Differing Brands of Generic Metformin Behave Differently

Dr. Bernstein has been preaching about this on his web telecasts for years, but it bears repeating: If you are having problems with generic metformin or not seeing it make much impact on your blood sugar, change brands before you assume it isn't working or that you can't tolerate it.

I just had this message brought home to me when my pharmacy (Walgreens) filled my prescription for metformin ER with tablets from SunPharma instead of the ones from Teva they'd given me for years.

The pills were about half the size of the ones I'd been getting, which suggested they contained less of a matrix substance to slow the release of the metformin. And sure enough, when I took the same dose I had been taking with no problems with the Teva brand metformin, I felt exhausted and semi-poisoned. It felt just like when I had taken an overdose of metformin some years ago, when my family doctor prescribed an overdose after confusing the dosage instructions for regular metformin--which can be taken in larger doses--with those of metformin ER.

Not only that, but my fasting blood sugars went up. Clearly the SunPharma metformin ER was not behaving like a true extended release should and releasing slowly through a 24 hour period but was hitting my blood stream all at once and then was done.

A quick visit to Google revealed that Sun Pharmaceuticals is an Indian company and that in the past the FDA has forced them to recall batches for quality issues.

When it was time to refill my prescription, I called my pharmacy and spoke with the pharmacist who shrugged off my concerns and told me I'd have to speak to the pharmacy manager (not available that day.) So I got on the phone and called other local pharmacies and asked them what brand they were dispensing. Two of them still carry the Teva brand, so I took my empty pill bottle to the closest one and they transferred the prescription and filled it with the Teva. I was very happy to find that it worked just the way I remembered, with no unpleasant side effects.

This experience made me wonder how many of the people who tell me they can't take metformin because of the side effects were victims of cheap versions like the SunPharma one.

If you try metformin and find the side effects overwhelming after a month's trial--typical problems would be dramatic digestive problems or a feeling of exhaustion and low grade toxicity--talk to your pharmacist about trying another brand or move your prescription to another pharmacy that carries another brand.

Dr. Bernstein says that the brand name version, Glucophage, is the best. I've never tried it so I can't verify that. If you can get it, go for it. I've heard that some pharmacies will order a specific brand for you if you ask, but before you do this, check how much the prescription will cost you as some insurers may not pay for your prescription if you specify the brand or they may make you to pay much more.

If you're taking metformin ER, which brand you are taking? How well does it work for you? Have you switched brands and seen a difference? Please cite the manufacturer name if you can. It would be nice to build up some expertise here as to how the different versions work. If I get enough feedback I'll add it to the page where I describe metformin on the Blood Sugar 101 site.

NOTE: You should be able to find the name of the manufacturer somewhere on your label. I believe this is a legal requirement in the U.S..

 

The Link Between Diet Soda Consumption and Stroke

A study to be presented at the International Stroke Conference 2011 in Los Angeles is getting some play in the health news. You can read a good summary here:

U.S News and World Report: Can Diet Soda Boost Your Stroke Risk?

The researchers "evaluated the soda habits of 2,564 people enrolled in the large Northern Manhattan Study (NOMAS) to see if there was an association, if any, with stroke. The participants were 69 years of age, on average, and completed food questionnaires about the type of soda they drank and how often."

Over 9 years, 22% of the study subjects had a stroke. After controlling for age, gender, ethnicity, physical activity, calorie intake, smoking, alcohol drinking habits, the presence of metabolic syndrome, vascular disease in the limbs and heart disease history those who reported drinking diet soda as opposed to no soda were 48 percent more likely to have a stroke.

In another article covering this same story published by MSNBC
other doctors are quoted as suggesting the problem might be what they eat with the soda--fast food, or possibly something in caramel coloring used to give sodas a brown color, which has been linked to stroke in animal studies.

Alert readers of this blog will, however, remember another equally likely explanation--one that has been known for years, but has received no coverage in the press, because the media get too much advertising money from Coke and Pepsi.

The link between diet soda and stroke may well be the phosphoric acid that is used in the all brown-colored sodas. As documented in my earlier blog post Coke Adds Death, brown-colored sodas are known to damage the kidneys. In fact, drinking as few as two brown-colored sodas--either diet or regular--a day doubles the risk of developing chronic kidney disease. Researchers believe the phosphoric acid is the culprit. Phosphates are a known problem for people who already have kidney disease.

It turns out that kidney damage and cardiovascular disease are tightly linked, and the presence of kidney disease often points to the existence of other vascular problems. This makes it very possible that damage to the kidney from phosporic acid is contributing to vascular damage in the brain which leads to stroke.

If phosphoric acid is the problem--and it is likely, since people consuming non-brown colored sodas had a normal risk of chronic kidney disesae, you can avoid it by avoiding heavily-advertised brown sodas like Coke, Pepsi and Dr. Pepper, in favor of the light and colored sodas that don't. If in doubt read the label. If it says "phosporic acid" give it a miss. People with diabetes have enough issues to contend with kidney-wise without adding to them.

 

Study Finds Dreamfields Pasta Produces Identical Glucose Curves as Regular Dry Pasta

UPDATE: The study referred to in this post was retracted by its authors and is no longer available online. The reason for the retraction was NOT that the data was wrong or that the study was misleading, but "because some of the data were obtained prior to receiving IRB [Institutional Review Board] approval."

Since it is not likely that the institution the authors of this study work retracted the study because of the horrifying ethical violation implied in forcing innocent volunteers to eat pasta—IRBs are set up to protect the public from unethical research—it’s likely someone did not have the deep pockets needed to withstand a lawsuit launched by the manufacturer of this profitable product that costs more than twice as much as regular pasta.
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ORIGINAL POST

I have long been suspicious of the claims for Dreamfield's pasta that all but three grams of the over-50 grams reported on the label somehow mysteriously dissappear due to some magical process they refuse to describe. Now a report in this month's journal, Diabetes Care confirms I was right to be suspicious.

Here's the study:

Glycemic Response to Ingested Dreamfields Pasta Compared With Traditional PastaFrank Q. Nuttall et al.Diabetes Care January 26, 2011 vol. 34 no. 2 e17-e18. doi: 10.2337/dc10-1957

Here are the relevant graphs:

http://care.diabetesjournals.org/content/34/2/e17/F1.expansion.html

This study was done with subjects who did not have diabetes, however the significant and prolonged average blood sugar spike seen in the first group, suggests it contained someone (or two) with less "normal" blood sugars than would have been indicated by their fasting glucose test. The results make it clear that in thse study subjects, Dreamfields was metabolizing into glucose at the identical rate as cheap dry pasta.

Now mind you, the 50-some grams of carbohydrate in regular dry pasta does hit the blood sugar a lot more slowly than does bread of potatoes, which is why those dreadful diabetes magazines you find at your doctor's offices are full of pasta recipes.

But while dry pasta is a better choice than Froot Loops, as the curves on these graphs make clear, the carbohydrates contained in pasta trickle into the blood stream for hours after you eat. In people with Type 2 who still have a significant amount of second phase insulin response left, the trickle might be slow enough that you won't see a pronounced spike, but all that glucose will have to be metabolized--and most of it will turn into triglycerides and eventually be stored as body fat.

The data in this study explain to me why there are such varying reports within the diabetes community about whether Dreamfields does what the company claims it does, with some saying it works for them, and others reporting that it causes prolonged high blood sugars. Obviously, the people for whom Dreamfields works are still secreting enough second phase insulin to cover the long slow tail it produces.

But if Dreamfields does work for you, this study stronlgy suggests you could get the same effect from eating $.99 store brand pasta as you could eating the much more expensive Dreamfields. Just cook the regular pasta for the 9 minutes that Dreamfields suggests. Cooking any pasta longer than that will makes it digest more quickly.

Two last things:

1. Only cooked dry pasta metabolizes slowly. Fresh pasta--the kind you buy in the freezer section or at some fancy italian restaurants--is made with regular flour, not the more semolina flour that contains resistant starch. Fresh pasta digests very quickly and you will see a much larger spike after eating it.

2. The label portion size for a serving of pasta is tiny. Measure out 2 dry ounces on a cooking scale and cook it and you'll see what I mean. The serving of pasta you get at a restaurant is anywhere from 3 to 6 label portions. Since that very small 2 ounce portion contains over 50 grams of carbohydrate, the restaurant servings are anywhere from 150 to 300 grams. And that's without the "low fat" high carbohydrate sauce dumped on top.

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!

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.