Multinational Study Suggests Insulin Pump Better Than Multiple Daily Injections for Inadequatedly-Controlled Type 2 Diabetes

Lancet has the details. I’ve only read the abstract, so don’t know much about the actual research. Study subjects were sub-optimally controlled (HgbA1c of 8-12%) on multiple daily injections; that’s why they were considered for pump therapy. They were randomized to pump or continued multiple daily injections. What I can’t tell – and it matters – is whether the multiple injection group underwent changes in their management or whether they were told to “just keep doing what your were doing” (which wasn’t working well).

 

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Metformin Works Twice as Well in Blacks as Whites

Diabetes Self-Management has some of the details.

The implication is that the genetically determined physiology of black diabetics is different from whites. There could be other explanations, admittedly.

Here’s why I bring this to your attention. You don’t see me review many scientific articles involving mice, rats, pigs, or rabbits. I take care of human patients. I suspect there are too many genetic differences between us and them that clinically pertinent studies are rare. If you read my blogs carefully, you’ll also note I often hesitate to generalize clinical study results from one ethnic group to others. The different black/white responses to metformin validates my approach.

Type 2 diabetes in whites and blacks may not be the same disease, and it could be different in Asians, Australian aborigines, and North American Native Americans.

You may also be starting to understand why there’s so much confusion about which diabetic drugs are the best. We have 12 different classes of drugs now; what’s best for me may not be best for you.

Steve Parker, M.D.

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QOTD: Cicero on Food, Drink and the Mind

“ We cannot employ the mind to advantage when we are filled with excessive food and drink. ”

— Cicero

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A New Drug for Diabetes: Afrezza

Well, it’s not really new. It’s our old friend insulin, soon to be available via inhalation with the brand name Afrezza. The U.S. Food and Drug Administration approved it in July, 2014. Click for the package insert.

Who Can Use It?

Adults with either type 1 or 2 diabetes.

Who Should Avoid It Or Not Use It?

  • those with chronic lung disease such as asthma or chronic obstructive lung disease (COPD)
  • smokers
  • pregnant or lactating women
  • those in diabetic ketoacidosis (DKA)
  • users who see a significant deterioration in lung function over time

Common Side Effects:

Hypoglycemia, cough, throat pain.

What’s the Dose?

It comes in 4 and 8 unit cartridges. See the package insert for dosing details. Afrezza is a rapid-acting insulin taken at the start of meals, so you’re looking at two or three doses a day. Type 1 diabetics still need to take a basal (long-acting) insulin once or twice daily. As far as I can tell, the type 2 diabetics in the pre-approval clinical studies were all taking one or more oral diabetic drugs in addition to the Afrezza; the inhaled insulin was an add-on drug. The average time to maximum effect of the drug is 50 minutes with the 8 unit dose; blood levels of insulin are back to baseline after three hours.

Anything Else Interesting About It?

The manufacturer recommends a test of lung function before starting the drug, to identify folks with lung disease who shouldn’t inhale insulin. The test is called spirometry or FEV-1 (forced expiratory volume in 1 second). Moreover, spirometry should be repeated six months after start of the drug, then yearly thereafter.

Another form of inhaled insulin—Exubera—was on the U.S. market in 2006 and discontinued by the manufacturer the next year. The problem may have been poor sales or a concern about lung cancer.

You can’t get it at your pharmacy yet. Maybe later this year or the next.

Steve Parker, M.D.

 

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Recipe: Chicken Fafita Wraps

paleobetic diet

It looks more appealing if you use green and red bell peppers

My earliest recollection of fajitas is from Austin, Texas, in 1981. I had just moved there from Oklahoma City to start my internship and residency in Internal Medicine. Back then fajitas were made with skirt steak, the diaphragm of a cow or steer. It was considered a cheap low-quality cut of meat. It’s not so cheap these days. You can also make fajitas with chicken. The contents of a traditional fajita are wrapped in a tortilla usually made with flour. To avoid blood sugar toxic blood sugar spikes, we’ll skip the tortilla. Use lettuce as a wrapper if you wish.

I wonder if the El Azteca Restaurant in Austin is still in business. Best Mexican food I ever had. I think it was on 6th Street or so, about 3/4 mile east of I-35. Good times.

By the way, the j in fajita is pronounced “h.” Accent on second syllable. “Fuh-HEET-uh.”

Today we’re using chicken and making four servings

paleobetic diet, paleo diet for diabetics

Pre-cut chicken breasts and sweet mini-peppers

Ingredients:

1 lb (454 kg) chicken breast, raw, boneless and skinless, cut in strips about 1/4-inch wide (you can often buy it this way)

7 oz onion, raw, cut in long crescent shapes about a 1/4-inch wide (0.6 cm)

6 oz (170 g) bell pepper, raw, cut in long strips roughly a 1/4-inch wide (these are also called sweet peppers; a combination of the red and green ones is eye-pleasing)

2 tbsp (30 ml) olive oil

5 or 6 oz (155 g) tomato, raw, cut in long strips

1 tsp (5 ml) salt

1/2 tsp (2.5 ml) pepper

1/2 tsp (2.5 ml) chili powder

1 tsp (5 ml) parsley flakes

1/2 tsp (2.5 ml) oregano leaves

1 pinch of cumin

1/2 tsp (2.5 ml) paprika

(Optional: You could replace all these spices with a 1-oz (28 g) pack of Lawry’s Chicken Fajitas Spices & Seasoning. The sodium and potassium values below would be different.)

1/3 cup (80 ml) water

16 oz (454 g) lettuce (e.g., iceberg, romaine, or bibb)

4 oz (113 g) walnuts

4 pears, small (about 1/3 lb or 150 g each))

Instructions:

Add the onions, peppers, and 1 tbsp (15 ml)  olive oil to a 12-inch (30 cm) skillet and cook at medium-high heat until tender, stirring occasionally. This’ll take about 10 minutes. Set the skillet contents aside.

paleobetic diet, paleo diet for diabetes

This is double the recipe amount since there are six humanoids in my household

paleobetic diet, paleo diet for diabetics

The vegetables reduce volume by half while cooking

In the same pan, add 1 tbsp (15 ml) olive oil and the chicken and cook at medium to medium-high heat, stirring frequently, until chicken is thoroughly cooked. For me, this cooked quicker than the vegetables. But don’t overcook or the chicken will get tough. Then add the water and all the spices. Bring to a boil while stirring occasionally, then simmer on low heat a few minutes. This is your fajita filling.

My original plan was to make “fajita wraps,” wrapping the cooked fajitas into a large leaf of iceberg lettuce. This was pretty messy, especially since I love the sauce in the bottom of the pan. I tried two leafs as a base: still messy. Finally I just made a bed of lettuce (4 oz) and loaded the fajita concoction right on top. Mess gone. Try a different lettuce? Skip the lettuce entirely and you can reduce digestible carb count in each serving by 2 grams.

Enjoy the walnuts and pear with your meal.

Leftovers taste just as good as fresh-cooked, perhaps even better.

I have another fajita recipe using skirt steak marinated in commercial Zesty Italian Dressing in the refrigerator overnight or for at least four hours. Grill it over coals outside. Yum! I don’t recall whether I added lemon juice to the marinade or squirted it on the meat just before serving. You would just cook the onions and peppers on a pan on the stove as above, with salt and pepper to taste. Garnish with a margarita and I’ll make you an honorary Texan.

Number of servings: 4

Serving size: A cup (240 ml) of the fajita mixture, 4 oz (113 g) lettuce, 1 oz (28 g) walnuts, 1 small pear. One cup makes two lettuce wraps.

Nutritional Analysis Per Serving:

48% fat

26% carbohydrate

26% protein

Calories: 514

37 g carbohydrate

10 g fiber grams

27 g digestible carbohydrate (25 g if you skip the lettuce)

928 mg sodium

904 mg potassium

Prominent features: Rich in protein, vitamin B6, vitamin B12, vitamin C,copper, iron, manganese, niacin, phosphorus, and selenium.

paleobetic diet

Another view, prior to rolling it up (wrapping)

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Study Finds Shortened Lifespan From Obesity Even If “Metabolically Healthy”

I'll eat my hat if this dude doesn't have metabolic syndrome

I’ll eat my hat if this dude doesn’t have metabolic syndrome

See details at MedPageToday.

Some studies suggest you can be healthy and long-lived while obese as long as you are “metabolically healthy.” That is, if you have normal blood pressure, LDL cholesterol, triglycerides, blood sugar, and waist circumference. A new meta-analysis finds that isn’t the case: you’re still at higher risk for death or cardiovascular events if you’re obese and free of metabolic syndrome features.

“Our results do not support this concept of ‘benign obesity’ and demonstrate that there is no ‘healthy’ pattern of obesity,” Kramer and colleagues wrote. “Even within the same category of metabolic status (healthy or unhealthy) we show that certain cardiovascular risk factors (blood pressure, waist circumference, low high-density lipoprotein cholesterol level, insulin resistance) progressively increase from normal weight to overweight to obese.”

Click for the scientific journal abstract.

This report does not directly address the “fat but fit” concept, whereby you can counteract some of the adverse health effects of obesity by being fit. By fit, I mean regularly exercising and achieving a decent level of capacity and tolerance for physical activity. Fat but fit still holds. In other words, if your choice is between being fat or physically fit, you’ll probably live longer and be healthier if you’re fit.

Steve Parker, M.D.

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T1 and T2 Diabetes Are Both Rising in U.S. Youth

Between 2001 and 2009, the prevalence of type 1 diabetes and type 2 diabetes increased by 21% and 31%, respectively.

Reference: F. Bruder Stapleton, MD Reviewing Dabelea D et al., Journal of the American Medical Association 2014 May 7; 311:1778

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June 18, 2014 · 11:26 AM