September 28, 2007

FDA Doesn't Police Clinical Trials, Many Shady -- NYTimes

Today's New York Times reports on the study of regulation of clinical trials by the F.D. A. conducted by the inspector general of the Department of Health and Human Services, Daniel R. Levinson. His report said that federal health officials did not know how many clinical trials were being conducted, audited fewer than 1 percent of the testing sites and, on the rare occasions when inspectors did appear, generally showed up long after the tests had been completed.

Report Assails F.D.A. Oversight of Clinical Trials

The article goes on to cite examples of clinical trails being run by marginal criminal characters, like a psychiatrist about whom they write,"Last November, the Oklahoma Board of Medical Licensure and Supervision suspended Dr. Linden’s license for three months because he had sex with two patients and gave them genital herpes infections." [This is NOT the first New York Times report of drug companies doing business with doctors who have been disciplined for serious ethical violations .]

The most telling statement in the report is this one:

" 'In many ways, rats and mice get greater protection as research subjects in the United States than do humans,” said Arthur L. Caplan, chairman of the department of medical ethics at the University of Pennsylvania.

"Animal research centers have to register with the federal government, keep track of subject numbers, have unannounced spot inspections and address problems speedily or risk closing, none of which is true in human research, Mr. Caplan said.

Many so-called "clinical trials" are run by questionable clinical trial mills, after the drug has been approved for use. They have with one goal, and one goal only: to make it possible for the sponsoring drug company to expand the uses for its drug.

These trials are likely to be poorly supervised and often throw out any data that doesn't prove the result they set out to get. When doctors participate in these trials--which many do--they are paid hundreds of dollars--sometimes thousands--per participant. This is NEVER disclosed to the patients they enroll who may be given the impression that the doctor is prescribing the drug or device under study because it will improve their health--though often there is no evidence for this at all.

Trials run as part of drug company marketing efforts and conducted by by for profit clinical trial mills earn huge amounts of money for these clinical trail mills. Since it is very difficult to recover damages no matter how badly the participant is hurt, thanks to the legal disclaimers participants sign, there is no motivation to protect the people taking the drugs.

Why does this matter to you, a person with diabetes? Because people with diabetes are a huge market for expensive, dangerous new drugs, so you are very likely to run into a doctor who wants you to sign up for such a trial.

You'll also notice a lot of Google Ads displayed on Diabetes-related sites are trying to recruit you to participate in clinical studies. There is rarely any identifying information when you click through as to WHO is conducting the study. Unless the trial clearly identifies who is running the trial, and it is a major, well respected, well known medical organization like Joslin Medical Center or Rockefellar University, with a track record in diabetes or obesity research, you'd be well advised to ignore it.

Finally, be aware that drug companies often sponsor "clinical trials" of drugs already on the market where the purpose of the "study" is only to sign up hundreds of thousands of new patients to take their expensive new drug, with the idea being that once they are on it for a couple months, they will stay on it forever. Often these kinds of trials never result in any publication of any result, because no true study is being done. This kind of study is also common with medical devices. It's a technique companies use to lure you away from their competitors.

Before you participate in any clinical trial, get answers to the following questions in writing.

1. What are the known dangers of the drug, including all side effects? All drugs have serious side effects and if you are told, NONE it either means you are being lied to or the drug is so little understood that the purpose of the trial is to find out what dangerous side effects it causes.

2. What restitution will the testing company make if you suffer a serious side effect or see your health deteriorate as a result of taking the drug under study? Prepare to hear some major weasel wording here.

3. If your doctor "invites" you into a study for a new drug or device, ask the doctor how much they are being paid, per patient, to recruit people into the study? This is not an insult to your doctor. Doctors ARE paid for recruiting subjects. They should disclose this to the people they are profiting on. Ask the doctor what hard evidence he or she has seen that this drug will be good for you. Don't trust your doctor to know about side effects. Recent research shows that most doctors are unfamiliar with even the most dangerous side effects of commonly prescribed drugs. Google the drug using its generic name until you find out what is known about it. Then bring what you find to your doctor's attention.

4. Google the testing company on Google Scholar to see whether studies done by this clinical trial company ever turn into research papers and if they do, what the quality of the publications is that publishes them. Some supposed medical journals are marginal publications that verge on being Vanity Press offerings where anyone can publish if they pay enough. If you don't see the studies performed by the testing organization reported in top medical journals like New England Journal of Medicine, and Journal of the American Medical Association, be wary. The "clinical trial" may have one purpose only--drug marketing, and these are the kinds of trials where you are the most likely to be hurt.

5.If the drug or device involved is already on the market, research it carefully and be aware that the study may well be only an attempt to convert you from using a cheaper alternative. If the trial involves a psychiatric drug, like an antidepressant, be twice as careful. Many of these drugs are claimed to be non-addictive, but people who have tried to stop taking them report this is far from the case. Once you have been "habituated" to a powerful psychiatric drug [the euphemism now used in place of "addicted" though it means the same thing in practice], you may experience severe withdrawal symptoms if you go off it.

September 26, 2007

EASD: Why the OGTT Fails to Predict Heart Attack and Why this Harms People

Diabetes in Control reported today on a study presented at EASD by Dr Esther van 't Riet which found that in normal people the A1c is predictive of non-fatal heart attack, but, both fasting bg and the 2 hour OGTT [Oral Glucose Tolerance Test] results are not.

Before you conclude that this study "proves" that post-meal spikes are not what cause heart attacks, it is worth considering how the OGTT works and why it does NOT mimic the way your body responds to high carb meals.

The OGTT involves sucking down 70-75 grams of pure glucose and then testing blood sugar at various intervals to see what happens. It is a convention of medical research to use the OGTT value to diagnose "Impaired glucose tolerance" when the 2 hour result is over 140 mg/dl (7.7 mmol/L) and to diagnose diabetes when the 2 hour result is over 200 mg/dl (11.1 mmol/L).

However, glucose is the one form of sugar that does not require any digestion. It goes directly into the bloodstream within 15 minutes, unlike starch or sucrose which must be broken down in the stomach and may take up to an hour to reach the blood.

So the 75 grams of glucose you swill during an OGTT hit the blood in 15 minutes. In most people with the kinds of blood sugar control likely to result in a 5.5% A1c (the level Dr. Riet's study showed to correlate with heart attack)this initial very high blood sugar spike provokes reactive hypoglyecmia.

So what typically happens is that the person with marginal blood sugar control--the 5.5% A1c that marks a higher risk of heart attack--will get a very high blood sugar reading at 1 hour only to have the blood sugar plummet in the second hour. it is quite possible to have a normal or even a low blood sugar two hours after taking an OGTT where the one hour value was over 200 mg/dl (11.1 mmol/L). But this study only looked at that second hour response in diagnosing "impaired glucose tolerance."

However, look what happens when these same people with the 5.5% A1cs and "normal" two hour OGTT values eat the same number of grams of carbohydrate that are used in the OGTT in the form of real food.

That hamburger bun and order of fries with the 75 grams of carbohydrate digest more slowly, thanks to the carbohydrate they contain being combined with fat and protein. So if you have an A1c of 5.5% and test your blood sugar after eating 75 grams of carb in real food you are more likely to see something like 180 mg/dl (10 mmol/L) at one hour after eating and 160 (8.9 mmol/L) at two hours. By 3 hours your blood sugar may have dropped to 120 mg/dl, but until it does you have spend a couple hours with blood sugar levels that are known to be high enough to damage the organs!

It is a shame that almost no medical authorities test people for meal tolerance rather than using pure glucose syrup for the OGTT. The meal tolerance test, where a meal containing real food with a known carb count is served and blood sugar measured at one and two hours, would give doctors a much better idea of what is happening in the patient's body day in and day out. It would also be very likely to show a very tight correlation between exposure to elevated blood sugars after meals and increased incidence of heart attack.

Instead, the researchers here, who clearly have NEVER MEASURED THEIR OWN BLOOD SUGARS and do not understand that a "normal" two hour results on an OGTT may not indicate normal blood sugar response to meals day in and day out, look at that 2 hour OGTT results and conclude that, since the OGTT results don't correlate with heart attack incidence, blood sugar is not causing heart attack. Instead they hypothesize that the A1c is only "a marker" and elevated blood sugars is NOT the cause of heart disease.

This is tragic. Because lowering blood sugar after meals is probably the single most powerful tool available to us to avoid heart disease!

But sadly, the researchers in this case conclude that doctors should not attempt to lower A1c but should just keep treating cardiac risk factors with expensive drugs.

I am sure you will hear doctors citing this study as a reason to avoid testing after meals or reducing blood sugar spikes since "clearly" the study shows that spikes don't correlate with heart disease.

But those of us who do control our blood sugar and avoid post-meal blood sugar spikes know that controlling spikes so that they don't go over 140 mg/dl (7.7 mmol/L) lowers blood pressure, lowers triglycerides and LDL and raises HDL without the need for expensive drugs. Which suggests that elevated post-meal blood sugars are what raise the risk factors and that normalizing blood sugar could prevent heart disease.

Sadly, bad science in the form of over-reliance on the OGTT will keep most people from ever learning this.

September 25, 2007

EASD: Imbecile Insulin Dosing Schedules Not Much Help for Type 2s

The "DUH" of the Week goes to the geniuses at EASD who reported studies showing that giving "insulin" to a person with Type 2 diabetes and extremely high blood sugars doesn't do much when that "insulin" is ONLY a basal insulin prescribed at the wrong dosage.

Imbecile mistake #1: Prescribing only a basal insulin which has no impact on post-meal blood sugars. What part of "Very high blood sugar spikes after meals damage the body" don't these people get?

Imbecile mistake #2: Giving patients only enough insulin to lower their fasting blood sugar to a level that is still way too high. I have spoken with many Type 2s whose doctors tell them they are doing great if their fasting blood sugar "on insulin" is around 120 mg/dl (6.7 mmol/L). Since this means that every time they eat a few grams of carbs they go over 140 mg/dl (7.8 mmol/L)--the level at which organ damage occurs--and stay there for hours you can see why this is a futile treatment plan.

When you add to the mix that these people are still being told to eat a low fat/very high carb diet, so that they are eating 50-100 grams of carbs at each meal pushing them into the 200s or higher, you can see why their "insulin" regimen is near worthless. Even sadder, these patients with the 120 mg/dl fasting blood sugars are the "good ones" in these doctors' practices. Many type 2s "on insulin" are still getting fasting blood sugars well over 150 mg/dl!

But sadly, this kind of rotten medical treatment is Standard Operating Procedure. Most people with Type 2 are treated by their busy family doctors and most family doctors treating people with diabetics ONLY prescribe basal insulins. And when they do, they almost always prescribe insulin in the generic doses that, out of fear of hypo, are set high enough to guaranteed that the fasting blood sugar level is high enough to damage the organs.

What is so sad here is that the only reason that these people aren't put on "insulin" regimens that give them normal or near normal blood sugars is that their doctors are too busy to bother with the interaction involved and it doesn't occur to them to send Type 2s to the same "Diabetes Educators" that they prescribe for Type 1s. A correctly prescribed basal/bolus regimen-- with insulin for both the fasting and the post-meal state, carefully titrated to match the carb input at mealtimes--can normalize blood sugars.

So because of medical ignorance hundreds of thousands of people are condemned, unnecessarily, to blindness, amputation, kidney failure, and heart attack death.

The fact is, insulin, prescribed right, ALWAYS lowers blood sugar and with some work and education it will produce blood sugars low enough to avoid all the serious diabetic complications. But "insulin prescribed right" means this:

1. Covering the fasting state with a basal insulin titrated to avoid hypos at 3 AM and provide a fasting blood sugar under 100 mg/dl. This may mean using 2 shots of different sizes since none of the basal insulins really lasts exactly 24 hours. One larger shot in the morning, one small at night works well for many people.

2. Covering meals with a faster insulin--Novolog, Humalog, Apidra or R (humulin/novalin), using a carefully computed "insulin/carb" ratio that matchs the dose of meal-time insulin to the estimated amount of carbohydrate in the meal. Ideally, the amount of carb in the meal should be kept low enough that mistakes in guestimating the carb count won't end up causing severe hypos. For many of us this means keeping carbs between 20 - 50 grams per meal.

Getting the correct dose figured out for both basal and bolus insulin involves starting with a low dose and very carefully working up until it's right. This takes time and, for most people, requires the help of a person trained in adjusting insulin doses--a Diabetes Educator.

But the hard work and initial effort involved in learning how to match your insulin dose to the carbohydrate in your meals will pay people with Type 2 diabetes back with decades of improved quality of life.

If you are currently "on insulin" and seeing fasting blood sugars around 120 mg/dl (6.7 mmol/L) and post-meal blood sugars routinely over 160 mg/dl (8.9 mmol/L) 2 or even 3 hours after each meal ask your doctor to send you to see a competent diabetes educator so you can work out an insulin regimen that works. If he or she won't, find a new doctor.

And if you are a person with Type 2--whether or not you are on insulin--who is still eating 100 grams of carbohydrates a meal and wondering why your blood sugar keeps getting worse, check out the web page below and try the strategy described there for two weeks. It may keep you from ever needing insulin!

Jennifer's Advice to Newbies. Don't let the name put you off, this advice has helped people who have had diabetes for decades, too.

September 22, 2007

Extremely Bad Science: Depression & Type 2

Here's a study that is a "perfect storm" of bad science. Unfortunately, as you can see from the way the media report is titled, the findings are being presented by the media in a way that suggests people with Type 2 have mental problems, though, in fact, the study is so badly flawed as to be worthless.

Here's one version of the media coverage:

EASD: Studies Link Depression and Type 2 Diabetes

From the article: "Type 2 diabetes may be linked to mental health disorders, but age and gender may be contributing factors, according to two separate studies.

"Symptoms of depression or psychological stress were associated with increased risk of type 2 diabetes in men, but not in women, Swedish researchers reported

Why is this bad science? Two reasons.

1. The symptoms of "depression" used to compute the amount of depression in the study subjects included "sleep difficulties, apathy, anxiety, depression, fatigue, and back or shoulder pain during the preceding 12 months." [emphasis mine]

Anyone who knew anything about diabetes would immediately note that "back and shoulder pain" can be caused by a lot of other things besides depression. Like, for example, the tendon and disc problems associated with abnormally high blood sugars.

It is now known that carpal tunnel syndrome develops about 10 years before people receive a diagnosis of diabetes and may indicate the presence of high post-meal blood sugars that are missed by the fasting plasma glucose test used for diagnosing diabetes.

It is also known that Frozen Shoulder is much more common among people with diabetes and it too is probably caused by high blood sugars which thicken tendons. I recently read in the book Sciatica solutions : diagnosis, treatment, and cure for spinal and piriformis problems by Dr. Loren Fishman that some specialists believe that vertebral disc problems may be caused by blood sugar abnormalities.

So my conclusion--and that of anyone familiar with diabetic tendon problems--would be that people who have diabetes or undiagnosed diabetes who also have back and shoulder pain probably have physiological back and shoulder problems caused by high blood sugars, NOT psychosomatic symptoms caused by depression. And diagnosing them as depressed based on this laundry list of vague symptoms is a mistake.

2. The second problem here, a major one, is that we know that some of the powerful psychiatric drugs given--often very inappropriately--to people who complain of mild depression can cause diabetes. Zyprexa is only one of these, the best known, but the other drugs commonly used may also affect glucose metabolism.

However, the article states that these studies did NOT identify patients who had been treated for depression with these drugs that can destroy blood sugar control. Hence the association of "depression" with diabetes is worthless. Yes, inappropriate drug TREATMENT for depression may CAUSE diabetes, but this is not the conclusion being drawn here, that somehow, having Type 2 diabetes makes people more depressed.

How do people get media attention for such poorly conducted research? These studies wouldn't get an "A" at a well conducted high school science fair! But it still got international media attention and you can bet that a lot of doctors are going to only read the headline and conclude that depression and diabetes go together.

It DOES depress me to see yet another example of the lousy science that hurts people with diabetes, just as it depresses me to see the rotten treatment so many people with diabetes get.


September 21, 2007

Three Different Conversations

This past week I had some version of the following exchange with three different people. One works at the local diner. One is an executive at a well known political action organization. One is an excellent dentist. All occurred in the midst of a conversation about something else.

Me: I maintain a web site that summarizes what mainstream lab research tells us about controlling diabetes.

Other Person: Oh, really. My [mother/father, sister/brother, aunt/uncle, and grandparents -- chose 3] all died of diabetes. I really worry about it.

Me: Have you tested your blood sugar after eating?

OP: No. Why would I do that?

Me: To get an early indication of whether you are developing diabetes--so that you can cut back on the carbohydrates you eat and prevent it from getting much worse.

OP: Carbs? Why carbs. Aren't you supposed to eat a low fat diet? That's what they told my [mother/father, sister/brother, aunt/uncle, and grandparents -- choose 1.]

Me: Yes. Well that's sadly part of why they probably died of diabetes. It is carbs that raise blood sugar, not fat.

OP: Wow. I didn't know that. You ought to write something about this!

Me: I have!

The sad part here is that these people all see doctors. The doctors know that they are overweight and also know their family histories. But no doctor ever mentioned any of these ideas to them. Instead, they were simply told to "lose weight" and "to exercise" which they've tried in the past with little success, like 95% of all people over age 45. When they do try to lose weight, they eat a low fat diet full of healthy grains. Guess how much weight they lose. You got it. None.

None of these people had been tested for diabetes with anything but the fasting plasma glucose test. I suspect their FPGs are well over normal, too. But in this region at least, most family doctors won't tell a person they have a problem with their blood sugars until their fasting blood sugar reaches the 120 mg/dl range. And if they do tell them to diet, they still tell them to eat a Low Fat/HIGH carb diet.

Every one of these people could have been given the information that--without the need to lose midlife weight--could have given them normal blood sugars and an unrestricted future. None of them were. Sadly, all of them probably will develop diabetes, because who is going to pay attention to what some woman with a computer says?

September 18, 2007

Why Monitoring Doesn't Reduce High A1cs

This AP news release

Diabetics Try New Round-The-Clock Sensor

touting the success of Continuous Glucose Monitoring Systems (GGMS) cited this statistic attributing it to Dr. Irl Hirsch of the University of Washington:

Diabetics who do the worst job fighting their disease aren't going to put in extra effort to improve just because of a sensor, says Dr. Irl Hirsch of the University of Washington.

"We learned that lesson the hard way," says Hirsch, who presented research at a recent diabetes meeting suggesting the sensors instead will most benefit patients who can't lower their blood sugar to optimal levels — a score below 7 on a test called the A1C — despite following best-care guidelines.

Hirsch finds the sensors help lower A1Cs between 7 and 8.5, but not those who start out higher.
[emphasis mine]

There's a reason for this, and sadly, it is another case of iatrogenic [doctor-caused] failure.

Monitoring and testing are worthless if doctors don't give people effective strategies for responding to unfavorable test results.

In the case of an unacceptably high blood sugar, the one strategy that will solve the problem is cutting way back on carbohydrates. It is carbohydrates that raise blood sugar and it is by lowering carbohydrates that you can bring down a very high blood sugar.

But most patients and, sadly, most doctors, don't get this.

Every week I get emails from recently diagnosed people with diabetes that they are baffled because at their doctor's urging they have "improved their diets" by adding lots more fruit and healthy whole grains, but their blood sugar is not improving.

Well, given that most fruit and all grains--whole or not--are full of carbohydrate, this should surprise no one. But when even doctors and nutritionists are telling people with diabetes to start out the day with a big bowl of oatmeal and a banana, you can see why these poor victims/I mean, patients can test 20 times a day and it isn't going to make a bit of difference.

If you give a patient a meter or CMGS and tell them that they should cut out the starches and sugars in their diet--no matter how "low GI"--and replace them with protein and fat until the blood sugar comes down into the safe zone, you will see huge improvements in people with A1cs as high as 13%.

My web page documenting reports from people who joined "The 5% Club" shows this very clearly.

The reason that Dr. Hirsch's patients with high A1cs aren't benefiting from monitoring is most likely because the reason they got those high A1cs in the first place is that they were eating the usual high carb/low fat diet that a frightening number of nutritionists and doctors still prescribe their patients.

Give people with high A1cs a CGMS or a blood sugar meter along with the simple advice you'll find here:

and you'll see people attaining far better A1cs than the not-low-enough-to-prevent-blindness 7% A1c that Dr. Hirsch seems to think is impossible to attain.

September 14, 2007

Invasion of the Blog Stealers

Some readers have expressed concern about the copyright violation notice I went and stuck on the bottom of my last ten posts.

Here's the reason it's there. Some bottom feeding web site hosted in a Far Eastern country has set up something that sucks in other people's blog postings and republishes them as if they were the blogger's own content. The point of all this appears to be to make money off the many Google Ads that top the page. When I checked my blog in Technorati recently, I saw dozens of my blog posts being copied in full this way by one site with the only clue as to where they came from buried in very fine print. Since these weasels seem to strip content on a daily basis, I figured I'd include the copyright violation note so that it would appear on their scum sucking site.

I love being linked and or quoted for a paragraph or so by people who share a common interest in improving the health of people with diabetes. Just don't pick up my entire post and publish it as if you wrote it!

Copyright Janet Ruhl, 2007. If you are reading this entire blog post anywhere but the contents were stolen.

September 13, 2007

ADA Whores for another Sponsor

One of the ADA's shills brought it to my attention the "new partnership between the American Diabetes Association and V8 100% Vegetable Juice to help Americans bridge the vegetable consumption gap."

Campbell Soup is one of the many food companies who sell primarily starchy, salty foods that are are listed as The American Diabetes Association's corporate "friends" on the ADA site here. Do take a look. If you ever wondered why the ADA promotes questionable oral drugs, high carb foods, and a visit to the gym as the only way to treat Type 2 diabetes, a look at its big donors will answer your question.

So now it seems that the ADA has decided to promote a big donor's V8 juice as a suitable "vegetable" for people with diabetes

And what a vegetable it is! One 11.5 ounce bottle--the size you usually see sold--contains 15 grams of carbohydrate. Not only that, but if you do the math you'll see that the "fiber" listed on their label has already been deducted from the carb count. Though the way they list the fiber using the deceptive, European label style, makes it look like you could deduct them. Don't. They're all in the container. (Verify this using the Hidden Carb Calculator)

What do you get for your 15 grams of carbs? Not much. Pureed vegetables that have been heated and processed so that they've lost many of the original nutrients they started out with. They are very likely to have had the original vitamins replaced with imported Chinese vitamin supplements. Extra salt. Preservatives. And, of course, more blood glucose than you'd get in an entire package of Spinach, a pound of green beans, three artichokes, two zucchinis, etc.

It's worth noting that this ADA partnership announcement comes just as Coca Cola has taken over the distribution of V8. If you'll remember, recent studies have shown that drinking as few as 2 cans of either regular or diet coke doubles the risk of kidney failure. But you didn't hear that from the ADA, despite the fact that people with diabetes are the most vulnerable to kidney failure. Instead the ADA teams up with the company distributing yet another questionable food substitute.

Finally, it's worth noting that Campbell's markets a whole line of V8 branded juices, many of which are fruit flavored drinks that have 26 grams of carbs in a 12 ounce bottle. With the ADA's "V8" is good for you campaign, it's likely many unsophisticated people with diabetes will conclude that these very high carb V8 branded juices are good for them, too.

Here's the question of the day

Why, with the hundreds of millions of dollars that have been raised by the ADA over the past decades supposedly to help people with diabetes, does the average person with diabetes still not know that it is the carbohydrates they eat at meal times that raise their blood sugar? Or that lowering the amount of carbs they eat at meals could lower their blood sugar?

How much would it have cost to get that message out? Or does Campbell's soup and Coke not want you to know that?

Copyright Janet Ruhl 2007. If you are NOT reading this on the content has been STOLEN.

September 12, 2007

Beware Cortisone!

Today's e-mailbag brought a letter from someone who reported that their blood sugar deteriorated significantly after a single shot of cortisone administered by an orthopedic doctor and that, even two months later, it has not returned to the level it was before the shot.

I wish this were an isolated, oddball occurrence, but sadly, it is not. Years ago when I posted a question on the old newsgroup about the events leading up to a Type 2 diabetes diagnosis, I heard from several people who said that their blood sugars, which had been marginal before a cortisone treatment, became fully diabetic afterwards.

It was only then that I connected my own diabetes diagnosis with the ten day long course of prednisone I'd been given the previous year and and realized that it was only after that treatment that I'd developed the raging hunger and uncontrollable weight gain that seems to have signaled that my blood sugars had crossed over some disastrous boundary.

Every doctor I've mentioned this too has pooh-poohed it. Yes, they say, cortisone temporarily raises blood sugars, but they should go back to normal afterwards. But my doctor said the same thing, even when faced with the evidence that I'd suddenly developed much stronger symptoms of diabetes.

So it is possible that doctors believe that cortisone will not worsen diabetes and because of that belief attribute the worsening when it occurs to something else! Alternatively, because cortisone is often given by orthopedic doctors who don't monitor a patients' blood sugar, it is possible that they don't ever learn of the effect of their shots on the patients.

My belief, after dealing with several rheumatologists and orthopedic doctors, is that these doctors often administer a shot of cortisone so that the patient--who is being billed well over $200 for the appointment--will feel that the doctor did something, since without cortisone, mostly all the doctor can do is advise patience.

Whatever the explanation, while I don't question that there are people with diabetes whose blood sugars return to normal after a cortisone treatment, I think we all need to be aware that cortisone can worsen our blood sugar, permanently. And if we have managed to get our blood sugars under control--especially if we've done it with diet and exercise, we should know that a single cortisone shot or course of prednisone may make it impossible to retain that good control without adding insulin.

That said, cortisone is a powerful drug that can dramatically improve symptoms of some severe autoimmune disorders and even, in some cases, save lives. If you need it for a serious autoimmune disease or to counter brain swelling, well, you'll just have to deal with any associated blood sugar issues. And they can be dealt with--usually by going on insulin.

But the tragic thing about cortisone is that it is often used in situations where the research makes it clear that it is nothing more than a placebo. Even worse, the conditions in which it is least likely to help are precisely those that many Type 2s are likely to develop: tendon problems like Frozen Shoulder and Carpal Tunnel syndrome.

While a cortisone shot may occasionally give some pain relief for frozen shoulder, the research shows that it does not shorten the healing time! The same is true of other tendon-related problems.

Here is a study that found that while cortisone shots produce short term improvement in frozen shoulder, three months later, the people who did NOT get the shots were in better shape!
Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial.
R Buchbinder, J L Hoving, S Green, S Hall, A Forbes and P Nash
Annals of the Rheumatic Diseases 2004;63:1460-1469

I was also assured by a doctor that electrophoresis would deliver cortisone to another injured tendon--in my foot this time--and not raise my blood sugar and was dumb enough to believe it. The blood sugars I saw over the next week were much higher than usual. And it may or may not be coincidental that my fasting blood sugar, which until then had been controlled on a low carb diet, started to deteriorate.

Questions to Ask Before Taking a Cortisone Treatment

Before you go to any doctor about a joint- or spine-related problem--the ones most likely to result in a cortisone treatment, read up about your condition on the web.

Then answer these questions:

  1. Does cortisone have an impact on the healing time for this condition or is it only being used as a pain relief strategy? If the latter, ask your doctor for alternative pain treatments. When I did this my family doctor was able to find a safe drug for me to use that made the pain bearable until nature healed the tendon problem.

  2. Are there alternative treatments that have as good an impact on the underlying condition that won't raise blood sugar?

  3. If you have a condition, like an autoimmune disease, where cortisone drugs are effective and perhaps life or joint-saving, will your doctor prescribe insulin to control the dramatic blood sugar spikes cortisone will cause? Insulin is the only treatment that can prevent these very high blood sugars which will kill your remaining beta cells. Lowering your carbs, sadly, will not. But there's some reason to believe that using insulin to lower these blood sugars may help preserve the cells.

Remember, at blood sugars over 200 mg/dl beta cells succumb to "glucose toxicity" i.e. sugar poisoning. If you're down to having 25% of your beta cell mass functional, losing that last 5% may be all it takes to make it impossible to control with diet alone.

If your doctor won't prescribe insulin demand to know why, and if the reason isn't a very good one, find a doctor more respectful of your health.

Copyright Janet Ruhl 2007. If you are NOT reading this on the content has been STOLEN.

September 10, 2007

Why A1c "Average" Doesn't Match Meter Tests at Normal Blood Sugars

If you've been working hard to bring your blood sugars down to normal, your next A1c might be a disappointment. That's because many of us find that even if our meters show us having much better blood sugars--those truly in the normal range--we still may get A1cs of 5.5-5.7%. According to the formula most doctors use, these A1cs correspond to an average blood sugar of 118 mg/dl to 126 mg/dl (6.6 mmol/L - 7 mmol/L).

Why you'd get an average of 118 mg/dl when you are spending only 3 hours a month over 140 and have fasting blood sugars under 100 mg/dl seems hard to understand. It has happened to me, and to several other people I know.

Doctors will tell you that your testing must be missing significant highs. But a friend of mine who believed that was the case for her blood sugars which tested in the normal range but resulted in a mid-6% A1c used a CGMS for a month and did not find that her blood sugar was spiking at times she hadn't thought to test. It was pretty much what her meter had told her it was. Something else was causing the high A1c.

The real problem is, as I discussed in an earlier blog posting, that the averages associated with A1cs were derived from DCCT, a study where almost all the participants had A1cs ranging from 7% to as high as they go. So those A1c to mean glucose averages derived from DCCT appear to only hold true at the damagingly high blood sugars that were found in that study. (7% corresponds to an average blood sugar of 170-180 depending on the formula you use. We know from a ton of studies that blood sugars over 140 mg/dl damage all kinds of cells. )

Here's a study that shows why at normal blood sugars, red blood cells live a lot longer, so that those formulas no longer apply.

In this study the scientists measured the lifetimes of hemoglobin cells in normal people and diabetics and found that the cells of the diabetics turned over much faster--as little as 81 days, while normal people's could live up to 146

They suggest that getting better control will cause the cells to live
longer. But when they live for a couple extra months, they will also continue to glycate--i.e. collect the bits of sugar that are measured in the A1c test. Cells that are living longer may collect after 5 months of life the same amount of glucose a person with poor control might collect in 3 months. That doesn't mean they have the average blood sugars as the person who developed that degree of glycation in the much shorter period.

This data also suggests if you lower your blood sugars from good control to great control, control, you probably want to test only every 6 months, not every three because it will take that long for your good control to show up.

This may also explain why many truly normal people have A1cs in the lower 5% range. They may have much longer lived red blood cells than normal. I have one very physically fit friend whose fasting blood sugar is never over 95 mg/dl and who tests no higher than 115 mg/dl after eating a very high carb meal that would put me into a coma, yet his A1c is 5.4%.

Copyright Janet Ruhl 2007. If you are NOT reading this on the content has been STOLEN.

September 9, 2007

The Hubris of "Medical Professionals"

This morning's email brought an angry letter from an anonymous nurse who told me that my views were worthless because she was a "medical professional" and I wasn't. No further information backed up this claim.

That made me think of the story I'd recently read in the Washington Post that documented just how ignorant "medical professionals"--in this case Doctors--can be.

Doctors Flunk Quiz about Supplements their Patients Use

There are two disturbing things in this study. One was that one third of 335 doctors did not know that the FDA doesn't regulate supplements and that no proof of supplements' efficacy is required before they are sold to the public. Almost two thirds did not know that they are supposed to report side effects from supplements to the FDA.

That's bad enough. But what is worse is this: After being given a brief course about supplements 9% of the doctors who had taken the course still flunked a quiz about supplements.

The torrent of email I get from patients who have been misdiagnosed with the wrong kind of diabetes, undiagnosed with blood sugars repeatedly over 200 mg/dl, told by their doctors that a "diabetes diet" is a low fat diet full of carbs, and left untreated with blood sugars high enough to give them the a1c of 7-8%-which represents average blood sugar of 172-207 mg/dl, convinces me that many doctors would flunk any test they were given about the current understanding of diabetes and its effective treatments.

Unfortunately, once a doctor goes into private practice, there is no requirement that he or she pass any test demonstrating that they have kept up with diabetes treatment. This is true, no matter how many patients with diabetes they treat. Doctors do have to take "continuing medical education" to retain their licenses but it is up to them what courses they take. If they aren't interested in diabetes, they can ignore it for the rest of their professional careers and many do.

I run into medical professionals from time to time who support what I do here. They aren't all self-satisfied egoists. But for those who are, let me stress this again, the appeal to authority won't impress any of us who use a blood sugar meter and our access to up-to-date medical research to determine the quality of advice dished out by medical professionals.

Copyright Janet Ruhl 2007. If you are NOT reading this on the content has been STOLEN.

September 6, 2007

The Worst Non-Facts from Nutritionists

Here are a randomly chosen list of horribly bad advice people with diabetes have reported getting from registered dietitians in the last couple months. They all have in common that they are completely wrong.

1. If your blood sugar goes below 100 mg/dl, it's a hypo and you have to eat some carbs right away to bring it back up. (Told to a Type 2 controlling with only diet and exercise!)

No. The normal blood sugar range goes down to 70 mg/dl. The ideal blood sugar for someone who is controlling with diet alone is mid-80s.

2. Your brain stops working if you eat less than 130 mg/dl of carbs a day.

No. Your brain works fine with 0 carbs as long as you eat enough protein that the liver can convert that protein to provide the roughly 60 grams of carbs you need to run your brain. About 58% of the protein in your diet can be converted to glucose.

3. If you are low on potassium, you should eat bananas.

Not unless you love having very high blood sugars. You can get potassium from avocados, broccoli, spinach, winter squash, mushrooms, lean meats, clams, and fish, including salmon. If you still don't think you are getting enough, one sprinkle of Morton's Salt Substitute will provide more than enough potassium for anyone.

4. You have to drink at least 8 glasses of water a day. A lot more is even better.

No. This is the "Water Myth" which was invented by the companies that sell bottled water. Too much water washes water soluble vitamins out of the body and can stress marginal kidneys.

5. Eat a lot of healthy whole grains. (To a Type 2 controlling with diet)

Not unless you want unhealthy high blood sugars. All the studies supposedly proving whole grains were "healthy" compared a diet of whole grains to an even higher carb diet full of white flour and potatoes.

No one has funded a study that compares a diet rich in whole grains with one free of almost all grain products, where the whole grain diet would come in very poorly. That's probably because no one will get rich NOT selling cheap grain to the public. Studies of low carbohydrate diets very low in grain of all types have shown that they make huge improvements in the blood sugar and lipids of people with diabetes.

6. Pasta is very good for your blood sugar.

Pasta LOOKS good if you test your blood sugar only at 1 or 2 hours after eating it because it takes 5-7 hours to digest. If you tested after it digested you'd be likely to see the 23 grams per ounce hitting the blood stream and the sight would not be pretty. A typical restaurant serving of pasta contains about 160 grams of carbohydrate. Without any sauce. Add the sugary tomato sauce and you just plain don't want to know!

That's a start. Send me your nutritionist horror stories!

Copyright Janet Ruhl 2007. If you are NOT reading this on the content has been STOLEN.