Wine is a time-honored component of the healthy Mediterranean diet and, traditionally, is consumed with meals.
For science and food geeks, Bix at the Fanatic Cook blog has a post outlining how red wine consumption with meals might be healthy: it reduces blood levels of cytotoxic lipid peroxidation products like malondialdehyde.
By no means is Fanatic Cook always this esoteric. Check out some of the other topics there.
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Filed under Alcohol, Mediterranean Diet
Metformin is a major drug for treatment of type 2 diabetes. In fact, it’s usually the first choice when a drug is needed.
This review is quite limited—consult your physician or pharmacist for full details. Remember that drug names vary by country and manufacturer. Glucophage is a common brand name for metformin in the U.S.
Class
Biquanide (it’s the only one in this class).
How does it work?
In short, metformin decreases glucose output by the liver. The liver produces glucose (sugar) either by breaking down glycogen stored there or by manufacturing glucose from smaller molecules and atoms. The liver then kicks the glucose into the bloodstream for use by other tissues. Insulin inhibits this function of the liver, thereby keeping blood sugar levels from getting too high. Metformin improves the effectiveness of insulin in suppressing sugar production. In other words, it works primarily by decreasing the liver’s production of glucose.
Physicians talk about metformin as an “insulin sensitizer,” primarily in the liver but also to a lesser extent in peripheral tissues such as fat tissue and muscle. It doesn’t work without insulin in the body.
Metformin typically lowers fasting blood sugar by about 20% and hemoglobin A1c by 1.5% (absolute decrease, not relative).
When used as the sole diabetic medication, metformin is associated with decreased risk of death and heart attack, compared to therapy with sulfonylureas, thiazolidinediones, alpha-glucosidase inhibitors, and meglitinides.
Not uncommonly, metformin leads to a bit of weight loss and improved cholesterol levels. Insulin and sulfonylurea therapy, on the other hand, typically lead to weight gain of 8–10 pounds (4 kg) on average.
Usage
Metformin works by itself, but can also be used in combination with most of the other diabetic medications. It’s usually taken 2–3 times daily.
Dose
Starting dose is typically 500 mg taken with the evening meal. The dose can be increased every week or two. If more than 500 mg/day is needed the second dose—500 mg—is usually given with breakfast. Usual effective maximum dose is around 2,000 mg daily.
Side effects
Metallic taste, diarrhea, belly pain, loss of appetite. Possible impaired absorption of vitamin B12, leading to anemia. When used alone, it has very little risk of hypoglycemia. Rare: lactic acidosis.
Don’t use metformin if you have . . .
Impaired kidney function (keep reading), congestive heart failure of a degree that requires drug therapy (this is debatable), active liver disease, chronic alcohol abuse.
Regarding impaired kidney function: don’t use metformin if your eGFR (estimated glomerular function rate) is under 30 ml/min/1.73 m squared), and use only with extreme caution if eGFR drops below 45 while using metformin. Don’t start metformin if eGFR is between 30 and 45. Your doctor can calculate your eGFR and should do so annually if you take metformin.
Updated April 10, 2016
Filed under Drugs for Diabetes
Researchers in the U.K. suggest that a hemoglobin A1c of 7.5% may be optimal in terms of longevity for type 2 diabetics treated with drugs, according to a study published recently in The Lancet.
Hemoglobin A1c (HgbA1c) is a blood test widely used as a gauge of blood sugar control, reflecting average blood sugars over the previous three months. The American Diabetes Association recommends a HgbA1c goal of 7% or less. The American Association of Clinical Endocrinologists recommends 6.5% or less. Dr. Richard K. Bernstein, a diabetologist and himself a type 1 diabetic, recommends HgbA1c’s as near normal as possible (about 5%).
Many physicians believe that keeping blood sugar levels as close to normal as possible—often referred to as “tight control”— will help prevent certain diabetes complications such as blindness, kidney failure, and nerve damage. We have good supportive evidence.
We assume tight control would also help prevent premature death from heart attacks and strokes, too. Several recent studies—the ACCORD and ADVANCE trials—call this into question, however. The ACCORD trial, for example, achieved near-normal glucose control with multiple medication options, yet found that the effort was linked to increased death rates from cardiovascular disease and from any cause (all-cause mortality).
The scariest thing about tight control is hypoglycemia, which can kill you quickly, for example, if you’re operating dangerous machinery (e.g., driving), scuba-diving, or rock-climbing.
U.K. researchers recently reviewed records of diabetics treated either with 1) two oral medications (usually metformin and a sulfonylurea), or 2) a regimen containing insulin. Each group had over 20,000 subjects. They found that risk of death for those with an average HgbA1c of 6.4% (the lowest blood sugar levels in this study) was 52% higher than those with HgbA1c of 7.5%. Those with the highest blood sugar levels over time—HgbA1c over 10% if I recall correctly—had the highest risk of death. In general, those taking insulin had higher rates of death than those on pills.
It’s extremely difficult to interpret studies like this. There are myriad ways to treat diabetes. We have 10 classes of drugs for treatment of diabetes: this study looked at three. There are at least three types of “diabetic diet” in common use: low-fat/high-carb, low-carb, and just regular eating, which depends on where you live. Exercise, too, plays a role in treatment and longevity.
With all these variables, should we put much stock in a study that looks at longevity from the perspective of just two therapeutic regimens? How well would a football team do with just two plays in its play-book?
You’d think we would have a definite answer to the “tight versus loose control” issue by 2010. We don’t. It’s still very appealing to me to think that, if done right, tight control would yield the better outcomes. Problem is, we don’t always know what’s right.
One thing is clear: Having a HgbA1c of 7.5% is better than 10% in terms of health and longevity.
But is 7.5% really better than 6.5 or 5.5 or 5.0% for a particular individual on a particular treatment program? Probably not. That’s why the ADA and AACE emphasize that treatment programs be tailored to the individual patient.
Maybe controlling blood sugar levels is like controlling high blood pressure. The ideal may be 120/80, but you gain very little, if any, by reducing high blood pressure below 140/90 (130/85 for diabetics). HgbA1c of 5.0% may be ideal, but not necessary.
References:
Currie, Craig, et al. Survival as a function of HgA1c in people with type 2 diabetes: a retrospective cohort study. The Lancet, January 27, 2010. Early online publication doi: 10.1016/S0140-6736(09)61969-3
Dluhy, Robert and McMahon, Graham. Intensive glycemic control in the ACCORD and ADVANCE trials. New England Journal of Medicine, 358 (2008):2630-2633.
Filed under Diabetes Complications, Drugs for Diabetes
This is the beginning of a new day. You have been given this day to use as you will. You can waste it or use it for good. What you do today is important because you are exchanging a day of your life for it. When tomorrow comes, this day will be gone forever; in its place is something that you have left behind . . . let it be something good.
-Author unknown
Filed under Quote of the Day
Reuters reported on January 25, 2009, the U.S. Food and Drug Administration’s recent approval of liraglutide (brand name: Victoza).
It joins Byetta (exenatide) as the second GLP-1 (glucagon-like peptide-1) analog available in the U.S. Both are injections and work by stimulating the release of insulin by pancreas beta cells when blood sugar is too high.
The FDA indicated liraglutide is not generally a first-choice drug for diabetes.
It’s always good to have options.
Filed under Drugs for Diabetes
The direct yearly medical cost of being obese in the U.S. is $1,723 per obese person, according to a just-released report in Obesity Reviews. Being overweight is a relative bargain at $266.
These numbers translate into $114 billion yearly, or five to 10 percent of total healthcare spending.
Not included in the numbers are costs such as lost productivity due to obesity-related illness and replacement or repair of items that wear out or break due to excessive amounts of physical stress. Not to mention pain and suffering.
Are you overweight or obese? Find out with an online body mass index calculator.
Want to do anything about it? See my “Prepare for Weight Loss” series.
Reference: Tsai, A.G., et al. Direct Medical Cost of Obesity in the U.S.A. Obesity Reviews, online January 6, 2009. doi: 10.1111/j.1467-789x.2009.00708.x
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Filed under Overweight and Obesity
Several scientific studies published in the first five years of this century suggest that whole grain consumption protects agains coronary heart disease and possibly other types of cardiovascular disease, such as stroke.
Note that researchers in this field, especially outside the U.S., use the term “cereal” to mean “a grass such as wheat, oats, or corn, the starchy grains of which are used as food.” They also refer frequently to glycemic index and glycemic load, spelled “glycaemic” outside the U.S. Most of the pertinent studies are observational (aka epidmiologic): groups of people were surveyed on food consumption, then rates of diseases were associated with various food types and amounts. “Association” is not proof of causation.
Here are highlights from a 2006 review article in the European Journal of Clinical Nutrition:
The researchers concluded that a relationship between whole grain intake and coronary heart disease is seen with at least a 20% and perhaps a 40% reduction in risk for those who eat whole grain food habitually vs those who eat them rarely.
Whole grain products have strong antioxidant activity and contain phytoestrogens, but there is insufficient evidence to determine whether this is beneficial in coronary heart disease prevention.
Countering the positive evidence for whole grain and legume intake has been the Nurses Health Study in 2000 that showed women who were overweight or obese consuming a high glycaemic load (GL) diet doubled their relative risk of coronary heart disease compared with those consuming a low GL diet.
The intake of high GI carbohydrates (from both grain and non-grain sources) in large amounts is associatied with an increased risk of heart disease in overweight and obese women even when fiber intake is high but this requires further confirmation in normal-weight women.
Promotion of carbohydrate foods should befocused on whole grain cereals because these have proven to be associatied with health benefits.
Whether adding bran to refined carbohydrate foods can improve the situation is also not clear, and it was found that added bran lowered heart disease risk in men by 30%.
Recommendation: Carbohydrate-rich foods should be whole grain and if theyare not, then the lowest GI product available should be consumed.
My Comments
This journal article focuses on whole grains rather than legumes, and promotes whole grains more than legumes. For people with diabetes, this may be a bit of a problem since grains—whole or not—generally have a higher glycemic index than legumes, which may have adverse effects on blood sugar control. Keep in mind that highly refined grain products, like white bread, have a higher glycemic index than whole grain versions.
Did you notice that the abstract doesn’t recommend a specific amount of whole grains for the general population? My educated guess would be one or two servings a day.
Grains are high in carbohydrate, so anyone on a low-carb diet may have to cut carbs elsewhere.
Diabetes predisoses to development of coronary heart disease. Whole grains seem to help prevent heart disease, yet may adversely affect glucose control, contributing to diabetic complications. It’s a quandary. “Caught between the horns of a dilemma,” you might say. So, what should a diabetic do with this information in 2010, while we await additional research results?
Several options come to mind:
Before you stress out over this, be aware that we don’t really know whether a diabetic who doesn’t eat grains will have a longer healthier life by starting a daily whole grain habit. Maybe . . . maybe not. The study hasn’t been done.
References:
Flight, I. and Clifton, P. Cereal grains and legumes in the prevention of coronary heart disease and stroke: a review of the literature. European Journal of Clinical Nutrition, 60 (2006): 1,145-1,159.
Malik, V. and Hu, Frank. Dietary prevention of atherosclerosis: go with whole grains. American Journal of Clinical Nutrition, 85 (2007): 1,444-1,445.
Filed under Carbohydrate, coronary heart disease, Diabetes Complications, Grains, legumes, Stroke
Harvard’s Dr. Frank Hu in 2007 called for a paradigm shift in dietary prevention of heart disease, de-emphasizing the original diet-heart hypothesis and noting instead that “. . . reducing dietary GL [glycemic load] should be made a top public health priority.” Jim Mann at the University of Otago (Dunedin, New Zealand) authored a 2007 review of carbohydrates and effects on heart disease and diabetes. Here are highlights from the article summary in the European Journal of Clinical Nutrition:
The nature of carbohydrate is of considerable importance when recommending diets intended to reduce the risk of type II diabetes and cardiovascular disease and in the treatment of patients who already have established diseases. Intact fruits, vegetables, legumes and whole grains are the most appropriate sources of carbohydrate. Most are rich in [fiber] and other potentially cardioprotective components. Many of these foods, especially those that are high in dietary fibre, will reduce total and low-density lipoprotein cholesterol and help to improve glycaemic control in those with diabetes.
Frequent consumption of low glycaemic index foods has been reported to confer similar benefits, but it is not clear whether such benefits are independent of the dietary fibre content of these foods or the fact that low glycaemic index foods tend to have intact plant cell walls.
A wide range of carbohydrate intake is acceptable, provided the nature of carbohydrate is appropriate. Failure to emphasize the need for carbohydrate to be derived principally from whole grain cereals, fruits, vegetables and legumes may result in increased lipoprotein-mediated risk of cardiovascular disease, especially in overweight and obese individuals who are insulin resistant.
Why does this matter to me and readers of this blog? Dietary carbohydrates are a major determinant of blood sugar levels, tending to elevate them. Chronically high blood sugar levels are associated with increased complication rates from diabetes. People with diabetes are prone to develop heart disease, namely coronary artery disease, which causes heart attacks, weakness of the heart muscle, and premature death.
References:
Mann, J. Dietary carbohydrate: relationship to cardiovascular disease and disorders of carbohydrate metabolism. European Journal of Clinical Nutrition, 61 (2007): Supplement 1: S100-11.
Hu, Frank. Diet and cardiovascular disease prevention: The need for a paradigm shift. Journal of the American College of Cardiology, 50 (2007): 22-24.
Filed under Carbohydrate, coronary heart disease, Fiber, Fruits, Glycemic Index and Load, Grains, legumes, Vegetables
Lowering glycemic index (GI) led to improved contol of blood sugar, better insulin sensitivity, and weight loss in people with type 2 diabetes given group education sessions, according to researchers at Pennsylvania State University.
As background, the scientists note that:
GI may play a role in preventing or treating type 2 diabetes by decreasing the risk for obesity or by altering metabolic endpoints. Improvements in glycaemic control were observed in people with diabetes in a recent meta-analysis. A lower-GI diet was shown to decrease postprandial glucose [blood sugar after meals] and insulin responses and improve serum lipid concentrations. Lower-GL [glycemic load] diets were associated with decreased risk for type 2 diabetes, decreased levels of C-reactive protein and inflammation, and weight loss.
Ninety-nine test subjects completed the study that enrolled adults 40 to 70 years old who had diabetes at least one year but were not taking insulin shots. Average body mass index was 33, so they were obese. Average weights were 84.5 kg (186 lb) for women and 108.7 kg (239 lb) for men. Average baseline hemoglobin A1c was estimated at 7%, so these folks were under good glucose control. Baseline carbohydrate intake was 45% of total energy, a bit lower than the general population.
The 9-week intervention involved nine weekly group education sessions—lasting 1.5 to 2 hours—focusing on selection of lower-GI (vs higher-GI) foods instead of restricting carbohydrates. Also covered were monitoring of portion sizes to control carb consumption, carb counting to control carb distribution and intake, and self-monitoring of food intake.
Results
Although weight loss was not a goal, weights fell by 1-2 kg (2-4 pounds). Men lost more than women. Overall diet glycemic index fell by 2-3 points (a modest amount). Comparing values before and after intervention, fasting glucose and postprandial glucose fell significantly, and insulin sensitivity improved. Although not measured, the authors estimate hemoglobin A1c levels would have fallen an absolute 0.3%, based on measured glucose levels. Percentage of calories from carbohydrate did not change.
Comments
This is one of the few studies to try low-glycemic index behavioral intervention in adults with type 2 diabetes. Results are encouraging.
The researchers and I wonder if results would have been even more dramatic if the test subjects hadn’t been so well controlled before intervention or if they had dropped their glycemic index even lower. Probably so. Many people with type 2 diabetes have hemoglobin A1c’s well over 7%.
The researchers attribute the weight loss to portion control and simple self-monitoring of consumption.
For people with diabetes, this study supports selection of lower-glycemic index instead of higher-GI. In fact, we’d see less diabetes, heart disease, breast cancer, and gallbladder disease if all women—diabetic or not—ate lower-GI.
Reference: Gutschall, Melissa, et al. A randomized behavioural trial targeting glycaemic index improves dietary, weight and metabolic outcomes in patients with type 2 diabetes. Public Health and Nutrition, 12(2009): 1,846-1,854.
Filed under Carbohydrate, Glycemic Index and Load
Harvard researchers suggest that our food consumption does indeed influence our risk of suffering a stroke. This matters since stroke is the third leading cause of death in the U.S.
Scientists looked carefully at 121 different studies—published between 1979 and 2004—on the relationship between dietary factors and stroke. High blood pressure is a major modifiable risk factor for stroke, so it also was considered. Dietary factors included fats, minerals, animal protein, cholesterol, fish, whole grains, fiber, carbohydrate quality, fruits and vegetables, antioxidants, B vitamins, and dietary patterns.
I quote their conclusions:
Diets low in sodium and high in potassium lower blood pressure which will likely reduce stroke risk.
Consumption of fruits and vegetables, whole grains, folate, and fatty fish are each likely to reduce stroke risk.
A prudent or traditional Mediterranean dietary pattern, which incorporates these individual dietary components as well as intake of legumes and olive oil, may also prevent stroke.
Evidence is limited or inconsistent regarding optimal levels of dietary magnesium, calcium, antioxidants, total fat, other fat subtypes, cholesterol, carbohydrate quality, or animal protein for stroke prevention.
A diet low in sodium, high in potassium, and rich in fruits, vegetables, whole grains, cereal fiber, and fatty fish will likely reduce the incidence of stroke.
Take Home Points
The article abstract does not address the optimal intake amount of these various foods, vitamins, and minerals. That’s probably not known with any certainty.
The traditional Mediterranean diet incorporates many of these stroke-preventing foods. The Advanced Mediterranean Diet helps people lose weight while teaching how to eat Mediterranean-style.
The very low-carb Ketogenic Mediterranean Diet includes these stroke-preventing foods and minerals, except for whole grains and a tendency to be low in potassium. The KMD is high in total fat and animal protien, and potentially high in cholesterol; this study indicates those issues are nothing to worry about in terms of future strokes.
I’ll use articles such as this to recommend long-term food consumption for followers of any future Diabetic Mediterranean Diet.
Reference: Ding, E.L, and Mozaffarian, D. Optimal dietary habits for the prevention of stroke. Seminars in Neurology, 26 (2006): 11-23.
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Filed under Fish, Fruits, Grains, Health Benefits, legumes, Mediterranean Diet, olive oil, Stroke, Vegetables
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Diabetic Mediterranean Diet 