Inspiration

I find it inspirational to read the success stories that others post in the various forums I read. Some are spectacular, some seem ordinary until you read between the lines to see the courage, determination and character that led to success. To me they are all illustrations of ordinary people who have decided to become extraordinary when they decided to take charge of their own future. I posted these stories previously:

xita's Story

Jennifer's Story

Good Advice, Bad Advice - Nicky's Experience

LuckyKat

Here is another, from nanna2six. That nick implies lots of other happy stories too. She originally posted this on the ADA Forum.

I would be delighted to help someone else.

When I was diagnosed in April 2008, I wasn't sure where to start. I went in for my annual exam, on a Friday, on the following Tuesday the nurse called and said I needed to repeat my glucose test because it was a "little high". I said how high? She said 289. I repeated the fasting glucose, I work at a hospital, so this time I had the blood drawn there (to keep from missing so much work), it came back 269, the nurse called again and said the doctor wants to see you Friday morning. I already knew, so I was sort of prepared (not really) but as much as possible.

I give credit to my doctor because he took quite a bit of time going over things with me. He started me on Metformin 500 mg, over the next few weeks, he increased it until I am now taking Met 500 mg with breakfast, and Met 1000 mg with dinner. So over that first week end...I was lost.

The only thing I didn't agree with my doctor about was that he told me that until I went to Diabetes Education class...I could drop by the office once a week and have my finger stuck??? I bought a meter on Saturday morning. By Saturday evening I had found this message board...but because I had been all over the internet, I couldn't remember how to get back to it. So it took me a couple of days to find it again.

I started reading and I have been reading since then. I am by nature a quiet person...I listen more than I talk. From reading, I learned to start MOVING! I get to work 30 minutes early...so instead of reading...I started walking. My first attempt was this big hill, it took me about 3 days before I could get all the way to the top LOL, then I stopped noticing the hill and I started going around the block, I am now at eight blocks before work. I also walk at lunch time, my lunch is usually something that I can carry, don't need a knife or fork kind of meal, then I walk about 7 blocks to the bus stop after work. NO, I don't walk after I get home.

But the most drastic change is what I eat. In my D class, I was given a meal plan that said I could have 60 carbs a meal (NOT!). From THIS BOARD and the people here, I learned that I had to find out what my body could handle and it was not 60 carbs a meal. I eat approx 15 plus for breakfast. I didn't use to eat breakfast at all, but since I had meds to take, and I was told I need breakfast I do. At lunch and dinner I eat between 30 at the most 45 (not too often) of carbs. I drink lots of water.

I have lost 26 lbs, since April, but 36 lbs total since my last Dr visit which was for an unrelated issue in October 2007. I would love to help someone. I don't want to forget to say that the only way to find out how food effected me was to test almost all the time. I wasn't told that in D class either...just to test as soon as I got up each morning, nothing about before and after meals.

I have a friend that is also D, but she is totally noncompliant...does not care. I just thought that if I can't help her, and I see her most days....but I will become more active on the boards. I hope this tells you a little more about me.

Thanks for your permission to post another inspirational story, nanna2six. I'm sure that you have already helped others.

Cheers, Alan

Everything in Moderation - Except Laughter

Smoking and Diabetes

So, you're a smoker and you've been diagnosed with type 2 diabetes. And you're sick of people telling you to quit? Yeah, I know. Been there, done that. In 2001 I finally succeeded in quitting after nearly forty years of forty-a-day. As an ex-heavily-addicted smoker, I know how hard it was to give up. There were few people I detested more when I smoked than ex-smokers who would say "I just decided to stop - it's just willpower." Yeah, right. Idiot.

So why should you?

Well, I presume you're reading here because you have diabetes and want to avoid the usual complications. That word doesn't really seem nasty enough to cover heart disease, kidney failure leading to dialysis, blindness or salami surgery, does it? So, to try to avoid those you are testing your blood glucose levels, changing your menu, doing some extra exercise and learning everything you can to give yourself a chance of a more enjoyable, longer life. Great stuff - you are doing the work and deserve the rewards.

But you still smoke? It's time to think about that.

Usually, scare stories only provide partial help - but I'll pass these on anyway. Because I don't want to hear from anyone, anywhere, claiming that smokes aren't harmful to a diabetic.

Start by doing a simple google scholar search on "smoking and diabetes". The references at the foot of this article are a small sample of the 283,000 hits. Just one small snippet among many: "Particularly, survival of smokers with diabetes on hemodialysis is abysmal."

I first discussed this in 2005 on alt.support.diabetes. A friend of mine, Annette, responded with this interesting, but alarming, comment:

"Here are a few interesting tit-bits about tobacco use and metabolism to add to the list. I discovered some during my look at cyanide in plants and how the body detoxifies itself from this potentially deadly poison.

Tobacco contains a VERY high level of cyanide. Workers who handle and process the leaf have been fatally poisoned just through skin contact with the leaf.

I have read that people who smoke or use tobacco have been found to be consistently deficient in Vitamin B12. This vitamin is the body's main line of defense against the chronic low-level state of cyaniditis. It gets depleted by having to de-toxify the cyanide that keeps coming in all the time. After all there are small amounts of cyanide in most of plants we eat. Fine, unless you smoke. Diabetics are particularly likely to have sub-optimal levels of Vit B12 anyway, especially if they use that otherwise helpful med, metformin. So that's a double whammy. Even supps have a hard time keeping up the supply.

Cyanide binds strongly to the iron in the body, which then lowers the uptake and presence of oxygen in the blood and cells. That's why it can kill so fast. No oxygen! Smoking contains carbon monoxide, which also replaces oxygen in the blood. Breathe in enough, and that will cause death too. Same reason. Cigarette smoke lays down "soot" in the lungs, as well as being carcinogenic. So less oxygen is being absorbed by those wonderful "ventilators". A triple whammy!

Now the body does fight bravely to deal with these assaults. It tries to "wash" the offending soot out of the airways with mucous, hence the classic "smoker's" cough. It tries to detoxify the cyanide, hence low levels of B12 that are needed elsewhere. It does it's best to kill cancerous cells, but of course can simply fail to handle such a constant intake of carcinogens, and cancer can get the better of all it's efforts. Finally, the lungs endeavour to correct the lack of sufficient oxygen for normal metabolism, and stretch so as to increase the amount of air taken in with each breath. Long term though, they gradually lose their elasticity, like worn out elastic in waist bands, and can no longer function effectively. I'm not surprised that smoking raises the risk of heart attacks. Every living cell in our bodies need oxygen, those hard working muscles in the heart in particular. But if none of the above get you, the emphesema will.

Just one more tip to close off. I'm not cogniscent of why, but smoking definitely has been shown to raise insulin resistance. If you decide to quit, keep an eye on your bg levels (especially if you are a T2). The insulin resistance can improve so rapidly, you may find yourself suffering from a hypo!

Good grief, you may even be able to drop all your oral medications, enjoy exercise, and find bg management a breeze. It's that much of an influence."

You already know you need to quit, but if you need further convincing browse through the references below. I've checked that all the links still work if you want to read deeper.

For the sake of those who love you , even if that's only you, quit. I know it's not easy, but it will be worth it.

Cheers, Alan
Everything in Moderation - Except Laughter.

Further reading:
Cigarette smoking and health. American Thoracic Society Cigarette smoking remains the primary cause of preventable death and morbidity in the United States.
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Preventing cardiovascular events in patients with diabetes mellitus. Abraham WT.
Smoking is known to be particularly dangerous for those with diabetes, and it is important for health care providers to help their patients stop smoking.
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Effects of smoking on systemic and intrarenal hemodynamics: influence on renal function. The mechanisms of smoking-induced renal damage are only partly understood and comprise acute hemodynamic (e.g., increase in BP and presumably intraglomerular pressure) and chronic effects (e.g., endothelial cell dysfunction). Renal failure per se leads to an increased cardiovascular risk. The latter is further aggravated by smoking. Particularly, survival of smokers with diabetes on hemodialysis is abysmal.
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Effects of cigarette smoking, diabetes, high cholesterol,and hypertension on all-cause mortality and cardiovasculardisease mortality in Mexican Americans. The San AntonioHeart Study
After adjustment for sex, age, and socioeconomic status in multivariate analyses, current smoking, diabetes, high cholesterol, and hypertension were positively associated with all-cause mortality and cardiovascular disease mortality in Mexican Americans. Overall, these risk factors accounted for 45% of all-cause mortality and 55% of cardiovascular disease mortality in this ethnic group.
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Smoking, diabetes and hyperlipidaemia. Mikhailidis DP, Papadakis JA, Ganotakis ES.
Department of Chemical Pathology & Human Metabolism, Royal Free Hospital & School of Medicine, Univ. of London, United Kingdom.
The epidemiological evidence linking smoking with insulin resistance is considerable. This evidence is even more convincing because there is a dose response relationship between smoking and the risk of non-insulin dependent diabetes (NIDDM). Similarly, there is a time-dependent decrease in risk of NIDDM for those who quit smoking.
Insulin resistance (in the form of impaired glucose tolerance, IGT) may precede the development of NIDDM. There is a biochemical basis for the smoking-IGT/NIDDM relationship. Smoking increases the risk of developing diabetic complications like nephropathy, neuropathy and retinopathy Smoking is also an independent risk factor for myocardial infarction and all-cause mortality in NIDDM. Smokers are both insulin resistant and lipid intolerant.
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Smoking and diabetes D Haire-Joshu, RE Glasgow and TL Tibbs
There are consistent results from both cross-sectional and prospective studies showing enhanced risk for micro- and macrovascular disease, as well as premature mortality from the combination of smoking and diabetes.
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Smoking is associated with progression of diabetic nephropathy
RESULTS--Progression of nephropathy was less common in nonsmokers (11%) than in smokers (53%) and patients who had quit smoking (33%), P < 0.001. In a stepwise logistic regression analysis, cigarette pack years, 24-h sodium excretion, and GHb were independent predictive factors for the progression of diabetic nephropathy.
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The Effects of a Smoking Cessation Intervention on 14.5-Year Mortality
Intervention: The intervention was a 10-week smoking cessation program that included a strong physician message and 12 group sessions using behavior modification and nicotine gum, plus either ipratropium or a placebo inhaler. Results: <snip>Differences in death rates for both lung cancer and cardiovascular disease were greater when death rates were analyzed by smoking habit.
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Getting to Goal in Type 2 Diabetes: Role of Postprandial Glycemic Control
Slide 9. MRFIT: Impact of Diabetes on CVD Mortality These are data from the Multiple Risk Factor Intervention Trial (MRFIT) study, where people with and without diabetes were classified as having: no risk factors at all, only 1 risk factor, 2 risk factors, or all 3 risk factors. Risk factors were hypertension, hyperlipidemia, and smoking. For any given number of risk factors, the chances of getting cardiovascular disease are markedly increased in people with type 2 diabetes. This increased risk is related to hyperglycemia.

The Diabetes Diet Wars

So, you’re a type 2 diabetic and you want to know what to eat? It seems such a simple question. After all, scientists all around the world have been studying the subject for nearly a century. How long does it take to discover which foods are good and bad for a type 2 to eat?

Going by the results, a very long time.

Welcome to the diet wars.

Which camp are you in? Do you follow the low-fat dietary guidelines of the ADA, AHA and USDA? Those guidelines usually start with something like "People with diabetes have the same nutritional needs as anyone else". That is technically accurate, but it implies that we must meet those needs in the same way as everyone else; and that is simply not true. Somehow they blithely ignore the fact that everyone else doesn’t have insulin resistance and a struggling or defunct pancreas. They will often follow with something like "The message today: Eat more whole grains! Whole grains and starches are good for you". But we all know that will raise our blood glucose levels, don’t we? No problem – they have a solution for that too: "Your doctor may need to adjust your medications when you eat more carbohydrates". In fact, despite the "same as anyone else" preamble the recommended diet is very low-fat and high-carb. It leads, in my opinion, inevitably to over-medication and progression.

I did the approved training with the dietician, but I kept having this radical thought as I saw my numbers go into the stratosphere and realised I would have to ask the doctor for lots of medications if I ate as the dietician recommended – what if there was a way of eating that gave all of the benefits of those grains and starches without doing that to my blood glucose? Much later I have started to read the book "Good Calories, Bad Calories" by Gary Taubes. I'm so glad he wrote it because he supports with science many of the decisions I made using logic and my meter some years ago.

Or are you in the low-carbohydrate camp, following weight-loss diets such as Atkins or South Beach and similar, or ultra-low-carb diabetes control diets such as that recommended by Dr Richard Bernstein? Or are you following something less radical such as Gannon and Nuttall’s LoBAG (Low Biologically Available Glucose) diet?

If I had to choose one of those it would be Gannon and Nuttall; but I don’t belong to any of those warring camps. I know my signature of "Everything in Moderation – Except Laughter" seems rather boring, but I chose it with care. The more I read about diabetes, the more I realised that extremes can kill us. In blood glucose terms both hypo- and hyper- are to be avoided; normal numbers are my aim. The same applies to lipids (cholesterol, especially triglycerides), weight, blood pressure and all of the various medical indicators we have to be aware of. I am honestly mystified as to why the experts keep urging us to go to extremes of low-this and high-that.

Another part of the problem is the word "diet"; it implies a short-term restriction to meet a goal such as weight loss. Diets do not work for us. As diabetics we have a chronic, life-long, life-threatening condition that is directly affected, more than most other conditions, by the food we eat at every meal. We do not need a short-term quick-fix diet. Instead we need to each discover for ourselves a "way of eating" that is delicious and enjoyable to ensure that we can happily follow that way for the rest of our lives, but which also meets our nutrition needs while aiding, rather than exacerbating, our diabetes control or other health problems.

But people like labels so I call my way of eating "low-spike" because that is my aim: to minimise blood glucose spikes after I eat. Compared to the ADA guidelines I eat low-carb, but I don’t count carbs because that is not my aim; instead I read my meter after I eat, review what I ate, and adjust the menu next time if the result was unacceptable. It’s pretty simple really. Occasionally I check to be sure nothing vital is missing, but the only thing I seem to be missing after six years of eating low-spike is complications.

So I’ll keep doing what I’m doing and let the others keep fighting the diet wars.

Cheers, Alan
Everything in Moderation - Except Laughter

PS That was my third and final dLIfe column.

Miracles and Wonders

What an interesting world we live in. As Paul Simon wrote, these are the days of miracles and wonders.

When I was diagnosed with type 2 back in 2002 I was totally ignorant of diabetes. I lived in a naive world that didn’t talk about such things; I had no idea that my aunt and several other close relatives were diabetic. Mum wasn’t, and Dad died of a war-related heart condition in his fifties. I was a blank slate.

Six years later, I read and write on several diabetes forums. I see many posts from shocked, scared, newly-diagnosed type 2 diabetics who are following terrible dietary advice and wondering why they get worse. I sometimes reflect on how lucky my ignorance was for me.

Of course, better knowledge may have caused me to get fit earlier and maybe stave off that diagnosis, but I doubt it. For example, despite all the information available on smoking I had only given up the noxious weed a year before, after nearly forty years of forty a day. Why would I have lost weight or become fit on the vague possibility of diabetes? I most likely would have changed the same things as the vast majority of the type 2 diabetes population – nothing.

That fortunate ignorance meant that I had no pre-conceptions at all. I knew no more about carbohydrates, protein and fats than any other ordinary guy, I had never heard of Atkins or Ornish, or the low-fat versus low-carb diet wars, and I had no guilt or shame about the condition being my fault. Far too many newly-diagnosed type 2s appear on the forums with that hang-up.

What a great benefit that ignorance was, because I then embarked on a voyage of discovery over the next few years, learning what I needed to fight my personal battle against this condition from every source that I could. I listened to and read doctors, dieticians, books, the web, the net and most important of all, other diabetics. What a wonderful modern miracle the internet is; used with discretion and judgement, it is an empowering tool for all patients of any affliction wanting to understand, to learn, and to find others who can support and empathise with them. We can discuss our problems with family, friends, doctors and nurses - but only another diabetic can really relate to how we feel about this condition.

At the start, no-one had told me that if I went below certain carbohydrate levels my brain would atrophy, nor that even a little more protein would lead to dialysis and that a little more fat would fill my arteries with plaque, nor that I would go insane if I tested too often, nor that artificial sweeteners would kill me, nor that it was dangerous to aim for normal HbA1c’s, nor a whole lot of other rules that so many doctors, dieticians, and diabetes authorities seem to have. By the time I did start to hear these alarms and scares, and I have been told all those and worse over the past six years, I was discovering that they were almost all completely wrong.

Along the way I read Jennifer's advice to the newly diagnosed. It was so simple and yet so effective. As an ex-engineer the concept of test, review, adjust was a basic one to me. Plan and execute an action, test the outcome, review the result and then change the plan next time for a better result. A process of iteration. Always aiming to improve.

That is what caused me to ponder on miracles and wonders. Not the Wonders of the World, although they were fun to visit, but the wonders of modern science and technology. The internet was a modern miracle that helped me immensely; another was the blood glucose meter. It is only a few short decades since the first blood glucose meter was developed for home use. It is only in the past two decades that it became possible to use meters intensively at home in the way so many type 2’s I know have done; using post-prandial testing to develop a better lifestyle complemented by medications when necessary, rather than using medications to combat and overcome an incorrect diet.

We have some miraculous tools available to us as type 2 diabetics in the 21st century if only we utilise them correctly. Take advantage of them.

Cheers, Alan

Everything in Moderation - Except Laughter

PS This was my second dLife column.

Turning Points

There are turning points in all our lives. Some we only recognize in hindsight, while others are immediately obvious.

My life changed completely on the 18th of February, 2002, four days before my 55th birthday.

I went to see the doctor for a routine physical after a blood draw to renew a standing prescription for a statin. I had been placed on the statin a couple of years earlier by a previous doctor who said, "your cholesterol is a little high", but you don’t need to worry - we have a pill that fixes that." He prescribed Lipitor 20mg. He never mentioned my 120Kg (260lbs) weight, or my fasting BG’s of 7.9mmol/l(140mg/dl), or diet, or exercise, or even the hint of diabetes. Just the instruction to "take this pill." So I took the pill, and changed nothing else. I was fat and happy. Does that sound familiar to anyone?

Then, on the day my life changed, I sat in the doctor’s office and went into shock as he told me I had leukemia. You thought I was going to say Type 2 Diabetes, didn’t you? Nope – on that day in February 2002 he told me I had CLL. Happy birthday...

I went home in a daze. But by the time I reached home, I had made up my mind to be “officially retired” and that I was going to do some of the things I had always wanted to do. I was not going to die with my song unsung. So I told my wife, as she opened the door, that I was going to travel around the world. I had always wanted to travel but always spent the time or money on something more important or more responsible. It was only later in the day I got up the courage to tell her why. A year later we went around the world for the first time.

Over the next two months I went through all the fun things of confirming my cancer diagnosis; a multitude of blood tests and a bone marrow aspiration. I got on the Web and searched for things I could do to help myself beat it. I found nothing.

The depression of diagnosis set in. I was told I was on “W&W: Watch and Wait." Wrong. “W&W” really means “Wonder and Worry.”

And then, in early May I was told by my doctor I also had Type 2 diabetes. Oh joy. But this was different. The doc told me to get a meter, and suggested I test fasting and pre-dinner blood glucose levels, and gave me targets for these numbers. What he didn’t give me was any advice on how to achieve those targets, except to "lose 8% of your body-weight."

The CLL diagnosis had primed me. There I was, all frustrated and depressed, and suddenly I had a goal that I could achieve. I designed my own weight-loss cooking and eating plan, and put it into practice. And it worked. When I lost the 8%, I just kept going. But it wasn’t enough. My A1C only dropped from 8.2% to 7.5%, despite my weight loss. So I started searching for more information. Over the next couple of months, I attended dietician’s appointments and a course with a dietician. My weight loss stalled and my blood sugars got worse as I started adding extra carbohydrates to follow the dietician’s advice. And then, like a new world, I discovered the anarchy of Usenet’s diabetes groups and eventually the most powerful, simple, logical advice I’ve seen before or since for new type 2 diabetics.

This advice is written by a diabetic named Jennifer. In essence, she says to test after you eat to see what your food does to you. Then change what you eat to improve the results next time. That’s basically it. So simple, but so incredibly effective and powerful if you think about it and then put it into practice. Naturally, everyone who uses it adapts it for themselves. I modified it for my own use. Of course, it is simplistic to concentrate only on blood glucose levels, as other aspects of nutrition had to be reviewed as I made those changes. But I always made blood glucose control the first priority.

Serendipity is a wonderful thing. These days I spend a lot of my time trying to persuade newly diagnosed diabetics to follow that testing advice and I am out-spoken on the effects of diet on diabetes, but I make no claims about diet and leukemia. But something odd happened. My CLL numbers also all improved since I took control of my diet.

For several years I was involved in the excellent ACOR mailing list for support and information for the CLL, eventually becoming one of the list managers. My improvement led to me resigning from that a year ago; it became increasingly difficult to see old friends passing away or in pain as I improved. If the Sword of Damocles drops and the numbers start rising again I’ll return, but for now I just see the haemo a couple of times a year and get on with the rest of my life.

My haematologists remind me that it’s serendipitous, but they also tell me to keep doing what I’m doing. That sounds like good advice to me, so I will.

PS This was the first of three posts I wrote as a guest columnist on dLife.com. I have received permission to re-post them on my blog so that they don't get lost with time.

Cheers, Alan
Everything in Moderation - Except Laughter

Snacks

One of the most common questions from newly diagnosed type 2s is "what can I eat as a snack".
What follows are just a few ideas based on my own menu and test results. Experiment, base your choices on the foods you like and develop your own choices to fill those "gotta have something" moments or to be sure you graze properly.

Nuts.
An occasional handful. My preferred mix is unsalted roasted cashews, brazils, hazelnuts, almonds and walnuts (or pecans). Peanuts are not nuts. 
 
Olives.
Eat them in any form you like. I stopped buying pitted olives because I ate too many at a time. I found that eating marinated whole olives slowed down my snacking because it takes a little longer when you have to munch around the seed. I buy them cheap in large bottles and add chopped hot chili, onion and herbs to my own liking to the bottle to flavour them.

Cheesy dips.
Check labels for carb content or make your own. Use low-carb crackers or vege strips as dippers.

Other dips.
Try guacamole, hommus and similar.

Avocado.
I slice an avocado in half, twist so that I have a free portion and a seed portion, put the seed half in the fridge for ‘Ron (later on:-), sprinkle a little salt and maybe a squirt of lime-juice on the other half and eat it direct from the shell with a teaspoon. If it’s a big one I may get four serves out of one. Another option is to spread avocado on a cracker.

Half and quarter portions of fruit.
A quarter or half portion of an apple or orange or pear or similar can fill that gap without leading to a BG spike, the leftovers become another snack later in the day.

Left-over salad from an earlier meal.
Makes another good ‘tween meal snack, dressed with a lttle balsamic vinegar and extra-virgin olive oil.

Crackers.
Check the carb content. I use a version that is 6gms carb per cracker and spread peanut butter or real butter with the secret Aussie wonder food on them. Consider fish (sardines, tuna etc) or cold cuts on crackers.

Celery and PB
I cut off a chunk and spread PB in the channel.

Pork Crackling/Crisps

There are several brands available now but they can be expensive. I am experimenting with making my own by buying the cheapest lump of pork with skin I can find. I skin it to make crackling snacks and slow cook the meat to be pulled pork or similar which can also be a snack on a cracker.

Boiled Eggs

Cook up a batch and store them in the fridge.

(up-dated 7^th March 2019)

Cheers Alan
Everything in Moderation - Except Laughter

Experts

One of the most difficult things about incurable conditions, like type 2 diabetes, and how to treat them is the variety of opinions available to us. The major diabetes authorities disagree over treatment, medications, diet, causes, and the right targets to aim for. Sometimes the differences are trivial, but at other times they can be very significant. It gets even more confusing when you get to the differences between those authorities and the pro-active patients out there in the real world struggling to beat this thing.

In the 6 1/2 years since I was diagnosed with diabetes I've asked many experts many questions. Most gave excellent answers. But some didn't answer at all; some ignored my questions and only gave answers to the questions I hadn't asked but that they wanted to answer; and some gave me answers that were more like orders and made my condition worse. Most of the latter group were dieticians.

Asking experts is excellent advice. Believing experts as though they are infallibly beyond question is not.

To learn in any field, ask many experts, not one. When you do that you will find confusion, because they won't all agree. It is up to you to read and learn enough to be able to assess the worth of their advice and decide which expert's advice to trust and which to discard, and also to pass all the advice that you get through the filter of your own common sense.

Remember that not all experts have to have letters after their name; experience and expertise can make an expert. A relevant example that comes to mind is Gretchen Becker, a "Patient Expert" who I learned a lot from myself. Another would be David Mendosa, or Jennifer of "test, test, test" fame, or Jenny Ruhl; and many others.

My most important point is one that I repeat to every newly diagnosed diabetic.

Never forget that the person who will be most affected by poor advice from any source will be you – not me, not your doctor, but you. In my opinion, more than nearly any other condition, the success of management of diabetes depends on the diabetic. So, while medics can advise and prescribe – it’s your decisions and your actions that will decide your future.

Cheers, Alan
Everything in Moderation - Except Laughter.

Analysis of a Day's Meals, Day 2

This is a quick follow-up to my previous post.

I performed another analysis today, mainly to see if any of the micronutrients below RDAs in the previous day's check had changed. Although I do this for my own benefit, I hope it helps those who are interested in doing a similar analysis of their own diet. It also helps refute the doomsayers who ignorantly claim that eating in a way that is primarily aimed at blood glucose management must mean I am missing out on good nutrition.

This time breakfast was a two-egg omelette with mushrooms, cheddar cheese, asparagus and onion; lunch was a cold chicken drumstick with a salad of lettuce, cherry tomatos, beetroot, apsaragus, yellow capsicum (peppers) and cheese; dinner was half of a large pork chop cooked on the BBQ with a small boiled potato in it's jacket, mashed pumpkin (winter squash), steamed broccoli, steamed green peas and a home-made tomato, garlic and onion sauce. The snacks and drinks through the course of the day were similar to last time, with the addition of a little more blue cheese and a cup of home-made yoghurt.

Here are the numbers for the macronutrients:
Item.....quantity unit......Average for two days
Calories.......2124 cal............2094
Protein............81 gm...........81 gm
Total Fat........132 gm.........121 gm
Sat. Fat...........53 gm..........45 gm
Mono. Fat........52 gm.........49 gm
Poly. Fat..........15 gm............15 gm
Carbohydrate..118 gm.......137 gm
Fiber................32 gm.........30 gm
Cholesterol...516 mgm...531 mgm

After combining the two menus and averaging the results, the only micronutrient still below RDA's was calcium. I haven't added in my bedtime Psyllium, Fibre, Muesli and Nuts; that will add about 200 calories, a lot of fibre and some more calcium in the form of some milk. However, I have decided to also add more Yoghurt to my future menus.

Cheers, Alan

Analysis of a Day's Meals

Every so often I take the time to examine and analyse a day’s meals. Not just by post-prandial blood glucose testing, because I do that much more frequently, but to see the actual macro and micro-nutrient content in case I need to change anything.

I don’t usually count carbs. In the past, when I have performed this exercise, I found that I can vary anywhere from 50gms to over 200gms in a day but I am usually around the 100-150 range.

So, just for fun, this was yesterday. Breakfast was a two-egg omelette that included some sautéd mushrooms and spring onion. Lunch was an open sandwich on a single slice of multigrain, spread with English mustard and topped with lettuce, a slice of ham, tomato and a little cheddar. Dinner was 1 ½ grilled chicken thighs (skin on) with cauliflower au gratin (with cheddar and parmesan), steamed broccoli, a small boiled potato soaked with a teaspoon of butter. Supper was a small serve of my Psyllium, Fibre, Muesli and Nuts mix.

Snacks were spread across the day and included a mandarin, four crackers (6gms carb each) and two slices of multigrain bread. On the various crackers and half-slices of bread I spread choices of squashed avocado, peanut butter, brie or vegemite in small portions. But not all at once :-)

Over the period of the day I had three mugs of good coffee, with cream, and three glasses of Shiraz.

When I analysed all those using an old program called DWIDB (mine is an old free version) I found that half of my calories and more than half of my carbs are actually in those snacks. That makes it easy to adjust if I am having too much or too little.

Here are the numbers for the macronutrients:

Item.....quantity unit
Calories.......2064 cal
Protein............81 gm
Total Fat........110 gm
Sat. Fat...........37 gm
Mono. Fat........46 gm
Poly. Fat..........15 gm
Carbohydrate..156 gm
Fiber................32 gm
Cholesterol.....546 gm

The calories are fine as far as I am concerned; I am a 6' male with a BMI of 28. Theoretically I should be under 25 according to the experts, but I am quite happy at that level. I've written previously why I am unconcerned at exceeding the ingested cholesterol RDA. Working out the proportions of calories from the three macronutrients that the dieticians love they come to this:

Protein 17%
Carbohydrate 32%
Fat 51% (including Sat Fat 17%)

I had not noticed before, but those numbers are not too far from Gannon and Nuttall's LOBAG 20/30 series; a little lower in protein, a little higher in carbs.

Just as interesting to me are the micronutrients. This shows why I don't add many supplements to my day, because I get more than I need from my menu for most things. The list doesn't include my psyllium mix so some of the numbers below RDA are actually a little higher. Similarly, I sprinkle a little salt on some things so that would increase the sodium figure.

Next week I will repeat the exercise with a different day's menu with red meats and fish instead of chicken, and a different selection of vegetables to see if the result changes for those items I've noted for review. If I find I need to increase something, I first attempt to do that with a food rather than a supplement. For example, I would expect to find my B12 is OK because on several other days I eat red meat. However, if that calcium figure is still low on review I would consider adding more cheese or yoghurt before I add a supplement.

Vit. A 5011.07__IU 100% RDA
Vit. B6 2.09__mg 130% RDA
Vit. B12 1.71__mcg 86% RDA
Vit. C 184.54__mg 308% RDA
Vit. E 9.89__mg 124% RDA
Thiamine 1.31__mg 119% RDA
Folacin 383.37__mcg 213% RDA
Riboflavin 1.88__mg 144% RDA
Niacin 22.86__mg 152% RDA
Panto. Acid 6.89__mg 138% SA
Calcium 482.58__mg 40% RDA
Copper 1.41__mg 71% SA
Iron 13.19__mg 88% RDA
Magnesium 329.75__mg 118% RDA
Manganese 4.84__mg 161% SA
Phosphorus 1038.40__mg 87% RDA
Potassium 3499.55__mg 175% RDA
Selenium 77.82__mcg 141% RDA
Sodium 1497.73__mg 62% SA
Zinc 8.58__mg 71% RDA
Tyrosine 5.11__gm 533% RDA
Lysine 11.32__gm 1572% RDA
Phenylalanine 6.28__gm 654% RDA
Leucine 11.54__gm 1202% RDA
Valine 7.52__gm 895% RDA
Methionine 3.68__gm 1228% RDA
Cystine 1.96__gm 654% RDA
Tryptophan 1.75__gm 971% RDA
Threonine 6.24__gm 1300% RDA
Isoleucine 6.92__gm 961% RDA

Most people don't have the time to do this sort of analysis, but for a retired person like myself it is an interesting exercise.

Cheers, Alan
Everything in Moderation - Except laughter

Eggs, Carbs and Cholesterol

On the various forums I visit one of the most common things I see when people describe their low-carb breakfasts is "egg-beaters" or other yolk-less forms of eggs. When I query them on the reasons, their fear is almost always that the cholesterol in eggs would raise their cholesterol levels.

Well, it appears that they may be partially correct if you eat a low-fat diet, but if you eat eggs as part of a reduced carb diet the cholesterol that is raised is the GOOD cholesterol, HDL. This article is from J. Nutr. 138:272-276, February 2008:

Dietary Cholesterol from Eggs Increases Plasma HDL Cholesterol in Overweight Men Consuming a Carbohydrate-Restricted Diet

Here is the abstract, I've edited by adding para breaks for clarity and to get past blogger's html gremlins; the comments in black are my own.

"Carbohydrate-restricted diets (CRD) significantly decrease body weight and independently improve plasma triglycerides (TG) and HDL cholesterol (HDL-C). [An interesting statement in itself.]

Increasing intake of dietary cholesterol from eggs in the context of a low-fat diet maintains the LDL cholesterol (LDL-C)/HDL-C for both hyper- and hypo-responders to dietary cholesterol. In this study, 28 overweight/obese male subjects (BMI = 25–37 kg/m2) aged 40–70 y were recruited to evaluate the contribution of dietary cholesterol from eggs in a CRD. Subjects were counseled to consume a CRD (10–15% energy from carbohydrate) and they were randomly allocated to the EGG group [intake of 3 eggs per day (640 mg/d additional dietary cholesterol)] or SUB group [equivalent amount of egg substitute (0 dietary cholesterol) per day]. Energy intake decreased in both groups from 10,243 ± 4040 to 7968 ± 2401 kJ compared with baseline. All subjects irrespective of their assigned group had reduced body weight and waist circumference [The reduced-carb diet worked for ALL of them, regardless of egg intake].

Similarly, the plasma TG concentration was reduced from 1.34 ± 0.66 to 0.83 ± 0.30 mmol/L after 12 wk in all subjects. [That is a very significant decrease, the mg/dl equivalent is: "plasma TG concentration was reduced from 119±58 to 73±26 mg/dl after 12 wk in all subjects"] .

The plasma LDL-C concentration, as well as the LDL-C:HDL-C ratio, did not change during the intervention. In contrast, plasma HDL-C concentration increased in the EGG group from 1.23 ± 0.39 to 1.47 ± 0.38 mmol/L, whereas HDL-C did not change in the SUB group. Plasma glucose concentrations in fasting subjects did not change. Eighteen subjects were classified as having the metabolic syndrome (MetS) at the beginning of the study, whereas 3 subjects had that classification at the end. [Just a reminder - ALL were on the CRD] .

These results suggest that including eggs in a CRD results in increased HDL-C while decreasing the risk factors associated with MetS."

It also says quite a lot about the benefits of a Carbohydrate-restricted diet for Metabolic Syndrome; presumably another paper is on the way or recently published.

Have an omelette for breakfast tomorrow folks - and also notice the improvement in your peak post-breakfast BG's.

Cheers, Alan
Everything in Moderation - Except Laughter

Nutrition For Blokes

Over the years since diagnosis I learned from many people. I have mentioned some here in past posts, particularly Jennifer, who wrote the Test,test,test advice, and Quentin, who is a guy in New Zealand who wrote on alt.support.diabetes with an amazing knowledge of the various foods that are good for us, which micronutrients are available in different foods and how they can help us.

Unfortunately, in 2005, Quentin had a second diagnosis some years after his type 2 was diagnosed. He has an aggressive form of multiple myeloma, a terrible condition which he has found is unaffected by diet. Despite that he is defying the odds and he is still with us, although he is very ill. My wife and I spent a pleasant afternoon and evening with him in early 2006 when we were on a holiday to the North Island. He was happiest when showing us around his small but very productive garden, describing the fruits and vegetables he was growing and what their benefits were.

After that diagnosis many of his friends urged him to write a book on nutrition. It was published earlier this year, with a very limited circulation in New Zealand; a few of us in other parts of the world also bought it direct from him. He aimed it at men in his country and titled it “Nutrition for Blokes”. I bought my own copy from Quentin as soon as it was available.

A friend of mine, Jenny Ruhl, has just let me know that Quentin’s book is now available via the web. If anyone is interested in obtaining it, here is the web-site: Nutrition for Blokes



Just for the record, I have no financial interest of any sort in Quentin or his book. However, I thoroughly recommend his book to all, not just to "blokes".

Cheers, Alan
Everything in Moderation - Except laughter

Be Smart, Be Skeptical

The internet is a wonderful and empowering tool for us in this modern age. I am very grateful that it was available to me as a source of knowledge when I first decided to learn about diabetes. There is no way I would have been able to educate myself in the same way from courses, libraries and local support groups. Apart from the time involved, I simply would not have had the motivation to go out and find all of those sources. The internet made it simple and easy. However, the net also has it’s dangers. All of us realise that there is a lot of nonsense on the web and that we must filter the good from the bad. However, sometimes that becomes more difficult when we are reading "real people" on support forums.

On medical support forums there is a tendency to accept all new people as genuine. When someone arrives telling their story, or seeking help, our natural reaction is to believe them and offer our support and assistance or accept their story of success or woe.

Over a few years of wandering the web and the net, reading and posting on medically-oriented groups, I have found that cyber-space has a population of fringe-dwellers; kooks and fanatics who have discovered their divine purpose in life is to convert us to their own beliefs. That belief can be a cure for all our ills with herbal potions or vegan diets or magnetic rings or even stranger gizmos; or the one true religion; or the dangers of ingesting everything from artificial sweeteners to drinking water to eating meat.

Often they are easy to pick. The most common are dupes of snake-oil salesmen; either trying to convince others to reassure their own wavering beliefs, or sucked into yet another multi-level-marketing scheme for yet another wonderful cure. As the FCA warns us, Be Smart, Be Skeptical (click on any link after you've read the opening page). However, sometimes they are more cunning or devious, using search engines to alert them whenever key words appear on the net. For example, if you post a message to your favourite web forum with "aspartame" or "stevia" in the title or text you have a pretty good chance of getting a response quickly telling you of the terrible dangers of the first or the wonderful benefits of the latter. Usually from someone who has never posted to your forum before.

Similarly, if you include "PCRM" or "PETA" or "Vegan" or "Dr Neil Barnard" or "McDougal" in your title or text you can almost guarantee that a new person will arrive, usually in a separate thread, giving a glowing report of the benefits of a Vegan diet. They may remain for a week or two, then they disappear forever. Until the next time those words are used and another new person appears. Almost certainly the person posting is a figment of the author’s imagination, created to spread the word.

I have used the anti-aspartame and PCRM kooks as examples, but there are many others.

There is so much of value we can learn from the net, but always treat free medical advice as worth the price you paid for it until you have checked it with your doctor. For all other advice on the web use your common sense and logic.

Be smart, be skeptical.

Cheers, Alan

How Often Should We Test?

Over the past few years there have been some truly abysmal scientific research papers published on the futility of frequent self-testing by type 2 diabetics. Three that come to mind are The Fremantle Diabetes Study from Western Australia, Self-monitoring in Type 2 diabetes: a randomized trial of reimbursement policy from Canada; and Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial from the UK.

All of these papers have three things in common: they were published in countries where the government subsidises test strip supplies to diabetics, and thus has an interest in cutting health budget costs; they considered testing more than once a day to be "frequent"; and they did not educate the subjects being studied on how to interpret test results with a view to adjusting their lifestyle to improve results. I previously discussed the UK paper by Farmer et al in Self-Testing and Type 2 Management a year ago. Those same comments apply to all those papers.

The ignorance of the mainstream medical establishment concerning the benefits that can be gained from systematic self-monitoring of blood glucose appals me. Worse than that, many doctors and diabetes educators seem to feel that "obsessive" testing is much more dangerous to our health than the possibility of amputation, blindness or kidney failure so they actively discourage newly diagnosed diabetics from testing more than a couple of times per day - and usually only for fasting or pre-meal.

That fear of obsession is misplaced. I believe that it is partly due to two things. The first is the ignorant assumption that extra tests only lead to extra worry. My experience has been that, after newly-diagnosed type 2s discover that they can actually improve their test results by modifying their diet or lifestyle, worry is reduced. Action conquers fear. To me, the tests that lead to worry are those ordered by the doctors; the tests their patients do religiously for fasting and pre-meal that tell the patient nothing and that the doctor barely glances at during the next consultation.

The second reason is the equally ignorant assumption that those doing the extra tests will continue doing them frequently forever.

I always test with a purpose, to either learn or confirm knowledge. When I first read Test, Test, Test I put it into practice - totally. For a short period I tested before EVERY meal and snack, then at one hour after the last bite and then at two hours. On some days I tested over 20 times; that period also taught me how to achieve Painless Pricks.

But that was just the start. Very quickly I found that some tests became very predictable. I quickly dropped my pre-meal tests as unnecessary when I could predict them with good accuracy. Then, as I discovered that my own peak post-prandial time is one hour after I finish eating, I dropped the two-hour tests unless the one-hour was unusual. Within a couple of weeks I was testing fasting and my peak post-prandial after every meal or snack, usually 6-8 times daily.

With time those tests became predictable too, as I slowly modified my diet from disastrous (as taught to me by the dieticians) to low-spike using Test, Review, Adjust. Within a few months I was testing only 1-4 times daily.

Now that my personal data base of food BG effects is fairly comprehensive I only test for "maintenance", to check that things haven't changed. For several days I may not test at all, others I may test 3 or 4 times if trying a new recipe or menu.

I consider the invention and development of the blood glucose test meter one of the true miracles of modern science for diabetes self-management; a wonderful benefit for all diabetics. But, sadly, after over three decades of continual development and improvement of meters the medical establishment still has not come to terms with the correct ways to educate patients in their use.

Cheers, Alan
Everything in Moderation - Except Laughter

Past, Present and Future

When diagnosed with a serious chronic condition, it's a totally human reaction to immediately ask "Why me?" and to start reviewing all of the things that happened in the past to blame for this new affliction. We look for the cause. Was it lack of exercise, obesity, diet, genes or exposure to chemicals? Or was it unsafe work conditions, the government, alien experiments or cosmic rays? Who or what should we blame?

After a while most of us realise that the right people to ask those questions are researchers and doctors seeking new treatments and cures. But for the newly diagnosed diabetic, in the immediacy of deciding what to do now, those questions are irrelevant unless we are still doing whatever it was that was a problem.

When I got over the "Why me?" stage my logic was simple. Once I knew I had diabetes the past was irrelevant to me. I didn't care why I got it, I cared about what to do next.

I read everything I could find and understood some of it. My reading showed that several factors were likely to shorten my life or make it less enjoyable by causing complications. Among other things a few stood out: uncontrolled blood glucose, smoking, lack of exercise, obesity and poor nutrition. All of those were things I could change myself.

I also found from various scientific articles that these factors could be cumulative in their effect. Maybe not always for diabetes, but for long term health in other ways. And diabetes is not my only affliction.

Thus blood glucose control, while a priority, was not enough if I continued to be fat or smoke or be sedentary or eat poorly. Each was a factor, each unchecked could exacerbate the others.

I had ceased smoking the year prior to diagnosis but from that moment on I started acting on all of the other factors.

As I said, the past was irrelevant. Why I was now a diabetic was purely academic. What I was going to do about it was not. Focus on your future, not your past, and do things in the present to achieve the future you want.

Just my opinion.

Cheers, Alan

Everything in Moderation - Except Laughter.

The Price of Eating Healthy

Money can be tight in these troubled times of bank closures and uncertainty. As well as medical costs, this response I received recently when I suggested adding more vegetables and fish to a menu for a new type 2 is typical of many: "But eating lower carb versions of food is EXPENSIVE. I know some people say that eating healthy is not any more expensive than eating cheap but they are full of it."

I found that I actually saved money when we started "eating healthy". But I had to work at it, because it takes a little planning and effort. To start with, I ate less than I did in the past ; significantly less for some foods. That didn’t cover the higher costs of some new foods like asparagas, avocado and similar, but I certainly saved on breads, potatoes, corn, rice and similar starches. I also saved a lot on meat, by eating a lot less than I did in the past, and by not purchasing a lot of processed sauces and packet foods.

Money isn’t everything; there are other costs such as time. I accepted that part of the price for better health was a little more time spent in the kitchen. I write more on that here: Cooking as a Survival Skill

Thus, I accept some additional inconvenience. Cooking more at home also saves on the costs of eating out or fast-foods. It is always cheaper to cook at home even if you cook the same things as the fast-food places such as hamburgers or fried fish. But it does take more time and work.

However, there are ways to use time efficiently there too. Once I was already spending more time in the kitchen, I looked at ways of economising money and time. One major way to do that is to both buy and cook in bulk. An investment in a freezer and microwave will repay you many times over in being able to buy freezable ingredients in season when prices are low and store them appropriately for later use.

I buy meats and fish in bulk packs from the butcher. For example, I bought five kilos (11lbs) of rump (flank) steak as an uncut lump of meat from the butcher a couple of weeks ago. At home I sliced the premium parts, trimmed of fat, into a large number of small 100gm (4oz) steaks. I trimmed the scrappier bits and cut them roughly into 2.5cm (1") cubes for stews. I then cling-wrapped each individual steak and 1/2Kg(1lb) lots of stew chunks for freezing for future use. When I need a steak in the future it’s there in the freezer ready for me. Later I spent a Saturday afternoon cooking up stews, casseroles and soups in bulk, freezing the results in single-serve containers. When it comes time to eat those I've got a meal via the microwave in minutes that is cheaper, faster, healthier and tastier than anything from a restaurant. I do the same thing for fish, chicken and pork, waiting until "specials" appear for bulk lots, or a seasonal glut occurs, and purchasing then.

Many vegetables and fruits can be bulk cooked and frozen too. I buy (or grow) in season veges like tomatoes, silver-beet (similar to swiss chard, a good spinach substitute), sweet corn (I blanch and freeze 1/3 cob portions), string beans and several others. I buy mango, which can be very cheap in season here, or berries, and freeze those for later addition to home-made yoghurt. Some non-freezable veges can be stored longer in the fridge with little tricks like blanching.

As well as eating less I waste less. The change in the level of waste in our rubbish bin was quite dramatic when we stopped buying processed packet foods and also started being stricter for portion sizes; allied to that we are much more aware of separating scraps for the compost bin to help grow some of our own veges, another way to save on food costs for those with the luxury of some backyard or even planter pot space to do so.

We, as a couple, took the time to compare grocery bills from before my diagnosis and a couple of years later. Despite inflation, we were paying slightly less for our weekly food while eating healthier and tastier.

In the end, everything has a price. The cost may be calculated in dollars, health, time, or some other currency. What it boils down to is whether the goals we set for ourselves are worth the price. Each of us has to make that decision, but it helps if you truly calculate the cost.

Cheers, Alan
Everything in Moderation - Except laughter

Eating Out

In this fast, convenience society of ours we eat out so much more than our parents did. One of the most frequently asked questions by newly diagnosed type 2 diabetics is "what can I eat when I eat out?".

I just went around the world for seven weeks via nine cuisines. Every meal was eating out; but I didn’t put on weight and my blood glucose levels were good as I travelled. Here are some of the tips that I’ve learned, to make sure I don’t undo the good work I’ve done at home when I’m eating out.

1. Be strong. We were brought up to clean our plate, not to waste food. But now that "waste not, want not" attitude to food on our plate that can kill us. Be strong enough to leave food on your plate even though you paid for it.

2. Order appetisers or soups. One is often enough for a meal, but if it isn't have a second appetiser. Or a soup. In the USA, UK and Australia I very rarely order a main course. In other countries the serve sizes tend to be smaller but I still often left food on the plate.

3. Make it clear to the waiter or server that you absolutely do NOT want chips/fries even though they are included with the meal. Often they will substitute vegetables or salad if you ask. If unwanted foods do appear, it can sometimes help if you transfer them to a side plate and then ignore them.

4. Avoid fast-food franchises where possible; although in some countries they can be useful for other things such as clean conveniences. In that case I order the least dangerous food item I can to "pay" for using them; whether or not I eat it depends on the situation. Actually, I quite liked McAloo Tikki in India the one time I tried it. Then I read the nutrition detail when I got home. I won't be trying it again.

5. Don't ask for low-carb or diabetic meals. Both will only confuse your waiter. Just pick the best you can from the menu and do what you can to modify it easily, such as substituting vegetables for fries or potatoes and similar.

6. When fast food is the only choice, be strong again. Eat the burger, toss the bun. Don't order up. Don't drink post-mix sodas - you have no control over which button the waiter presses or even which line is connected to the diet soda when they run out of diet syrup. If you can't buy a bottle or can - drink water or coffee or tea, with sweetener if necessary, not sugar.

7. If you eat at a restaurant you are likely to return to, test one hour afterwards to see what happened. That may affect your decision on returning or your menu selection when you do. Test, don't guess.

8. If possible, share meals with a partner. Order one meal, extra cutlery and an empty plate, then split it. Where it isn’t possible because of language barriers or embarrassment of others order a main course and a side salad or starter – just to get the plate – then mix between the two.

9. For low-carb breakfasts, many European hotels include buffets where you can choose appropriately. In the USA and UK, if an appropriate breakfast is not available or prohibitively expensive, I check out the local area on an evening walk after arrival and note where any diners or breakfast cafes are. Bacon and eggs at the diner or a "Full English Breakfast" minus it's carbs at a cafe not only may be cheaper but the walk there and back can be part of the day's exercise.

10. If in Asia - leave almost all of the rice on the plate.

Use your imagination, but always remember that the portion sizes on your plate are chosen by the chef to entice you to return, not by your doctor to improve your health.

Cheers, Alan

Money, Medications and Motives

From the New York Times, June 8, 2008

Researchers Fail to Reveal Full Drug Pay

"A world-renowned Harvard child psychiatrist whose work has helped fuel an explosion in the use of powerful antipsychotic medicines in children earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but for years did not report much of this income to university officials, according to information given Congressional investigators."

"In the last 25 years, drug and device makers have displaced the federal government as the primary source of research financing, and industry support is vital to many university research programs. But as corporate research executives recruit the brightest scientists, their brethren in marketing departments have discovered that some of these same scientists can be terrific pitchmen."

Corruption always smells putrid.

We are in a catch-22 that is difficult to resolve. Research is expensive, very expensive. Medicine has changed to the point where big pharma has become the most significant non-government funder of research; and in many fields it is more significant than government.

There is a very, very old cliche that is still unfortunately true. He who pays the piper calls the tune.

And make no mistake about it - big pharma is BIG.

Ten seconds on google found this: "Pfizer’s U.S. operations decreased last year as competition in the cholesterol market contributed to an 8 percent decline in revenues for the firm’s flagship product Lipitor. The company’s $48.6 billion 2007 total revenue was 1 percent better than its 2006 revenue of $48.4 billion."

That's just Pfizer. You can fund a lot of research with a tiny percentage of nearly 50 billion dollars. Of course, the company would never attach strings to that funding...yeah, right.

Now consider some of their competitors. I came across this list, it's not exhaustive:

* Baxter
* Bayer HealthCare, Diagnostics Division
* BD Medical Diabetes Care
* Eli Lilly and Company
* GlaxoSmithKline
* Lifescan, Inc., a Johnson & Johnson Company
* Merck & Co., Inc.
* Novo Nordisk Inc.
* Pfizer Inc.
* sanofi-aventis
* Takeda Pharmaceuticals North America, Inc.

Do your own googling to find out the revenues for those; this may help: Fortune 500 Industry: Pharmaceuticals. Add it up and you probably exceed the combined gross domestic product of half the countries in the United Nations.

So, is it any wonder that the funding for long-term studies into non-pharmaceutical aspects of diabetes or heart treatment, such as diet, BG testing and exercise, is minuscule compared to that for medication interventions such as ACCORD and ADVANCE?

Incidentally, I didn't need to google for that list. I found it here, at the top of the page: ADA FY06 Corporate Recognition Program. (2018 note: that link is now closed but can be found on the wayback machine)

I don't wish to imply that sponsorship or research funding necessarily means that influence is exerted. Without sponsorship many of the most worthy and useful support groups in the world would disappear and without research funding many of the miracles of modern medicine would never have been discovered. However, even when a funding source has impeccable integrity there is still an inherent problem that those receiving the funds will tend to investigate or promote in particular directions, mindful of the next project and the funding needed for that. There is nothing corrupt about that - it is simply reality.

Consequently, when organisations issue guidelines, or scientists publish the results of research, one of the first sections we should read is the "Funding Acknowledgements" section to include that information in our assessment of the merits of those guidelines or the validity of that research.

Cheers, Alan

ADVANCE and ACCORD

Today both the ACCORD and ADVANCE trials, and some editorials related to them, were published in the new England Journal of Medicine. They were massive studies covering thousands of subjects over long periods. The newspapers today are already trumpeting the news. News like this in the New York Times:
Tight Rein on Blood Sugar Has No Heart Benefits

I'm very disappointed by these studies. Not so much for the conclusions they drew, but for the ones that I believe they missed.

You can read them in full on the links. I've only had time for a very quick glance. I hope someone can show me where I'm wrong and point out where the valid conclusions are from these massive studies.
ACCORD
Effects of Intensive Glucose Lowering in Type 2 Diabetes The Action to Control Cardiovascular Risk in Diabetes Study Group

ADVANCE
Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes The ADVANCE Collaborative Group

New England Journal of Medicine Editorial
Intensive Glycemic Control in the ACCORD and ADVANCE Trials

New England Journal of Medicine Editorial
Glycemic Targets and Cardiovascular Disease

That second editorial is the better of the two in my opinion, and makes this point:
"In the ACCORD trial, patients in the intensive-therapy group who did not have a history of a cardiovascular event or whose baseline glycated hemoglobin level was below 8% had significantly fewer fatal and nonfatal cardiovascular events than did patients at higher risk. These findings suggest that intensive therapy was beneficial at least in this subgroup. Whether achieving glycemic targets below 7% will be beneficial to the vast majority of patients with type 2 diabetes and a low risk of cardiovascular disease remains another unanswered question."

This is a section from the first NEJM editorial, which didn't actually compare the two trials so much as attempt to make a conglomerate sense out of them. Judging by the snippet I include at the foot of one of their conclusions, I believe they failed.

"Two studies in this issue of the Journal — the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial7 (ClinicalTrials.gov number, NCT00000620) and the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation) trial8 — sought to determine the effect of the lowering of glucose to near-normal levels on cardiovascular risk. Although the ACCORD and ADVANCE trials both compared intensive and standard glucose-lowering targets in type 2 diabetes, the trials differed substantially (Table 1). Most patients in both studies received drugs from a variety of classes, with or without insulin. However, in the ACCORD study, there were no restrictions on glucose-lowering treatments to reach glycemic targets, whereas in the ADVANCE study, all patients in the intensive-control group were required to receive the sulfonylurea gliclazide (modified release) at initiation. Thiazolidinedione treatment was infrequent during the ADVANCE ."
And they note:
"Neither study appears to have emphasized lifestyle or dietary modification."

In other words, both studies ignored that as a means of lowering A1c to their respective targets or even of assisting the meds. I know from past discussions that ACCORD educated subjects in "adhering to" the standard low-fat high-carb dogma. My brief skim of both papers indicates that there were two major differences; ADVANCE covered a wider range of nationalities, and thus lifestyles, and both studies intensively used drugs, but different drugs. However, that was a very quick skim so I would be very interested in hearing opinions from others more analytical or more qualified than I.

And the NEJM analysis conclusions? In part:
"The most appropriate target for glycated hemoglobin should remain 7%, though lower individualized targets may be appropriate when the focus is primary prevention of macrovascular disease. When glycated hemoglobin values under 7% are the goal, clinicians will need to balance the incremental benefit of a reduction in microvascular events with the increased rates of adverse events; these patients may benefit from consultation with a specialist.

*sigh*

These studies could have achieved so much and they actually achieved so little. Worse than that, the scientists are missing a point that to me is blindingly obvious, and using that misunderstanding to reinforce an incorrect conclusion.The conclusion that jumps out at me from just this cursory analysis of both papers is that attempting to use medications to drive down type 2 diabetes glycemic levels without individually reviewing the appropriateness of the present dietary guidelines for each patient has inherent dangers clearly shown in ACCORD and shown to a lesser degree in ADVANCE.



Cheers, Alan

Grazing

"Ozgirl", a good friend on the alt.support.diabetes newsgroup, introduced me to "grazing" as a blood glucose management tool some years ago. She developed her own method to combat her pronounced reactive hypoglycemia and I found that the method was very effective.

As a diabetic one of my management goals is to try to keep my BG's as stable and as close to normal as I can. I found that eating the traditional "three square meals" daily caused problems and it became much easier when I broke those meals up into a series of smaller meals and snacks. Dinner is still my biggest meal, but the others are all small. And I rarely feel hungry.

My day goes something like this:

Breakfast, as soon as possible after waking, usually 5-6:30am.
Mid-morning, 10am, a small snack.
Lunch, around noon.
Mid-afternoon, a small snack.
Dinner, about 6pm.
An hour or two after dinner, a small snack
Bedtime supper.

Effectively I rarely go more than three hours without eating something, but the portion I eat is very small. When I say a small snack, that is the equivalent of half an apple, or a cracker with cheese, or a half-cup of yoghurt with berries; that's the sort of portion sizes I mean. Breakfast is equivalent to an egg or two and a slice of ham; lunch an open sandwich, or a soup, or a stir-fry or similar.

The total calories in the day are the same; they are just spread across the time more evenly. By testing after each of these snacks or small meals I've also found that I need to start with a very low carb breakfast but as I approach the evening I can eat higher carbohydrate snacks without spiking. That's why I can have my Psyllium, Fibre, Muesli and Nuts as a bedtime snack.

It works for me. Maybe it could work for you.

Cheers, Alan

What to Eat at First

Every so often a newly diagnosed person arrives on the various forums I read who has no meter and is unlikely to get one for a period. Of course, I suggest they don't delay in correcting that, but that doesn't help in the short term. So this page is some suggestions for people in that position. Not advice for a permanent menu, but as a temporary measure until a meter is available and blood glucose testing can be started.

These are broad guidelines that should help minimise post-meal blood glucose spikes without jeopardising overall nutrition. Note that these are just my opinion, I'm a diabetic, not a doctor. If you are on insulin you should discuss them with your doctor - but if you are on insulin you should also have a meter.

Minimise:

Anything made in a bakery.
Pasta.
Rice.
All wheat products.
All corn products.
All cereals and other processed grains.
Starches - especially root vegetables.
All sugared drinks - sodas, sport drinks, milk.
All juices.
All fast foods.
And ignore colour, fibre content, or advertising hype about wholegrain or low-GI.

Be wary of:

Fruits, good in small portions, possibly harmful in large portions.

Maximise

All vegetables, apart from root vegetables.

Use in appropriate portions:

Fish
Meats
Eggs
Beans
Nuts
Avocado

Those lists are not exhaustive but I think you'll pick up the trends.

Cheers, Alan

Is Testing Worthwhile?

I have friends in the UK who are finding it increasingly difficult to get adequate test strip supplies prescribed from their NHS surgeries to use self-monitoring of their blood glucose (SMBG) in the way that enabled them to gain control of their type 2 diabetes. I am fortunate to live in Australia where the NDSS subsidises test strips. However, I am becoming concerned at several poor "studies" conducted in Australia, Canada and the UK implying that SMBG is a waste of money and time and may also cause depression.

I suspect that it is no coincidence that all of those countries subsidise test strip supplies for diagnosed diabetics. I fear a concerted push by the "bean-counters" in our various health systems to cut costs in this area; a very short-sighted view of diabetes treament in my opinion. I am convinced that systematic use of SMBG to improve and maintain dietary control of type 2, complementary to any medication or insulin treatments, will lead to much greater savings in the long term in both the cost of treating complications and the overall social and economic costs to the community.

The most recent flawed study was published in the British Medical Journal: Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial The crux of the problem in this study lies in the following section.

First, I'll give the unabridged version, then highlight some points. You can save time by scrolling down to "This is the absolutely critical part".

From the study: "After an initial assessment visit, eligible patients were randomised into intervention (self monitoring of blood glucose) or control (no monitoring) groups with a randomly generated allocation code in consecutively numbered sealed envelopes. The study diabetes nurse at each hospital site performed the treatment allocation.

Patients in the self monitoring group were all provided with a single glucose monitor (Lifescan OneTouch Ultra; Johnson and Johnson, Milpitas, CA) and instructed in its use. They were asked to monitor four fasting and four postprandial capillary blood glucose measurements each week. They were advised on appropriate responses to high or low readings. Such advice included the need for dietary review or the suggestion of exercise (such as walking) in response to high readings.

At each clinic visit, concordance with the self monitoring regimen was verified by downloading meter readings.

Patients in the no monitoring group (control) were asked not to acquire a meter or perform monitoring for the duration of the study. Patients in both groups underwent an identical structured education programme involving diabetes nurse practitioners, dieticians, podiatrists, and medical staff. All patients were reviewed by the doctor, diabetes nurse practitioner, and dietician at three monthly intervals for one year. At each visit all aspects of diabetes care were reviewed including indices of glycaemic control (HbA1c for both groups and self monitoring results for the self monitoring group).

Patients in the self monitoring group received ongoing advice and support in the appropriate interpretation of and response to their capillary glucose results. We used an identical treatment algorithm for dietary and pharmacological management of glycaemia for both groups based on HbA1c targets (figure 1). Blood concentrations of HbA1c, lipids, and electrolytes were measured at or before each clinic and results were discussed with patients in the context of the treatment targets. Measurement of HbA1c was performed in the local hospital laboratory with a diabetes control and complications trial (DCCT) aligned HbA1c assay.2 All laboratories participated in HbA1c external quality assurance, which was satisfactory for the duration of the study. All other laboratory tests were also performed in the local hospital laboratory, where staff were blinded to treatment allocation."

This is the absolutely critical part:

"They were asked to monitor four fasting and four postprandial capillary blood glucose measurements each week. They were advised on appropriate responses to high or low readings. Such advice included the need for dietary review or the suggestion of exercise (such as walking) in responseto high readings."

What were the "appropriate" responses they used? What was that advice?

Some idea of what may have been advised appears here: "Patients in both groups underwent an identical structured education programme involving diabetes nurse practitioners, dieticians, podiatrists, and medical staff."

And what do we know of the education dietary programme provided by the NHS or Diabetes UK(see P788 table 2)? Basically it is low-fat, high carb and add more metformin or insulin to counter the carbs. On the use of meds, take a look at Table 5 noting the increase in medications across the board and the higher use of multiple medications in the SMBG group.

When these meter users tested at their random four post-prandials (or, at least, the 63 of 96 who actually tested 80% of the required four FBG and four PP weekly; meaning that 50% actually tested that much, almost certainly at two hours and well after their post-prandial spike), what did they do about it if it was high? Did they reduce carbs? Possible, but most unlikely if they complied with their advice. More likely they went for a walk or the doctor upped their metformin or added a med (see Figure 1 and Figure 5). And they probably missed most of their spikes anyway, often seeing only the reactive post-spike numbers at two hours.

So they did what they were told and their numbers didn't improve. No wonder they got depressed. I would have too. What was that old definition for insanity? "To continue to do the same thing and expect a different result."

In my opinion the control group weren't as depressed because they put themselves in the hands of their doctors - no personal responsibility for their plight. But the SMBG group felt they must share the blame for their poor response; especially those who were in the 50% who didn't do all the weekly tests.

The problem was not the SMBG but the ignorance of those conducting the research on how to best train the SMBG group on how to use the test results to improve the diet to improve results. This research follows the earlier and similar BMJ report from Farmer et al, which I note is listed as the 13th reference: Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial You will see my response to that in BMJ at the foot of that page. It is equally relevant to this load of nonsense. If you go to the ready response index you will find several other patient's and doctor's similar responses.

The only funding acknowledgement for this latest nonsense was "Funding: Northern Ireland research and development office. MC was employed as a research associate as part of the funding allocation. The blood glucose meters were supplied free of charge by Johnson and Johnson, Milpitas, CA." I am cynical enough to wonder how much of the funding effectively came from the bean-counters of the NHS.

Cheers, Alan

Everything in Moderation, Except Laughter