Tag Archives: hypoglycemia

November 8, 2017 · 4:25 AM

Tips on Fasting From Dr. Fung, But Beware Hypoglycemia

This guy had long spans of time between meals, perhaps days

This guy had long spans of time between meals, perhaps days

Yet another good post from DietDoctor! Why fast? Among many reasons is that fasting turns on autophagy, which helps clear the debris of daily living out of your cells, probably leading to longer life.

Click here for P.D. Mangan’s post on fasting and autophagy.

Dr. Fung at DietDoctor also warns about the danger of hypoglycemia for certain folks with diabetes. Read that part carefully (click the Source link below).

Anyway, here are Dr. Fung’s top eight tips (direct quotes):

  • Drink water: Start each morning with a full eight-ounce glass of water.
  • Stay busy: It’ll keep your mind off food. It often helps to choose a busy day at work for a fast day.
  • Drink coffee: Coffee is a mild appetite suppressant. Green tea, black tea, and bone broth may also help.
  • Ride the waves: Hunger comes in waves; it is not continuous. When it hits, slowly drink a glass of water or a hot cup of coffee. Often by the time you’ve finished, your hunger will have passed.
  • Don’t tell anybody you are fasting: Most people will try to discourage you, as they do not understand the benefits. A close-knit support group is often beneficial, but telling everybody you know is not a good idea.
  • Give yourself one month: It takes time for your body to get used to fasting. The first few times you fast may be difficult, so be prepared. Don’t be discouraged. It will get easier.
  • Follow a nutritious diet on non-fast days: Intermittent fasting is not an excuse to eat whatever you like. During non-fasting days, stick to a nutritious diet low in sugars and refined carbohydrates.
  • Don’t’ binge: After fasting, pretend it never happened. Eat normally, as if you had never fasted.

Source: More Practical Tips for Fasting – Diet Doctor

Steve Parker, M.D.

PS: I don’t feature fasting in any of my books, but I’ve gradually come around to seeing the potential benefits.

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February 3, 2016 · 6:12 PM

Which Diabetes Drugs Cause Hypoglycemia?

Hypoglycemia—aka low blood sugar—can kill you. The most common cause is medications taken by people with diabetes.

DRUGS THAT RARELY, IF EVER, CAUSE HYPOGLYCEMIA

Diabetics not being treated with pills or insulin rarely need to worry about hypoglycemia. That’s usually true also for prediabetics. Yes, some type 2 diabetics control their condition with diet and exercise alone, without drugs.

Similarly, diabetics treated only with diet, metformin, colesevalam, sodium-glucose co-transport 2 inhibitor (SGLT2 inhibitor), and/or an alpha-glucosidase inhibitor (acarbose, miglitol) should not have much, if any, trouble with hypoglycemia. The DPP4-inhibitors (sitagliptan and saxagliptin) do not seem to cause low glucose levels, whether used alone or combined with metformin or a thiazoladinedione. Thiazolidinediones by themselves cause hypoglycemia in only 1 to 3% of users, but might cause a higher percentage in people on a reduced calorie diet. Bromocriptine may slightly increase the risk of hypoglycemia. GLP-1 analogues rarely cause hypoglycemia, but they can.

DRUGS THAT CAUSE HYPOGLYCEMIA

Regardless of diet, diabetics are at risk for hypoglycemia if they use any of the following drug classes. Also listed are a few of the individual drugs in some classes:

  • insulins
  • sulfonylureas: glipizide, glyburide, glimiperide, chlorpropamide, acetohexamide, tolbutamide
  • meglitinides: repaglinide, nateglinide
  • pramlintide plus insulin
  • possibly GLP-1 analogues
  • GLP-1 analogues (exanatide, liragultide, albiglutide, dulaglutide) when used with insulin, sufonylureas, or meglitinides
  • possibly thiazolidinediones: pioglitazone, rosiglitazone
  • possibly bromocriptine

BECOME THE EXPERT ON YOUR OWN DRUGS

If you take drugs for diabetes, you need to be your own pharmaceutical expert. Don’t depend solely on your physician or pharmacist. Your doctor has to be familiar with 150–200 drugs, and the pharmacist, even more. You only need to master two or three, I hope. Here are important things to know about your drugs:

  • interactions with other drugs or supplements you take, whether prescription or over-the-counter
  • how to monitor for drug toxicity (e.g., periodic blood tests)
  • potential adverse effects
  • is the money-saving generic just as good as the brand-name drug
  • what’s the maximum dose and how often can the dose be adjusted
  • if you take a brand-name drug, what’s the generic name

Steve Parker, M.D.

low-carb mediterranean diet

Front cover of book

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December 21, 2014 · 12:28 AM

Could Glucagon Be Just as Important as Insulin in Diabetes?

I couldn't find a pertinent picture

I couldn’t find a pertinent picture

Everybody knows that insulin is the key hormone gone haywire in diabetes, right? Did you know it’s not the only one out of whack? Roger Unger and Alan Cherrington in The Journal of Clinical Investigation point out that another hormone—glucagon—is also very important in regulation of blood sugar in both types of diabetes.

Insulin has a variety of actions the ultimately keep blood sugar levels from rising dangerously high. Glucagon, on the other hand, keeps blood sugar from dropping too low. For instance, when you stop eating food, as in an overnight or longer fast, glucagon stimulates glucose (sugar) production by your liver so you don’t go into a hypoglycemic coma and die. It does the same when you exercise, as your muscles soak up glucose from your blood stream.

Glucagon works so well to raise blood sugar that we inject it into diabetics who are hypoglycemic but comatose or otherwise unable to swallow carbohydrates.

Glucagon also has effects on fatty acid metabolism, ketone production, and liver protein metabolism, but this post is already complicated enough.

So where does glucagon come from? The islets of Langherhans, for one. You already know the healthy pancreas has beta cells that produce insulin. The pancreas has other cells—alpha or α cells—that produce glucagon. Furthermore, the stomach and duodenum (the first part of the small intestine) also have glucagon-producing alpha cells. The insulin and glucagon work together to keep blood sugar in an fairly narrow range. Insulin lowers blood sugar, glucagon raises it. It’s sort of like aiming for a hot bath by running a mix of cold and very hot water.

Update: I just licensed this from Shutterstock.com

Update: I just licensed this from Shutterstock.com

Ungar and Cherrington say that one reason it’s so hard to tightly control blood sugars in type 1 diabetes is because we don’t address the high levels of glucagon. The bath water’s not right because we’re fiddling with just one of the faucets. Maybe we’ll call this the Goldilocks Theory of Diabetes.

When you eat carbohydrates, your blood sugar starts to rise. Beta cells in the healthy pancreas start secreting insulin to keep a lid on the blood sugar rise. This is not the time you want uncontrolled release of glucagon from the alpha cells, which would work to raise blood sugars further. Within the pancreas, beta and alpha cells are in close proximity. Insulin from the beta cells directly affects the nearby alpha cells to suppress glucagon release. This localized hormone effect is referred to as “paracrine guidance” in the quote below, and it takes very little insulin to suppress glucagon.

From the Ungar and Cherrington article:

Here, we review evidence that the insulinocentric view of metabolic homeostasis is incomplete and that glucagon is indeed a key regulator of normal fuel metabolism, albeit under insulin’s paracrine guidance and control. Most importantly, we emphasize that, whenever paracrine control by insulin is lacking, as in T1DM, the resulting unbridled hyperglucagonemia is the proximal cause of the deadly consequences of uncontrolled diabetes and the glycemic volatility of even “well-controlled” patients.

*  *  *

All in all, it would seem that conventional monotherapy with insulin is incomplete because it can provide paracrine suppression of glucagon secretion only by seriously overdosing the extrapancreatic tissues.

So What?

Elucidation of diabetes’ disease mechanisms (pathophysiology) can lead to new drugs or other therapies that improve the lives of diabetics. A potential drug candidate is leptin, known to suppress glucagon hyper secretion in rodents with type 1 diabetes.

RTWT.

Steve Parker, M.D.

PS: Amylin is yet another hormone involved in blood sugar regulation, but I’ll save that for another day. If you can’t wait, read about it here in my review of pramlintide, a drug for type 1 diabetes.

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October 13, 2013 · 8:37 PM

Exercise Issues for the PWD (Person With Diabetes)

People with diabetes may have specific issues that need to be taken into account when exercising.

DIABETIC RETINOPATHY

Photo of the retina at the back of the eyeball

Photo of the retina at the back of the eyeball

Retinopathy, an eye disease caused by diabetes, increases risk of retinal detachment and bleeding into the eyeball called vitreous hemorrhage. These can cause blindness. Vigorous aerobic or resistance training may increase the odds of these serious eye complications. Patients with retinopathy may not be able to safely participate. If you have any degree of retinopathy, avoid the straining and breath-holding that is so often done during weightlifting or other forms of resistance exercise. Vigorous aerobic exercise may also pose a risk. By all means, check with your ophthalmologist first. You don’t want to experiment with your eyes.

DIABETIC FEET AND PERIPHERAL NEUROPATHY

Diabetics are prone to foot ulcers, infections, and ingrown toenails, especially if peripheral neuropathy (numbness or loss of sensation) is present. Proper foot care, including frequent inspection, is more important than usual if a diabetic exercises with her feet. Daily inspection should include the soles and in-between the toes, looking for blisters, redness, calluses, cracks, scrapes, or breaks in the skin. See your physician or podiatrist for any abnormalities. Proper footwear is important (for example, don’t crowd your toes). Dry feet should be treated with a moisturizer regularly. In cases of severe peripheral neuropathy, non-weight-bearing exercise (e.g., swimming or cycling) may be preferable. Discuss with your physician or podiatrist.

HYPOGLYCEMIA

Low blood sugars are a risk during exercise if you take diabetic medications in the following classes: insulins, sulfonylureas, meglitinides, and possibly thiazolidinediones and bromocriptine.

Are you sure your symptoms are from hypoglycemia?

Are you sure your symptoms are from hypoglycemia?

Hypoglycemia is very uncommon with thiazolidinediones. Bromocriptine is so new (for diabetes) that we have little experience with it; hypoglycemia is probably rare or non-existent. Diabetics treated with diet alone or other medications rarely have trouble with hypoglycemia during exercise.

Always check your blood sugar before an exercise session if you are at risk for hypoglycemia. Always have glucose tablets, such as Dextrotabs, available if you are at risk for hypoglycemia. Hold off on your exercise if your blood sugar is over 200 mg/dl (11.1 mmol/l) and you don’t feel well, because exercise has the potential to raise blood sugar even further early in the course of an exercise session.

As an exercise session continues, active muscles may soak up bloodstream glucose as an energy source, leaving less circulating glucose available for other tissues such as your brain. Vigorous exercise can reduce blood sugar levels below 60 mg/dl (3.33 mmol/l), although it’s rarely a problem in non-diabetics.

The degree of glucose removal from the bloodstream by exercising muscles depends on how much muscle is working, and how hard. Vigorous exercise by several large muscles will remove more glucose. Compare a long rowing race to a slow stroll around in the neighborhood. The rower is strenuously using large muscles in the legs, arms, and back. The rower will pull much more glucose out of circulation. Of course, other metabolic processes are working to put more glucose into circulation as exercising muscles remove it. Carbohydrate consumption and diabetic medications are going to affect this balance one way or the other.

If you are at risk for hypoglycemia, check your blood sugar before your exercise session. If under 90 mg/dl (5.0 mmol/l), eat a meal or chew some glucose tablets to prevent exercise-induced hypoglycemia. Re-test your blood sugar 30–60 minutes later, before you exercise, to be sure it’s over 90 mg/dl (5.0 mmol/l). The peak effect of the glucose tablets will be 30–60 minutes later. If the exercise session is long or strenuous, you may need to chew glucose tablets every 15–30 minutes. If you don’t have glucose tablets, keep a carbohydrate source with you or nearby in case you develop hypoglycemia during exercise.

Re-check your blood sugar 30–60 minutes after exercise since it may tend to go too low.

For myself, I prefer high intensity interval training (HIIT) over long slow cardio (aerobics)

For myself, I prefer high intensity interval training (HIIT) over long slow cardio (aerobics)

If you are at risk of hypoglycemia and performing moderately vigorous or strenuous exercise, you may need to check your blood sugar every 15–30 minutes during exercise sessions until you have established a predictable pattern. Reduce the frequency once you’re convinced that hypoglycemia won’t occur. Return to frequent blood sugar checks when your diet or exercise routine changes.

These general guidelines don’t apply across the board to each and every diabetic. Our metabolisms are all different. The best way to see what effect diet and exercise will have on your glucose levels is to monitor them with your home glucose measuring device, especially if you are new to exercise or you work out vigorously. You can pause during your exercise routine and check a glucose level, particularly if you don’t feel well. Carbohydrate or calorie restriction combined with a moderately strenuous or vigorous exercise program may necessitate a 50 percent or more reduction in your insulin, sulfonylurea, or meglitinide. Or the dosage may need to be reduced only on days of heavy workouts. Again, enlist the help of your personal physician, dietitian, diabetes nurse educator, and home glucose monitor.

Finally, insulin users should be aware that insulin injected over muscles that are about to be exercised may get faster absorption into the bloodstream. Blood sugar may then fall rapidly and too low. For example, injecting into the thigh and then going for a run may cause a more pronounced insulin effect compared to injection into the abdomen or arm.

AUTONOMIC NEUROPATHY

His heart's on fire!

His heart’s on fire! (My son made this)

This issue is pretty technical and pertains to function of automatic, unconscious body functions controlled by nerves. These reflexes can be abnormal, particularly in someone who’s had diabetes for many years, and are called autonomic neuropathy. Take your heart rate, for example. It’s there all the time, you don’t have to think about it. If you run to catch a bus or climb two flights of stairs, your heart rate increases automatically to supply more blood to exercising muscles. If that automatic reflex doesn’t work properly, exercise is more dangerous, possibly leading to passing out, dizziness, and poor exercise tolerance. Other automatic nerve systems control our body temperature regulation (exercise may overheat you), stomach emptying (your blood sugar may go too low), and blood pressure (it could drop too low). Only your doctor can tell for sure if you have autonomic neuropathy.

GETTING STARTED

I’ve run out of time today. For ideas, scan some of the articles under the Exercise category in the far right panel. FYI, here’s what I’m doing, but it’s not a good place for rank beginners to start. If you want to being resistance training, strongly consider some sessions with a personal trainer.

Steve Parker, M.D.

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February 4, 2013 · 2:00 AM

How To Recognize and Treat Hypoglycemia (Low Blood Sugar)

Insulin and sulfonylurea drugs are common causes of hypoglycemia

Insulin and sulfonylurea drugs are common causes of hypoglycemia

Hypoglycemia is the biggest immediate risk for a diabetic on drugs starting a carbohydrate-restricted diet such as the Low-Carb Mediterranean Diet. Traditional calorie-restricted diets also have the potential to cause hypoglycemia.

SYMPTOMS

Your personal physician and other healthcare team members should teach you how to recognize and manage hypoglycemia.  Hypoglycemial means an abnormally low blood sugar (under 60–70 mg/dl or 3.33–3.89 mmol/l) associated with symptoms such as weakness, malaise, anxiety, irritability, shaking, sweating, hunger, fast heart rate, blurry vision, difficulty concentrating, or dizziness. Symptoms often start suddenly and without obvious explanation. If not recognized and treated, hypoglycemia can lead to incoordination, altered mental status (fuzzy thinking, disorientation, confusion, odd behavior, lethargy), loss of consciousness, seizures, and even death (rare).

You can imagine the consequences if you develop fuzzy thinking or lose consciousness while driving a car, operating dangerous machinery, or scuba diving.

TREATMENT

Immediate early stage treatment involves ingestion of glucose as the preferred treatment—15 to 20 grams. You can get glucose tablets or paste at your local pharmacy without a prescription. Other carbohydrates will also work: six fl oz (180 ml) sweetened fruit juice, 12 fl oz (360 ml) milk, four tsp (20 ml) table sugar mixed in water, four fl oz (120 ml) soda pop, candy, etc. Fifteen to 30 grams of glucose or other carbohydrate should do the trick. Hypoglycemic symptoms respond within 20 minutes.

If level of consciousness is diminished such that the person cannot safely swallow, he will need a glucagon injection. Non-medical people can be trained to give the injection under the skin or into a muscle. Ask your doctor if you are at risk for severe hypoglycemia. If so, ask him for a prescription so you can get an emergency glucagon kit from a pharmacy.

Some people with diabetes, particularly after having the condition for many years, lose the ability to detect hypoglycemia just by the way they feel. This “hypoglycemia unawareness” is obviously more dangerous than being able to detect and treat hypoglycemia early on. Blood sugar levels may continue to fall and reach a life-threatening degree. Hypoglycemia unawareness can be caused by impairment of the nervous system (autonomic neuropathy) or by beta blocker drugs prescribed for high blood pressure or heart disease. People with hypoglycemia unawareness need to check blood sugars more frequently, particularly if driving a car or operating dangerous machinery.

Do not assume your sugar is low every time you feel a little hungry, weak, or anxious. Use your home glucose monitor for confirmation when able.

If you do experience hypoglycemia, discuss management options with your doctor: downward medication adjustment, shifting meal quantities or times, adjustment of exercise routine, eating more carbohydrates, etc. If you’re trying to lose weight or control high blood sugars, reducing certain diabetic drugs makes more sense than eating more carbs. Eating at regular intervals three or four times daily may help prevent hypoglycemia. Spreading carbohydrate consumption evenly throughout the day may help. Someone most active during daylight hours as opposed to nighttime will generally do better eating carbs at breakfast and lunch rather than concentrating them at bedtime.

DRUG  ADJUSTMENTS  TO  AVOID  HYPOGLYCEMIA

Diabetics considering or following a low-carb or very-low-carb ketogenic diet must work closely with their personal physician and dietitian, especially to avoid hypoglycemia caused by certain classes of diabetic drugs. Two common diabetes drug classes that cause hypoglycemia are the insulins and sulfonylureas. More are listed below. Those who don’t know the class of their diabetic medication should ask their physician or pharmacist.

Clinical experience with thousands of patients has led to generally accepted guidelines that help avoid hypoglycemia in diabetics on medications.

Diabetics and prediabetics not being treated with pills or insulin rarely need to worry about hypoglycemia.

Similarly, diabetics treated only with diet, metformin, colesevalam, and/or an alpha-glucosidase inhibitor (acarbose, miglitol) should not have much, if any, trouble with hypoglycemia. The DPP4-inhibitors (sitagliptan and saxagliptin) do not seem to cause low glucose levels, whether used alone or combined with metformin or a thiazoladinedione.

Thiazolidinediones by themselves cause hypoglycemia in only 1 to 3% of users, but might cause a higher percentage in people on a reduced calorie diet. Bromocriptine may slightly increase the risk of hypoglycemia.

THESE DRUGS MAY CAUSE HYPOGLYCEMIA

Type 2 diabetics are at risk for hypoglycemia if they use the following drug classes. Also listed are a few of the individual drugs in some classes:

■  insulin

■  sulfonylureas: glipizide, glyburide, glimiperide, chlorpropamide, acetohexamide, tolbutamide

■  meglitinides: repaglinide, nateglinide

■  pramlintide plus insulin

■  exenatide plus sulfonylurea

■  possibly thiazolidinediones: pioglitazone, rosiglitazone

■  possibly bromocriptine

Open wide!

Open wide!

Remember, drugs have both generic and brand names. The names vary from country to country, as well as by manufacturer. If you have any doubt about whether your diabetic drug has the potential to cause hypoglycemia, ask your physician or pharmacist.

MANAGEMENT STRATEGIES TO AVOID HYPOGLYCEMIA

Common management strategies for diabetics on the preceding drugs and starting a very-low-carb diet include:

■  reduce the insulin dose by half

■  change short-acting insulin to long-acting (such as glargine)

■  stop the sulfonylurea, or reduce dose by half

■  reduce the thiazolidinedione by half

■  stop the meglitinide, or reduce the dose by half

■  monitor blood sugars frequently, such as four times daily, at least until a stable pattern is established

■  spread what few carbohydrates are eaten evenly throughout the day

Management also includes frequent monitoring of glucose levels with a home glucose monitor, often four to six times daily. Common measurement times are before meals and at bedtime. It may be helpful to occasionally wake at 3 AM and check a sugar level. To see the effect of a particular food or meal on glucose level, check it one or two hours after eating. Keep a record. When eating patterns are stable, and blood sugar levels are reasonable and stable, monitoring can be done less often. When food consumption or exercise habits change significantly, check sugar levels more often.

If you’re thinking that many type 2 diabetics on low-carb and very-low-carb ketogenic diets use fewer diabetic medications, you’re right. That’s probably a good thing since the long-term side effects of many of the drugs we use are unknown. Remember Rezulin (troglitazone)? Introduced in 1997, it was pulled off the U.S. market in 2001 because of fatal liver toxicity. More recently, rosiglitazone usage has been highly restricted due to concern for heart toxicity.

Steve Parker, M.D.

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March 20, 2011 · 7:41 AM

Exercise, Part 8: Warnings and Precautions for Diabetics

Exercise clearly has many benefits, as discussed in prior installments of this series.  Yet we shouldn’t overlook the potential risks to diabetics either. 

Diabetic Retinopathy

Diabetics with retinopathy (an eye disease caused by diabetes) have an increased risk of retinal detachment and bleeding into the eyeball called vitreous hemorrhage. These can cause blindness. Vigorous aerobic or resistance training may increase the odds of these serious eye complications. Patients with retinopathy may not be able to safely participate. If you have any degree of retinopathy, avoid the straining and breath-holding that is so often done during weightlifting or other forms of resistance exercise. Vigorous aerobic exercise may also pose a risk. By all means, check with your ophthalmologist first. You don’t want to experiment with your eyes.

Diabetic Feet and Peripheral Neuropathy 

Diabetics are prone to foot ulcers, infections, and ingrown toenails, especially if peripheral neuropathy (numbness or loss of sensation) is present. Proper foot care, including frequent inspection, is more important than usual if a diabetic exercises with her feet. Daily inspection should include the soles and in-between the toes, looking for blisters, redness, calluses, cracks, scrapes, or breaks in the skin. See your physician or podiatrist for any abnormalities. Proper footwear is important (for example, don’t crowd your toes). Dry feet should be treated with a moisturizer regularly. In cases of severe peripheral neuropathy, non-weight-bearing exercise (e.g., swimming or cycling) may be preferable. Discuss with your physician or podiatrist.

Hypoglycemia

Low blood sugars are a risk during exercise if you take diabetic medications in the following classes: insulins, sulfonylureas, meglitinides, and possibly thiazolidinediones and bromocriptine. Hypoglycemia is very uncommon with thiazolidinediones. Bromocriptine is so new (for diabetes) that we have little experience with it; hypoglycemia is probably rare or non-existent. See drug details in chapter four. Diabetics treated with diet alone or other medications rarely have trouble with hypoglycemia during exercise.

Always check your blood sugar before an exercise session if you are at risk for hypoglycemia. Always have glucose tablets, such as Dextrotabs, available if you are at risk for hypoglycemia. Hold off on your exercise if your blood sugar is over 200 mg/dl (11.1 mmol/l) and you don’t feel well, because exercise has the potential to raise blood sugar even further early in the course of an exercise session.

As an exercise session continues, active muscles may soak up bloodstream glucose as an energy source, leaving less circulating glucose available for other tissues such as your brain. Vigorous exercise can reduce blood sugar levels below 60 mg/dl (3.33 mmol/l), although it’s rarely a problem in non-diabetics.

The degree of glucose removal from the bloodstream by exercising muscles depends on how much muscle is working, and how hard. Vigorous exercise by several large muscles will remove more glucose. Compare a long rowing race to a slow stroll around in the neighborhood. The rower is strenuously using large muscles in the legs, arms, and back. The rower will pull much more glucose out of circulation. Of course, other metabolic processes are working to put more glucose into circulation as exercising muscles remove it. Carbohydrate consumption and diabetic medications are going to affect this balance one way or the other.

If you are at risk for hypoglycemia, check your blood sugar before your exercise session. If under 90 mg/dl (5.0 mmol/l), eat a meal or chew some glucose tablets to prevent exercise-induced hypoglycemia. Re-test your blood sugar 30–60 minutes later, before you exercise, to be sure it’s over 90 mg/dl (5.0 mmol/l). The peak effect of the glucose tablets will be 30–60 minutes later. If the exercise session is long or strenuous, you may need to chew glucose tablets every 15–30 minutes. If you don’t have glucose tablets, keep a carbohydrate source with you or nearby in case you develop hypoglycemia during exercise.

Re-check your blood sugar 30–60 minutes after exercise since it may tend to go too low.

If you are at risk of hypoglycemia and performing moderately vigorous or strenuous exercise, you may need to check your blood sugar every 15–30 minutes during exercise sessions until you have established a predictable pattern. Reduce the frequency once you’re convinced that hypoglycemia won’t occur. Return to frequent blood sugar checks when your diet or exercise routine changes.

These general guidelines don’t apply across the board to each and every diabetic. Our metabolisms are all different. The best way to see what effect diet and exercise will have on your glucose levels is to monitor them with your home glucose measuring device, especially if you are new to exercise or you work out vigorously. You can pause during your exercise routine and check a glucose level, particularly if you don’t feel well. Carbohydrate or calorie restriction combined with a moderately strenuous or vigorous exercise program may necessitate a 50 percent or more reduction in your insulin, sulfonylurea, or meglitinide. Or the dosage may need to be reduced only on days of heavy workouts. Again, enlist the help of your personal physician, dietitian, diabetes nurse educator, and home glucose monitor.

Finally, insulin users should be aware that insulin injected over muscles that are about to be exercised may get faster absorption into the bloodstream. Blood sugar may then fall rapidly and too low. For example, injecting into the thigh and then going for a run may cause a more pronounced insulin effect compared to injection into the abdomen or arm.

Autonomic Neuropathy

This issue is pretty technical and pertains to function of automatic, unconscious body functions controlled by nerves. These reflexes can be abnormal, particularly in someone who’s had diabetes for many years, and are called autonomic neuropathy. Take your heart rate, for example. It’s there all the time, you don’t have to think about it. If you run to catch a bus or climb two flights of stairs, your heart rate increases automatically to supply more blood to exercising muscles. If that automatic reflex doesn’t work properly, exercise is more dangerous, possibly leading to passing out, dizziness, and poor exercise tolerance. Other automatic nerve systems control our body temperature regulation (exercise may overheat you), stomach emptying (your blood sugar may go too low), and blood pressure (it could drop too low). Only your doctor can tell for sure if you have autonomic neuropathy.

Steve Parker, M.D.

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November 22, 2009 · 2:00 AM

Low-Carb Ketogenic Diet for Overweight Diabetic Men: A Pilot Study

A low-carb ketogenic diet in patients with type 2 diabetes was so effective that diabetes medications were reduced or discontinued in most patients, according to U.S. researchers.  The 2005 report recommends that similar dieters be under close medical supervision or capable of adjusting their own medication, because the diet lowers blood sugar  dramatically. 

Methodology

Twenty-eight overweight people with type 2 diabetes were placed on the study diet and followed for 16 weeks.  Seven people dropped out, so the analysis involved 21, of which 20 were men—the study was done at a Veterans Administration clinic.  Thirteen were caucasian, eight were black.  Average age was 56; average body mass index was 42.  The seven dropouts were unable to come to the scheduled meetings or couldn’t follow the diet.  No dropout complained of adverse effects of the diet.

Results

Participants were instructed on the Atkins Induction Phase diet, which daily includes:

  • under 20 g carbohydrate
  • one cup of low-carb vegetables
  • two cups of salad greens
  • four ounces of hard cheese
  • unlimited meat, poultry, fish, eggs, shellfish
  • a multivitamin

At the outset, diabetes medication dosages were reduced in this general fashion: insulin was halved, sulfonyureas were halved or discontinued.  If the participant were taking a diuretic (fluid pill), low doses were discontinued; high doses were halved.

Study subjects returned every two weeks for diet counseling and medication adjustment (based on twice daily glucose readings and episodes of hypoglycemia).  Food cravings and/or good progress on weight goals triggered a 5-gram (per day) weekly increase in carbohydrate allowance.  In other words, if a participant’s weight loss goal was 20 pounds and he’d already lost 10, he could increase his daily carbs during the next week from 20 to 25 g.  Carbs could be increased weekly by five gram increments as long as weight loss progressed.  [This is typical Atkins.]   Food records were analyzed periodically.   

Results

  • hemoglobin A1c decreased from an average baseline of 7.5% down to 6.3% (a 1.2% absolute decrease and 16% relative drop)
  • the absolute hemoglobin A1c decrease was at least 1.0% in half of the participants
  • diabetic drugs were reduced in 10 patients, discontinued in seven, and unchanged in four
  • average body weight decreased by 6.6%, from 131 kg (288 lb) to 122 kg (268 lb)
  • triglycerides decreased 42%, while cholesterols (total, HDL, and LDL) didn’t change significantly
  • no change in blood pressures
  • average fasting glucose decreased by 17% (by week 16)
  • uric acid decreased by 10%
  • no serious adverse effects occurred
  • one hypoglycemic event involved EMS but was treated without transport
  • only 27 of 151 urine ketone measurements  were greater than trace

My Comments

The degree of improvement in hemoglobin A1c—our primary gauge of diabetes control—is equivalent to that seen with many diabetic medications.  I see many overweight diabetics on two or three drugs and a standard “diabetic diet,” and they’re still poorly controlled.  This diet could replace the expense and potential adverse effects of an additional drug.   

In August this year I blogged about a study comparing the Atkins diet with a traditional low-fat diet in overweight diabetic black women in the U.S.  As measured at three months, the Atkins diet proved superior for weight loss and glucose control.

This study at hand is small, but certainly points to the effectiveness of an Atkins-style very low-carb ketogenic diet in overweight men with type 2 diabetes.

Steve Parker, M.D.

Yancy, William, et al.  A low-carbohydrate, ketogenic diet to treat type 2 diabetes [in men].  Nutrition and Metabolism, 2:34 (2005).   doi: 10.1186/1743-7075-2-34

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August 17, 2009 · 8:05 AM

Wine Safely Lowers Fasting Blood Sugar in Type 2 Diabetes

"Is the room spinning, or is it just me?"

"Is the room spinning, or is it just me?"

Wine consumption lowered fasting blood sugar levels by 15% in type 2 diabetics who had previously not been habitual drinkers, according to a 2007 study in Israel.

Background

Judicious alcohol consumption is linked to lower rates of cardiovascular disease (heart attack and stroke), longer lifespan, and lower risk of developing type 2 diabetes.  The beneficial health effects of alcohol seem to be more pronounced in people who already have type 2 diabetes. 

Israeli investigators wondered how initiation of an alcohol habit would effect fasting and after-meal blood glucose levels in type 2 diabetics.

Methodology

Researchers studied 109 type 2 diabetics (41-74 years old)  in Israel who previously had abstained from alcohol.  They were randomly assigned to drink either 150 ml (5 oz) of wine or nonalcoholic diet malt beer (as a control) during dinner daily for three months.  Wine choices were a dry red (Merlot) or white (Sauvignon Blanc).  Three out of four chose the Merlot.

Use of anti-diabetic medications was not reported.  People using more than two insulin injections daily or an insulin pump were excluded from participation.

Results

In the wine group, average fasting plasma glucose decreased by 21 mg/dl, from 139 to 118 mg/dl, a 15% drop.  [The authors calculated this as a 9.2% drop, but I stand by my calculation of 15%.]   Fasting glucose did not change in the control group. 

There was no difference between the groups in glucose levels measured two hours after dinner.

In the wine group, 5% reported low blood sugar, headaches, or weakness, and 8% reported increased sexual desire.  But these numbers were not statistically significant compared to the control group.

Patients with higher baseline hemoglobin A1c levels had greater reductions in fasting glucose.

The wine group reported an improved ability to fall asleep.

Three months after the end of the study, 61% of the wine group said they thought the alcohol was beneficial to them, and half of the group continued to drink in moderation.

Conclusions of the Investigators

Among patients with type 2 diabetes who had previously abstained from alcohol, initiation of moderate daily alcohol consumption reduced FPG [fasting plasma glucose] but not postprandial glucose.  Patients with higher A1C may benefit more from the favorable glycemic effect of alcohol.  Further intervention studies are needed to confirm the long-term effect of moderate alcohol intake.

My Comments

The investigators imply that the various types of alcohol – beer, wine, spirits (whiskey, vodka, gin, etc) – will have the same effect on fasting glucose levels.  The study at hand provides no evidence except for wine.   

Some type 2 diabetics have fasting glucose levels routinely as low as 80 mg/dl.  If they start drinking wine like this, dropping their fasting glucose to around 6o or less, they could end up with symptomatic hypoglycemia in the mornings, or even hypoglcymia while asleep.  Use caution.  I’ve read other studies indicating that hypoglycemia usually is not a problem with light to moderate alcohol consumption. 

The potential adverse health effects of alcohol are well-documented elsewhere, as are other reasons not to drink.

Diabetics who are diet-controlled, or on diabetic medications that don’t cause hypoglycmia by themselves, are unlikely to develop hypoglycmia with wine or other alcohol. 

Wine has significant potential to prolong life and reduce rates of cardiovascular disease in type 2 diabetes.  It will be years, if ever, before we have confirmatory studies.  Who’s going to pay for the research?  The California Winegrowers Association?

Steve Parker, M.D.    
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Reference:  Shai, Iris, et al.  Glycemic effects of moderate alcohol intake among patients with type 2 diabetes: A multicenter, randomized, clinical intervention trial.  Diabetes Care, 30 (2007): 3,011-3,016. 

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

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