Tag Archives: diabetes

Over Three Years, Gastric Bypass Beats Intensive Medical Therapy in Obese Type 2 Diabetes

…in terms of weight loss, lowering of HgbA1c, and weight-related quality of life. The specific gastric bypass surgery used in the study is the Roux-en-Y version.

bariatric surgery, Steve Parker MD

Band Gastric Bypass Surgery (not the only type of gastric bypass): very successful at “curing” T2 diabetes if you survive the operation

Average initial weight of participants was 104 kg (229 lb). Bypass patients dropped their weight by 25 kg (55 lb)and HgbA1c decreased by 1.8% (absolute decrease), compared to intensive medical management participants who lost 10.3 kg (32 lb) and dropped HgbA1c only by 0.4%.

I doubt that intensive medical therapy included a low-carb Mediterranean or paleo diet.

Source: Clinical and Patient-Centered Outcomes in Obese Patients With Type 2 Diabetes 3 Years After Randomization to Roux-en-Y Gastric Bypass Surgery Versus Intensive Lifestyle Management: The SLIMM-T2D Study | Diabetes Care

 

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When Is the Hemoglobin A1c Test Misleading?

From 97 to 90 mg/dl

Not the only way to assess glucose control

Can you believe I’ve had patients show me a week’s worth of home glucose tests showing great numbers, tell me they’ve been that good for the last three months, and then I find a sky high hemoglobin A1c test? How can that be? Sometimes the patient, usually a young one, is trying to pull the wool over my eyes. But there are other potential explanations.

Hemglobin A1c (or HgbA1c) is a standard measure of glucose control, or lack thereof, over the three months preceding the blood test.

It’s also used for diagnosis of diabetes and prediabetes. Levels between 5.7 and 6.4% suggest prediabetes. Levels of 6.5% of higher indicate diabetes.

Hemoglobin is the oxygen-carrying protein in red blood cells. HgbA1c tells us if many sugar molecules are stuck to the hemoglobin, a process called glycosylation. HgbA1c is sometimes referred to as glycated hemoglobin. About half of the HgbA1c value is determined by blood sugar levels in the month before the blood draw.

But the HgbA1c test isn’t always an accurate reflection of blood sugar levels.

Many factors unrelated to serum glucose (sugar) levels can alter the HgbA1c value. Here they are:

Pregnancy

Pregnant women tend to have lower than average HgbA1c.

Certain Types of Anemia

Iron-deficiency anemia may yield falsely low or high HgbA1c, depending on whether it’s being treated or not.

Acute bleeding and hemolytic anemia give falsely low HbA1c values.

The unifying feature here is that young red blood cells, called reticulocytes, take some time to get glycosylated.

Lack of a Spleen 

HgbA1c will be falsely high. Your spleen removes old red blood cells. Not having a spleen increases the life span of red blood cells, so they can accumulate more glucose molecules.

Various Hemoglobin Types or Congenital Abnormalities

Hemoglobin S and hemoglobin C may lead to deceptively low HgbA1c. Hemoglobin F tends to overestimate.

Blood Transfusions

Recent red blood cell transfusions will lower the HgbA1c if it was elevated to begin with, especially if lots of blood is transfused.

Renal Failure

It’s complicated; talk to your kidney specialist.

Chronic Disease

HgbA1c values can be unreliable in chronic alcoholism, chronic narcotic users, severely high triglyceride or bilirubin levels, kidney failure, vitamin and mineral deficiencies (particularly the vitamins and minerals needed to make red blood cells).

Race

Hispanics, Asians, and Blacks tend to have higher HgbA1c’s than Whites who have the same blood sugar levels. The difference is about 0.3% (absolute, not relative.

Wild Glycemic Excursions

What’s this? You might call it labile diabetes: dramatic swings between sugars too low and way too high. For example, this patient may have daily glucose swings between 40 and 210 mg/dl (2.2  and 11.7 mmol/l). His HgbA1c may turn out near normal or acceptable, but many experts worry that the wild oscillations may contribute to diabetic microvascular complications like eye and kidney disease.

Are There Alternatives to HgbA1c?

Yes. If you think the HgbA1c test is inaccurate, consider other tests such as continuous glucose monitoring, fructosamine, glycated albumin, 1,5-anhydroglucitol, and more frequent home glucose monitoring.

Steve Parker, M.D.

Reference: Bazerbachi, F., et al. Is hemoglobin A1c an accurate measure of glycemic control in all diabetic patients? Cleveland Clinic Journal of Medicine, vol. 81, #3, March 2014: 146-149

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Are You Visiting This Site From India?

Gadi Sagar temple on Gadisar lake at sunset, Jaisalmer, India

Gadi Sagar temple on Gadisar Lake, Jaisalmer, Rajasthan, India

I’ve been surprised by how many blog visitors I get from India—often more than I see from U.K, Canada, or Australia.

If you’re Indian, is there anything in particular you’d like to see me address here? Leave a comment below or email me at steveparkermd AT gmail.com. Thank you.

Steve Parker, M.D.

PS: Please let me know if you are aware of a good source of low-carb Indian recipes in English. I have a growing interest in curries.

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Is the Vegetarian Diet Good for Diabetes?

low-carb diet, spaghetti squash, paleobetic diet, diabetic diet

These can be part of a low-carb vegetarian diet

The answer to the headline question is: Maybe.

I was surprised to learn that well-known diabetes writer David Mendosa (Type 2 DM) has switched from a very low-carb diet to a low-carb vegetarian diet, eating no more than 50 grams/day of carbohydrate. Why?

For me the issue is that I don’t want to be responsible for harming sentient beings as much as I can avoid it while still following a healthy diet.

I respect that sentiment.

I’m sure David is monitoring the effects of the diet on his blood sugars and weight. Probably his blood lipids, too.

It sounds like all David had to do was drop fish from his prior diet. He still eats eggs (whites only?), cheese, and full-fat yogurt, so I’d call him a lacto-ovo-vegetarian.

If you’re already convinced that you know the perfect diet for people with diabetes, read no further.

What Is a Vegetarian Diet?

From UpToDate.com:

Vegetarian diets vary considerably depending on the degree of dietary restrictions. According to the strictest definition, a vegetarian diet consists primarily of cereals, fruits, vegetables, legumes, and nuts; animal foods, including milk, dairy products, and eggs generally are excluded. Several less restrictive vegetarian diets may include eggs and dairy products. Some vegetarian diets may be grouped as follows:

●Macrobiotic — Vegetables, fruits, legumes, and seaweeds are included in the diet, while whole grains, especially brown rice, are also emphasized. Locally-grown fruits are recommended. Animal foods limited to white meat or white-meat fish may be included in the diet once or twice a week.
●Semi-vegetarian — Meat occasionally is included in the diet. Some people who follow such a diet may not eat red meat but may eat fish and perhaps chicken.
●Lacto-ovovegetarian — Eggs, milk, and milk products (lacto = dairy; ovo = eggs) are included, but no meat is consumed.
●Lactovegetarian — Milk and milk products are included in the diet, but no eggs or meat are consumed.
●Vegan — All animal products, including eggs, milk, and milk products, are excluded from the diet. Some vegans do not use honey and may refrain from using animal products such as leather or wool. They also may avoid foods that are processed or not organically grown.

A 2012 poll estimated that 7% of U.S. adults eat at least one meal a week that does not include meat, fish or poultry, 4% do not eat meat, fish, or poultry, and 1–2% do not eat meat, fish, poultry, dairy products, or eggs. Roughly 5% of individuals in the UK, Germany, and Australia describe themselves as vegetarian.

Switching to the paleo diet often leads to increased vegetable and fruit consumption

Are Vegetarian Diets Safe?

Vegetarians need to be careful to get enough high-quality protein, iron, vitamin B12, vitamin D, and perhaps calcium. B12 comes only from animal products, as far as I know. You can make vitamin D by exposing your skin to sufficient sunlight. Some vegetarians will need to consult a dietitian to ensure adequate nutrition. (BTW, all my comments about vegetarian diets apply to adults only—I don’t treat children, so I’m not up-to-date on their nutritional needs.)

I’ve written about vegetarian diets for diabetes before: here and here. Dr. Michael Greger couldn’t convince Dr. Harriet Hall (or me) that we should avoid eating all animal products.

The Grashow Question

Someone claiming to be Charles Grashow left a comment on one of my blogs:

As I’ve posted before, this [vegetarian macrobiotic diet] took Insulin Dependent T2D [patients] OFF MEDS within 21 days!

Seems much better – but then again this diet is vegan not paleo!

http://www.hoajonline.com/internalmedicine/2052-6954/2/3
Ma-Pi 2 macrobiotic diet intervention during 21 days in adults with type 2 diabetes mellitus, Ghana 2011

http://www.nutritionandmetabolism.com/content/11/1/39
The effect of the macrobiotic Ma-Pi 2 diet vs. the recommended diet in the management of type 2 diabetes: the randomized controlled MADIAB trial

http://www.hindawi.com/journals/jnme/2012/856342/
Medium- and Short-Term Interventions with Ma-Pi 2 Macrobiotic Diet in Type 2 Diabetic Adults of Bauta, Havana

SO – my question is this. Why do you not recommend this type of diet instead? Or does it not fit into your paradigm?

I responded:

Charles, that macrobiotic Ma-Pi 2 diet looks like it has significant potential. I quickly scanned your first link only. For those not familiar with the diet, here’s a description from your first link:

“Vegetarian Ma-Pi 2 macrobiotic diet, designed especially by Mario Pianesi for treating diabetic patients. Total volume of the Ma-Pi 2 diet consisted of 40–50% whole grains (rice, millet and barley), 35–40% vegetables (carrots, savoy cabbage, cabbage, chicory, onions, red radish, parsley), and 8% legumes (adzuki beans, chickpeas, lentils, black beans). As a complement we used gomasio (roasted ground sesame seeds with unrefined sea salt), fermented products (miso, tamari, umeboshi) and seaweeds (kombu, wakame, nori). Bancha tea (theine-free green tea) was the main liquid diet.”

“The assayed Ma-Pi 2 diet is lower in energy than the traditional one recommended for diabetic patients, but safe, with adequate satiating effect due to the high fiber content, adequate in protein (12% of the total energy), with an acceptable amino acid score, low in fat (15% of the total energy), and high in complex carbohydrates (73%). The diet has a high antioxidant capacity and a high content of bioactive compounds with recognized functional properties (Table 2). Foods were elaborated by culinary macrobiotic specialists from UPM, Italy, and offered at the hospital during breakfast, lunch, dinner and snacks. Unfortunately, the variety of vegetables was restricted because of limited availability.”

I wonder if that would be deficient in vitamin B12.

It looks like it would be worth a try for a type 2 diabetic under medical supervision (some risk of hypoglycemia). I’d like to try a few meals with those ingredients, some of which I’ve never heard of, prepared by someone who knows what they’re doing. Unless I missed it in the link, it might be hard for the average person to replicate that study diet. If I understood correctly, the study participants stayed in a hospital for three weeks and meals were prepared for them.

I don’t have time to hit the other links right now.

-Steve

My Current Stance on Vegetarian Diets For Diabetes

I say “current stance” because I’ll change my mind based on scientific evidence as it becomes available.

I’m not convinced that any of the vegetarian diets is clearly superior to the other available “diabetic diets” in terms of quality of life, longevity, and avoidance of diabetes complications.

We have some evidence that some vegetarian diets may help control diabetic blood sugars and help reduce the need for diabetes medications, at least short-term.

If my diabetic patients want to try a vegetarian diet, I have no objections as long as these criteria are met:

  • it’s a well-designed diet that provides adequate nutrition (which may require a dietitian consultation)
  • blood sugars, hemoglobin A1c, body weight, and blood lipids are monitored periodically
  • the patient is able and willing to self-monitor blood sugars fairly frequently
  • physician oversight, especially for those taking diabetes drugs

Vegetarian diets can be very high in carbohydrate content, which potentially could wreck blood sugar control. If that happens, consider a vegetarian diet with fewer starches and sugars.

Steve Parker, M.D.

PS: Did  you catch that the Ma-Pi 2 diet is “lower in energy than the traditional one recommended for diabetic patients…”? That means a reduced-calorie diet. Drop calories enough on most any diet, and you’ll likely see lower serum glucose levels, reduced triglycerides (and perhaps other lipid improvements), and loss of excess weight.

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Is Diabetes Caused by Poor Regulation of Glucagon?

From Shutterstock.com

Glucagon is produced in the alpha cells and works to increase blood sugar levels. Insulin is from the beta cells.

Most folks assume that the hormone called insulin is at the heart of diabetes: either there’s not enough of it or it’s not working right.

But thats’s not the only possible mechanism for diabetes. I’ve written several times here about the glucagon-centric theory of diabetes, which is most closely associated with Roger Unger, M.D. If you’re interested in a scientific review article on glucagon and type 2 diabetes, here’s one:

Reference: Xiao C. Li and Jia L. Zhuo. Current Insights and New Perspectives on the Roles of Hyperglucagonemia in Non Insulin-dependent Type 2 DiabetesCurrent Hypertension Reports. Oct 2013; 15(5): 10.1007/s11906-013-0383-y.  doi: 10.1007/s11906-013-0383-y

Steve Parker, M.D.

low-carb mediterranean diet

Front cover of book

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Recipe: Fruit Smoothie #1

 

A 12 fl oz serving

A 12 fl oz serving

Smoothies are a great substitute for junk food desserts. My wife has been experimenting with them. Most Americans should probably eat more fruit; smoothies are one way to do that. Here’s one she made up. Note the trendy chia seeds and kale (or is that fad over?).

Since I provide the nutritional analysis below, you can easily incorporate this smoothie into a diabetic diet. Total digestible carb grams are 32; if that’s too much, cut the portion in half.

We’re using a Vitamix mixer. Other devices may be able to get the job done. The mixing speeds our device range from one to 10. (Tip for a competitor: make one that goes to 11.) We love our Vitamix and have no regrets about the purchase. It is hard to hear anything else when it’s running at top speed.

One potential advantage of blending these fruits is that one fruit may provide nutrients that the others lack

One potential advantage of blending these fruits is that one fruit may provide nutrients that the others lack

Ingredients

1 cup (240 ml) grapes, green seedless

1 mandarin orange, peeled, halved

1 banana (7 inches or 18 cm), peeled, cut into 3–4 pieces

1 pear, medium-size, cored, quartered (ok to leave peel on)

1/2 tbsp (7 g) chia seeds

1 cup (50 g) raw kale

Instructions

First put the water in the Vitamix, then grapes, pear, orange, banana, chia seeds, kale, and finally ice. Ice is always last. Then blend on variable speed 1 and gradually go up to high level (10). Total spin time is about 45 seconds.

Full speed ahead!

Full speed ahead!

Number of Servings: 2.5 consisting of 12 fl oz (350 ml) each.

Nutritional Analysis per Serving:

7% fat

88% carbohydrate

5% protein

160 calories

38 g carbohydrate

6 g fiber

32 g digestible carbohydrate

15 mg sodium

520 mg potassium

Prominent features: Good source of vitamin C, fair amount of fiber, miniscule sodium.

Steve Parker, M.D.

 

 

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Endocrine-Disrupting Chemicals May Cause T2 Diabetes and Obesity

See text for mention of pancreatic alpha and beta cells

See text for mention of pancreatic alpha and beta cells

A panel of university-based scientists convened by The Endocrine Society recently reviewed the available literature on health effects of endocrine-disrupting chemicals (aka EDCs). The executive summary is available free online. Some excerpts:

The full Scientific Statement represents a comprehensive review of the literature on seven topics for which there is strong mechanistic, experimental, animal, and epidemiological evidence for endocrine disruption, namely: obesity and diabetes, female reproduction, male reproduction, hormone-sensitive cancers in females, prostate cancer, thyroid, and neurodevelopment and neuroendocrine systems. EDCs such as bisphenol A, phthalates, pesticides, persistent organic pollutants such as polychlorinated biphenyls, polybrominated diethyl ethers, and dioxins were emphasized because these chemicals had the greatest depth and breadth of available information.

*  *  *

Both cellular and animal models demonstrate a role for EDCs in the etiology of obesity and T2D [type 2 diabetes]. For obesity, animal studies show that EDC-induced weight gain depends on the timing of exposure and the age of the animals. Exposures during the perinatal period [the weeks before and after birth] trigger obesity later in life. New results covering a whole range of EDC doses have underscored the importance of nonmonotonic dose-response relationships; some doses induced weight increase, whereas others did not. Furthermore, EDCs elicit obesity by acting directly on white adipose tissue, al- though brain, liver, and even the endocrine pancreas may be direct targets as well.

Regarding T2D, animal studies indicate that some EDCs directly target 􏰁beta and alpha cells in the pancreas, adipocytes, and liver cells and provoke insulin resistance together with hyperinsulinemia. These changes can also be associated with altered levels of adiponectin and leptin— often in the absence of weight gain. This diabetogenic action is also a risk factor for cardiovascular diseases, and hyperinsulinemia can drive diet-induced obesity. Epide- miological studies in humans also point to an association between EDC exposures and obesity and/or T2D; however, because many epidemiological studies are cross-sectional, with diet as an important confounding factor in humans, it is not yet possible to infer causality.

RTWT.

Bix at Fanatic Cook blog says foods of animal origin are the major source of harmful persistent organic pollutants, some of which act as ECDs.

Keep your eyes and ears open for new research reports on this critically important topic.

Steve Parker, M.D.

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