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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

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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

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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

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Which Diet Improves Insulin Resistance Better: Alternate-Day Fasting or Daily Calorie Restriction?

Horses, like Java, also get Metabolic Syndrome but it’s not quite the same as in humans. Java had to lose weight and change his diet.

Body tissue resistance to the effect of insulin is considered harmful by many experts. For instance, it may contribute to obesity, high blood pressure, type 2 diabetes, and cancer. BTW, if you have Metabolic Syndrome, you probably have insulin resistance. Regular exercise and loss of excess body fat are two ways  to reduce insulin resistance. Fasting also has an effect, but is it better than daily calorie restriction?

From a small study in the journal Obesity:

ABSTRACT

Objective

This study compared the effects of alternate‐day fasting (ADF) with those of daily calorie restriction (CR) on body weight and glucoregulatory factors in adults with overweight or obesity and insulin resistance.

Methods

This secondary analysis examined the data of insulin‐resistant individuals (n = 43) who participated in a 12‐month study that compared ADF (25% energy needs on “fast days”; 125% energy needs on alternating “feast days”) with CR (75% energy needs every day) and a control group regimen.

Results

In insulin‐resistant participants, weight loss was not different between ADF (−8% ± 2%) and CR (−6% ± 1%) by month 12, relative to controls (P < 0.0001). Fat mass and BMI decreased (P < 0.05) similarly from ADF and CR. ADF produced greater decreases (P < 0.05) in fasting insulin (−52% ± 9%) and insulin resistance (−53% ± 9%) compared with CR (−14% ± 9%; −17% ± 11%) and the control regimen by month 12. Lean mass, visceral fat mass, low‐density lipoprotein cholesterol, high‐density lipoprotein cholesterol, triglycerides, blood pressure, C‐reactive protein, tumor necrosis factor α, and interleukin 6 values remained unchanged.

Conclusions

These findings suggest that Alternate-Day Fasting may produce greater reductions in fasting insulin and insulin resistance compared with Calorie Restriction in insulin‐resistant participants despite similar decreases in body weight.

Source: Differential Effects of Alternate‐Day Fasting Versus Daily Calorie Restriction on Insulin Resistance – Gabel – – Obesity – Wiley Online Library

It would be interesting to compare the compliance and drop-out rates between the two groups studied. Is a daily 25% calorie deficit easier to stomach than a 75% reduction every other day?

Click for info on Equine Metabolic Syndrome.

Caution: Folks with diabetes who take drug that can cause hypoglycemia may well suffer actual severe hypoglycemia if they reduce their usual daily calories by 75%, or even 25%.

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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Mediterranean Diet May Prevent Gestational Diabetes

You can’t tell if she has gestational diabetes just by looking

From Newsweek:

Eating a Mediterranean diet while pregnant could prevent women at risk of gestational diabetes from developing the condition, a study has found.The women who took part in the study followed a Mediterranean-style diet, by eating more nuts, extra virgin olive oil, fish, white meat and pulses; while cutting their levels of red meat, butter, margarine, and cream. Researchers also asked the women to avoid sugary drinks, fast food, and those high in animal fats.

Source: Eating Mediterranean Diet During Pregnancy Could Cut Gestational Diabetes Risk: Study

Steve Parker, M.D.

low-carb mediterranean diet

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Ascension Shared Confidential Healthcare Info on Millions with Google

…according to Daily Mail:

Lawyers, medical professionals and tech experts have reacted with a mixture of horror and fury after it emerged that Google has been secretly acquiring sensitive medical data on millions of people without their knowledge or consent.

Questions were immediately raised around the ethics of the data-gathering operation – code-named Project Nightingale – as well as the security of patient data after the program was first reported on Monday.

Others called for an immediate change to privacy laws after Google and Ascension, the healthcare organization it has partnered with, boasted that the scheme is completely legal.

Dr. Robert Epstein, an author, medical researcher and former editor-in-chief at Psychology Today, summed up the mood when he tweeted: ‘You can’t make this s*** up. #BeAfraid.’

Source: Furious backlash after it emerges Google has secretly amassed healthcare data on millions of people | Daily Mail Online

The “confidential” date reportedly included names, dates of birth, lab results, diagnoses, and hospitalization records.

Thanks, Ascension. How much did you make off the deal?

I’ve increasingly noticed that I have to depend on Daily Mail or other non-U.S. sources for news that “the powers that be” apparently don’t want me to hear about.

Steve Parker, M.D.

PS: Keep your sensitive healthcare data out of Google’s and Ascension’s clutches by getting healthier.

PPS: I wonder if Google will censor this post by keeping it out of search results. Nah, my readership isn’t big enough. It would naturally show up on page 46 of results, and nobody goes that far down.

low-carb mediterranean diet

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LCHF Diet Improves Metabolic Syndrome Even Without Weight Loss

Use the search box to find the recipe for this LCHF avocado chicken soup

“Metabolic syndrome” may be a new term for you. It’s a collection of clinical features that are associated with increased future risk of type 2 diabetes and atherosclerotic complications such as heart attack and stroke. One in six Americans has metabolic syndrome. Diagnosis requires at least three of the following five conditions:

  • high blood pressure (130/85 or higher, or using a high blood pressure medication)
  • low HDL cholesterol:  under 40 mg/dl (1.03 mmol/l) in a man, under 50 mg/dl (1.28 mmol/l) in a women (or either sex taking a cholesterol-lowering drug)
  • triglycerides over 150 mg/dl (1.70 mmol/l) (or taking a cholesterol-lowering drug)
  • abdominal fat:  waist circumference 40 inches (102 cm) or greater in a man, 35 inches (89 cm) or greater in a woman
  • fasting blood glucose over 100 mg/dl (5.55 mmol/l)

One approach to improving the numbers is a low-carb, high-fat (LCHF) diet. Here’s a journal article abstract from JCI Insight:

BACKGROUND. Metabolic syndrome (MetS) is highly correlated with obesity and cardiovascular risk, but the importance of dietary carbohydrate independent of weight loss in MetS treatment remains controversial. Here, we test the theory that dietary carbohydrate intolerance (i.e., the inability to process carbohydrate in a healthy manner) rather than obesity per se is a fundamental feature of MetS.

METHODS. Individuals who were obese with a diagnosis of MetS were fed three 4-week weight-maintenance diets that were low, moderate, and high in carbohydrate. Protein was constant and fat was exchanged isocalorically for carbohydrate across all diets.

RESULTS. Despite maintaining body mass, low-carbohydrate (LC) intake enhanced fat oxidation and was more effective in reversing MetS, especially high triglycerides, low HDL-C, and the small LDL subclass phenotype. Carbohydrate restriction also improved abnormal fatty acid composition, an emerging MetS feature. Despite containing 2.5 times more saturated fat than the high-carbohydrate diet, an LC diet decreased plasma total saturated fat and palmitoleate and increased arachidonate.

CONCLUSION. Consistent with the perspective that MetS is a pathologic state that manifests as dietary carbohydrate intolerance, these results show that compared with eucaloric high-carbohydrate intake, LC/high-fat diets benefit MetS independent of whole-body or fat mass.

TRIAL REGISTRATION. ClinicalTrials.gov Identifier: NCT02918422.

FUNDING. Dairy Management Inc. and the Dutch Dairy Association.

Source: JCI Insight – Dietary carbohydrate restriction improves metabolic syndrome independent of weight loss

Steve Parker, M.D.

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Cross the Border for Affordable Insulin

Great article by Robin Cressman. Read the whole thing.

“Just a week before the trip [to Tijuana, Mexico], I was down to my very last vial of Humalog. It was June and I was close, but still so far, from hitting my $5,000 deductible for the year, which meant I was still paying full price out of pocket for all of my medical costs until I hit that figure. I had started the year low on supplies (a rookie mistake that I now know to avoid) and had been juggling bills from Dexcom, my doctor’s office, and my pump supplier for months, trying to only use our health savings account but often having to pull out credit cards to cover the costs. I called my pharmacy and asked to fill a single vial of Humalog, and the cost was $248.13. I hung up the phone. Instead I went to Walmart and for the first time bought vials of Novolin NPH and Regular for $24.99 each. It was those vials that were serving as my backup insulin a week later when I found myself in that pharmacy in Tijuana.”

Source: Crossing Borders to Afford Insulin – T1International

Whether it’s legal or not, I don’t know.

Steve Parker, M.D.

low-carb mediterranean diet

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