Narrowing Down Your Choice of Diabetes Drugs

Conquer Diabetes and Prediabetes

Metformin is the most-recommended drug for type 2 diabetes

We now have 12 classes of drugs for the treatment of diabetes. How does your doctor choose which ones to use?

It’s easy for type 1 diabetes: insulin. Type 2’s have more options.

Earlier this year I reviewed the American Diabetes Association’s Standards of Medical Care in Diabetes – 2014. A type 2 treatment algorithm therein mentions only six of the 12 classes. This gives you an idea of expert consensus on which drugs to use. The classes are biquanides (metformin), sulfonylureas, thiazolidinediones, DPP-4 inhibitors, GLP-1 agonists, and insulins. This is one reason you don’t see much use of bromocriptine and colesevelam.

The American Association of Clinical Endocrinologists also has a type 2 diabetes treatment algorithm, published in 2013. It also addresses prediabetes and overweight/obesity. You’ll see some of the other classes mentioned. You may find it confusing because of abbreviations.

Believe it or not, most doctors want to do what’s right for our patients. We want positive results that reduce suffering and death. Does Big Pharma influence the production of guidelines and individual physician drug choices? If I had to guess, I’d say yes. But I don’t have the resources to investigate that in any depth. I know without a doubt that if I recommend a drug and the patient has a bad outcome, it helps me win the malpractice lawsuit if I’ve recommended a guideline-approved drug. Other docs know that, and it’s one of many factors that influence drug choice. We also consider cost (if you bring it up), convenience, patient preference, what our local colleagues are doing, what other illnesses the patient has, potential adverse drug effects, etc. Click here for a summary of the various drug classes.

We don’t know the long-term adverse effects of many of these drugs. That’s why I favor doing as much as reasonably possible with lifestyle modification, such as diet and exercise, before stacking up multiple drugs. If you need drugs, and most with diabetes do, lifestyle modification can help you minimize drug use.

Steve Parker, M.D.

PS: My Conquer Diabetes and Prediabetes book is now available on Kindle and other digital formats.

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QOTD: Mark Rippetoe on Below-Parallel Squats

The below-parallel squat is the best exercise in the entire catalog for whole-body strength, power, balance, coordination, bone density, joint integrity, and mental toughness — good things to develop if you don’t have them.

—Mark Rippetoe

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Low-Carb Recipe: Turkey Tomato Bowl plus Macadamia Nuts

paleobetic diet, low-carb

Not enough tomatoes here to spike your blood sugar

With the high price of hamburger and steak, we’re eating more turkey at the Parker Compound. This is what I did with some of our leftover Thanksgiving turkey last year. If you don’t have leftover turkey, I bet leftover chicken or steak would be  fine substitutes. I’m tempted to try it with salmon or canned tuna or chicken. In addition to the flavor, what I like about this meal is that it’s crazy quick. You can easily work this meal into the Low-Carb Mediterranean Diet or Ketogenic Mediterranean Diet.

Ingredients:

6 oz (170 g) cooked turkey chunks, light meat (or 8 oz (225 g) if you’re starting raw and planning to cook it)

5 oz (140 g) raw tomato (2 small roma tomatoes, for example), cut into chunks

2 tbsp (30 ml) balsamic vinaigrette

black pepper to taste

1 oz (30 g) roasted macadamia nuts

paleobetic diet, low-carb, diabetes, diabetic diet, paleo diet

These roma tomatoes were amazingly flavorful for late Fall in the northern hemisphere. Before cooking, my wife injected the bird with olive oil, massaged periodically over 30 minutes, then popped it in the oven.

Instructions:

Toss the turkey and tomato chunks in a bowl, splash on the vinaigrette, then microwave for 60-80 seconds. Pepper as desired. Drink the leftover juice right out of the bowl. Enjoy with macadamia nuts for dessert and you’ve got a full meal.

Discussion:

paleobetic diet, low-carb, diabetes, diabetic diet

Grok wouldn’t have access to this

I was lazy when I made this so I just used a commercial salad dressing rather than making my own vinaigrette. I like the flavor of Wish-Bone Balsamic Vinaigrette Dressing “with extra virgin olive oil.” Here are the top ingredients, in order: water, balsamic vinegar, soybean oil and extra virgin olive oil (sic), sugar, salt, spices, etc. So the oil could have been soybean oil with one drop of EVOO for all I know. Olive oil is a rich source of monounsaturated fatty acid, so you might be able to calculate how much EVOO was in the dressing if I tell you there were five grams of fat per two tbsp (30 ml) serving, of which 1.5 grams were monounsaturated. That serving also has three grams of carbohydrate (all sugar) and only 60 calories. Right there on the bottle is says” gluten-free” and “no high fructose corn syrup.” I bet it had HFCS in it three years ago and there would be no mention of the trendy “gluten-free.”

I don’t know any home cooks who add water to vinaigrettes. They are essentially oil and vinegar (in a ratio of 3:1) and spices. The ones I make have quite a bit more than 60 calories per two tbsp (30 ml); more like 220 cals. All of the oils you would use have about 120 calories per tbsp, all from fat. If you make this recipe with home-made vinaigrette, add 150 calories to the nutritional analysis below. It won’t affect the carb count.

Note that of the common vinegars, balsamic has the most carbohydrates—some vinegars have zero. If you use typical amounts of balsamic vinaigrette, you shouldn’t need to worry about the carbohydrates unless perhaps you’re on a strict ketogenic diet and limited to 20-30 grams of carb daily.

Servings: 1

Nutritional Analysis:

58% fat

7% carbohydrate

35% protein

620 calories

11.5 g carbohydrate

3.7 g fiber

8 g digestible carbohydrate

743 mg sodium

877 mg potassium

Prominent features: High in protein, vitamin B6, iron, manganese, niacin, phosphorus, selenium, and zinc.

paleobetic diet, low-carb, diabetic diet, paleo diet

Bonus pic! A horse at the Parker Compound, an old-style Morgan. I call him Java but his formal name’s Espresso.

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Low-Carb Recipe: Waldorfian Salad

paleobetic diet, low-carb diet

One cup of Waldorfian salad. I doubled the cinnamon in this batch, so yours won’t look quite like this.

Today’s meal is inspired by the classic Waldorf salad, made famous by New York’s Waldorf Hotel over a century ago. Now the hotel is called the Waldorf-Astoria.

The primary ingredients are apples, walnuts, and celery.

The original Waldorf salad was made with mayonnaise, which I’ve left out of this recipe since I designed it for a paleo-style diet I’m working on. Most commercial mayonnaises are made with vegetable oil, so they wouldn’t be fully compliant with a pure paleo diet.

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Good source of omega-3 fatty acids

Instead of mayonnaise, we use a dressing—a vinaigrette—made with walnut oil. Walnut oil is attractive in part because it is rich in omega-3 fatty acids: 1.77 grams per tbsp (15 ml). Compared with Paleolithic diets, modern Western diets are too low in omega-3s and too high in omega-6s (thanks to vegetable oils). You can use your left-over walnut oil the way you’d use olive oil. If you don’t want to buy or can’t find  walnut oil, just use extra virgin olive oil.

paleobetic diet, low-carb diet, ketogenic diet

I made my dressing in this BPA-laden plastic container

This recipe makes two large servings of 2 cups (480 ml) each. Small or sedentary folks may well be satisfied with a 1- or 1.5-cup serving.

paleobetic diet, low-carb diet, ketogenic diet

Apples are the primary source of carbohydrates in this recipe.

Ingredients:

2 apples, raw, medium size, skin on, diced (I used Red Delicious; consider Granny Smith, Fuji, or Gala)

3 celery stalks, 8-inches long (20 cm), diced

1 cup (240 ml) walnuts, broken by hand into small chunks (Option for ? more flavor: toast in a skillet over medium-high heat for 7-10 minutes or in oven (350 F or 175 C) on baking sheet for 10 minutes

1/4 tsp (1.2 ml) black pepper, ground

1/4 tsp (1.2 ml) salt

1.5 tbsp (22 ml) walnut oil (or extra virgin olive oil)

1 tbsp (15 ml) cider vinegar

1/2 tsp (2.5 ml) cinnamon

1/4 tsp (1.2 ml) nutmeg

Instructions:

First make a dressing with the bottom six ingredients. I put mine in a small container with a lid, then shook vigorously. Or you can put them in a small bowel and whisk them.

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Walnut pieces

Place the walnuts, apples and celery in a bowel, add the dressing and toss thoroughly. You’re done.

Serve as is, or chill first in the refrigerator. Maybe it was my imagination, but I thought it tasted better after it sat on the counter for 10 minutes. Consider serving on a bed of lettuce (1-2 oz), but if you do, increase your digestible carb count by 1-2 grams.

If you want more calories or protein than this recipe provides, chicken or steak should go well with Waldorfian salad and won’t increase your carb grams.

Number of Servings: 2 (2 cups each)

Nutritional Analysis:

73% fat

21% carbohydrate

6% protein

500 calories

27.5 g carbohydrate

7.6 g fiber

20 g digestible carbohydrate

341 mg sodium

529 mg potassium

Prominent features: High in copper and manganese, low in sodium. On a 2,000 calorie diet, this provides only 15% of the Recommended Dietary Allowance for protein, so you’ll want to eat more protein at some point during the day.

Steve Parker, M.D.

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Which Tree Nut Provides the Most Omega-3 Fatty Acid?

David Mendosa says the answer is the macadamia nut.

Paleobetic diet

Macadamia nuts

A great thing about the macadamia nut is that it’s one of the few nuts with a good omega-6/omega-3 fatty acid ratio. In other words, it’s high in omega-3 and low in 6. This may have important cardiovascular health implications. Macadamias are one of the nuts I recommend in the Low-Carb Mediterranean Diet and  Paleobetic Diet.

David writes:

The first Australian macadamia plantation didn’t begin until the 1880s. And not until 1954 with the introduction of mechanised processing did commercial production became viable. Nowadays about 90 percent of the the world’s macadamia nut production comes from Hawaii, where it has become its third most important crop, according to The Wellness Encyclopedia of Food and Nutrition, University of California at Berkeley (1992).

Read the rest, where you’ll learn that macadamia nuts are the highest of all nuts in calories, gram for gram.

Steve Parker, M.D.

Paleobetic diet

Macadamia nuts on the tree

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Conquer Constipation on Your Ketogenic Diet

Georgia Ede, M.D., has a good article on constipation that is sometimes seen with ketogenic diets. Some think it’s related to low fiber content of the diet. But Dr. Ede found a study that indicates cutting down on fiber consumption helps alleviate constipation! A quote from the good doctor:

If you experience constipation on a ketogenic diet, it is not because you are eating less fiber; it is most likely because you have started eating something that you were not eating before (or a larger amount of something you didn’t eat much of before) that is hard for you to digest. In order to eat a ketogenic diet, which is a high-fat, limited protein, ultra-low-carb diet, most people find themselves turning to high amounts of foods that are notoriously difficult to digest, including nuts, low-starch vegetables such as crucifers, and full-fat dairy products.These foods just so happen to be 3 of the top 5 causes of chronic constipation, regardless of what kind of diet you choose to eat.

Read the whole enchilada for her tips on countering constipation. Another trick that works for many folks is cabbage soup.

A well-designed ketogenic diet is a great weight to reduce elevated blood sugars. Don’t let constipation dissuade you.

Steve Parker, M.D.

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Sulfonylurea Diabetes Drugs Linked to Heart Disease in Women

…according to this article at Diabetes Care. The study population was the Nurses Health Study. The longer the sulfonylurea was used, the stronger the association with coronary heart disease. CHD is by far the most common cause of heart attacks. On the bright side, the drugs were not linked to stroke risk. Remember, correlation is not causation, blah, blah, blah…

I rarely start my patients on sulfonylureas these days.

Steve Parker, M.D.

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