Category Archives: Prevention of T2 Diabetes

March 12, 2016 · 2:00 AM

Nearly Half of Adults in California Have Prediabetes

The actual figure is 46%, according to researchers at UCLA. The LA Times has the story.

“Our genes and our environment are kind of on a collision course,” said Dr. Francine Kaufman, the former head of the American Diabetes Assn., who was not involved with the research. “It’s not stopping.”

The problem with prediabetes is that it often evolves into full-blown diabetes. It’s also associated with increased risk for cardiovascular disease such as heart attack and stroke. The Times article says “up to 70% of those with prediabetes develop diabetes in their lifetime.” I’d never heard that vague number before; I say vague because “up to 70%” could be anything between zero and 70. It’s more accurate to note that one in four people with prediabetes develops type 2 diabetes over the course of three to five years.

Prediabetes is defined as:

  1. fasting blood sugar between 100 and 125 mg/dl (5.56–6.94 mmol/l), or
  2. blood sugar level 140–199 mg/dl (7.78–11.06 mmol/l) two hours after drinking 75 grams of glucose
Most adults with prediabetes don't know they have it

Most adults with prediabetes don’t know they have it

How To Prevent Progression of Prediabetes Into Diabetes

  • If you’re overweight or obese, lose excess fat weight. How much should you lose? Aim for at least 5% of body weight and see if that cures your prediabetes. For instance, if you weigh 200 lb (91 kg), lose 10 lb (4.5 kg).
  • If you’re sedentary, start exercising regularly.
  • Cut back on your consumption of sugar-sweetened beverages, other sugar sources, and other refined carbohydrates like wheat flour.

Steve Parker, M.D.

 

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January 27, 2016 · 2:16 AM

The Peter Sheehan Diabetes Care Foundation Requests Your Help to Fight Diabetes

 

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The Executive Director of the aforementioned foundation contacted me and asked me to help spread the word about the work they are doing. Goals of this new foundation include diabetes prevention and improvement of diabetes care, especially in at-risk communities. Click the link for more information and consider contributing to their current crowdfunding effort.

Steve Parker, M.D.

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January 4, 2014 · 6:13 AM

Mediterranean Diet Once Again Linked to Lower Risk of Type 2 Diabetes

Conquer Diabetes and Prediabetes, Steve Parker MD

Olive oil and vinegar

And eating low glycemic load helps, too, according to an article at MedPageToday. The 22,000 Greek study participants were followed for 11 years. From the article:

The findings suggest that eliminating or strictly limiting high glycemic load foods such as those high in refined sugars and grains and following the largely plant-based Mediterranean diet, which emphasizes vegetables, fruits, nuts and legumes, can have a significant impact on diabetes risk, La Vecchia said.

“The impact of the diets was synergistic,” he told MedPage Today. “The message is that eating a largely Mediterranean diet that is also low in glycemic load is particularly favorable for preventing diabetes.”

Spanish researchers found the same thing a few years ago.

The Mediterranean diet is also healthy for those who already have type 2 diabetes.

The Low-Carb Mediterranean Diet may be the ideal way of eating for diabetics.

Steve Parker, M.D.

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September 23, 2013 · 1:33 AM

Book Review: The Heart Healthy Lifestyle – The Prevention and Treatment of Type 2 Diabetes

I just finished an ebook, The Heart Healthy Lifestyle: The Prevention and Treatment of Type 2 Diabetes by Sean Preuss, published in 2013. Per Amazon.com’s rating system, I give it five stars (I love it).

♦   ♦   ♦

This is an invaluable resource for 1) anyone recently diagnosed with type 2 diabetes or prediabetes, 2) those who aren’t responding well to their current therapeutic regimen, and 3) type 2 diabetics who want to reduce their drug use.

Strength Training Helps Get Excess Blood Sugar Out of Circulation

Strength Training Helps Get Excess Blood Sugar Out of Circulation

Mr. Preuss is a fitness trainer who has worked with many type 2 diabetics. He demonstrates great familiarity with the issues diabetics face on a daily basis. His science-based recommendations are familiar to me since I reviewed many of his references at my blog, Diabetic Mediterranean Diet.

Like me, Mr. Preuss recognizes the primacy of lifestyle modification over drug therapy for type 2 diabetes, as long as drugs can safely be avoided or postponed. The main lifestyle factors are diet and exercise. Too many physicians don’t spend enough time on these, preferring instead to whip out the prescription pad and say, “Here ya go. I’ll see you in three months.”

I have gradually come to realize that most of my sedentary type 2 diabetes patients need to start a work-out program in a gym where they can get some personal attention. That’s Mr. Preuss’s opinion, too. The clearly explained strength training program he recommends utilizes machines most commonly found in a gym, although some home gyms will have them also. His regimen is easily done in 15-20 minute sessions two or three times a week.

He also recommends aerobic activity, such as walking at least several days a week. He recommends a minimum of 113 minutes a week of low intensity aerobic work, citing evidence that it’s more effective than higher intensity effort for improving insulin sensitivity.

I don’t recall specific mention of High Intensity Interval Training. HIIT holds great promise for delivering the benefits of aerobic exercise in only a quarter of the time devoted to lower intensity aerobics. It may be that it just hasn’t been studied in type 2 diabetics yet.

I was glad to see all of Mr. Preuss’s scientific references involved humans, particularly those with type 2 diabetes. No mouse studies here!

Another strength of the book is that Sean tells you how to use psychological tricks to make the necessary lifestyle changes.

The author notes that vinegar can help control blood sugars. He suggests, if you can tolerate it, drinking straight (undiluted) red wine vinegar or apple cider vinegar – 2 tbsp at bedtime or before carbohydrate consumption. I’ve heard rumors that this could be harmful to teeth, so I’d do some research or ask my dentist before drinking straight vinegar regularly. For all I know, it could be perfectly harmless. If you have a definitive answer, please share in the comments section below.

I read a pertinent vinegar study out of the University of Arizona from 2010 and reviewed it at one of my blogs. The most effective dose of vinegar was 10 g (about two teaspoons or 10 ml) of 5% acetic acid vinegar (either Heinz apple cider vinegar or Star Fine Foods raspberry vinegar).  This equates to two tablespoons of vinaigrette dressing (two parts oil/1 part vinegar) as might be used on a salad.  The study authors also say that “…two teaspoons of vinegar could be consumed palatably in hot tea with lemon at mealtime.”

The diet advice herein focuses on replacement of a portion of carbohydrates with proteins, healthy oils, and vegetables.

I highly recommend this book. And sign up for Mr. Preuss’s related tweets at @HeartHealthyTw.

Steve Parker, M.D.

Disclosure: Mr. Preuss gave me a free copy of the book, otherwise I have received no monetary compensation for this review.

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April 13, 2013 · 2:00 AM

Periodic Tests, Treatments, and Goals for PWDs (Persons With Diabetes)

If you don't like your physician, find a new one

If you don’t like your physician, find a new one

So, you’ve got diabetes. You’re trying to deal with it or you wouldn’t be here. You’ve got a heck of a lot of medical information to master.

Unless you have a good diabetes specialist physician on your team, you may not be getting optimal care. Below are some guidelines you may find helpful. The goal is to prevent diabetes complications. Many primary care physicians will not be up-to-date on the guidelines. Don’t hesitate to discuss them with your doctor. Nobody cares as much about your health as you do.

Annual Tests

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.) The complete ADA guidelines are available on the Internet.

  • Lipid profile (every two years if results are fine and stable)
  • Comprehensive foot exam
  • Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense
  • Serum creatinine and estimate of glomerular filtration rate (MDRD equation)
  • Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
  • Comprehensive eye exam by an ophthalmologist or optometrist (if exam is normal, every two or three years is acceptable)
  • Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
  • Flu shots

Other Vaccinations, Weight Loss, Diabetic Diet, Prediabetes, Alcohol, Exercise, Etc.

Additionally, the 2013 ADA guidelines recommend:

  • Pneumococcal vaccination. “A one time re-vaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
  • Hepatitis B vaccination to unvaccinated adults who are 19 through 59 years of age.
  • Weight loss for all overweight diabetics. “For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).” For those on low-carb diets, monitor lipids, kidney function, and protein consumption, and adjust diabetic drugs as needed. The optimal macronutrient composition of weight loss diets has not been established. (Macronutrients are carbohydrates, proteins, and fats.)
  • “The mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes.” “It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal.”
  • “A variety of dietary meal patterns are likely effective in managing diabetes including Mediterranean-style, plant-based (vegan or vegetarian), low-fat and lower-carbohydrate eating patterns.”
  • “Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control.”
  • Limit alcohol to one (women) or two (men) drinks a day.
  • Limit saturated fat to less than seven percent of calories.
  • During the initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
  • Those at risk for diabetes, including prediabetics, should aim for moderate weight loss (about seven percent of body weight) if overweight. Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years). Also important is exercise: at least 150 minutes per week of moderate-intensity aerobic activity. “Individuals at risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake).” Limit intake of sugar-sweetened beverages.
  • “Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than two consecutive days without exercise. In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week.”
  • Screening for coronary artery disease before an exercise program is depends on the physician judgment on a case-by-case basis. Routine screening is not recommended.
Steve Parker MD, low-carb diet, diabetic diet

Olive, olive oil, and vinegar: classic Mediterranean foods

Obviously, some of my dietary recommendations conflict with ADA guidelines. The experts assembled by the ADA to compose guidelines were well-intentioned, intelligent, and hard-working. The guidelines are supported by 528 scientific journal references. I greatly appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

General Blood Glucose Treatment Goals

The ADA in 2013 suggests these therapeutic goals for non-pregnant adults:

  • Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
  • Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
  • Hemoglobin A1C: under 7%
  • Blood pressure: under 140/80 mmHg
  • LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular disease: <70 mg/dl or 1.8 mmol/l may be a better goal.)
  • HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
  • Triglycerides: under 150 mg/dl (1.7 mmol/l)

The American Association of Clinical Endocrinologists (AACE) in 2011 proposed somewhat “tighter” blood sugar goals for non-pregnant adults:

  • Fasting blood glucoses: under 110 mg/dl (6.11 mmol/l)
  • Peak glucoses 2 hours after start of meals: under 140 mg/dl (7.78 mmol/l)
  • Hemoglobin A1C: 6.5% or less

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely.

Steve Parker, M.D.

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March 19, 2013 · 2:17 PM

What Causes Type 2 Diabetes?

Prediabetes and type 2 diabetes are epidemics because of excessive consumption of refined sugars and starches, and lack of physical activity.  I can’t prove it; nevertheless that’s my impression after years of pondering the nutrition science literature.

I could be wrong.  I reserve the option to change my mind based on evidence as it becomes available.  That’s one of the great things about science.  Accurately identifying the cause of diabetes could provide strong clues about optimal prevention and treatment strategies.

Genetics undoubtedly plays a major role in diabetes, but the gene pool hasn’t changed much over the last several decades as type 2 diabetes rates have soared.

The problem in type 2 diabetes and prediabetes is that the body cannot handle ingested carbohydrates in the normal fashion. In a way, dietary carbohydrates (carbs) have become toxic instead of nourishing. This is a critical point, so let’s take time to understand it.

NORMAL DIGESTION AND CARBOHYDRATE HANDLING

The major components of food are fats, proteins, and carbohydrates. We digest food either to get energy, or to use individual components of food in growth, maintenance, or repair of our own body parts.

We need some sugar (also called glucose) in our bloodstream at all times to supply us with immediate energy. “Energy” refers not only to a sense of muscular strength and vitality, but also to fuel for our brain, heart, and other automatic systems. Our brains especially need a reliable supply of bloodstream glucose.

In a normal, healthy state, our blood contains very little sugar—about a teaspoon (5 ml) of glucose. (We have about one and a third gallons (5 liters) of blood circulating. A normal blood sugar of 100 mg/dl (5.56 mmol/l) equates to about a teaspoon of glucose in the bloodstream.)

Our bodies have elaborate natural mechanisms for keeping blood sugar normal. They work continuously, a combination of removing and adding sugar from the bloodstream to keep it in a healthy range (70 to 140 mg/dl, or 3.9 to 7.8 mmol/l). These homeostatic mechanisms are out of balance in people with diabetes and prediabetes.

By the way, glucose in the bloodstream is commonly referred to as “blood sugar,” even though there are many other types of sugar other than glucose. In the U.S., blood sugar is measured in units of milligrams per deciliter (mg/dl), but other places measure in millimoles per liter (mmol/l).

When blood sugar levels start to rise in response to food, the pancreas gland—its beta cells, specifically—secrete insulin into the bloodstream to keep sugar levels from rising too high. The insulin drives the excess sugar out of the blood, into our tissues. Once inside the tissues’ cells, the glucose will be used as an immediate energy source or stored for later use. Excessive sugar is stored either as body fat or as glycogen in liver and muscle.

When we digest fats, we see very little direct effect on blood sugar levels. That’s because fat contains almost no carbohydrates. In fact, when fats are eaten with high-carb foods, they tend to slow the rise and peak in blood sugar you would see if you had eaten the carbs alone.

Ingested protein can and does raise blood sugar, usually to a mild degree. As proteins are digested, our bodies can make sugar (glucose) out of the breakdown products. The healthy pancreas releases some insulin to keep the blood sugar from going too high.

In contrast to fats and proteins, carbohydrates in food cause significant—often dramatic—rises in blood sugar. Our pancreas, in turn, secretes higher amounts of insulin to prevent excessive elevation of blood glucose. Carbohydrates are easily digested and converted into blood sugar. The exception is fiber, which is indigestible and passes through us unchanged.

During the course of a day, the pancreas of a healthy adult produces an average of 40 to 60 units of insulin. Half of that insulin is secreted in response to meals, the other half is steady state or “basal” insulin. The exact amount of insulin depends quite heavily on the amount and timing of carbohydrates eaten. Dietary protein has much less influence. A pancreas in a healthy person eating a very-low-carb diet will release substantially less than 50 units of insulin a day.

To summarize thus far: dietary carbs are the major source of blood sugar for most people eating “normally.” Carbs are, in turn, the main cause for insulin release by the pancreas, to keep blood sugar levels in a safe, healthy range.

Hang on, because we’re almost done with the basic science!

You deserve a break

CARBOHYDRATE  HANDLING  IN  DIABETES  &  PREDIABETES

Type 2 diabetics and prediabetics absorb carbohydrates and break them down into glucose just fine. Problem is, they can’t clear the glucose out of the bloodstream normally. So blood sugar levels are often in the elevated, poisonous range, leading to many of the complications of diabetes.

Remember that insulin’s primary function is to drive blood glucose out of the bloodstream, into our tissues, for use as immediate energy or stored energy (as fat or glycogen).

In diabetes and prediabetes, this function of insulin is impaired.

The tissues have lost some of their sensitivity to insulin’s action. This critical concept is called insulin resistance. Insulin still has some effect on the tissues, but not as much as it should. Different diabetics have different degrees of insulin resistance, and you can’t tell by just looking.  (There are several other hormones involved in regulation of blood sugar.)

Did you know that people who work at garbage dumps, sewage treatment plants, and cattle feedlots get used to the noxious fumes after a while? They aren’t bothered by them as much as they were at first. Their noses are less sensitive to the fumes. You could call it fume resistance. In the same fashion, cells exposed to high insulin levels over time become resistant to insulin.

Insulin resistance occurs in most cases of type 2 diabetes and prediabetes. So what causes the insulin resistance? It’s debatable. In many cases it’s related to overweight, physical inactivity, and genetics. A high-carbohydrate diet may contribute. A few cases are caused by drugs. Some cases are a mystery.

To overcome the body tissue’s resistance to insulin’s effect, the pancreas beta cells pump even more insulin into the bloodstream, a condition called hyperinsulinemia. Some scientists believe high insulin levels alone cause some of the damage associated with diabetes. Whereas a healthy person without diabetes needs about 50 units of insulin a day, an obese non-diabetic needs about twice that to keep blood sugars in check. Eventually, in those who develop diabetes or prediabetes, the pancreas can’t keep up with the demand for more insulin to overcome insulin resistance. The pancreas beta cells get exhausted and start to “burn out.” That’s when blood sugars start to rise and diabetes and prediabetes are easily diagnosed. So, insulin resistance and high insulin production have been going on for years before diagnosis. By the time of diagnosis, 50% of beta cell function is lost.

Steve Parker, M.D.

EXTRA  CREDIT  FOR  INQUISITIVE  MINDS

You’ve learned that insulin’s main action is to lower blood sugar by transporting it into the cells of various tissues. But that’s not all insulin does. It also 1) impairs breakdown of glycogen into glucose, 2) stimulates glycogen formation, 3) inhibits formation of new glucose molecules by the body, 4) promotes storage of triglycerides in fat cells (i.e., lipogenesis, fat accumulation), 5) promotes formation of fatty acids (triglyceride building blocks) by the liver, 6) inhibits breakdown of stored triglycerides, and 7) supports body protein production.

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January 3, 2011 · 2:00 AM

Mediterranean Diet Prevents Diabetes – Again

Spanish researchers report that the Mediterranean diet reduced the risk of developing diabetes by 50% in middle-aged and older Spaniards, compared with a low-fat diet. 

Over 400 people participated in a trial comparing two Mediterranean diets and a low-fat diet.  Over the course of four years, 10 or 11% of the Mediterraneans developed type 2 diabetes, compared to 18% of the low-fatters.  One of the Mediterranean diets favored olive oil, the other promoted nut consumption.

We’ve seen previously that the Mediterranean diet prevents diabetes—not all cases, of course—in folks who have had a heart attack.  It also reduced the risk of diabetes in younger, generally healthy people in Spain.

So What?

The study at hand is not ground-breaking.  It enhances the body of evidence that the Mediterranean diet is one of the healthiest around.  I suppose another way to look at this study would be to say that the low-fat diet caused diabetes.

Learn how to move your diet in a Mediterranean direction at Oldways or the Advanced Mediterranean Diet website. 

Diabetics and prediabetics should consider the Low-Carb Mediterranean Diet; otherwise look into the Advanced Mediterranean Diet if you need to lose weight.

Steve Parker, M.D.

Reference:  Salas-Salvado, Jordi, et al.  Reduction in the incidence of type 2 diabetes with the Mediterranean diet: Results of the PREDIMED-Reus Nutrition Intervention Randomized Trial.  Diabetes Care, epub ahead of print, October 7, 2010.  doi: 10.2337/dc150-1288

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November 10, 2010 · 11:46 PM

Health Benefits of the Mediterranean Diet

The enduring popularity of the Mediterranean diet is attributable to three things:

1.       Taste

2.       Variety

3.       Health benefits

For our purposes today, I use “diet” to refer to the usual food and drink of a person, not a weight-loss program.

The scientist most responsible for the popularity of the diet, Ancel Keys, thought the heart-healthy aspects of the diet related to low saturated fat consumption.  He also thought the lower blood cholesterol levels in Mediterranean populations (at least Italy and Greece) had something to do with it, too.  Dietary saturated fat does tend to raise cholesterol levels.

Even if Keys was wrong about saturated fat and cholesterol levels being positively associated with heart disease, numerous studies (involving eight countries on three continents) strongly suggest that the Mediterranean diet is one of the healthiest around.  See References below for the most recent studies.

Relatively strong evidence supports the Mediterranean diet’s association with:

■ increased lifespan

■ lower rates of cardiovascular disease such as heart attacks and strokes

■ lower rates of cancer (prostate, breast, uterus, colon)

■ lower rates of dementia

■ lower incidence of type 2 diabetes

Weaker supporting evidence links the Mediterranean diet with:

■ slowed progression of dementia

■ prevention of cutaneous melanoma

■ lower severity of type 2 diabetes, as judged by diabetic drug usage and fasting blood sugars

■ less risk of developing obesity

■ better blood pressure control in the elderly

■ improved weight loss and weight control in type 2 diabetics

■ improved control of asthma

■  reduced risk of developing diabetes after a heart attack

■ reduced risk of mild cognitive impairment

■  prolonged life of Alzheimer disease patients

■ lower rates and severity of chronic obstructive pulmonary disease

■ lower risk of gastric (stomach) cancer

■ less risk of macular degeneration

■ less Parkinsons disease

■ increased chance of pregnancy in women undergoing fertility treatment

■  reduced prevalence of metabolic syndrome (when supplemented with nuts)

■ lower incidence of asthma and allergy-like symptoms in children of women who followed the Mediterranean diet while pregnant

Did you notice that I used the word “association” in relating the Mediterranean diet to health outcomes?  Association, of course, is not causation. 

The way to prove that a particular diet is healthier is to take 20,000 similar young adults, randomize the individuals in an interventional study to eat one of two test diets for the next 60 years, monitoring them for the development of various diseases and death.  Make sure they stay on the assigned test diet.  Then you’d have an answer for that population and those two diets.  Then you have to compare the winning diet to yet other diets.  And a study done in Caucasians would not necessarily apply to Asians, Native Americans, Blacks, or Hispanics.

Now you begin to see why scientists tend to rely on observational  rather than interventional diet studies.

I became quite interested in nutrition around the turn of the century as my patients asked me for dietary advice to help them lose weight and control or prevent various diseases.  At that time, the Atkins diet, Mediterranean diet, and Dr. Dean Ornish’s vegetarian program for heart patients were all popular.  And you couldn’t pick three programs with more differences!  So I had my work cut out for me. 

After much scientific literature review, I find the Mediterranean diet to be the healthiest for the general population.  People with particular medical problems or ethnicities may do better on another diet.  People with diabetes or prediabetes are probably better off with a carbohydrate-restricted diet, such as the Low-Carb Mediterranean Diet. 

Dan Buettner makes a good argument for plant-based diets in his longevity book, The Blue Zones.  The Mediterranean diet qualifies as plant-based.

What do you consider the overall healthiest diet, and why?

Steve Parker, M.D.

References:

Sofi, Francesco, et al.  Accruing evidence about benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.  American Journal of Clinical Nutrition, ePub ahead of print, September 1, 2010.  doi: 10.3945/ajcn.2010.29673

Buckland, Genevieve, et al.  Adherence to a Mediterranean diet and risk of gastric adenocarcinoma within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study.  American Journal of Clinical Nutrition, December 9, 2009, epub ahead of print.  doi: 10.3945/ajcn.2009.28209

Fortes, C., et al.  A protective effect of the Mediterraenan diet for cutaneous melanoma.  International Journal of Epidmiology, 37 (2008): 1,018-1,029.

Sofi, Francesco, et al.  Adherence to Mediterranean diet and health status: Meta-analysis.  British Medical Journal, 337; a1344.  Published online September 11, 2008.  doi:10.1136/bmj.a1344

Benetou, V., et al.  Conformity to traditional Mediterranean diet and cancer incidence: the Greek EPIC cohort.  British Journal of Cancer, 99 (2008): 191-195.

Mitrou, Panagiota N., et al.  Mediterranean Dietary Pattern and Prediction of All-Cause Mortality in a US Population,  Archives of Internal Medicine, 167 (2007): 2461-2468.

Feart, Catherine, et al.  Adherence to a Mediterranean diet, cognitive decline, and risk of dementia.  Journal of the American Medical Association, 302 (2009): 638-648.

Scarmeas, Nikolaos, et al.  Physical activity, diet, and risk of Alzheimer Disease.  Journal of the American Medical Association, 302 (2009): 627-637.

Scarmeas, Nikolaos, et al.  Mediterranean Diet and Mild Cognitive Impairment.  Archives of Neurology, 66 (2009): 216-225.

Scarmeas, N., et al.  Mediterranean diet and Alzheimer disease mortality.  Neurology, 69 (2007):1,084-1,093.

Fung, Teresa, et al.  Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women.  Circulation, 119 (2009): 1,093-1,100.

Mente, Andrew, et al.  A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart Disease.  Archives of Internal Medicine, 169 (2009): 659-669.

Salas-Salvado, Jordi, et al.  Effect of a Mediterranean Diet Supplemented With Nuts on Metabolic Syndrome Status: One-Year Results of the PREDIMED Randomized Trial.  Archives of Internal Medicine, 168 (2008): 2,449-2,458.

Mozaffarian, Dariush, et al.  Incidence of new-onset diabetes and impaired fasting glucose in patients with recent myocardial infarction and the effect of clinical and lifestyle risk factors.  Lancet, 370 (2007) 667-675.

Esposito, Katherine, et al.  Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes.  Annals of Internal Medicine, 151 (2009): 306-314.

Shai, Iris, et al.  Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet.  New England Journal of Medicine, 359 (2008): 229-241.

Martinez-Gonzalez, M.A., et al.  Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study.  British Medical Journal, BMJ,doi:10.1136/bmj.39561.501007.BE (published online May 29, 2008).

Trichopoulou, Antonia, et al.  Anatomy of health effects of the Mediterranean diet: Greek EPIC prospective cohort study.  British Medical Journal, 338 (2009): b2337.  DOI: 10.1136/bmj.b2337.

Barros, R., et al.  Adherence to the Mediterranean diet and fresh fruit intake are associated with improved asthma control.  Allergy, vol. 63 (2008): 917-923.

Varraso, Raphaelle, et al.  Prospective study of dietary patterns and chronic obstructive pulmonary disease among US men.  Thorax, vol. 62, (2007): 786-791

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April 9, 2010 · 2:00 AM

Prediabetes Ignored Way Too Often

Only half of Americans with prediabetes take steps to avoid progression to diabetes, according to a recent report in the American Journal of Preventive Medicine.

Prediabetes is defined as:

  1. fasting blood sugar between 100 and 125 mg/dl (5.56–6.94 mmol/l) or
  2. blood sugar level 140–199 mg/dl (7.78–11.06 mmol/l) two hours after drinking 75 grams of glucose

Prediabetes is a strong risk factor for development of full-blown diabetes.  It’s also associated with increased risk for cardiovascular disease such as heart attack and stroke.  One of every four adults with prediabetes develops diabetes over the next 3 to 5 years.  The progression can often be prevented by lifestyle modifications such as dietary changes, moderate-intensity exercise, and modest weight loss.  

Investigators looked at 1,402 adult participants in the 2005-2006 National Health and Nutrition Examination Survey (NHANES) who had fasting blood sugar tests and oral glucose tolerance tests diagnostic of  prediabetes.  

The researchers estimate that 30% (almost one out of every three) of the adult U.S. population had prediabetes in 2005-2006, but only 7% of them (less than one in 10) were aware they had it.

Only half of the prediabetics in this survey reported attempts at preventative lifestyle changes in the prior year.  Only one of every three prediabetics reported hearing about risk reduction advice from their healthcare provider.

People, we’ve got to do better! 

My fellow physicians, we’ve got to do better!

The U.S. Centers for Disease Control and Prevention predicts that one of every three Americans born in 2000 will develop diabetes.  The great majority of this will be type 2 diabetes.  You understand now why James Hirsch, author of Cheating Destiny, calls diabetes America’s leading public health crisis.  I agree.

Steve Parker, M.D.

Reference:  Geiss, Linda S., et al.  Diabetes risk reduction behaviors among U.S. adults with prediabetes.  American Journal of Preventive Medicine, 38 (2010): 403-409.

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Filed under Causes of Diabetes, coronary heart disease, Overweight and Obesity, Prevention of T2 Diabetes, Stroke, Weight Loss

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March 15, 2010 · 2:00 AM

Review: Gestational Diabetes

You can't tell if she has it just by looking

You can’t tell if she has it just by looking

Ever heard of gestational diabetes?  It’s when a when a woman develops diabetes during pregnancy.  It usually goes away soon after the baby is born.  All pregnancies are characterized by some degree of insulin resistance and high insulin levels: they are necessary for the baby.  Nevertheless, healthy pregnant women run blood sugars 20% lower than when they are not pregnant.

In the U.S., gestational diabetes occurs in 5% of pregnancies, affecting more than 240,000 births annually.  Compared to caucasians, gestational diabetes mellitus (GDM) occurs more often in blacks, native Americans, Asians, and Latinos.

So What’s the Big Deal?

Numerous problems are associated with GDM, for both the mother and the baby:

  • dangerously high blood pressure (preeclampsia)
  • excessive amount of amniotic fluid (the baby in the uterus floats in this fluid)
  • delivery requiring an operation
  • early or premature delivery
  • death of the baby
  • birth trauma, such as broken bones or nerve injury
  • metabolic problems in the baby (low blood sugar, for example)
  • abnormally large baby (macrosomia, a major problem)

Diabetic ketoacidosis—a life-threatening complication of diabetes—is rare in GDM.

How Is GDM Diagnosed?  (section updated December 28, 2013)

Most women should undergo a screening test around the 24th to 28th week of pregnancy.  Screen earlier if undiagnosed type 2 diabetes is suspected or if risk factors for diabetes are present.  The American Diabetes Association (2014 guidelines) recommends either one of two screening tests.

  • “One-step test.” It’s a morning oral glucose tolerance test after at least eight hours of fasting. Fasting blood sugar is tested then he woman drinks 75 grams oral of glucose.  Blood sugar is tested again one and two hours later.  This blood sample is obtained by a needle in a vein, not by finger prick.  Gestational diabetes is diagnosed if any of the following apply: 1) fasting glucose is 92 mg/dl (5.1 mmol/l) or higher, 2) 0ne-hour level is 180 mg/dl (10.0 mmol/l) or higher, or 3) two-hour level is 153 mg/dl (8.5 mmol/l) or higher.
  • “Two-step test.” This is a nonfasting test with only one needle-stick. The woman drinks 50 grams of glucose; plasma glucose is tested one hour later. But if it’s over 140 mg/dl (10.0 mmol/l), that’s a flunk and a three-hour 100-gram oral glucose tolerance test in the fasting state must be done (step two). Gestational diabetes is present if the three-hour glucose is 140 mg/dl (7.8 mmol/l) or higher. Other experts say the diagnosis requires two or more of the following:
    • fasting blood sugar > 95 mg/dl (5.3 mmol/l)
    • 1-hour blood sugar > 180 mg/dl (10 mmol/l)
    • 2-hour blood sugar > 155 mg/dl (8.6 mmol/l)
    • 3-hour blood sugar > 140 mg/dl (7.8 mmol/l)

You’ll find that various expert panels have proposed different criteria for the diagnosis. The National Institutes of Health in the U.S. published their consensus statement in 2013. 

There’s no need for the screening test if a random blood sugar is over 200 mg/dl (11.1 mmol/l) or a fasting sugar is over 126 mg/dl: those numbers already define diabetes, assuming they are confirmed with a second high reading.  A random blood sugar over 200 mg/dl (11.1 mmol/l) should probably be repeated for confirmation.  Gestational diabetes can be diagnosed at the first prenatal visit if fasting blood sugar is 92 or over mg/dl (5.1 mmol/l or over) but under 126 mg/dl (7 mmol/l), or if hemoglobin A1c at the first prenatal visit is 6.5% or greater.

Women with diabetes in the first trimester have overt diabetes, not gestational diabetes.

What’s the Treatment for Gestational Diabetes?

Briefly: diet, exercise, blood glucose self-monitoring,  and insulin if needed.  The immediate goal is to achieve normal blood sugars.

A registered dietitian is involved in teaching diet modification.  The standard recommendation is to reduce carbohydrate consumption to 35-40% of total calories.  [By comparison, the standard American diet provides about 55% of calories as carbohydrates.]  Protein and fat are about 20% and 40%, respectively.  Total calorie recommendations are based on the mother’s ideal body weight.  Insulin resistance is greatest in the morning, so breakfast is small.  Complex carbohydrates are favored over simple sugars.  Most women will achieve normal glucose (blood sugar) levels with diet modification.

Moderate exercise also helps control blood sugars, partially by increasing sensitivity of body tissues to insulin.

How often should blood sugar be monitored by the mother?  Ideally, at least four times daily: fasting (on an empty stomach before breakfast) and one hour after the first bite of each meal.

Insulin therapy should be seriously considered when fasting glucose is over 90–95 mg/dl (5.0–5.3 mmol/l) or 1-hour-after-meal glucose is over 120-130 mg/dl (6.7–7.2 mmol/l).  Fifteen percent of mothers with GDM will need insulin injections.  If elevated fasting glucose is the only problem, NPH insulin before bedtime is prescribed.  If sugar levels one hour after meals are elevated, then use rapid-acting insulin aspart or insulin lispro just before meals.  In some cases, both NPH and rapid-acting insulin are both necessary.

Outside the U.S., glucose-lowering pills are sometimes used: glyburide and/or metformin most commonly.

What About After Delivery?

Having had gestational diabetes, the mother is at high risk of developing typical non-pregnant diabetes in the future. She should be screened for the development of diabetes and prediabetes at least every three years. Regular exercise and loss of excess weight decrease the risk substantially.

Steve Parker, M.D.

Sources:  UpToDate.com article on gestational diabetes, accessed March, 2010 and October, 2011.  American College of Obstetrics and Gynecology position paper published in 2001.  Diabetes Care, vol. 34, 2011: supplement 1: S62.  Blood sugar levels on the 3-hour 100-gram glucose tolerance test are from the Fourth International Workshop-Conference on Gestational Diabetes, published in 2000. For gestational diabetes diagnosis: American Diabetes Association’s Standards of Care in Diabetes – 2014.

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