September 22, 2013 · 4:28 AM

Heart-Healthy Lifestyle Prevents Cancer, Too

…according to a report in MedPageToday. Type 2 diabetes is linked to higher incidence of several cancers: liver, pancreas, uterus, colo-rectal, breast, and bladder.  On a brighter note, diabetics have lower risk of prostate cancer. Diabetes is also associated with higher risk of heart disease.

I'm still not convinced that severe sodium restriction is necessary or even possible for most people

I’m still not convinced that severe sodium restriction is necessary or even possible for most people

The American Heart Association has published guidelines aiming to reduce premature death and illness caused by cardiovascular diseases such as heart attacks, high blood pressure, and strokes.

The guidelines focus on seven factors critical to cardiovascular health:

  • smoking
  • blood sugar
  • blood pressure
  • physical activity
  • total cholesterol
  • body mass index (BMI)
  • ideal diet

Using data from the Atherosclerosis Risk In Communities study (almost two decades’ follow-up), researchers found that those who maintained goals for six or seven of the American Heart Association critical factors had a 51% lower risk of cancer compared with those meeting no goals.

For detailed information about the specific goals, click here.

As you might expect, I was curious about what the American Heart Association considered a heart-healthy diet.  I quote the AHA summary:

The recommendation for the definition of the dietary goals and metric, therefore, is as follows: “In the context of a diet that is appropriate in energy balance, pursuing an overall dietary pattern that is consistent with a DASH [Dietary Approaches to Stop Hypertension]-type eating plan, including but not limited to:

  • Fruits and vegetables: ≥ 4.5 cups per day
  • Fish: ≥ two 3.5-oz servings per week (preferably oily fish)
  • Fiber-rich whole grains (≥ 1.1 g of fiber per 10 g of carbohydrate): ≥ three 1-oz-equivalent servings per day
  • Sodium: < 1500 mg per day
  • Sugar-sweetened beverages: ≤ 450 kcal (36 oz) per week

Intake goals are expressed for a 2000-kcal diet and should be scaled accordingly for other levels of caloric intake. For example, ≤ 450 calories per week represents only up to one quarter of discretionary calories (as recommended) coming from any types of sugar intake for a 2000-kcal diet.

Diet recommendations are more complicated than that; read the full report for details.  Only 5% of study participants ate the “ideal diet.”  The AHA-recommended diet may have too many carbohydrates for some diabetics. The Mediterranean diet easily meets four out of five of those diet goals; you’d have to be extremely careful to reach the sodium goal on most any diet.

Cardiovascular diseases and cancer are among the top causes of death in Western societies.  Adhering to the guidelines above may kill two birds with one stone.

Steve Parker, M.D.

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September 16, 2013 · 1:01 PM

Treatment of Gestational Diabetes Mellitus

…more from Amy Campbell at Diabetes Self-Management. This is part 2 her series on gestational diabetes mellitus. 

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September 16, 2013 · 3:55 AM

Meal Plans For “Conquer Diabetes and Prediabetes”

For both types 1 and type 2 diabetes, carbohydrate restriction is a great way to help control blood sugars and minimize the toxicity and expense of drug therapy. Here are some low-carb recipes from my book, Conquer Diabetes and Prediabetes.

Breakfast:  Brats and Tomatoes

6 oz (170 g) tomato, sliced

2 tbsp (30 ml) AMD vinaigrette (see below) or commercial Italian dressing (regular, not low-fat, with 3 g or fewer carbs per 2 tbsp or 30 ml)

salt and pepper

2 pre-cooked bratwursts (about 2.3 oz or 65 g each)

6 tsp (30 ml) mustard (optional)

Dress the tomato slices with the vinaigrette, plus salt and pepper to taste. Heat 2 pre-cooked bratwursts as instructed on package. Use mustard on the brats if desired. Digestible carb grams: 8.

AMD VINAIGRETTE

Try this on salads, fresh vegetables, or as a marinade for chicken, fish, or beef. If using as a marinade, keep the entree/marinade combo in the refrigerator for 4–24 hours. Seasoned vinaigrettes taste even better if you let them sit for several hours after preparation. This recipe was in my first book, The Advanced Mediterranean Diet; hence, “AMD vinaigrette.”

Ingredients

1 clove (3 g) garlic

juice from ½ lemon (23 g or ml)

a third of a cup (78 ml) oil olive

2 tbsp (8 g) fresh parsley

½ tsp (2.5 ml)) salt

½ tsp (2.5 ml) yellow mustard

½ tsp (1.2 ml) paprika

2 tbsp (30 ml) red wine vinegar

Preparation

In a bowl, combine all ingredients and whisk together. Alternatively, you can put all ingredients in a jar with a lid and shake vigorously. Let sit at room temperature for an hour, for flavors to meld. Then refrigerate. It should “keep” for at least 5 days in refrigerator. Shake before using. Servings per batch: 3.

Nutrient Analysis:

Recipe makes 3 servings (2 tbsp or 30 ml per serving). Each serving has 220 calories, 2 g digestible carb, almost no fiber, negligible protein, 24 g fat. 3% of calories are from carbohydrate, 97% from fat.

Lunch:  Easy Tuna Plus Pecans

5-oz can (140 g) of albacore tuna

2 tbsp (30 ml) Miracle Whip Salad Dressing (or real, high-fat mayonnaise)

1 tsp (5 ml) lemon or lime juice

1 oz (28 g) pecan halves

Drain the liquid off the can of tuna then place tuna in a bowl. Add Miracle Whip Salad Dressing and lemon or lime juice. Mix thoroughly and enjoy. Eat 1 oz of pecan halves around mealtime or later as a snack. If you want to simplify this, forget the Miracle Whip and lemon; just use 1 oz (28 g) of commercial tartar sauce that derives at least 80% of calories from fat and has less than 3 g of carb per 2 tbsp or 30 ml. Digestible carb grams: 5.

Dinner:  Ham Salad

2 oz (60 g) cooked ham, cut in to small cubes

1 oz (28 g) celery, sliced and diced

1 oz (28 g) seedless grapes (about 4 grapes), cut into small chunks

1 oz (28 g) walnuts, coarsely crumbled

4 oz (110 g) romaine lettuce

3 tbsp AMD vinaigrette or commercial Italian, French, or ranch dressing having 2 or fewer grams of carb per 2 tbsp or 30 ml)

Lay out a bed of lettuce then sprinkle these on top: ham, celery, grapes, walnuts. Finish construction with AMD vinaigrette or commercial dressing. You’re done. Alternatively, substitute cooked chicken or steak for ham. With chicken, apple may work better than grapes. If having a glass of wine (6 fl oz or 180 ml) with meal, delete the grapes or the carb count will be too high. Digestible carb grams: 10.

(When commercial dressing is used, the digestible carb count is closer to 13 than 10 g.)

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September 12, 2013 · 2:00 AM

What’s “Gestational Diabetes”? No, It’s Not Type 3

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

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

In a recent article Amy Campbell over at Diabetes Self-Management defines it and goes over risk factors, diagnosis, and why it’s important. I expect a second post on management principles in the near future.

Here’s my review from 2010.

In terms of the best diet, a recent study found no significant outcome differences on a 40% carb diet compared to a standard 55% carb diet. I would have guessed the lower-carb diet would better (see below).

Update Sept. 16, 2013:

Here’s part 2 of Amy’s series, beginning discussion of treatment.

I logged onto UpToDate.com and reviewed treatment briefly. The high points are:

  • See a registered dietitian for counseling.
  • “There is scant level 1 [high quality] evidence to support most aspects of the nutritional prescription for gestational diabetes mellitus.”
  • The authors limit carbohydrates to less than 40% of total calories.
  • Goals of treatment are 1) prevent ketosis, 2) support adequate weight gain of the mother based on body mass index, 3) support the baby, and 4) when drug therapy is needed, use insulin instead of pills.
  • UTD agrees with Amy that frequent blood sugar tests (at least 4x/day) with a home glucose monitor are helpful.

 

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September 11, 2013 · 4:17 AM

Metformin Impairs Brain Function In Some Users

 

 

Conquer Diabetes and Prediabetes

Metformin is the most-recommended drug for type 2 diabetes

…according to an article at MedPageToday. I consider this finding preliminary, but definitely something to keep an eye on. We need confirmatory data before taking action. Long-term metformin users should get vitamin B12 levels checked periodically in view of the well-established association of low levels in users. Low B12 impairs cognition and is easily preventable or treated.

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September 10, 2013 · 3:28 AM

Exercise Versus Recreational Physical Activity

MP900049602Melanie Thomassian’s blog post on physical activity reminded me of an essay called “Exercise vs Recreation” by Ken Hutchins.

One of the key points of the essay for me is that exercise isn’t supposed to be fun.  Ken wrote, “Do not try to make exercise enjoyable.”  Getting your teeth cleaned or car’s oil changed isn’t supposed to be fun, either.

Once I got that through my thick skull, it made it easier for me to slog through my  twice weekly workouts.  Another excerpt:

We accept that both exercise and recreation are important in the overall scheme of fitness, and they overlap to a great degree.  But to reap maximum benefits of both or either they must first be well-defined and then be segregated in practice.

Read the whole thing.

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September 5, 2013 · 5:31 AM

European Guidelines Not In Favor of Low Carbohydrate Diets for Diabetes

Conquer Diabetes and Prediabetes

“Really?”

A recent diabetes treatment guide from European doctors states “there is no justification for the recommendation of very low carbohydrate diets in diabetes mellitus.”

I disagree.

The 2013 guidelines are from the European Society of Cardiology and the European Association for the Study of Diabetes. I compiled the following articles in favor of carbohydrate restriction a couple years ago. You won’t find anything newer listed. Admittedly, all or nearly all of the patients involved had type 2 diabetes, not type 1.

Enjoy!

♦  ♦  ♦

Accurso, A., et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutrition & Metabolism, 9 (2008). PMID: 18397522. One of the watershed reports that summarize the major features and benefits, based on 68 scientific references.

Boden, G., et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Annals of Internal Medicine, 142 (2005): 403-411. In these 10 obese diabetics, a low-carb diet spontaneously reduced calorie consumption from 3100 daily to 2200, accounting for the weight loss—1.65 kg (3.63 pounds) in 14 days. Blood sugar levels improved dramatically and insulin sensitivity improved by 75%.

Daly, M.E., et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes—a randomized controlled trial. Diabetes Medicine, 23 (2006): 15-20. Compared with a low-fat/reduced-calorie diet, weight loss was much better in the low-carb group over three months, and HDL ratio improved.

Davis, Nichola, et al. Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes. Diabetes Care, 32 (2009): 1,147-1,152. The Atkins diet was superior—for weight loss and glycemic control—when measured at three months, when compliance by both groups was still probably fairly good. After one year, the only major difference they found was lower HDL cholesterol in the low-carb eaters. 

Elhayany, A., et al. A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Diabetes, Obesity and Metabolism, 12 (2010): 204-209. In overweight type 2 diabetics, a low-carbohydrate Mediterranean diet improved HDL cholesterol levels and glucose control better than either the standard Mediterranean diet or American Diabetes Association diet, according to Israeli researchers.

Haimoto, Hajime, et al. Effects of a low-carbohydrate diet on glycemic control in outpatients with severe type 2 diabetes. Nutrition & Metabolism, 6:21 (2009). DOI: 10.1186/1743-7075-6-21. A low-carbohydrate diet is just as effective as insulin shots for people with severe type 2 diabetes, according to Japanese investigators. Five of the seven patients on sulfonylurea were able to stop the drug. 

Nielsen, Jörgen and Joensson, Eva.  Low-carbohydrate diet in type 2 diabetes: stable improvement of body weight and glycemic control during 44 months follow-up. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-14. Obese people with type 2 diabetes following a 20% carbohydrate diet demonstrated sustained improvement in weight and blood glucose control, according to Swedish physicians. Proportions of carbohydrates, fat, and protein were 20%, 50%, and 30% respectively. Total daily carbs were 80-90 g. Hemoglobin A1c, a measure of diabetes control, fell from 8% to 6.8%. These doctors had previously demonstrated that a 20% carbohydrate diet was superior to a low-fat/55-60% carb diet in obese diabetes patients over six months.

Vernon, M., et al. Clinical experience of a carbohydrate-restricted diet: Effect on diabetes mellitus. Metabolic Syndrome and Related Disorders, 1 (2003): 233-238. This groundbreaking study demonstrated that diabetics could use an Atkins-style diet safely and effectively in a primary care setting.

Westman, Eric, et al. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-36. Duke University (U.S.) researchers demonstrated better improvement and reversal of type 2 diabetes with an Atkins-style diet, compared to a low-glycemic index reduced-calorie diet.

Yancy, William, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes [in men]. Nutrition & Metabolism, 2:34 (2005). DOI: 10.1186/1743-7075-2-34. A low-carb ketogenic diet in patients with type 2 diabetes was so effective that diabetes medications were reduced or discontinued in most patients. The authors recommend that similar dieters be under close medical supervision or capable of adjusting their own medication, because the diet lowers blood sugar  dramatically.

Yancy, W., et al. A pilot trial of a low-carbohydrate ketogenic diet in patients with type 2 diabetes.  Metabolic Syndrome and Related Disorders, 1 (2003): 239-244. This pioneering study used an Atkins Induction-style diet with less than 20 grams of carbohydrate daily.

So there!

Steve Parker, M.D.

h/t to Reijo Laatikainen for tweeting the European article.

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September 3, 2013 · 2:00 AM

Radiologist With Type 1 Diabetes Thrives on Very Low Carb Diet

"Put down the bread and no one will get hurt!"

“Put down the bread and no one will get hurt!”

ABC Radio provides the audio and transcript of an interview with Dr. Troy Stapleton, who was diagnosed with type 1 diabetes at age 41. Dr. Stapleton lives in Queensland, Australia. At the time of his diagnosis…

I was advised to eat seven serves of bread and cereals, two to three serves dairy, fruit, starchy vegetables, and to balance that intake with insulin. If you add up all those serves, they were recommending a diet of up to about 240 grams of carbohydrates a day, and to balance it with insulin. I was going to be the best patient, and there has been some important trials that show that if you do control your blood glucose well then you can reduce your incidence of the complications.

Dr. Stapleton believes we evolved on a very low carbohydrate diet; the Agricultural Revolution led to our current high carb consumption. He was concerned about the risk of hypoglycemia with standard diabetic diets.

There was a different approach where essentially you went on a very low carbohydrate diet, this made a little bit of sense to me. Why would I eat carbohydrates and then have to balance it with insulin?

Here’s what the diabetes educators told him:

What they say is you need to estimate the amount of carbohydrate you’re going to eat, and then you need to match that carbohydrate dose essentially with an insulin dose. So you sort of look at your food and you go, okay, I’m having 30 grams of carbohydrate and I need one unit of insulin per 15 grams of carbohydrate, so two units. It sounds really quite straightforward, except that it’s very, very difficult to estimate accurately the amount of carbohydrate you’re eating. The information on the packets can be out by 20%. Most people say that your error rate can be around 50%.

And then of course it changes with what you’ve eaten. So if you eat carbohydrates with fat and then you get delayed absorption, then that glucose load will come in, and then the type of carbohydrates will alter how quickly it comes in to your bloodstream. And then of course your insulin dose will vary, your absorption rate will vary by about 30%. Once you think through all the variables, it’s just not possible. You will be able to bring your blood glucose under control, but a lot of the time what happens is you get a spike in your glucose level immediately after a meal, and that does damage to the endothelium of your blood vessels…

Norman Swan: The lining.

Troy Stapleton: That’s correct, it causes an oxidative stress to your endothelium, and that is the damage that diabetes does, that’s why you get accelerated atherosclerosis.

Here’s what happened after he started eating very low carb:

It’s been amazing, it’s been the most remarkable turnaround for me and I just cut out carbohydrates essentially completely, although I do get some in green leafy vegetables and those sorts of things. My blood sugar average on the meter has gone from 8.4 [151 mg/dl] down to 5.3 [95 mg/dl]. My HbA1c is now 5.3, which is in the normal range. My blood pressure has always been good but it dropped down to 115 over 75. My triglycerides improved, my HDL improved, so my blood lipid profile improved. And I would now have a hypoglycaemic episode probably about once a month after exercise. [He was having hypoglycemia weekly on his prior high carb diet with carb counting insulin adjustments.]

He was able to reduce his insulin from about 27 units a day down to 6 units at night only (long-acting insulin)! He admits his low insulin dose may just reflect the “honeymoon period” some type 1s get early on after diagnosis.

Norman Swan: So when you talk to your diabetes educator now, what does he or she say?

Troy Stapleton: Look, they’re interested, but they’ll tell me things and I’ll say, well, that’s actually not true. I’m quite a difficult patient, Norman.

He says he’s eating an Atkins-style diet. Combining the transcript and his notes in the comments section:  1) he doesn’t eat potatoes or other starchy vegetables or bread, 2) he eats meat, eggs, lots of starchy vegetable, some berries and tree nuts, olives, and cheese, 3) an occasional wine or low-carb beer, 4) coffee, and 5) he eats under 50 g/day of carbohydrate, probably  under 30 g. This is a low-carb paleo diet except for the cheese, alcohol, and coffee.  Cheese, alcohol and coffee are (or can be) low-carb, but they’re not pure paleo.

He notes that…

There is an adaption period to a very low carbohydrate diet which takes 4-6 weeks (ketoadaption). During this time symptoms include mild headaches, lethargy, cramps, carb cravings and occasional light headedness. These symptoms all pass.

Read or listen to the whole thing. Don’t forget the comments section. All the blood sugars you see there are in mmol/l; convert them to mg/dl (American!) by multiplying by 18.

Steve Parker, M.D.

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August 30, 2013 · 5:45 AM

What’s HIIT and Why Should You Care?

A treadmill is one of many ways to do high-intensity interval training. Tabata's classic study used a stationary bicycle.

A treadmill is one of many ways to do high-intensity interval training. Tabata’s classic study used a stationary bicycle.

I found a free article by Martin Gibala,Ph.D., a major researcher into high-intensity interval training (HIIT).  He prefers to abbreviate it as HIT.

I don’t like to exercise, so I’ve been incorporating HIIT into my workouts for over a year.  It’s helped me maintain my level of fitness to that required of U.S. Army soldiers, without being a exercise fanatic. Why exercise if I don’t enjoy it? For the health and longevity benefits.

Here’s Gibala’s definition of HIIT:

High-intensity interval training is characterized by repeated sessions of relatively brief, intermittent exercise, often performed with an “all out” effort or at an intensity close to that which elicits peak oxygen uptake (i.e., ≥90% of VO2peak).

HIIT involves short sessions of very intense exercise about three times per week, for as little as 15 minutes.  That’s total time, not 15 minutes per session!  Yet you see a significant fitness improvement.  Be aware: the brief exercise bouts should be exhausting.

The Gibala article has all the scientific journal references you’d want, plus a suggested HIIT program for an absolute beginner.

One final quote from Dr. Gibala:

It is unlikely that high-intensity interval training produces all of the benefits normally associated with traditional endurance training. The best approach to fitness is a varied strategy that incorporates strength, endurance and speed sessions as well as flexibility exercises and proper nutrition. But for people who are pressed for time, high-intensity intervals are an extremely efficient way to train. Even if you have the time, adding an interval session to your current program will likely provide new and different adaptations. The bottom line is that — provided you are able and willing (physically and mentally) to put up with the discomfort of high-intensity interval training — you can likely get away with a lower training volume and less total exercise time.

Read the rest.

Steve Parker, M.D.

PS:  Why won’t Gibala give some credit to Izumi Tabata who did a pioneering study on HIIT in 1996?

PPS:  Gibala narrated this stationary bike HIIT video.

h/t Tony Boutagy

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August 25, 2013 · 11:34 PM

Should Diabetics Avoid or Seek Fruit?

Advanced Mediterranean Diet, paleo diet, paleobetic diet

Grapes probably destined for wine

Newly diagnosed type 2 diabetics have no need to avoid fruit …according to an article in Nutrition Journal.  Fruit is a prominent component of the Mediterranean and paleo diets.  It can be good for us, containing phytonutrients, fiber, etc.  But fruit has the potential to increase blood sugars, too, which may be harmful over the long run.  So whadda you do?

Researchers took newly diagnosed type 2 diabetics and split them into two groups. One group was told to eat at least two pieces of fruit daily, the other was told to eat no more than two pieces.

The researchers conclusions:

A recommendation to reduce fruit intake as part of standard medical nutrition therapy in overweight patients with newly diagnosed type 2 diabetes resulted in eating less fruit. It had however no effect on HbA1c, weight loss or waist circumference. We recommend that the intake of fruit should not be restricted in patients with type 2 diabetes.

Read the full research report.

PS: I haven’t read the full report yet.

Steve Parker, M.D.

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