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Not Into Salads? Try This!

Salad and cheese

Jan over at Low Carb Diabetic has a great post on building a salad from the ground up.

“Salads make a nutritious and satisfying meal, whether it’s for lunch or dinner. The best part is that no two salads are exactly the same. There are limitless ways to make salad unique and flavourful. Get some tips for what to add to your next salad….”

Source: The Low Carb Diabetic: Super Salads – Some Tips for Building A Better Salad

Click for my nutritional assessment of various salad greens. Variety is also important.

Steve Parker, M.D.

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Science Skepticism

 

“You can’t tell whether I’m lying, delusional, ignorant, or simply incompetent. Sometimes even I don’t know!”

I ran across a 2016 article by Callie Joubert that summarizes skeptical ideas I’ve read about for years, but most people and physicians don’t know about. Bottom line: scientific research and medical studies aren’t nearly as reliable as you think.

Read the whole thing, but here are some excerpts:

We tend to think of science as a dispassionate (impartial, neutral) search for truth and certainty. But is it possible that we are facing a situation in which there is a massive production of wrong information or distortion of information? Is it possible that certain scientific disciplines are facing a crisis of credibility? Mounting evidence suggests this is indeed the case, which raises two questions: How serious is the problem? And what could explain this?

***

The title of an editorial in the prestigious medical journal The Lancet, dated April 6, 2002, asks the question, “Just How Tainted Has Medicine Become?”4 The article states, “Heavily, and damagingly so, is the answer.” Among other things, in 2001, researchers completed experiments with biotechnology products in which they had a direct financial interest and doctors did not tell their patients that others had died using these products when safer alternatives were available. In the same journal, dated April 11, 2015, Dr. Richard Horton stated the gravity of the problem as follows: “The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue . . . science has taken a turn towards darkness.”

In 2004, under the heading of “Depressing Research,” the editor of The Lancet had this to say about antidepressants for children: “The story of research into selective serotonin reuptake inhibitor (SSRI) use in childhood depression is one of confusion, manipulation, and institutional failure. . . . In a global medical culture where evidence-based practice is seen as the gold standard for care, these failings [i.e., of the USA Food and Drug Administration to act on information provided to them about the harmful effects of these drugs on children] are a disaster.”6 After being editor of the New England Journal of Medicine for 20 years, Dr. Marcia Angell stated that “physicians can no longer rely on the medical literature for valid and reliable information.”7 She referred to a study of 74 clinical trials of antidepressants that indicates that 37 of 38 positive studies were published. In contrast, 33 of the 36 negative studies were either not published or published in a form that conveyed a positive outcome. She also mentions the fact that drug companies are financing “most clinical research on the prescription drugs, and there is mounting evidence that they often skew the research they sponsor to make their drugs look better and safer.”

In 2011, researchers at Bayer decided to test 67 recent drug discoveries on preclinical cancer biology research. In more than 75 percent of cases, the published data did not match their attempts to replicate them.8 In 2012, a study published in Nature announced that only 11 percent of the sampled preclinical cancer studies coming out of the academic pipeline were replicable.9

In the prestigious Science journal, in 2015, the Open Science Collaboration10 presented a study of 100 psychological research studies that 270 contributing authors tried to replicate. An astonishing 65 percent failed to show any statistical significance on replication, and many of the remainder showed greatly reduced effect sizes. In plain terms, evidence for original findings is weak.

***

A discovery in physics, the hardest of all hard sciences, is usually thought of as the most reliable in the world of science. However, two of the most vaunted physics results of the past few years—“cosmic inflation and gravitational waves at the BICEP2 experiment in Antarctica, and the supposed discovery of superluminal neutrinos at the Swiss-Italian border—have now been retracted, with far less fanfare than when they were first published.”

***

Parker here again….

The science skeptic best known to physicians is John P.A. Ioannidis:

Empirical evidence from diverse fields suggests that when efforts are made to repeat or reproduce published research, the repeatability and reproducibility is dismal.

Another quote form Ioannidis:

There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias.

Ioannidis again:

Most physicians and other healthcare professionals are unaware of the pervasiveness of poor quality clinical evidence that contributes considerably to overuse, underuse, avoidable adverse events, missed opportunities for right care and wasted healthcare resources. The Medical Misinformation Mess comprises four key problems. First, much published medical research is not reliable or is of uncertain reliability, offers no benefit to patients, or is not useful to decision makers. Second, most healthcare professionals are not aware of this problem. Third, they also lack the skills necessary to evaluate the reliability and usefulness of medical evidence. Finally, patients and families frequently lack relevant, accurate medical evidence and skilled guidance at the time of medical decision‐making.

If you like videos, here’s Ioannidis on YouTube.

Staying skeptical,

Steve Parker, M.D.

h/t Vox Day

 

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ADA Nutrition Conference in 2019: Low-Carb Eating on the Rise

Spaghetti squash with parsley, olive oil, snow peas, garlic, salt, pepper

I’m astounded by how many people with diabetes I meet who pretty much eat whatever they want. Others, when I ask if they’re on a particular diet, say, “I watch what I eat.” Which usually just means avoiding obvious sugar bombs.

The American Diabetes Association in 2019 hosted a conference on nutrition therapy for diabetes. I assume the ADA endorses the panel’s recommendations. The big news is continued movement toward carb-restricted eating. Some excerpts:

Today, there is strong evidence to support both the efficacy and cost-effectiveness of nutrition therapy as a key component of integrated management of individuals with diabetes. This is increasingly relevant as it is evident that “one-size-fits-all” eating plan is not suitable for prevention or management of diabetes, also considering diverse cultural backgrounds, personal preferences, comorbidities, and socioeconomic settings. The American Diabetes Association (ADA) is now emphasizing that medical nutrition therapy (MNT) is fundamental for optimal diabetes management, and the new report also includes information on prediabetes.

***

One of the key recommendations is to refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT [medical nutrition therapy] at diagnosis and as needed throughout the life span, particularly during times of changing health status to achieve treatment goals.

           ***

The new consensus recommendations consider that a variety of eating patterns are acceptable for the management of diabetes.

In the absence of additional strong evidence on the comparative benefits of different eating patterns in specific individuals, healthcare providers should focus on the key factors that are common among the patterns, including emphasizing non-starchy vegetables, minimizing added sugars and refined grains, and preferring whole foods over highly processed foods.

Reducing overall carbohydrate intake for individuals with diabetes is associated with the most evidence for improving glycemia and may be applied in a variety of eating patterns.

For selected adults with type 2 diabetes who are not meeting glycemic targets or where reducing anti-glycemic medications is a priority, reducing overall carbohydrate intake with low or very low carbohydrate eating plans is also a viable approach.

***

Regarding weight loss in overweight or obese folks with diabetes or prediabetes:

…a low carbohydrate diet is now recognized as a safe, viable, and important option for patients with diabetes, and the other is that greater emphasis is now placed on weight loss in patients who are overweight/obese for the prevention of diabetes and its treatment.

Indeed, in type 2 diabetes, 5% weight loss is recommended to achieve clinical benefits, with a goal of 15%, when feasible and safe, in order to achieve optimal outcomes.

In prediabetes, the goal is 7–10% for preventing progression to type 2 diabetes.

“Metabolic surgery,” better known as bariatric surgery, and medication-assisted weight loss (aka weight-loss drugs) should be considered in some cases.

***

Best approach for optimizing blood sugars:

For macronutrients, the available evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.

[Self-monitoring of carbohydrate consumption is important.]

People with diabetes and those at risk for diabetes are encouraged to consume at least the amount of dietary fiber recommended for the general population; increasing fiber intake, preferably through food (vegetables, pulses (beans, peas, and lentils), fruits, and whole intact grains) or through dietary supplement, may help in modestly lowering HbA1C.

***

What about sugar-sweetened beverages?

Firstly, sugar-sweetened beverages should be replaced with water as often as possible.

Secondly, if sugar substitutes are used to reduce overall calorie and carbohydrate intake, people should be counseled to avoid compensating with intake of additional calories from other food sources.

***

Is alcohol forbidden? No.

…educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended.

To reduce hypoglycemia risk, the importance of glucose monitoring after drinking alcohol beverages should be emphasized.

Steve Parker, M.D.

PS: I note that William Yancy, M.D., was on the expert panel.

PPS: Bold emphasis above is mine.

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

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Are You Wiping Your Butt Wrong?

This is a topic I’d never run across online until recently. In the anal hygeine department, it looks like the Europeans and Japanese—with their bidets—are ahead of us in North America.

From Insider:

To keep your backside happy, Goldstein [a rectal surgeon] recommended using a patting motion rather than a wiping motion and being as gentle as possible. Ideally, he added, you should use a bidet to clean yourself and then pat the excess water dry with a bit of toilet paper if need be.

From MF (Mental Floss):

Asbury [a dermatologist] is an advocate of the standalone or add-on toilet accessory that squirts a spray of water between your cheeks to flush out residual fecal matter. While bidets are common in Europe and Japan, the West has been slower to adopt this superior method of post-poop clean-up; others might be wary of tapping into existing home plumbing to supply fresh water, even though DIY installation is quite easy. For those patients, Asbury has developed an alternative method.

TRY PAPER TOWELS AND WATER

“What I tell people to use is Viva, a really soft, thick paper towel made by Kleenex,” he says. “You get a squirt bottle and you leave it near the toilet and moisten the paper towel.” Regular toilet paper is usually too flimsy to stand up to a soaking, while normal paper towels are too harsh for rectal purposes. Viva is apparently just right. (And no, Asbury is not a brand ambassador, nor does Kleenex endorse this alternative use.)

This advice does come with a major caveat: Viva wipes are not flushable and might very well clog your pipes if you try to send them down the drain.

From Shape:

When it comes to wiping, less is more and not just because it keeps you from replacing the toilet paper roll every other day. “Overwiping can irritate the perianal skin and lead to small abrasions that trigger inflammation and itching,” Sheth [a gastroenterologist] says. One or two wipes are all it takes, he says. If you need to wipe more than that you may not have completely emptied your system or you could be constipated (in which case, up your fiber and water intake like you would to prevent hemorrhoids). If you still require more than a few wipes, consider switching to wet toilet paper or unscented baby wipes. “Moist wipes decrease the friction of wiping and cause less irritation,” Sheth says.

The first two links recommend against baby wipes.

From Sussex Surgery:

Many people cannot bear the thought of a dirty anus and they go to great lengths to keep their anus spotlessly clean using large amounts of toilet paper and vigorously washing the area, especially after defaecation.  Unfortunately this breaks down the fragile anal skin and then this usually effective barrier to bacteria lets in microbes to the surrounding tissues.  This is very irritating to local nerves and people then get in to a viscious cycle because they get itchy, feeling the need to clean the anus even more, which breaks down the anal skin barrier even further.  Therefore it is ironically and usually the cleanest people that end up in my specialist bowel surgery clinic rather than the dirtiest!

The first thing to do is to break the vicious cycle and I recommend that people tone down their anal cleaning routine.  Fingernails and abrasive materials such as rough toilet paper should be kept away from the anus.  Non-scented baby wipes or luxury toilet tissue are usually the kindest and most effective ways of wiping the bottom after opening the bowels.  Running water is the best way to wash the anal surfaces.

Often people think that they must keep on wiping their bottom with toilet paper until they do not see any more brown smears on the toilet paper but this can cause significant damage.  Instead people should stop wiping when the brown smears have lessened but before they rub their fragile anal skin raw.

From Atlas Obscura:

All of this provides a mixed view on the ideal material for wiping. Water is very good, because it’s gentle and won’t cause tears, but you want to stay away from residual moistness. Toilet paper isn’t bad, because it easily soaks up any moisture, but it also can be a little rough, which is bad. The ideal method would probably be a water bath followed by careful, gentle, and immediate drying, whether that’s with toilet paper or a jet of warm air.

For a history of anal hygeine and a tour of various cultures, visit Toilet Guru.

Steve Parker, M.D.

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

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Merry Christmas to One and All!

Don’t forget the reason for the season

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Support for Tighter Diabetes Control

Spaghetti squash “spaghetti” with meaty sauce

In Diabetes Care:

Glycated hemoglobin targets have been given in guidelines for the last three decades, mostly without change at around 6.5–7.0% (47–53 mmol/mol). Personalization of such targets has also long been advocated, but often with little and inappropriate guidance. More recently some have suggested higher targets might be indicated, and more specifically lower targets avoided, even in those in whom they are easily attained without seeming burden or risk. Prospective data from randomized and observational studies, in people with type 2 diabetes and indeed those without diabetes, find cardiovascular and mortality risk are uniformly lowest at lower levels including into the normal range. In some studies with large populations, a high proportion of people are found to attain such levels, and the UK Prospective Diabetes Study (UKPDS) and more recent studies appear to confirm the importance of starting low and continuing long. Studies of cardiovascular events and mortality in people with diabetes will already factor in any effect of hypoglycemia, which therefore should not be double-counted in setting targets. Nevertheless, some factors should lead to modification of target levels, and these will include experience of hypoglycemia where therapy change and glucose monitoring cannot ameliorate it and sometimes prospectively in those at social or occupational risk. The fact that clinical experience will modify targets emphasizes that targets will not be stable over time but will change, for example, with occurrence of adverse events or perceptions of increased/decreased burden of therapy. The evidence suggests that glucose control takes 5 years or more to have any impact on vascular outcomes or mortality, so targets may also be higher in those with shorter life expectancy or higher health burden or simply reflect individual preferences. This article discusses the evidence behind these conclusions.

Source: Controversies for Glucose Control Targets in Type 2 Diabetes: Exposing the Common Ground | Diabetes Care

If I had diabetes, I’d aim for HgbA1c under 5.7%, expecting that would increase my longevity and decrease my risk of diabetes complications. Such an ambitious goal would require frequent blood sugar monitoring, exercise, and a very low-carb diet.

Steve Parker, M.D.

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

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How Can You Achieve Great Hemoglobin A1c Results?

How old is this device?

The good folks over at Diabetes Daily conducted a survey of people with diabetes to find out what they were doing to get good HgbA1c levels. HgbA1c is a measure of average blood sugar levels over the prior three months. Lower HgbA1c levels, generally speaking, are linked to fewer diabetes complications. Prevention is always better than treatment. If you run across someone succeeding at anything, wouldn’t you want to know how they do it, assuming it’s a goal you share?  I recommend the entire report to you. An excerpt:

Type 2 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to:

  • Eat a very low-carbohydrate diet (<40 g per day): 32% vs. 13%
  • Eat a ketogenic diet (<20 g per day): 13% vs. 0%
  • Not vary their daily carbohydrate intake: 16% vs. 29%
  • Eat a low-carbohydrate lunch (<20 g) on a regular basis: 50% vs. 28%
  • Use an insulin pump: 10% vs. 3%
  • Vary the timing of their meal-time insulin: 53% vs. 40%
  • Exercise: Daily: 14% vs 8%. Exercise 4-6 times per week: 20% vs 8%.Exercise less than once per week: 51% vs 73%
  • Feel very confident about their diabetes management skills: 69% vs. 26%
  • Feel very optimistic about their long-term health: 58% vs. 30%
  • Feel that diabetes doesn’t greatly interfere with their daily life: 56% vs. 19%
  • Report a high degree of socioemotional support related to diabetes: 59% vs. 46%

Type 1 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to:

  • Eat a very low-carbohydrate diet (<40 g per day): 22% vs. 7%
  • Not vary their daily carbohydrate intake: 9% vs. 28%
  • Use an insulin pump: 71% vs. 53%
  • Wear a continuous glucose monitor (CGM): 76% vs. 60%
  • Have lower “high glucose alert” setting on their CGM
  • Have lower “low glucose alert” settings on their CGM
  • Not vary the timing of their meal-time insulin: 43% vs. 59%
  • Incorporate the protein content of their meal in determining their bolus insulin dose: 44% vs. 23
  • Eat similar food every day, at similar times, AND limit eating out at restaurants: 20% vs. 7%
  • Exercise: Daily: 21% vs 11%. Exercise 4-6 times per week: 24% vs 8%. Exercise less than once per week: 40% vs 66%
  • Feel very confident about their diabetes management skills: 82% vs. 39
  • Feel very optimistic about their long-term health: 59% vs. 42el that diabetes doesn’t greatly interfere with their daily life: 35% vs. 21%
  • Report a high degree of socioemotional support related to diabetes: 68% vs. 56%

Source: Habits of a Great A1c Survey Data Report – Diabetes Daily

Lead researcher was Maria Muccioli, PhD.

Steve Parker, M.D.

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

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