I first posted the following entry on the Low Carb Friends bbs. Quite a lot of people wrote that they found it helpful, so I thought I'd reprint it here:
Looking at everyone's weight loss stats--starting/current/goal--my own included--has been making me think deeply about a phenomenon that I've observed happen a lot over my decade of hanging out on low carb diet discussion groups.
Almost everyone who sticks with the diet loses a significant amount of weight.
Almost no one gets to their stated goal.
Most of us stall out at a weight considerably higher than our goal and when we do, over time, we end up feeling frustrated, lose the motivation to stick with our diets, and all too often end up getting into eating habits that put the weight back on us.
This isn't because anything is wrong with us. It is exactly what every major study of every diet ever tested shows happens to most dieters.
But our strong, negative psychological reaction to not getting to goal undermines the good of what we can achieve with weight loss.
I think we need to realize how dangerous this frustration is. When someone posts about a stall, give suggestions, of course, but also remind people of what they have already achieved. Celebrate that 20, 30, 40 or 50 pounds they have lost. Because if the focus stays on the stall too long, those pounds will be coming back.
Think of it this way: Maintenance starts the day you lose 3 pounds of fat (i.e. not the water we all lose when we go into ketosis.) Maintenance is the most important part of dieting. Start celebrating not pounds to goal but DAYS IN MAINTENANCE--maintenance of the weight loss you have already achieved.
I've managed to lose a whopping 2 real lbs over 6 weeks of ridiculously stringent, book perfect low carb dieting. Frustrating? YES. But I also am in YEAR SIX of maintaining my original weight loss. And I weigh 26 lbs less than I did ten years ago.
Will I get to my new weight goal? (Which mostly means getting the flab off my tummy that got put on during my two months of using Lantus). Maybe. Maybe not.
Will I maintain my current weight? THAT is nonnegotiable.
======
A couple other thoughts that sprang from reactions others posted to this thread:
1. Most of us seem to stall out very seriously when we've lost about 20% of our starting weight. Some of us permanently. But 20% is far more than all the studies show most people ever lose. If you can lose 20% of your starting weight, no matter what that weight might have been, you will experience health benefits. Concentrate on percentage of starting weight rather than absolute numbers and treat anything over 20% as gravy!
2. If you have been very heavy for any period of time, your body will have built a lot of bone and put on additional muscle just to help you carry that weight around. That bone and muscle does not go away when you lose weight and it can be surprisingly heavy. So no matter what you might have once weighed, if you have ever been obese, expect your final, healthy weight to be 20 or more pounds heavier than what might have been a good weight for you before the weight gain.
3. When you are dealing with both diabetes and weight issues, blood sugar control comes first. Despite all the constant repetition in the media of how dangerous obesity is, the truth is that it is not obesity per se that damages health but the high blood pressure and high blood sugar that so often accompany obesity.
In fact, what the media don't tell you is that there is something called "The obesity paradox." What that means is this: Though obese people are more likely to have heart attacks, they are also more likely to survive them!
Finally, it's worth noting that Dr. Nir Barzilai, who has been conducting a long-term study of people who live to be 100 years old reported to the media that fully one third of the centenarians he studies had been obese in their 50s!
Bottom line: Take care of your blood sugar and blood pressure first. Work on getting that 20% of starting weight off that realistically is what most people can accomplish. Celebrate your success every day. Maintenance starts the day you lose 3 lbs!
July 13, 2008
July 10, 2008
How Much Did Drug Companies Pay Your Doctor Last Year?
Vermont is a small state. It's largest city would be called a "Town" if it was found in any other state.
It has few hospitals and none of the huge regional medical centers found in neighboring states like Massachusetts or Connecticut. What it does have is a law that forces drug companies to reveal--in carefully cloaked terms--how much they paid to the 100 anonymous doctors who received the most money from them. The identities of these doctors are kept secret. All we learn is their specialty.
Even so, this year's report finds that drug companies paid an average of $56,944 to eleven Vermont psychiatrists. And according to the Rutland Herald--a fact that has not been reported in many news wire versions of this story--two Vermont cardiologists split over $300,000.
You would be a good candidate for psychiatric care yourself if you didn't wonder what those doctors were doing in return for that money.
For the first time this past year the Vermont law also specified that the drug companies must reveal the top ten drugs they were marketing, and to no one's surprise, half of the top ten drugs that are marketed with drug company money are used to treat psychiatric disorders--specifically depression and ADHD.
I have not been able to find the entire report online, but my guess is that the rest of the drugs that were being marketed heavily were the very expensive cholesterol drugs: Crestor, Zetia, and Vytorin. That would explain the payments to cardiologists.
Here are the questions you should be asking yourself on hearing this.
1. If drug companies are paying this much to doctors to promote drugs in a little out-of-the-way state like Vermont with a tiny population and no major medical center, what are they paying doctors in places like New York, Boston, Los Angeles and [insert your city name here]?
2. How likely is it that the figures released here were correct? The State of Vermont has a very small state government and lacks the resources it would take to audit this kind of report.
3. How much do drug companies pay your doctor to motivate them to prescribe their biggest profit makers? Did the drug reps take your doctor to a nice dinner, send them on a cruise where they put in 1/2 an hour listening to a drug presentation and then vacationed at drug company expense? Did the drug company enroll your doctor's patients into an aftermarketing "study" where the doctor was payed hundreds or thousands of dollars per patient to "enroll" each patient--which meant prescribing a drug that was paid for by the patient or the patient's insurance company?
Finally, if your doctor put you on a new, possibly dangerous and definitely expensive drug like $145/month Januvia or Janumet shortly after you were diagnosed with diabetes instead of $8/month Metformin--which is the drug that current practice recommendations say you should have been started on, you might want to ask how much payment they received last year from Merck.
If your doctor did not tell you that you can buy R insulin for $23 a month rather than analog insulin at $89 a month, you might want to know what they received from Novo-Nordisk, Adventis, or Lilly.
Finally ask yourself how unbiased you would be in your recommendations if someone was paying your $58,000 a year for, ostensibly nothing and that someone just happened to have a product out there that you could prescribe for your patients--one that cost ten times or more what competing equally effective products could do.
Pretty scary, eh?
====
Update June 12, 2008:
The New York Times ran an article today that has more detail about the drug company payoffs received by psychiatrists around the country and how several of them lied about the amount when asked to disclose.
A key phrase in the article leapt out to me and points to yet another cause of the childhood obesity epidemic:
"An analysis of Minnesota data by The New York Times last year found that on average, psychiatrists who received at least $5,000 from makers of newer-generation antipsychotic drugs appear to have written three times as many prescriptions to children for the drugs as psychiatrists who received less money or none. The drugs are not approved for most uses in children, who appear to be especially susceptible to the side effects, including rapid weight gain." [emphasis mine].
It's worth noting that these psychiatric drugs have been shown, in adults, to cause not only rapid weight gain but diabetes.
Here's the whole article which I recommend you read:
Psychiatric Group Faces Scrutiny over Drug Company Ties
It has few hospitals and none of the huge regional medical centers found in neighboring states like Massachusetts or Connecticut. What it does have is a law that forces drug companies to reveal--in carefully cloaked terms--how much they paid to the 100 anonymous doctors who received the most money from them. The identities of these doctors are kept secret. All we learn is their specialty.
Even so, this year's report finds that drug companies paid an average of $56,944 to eleven Vermont psychiatrists. And according to the Rutland Herald--a fact that has not been reported in many news wire versions of this story--two Vermont cardiologists split over $300,000.
You would be a good candidate for psychiatric care yourself if you didn't wonder what those doctors were doing in return for that money.
For the first time this past year the Vermont law also specified that the drug companies must reveal the top ten drugs they were marketing, and to no one's surprise, half of the top ten drugs that are marketed with drug company money are used to treat psychiatric disorders--specifically depression and ADHD.
I have not been able to find the entire report online, but my guess is that the rest of the drugs that were being marketed heavily were the very expensive cholesterol drugs: Crestor, Zetia, and Vytorin. That would explain the payments to cardiologists.
Here are the questions you should be asking yourself on hearing this.
1. If drug companies are paying this much to doctors to promote drugs in a little out-of-the-way state like Vermont with a tiny population and no major medical center, what are they paying doctors in places like New York, Boston, Los Angeles and [insert your city name here]?
2. How likely is it that the figures released here were correct? The State of Vermont has a very small state government and lacks the resources it would take to audit this kind of report.
3. How much do drug companies pay your doctor to motivate them to prescribe their biggest profit makers? Did the drug reps take your doctor to a nice dinner, send them on a cruise where they put in 1/2 an hour listening to a drug presentation and then vacationed at drug company expense? Did the drug company enroll your doctor's patients into an aftermarketing "study" where the doctor was payed hundreds or thousands of dollars per patient to "enroll" each patient--which meant prescribing a drug that was paid for by the patient or the patient's insurance company?
Finally, if your doctor put you on a new, possibly dangerous and definitely expensive drug like $145/month Januvia or Janumet shortly after you were diagnosed with diabetes instead of $8/month Metformin--which is the drug that current practice recommendations say you should have been started on, you might want to ask how much payment they received last year from Merck.
If your doctor did not tell you that you can buy R insulin for $23 a month rather than analog insulin at $89 a month, you might want to know what they received from Novo-Nordisk, Adventis, or Lilly.
Finally ask yourself how unbiased you would be in your recommendations if someone was paying your $58,000 a year for, ostensibly nothing and that someone just happened to have a product out there that you could prescribe for your patients--one that cost ten times or more what competing equally effective products could do.
Pretty scary, eh?
====
Update June 12, 2008:
The New York Times ran an article today that has more detail about the drug company payoffs received by psychiatrists around the country and how several of them lied about the amount when asked to disclose.
A key phrase in the article leapt out to me and points to yet another cause of the childhood obesity epidemic:
"An analysis of Minnesota data by The New York Times last year found that on average, psychiatrists who received at least $5,000 from makers of newer-generation antipsychotic drugs appear to have written three times as many prescriptions to children for the drugs as psychiatrists who received less money or none. The drugs are not approved for most uses in children, who appear to be especially susceptible to the side effects, including rapid weight gain." [emphasis mine].
It's worth noting that these psychiatric drugs have been shown, in adults, to cause not only rapid weight gain but diabetes.
Here's the whole article which I recommend you read:
Psychiatric Group Faces Scrutiny over Drug Company Ties
July 8, 2008
Statins for Children: a Horrifying Proposal
I have been so appalled by the recent news that the American Academy of Pediatrics is now recommending that children be put on statin drugs that I have been rendered temporarily speechless.
What part of "Statins do not prevent heart attacks in anyone but middle aged men who have already had heart attacks" don't these doctors understand?
What part of "Statins cause cognitive deficits--some of which are permanent" escaped them? "Cognitive deficits" is fancy lingo for "Makes you stupid." To give a drug that makes people stupid to an eight year old child whose brain is still developing is, simply stated, criminal. Cholesterol is used all over the brain. Lower it in the brain and that brain won't work properly. Lower it while the brain is being constructed and you have damaged a person for life.
The drug companies don't care. There are millions of fat eight year old kids out there and they are an "exciting new market." Stockholders applaud.
Obesity in children is right up there with transgendered frogs as a sign that the pollution of our environment with chemicals, plastics, and pesticides has reached the point where it is causing genetic damage. Genetic damage always shows up most clearly in offspring. To blame childhood obesity on "lifestyle" choices is absurd. Children in my youth in the 1950s ate enormous amounts of crap--ice cream every day all summer, three candy bars every time we went to the movies, pastries full of lard every day at lunch, mounds of potatoes at every meal. We did not walk miles to school every day. We rode the bus. We watched plenty of TV after our homework was done.
But in those days, if you said, "The fat boy" or "the fat girl" everyone knew who you meant because there was at most one in every class. Obesity was very rare.
The reasons why were not hard to find: We played with sheet metal toys, not ones leaching organic compounds into our skin. We drank from glass not plastic, wore clothes that had not been dosed with flame retardants, and our moms cooked our dinner on steel or aluminum pans, not cookware coated with flurine compounds (a.k.a. Teflon) that leach into our bodies and once there cannot be removed. There were not detectable amounts of estrogen and mood altering/insulin resistance-causing SSRIs in our water supply the way there are now.
Something has changed, and it is not that kids haven't been taking enough drugs. Which reminds me of the other ugly truth about what has changed with our kids--a fact that isn't getting any attention in the media. The number of kids nowadays who are on psychiatric drugs that increase insulin resistance--SSRIs and other mood and behavior changing drugs is scandalously high. Statins, in case you missed my earlier blog post also increase insulin resistance.
If your pediatrician tells you to put your kid on a statin, find a new one, and let your former pediatrician know why you left his practice. If adults want to waste their money on expensive, dangerous, largely ineffective drugs that change surrogate markers (LDL levels) without improving health, that's one thing. To foist such a drug on a child--a drug that could damage their brain for life, is something else--something that in my humble opinion constitutes child abuse.
What part of "Statins do not prevent heart attacks in anyone but middle aged men who have already had heart attacks" don't these doctors understand?
What part of "Statins cause cognitive deficits--some of which are permanent" escaped them? "Cognitive deficits" is fancy lingo for "Makes you stupid." To give a drug that makes people stupid to an eight year old child whose brain is still developing is, simply stated, criminal. Cholesterol is used all over the brain. Lower it in the brain and that brain won't work properly. Lower it while the brain is being constructed and you have damaged a person for life.
The drug companies don't care. There are millions of fat eight year old kids out there and they are an "exciting new market." Stockholders applaud.
Obesity in children is right up there with transgendered frogs as a sign that the pollution of our environment with chemicals, plastics, and pesticides has reached the point where it is causing genetic damage. Genetic damage always shows up most clearly in offspring. To blame childhood obesity on "lifestyle" choices is absurd. Children in my youth in the 1950s ate enormous amounts of crap--ice cream every day all summer, three candy bars every time we went to the movies, pastries full of lard every day at lunch, mounds of potatoes at every meal. We did not walk miles to school every day. We rode the bus. We watched plenty of TV after our homework was done.
But in those days, if you said, "The fat boy" or "the fat girl" everyone knew who you meant because there was at most one in every class. Obesity was very rare.
The reasons why were not hard to find: We played with sheet metal toys, not ones leaching organic compounds into our skin. We drank from glass not plastic, wore clothes that had not been dosed with flame retardants, and our moms cooked our dinner on steel or aluminum pans, not cookware coated with flurine compounds (a.k.a. Teflon) that leach into our bodies and once there cannot be removed. There were not detectable amounts of estrogen and mood altering/insulin resistance-causing SSRIs in our water supply the way there are now.
Something has changed, and it is not that kids haven't been taking enough drugs. Which reminds me of the other ugly truth about what has changed with our kids--a fact that isn't getting any attention in the media. The number of kids nowadays who are on psychiatric drugs that increase insulin resistance--SSRIs and other mood and behavior changing drugs is scandalously high. Statins, in case you missed my earlier blog post also increase insulin resistance.
If your pediatrician tells you to put your kid on a statin, find a new one, and let your former pediatrician know why you left his practice. If adults want to waste their money on expensive, dangerous, largely ineffective drugs that change surrogate markers (LDL levels) without improving health, that's one thing. To foist such a drug on a child--a drug that could damage their brain for life, is something else--something that in my humble opinion constitutes child abuse.
July 4, 2008
Blood Sugar 101 Now Available from Amazon UK with Free Shipping Offer!
My new book, Blood Sugar 101: What They Don't Tell You About Diabetes just went live on Amazon.co.uk and is eligible for the £15 free shipping deal. Find it here:
Amazon: Blood Sugar 101
Also, if you are in the UK and have already purchased Blood Sugar 101 and found it helpful, please consider posting a review of it on the Amazon page. It would be greatly appreciated!
You can also buy Blood Sugar 101 in the UK from Blackwell:
Blackwell: Blood Sugar 101
and Bookstore.co.uk:
Bookstore.co.uk: Blood Sugar 101
Amazon: Blood Sugar 101
Also, if you are in the UK and have already purchased Blood Sugar 101 and found it helpful, please consider posting a review of it on the Amazon page. It would be greatly appreciated!
You can also buy Blood Sugar 101 in the UK from Blackwell:
Blackwell: Blood Sugar 101
and Bookstore.co.uk:
Bookstore.co.uk: Blood Sugar 101
July 3, 2008
A Massive Long Term Study Sheds More Light on Truly Normal Fasting Glucose Values
A study brought to my attention by this week's edition of Diabetes in Control newsletter makes it very clear that for people with symptoms of the metabolic syndrome a fasting glucose blood sugar test result of 95 mg/dl or higher should impel their physicians to order a glucose tolerance test.
What the study found in brief is this: Over a 9 year period, within a group of 46,578 members of Kaiser Permanente Northwest, 10% of those who started out with fasting plasma glucose values of 95 to 100 mg/dl ended up diagnosed as diabetic based on a fasting plasma glucose test result greater than 125 mg/dl.
In contrast, only about 3% of those with fasting blood sugars below either 85 mg/dl or 89 mg/dl were diagnosed with diabetes.
Within the group which became diabetic, other factors which increased the likelihood of becoming diabetic, in order of impact, were diagnosed cardiovascular disease, high blood pressure, smoking, high triglycerides, and elevated BMI.
Significantly, there was NO significant correlation between the levels of LDL or HDL cholesterol and the likelihood of becoming diabetic. ONLY the trigyclerides--which are a good reflection of the blood sugar level after meals, predicted oncoming diabetes.
The complete text of the study is free, which is a nice change. You can read it here:
Normal Fasting Plasma Glucose and Risk of Type 2 Diabetes Diagnosis.
Gregory A. Nichols, Ph.D. et. a.. The American Journal of Medicine. Vol 121,issue 6, 519-524 (June 2008)
Note in particular this graph: Kaplan-Meier plot of cumulative diabetes incidence by category of normal fasting plasma glucose.
In their conclusions the authors point out that the lack of glucose tolerance test data for this population limited the value of the study and suggest that those with fasting glucose values of 95 mg/dl and higher most probably would have tested at the prediabetic level on a glucose tolerance test. They also point out that "Among those who developed diabetes by our criteria, however, the mean hemoglobin A1c at diagnosis was more than 7%, a level that strongly suggests that abnormal glucose metabolism has been maintained for several months."
My guess is that the over 7% A1cs suggest that the glucose metabolism had been abnormal for several years--probably beginning when that fasting glucose went over 94 mg/dl.
The group in this study whose fasting blood glucose was between 90 and 94 mg/dl had an incidence of diabetes that was about 5%.
What does this mean for you if your fasting glucose is in the 90s?
It means you need to get yourself a meter and to start testing your post-meal blood sugars, one and two hours after eating, to see how high your blood sugar is rising. You don't have to do this very often. Once or twice a year is all you need to do assuming you do not see post-meal blood sugars over 125 mg/dl which seems to be the peak most truly normal people attain, very briefly, before their blood sugar drops back to their fasting level.
If you see your blood sugar rising over 140 mg/dl after meals, take it as a sign that you are very likely to have prediabetes and start taking steps to improve your blood sugar health now, when it is still relatively easy to reverse any early diabetic changes in your body and preserve your beta cells from harm.
If your fasting blood sugar is in the 90s here are some steps you can take to improve your blood sugar health.
1. Cut the carbs. Carbs are what raise blood sugar and you are probably eating a lot of junk carbs that are stressing your body and pushing you towards developing diabetes. Try cutting out the following: All non-diet sodas, fries, white bread, breakfast cereals containing more than 10 grams of carbs per serving (most people eat two or three "servings" every time they fill a bowl with cereal, large muffins (6-8 oz), large servings of pasta, etc. Cutting carbs will lower your triglycerides, the only part of your cholesterol linked with developing diabetes.
2. Exercise. If you aren't the gym rat kind, start taking a 40 minute walk four or five times a week. That has been shown to be enough to make significant improvements in your fitness without causing injury.
3. Check your meds. Many commonly prescribed medications have a side effect of causing "hyperglycemia" i.e. high blood sugar. Read the official Prescribing Information for all medications you are taking and see which ones might be contributing to your rising blood sugars. Some drugs known to raise blood sugar are HCTZ, SSRI antidepressants, Zyprexa, prednisone and other corticosteroids. There are others. If you are taking a medication that raises blood sugar, talk to your doctor about whether there are alternatives which won't put you at risk of kidney failure, blindness, increasing heart disease, and amputation--which are what can happen to you over time if you allow your blood sugar to rise unchecked.
What the study found in brief is this: Over a 9 year period, within a group of 46,578 members of Kaiser Permanente Northwest, 10% of those who started out with fasting plasma glucose values of 95 to 100 mg/dl ended up diagnosed as diabetic based on a fasting plasma glucose test result greater than 125 mg/dl.
In contrast, only about 3% of those with fasting blood sugars below either 85 mg/dl or 89 mg/dl were diagnosed with diabetes.
Within the group which became diabetic, other factors which increased the likelihood of becoming diabetic, in order of impact, were diagnosed cardiovascular disease, high blood pressure, smoking, high triglycerides, and elevated BMI.
Significantly, there was NO significant correlation between the levels of LDL or HDL cholesterol and the likelihood of becoming diabetic. ONLY the trigyclerides--which are a good reflection of the blood sugar level after meals, predicted oncoming diabetes.
The complete text of the study is free, which is a nice change. You can read it here:
Normal Fasting Plasma Glucose and Risk of Type 2 Diabetes Diagnosis.
Gregory A. Nichols, Ph.D. et. a.. The American Journal of Medicine. Vol 121,issue 6, 519-524 (June 2008)
Note in particular this graph: Kaplan-Meier plot of cumulative diabetes incidence by category of normal fasting plasma glucose.
In their conclusions the authors point out that the lack of glucose tolerance test data for this population limited the value of the study and suggest that those with fasting glucose values of 95 mg/dl and higher most probably would have tested at the prediabetic level on a glucose tolerance test. They also point out that "Among those who developed diabetes by our criteria, however, the mean hemoglobin A1c at diagnosis was more than 7%, a level that strongly suggests that abnormal glucose metabolism has been maintained for several months."
My guess is that the over 7% A1cs suggest that the glucose metabolism had been abnormal for several years--probably beginning when that fasting glucose went over 94 mg/dl.
The group in this study whose fasting blood glucose was between 90 and 94 mg/dl had an incidence of diabetes that was about 5%.
What does this mean for you if your fasting glucose is in the 90s?
It means you need to get yourself a meter and to start testing your post-meal blood sugars, one and two hours after eating, to see how high your blood sugar is rising. You don't have to do this very often. Once or twice a year is all you need to do assuming you do not see post-meal blood sugars over 125 mg/dl which seems to be the peak most truly normal people attain, very briefly, before their blood sugar drops back to their fasting level.
If you see your blood sugar rising over 140 mg/dl after meals, take it as a sign that you are very likely to have prediabetes and start taking steps to improve your blood sugar health now, when it is still relatively easy to reverse any early diabetic changes in your body and preserve your beta cells from harm.
If your fasting blood sugar is in the 90s here are some steps you can take to improve your blood sugar health.
1. Cut the carbs. Carbs are what raise blood sugar and you are probably eating a lot of junk carbs that are stressing your body and pushing you towards developing diabetes. Try cutting out the following: All non-diet sodas, fries, white bread, breakfast cereals containing more than 10 grams of carbs per serving (most people eat two or three "servings" every time they fill a bowl with cereal, large muffins (6-8 oz), large servings of pasta, etc. Cutting carbs will lower your triglycerides, the only part of your cholesterol linked with developing diabetes.
2. Exercise. If you aren't the gym rat kind, start taking a 40 minute walk four or five times a week. That has been shown to be enough to make significant improvements in your fitness without causing injury.
3. Check your meds. Many commonly prescribed medications have a side effect of causing "hyperglycemia" i.e. high blood sugar. Read the official Prescribing Information for all medications you are taking and see which ones might be contributing to your rising blood sugars. Some drugs known to raise blood sugar are HCTZ, SSRI antidepressants, Zyprexa, prednisone and other corticosteroids. There are others. If you are taking a medication that raises blood sugar, talk to your doctor about whether there are alternatives which won't put you at risk of kidney failure, blindness, increasing heart disease, and amputation--which are what can happen to you over time if you allow your blood sugar to rise unchecked.
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