Tag Archives: type 2 diabetes

Elevated Fasting Blood Sugar Linked to Pancreatic Cancer

A recent meta-analysis found that elevated fasting blood glucose levels, even in the prediabetic range, are associated with higher risk of developing pancreatic cancer. This is important because you can take action today to lower your fasting blood sugar level, which may lower your risk of pancreatic cancer over the long-term. The researchers conclude that…

“Every 0.56 mmol/L [10 mg/dl] increase in fasting blood glucose is associated with a 14% increase in the rate of pancreatic cancer.”

In the developed world, your risk of getting an invasive cancer is roughly one in four. Pancreatic cancer is the most lethal. Surgery is the way to cure it, but at the time of diagnosis only two in 10 patients are candidates for surgery because the cancer has already spread. Pancreatic cancer is the fourth leading cause of cancer death in the USA and the fifth in the UK. Nevertheless, pancreas cancer is not terribly common; the US has 50,000 new cases annually. As a hospitalist, I run across one or two new cases of pancreas cancer every year.

We’ve known for years that type 2 diabetes is linked to pancreatic cancer, with diabetics having twice the risk of nondiabetics.

What if you have elevated fasting blood sugars? There’s no proof that reducing them to the normal range will reduce your risk of pancreatic cancer. But if it were me, that’s what I’d shoot for.

Other that type 2 diabetes and prediabetes, some other risk factors for pancreas cancer are:

  • heredity
  • smoking
  • sedentary lifestyle
  • body mass index over 30 (obesity in other words)

You can alter most of those risk factors. Why not get started now?

Steve Parker, M.D.

PS: If you’re not sure if your fasting blood sugar’s elevated, click here.

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Filed under Diabetes Complications

Dulaglutide Joins War Against Diabetes

In September, 2014, the U.S. Food and Drug Administration approved the fourth drug in the GLP-1 analogue class: dulaglutide. The granddaddy in the class is exenatide (Byetta). The new GLP-1 receptor agonist will be sold in the U.S. under the name of Trulicity. It’s a once-weekly injection.

This is only a summary and is liable to change. Get full information from your prescribing healthcare provider and pharmacist.

Even walking helps with blood sugar control

Even walking helps with blood sugar control


For adults with type 2 diabetes, in conjunction with diet and exercise. It’s not a first-line drug. It can be used by itself or in combination with metformin, pioglitazone, glimiperide (and presumably other sulfonylureas), and insulin lispro (e.g., Humalog, a rapid-acting insulin). The drug has not been tried with basal (long-acting) insulins.


Start with 0.75 mg subcutaneously every week. Can go up to 1.5 mg weekly if needed.

Adverse Effects

Hypoglycemia is rare, but possible, when GLP-1 analogues are used as the sole diabetes drug. When it happens, it’s rarely severe. But the risk increases substantially when dulaglutide is used along with insulin or insulin secretagogues such as sulfonylureas or meglitinides.

Common side effects are nausea, vomiting, diarrhea, abdominal pain, decreased appetite, dyspepsia, and fatigue.

It might cause thyroid tumors and pancreatitis.

Do Not Use If…

…you have a family or personal history of medullary thyroid cancer, or if you have Multiple Endocrine Neoplasia syndrome type 2 or pre-existing severe gastrointestinal disease. Those who are pregnant or nursing babies should probably not take it since we have no data on safety. Don’t use for diabetic ketoacidosis.

Use only with caution if you have a history of pancreatitis or known liver impairment.

Steve Parker, M.D.

Click for full prescribing information.


Filed under Drugs for Diabetes

Multinational Study Suggests Insulin Pump Better Than Multiple Daily Injections for Inadequatedly-Controlled Type 2 Diabetes

Lancet has the details. I’ve only read the abstract, so don’t know much about the actual research. Study subjects were sub-optimally controlled (HgbA1c of 8-12%) on multiple daily injections; that’s why they were considered for pump therapy. They were randomized to pump or continued multiple daily injections. What I can’t tell – and it matters – is whether the multiple injection group underwent changes in their management or whether they were told to “just keep doing what your were doing” (which wasn’t working well).


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Very Low-Carb Diet Beats ADA Diet in Type 2 Diabetes According to New Study

Compared to a mildly carbohydrate-restricted American Diabetes Association diet, a very-low-carbohydrate ketogenic diet was more effective at controlling type 2 diabetes and prediabetes, according to University of California San Francisco researchers.

Some non-starchy low-carb vegetables

Some non-starchy low-carb vegetables

Details, please!

Thirty-four overweight and obese type 2 diabetics (30) and pre diabetics (4) were randomly assigned to one of the two diets:

  1. MCCR: American Diabetes Association-compliant medium-carbohydrate, low-fat, calorie-resticted carb-counting diet. The goals were about 165 grams of net carbs daily, counting carbohydrates, an effort to lose weight by eating 500 calories/day less than needed for maintenance, and 45–50% of total calories from carbohydrate. Protein gram intake was to remain same as baseline. (Note that most Americans eat 250–300 grams of carb daily.)
  2. LCK: A very-low-carbohydrate, high-fat, non-calorie-restricted diet aiming for nutritional ketosis. It was Atkins-style, under 50 grams of net carbs daily (suggested range of 20–50 g). Carbs were mostly from non-starchy low-glycemic-index vegetables. Protein gram intake was to remain same as baseline.

Baseline participant characteristics:

  • average weight 100 kg (220 lb)
  • 25 of 34 were women
  • average age 60
  • none were on insulin; a quarter were on no diabetes drugs at all
  • most were obese and had high blood pressure
  • average hemoglobin A1c was about 6.8%
  • seven out of 10 were white

Participants followed their diets for three months and attended 13 two-hour weekly classes. Very few dropped out of the study.


Average hemoglobin dropped 0.6% in the LCK group compared to no change in the MCCR cohort.

A hemoglobin A1c drop of 0.5% or greater is considered clinically significant. Nine in the LCK group achieved this, compared to four in the MCCR.

The LCK group lost an average of 5.5 kg (12 lb) compared to 2.6 kg (6 lb) in the MCCR. The difference was not statistically significant, but close (p = 0.09)

44% in the LCK group were able to stop one or more diabetes drugs, compared to only 11 % in the other group

31% in the LCK cohort were able to drop their sulfonylurea, compared to only 5% in the MCCR group.

By food recall surveys, both groups reported lower total daily caloric intake compared to baseline. The low-carbers ended up with 58% of total calories being from fat, a number achieved by reducing carbohydrates and total calories and keeping protein the same. They didn’t seem to increase their total fat gram intake;

The low-carbers apparently reduced daily carbs to an average of 58 grams (the goal was 20-50 grams).

There were no differences between both groups in terms of C-reactive protein (CRP), lipids, insulin levels, or insulin resistance (HOMA2-IR). Both groups reduced their CRP, a measure of inflammation.

LCK dieters apparently didn’t suffer at all from the “induction flu” seen with many ketogenic diets. They reported less heartburn, less aches and pains, but more constipation.

Hypoglycemia was not a problem.

If I recall correctly, the MCCR group’s baseline carb grams were around 225 g.

Bottom Line

Very-low-carb diets help control type 2 diabetes, help with weight loss, and reduce the need for diabetes drugs. An absolute drop of 0.6% in hemoglobin A1c doesn’t sound like much, translating to blood sugars lower by only 15–20 mg/dl (0.8–1 mmol/l). But remember the comparator diet in this study was already mildy to moderately carbohydrate-restricted. At least half of the type 2 diabetics I meet still tell my they don’t watch their carb intake, which usually means they’re eating around 250–300 grams a day. If they cut down to 58 grams, they most likely will see more than a 0.6% drop in hemoglobin A1c after switching to a very-low-carb diet.

This is a small study, so it may not be reproducible in larger clinical trials and other patient populations. Results are consistent with several other similar studies I’ve seen, however.

Steve Parker, M.D.

Reference: Saslow, Laura, et al (including Stephen Phinney). A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or PrediabetesPLoS One. 2014; 9(4): e91027. Published online Apr 9, 2014. doi: 10.1371/journal.pone.0091027     PMCID: PMC3981696

PS: When I use “average” above, “mean” is often a more accurate word, but I don’t want to have to explain the differences at this time.

PPS: Carbsane Evelyn analyzed this study in greater detail that I did and came to different conclusions. Worth a read if you have an extra 15 minutes.




Filed under Carbohydrate, Glycemic Index and Load, ketogenic diet, Prediabetes

One More Drug for Type 2 Diabetes: Albiglutide

The U.S. Food and Drug Administration approved albiglutide for treatment of adult type 2 diabetes in mid-April, 2014. It will be sold in the U.S. as Tanzeum. It’s a once-a-week subcutaneous injection.

Albiglutide is a GLP-1 receptor agonist, joining exenatide and liraglutide in that class.

It’s not a first-line drug for diabetes. In clinical studies, it’s been used alone and with metformin, glimiperide (a sulfonylurea), pioglitazone, and insulin.

The most frequent side effects have been upper respiratory infections, diarrhea, nausea, and injection site reactions.

Steve Parker, M.D.

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Yet Another Reason to Exercise as You Get Older

Compared to others, elderly type 2 diabetics are more afflicted with lower leg muscle mass, leg strength, and functional capacity. Click for details.

The right exercise program can counteract these problems and improve quality of life.

Steve Parker, M.D.

h/t Bill Lagakos

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Does Coffee Prevent Type 2 Diabetes?

Fanatic Cook Bix details the surprising answer: Yes.

“Still, study after study, it’s an association that won’t go away … coffee consumption lowers the risk for diabetes. And the more you drink, the lower your diabetes risk. It doesn’t matter whether the coffee is regular or decaf, but regular does consistently show a slight edge over decaf.”

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More on the New Type 2 Diabetes Drug: Dapagliflozin (Farxiga)

We have 12 classes of drugs for the war on diabetes. The latest class is SGLT2 inhibitors and the newest of these is dapagliflozin. I read the manufacturer’s package insert an updated my SGLT2 inhibitor post.

Fun Fact: Taking 10 mg/day of dapagliflozin leads to loss of blood glucose into the urinary tract to the tune of 70 grams a day.

That’s 280 calories down the drain. I suspect that cutting 70 grams of carbohydrate from your diet would have just as much effect on diabetes as do these drugs.

Steve Parker, M.D.

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Drug Review: SGLT2 Inhibitors (Canagliflozin, Dapagliflozin, Empagliflozin)

diabetic mediterranean diet, Steve Parker MD

Pharmacist counting pills

In March, 2013, the U.S. Food and Drug Administration approved the first agent in a new class of diabetes drugs: canagliflozin. It’s sold in the U.S. as Invokana. So we now have 12 classes of drugs for treating diabetes. In January 2014 the second drug in this class was approved: dapagliflozin or Farxiga. Empagliflozin ( U.S. brand name: Jardiance) was approved in August, 2014. Ertugliflozin (U.S. brand name: Steglatro) was approved in early 2018 or so. Other SGLT2 inhibitors are in the pipeline.

This review is quite limited—consult your physician or pharmacist for full details. Remember that drug names vary by country and manufacturer. My info source is the manufacturers’ package inserts. Any of this information could change at any time.


Sodium-glucose co-transport 2 inhibitors, or SGLT2 inhibitors.

How Do They Work?

Our kidneys filter glucose (sugar) out of our bloodstream, then reabsorb that glucose back into the bloodstream. (Don’t ask me why.) SGLT2 inhibitors impair that reabsorption process, allowing some glucose to be excreted in our urine. You could call it a diuretic effect. Dapagliflozin at a dose of 10 mg/day, for example, causes the urinary loss of 70 grams of glucose daily.


These drugs are for adults with type 2 diabetes, to be used in combination with diet and exercise. They can be used alone or in combination with some of the other diabetes drugs, possibly to include insulin, metformin, sulfonylureas, or pioglitazone. Dapagliflozin has also been tested in combination with sitagliptin, a DPP4-inhibitor. Clinical experience in combination with other diabetes drugs is very limited.


Canagliflozin starts at 100 mg by mouth daily, taken before the first meal of the day. Dose can be increased to 300 mg daily. Dapagliflozin dosing starts at 5 mg by mouth every morning, with or without food, and can be increased up to 10 mg once daily. Start empagliflozin at 10 mg every AM, and max out at 25 mg every AM if needed. Ertugliflozin starts at 5 mg daily and can go up to 15 mg/day.

Side Effects

The most common side effects are vaginal yeast infections (about 5% of women), urinary tract infections, and penile yeast infections (e.g., balanitis). Also noted are increased urination, and dizziness or fainting from low blood pressure after arising to stand (orthostatic hypotension). The low blood pressures are related to a diuretic effect of this class.

Hypoglycemia (low blood sugar) is quite uncommon, perhaps nonexistent, unless these drugs are used with other drugs that often cause hypoglycemia, such as insulin and insulin secretagogues like sulfonylureas.

High potassium levels may be seen with canagliflozin. All three can cause elevations of LDL cholesterol (“bad cholesterol”).

Dapagliflozin and empagliflozin may cause elevations of creatinine in the blood, a warning that kidney function may be impaired.

Canagliflozin seems to promote weight loss, which may be welcome by some. It also doubles the risk of leg and foot amputations when compared to placebo. Ertugliflozin is also linked to increased risk of lower limb amputation.

Don’t Use If You . . .

  • have diabetic ketoacidosis
  • are pregnant or planning to get pregnant
  • have advanced or severe kidney disease
  • have severe liver impairment (glomerular filtration rate under 60 ml/min/1.73 m-squared, at least for dapagliflozin)
  • have type 1 diabetes
  • are on dialysis
  • are a nursing mother
  • for dapagliflozin: active bladder cancer (and use caution if you have history of bladder cancer)


Update: In 2019, the FDA approved an SGLT2 inhibitor in pill form, called semaglutide and sold in the U.S. as Rybelsus.

Updated September 26, 2019


Filed under Drugs for Diabetes

Low-Carb Diet Improves Glucose Control in Japanese Type 2 Diabetics

Mt. Fuji in Japan

Mt. Fuji in Japan

I don’ know anything about Japanese T2 diabetes. I’ve never studied it. Their underlying physiology may or may not be the same as in North American white diabetics, with whom I am much more familiar.

For what it’s worth, a small study recently found improvement of blood sugar control and triglycerides in those on a carbohydrate restricted diet versus a standard calorie-restricted diet.

Only 24 patients were involved. Half were assigned to eat low-carb without calorie restriction; the other half ate the control diet. The carbohydrate-restricted group aimed for 70-130 grams of carb daily, while eating more fat and protein than the control group. The calorie-restricted guys were taught how to get 50-60% of calories from carbohydrate and keep fat under 25% of calories. At the end of the six-month study, the low-carbers were averaging 125 g of carb daily, compare to 200 g for the other group. By six months, both groups were eating about the same amount of calories.

Average age was 63. Body mass index was 24.5 in the low-carb group and 27 in the controls. (If you did the research, I bet you’d find Japanese T2 diabetics have lower BMIs than American diabetics.) All were taking one or more diabetes drugs.

The calorie-restricted group didn’t change their hemoglobin A1c (a standard measure of glucose control) from 7.7%. The low-carb group dropped their hemoglobin A1c from 7.6 to 7.0% (statistically significant). The low-carb group also cut their triglycerides by 40%. Average weights didn’t change in either group.

Bottom Line

This small study suggests that mild to moderate carbohydrate restriction helps control diabetes in Japanese with type 2 diabetes. The improvement in hemoglobin A1c is equivalent to that seen with initiation of many diabetes drugs. I think further improvements in multiple measures would have been seen if carbohydrates had been restricted even further.

Steve Parker, M.D.

Link to reference.

h/t Dr Michael Eades

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Filed under Carbohydrate, Fat in Diet