January 28, 2011

Insight into The Prediabetes Epidemic

A recent headline blares that fully one third of people in the U.S. have "prediabetes." This sounds dire, because the implication is that it is only a matter of time until one third of the population has full-fledged diabetes.

In fact, it is highly unlikely that will ever happen. The incidence of full-fledged diabetes has remained around 9% in the entire population for decades and most of the small recent rise in diagnoses is attributable to the lowering of the blood sugar level at which diabetes is supposed diagnosed that happened in 1998.

Though the name makes it sound like prediabetes and diabetes are two stages of one condition, research that has studied the patterns in which the disease develops--makes it clear that they are not. (Details HERE.)

A diagnosis of prediabetes means only that a person's blood sugar has been tested and found to lie in a specific range, one that stretches from the top of normal to the lower bound of the range defined as diabetic. But there are two major--completely unrelated--reasons why people's blood sugar might rise into that prediabetic range. The first, and most common reason, is that they have developed insulin resistance.

Insulin resistance describes people who need to use more than normal amounts of insulin to counteract the blood-sugar-raising effects of the carbohydrates they eat. Where a normal person might be able to keep their blood sugars rising after eating 40 grams of sugar and starch by secreting two units of insulin, an insulin resistant person might need to secrete 20 units to keep blood sugars from rising after eating the same amount of food.

A surge in insulin resistance in the general population appears to be what is driving the increase in diagnoses of prediabetes.

The other, and much more serious, reason people's blood sugar rises into the prediabetic range is that their beta cells don't work properly, and are having trouble secreting insulin. In that case, a person who needs to secrete two units to keep their blood sugar normal after eating can only make one unit, when they need two. Or if they are also insulin resistant, they may be making only ten when they need that twenty.

However, it turns out that most people who become insulin resistant over time will grow new beta cells which though they don't secrete enough insulin to keep their blood sugar normal, keep it from rising into the very high range defined as diabetes.

The people who do become diabetic are those who can't grow new beta cells because their beta cells were already in poor shape. In fact, evidence is accumulating that while people who develop Type 2 diabetes often are insulin resistant, as are so many other people in the general population, it is the fact taht their insulin-producing beta cells are defective, not their insulin resistance, that causes them to progress from "pre-" to full-fledged diabetes. (Details HERE.)

This finding is confirmed by the finding that the most common gene defect found in people of Western European heritage who have developed Type 2 diabetes is TCF7L2, a gene that causes defective insulin production--not insulin resistance. This has turned out to be true of almost EVERY gene that has been associated with Type 2 diabetes. (Details HERE.)

Exactly what causes insulin resistance is not well understood. Too much of the research into this question has started at the wrong end. Researchers who think they know the answer--for years they were sure that it was eating fat that caused insulin resistance--engineer what they call mouse models of diabetes. These are mice chosen specifically because they become insulin resistant when they eat high fat diets. Unfortunately, the genes that make this happen in these mice bear no relationship to the genes found in humans who have Type 2 diabetes--who almost never become insulin resistant when they eat fat.

That's because in humans eating carbohydrates appears to be what raises insulin resistance. Eating starches and sugars raises blood fats--the triglycerides which may increase insulin resistance. But more significantly, fructose has an even stronger impact on insulin resistance. Eating fructose causes fat to be deposited in the liver, and it turns out that the more of this intracellular liver fat you have, the more insulin resistant you are likely to be. Even worse, once that fat is deposited, it is almost impossible to remove no matter what you eat.

So the increase in insulin resistance in the general population has a lot to do with the huge increase in their intake of fructose due to the huge amounts of high fructose corn syrup we've been getting in processed foods since the late 1970s.

Other causes for the increase in insulin resistance are the widespread use of SSRI antidepressants, large scale exposure to the herbicide Atrazine, and high blood levels of the plastic, Bisphenol-A. There are others. (Details HERE.)

If you have been diagnosed with prediabetes your chances of progressing to full-fledged diabetes are highest if your one hour glucose tolerance test result is over 155 mg/dl (8.6 mmol/L),(see the study HERE for details) if you have diabetic relatives, if you have taken any of the pharmaceutical drugs known to damage the beta cell, such as Zyprexa, if you have an autoimmune condition, and, ironically, if you aren't obese at diagnosis. The thinner you are when you are found to have abnormally high blood sugars, the more likely it is that failing beta cells is causing your elevated readings rather than increased insulin resistance.

Prediabetes, even when it does not progress to full-fledged diabetes, is not a benign condition. It does damage the body, and though this damage is often subtle--it causes small changes in the growth of blood vessels in the retina and kidneys, for example--the real danger lurking for people with prediabetes is heart disease. The risk of heart attack is much higher in people with prediabetic blood sugars than in those with normal blood sugars.

So if you have been diagnosed with prediabetes you should do all you can to lower your blood sugars to normal, since it is the blood sugars, not the insulin resistance that damage your organs.

The research makes it clear that what correlates most strongly with the risk of heart attack is how high your blood sugar goes after meals, not the fasting blood sugars which are, all too often, the only sugars doctors tell you to measure.

People whose blood sugars are over 155 mg/dl (8.6 mmol/L) an hour after eating have a higher risk for heart disease. (Details HERE.)

The experience of the online diabetes community suggests that if you keep your blood sugars under this level--many of us shoot for under 140 mg/dl (7.7 mmol/L) to be safe--you will do fine, no matter what your diagnosis, or even what the cause is of your diabetes. It appears to be the high concentrations of glucose in the blood that cause organ damage, not the underlying condition.

So use the simple strategy you'll find explained HERE to find out what foods you can eat safely without pushing your blood sugars into the danger zone.

The cheap, generic drug, Metformin is also highly recommended for people who are insulin resistant. It seems to block the process by which the liver deposits more liver fat, changes the way that muscles burn glucose to one that lowers insulin resistance, and lowers blood sugar.

Metformin's only significant side effects, observed after decades of use, appear to be that it decreases your chance of having a heart attack and also lowers your risk of developing various cancers. (Details HERE.) If only other drugs had those kinds of side effects!

January 21, 2011

Slow Digestion Can Explain Odd Readings

I received emails this week from three different correspondents that asked about strange blood sugar readings several hours after eating. In my replies I mentioned slowed digestion as a possible cause. As I did so I realized this is a blood-sugar related problem that isn't often discussed in mainstream media, so it isn't familiar to all of us.

I first learned about it in reading Dr. Bernstein's landmark book,Dr. Bernstein's Diabetes Solution. Bernstein explains that delayed digestions, which he calls by its medical name, gastroparesis, results when neuropathy affects the nerves of the autonomic nervous system that control the opening and closing of the valve at the bottom of the stomach.

If the valve stays shut after eating, your food does not get to the upper part of the gut where much of it digests. As a result, starch and complex sugars don't turn into glucose and your blood sugar stays low after eating. Eventually, of course, the valve does open, and when it does your food digests and your blood sugar rises.

If you aren't using insulin, this merely will give you odd readings. You'll see good readings an hour or two after eating, only to discover your blood sugar soaring the third hour.

However, if you use fast-acting insulin at meals this effect can be dangerous, because your insulin will peak at about an hour after you eat whether or not your blood sugar is high. If you inject enough insulin at the time you eat to cover a significant amount of carbohydrate, you may end up with a hypo if that carbohydrate doesn't digest into glucose in time to meet the insulin.

And even if you don't hypo, if digestion is delayed, by the time your food does digest you may not have any insulin left to cover it, so you will end up with a very high blood sugar.

Delayed stomach emptying can be very hard to deal with because there may be no pattern to how the valve behaves. It may open at different intervals after every meal. Fast one meal, very slow the next. You may eat lunch and not have it digest until you eat your dinner.

Dr. Bernstein's book contains a long section that lists various treatments he's found helpful when treating patients with the slow stomach emptying that results from autonomic diabetic neuropathy. It's well worth reading if you suffer from this problem.

Since the autonomic neuropathy that causes delayed stomach emptying is a late diabetic complication that occurs only after long exposure to very high blood sugars, most of the people with Type 2 diabetes who are reading this blog because they are devoted to keeping their blood sugar normal aren't likely to experience it.

But--and Dr. Bernstein does not discuss this--there are other conditions besides autonomic diabetic neuropathy that can also cause delayed stomach emptying. So slowed digestion does occur in otherwise healthy people with normal blood sugars.

A friend of mine experienced this problem--confirmed by gastroscopy--after suffering a severe bout of stomach flu. It lasted for more than five years until for no discernible reason it finally went away.

People who have other medical conditions that affect the functioning of their nerves or muscles may also experience this phenomenon, regardless of their blood sugar status. It may also come on with age, when the digestion seems to slow down for many people. It may even be a response to the inflammatory reactions associated with conditions like gluten sensitivity.

This is why some people with diabetes who have kept good control over of their blood sugars or who are recently diagnosed will still see readings that don't make sense to them. Delayed stomach emptying keeps their blood sugar from peaking at the average time--75 minutes after eating--and they see surprise blood sugar highs at some other time, anywhere from one to four hours after eating.

If this is your pattern, especially if it occurs in an unpredictable manner, you will have to be extremely careful when injecting insulin to cover a meal. If your meal delay is predictable--for example, if you always see a peak after eating at two hours rather than one, you can just inject your insulin an hour later. But if it isn't predictable, using insulin according to some "one size fits all" dose schedule your doctor handed you may become dangerous.

One helpful rule to use when dealing with this problem--one that is a lot easier to follow if you are eating a relatively low amount of carbohydrates--is to never inject more insulin before a meal than your body could handle even if there was no food coming in at all. This may not be enough to fully cover the meal, but if you don't know when your meal will digest, it's better to shoot less than too much. Then, an hour after you eat, test your blood sugar, and based on what you see then, inject an additional corrective dose.

Never injecting more insulin than you can handle on an empty stomach is a good practice to follow even if you don't have stomach issues, because things sometimes come up that keep you from eating a meal, after you've injected--like a sudden attack of vomiting or a family emergency. So it's never a good idea to inject more insulin than your body can handle without a lot of carbs in it.

However, in order to use this kind of strategy where you inject partial doses and calculate a correction dose, you will have to have a very good understanding of how to match insulin to carbohydrates. If you are injecting the same amount for each meal because that's what you were taught by the "diabetes nurse" at your doctor's practice, you need to get yourself some more education before you try it.

A good place to start is to read Dr. Bernstein's book or John Walsh's Using Insulin.If you don't understand how to match your insulin dose to what you ate after reading up on the subject, don't guess. Demand that your doctor hook you up with someone who can explain it properly. The combination of poorly calculated or generic insulin doses and unpredictable stomach emptying is dangerous and may be one erason why so many older people with diabetes end up with hypos that put them in the hospital.

Many people with Type 2 can avoid having to use insulin at meals if they cut back on their carbohydrate intake enough. If you haven't tried a lowered carb diet you might be surprised how well it works. The strategy described HERE can help you find out just how low you need to go to see results. An intake somewhere near 100 grams a day or 30 grams a meal is very helpful to many people with diabetes without being so low that they find it onerous to stick to it.

Cutting out all products containing gluten is worth a try, too, because so many people find that persistent digestive problems clear up when they do this.

However, if you jump on the currently fashionable gluten-free bandwagon, take care. I'm seeing a disturbing trend, now that this way of eating has become mainstream. The "health food" groceries are filling up with "gluten free" products that are extremely high in carbohydrates, which are being promoted as if they were good for you. They aren't. They are just expensive blood sugar bombs, filled with fast, refined carbs, both starches and sugars. They are a poor choice for anyone who is interested in preserving their health, and for people with diabetes they are dangerous since the high starch and sugar content is guaranteed to raise blood sugar very high.

Have you had experience with delayed stomach emptying? Any tips for dealing with it? Post them in the comments section if you do.

January 12, 2011

More Research of Note

Here's another quick round up of recently published research. Click on the link to see the journal article abstract.

1. Exercise does not change metabolic parameters associated with weight gain or insulin resistance. Birth weight has long been known to correlate with weight gain, and in the case of low birth weight, with increased insulin resistance. The European Youth Heart Study, a population-based study of 9 and 15 year olds (n = 1,254)
...did not find any evidence that physical activity or aerobic fitness can moderate the associations among higher birth weight and increased fat mass and greater waist circumference or between lower birth weight and insulin resistance in healthy children and adolescents.
2. More Evidence of the Desirability of an A1c under 5.7% and the dangers of one over 6.5%. Fourteen years of follow-up of 11,357 participants (773 with a history of diagnosed diabetes) from the Atherosclerosis Risk in Communities (ARIC) Study found that the risk for kidney disease and retinopathy rise significantly as A1c goes over 5.7% and dramatically increases when it is 6.5% or higher.

Compared to that of A1c of 5.7% or less, the risk of chronic kidney disease in this population was: 1.12 (0.94–1.34) at A1c 5.7-6.4%. and 1.39 (1.04–1.85) for A1c over ≥6.5%,

Compared to the A1c of 5.7 or less, the risk of End Stage Renal Disease (i.e. Kidney failure) was 1.51 (0.82–2.76)--about 50% higher to almost 3 times higher--for A1c 5.7-6.4%.and 1.98 (0.83–4.73)--twice to almost five times as high--for A1c of 6.5% or higher.

In the absence of diagnosed diabetes, A1c was cross associated with the presence of moderate/severe retinopathy (diabetic retinal damage leading to blindness), with adjusted odds ratios of 1.42 (0.69–2.92) for A1c between 5.8% and 6.4%--averaging about 60% higher but ranging to three times higher. But it was three to seven times as high--risk ratio of 2.91 (1.19–7.11)--3 to 7 times as high for A1c of 6.5% or higher.

3. Higher Levels of Cholesterol of ALL Types Correlates with LESS Likelihood of Alzheimers. It has long been known--though doctors have been brainwashed into ignoring it--that statins can cause permanent dementia, especially in older patients. Could it be because cholesterol is protective to the brain? This study would make you wonder.

It followed 1,130 adults 65 or older in New York City with no history of dementia or cognitive impairment.
Higher levels of HDL-C (>55 mg/dL) were associated with a decreased risk of both probable and possible A[lzheimers] D[isease] and probable AD compared with lower HDL-C levels (hazard ratio, 0.4; 95% confidence interval, 0.2-0.9; P = .03 and hazard ratio, 0.4; 95% confidence interval, 0.2-0.9; P = .03). In addition, higher levels of total and non–HDL-C were associated with a decreased risk of AD in analyses adjusting for age, sex, education, ethnic group, and APOE e4 genotype.

4. Educational Level Predicts Diagnosis of LADA vs. Type 2. This Norweigian study is titled "High Levels of Education Are Associated With an Increased Risk of Latent Autoimmune Diabetes in Adults", which makes it sound as if somehow the education is raising the risk of this late onset form of autoimmune Type 1 diabetes.

However, the result they found might also point to the likelihood that the college educated people, who they mention were also thinner, were more likely to get a correct diagnosis from their doctors because the doctors had more respect for them, and were more willing to put time into getting a correct diagnosis. When doctors see what they perceive as a lower class patient who is overweight, their prejudices (shared with society at large) may make them assume "Type 2" and fail to run the tests that would reveal LADA.

In fact, there are a significant number of overweight and obese people with LADA--all of the ones I've heard from report having a terribly tough time getting the tests that provide the correct diagnosis. Less educated people may be more cowed by doctors' authority and may never get that diagnosis.

5. Yet Another Study Finds Metformin Appears to Fight Cancer. If you've been putting off taking metformin out of fear of pharmaceutical drugs, get over it. The accumulating evidence about Metformin just keeps getting better and better. It's a cheap generic drug that is not making anyone rich, so the chances that this data have been skewed to sell the drug is low.

6. Byetta Slightly Reduces the Risk of Heart Attack, Stroke, and Stenting. Analyzing a large database of insurance claims and prescribing information, it was determined that people prescribed Byetta were sicker to start with--fatter and with pre-existing heart disease, high cholesterol, and high blood pressure, but they had fewer cardiovascular "events" than controls who didn't take Byetta.

7. The Diabetic Alelles of the TCF7L2 Gene--the One Most Strongly Associated with Diabetes in Western Europeans--Damage Insulin Production, But Have No Effect on Insulin Sensitivity. Other studies have already documented this, but this study in newly diagnosed people with Type 2 diabetes should drive home the message that the old saw that people with Type 2 produce lots of insulin is just plain not true.

That's it for now. I'll be doing further updates each month as the new journals come up.


January 8, 2011

Weight Loss Tips

By now many of you are one week into your Repentance Diet--the one that starts New Years Day and is done by the Super Bowl. In honor of this annual ritual, I thought I'd post a list of the most helpful dieting truths I've picked up over the twelve years I've been fighting blood-sugar-related weight gain.

1. The diet you are eating as you approach your lowest weight is the diet you will have to eat to maintain your weight loss. This is the dirty little secret of weight loss that no one who sells weight loss dreams will tell you. Instead, they make it sound like once you reach goal you'll be able to add in many of the foods--and calories--you had to deny yourself to get to goal.

It isn't true. My experience, and that of hundreds of other people who post on online diet support boards, has been that at goal you can add back between 200 and 300 calories a day without gaining. Exactly how much has to do with how big you are. If you get down below 150 lbs, it will be 200 calories. That's one 2% Greek Yogurt and a handful of nuts. Or a real-world serving of bacon. Or a piece of whole wheat toast with butter. In short, bubkis.

2. Dieting is easy, maintenance is hard. This is the logical conclusion to be drawn from statement #1 above. Most people can lose weight. Very few keep it off. After more than a decade of reading diet support groups online, I'm convinced that the reason for this is because people pursue weight loss diets that are too stringent to be maintained longterm, partly for psychological reasons and partly because these stringent diets slow their thyroids and down-regulate other hormonal systems in ways that make them more likely to gain weight when they return to normal eating.

3. Feelings of deprivation derail maintenance. If you spend a year losing a lot of weight by denying yourself many foods you secretly hope you will be able to eat again once you hit goal, you are setting yourself up for catastrophic regain.

It isn't about willpower or being a weak person. It's about millions of years of evolution that has one goal--to keep you alive in a world where food is hard to find. The changes that take place in your brain when you diet stringently for a long time will eventually impel you to eat. If your brain thinks you have just survived a famine, it will do what it has to do to replenish your fat stores so you don't die when the next prolonged famine occurs. The most successful diets are diets where you eat enough food to reassure your body you aren't starving.

4. There is no diet immune from maintenance problems, including the Low Carb and Paleo diets. After reading low carb support boards for 12 years I can tell you that people eating these diets crash off them with the same frequency as people on every other kind of diet. The research shows this, too. Lose enough weight on any diet, and your brain will go to work doing what it can to replenish those depleted fat stores.

Low carb diets are easier to maintain for the first year or so, and during that early period people often experience a near-religious conversion which fills them with enthusiasm and the desire to convert others. This passes. Almost all low carb dieters stop losing six months into their diets, except for a very lucky few, and once that dramatic falling off of pounds comes to an end, the enthusiasm is very hard to sustain.

There is some evidence, too, that the body interprets a ketogenic state as being a state of starvation and may downregulate the thyroid in response to it, too. This is why many people with diabetes do a lot better at a carb intake slightly over the ketogenic boundary (70-100 g per day depending on body size) than below it.

And of course, once we get to goal on any diet, there's no reinforcement from seeing the pounds come off. The only reward we get is seeing the weight stay the same, which most of us find is nowhere near as motivating. It is when the scale is no longer giving us a reward that many of us become aware of what we've given up and may find it more difficult to stick with our chosen eating plan.

5. Successful weight maintenance requires vigilance and frequent mini-diets. Those who manage to maintain their weight loss usually do it by setting some very low threshold--no more than 10 lbs and for most of us 5. Once that weight is regained, they go back on their diets--immediately. If you let yourself regain more than ten pounds you may wake up one day weighing what you started out weighing plus more. Telling you're going to do something about your weight gain "later" is the best way to ensure catastrophe.


1. Diet on a diet you really can eat for the rest of your life. We are all different, so what this turns out to be will vary from person to person, but the signs you have found a diet that you can maintain are these:
  • a) You don't dream about eating forbidden foods.
  • b) You don't feel resentful when you see other people eating foods that you aren't allowing yourself to eat or feel a need to talk others into eating your diet.
  • c) You don't find yourself looking at forbidden foods and thinking, "I'll be able to eat that when I get to goal."
  • d) You eat what you eat because you like eating it, not because you have to eat it.
2. If you find the diet you are eating is not meeting these tests, change it. If you are feeling deprived eating a diet that cuts your calories too stringently, boost your calories. You do need to eat less than you burn to lose weight on any diet, including a low carb diet, but you may be happier if you eat 300 calories a day less than you need, rather than 500.

If you need meds to allow yourself to nudge up the amount of carbohydrate you can eat without destroying your health, take them. Many of us will find that we can diet (and maintain) very happily eating 20-30 g of carb per meal, where limiting ourselves to 12 grams per meal leaves us depressed and exhausted.

You don't want to compromise on you blood sugar targets--but even there, you'll do better if you allow yourself times now and then when you don't meet them. A few hours a month over your targets won't make you go blind. Eating perfectly for a few years, until you burn out and crash off your diet in a way where you spend hours every day over your blood sugar targets may.

3. Weigh portions and log what you eat Most of us eat more than we think we do, both in terms of carbs and calories. Weighing portions and using software to track what you are actually eating can help you determine what your real daily caloric need is--most of us need less than the calculators may say we do--and it can also help us get a more realistic idea of how may grams of carbohydrate we are eating. Most portion sizes listed on boxes and in software are for unrealistically small portions.

A food scale and software can help you determine what intake levels will give you weight loss, but even more importantly, they will help you determine the caloric level at which you can maintain. This changes, because the more weight you lose the less calories you need to maintain your new weight.

4.Practice going back on plan after you blow it. The biggest mistake I see people making with carb restricted diets is developing a fear of carbs which can become so strong that, paradoxically, when they do go off plan, they go crazy and eating every carb in sight.

This is largely due to not understanding what happens, physiologically, when we reduce carbs and being taken by surprise by the psychological impact of sudden blood sugar surges. It also happens because people don't understand that the first 3-7 lbs they lose on a ketogenic low carb diet is glycogen and that boosting carbs will replenish their glycogen.

The psychological impact of having 3-7 pounds come back on after a single binge can completely derail diets. This is tragic, because the glycogen weight loss--and gain--is a one time thing. After glycogen has been altered, weight gain is really all about calories on any diet.

So learning how to recover from an off-diet overindulgence is essential if you are to succeed at weight loss. If you eat something you weren't supposed to, welcome this as a chance to practice this essential dieting art!

I have written a helpful page about this problem and urge anyone new to carb restricted dieting to read it.

When You Crash Off Your Diet

5. Stop periodically and maintain your weight loss--before you get to goal. Many of us find it a lot easier to maintain a 20% weight loss than we do a 40% weight loss. A diet is only successful if you can maintain it, and the problem with failing at maintenance is that when that happens most of us don't regain just 5 or 10 pounds, we regain all the weight we lost and more.

So for many of us, stopping at an intermediate stage of weight loss and maintaining for a month or two to get the hang of it is healthy for several reasons: It may prevent our brain from thinking we are living through a prolonged famine. And it will force us to reality check our goal.

If we can't maintain a 20% weight loss easily, it's 100% certain we will not be able to maintain the 50% loss we dream about. Settling for a modest weight loss you can maintain, long term, is a lot healthier than setting an ambitious goal, reaching it, and then gaining it all back. I would suggest stopping at 20% and then at every subsequent 10% lost to see if your current weight is maintainable. When you reach a level where maintenance has become difficult, go back to your previous level and stay there. You've just reached goal.

6. The moment you realize you need to go back on your diet, do it! If you are maintaining and notice you have gained more weight than you should, don't think, I'll go back on my weight next month, or after this project is done, or when I'm not so stressed. Start back on your diet that moment. This is the single most powerful "secret" of successful weight maintenance--and successful maintenance is what makes for a successful diet.