposed to the data that shows that their approach is far healthier for mother and baby. Then they are given simple techniques that start them off on the path to success. The basic meeting structure focusses on the essentials. More complex issues are resolved in discussion and by support newbies can get by calling successful peers.

With these successful approaches in mind, the cornerstone of this diabetes support group approach is to focus on the essentials: Teach people what a normal blood sugar is and what the research shows about what blood sugar levels lead to complications. Teach people how to use their meter to find out what the foods they are currently eating are doing to their blood sugars. Suggest to people that if their blood sugar is too high after meals, they can bring it down by lowering their carbohydrate input in whatever way works for them.

Simple, but VERY effective. There's nothing like the look of wonder on someone's face when they report "That oatmeal I ate for breakfast pushed my blood sugar up to 230!" or "Wow! I guess bananas are off the menu from now on!"

Some other, very important basic ground rules, adopted from other very successful support group formats, is that everyone in the group must understand that it is essential for the group's success that no one in the group ever tells anyone else what they should do. What people can and should do is describe their own experience with the focus on what improved their health.

Another important point is to be sure that a "weak leadership" model prevails. The preset format--rotating through the 4 topics--ensures that no one needs to take a strong leadership role and avoids the political infighting which can destroy any group.

Over time, people who have been successful in controlling their own blood sugars may volunteer to mentor newcomers if the newcomers would like someone they can call for help, on the model of the 12 Step Programs.

Here's the complete package:

Start Your Own Effective Type 2 Diabetes Support Group

I'd love to hear your comments!

New Heart Attack Page on "What They Don't Tell You"

I've put together a page that links to the major studies that show that a) total cholesterol is not a good predictor for heart attack risk and only triglycerides and HDL seem to predict anything at all b) A1c predicts heart attack risk perfectly, and that risk rises significantly as soon as blood sugars are over true normal: an a1c of 4.6%

A1c Predicts Heart Attack

Magical Thinking Wastes Money and Damages Health

No, fellow people with diabetes. There isn't a magic pill you can buy (at great expense) that will fix your blood sugar and let you eat the way you can now only eat in your dreams.

But that doesn't keep the bottom-feeders of the supplement industry from rolling out an endless series of products designed to separate you from your money by activating precisely that dream.

I get a lot of mail from people asking me if this or that miracle pill will help their diabetes. The pills contain vitamins, minerals, and spices like cinnamon or fenugreek. Their cost to you is at least 100 times more than it would cost to assemble the ingredients on your own.

Their effect on the blood sugar is minimal. But supplement sellers know that people who have spent $50 for a bottle of hope will do their best to convince themselves that they see an improvement, even if there isn't any to see. Who wants to admit they got taken?

Every time the word finally gets around the diet/diabetes community that supplement A is worthless--which happens to every supplement in time--the supplement makers roll out supplement B which, based on a single study done in Bozoland on 6 subjects demonstrated an amazing ability to drop blood sugar by astounding amounts! Or supplement C which is made from a lichen long eaten by natives of Northern Lappland that eliminates hunger and causes the pounds to drop off you without dieting!

These pitches rely on a couple factors. People want to believe something magic can solve their problems without work, and having been raised to take pills to fix things since childhood, they are open to the idea that magic might reside in pills.

Furthermore, people find it easier to believe that something found in a distant land full of picturesque primitive peoples will have just such magical powers. They also like to believe that something "natural" though completely uninspected or regulated is healthier than a pharmaceutical product, a belief that should be laid to rest by the current spinach fiasco but probably won't. Finally, these supplement sellers appeal to paranoia. They , i.e. the Go'mint, doctors etc are keeping this secret because they don't want you to know about it!

It's a very effective package, and it earns the sleazebags who promote this crap billions but it doesn't do anything for our health.

Metformin is just as "natural" as most of the supplements being touted. It's a molecule found in an herb, refined and purified and, most importantly, tested in large populations so we know what it does.

More importantly, when you buy a metformin pill, you get exactly what you pay for. When you buy a supplement you get whatever the supplement seller decides to put into the pill, knowing there is no regulation or oversight in that business, thanks to
Orrin Hatch, whose campaigns are funded by one of the largest--and most deceptive-- maker of supplements in the U.S..

If you want to know just how sleazy the supplement makers are and how closely tied to the Republican Party machine, read Scorin' with Orrin

Taking its message to heart will save you a LOT of money and possibly your health!

Diabetes is NOT for Dummies

Thinking over the immense amount of study and work it takes to keep my blood sugar near the normal range, it's been striking me lately that what causes complications and death for most diabetics isn't just their blood sugar, it's their scientific illiteracy.

Diabetes is complicated, and the only people I've met who are able to get their blood sugars to truly normal numbers are those who are willing to read, study, test, and refine their treatment based on their testing results. Not so surprisingly, most of these are people with engineering or science backgrounds.

But people diagnosed with diabetes, no matter how intelligent, who can't read a graph, can't understand the statistics (or lack thereof) in a medical study, can't do computations in their heads, and don't know a thing about the physiology underlying their disordered blood sugars are in big trouble.

Why? Because each person's diabetes works differently and needs a different combination of treatments. My diet won't control your diabetes, and my lunch time insulin won't cover your lunch. But if you're scientifically illiterate, and rely on the people who understand this stuff--like your doctor--you're guaranteed to get a generic one-size-fits-most treatment that will not prevent complications, because your doctor and other experts you consult don't have the time to figure out exactly how your diabetes works and what you need to do to control it. So they give you a regimen that has been carefully crafted with one end in view--to keep you from getting hypos, at the cost of ensuring that you'll have "hypers" that destroy your body.

I used to wonder why the typical Type 2 on insulin has an a1c of at least 7% and usually more like 8% or higher, when insulin allows for complete control of blood sugars. But now that I'm using insulin, I can see that for someone who isn't good at math and who isn't able to memorize carbohydrate counts, and for someone who can't estimate a food portion size correctly and isn't willing to read up extensively on the subject, the only safe way to use insulin probably IS to use far less than is needed, because the combination of ignorance and insulin is eventually going to lead to a very severe hypo.

Just watching people without diabetes attempt to do a low carb diet shows me what we are up against. You know them--the people who eat that big bowl of pasta and tell you how they can't understand why their low carb diet isn't working. Or the ones who eat "low carb" bars which have 20 grams of carbohydrate per serving and wonder why their blood sugar isn't getting better. Combine that kind of dietary ignorance with an insulin regimen which matches carbs to insulin units, and you can see why tight control leads so many people to the ER.

It isn't that there's anything wrong with tight control. It is that you can't do tight control unless you know how many grams of carb you are eating, and how far one unit will lower your blood sugar, how long the insulin lasts, when it peaks, and what happens if you take a drug that raises or lowers insulin resistance while using insulin. That requires a lot of knowledge and understanding, and sadly, people who can't handle their own taxes probably aren't going to be able to figure this stuff out.

But people who can't do their own taxes are willing to pay an accountant to straighten them out, because they understand what will happen if their inability to work with figures gets them in trouble with the IRS.

Unfortunately, there is no corresponding understanding among people with diabetes who are scientifically illiterate that they need help to keep their diabetes from killing or maiming them. They trust their doctor, without understanding that their doctor can't fix them up in the 15 minutes every three months they are allotted (if they are lucky!) any more than that their accountant could do their small business taxes in 15 minutes.

I'm not sure there is a simple solution for this one. The medical establishment would prosecute anyone who attempted to help people with their diabetes for pay who wasn't a qualified doctor, nurse or pharamcist, but those people who have that qualification don't have the time or inclination to give people with diabetes the help they really need. And if they do, the cost of their time makes their help unaffordable to most.

Should Pre-diabetics take Avandia?

A study published in the Lancet this week generated lots of buzz. The Canadian researchers running the study claimed Avandia dramatically reduced the progression from pre-diabetes to diabetes.

Does this mean YOU should rush out to get a prescription for this very expensive drug?

Not at all. Avandia is a drug whose side effects should make it a drug of last resort for anyone with pre-diabetes. In fact, its side effects, which are becoming more troubling with each passing year, seem to have made doctors lose their enthusiasm for Avandia for their patients with Type 2 diabetes, and many seem to be replacing it with the latest hot new drug, Byetta. This is probably the reason that Avandia's manufacturer is sponsoring studies like this whose aim is to get it prescribed off-label to a huge pool of new customers.

What's wrong with Avandia?

Three things:

1. It reduces insulin resistance by making your body to grow new fat cells into which it pushes glucose. People taking this drug get fatter! This is the last thing you need to do if you are already dealing with a condition that is worsened by obesity.

2. Avandia causes people to swell up with water and in some people this swelling causes major permanent damage. In fact, the researchers running the Canadian Avandia study mentioned that the people in that study who were taking Avandia developed more cases of congestive heart failure than matched controls who are not taking the drug.

Congestive heart failure is what happens when your heart muscle weakens and cannot pump blood properly. It often causes death anywhere from 1 to 5 years after diagnosis. The number of people with pre-diabetes who developed congestive heart failure in the study was small, but it was significantly MORE than the number in the control group. In fact, given the statistics published with the study, your chances of getting congestive heart failure from taking the drug were far greater than your chance of hitting a win of $1000 in a state lottery.

This is definitely not a statistical fluke, as it was already known that Avandia produced congestive heart failure in a significant number of people who were taking it for diabetes.

3. People taking Avandia develop macular edema at a rate higher than expected. Macular edema is the fancy name for the retinopathy which causes diabetic blindness. This side effect only emerged as an issue in the last year, though it was reported several years ago in newsletters intended for medical professionals. Since it has recently been reported that early "diabetic" retinopathy is surprisingly prevalent in people with pre-diabetes, any drug that can worsen it must be looked at with great caution.

These problems with Avandia and the research reporting them are all documented at my page, The Truth about Oral Diabetes Drugs. Just load the page and search for "Avandia".

If people with pre-diabetes had no other options, perhaps a drug with these problems would be worth trying. But people with pre-diabetes can achieve far better improvements in blood sugar just by cutting their carbohydrate intake down to where their blood sugar doesn't spike over 140 mg/dl (7.7 mmol/l) an hour after each meal. There are no side effects with this approach except, frequently, significant weight loss.

Reducing insulin resistance with a brisk 30 minute walk 3 times a week can also achieve similar effects for those whose insulin resistance is responsive to exercise.

Finally, even for those who can't modify their diets and can't exercise there is another, much cheaper, drug which has been shown in controlled studies to achieve at least as good results in slowing down diabetes: Metformin. Even better, Metformin not only doesn't have the dangerous side effects, it causes weight LOSS, rather than weight gain.

Why pay $85/month to grow new fat cells on your butt and gamble with your heart muscle and vision when you can get the same effects with a $20 dose of Metformin without the problems?

Why Do Strips Cost MORE When all Other Technology is Cheaper?

Ten years ago, I bought a cheap computer with a soon-to-be-outdated operating system for $1,900. Eight years later, I bought a much more fashionable computer for a mere $750.

So why is it that 100 blood sugar testing strips, which were $60 eight years ago now cost almost $100? Every other high tech item on the planet has dropped in price except these blood testing supplies we people with diabetes are dependent on.

Something stinks here!

There are technologies out there that can measure blood sugar without the need for any costly disposable. Several companies have gone into testing with meters that use noninvasive methods to measure blood sugar. Several seem to work quite well. But these are small upstart companies with limited funding and without the resources to bring new products to market.

Big Pharma, which is raking in the profits from the $100 a box strips, is most definitely not putting its efforts into developing this kind of technology.

The profit numbers for the test strip business are hard to find online, but a 2003 report available on the web estimated that profits from disposable blood sugar testing supplies would be near $6 billion dollars a year by 2005, with a 15% annual growth rate. View sales estimates here.

That's a LOT of money--and a lot of motivation for big Pharma to avoid investing in new technologies that would make noninvasive monitoring possible. A not terribly paranoid mind might find itself asking just how far these big companies might go to preserve that $6 billion dollars of profit. Do they buy up promising patents and sit on them? Do their lobbyists make sure that the small companies attempting to produce such devices encounter overwhelming amounts of regulatory intervention from their totally owned subsidiary, the FDA?

If the big companies had invested even a small amount of real money into developing new noninvasive testing technology, the chances are very good we'd have meters now that did burn money like a Hummer burns gas.

But with the money pouring into drug company coffers from the disposable strips, you can be sure that the only companies working on noninvasive meters will continue to be small, fringe companies with little funding, while the big guys will continue to assure the public that, "Noninvasive meters don't work"--while continuing to raise test strip prices.

Gives a whole new meaning to the concept of "Blood Suckers" doesn't it?

A Good Time to be Diagnosed?

There's plenty to depress us in the diabetes news. The ADA continues to pander to the snack food and drug companies. Medical researchers who are funded almost entirely now by drug companies continue to publish research so poorly designed a freshman can see the flaws in the design and statistical analysis. But even so, when I compare the situation now to what it was when I was first diagnosed in 1998, there are a lot of reasons to be optimistic. Here--listed in no particular order--are a few of them.

1. Doctors are Finally Prescribing the Right Drugs. When I was diagnosed in 1998, the only drug available for people with Type 2 diabetes in the U.S. that wouldn't damage their health was insulin--which most doctors would not prescribe until the patient had already developed life-ruining complications like nerve pain and kidney damage. Now we have metformin, arguably the best drug ever invented for people with diabetes because it reduces insulin resistance, enables weight loss, and after many years of use in Europe appears to have a safety profile no other drug can beat. Just this past month the ADA's last-to-get-on-the-bandwagon" "Experts" recommended that doctors use metformin followed by insulin instead of the traditional sulf drugs (Amaryl, Glipizide, Gliclazide, etc) which probably burn out beta cells and have been shown to increase the incidence of heart attacks.

[NOTE: An alert reader tells me that Metformin was, in fact, available in the U.S. in 1998, but if it was, my doctors sure weren't aware of it. The first time any one suggested I use it was in 2001. In 1998 I knew one person who was on Avandia as part of a drug trial, but most people who were taking oral drugs that I knew were taking sulfonylurea drugs.]

2. New Classes of Drugs are Appearing Which Don't Make you Fat and Dead. In the bad old days doctors routine prescribed Sulfs and Avandia/Actos, both of which make you fatter and do bad things to your heart. Avandia/Actos also turn out to occasionally cause blindness--via retinal edema. But the new class of drugs which is just emerging cause weight loss and, so far, show no evidence that they worsen heart disease. Byetta, the first of these, is already on the market and Januvia is coming, along with several other versions. These incretin hormone mimic drugs don't work for everyone, but for those for whom they do work, they work very well.

3. Insulin Pills that Work are in Human Trials. A pill from an Israeli company, Oramed, is being tested in humans. It looks like it might actually do what no insulin today can do--enter the liver and allow the body to release insulin quickly in response to incoming food, rather than release at the very slow speed of injected and inhaled insulins. It has been tested in a small group of people, and it worked for them.

The limitation on this pill looks to be that it cannot deliver very high doses of insulin, but for people in the EARLY stages of Type 2 diabetes or those, like me who are not insulin resistant but don't produce enough insulin, they could be the "Magic Bullet" we've all been waiting for. An oral insulin spray is also in testing which might be helpful, too, though it probably shares with inhaled insulin the property of not being able to be administered in a carefully controlled dose.

More on the insulin pill is available here

4. Some doctors ARE getting it. The AACE (American Association of Clinical Endocrinologists), unlike the ADA's elderly and reactionary Expert Committee, continues to revise downward the blood sugar targets they suggest for their patients. An increasing numbers of endos and even some family doctors are urging their patients to cut way back on carbohydrates to achieve better control, too.

Not everyone in the medical community is ignoring the findings of the multi-million dollar WHI study that showed that low fat diets are worthless for preventing heart disease and not everyone ignores the many studies that show that carb restriction improves both blood sugar and cholesterol profiles for people with diabetes.

Which doctors are most likely to recommend low carb diets? Those who themselves have diabetes! And beyond them, those whose patients have shown them how well they work by bringing their A1cs down from 10 or 12% to the 5% range.

More Bad Science? "Treating Post Prandial Hyperglycemia Does Not Delay Progression of Early Type 2 Diabetes"

Diabetes in Control reports on yet another pooly designed study sure to set back diabetes treatment.

The study, STOP-NIDDM gave people Acarbose (Precose) to see if it would delay onset and progression of diabetes. Precose is a carb blocker which I took for several years, so I know quite a lot about it.

The simple version of their finding is that using Acarbose to lower post-prandial blood sugars in people with fasting blood sugars near 125 mg/dl did not keep those blood sugars from rising to 140 mg/dl though it slightly lowered A1c.

What the article DOESN'T point out is that Acarbose only effectively blocks the equivalent of about 10-15 grams of carbohdrate, but the subjects in this study were told to eat a "healthy low fat diet" so they were eating more like 100 grams per meal.

So while their post-prandials might have been lowered from wretched (220-275 mg/dl) merely nasty (180 - 225 mg/dl) they could not have come anywhere near the normal level that it takes to prevent organ damage, including destruction of beta cells!

In addition, by the time someone's fasting blood sugar is in the 120s, as these subjects' were, Precose no longer eliminate spikes, it merely pushes them back a few hours. So testing at 2 hours post-prandially will miss the fact that at 3 or 4 hours the blood sugars are spiking dangerously high.

So the real conclusion of this study is not that controlling PP blood sugar doesn't delay progression of Type 2, it is that any treatment that doesn't NORMALIZE post prandial blood sugars but allows them to go over 140 mg/dl several times a day is a death sentence to beta cells, nerves, kidneys, and retinas.

Sadly, that probably isn't the message that doctors will be getting from this. After all, why tell your patients to test after meals when "research shows" that lowering post meal blood sugars doesn't do anything for them.

Meanwhile, on a related note, it's 8 years since my diagnosis this week and my recent blood work shows completely normal kidneys. My random fasting blood sugar was 86 mg/dl. I have no neuropathy in my feet except for that caused by my crushed lumbar discs. My retinas are perfect. My blood pressure yesterday was 120/80 without any BP meds. Over this entire 8 years I've kept my blood sugar truly normal using whatever it takes, low carb diet, then metformin, and now pre-meal insulin, and it is definitely paying off for me.

ADA Nutritional Guidelines -- Keeping Diabetics Diabetic!

The American Diabetes Association is funded heavily by Big Pharma and companies that manufacture high carb junk food. Not so suprisingly, despite a decade of peer-reviewed research proving that a) post-prandial blood sugars are what injure and kill diabetics and b) carbohydrates in meals cause high post-prandial blood sugars, and c) Limiting fat intake has no effect on heart disease, the ADA just came out with new Nutritional Guidelines telling people with diabetes to shun low carbohydrate diets, eat lots of whole grains, and restrict saturated fat to 7% of diet (replacing fats, with carbs, since they also tell people with diabetes to avoid high protein diets.)

There is no way of justifying these recommendations with scientific evidence. Not a single study has shown anything but good outcomes for people with diabetes who restrict carbohydrates. Major research has also proven that low fat diets do not improve cardiovascular health. In addition, study after study shows that cholesterol profiles improve for people on such diets in a way that corresponds to lowered cardiovascular risk (i.e. lower triglycerides and higher HDL).

But people on low carb diabetes diets aren't going to be buying products from ADA main sponsors, Cadbury Schwepps and General Mills. They aren't going to be buying $80 a month prescriptions from Big Pharma either. Obviously the ADA knows who is paying their executives' lavish salaries, and it isn't us poor schnooks with diabetes.

Here's the list of Corporate Sponsors of the ADA. Notice how many make drugs and junk food:

* ARAMARK Corporation [from their web site: "An international company specializing in food services for stadiums, arenas, campuses, businesses, and schools." Tater tots and nacho providers]
* Aventis Pharmaceuticals
* Bally Total Fitness Corporation
!!!!!* Blue Moon Licensing, LLC (Blue Moon Pizza)
!!!!! * Cadbury Schweppes -- America's Beverage [Chocolate, cookies etc]
* Colgate Palmolive Company
* Day-Timers, Inc.
!!!!! * General Mills, Inc. [cereal, cookies, snack foods]
* Gold's Gym International, Inc.
* Johnson Publishing Company, EBONY
!!!!! * Jones Soda Company
* MBNA America Bank, NA
* McNeil Nutritionals [The Splenda company]
* Merisant U.S., Inc. [The Aspartame company]
* Performance Bicycles, Inc.
* Rite Aid Corporation
* Solo Licensing LLC
!!!!* Specialty Brands of America [maple syrup, candy, etc]

List from This Page on the ADA Site

Don't give The ADA a cent of your money until they stop killing people with diabetes by telling them to eat food that raises their blood sugar. If you want to contribute towards diabetes cures, The Juvenile Diabetes Research Foundation (JDRF) uses its money far more wisely.

High Post Meal Blood Sugars Destroy Nerves -- Before Diagnosis

A new study adds to the mounting evidence that high post-meal blood sugars damage nerves long before people get diagnosed with diabetes.
Research conducted at Kings College, London found that people who went on to be diagnosed with diabetes had a much higher frequency of Carpal Tunnel Syndrome as early as 10 years before diagnosis. Carpal Tunnel is a nerve disorder.

The reason for this, not discussed in the article, is that the diagnostic test most frequently used to diagnose diabetes, the fasting plasma glucose test (FPG), misses abnormal blood sugars in a huge number of people, particularly women, in whom the early stages of diabetes are characterized by very high post-meal values and near normal fasting values.

Ten years of very high post-meal values will eventually destroy the beta cells, resulting in an official diabetes diagnosis. But by the time that happens, the ten years of exposure to high blood sugars have had time to ruin the nerves, blood vessels, retina, kidneys and other useful bits of equipment that we need to stay alive.

While Carpal Tunnel is a painful annoyance, what also goes unnoticed while high blood sugars run rampant after every meal is subtle destruction of the autonomic nervous system. The autonomic nerves, most notably the Vagus Nerve, control things like heartbeat, blood pressure, and the emptying of the stomach. Not only that, recent research by Dr. Kevin J. Tracy has shown that the Vagus nerve also regulates the immune system. His research shows that when the vagus nerve is not operating properly inflammation may go into overdrive.

It is possibly because the high post-meal blood sugars slowly destroy the vagus nerve which is so important for regulating heart beat and blood pressure, that for every 1% rise in the A1c the risk of cardiovascular "incident"--heart attack or stroke goes up almost two and a half times. It is also probably the reason why people with mildly elevated blood sugars may be prone to other inflammatory conditions.

If you have reason to believe you are at risk of diabetes, but your doctor diagnoses diabetes using only a fasting glucose test and does not investigate what your blood sugars are doing after meals or administer a Glucose Tolerance Test, it is time to find a new doctor. Waiting until your fasting blood sugars are bad enough to render a diagnosis of diabetes means waiting until your nerves are already half dead!

If you can't get a doctor to test your post-meal numbers, you can find instructions on how to do this yourself at home with an inexpensive drug store blood sugar meter at HERE

Bad Science: ADA: "Type 2 BG Testing Doesn't Work"

Just when you thought the ADA was finally starting to get some faint foggy idea of how to improve the lives of people with Type 2 diabetes, they put
this on their web site.

Here's the punchline:
"For patients with type 2 diabetes, control of blood sugar (glycemic control) does not appear to be improved if they self-monitor their blood glucose levels, according to researchers at the University of Western Australia, Fremantle."

As usual, the ADA page does not give any details about the study, in line with their usual belief that one of the complications of diabetes is extreme stupidity. This, apparently, is what keeps them from putting any explanations that could not be understood by a third grader into any of the materials they publish for diabetics.

But before you throw out your blood sugar meter, here's what the study actually proved: People who were told to only test their fasting blood sugars a couple times a week and whose only advice about how to control with diet was to eat a low fat diet full of healthy "whole grains" got no benefit from blood sugar testing.

Well, duh!

Fasting blood sugar is the hardest blood sugar to change. For people not on insulin, it can only be changed by modifying post-prandial blood sugars over a period of weeks. And, of course, before you can lower post prandial-blood sugar levels, you have to know what they are--by testing.

Then when you see blood sugar levels that are to high after a meal, you have to cut back on your carbohydrate intake until those post-prandial readings come down.

Unfortunately, Diabetes Australia still mandates that control via "Diet" for diabetics means cutting way back on FAT and eating "healthy grains".

So the poor victims here--I mean subjects--when they saw high fasting blood sugars, if they did anything at all, were likely to cut back even further on meat and cheese and pile their plates higher with pasta which, of course did not lower their fasting blood sugars. Not being as stupid as the researchers, when they couldn't change the test result, they didn't do much testing.

Does anyone still think this study showed that "blood sugar testing doesn't work?"

What wasn't explored at all by this study was what happens if you tell people to test AFTER MEALS and explain to them that if their blood sugar is too high, they can bring it down by eating less carbohydrates.

But as we all know, the ADA, which receives major funding from the big food and snack manufacturers, refuses to tell people with diabetes that they can change their blood sugars by cutting carbs. They still are resistant to the idea that people with diabetes deserve to know what their blood sugar is after meals and to be told--in terms any 3rd grader could understand--that starch and sugar are what raise it anc cutting back on them could keep them from needing hundreds of dollars a month of expensive drugs to counteract the impact of all those supposedly "healthy grains."

Bad advice and poorly thought-out research is nothing new from the ADA. But the real tragedy here is that this latest study gives insurers around the world the green light to stop paying for testing supplies for Type 2 diabetics, because "now we know, for Type 2s, blood sugar testing doesn't work."

Did ADA major-funder and carb supplier Cadbury Schwepps' stock just go up again on this news ? . .

STOP-NIDDM Research on HNF4-alpha and Type 2 Diabetes

A while back, I discussed the HNF4-a gene which is implicated both in one of the MODY forms of diabetes and in the Type 2 diabetes found among Ashkenazi Jews. I speculated that because researchers were only looking at people with Type 2 diabetes diagnosed with fasting glucose tests they were missing a lot of people with HNF4-a diabetes.

This is because, from what I can determine from the MODY research I've read, defects in this gene cause beta cells not to respond correctly to incoming glucose, pushing up post-prandial blood sugars. But because the problem first surfaces in post prandial blood sugars, in milder cases the fasting blood sugar may stay below the level used to diagnose diabetes for many years while very high blood sugars follow every meal--and destroy organs. Only when the PP control is completely gone does the fasting blood sugar start to rise.

Well, what do you know? An alert reader sent me notice of a newly published research paper which found that, in fact, women in the STOP-NIDDM trial who had a defective HNF4-a gene were almost twice as likely to become diabetic over the course of the study as those who lacked it.

The paper is "The Single nucleotide polymorphisms of the HNF4-a gene are associated with the conversion to type 2 diabetes mellitus: the STOP-NIDDM trial." Andrulionyte L, Laukkanen O, Chiasson JL, Laakso M.

These are researchers from the Department of Medicine, University of Kuopio, Kuopio, Finland, who earlier published an important study linking polymorphisms of this gene to Type 2 diabetes.

What does this mean for you? Just another bit of evidence that not all diabetes is necessarily caused by insulin resistance. The HNF4-a gene causes a secretory defect, rather than causing or increasing insulin resistance.

It also points out the importance of looking at your post-prandial blood sugars from time to time. Even if your doctor tells you that you are "fine" based on a fasting blood test, you need to make sure your blood sugars aren't going into the diabetic range years before your fasting blood sugars are high enough to diagnose you. By then, you'll have damaged your heart, your nerves, and possibly your eyes and kidneys.

On a related note: A visitor stopped by to post a comment saying that as a person with Type 1 diabetes he was offended that I didn't "understand" that all type 2 diabetes is caused by insulin resistance. I just want to make my point here very clear. I do not question that many type 2s are insulin resistant. But it turns out that many are not. Indeed, there is increasing evidence that secretory defects are an equal cause of type 2 diabetes, and that insulin resistance is NOT necessarily the major cause in a significant amount of type 2.

The best explanation of this is in a wonderful paper
The Genetic Basis of Type 2 Diabetes Mellitus: Impaired Insulin Secretion versus Impaired Insulin Sensitivity by John Gerich.

I invite anyone who still thinks all Type 2 is caused by insulin resistance to read this article and bring themselves up-to-date on what the researchers are finding.

The reason that I focus on Type 2s who are not significantly insulin resistant is because, since I started writing about this on my web site and on the alt.support.diabetes newsgroup, I've heard from a surprising number of people diagnosed as Type 2, who, like me, are not overweight and who have found when they use insulin or sulf drugs that they are not insulin resistant. Since something like 20% of all type 2s are not overweight, I often wonder just how big the pool of Type 2s with secretory defects like that caused by HNF4a might be.

British Meters are Whole Blood Calibrated!

I first saw someone post that British blood sugar meters still read in whole blood calibration rather than the plasma equivalent calibration now used in the U.S. on Dr. Bernstein's discussion board which you'll find here .

I checked this out by posting a question on alt.support.diabetes.uk and sure enough, it turns out that it was true. The Roche meters (and strips) sold in the UK are whole blood calibrated, while those sold in the U.S. are plasma calibrated. That includes all the Accuchek meters.


Why does this matter? Because for the same blood sample, meters that read in whole blood calibration give readings 12% lower than those that read in plasma calibration. So a Brit who reads online that a healthy blood sugar target according to the AACE is under 140 mg/dl or 7.7 mmol/l and then gets a reading of 7.6 on his Accuchek meter is happy. He'd be a lot less happy if he realized that 7.6 on the Accuchek would be 8.5 on an American Accuchek, which is, of course, what the AACE is referring to.

Similarly, the 200 mg/dl or 11 mmol/l that is diagnostic for diabetes on a random check is also a plasma calibrated value. The same reading would be 9.9 mmol/l on a blood calibrated meter.

And, just to make it really confusing, while some web sites claim that the Ultra sold in the UK is plasma calibrated, like those in the U.S., Lifescan's UK site specifically says that the strips sold for their Ultra meters in the UK are whole blood calibrated.

Here's a government pamphlet explaining the situation (though it incorrectly identifies the difference as 11% when it has been reported elsewhere as 12%.
UK Pamphlet

Here's the Lifescan link with conflicting information: Lifescan UK Info

From what the Brits have posted when this discussion comes up, it appears that their medical professionals are NOT aware of this issue at all.

If you are in the UK and attempting to maintain healthy blood sugar levels, be sure to convert your readings to plasma readings by multiplying them by 1.12!

Quoted again . . . Almost right but not quite

I seem to have become the Poster Girl for "Thinking Twice about Exubera". A new article which is popping of in quite a few newspaper web sites quotes me, a lot more accurately, as explaining my concern that it would be tough to match Exubera to carb intake.

http://www.philly.com/mld/philly/news/15171769.htm

The only thing not quite right here is that I didn't say there were only 2 dose sizes.

Here's what I actually wrote to the journalist who wrote the article:

> But Exubera isn't sold in units, it is sold in mg, and the prescribing
> information tells doctors to calculate the dose based on the patient's
> weight. Their guideline says that someone my weight should be taking 3 mg
> of Exubera, which they state is equivalent to 8 units of insulin. I can hypo
> severely on 5 units of insulin! In fact, I'd have to eat 80 - 100 grams of
> carbohydrate at once to keep from hypoing, which is about twice what I ever
> eat. But I have friends who weigh less than I do who need five times as
> much insulin as I do. For them that dose will be too little to keep them
> from developing dangerous blood sugar spikes aftere eating.
>
> To make it even worse, 3 mg of Exubera does not have the same insulin unit
> equivlence to three 1 mg doses of Exubera.

Insulin Fade - Yikes!!!!

I'd noticed I was using a lot more insulin but figured it was because I'd cut down on my metformin. But when I went back up to 1 750 mg tablet a day of the Metformin I didn't see much improvement and my fasting bgs were creeping up again, so I started to wonder if my two month old vial of R was getting weak.

I'd been keeping the vial at room temperature after reading various places that it would keep at room temperature for many months and had used about half the vial. But my room has been quite warm of late, even with our feeble window air conditioner cranking at full blast down the hall, so it seemed like a good idea to buy a new vial.

Yesterday I'd stayed well over 110 mg/dl for hours after using 2 units of the old stuff on a conservatively estimated 16 grams at lunch (1 slice of "lite" rye bread with a reasonable serving of natural peanut butter), I tried 2 units of the new stuff today with the identical lunch.

Wham! I peaked at 99 an hour after eating and then went right back into the 80s, which "forced" me to eat half of a delicious peach for a snack 2 hours later to avoid hypoing. Five hours later I'm at a perfect 81!

So that answers that question of whether it's me or the insulin.

I'll be keeping the R in the fridge this time and testing with this reference meal from time to time to make sure it is still fine.

But at least I can be reassured that using insulin for a while hasn't somehow increased my need for insulin which had been a concern.

Diabetics and Wound Healing, Alzheimers, Heart attack, etc.

You see these studies all the time that tell you cheery "facts" such as that diabetics are more likely to get heart attacks, Alzheimers, and have poor healing after wounds or surgery. Depressing, isn't it?

What they don't tell you is that the "diabetics" they are talking about are really "Diabetics with lousy blood sugar control". The diabetics in the studies that lead to these conclusions universally have A1cs of at least 7% and often more like 10% along with fasting blood sugars near 200 mg/dl (11 mmol/l).

Doctors all too frequently tell people with Type 2 diabetes that an A1c of 7% is "fine" and don't point out that an A1c that high almost guarantees neuropathy and early changes in the retina and kidneys leading, eventually, to disaster.

The 7% A1c target was originally established after the DCCT study found that people with Type 1 diabetes who achieved that A1c had far fewer complications than those whose A1cs were higher. (No study ever looked at what happened to complications if the A1cs were LOWER than 7%). But when they ran a similar study of Type 2s, the UKPDS, while they found that the 7% A1c resulted in fewer complications than higher ones, they also found that people with type 2 diabetes at the 7% A1c got far MORE complications than Type 1s had who had that same A1c. In short, an awful lot of people with Type 2 diabetes followed in the UKPDS study who kept their A1cs at 7% ended up with serious complications including retinopathy (med-speak for blindness).

The conclusion that should have been drawn from this is that people with Type 2 diabetes need to shoot for much lower A1cs than those with Type 1. Unfortunately, that isn't what happened. Most doctors still tell patients that 7% is a good A1c target that prevents complications and labs flag anything under 7% as "good control."
It isn't. Good control is control that gets you as close to normal numbers as is possible.

What is normal? There's some evidence that true normal is an A1c of 4.7%, a fasting of 83 mg/dl (4.6 mmol/L) and post-meal readings no higher than 120 mg/dl (6.7 mmol/l) within 2 hours of a meal. That's a tough target to meet and one that a lot of us can't reach. But the closer you can get to these numbers, the better off you will be.

Most people with Type 2 diabetes CAN get their A1cs into the 5% range with a combination of cutting way back on carbohydrates, taking insulin resistance drugs like Metformin, and if things are really out of control, insulin.

So when you see yet another study that tells you that because you have diabetes you are doomed to yet another nasty life-shortening condition, remind yourself it isn't some underlying condition causing these problems, it is high blood sugars, day after day, meal after meal. If you can bring your blood sugars down to normal, your risk for these conditions will drop to normal too!

PREFER - This Idiotically Designed Study will Set Back Diabetes Treatment for Years

Diabetes in Control reported this week on a study presented at the ADA conference this past June that could going to cause a lot of people to go blind and lose kidneys and toes.

[2006 American Diabetes Association Scientific Sessions : Liebl A et al. "Biphasic Insulin Aspart 30 (BIAsp30), Insulin Detemir (IDet) and Insulin Aspart (IAsp) Allow Patients with Type 2 Diabetes To Reach A1C Target: The PREFER Study" Presented June 11, 2006 Bretzel RG et al. "Equivalence of Basal Insulin Glargine vs Prandial Insulin Lispro for Glucose Control in Type 2 Diabetes Patients on Oral Agents - Results of the APOLLO Study" Presented June 12, 2006]

In brief, the study concludes that there is no reason for people with type 2 to use bolus insulin as the results of using a basal alone is comparable to a bolus/basal regime.

Why is this so dangerous? Because of the way the study was designed. What it really proved is that patients who don't use enough bolus insulin to control blood sugars will get little improvement from using bolus insulin. That's because the post-meal target in this study was 180 mg/dl, a level guaranteed to promote neuropathy in everyone and retinopathy in a lot of people with type 2. (Details of why can be found at Research Connecting Organ Damage with Blood Sugar Level)

This is, of course, the level the ADA has been pushing for years. One that the American College of Clinical Endocrinologists (AACE) has abandonned, because it is far too high.

Not only that, but the patients in this study were taken off ALL oral drugs, which of course meant that their insulin resistance went WAY up, making control that much harder.

The tragic thing is that insurers are likely to seize on this as a reason to deny coverage for bolus insulin to people with Type 2 diabetes.

Why doesn't ANYONE in the medical establishment get it that people with Type 2 deserve treatment that gives them NORMAL blood sugars, not those that ensure that most of them will suffer horribly for years?

Off Metformin for a Week.

I've been having a problem with mild nausea for several weeks, so I figured I better cut back on the metformin before going to the doctor and getting put through the whole misery of having tubes stuffed up various orifices, just to make sure the nauseous isn't a side effect of the Met.

I hadn't had a problem with metformin causing stomach problems in the past, but the endo told me last week she had another patient who developed the same problem after a couple years on metformin, had the expensive work up, and then found out the problem WAS from the drug.

So this is day 3 with no metformin, and boy am I hating it.

All my nice insulin dosages are now off because the Metformin drops me at least 20 mg/dl. So instead of being in the 80s this morning after my very low carb breakfast-- 4 grams--I was in the 100-110 range instead, and stayed there until my lunch injection. At dinner I saw a nasty spike though I'd done a bit more than usual hoping to cover it. And since it takes a few weeks for metformin to washout of the body, it's going to keep getting worse as time goes on.

Naturally, this would be he day that The World's Nicest Man brought me home an eclair from the Black Sheep Deli in Amherst, which is something I only get once every couple blue moons. It is almost my birthday and this is a pastry worth shortening your life for. I haven't had one for months and they don't keep, so I'd dosed the insulin with it in mind. But with that spike 90 minutes after dinner, no eclair for me, at least not until I'm back at a reasonable level.

Guess I better go see the doc and hope it's a treatable ulcer, though treating an ulcer when you can't take salicylates may be interesting, too. That said, the tummy is a lot happier without the metformin. Damn!

Figured out Comments - and Comments on the Comments

Apologies to those of you who posted comments that never appeared. I didn't realize I had to approve each one. They're visible now.

A few thoughts in response to the comments.

1. Re A1c: I controlled with diet for many years before starting insulin. I did not find the A1c a good guide at all, because my diabetes was characterized by very high post-meal readings, but near normal fasting values. As a result, my A1cs were often only slightly elevated while my blood sugar, for many hours a day, was high enough to do significant damage. This, it turns out is a common pattern among women who die of heart attacks. I've got some pointers to the Rancho Bernardo study that discovered this pattern on the "What they Don't Tell You About Diabetes" site.

It's also significant that two studies of neuropathy in people with non-diabetic blood sugars found no correlation between incidence of neuropathy and A1c, but a clear relationship between 2 hour glucose tolerance test result and neuropathy. So here too, post-prandial levels are much more indicative of early damage than A1c. All this is documented at the "At what blood sugar level does organ damage occur" page on the phlaunt.com site.

Finally, just this week, Diabetes in Control reported that the ADA is now saying that an A1c of 5.8% indicates a possibility of diabetes and should be screened. My endo told me that in her experience 5.7% is almost always diabetic! But most family doctors won't even mention diabetes until you are nearing 7%!

2. Byetta: I have heard very good things about Byetta, most notably from someone with a very similar kind of diabetes to what I have who is getting excellent results. However, I have a long history of getting bad side effects, some permanent, with common drugs, so I felt it would be smart to wait until there was more data available on Byetta use, long term. Since my current regimen is working very well, there's no hurry.

3. What if Exubera turns out not to harm lungs. Is it great then? No. Not unless they can come up with a dosing mechanism that allows finer titration. As I told the Business Week editor, I often dial in my dose to 1/2 a unit. An bolus insulin delivery system that has 3 units as the smallest increment is going to be useless for anyone who is insulin sensitive. Beyond that, since 2 mg isn't the same effective dose as 2 times 1 mg, according to what I've read, even an IR type 2 is going to have trouble figuring out how to match this stuff to meals.

There's a buccal insulin in the pipeline (absorbed via the cheek membrane) that would not have the lung issues and might be more easily dosed. That could be helpful. But we'll have to see what it really does. I don't trust any of the PR you read before the drug company has to put together something that has legal standing. And even there, I've read enough Prescribing Information to see the statistical tricks they pull to make their product look more effective than it is!