Cholesterol, Fats, Carbs, Statins and Exercise

The following random thoughts are just that - my thoughts, not facts. However, I have provided some selected cites for most of them. If you think I have been a little selective, I agree - I'm human and will spin things my way. So I've also given links to some medical search engines at the foot if you would like to do some further reading. Just one rule: papers funded by pharmaceutical companies, especially statin manufacturers, or written by authors with links to those companies have little credibility with me.

The cites are only representative of a lot of general reading. There are many more supporting papers out there. I am happy to hear from anyone with more specific papers on particular aspects - pro or con.

These thoughts are based on my own reading from many various sources over time. Lately I have found them reinforced in Taubes' book "Good Calories, Bad Calories", but most I had read before that from other sources.

1. Eating excessive carbohydrates leads to high triglycerides. The definition of "excessive" may depend on whether or not the diner has diabetes. Triglycerides are one of the three major reported components of the usual lipids panel, the other two being HDL and LDL. One that we should get but often don't is VLDL, the dangerous one; usually that is estimated by dividing the triglycerides by 5 (in mg/dl). But that estimate is very approximate.

2. LDL is considered by the mainstream medical establishment to be the bad cholesterol and most anti-cholesterol meds target that. But high triglycerides, high VLDL and low HDL are actually the ones we should be most concerned about.

3. The absolute number of our LDL is less important than the specific number of certain components of LDL; the dangerous ones are the small, dense particles. High triglycerides usually indicate high proportions of those small dense particles. Better indicators of our lipids health are VLDL and the apolipoproteins A1 and B.

4. ALL of the foods we eat affect our cholesterol levels. EXCESS of carbohydrates OR fats may lead to dyslipidemia.

5. The past research on the relationship between cholesterol and heart disease is misleading at best. There appears to be shaky support for the hypothesis that lowering cholesterol, particularly LDL, improves overall mortality and even less support for the use of statins to do that.

6. Inadequate dietary fat will lead to low HDL.

7. Exercise usually, but not always, helps increase HDL.

8. A low HDL is a better indicator of future cardiac problems than high LDL and apolipoprotein levels are a better predictor than either.

9. Diabetics should aim for a triglycerides to HDL ratio of less than 3.0 in mg/dl or 1.3 in mmol/l.

10. Cholesterol in the foods we eat such as eggs and seafood has an insignificant effect on the cholesterol in our blood stream.

11. Low LDL is also dangerous and can be related to other problems such as Parkinson's Disease, cancer and other causes of early death.

12. There is growing concern that the over-prescription of statins and limited but alarming research into their side effects needs a lot more investigation.

Putting that all together, I no longer worry about the level of fats in my diet for their affect on cholesterol. I am selective in my choices of oils, but for other reasons such as Omega 3 content or eliminating trans-fats. I also found that reducing carbohydrates reduced my triglycerides as well as my blood glucose levels. I also dropped my statin, lipitor, four years ago.

When you look back through that list, some things stand out to me. If I am going to worry about cholesterol at all, the two things that will improve it most are moderating carbohydrates for better triglycerides and increasing exercise for better HDL. It seems a happy coincidence that those are the same two things that improve my blood glucose levels most. Additionally, inclusion of some additional fats in my menu to replace those carbohydrates may also help increase HDL.

For those interested in further reading to support - or refute - my thoughts here are a few useful search engines: Google Advanced Scholar, Medline and Highwire.

Cheers, Alan

Everything in Moderation - Except Laughter.

Footnote:

Here are some additional references for you in no particular order. Most of these papers and articles apply to more than one of the points above, which is why I found it awkward to include them in the body. The titles tend to give the context.

Effects of a low-fat, high-carbohydrate diet on VLDL-triglyceride assembly, production, and clearance

Effect of Dietary Carbohydrate on Triglyceride Metabolism in Humans

Effects of a low-fat, high-carbohydrate diet on VLDL-triglyceride assembly, production, and clearance

Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes in the United States: an ecologic assessmentEffect of the Magnitude of Lipid Lowering on Risk of Elevated Liver Enzymes, Rhabdomyolysis, and Cancer

Exercise Prevents the Accumulation of Triglyceride-Rich Lipoproteins and Their Remnants Seen When Changing to a High-Carbohydrate Diet

Effects of Protein, Monounsaturated Fat, and Carbohydrate Intake on Blood Pressure and Serum Lipids

Carbohydrate-Induced Hypertriglyceridemia: An Insight into the Link between Plasma Insulin and Triglyceride Concentrations

A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia

Plasma high density lipoproteins HDL2, HDL3 and postheparin plasma lipases in relation to parameters of physical fitness.

Food, Farmers and Factories

When I offer suggestions on foods for newly diagnosed type 2 diabetics on various forums such as the ADA forum or the dLife forum I am occasionally accused of concentrating far too much on blood glucose levels and ignoring other aspects of nutrition. That is not true because I am very aware that our bodies need a wide range of micronutrients, vitamins and minerals for good health. I may post at some future time on that subject in general. I mention it in passing in several past posts such as Analysis of a Day's Meals and Cinnamon, Spices, Herbs and Similar. However, I agree that to me the first priority is to get those blood glucose levels under control. After that has been achieved is the time to fine tune the resulting way of eating for other aspects of good nutrition.

Today I want to look at another aspect of the foods we eat: processing, chemicals and sources.

When they go to the market or, more likely, the supermarket to buy food and groceries most new type 2 diabetics learn fairly quickly to read the nutrition labels to check on the carbohydrate, fat, and protein content of the portions they intend eating. However, I’ve noticed that very few go beyond that label to look at the actual ingredients list.

When you start doing that, it becomes clear that many of the foods in the packets on our shelves have a lot more in them than the foods mentioned on the front of the package.

The first one that stands out to me is trans-fats. Because many countries allow manufacturers to ignore an ingredient below a minimum threshold on the nutrition table you will often find "0 gms" listed for trans-fats but “partially hydrogenated oils” listed on the ingredients list. That means the product contains trans-fats, just less than that threshold for labelling laws. So my first suggestion is to avoid all products which do that. I know of no safe minimum level for trans-fats.

On other ingredients, I have slowly formed the opinion that simpler is better. Every day we see a new scare story on a food additive that is harming us, and every other day we see a refutation of past scare stories and find that foods we thought were harmful are not. It gets confusing, doesn’t it? What is a simple guy to believe?

I am not a chemist, just a type 2 diabetic struggling to find a reasonable way of eating that not only helps manage my blood glucose levels but does not jeopardise my health in other ways. Because I am not a chemist, I err on the side of simplicity. I am a firm believer in applying KISS (keep it simple, stupid) to my food choices.

Allied to that I have absorbed some basic principles from various writers on nutrition, particularly my friend Quentin Grady who is the author of Nutrition For Blokes. Probably the most important one is that there are many different foods, especially certain vegetables, which can provide some important specific benefits; too many to list here. My way of applying that information is to include as wide a variety of fresh vegetables and protein sources in my menu as I reasonably can, with an emphasis on local seasonal produce.

When I started reading the labels on packets more closely I found that I needed a degree in Chemistry to even start to understand some of them. Here are a few examples. As a simple guy I thought the breakfast sandwich I bought on the AMTRAK from DC to NYC was a small bun, with a slice of odd-looking bacon and an egg. Later, with nothing better to do on the train, I read the fine print on the wrapper:

Bacon, Egg & Cheese On A Biscuit
INGREDIENTS:
BISCUIT:
BLEACHED ENRICHED WHEAT FLOUR (MAY CONTAIN MALTED BARLEY FLOUR AND ENZYMES, CONTAINS NIACIN, REDUCED IRON, THIAMINE MONONITRATE [VITAMIN B1], RIBOFLAVIN [VITAMIN B2], FOLIC ACID), WATER, VEGETABLE SHORTENING (PARTIALLY HYDROGENATED SOYBEAN AND/OR COTTONSEED OILS, NATURAL AND ARTIFICIAL FLAVOR, BETA CAROTENE [COLOR]), DRY BUTTERMILK, DEXTROSE, CONTAINS 2% OR LESS OF THE FOLLOWING: SODIUM BICARBONATE, SODIUM ALUMINUM PHOSPHATE, SALT, VITAL WHEAT GLUTEN, SODIUM ACID PYROPHOSPHATE, PRESERVATIVES (CALCIUM PROPIONATE, POTASSIUM SORBATE, SORBIC ACID), XANTHAN GUM.

PRECOOKED EGG PATTY:
WHOLE EGGS, WATER, SOYBEAN OIL, NONFAT DRY MILK, MODIFIED FOOD STARCH, SALT, XANTHAN GUM, NATURAL AND ARTIFICIAL BUTTER FLAVOR (BUTTER [CREAM, MILK], PARTIALLY HYDROGENATED SOYBEAN AND COTTONSEED OIL, SOYBEAN OIL, LIPOLYZED BUTTER OIL, NATURAL AND ARTIFICIAL FLAVORS), CITRIC ACID. PASTEURIZED PROCESS

AMERICAN CHEESE:
AMERICAN CHEESE (CULTURED MILK, SALT, ENZYMES, ARTIFICIAL COLOR), WATER, CREAM, SODIUM CITRATE, SALT, SODIUM PHOSPHATE, SORBIC ACID (PRESERVATIVE), LACTIC ACID, SOY LECITHIN, ARTIFICIAL COLOR.

BACON CURED WITH:
WATER, SALT, SUGAR, SMOKE FLAVORING, SODIUM PHOSPHATE, SODIUM ERYTHORBATE, SODIUM NITRITE. CONTAINS EGG, MILK, SOY AND WHEAT

How did they get all that in that little biscuit? Incidentally, the nutrition table notes 3 gms trans-fat per serve.

Or are you one of the lucky diabetics who can still eat cereal for breakfast? Special K Protein Plus looks good, right? Here is the ingredients list, from the Special K web-site:

Ingredients
WHEAT BRAN, SOY GRITS, RICE, WHEAT GLUTEN, SOYBEAN OIL, WHOLE GRAIN WHEAT, SOY PROTEIN ISOLATE, SUGAR, SALT, HIGH FRUCTOSE CORN SYRUP, MALT FLAVOR, NATURAL AND ARTIFICIAL FLAVOR, ASCORBIC ACID (VITAMIN C), SUCRALOSE, ALPHA TOCOPHEROL ACETATE (VITAMIN E), REDUCED IRON, NIACINAMIDE, PYRIDOXINE HYDROCHLORIDE (VITAMIN B6), RIBOFLAVIN (VITAMIN B2), THIAMIN HYDROCHLORIDE (VITAMIN B1), VITAMIN A PALMITATE, FOLIC ACID AND VITAMIN B12, TO MAINTAIN QUALITY, BHT HAS BEEN ADDED TO PACKAGING.

But I’m being a bit unfair, just looking at breakfasts. How about a simple, healthy, dinner from Lean Cuisine? I looked for a random example, Balsamic Glazed Chicken looked tasty:

Ingredients:
Blanched Enriched Orzo Pasta (Semolina, Niacin, Ferrous Sulfate, Thiamin Mononitrate, Riboflavin, Folic Acid), Green Beans, Cooked Chicken Tenderloin (Chicken Tenderloins, Water, Seasoning (Modified Food Starch, Sugar, Potassium Chloride, Yeast Extract, Dextrose, Spice, Onion Powder, Paprika), Isolated Soy Protein, Salt, Sodium Phosphates), Water, Spinach, Onions, Red Peppers, Yellow Peppers, Dark Sweet Cherry Juice Concentrate, Parmesan Cheese (Cultured Milk, Salt, Enzymes), Almonds, Dark Balsamic Vinegar, Modified Cornstarch, Balsamic Vinegar (Grapes, Invert Sugar), Soybean Oil, Butterfat, Sugar, Garlic Puree, Asiago Cheese (Cultured Milk, Salt, Enzymes), Salt, Brown Sugar Syrup, Enzyme Modified Parmesan Cheese (Cultured Milk, Water, Salt, Enzymes), Whey Protein Concentrate, Spices.

I am not saying any of those ingredients are bad for you. The point is that I am not qualified to know and I don’t want to discover ten years from now that I should not have been eating one of them when I get diagnosed with something nasty.

Here is just one example of late discoveries. Note in those lists that all of them include wheat and soy in one form or another. Now read Jenny Ruhl’s recent blog on that subject: Wheat May Be Sparking Autoimmune Type 1 Thanks to Soy in Our Diets

Do a little research and look up your own examples. Better still read the labels on the packets in your pantry. You will get some surprises.

Over the years I have developed a few general basic principles that I apply when choosing the foods I eat. I don’t get obsessive or religious about it, but when it is reasonably possible I apply these criteria when I am shopping:

1. I choose foods that owe more to the farmer than to the factory for their production.

2. I choose as wide a variety as I can of local seasonal vegetables, when possible, and fresh vegetables over frozen (there are exceptions).

3. I take the time (and my glasses) to read labels in detail. If I don’t know what an ingredient is, I don’t buy that product until I’ve looked it up. Usually I don’t bother to look it up, so that product isn’t bought.

4. For meat, fish and eggs, I choose range-fed over feed-lot, free-range over caged birds, wild fish over farmed.

5. I cook and eat at home more often than out.

6. When eating out I choose restaurants that cook from basics rather than restaurants that re-heat from the freezer.

Those are just the basics, obviously I include other factors such as carb content.

What criteria do you use?

Cheers, Alan
Everything in Moderation - Except Laughter.

Swine Flu, Diabetes and Good Sense

I have become increasingly concerned about the implications of the H1N1, or Swine Flu, epidemic for people with conditions such as diabetes which weaken their immune systems.

I was initially quite dismissive of the danger. I also have hypogammaglobulinemia. I travelled around the world during the SARS scare and wandered places like Cambodia, India, Egypt and Mexico last year without catching anything. Living in a small seaside village I had taken a pretty casual view of the pandemic until it hit my own family members down south in Melbourne. The good news is that they have recovered well, but that tended to grab my attention.

So I checked on some statistics. And I was shocked.

Australians are travellers, both internationally and domestically. Consequently viruses can very swiftly jump between continents and states, city and country. We started with a few minor cases despite fairly strict precautions at airports. Then we had a cruise ship infected which dropped passengers in Brisbane and Sydney. Then it hit Melbourne and spread like wild-fire; but it's not just in the big cities, we have had cases dotted all over, from the bush to the outback.

For Australia the difference between the statistics in May and today, as we passed through our winter, are quite dramatic. These are the official statistics from the Australian Government Department of Health through the Australian winter:
[note: up-dated 11th October - Alan]

_____________Cases____Deaths
17-May-09______30_______1
14-Jun-09_____1515____not given
17-Jul-09_____11962______31
12-Aug-09____28307_____100
17-Sep-09____36210_____172
09-Oct-09____36895_____185

Surprisingly those numbers have not really been making big news headlines in my town. Maybe we have become desensitised to news on subjects like this; I certainly had.

For readers outside Australia this web-site appears up to date and accurate: http://www.flucount.org/. You will notice that although the USA has the worst numbers, those in Australia and South America are disproportionately high on a population comparison. Considering that America has a population of over 300 million and Australia is a little over 21 million this list of the top three is a worry:

Most Infected Countries:
[up-dated 11th October]

United States: 44555 cases, 821 deaths
Australia: 36895 cases, 185 deaths
Mexico: 36593 cases, 248 deaths

A couple of things stand out. The higher proportional numbers south of the Equator indicate that the winter season definitely accelerates the rate of infection. A surprising point in the Northern Hemisphere statistics is the difference in death rate between European countries and North America. It looks like US medical staff would be wise to spend some time chatting to those in Germany and Greece. So would ours. Americans and Europeans should pray that the virus loses its present dramatic ability to spread before the northern winter.

The good news is that it is not as deadly as first thought in the general population; the bad news is that it is rather dangerous for those with reduced immune systems such as people with other illnesses or for pregnant women.

Getting back to diabetes, a reduced immune system can be one of the side effects of our condition. I don't suggest that we should panic but we should certainly be aware of those around us and the risks from this virus.

As a consequence of my hypogammaglobulinemia I have always taken a little extra care with my personal hygiene when travelling. I don't suggest that you need to become as obsessive as Adrian Monk, but there are times when I could be mistaken for him. For example, I never touch any exposed surface in a public lavatory or a doctor's office or reception with my bare skin; whether that is my hands or any other part of my anatomy. I have little habits I have developed for that, such as carrying my own pen for signing forms in the doctor's reception or in a pharmacy. Consider the person who touched that pen before you, and why they may have been seeing the doctor or chemist.

I can't improve much on the excellent advice in this Australian Government H1N1 page for Individuals and households. I suggest you read that and adapt it for your own situation.

Once again I don't think it is cause for panic, just for good sense and caution. It certainly won't stop me travelling. My other affliction, wanderlust, has struck again and we are off to New Caledonia for 8 days on Saturday. I've also bought the tickets to go to South America next March; provided that they'll let me in while this pandemic is happening.

Cheers, Alan
Everything in Moderation - Except Laughter.

Lancet Change - St Swithun's Day

Today, July 15th, is St Swithun's Day.

When I first started learning about diabetes on misc.health.diabetes I discovered that most of the old-timers changed their lancets rarely. Most could not remember the last time they changed it, because they only bothered if it started to get dull or they were testing someone else.

Consequently, the practice of announcing that it was time for the annual lancet change on St Swithun's Day became traditional. Whether the change was needed or not.

So I have decided to continue the tradition.

Today is lancet-change day; even if your lancet is nearly brand new and has only been in use for a few months or a few hundred tests. I must admit I can't remember when I last changed mine.

I intend to hold a small ceremony, involving a nice glass of Shiraz, an hour after dinner before I test :-)

PS. For those who are changing their lancets every time they test, please read Painless Pricks.

Cheers, Alan

Everything in Moderation - Except Laughter.

Testimonials

This is a request for feed-back from any readers, past or present, here or on various diabetes forums, who believe that reading my ideas may have helped you.

I don't intend to make requests like this often, this is the first and only. But at this time some testimonials could be rather useful for me.

I started this blog just under three years ago. It grew from a need to find a way to archive some of the responses I was making on the ADA forum and other less active forums. I needed a way to be able to refer newly diagnosed people to some basic ideas. I found I was repeatedly typing much the same suggestions each day to each new person. As a two-finger typist that was getting to be a bit of a chore. Using the blog I could change that to a brief greeting and "please read Getting Started". Yeah, I know, I'm just lazy. But it worked and it let me write to many more people.

Slowly, it grew. I added the contents index on the side-bar because this blog is not just an occasional collection of my thoughts and opinions but also a reference source for myself and others who choose to use it that way. I recently added site-meter and was quite surprised to find that the blog is averaging 4000 different visitors a month, with 10,000 page views. One in four are repeat visitors; although the majority are from the USA, UK, Canada, Australia and New Zealand visitors have come from over 60 countries.

A number of people suggested that I should collect some of these ideas in a book intended for type 2 diabetics who do not have web access or who are uncomfortable with using the internet. I started drafting that book last Christmas, but I have found it a slow process because it is a new experience for me. This blog is the only form of published writing I have ever done; I find I am continually revising the presentation and content of the book.

However, I expect to finish it within a couple of months. Then I will need to decide whether to seek a publisher or to self-publish; another field in which I am a babe in the woods. But I can learn.

It could help a great deal if I can present a publisher with a few testimonials from past readers, or, if I self-publish, I could include those testimonials in the opening pages.

If you decide to post a comment, be aware that I will presume that in posting you are giving permission to include that comment, or a section from it, in the appropriate section of the book. I will be contacting those who have sent private emails in the past to seek their permission.

Thanks in advance,

Cheers, Alan

Everything in Moderation - Except Laughter.

Choices, Consequences and Responsibility

Life is full of choices. Diabetes is one of those conditions where we are presented with many choices. From the start we have to choose who to listen to, who to ignore, what foods to eat, what exercise to do, what medications to take; the list goes on and on.

Naturally we seek qualified professional advice to help us make those choices. Some of us place our lives in the hands of those advisors, some of us use them as just one source of information and seek input from others such as other diabetics, support groups, forums, the internet, blogs, books and similar to assist us.

But that has dangers. There is an awful lot of dangerous nonsense on the web. That is particularly true concerning diabetes, diet and medications. So we must filter those sources using common sense, research and our medical advisors to pick the good information from the rubbish.

There is no doubt that our medical advisors should be our first port of call and the source of the best information. We should value that source above all others. But sometimes that is not always true. Our medical advisors can only offer advice based on their training and professional experience; however, that training syllabus may not always be up to date. If it is current, the research leading to that training may still be continuing, making new discoveries that change the basic premises that advice is based on.

For example, the diagnostic blood glucose levels for diabetes have been steadily reducing over the past few decades. I was not diagnosed for several years when my fasting blood glucose levels were around 7.9mmol/l(140) but a diagnostic fasting blood glucose of 8 applied in Australia. Of course, when I was finally diagnosed the official level had come down to 7(126).

Similarly the guidelines for good blood glucose levels are slowly being reduced. Despite that I see many people reporting their doctors quoting the old ADA guidelines of 2hr post-meal BGs of less than 180 as "tight control" or that it does not matter how high the peak BG spike is, provided that your 2hr BGs have returned to an acceptable level. I mentioned earlier the nonsense we hear from many official sources about our vital need for lots of "good, healthy" carbohydrates.

If those examples are representative of the quality of advice you are receiving from professional sources, try this small test. A multi-choice question for you.

Choose one answer.

Who or which of the following may go blind, lose a limb, suffer kidney failure or have a heart attack if the advice from your Doctor, your Dietician, your Diabetes Educator or the ADA/NHS/DA (Diabetes Australia) is discovered to be incorrect in ten years time?

A. Your Doctor

B. Your Diabetes Educator.

C. Your Dietician

D. The ADA/NHS/DA

C. You.

D. Me.

D. None of the above.

You may use the following links as reference materials while considering your answer:

Research Connecting Organ Damage with Blood Sugar Level

Blood Glucose Targets

Cheers, Alan

Everything in Moderation - Except Laughter.

Health Care Funding By Governments

I write on several groups and forums; the most active ones are heavily US-oriented. As a result I have learned to automatically translate mg/dl to mmol/l and I understand that some parts of the world consider an entree to be a main course and that ketchup can be a staple food group. I also write on several UK forums.

Consequently, over time I have become well aware of the strengths and failings of both the US and UK health-care systems from a consumer's point of view as expressed by many diabetics in both lands. To a lesser degree I have read reports by diabetics in different Canadian Provinces commenting on their systems and from writers in Germany and the Netherlands on theirs.

I've noticed when the subject comes up the views of many writers in the US seem to be polarised. Some see any government involvement in health provision or funding as socialist. That is a word that US writers seem to define differently to the rest of the world. It seems, to an outsider, that it is considered to be socialism if the US Federal Government uses its authority or taxpayer's funds to support any activity other than Defence of the Nation or Foreign Affairs.

All governments have taxes; in democratic nations those governments usually spend the majority of those taxes on the services their constituents elected them to provide. Different countries choose different priorities for those politicians.

We are just one place you might compare to. Here, we choose to include basic Health-care provision as one of those priorities. However, unlike the UK, we have a strong parallel private health-care system which complements the public system.

I don't present the following as a criticism of any other system, but as just one example of the many systems operating around the world. Those in other lands may wish to use it as a basis for comparison and possibly as something they could learn from and improve on. Or not, as you wish.

Our system is not perfect and needs some major improvements. There are problems in some hospitals (which are usually administered by State Governments, but partly funded via Federal money) and shortages of medical staff in rural regions to mention just some of the shortcomings. A major part of the problem is the separation of Federal and State responsibilities, so quality of care can vary a bit between States.

I am sure that a search of our newspapers right now will find a crisis somewhere; there may be delays in elective (non-life-threatening) surgery, or delays with ambulance response, or insufficient beds or staff in certain hospitals. There is always something. But, every single time I, or a member of my family, has needed medical care we have received what we needed, when we needed it at a minimal financial cost.

This is a layman's description by a consumer; if any experts on the Australian system are reading this I am happy to be corrected if any errors are noticed.

I'm covered by the Australian Federal Government Medicare system (absolutely nothing like the US system by the same name). This web-page explains what Medicare covers, and this explains how Medicare works at the consumer level.

Included in the Medicare system is the Pharmaceutical Benefits Scheme. That provides heavily-subsidised prices to citizens for the majority of prescription drugs. The subsidies are greater for old-age pensioners, qualifying veterans and some others. Sometimes there are complaints that new drugs are not covered but usually they will be after safety and other considerations have been met. Of course, there will always be exceptions; for example it took years to add Lantus to the list.

An important sub-section of the PBS is the NDSS, the National Diabetes Services Scheme. That provides subsidisation of things such as blood glucose test strips, insulin consumables and similar items.

As I write this in 2009 the annual cost to the Federal taxpayer works out at about AU$3,400 per person. That seems pretty cheap to me when I compare with overseas prices. It is paid for by a levy on taxpayer's taxable income of 2%. I never found that onerous when I was fully employed and paying higher taxes than I do today, nor do I find it onerous now as a self-funded retiree. There are some State taxes involved too, but those vary by State and are difficult to assess for Health. They are certainly not at the same level as the Federal allocation.

Because I prefer to choose my own doctor, and also to avoid the possible delays I mentioned earlier in public hospitals, I choose to add Private Health Insurance. This is my own insurer; their premiums and benefits are representative of most: Defence Health Insurance. I've paid taxes since I was 16 years old; so I reckon I've paid my dues for Medicare. For the Private Health Insurance I pay top cover, which is about $200 per month for the two of us. That premium is also partly subsidised because it entitles me to some tax deductions in my annual tax return.

Between the Government cover and private insurance I don't get charged much for visits to the doc, medications, operations or hospital stays for myself or my wife. Additionally, for the leukemia and the diabetes I'm covered by DVA (Department of Veterans Affairs) so I pay even less for bills related to those, such as test strips. I paid those dues by serving for 20 years.

I'll repeat that our system is not perfect and needs some major improvements. But when I look at the financial and medical tragedy for those who are under-insured or unemployed in the US system; and the other extreme of the unwieldy inertia, restriction of treatment via the "post-code lottery"and bureaucratic waste of the UK NHS I'm very glad that I live where I live.

Everything has a price. Provision of a government healthcare system has a price; so does the absence of one. The first is paid in dollars; the second may be paid in misery.

Cheers, Alan

Everything in Moderation - Except Laughter

PS. For anyone interested in how the Australian system came into being, this links give an insight: 

Medicare - Background Brief

(edited to update and replace or delete changed links 12th March 2019)

Breakfast On The Run

Don't have time for breakfast?

Think outside the square. Don't assume cooking takes a lot of time. If you give it a try, you will find that you can turn a bacon rasher and two fresh eggs into a great breakfast via the frying pan in less than five minutes.

Consider some of these, just as examples of what you could do.

EGGS

Eggs are a wonderful breakfast food. Not only are they full of goodness if you eat the whole egg, but they can be very, very quick to cook. Use free range eggs if that is possible and if cholesterol worries you, read this: Eggs, Carbs and Cholesterol

Instant scrambled eggs.

Break an egg into a mug or cup, add a slosh of milk, season to taste, beat lightly with a fork and microwave for 60 seconds on high. Check, stir, repeat in 15 second bursts if necessary (time varies because microwave powers vary). After the first time you will know how long to set it.

Save on washing up time - eat direct from the mug with the fork you used to stir it.

If you want to get fancy, a little chopped parsley added before cooking is good. If one egg isn't enough - use two or use duck eggs.

Omelette.

Put your skillet on moderate heat. Break two eggs into a bowl, add a splash (about a tablespoonful or less) of water, whisk briefly with a fork, add oil to the skillet and pour in the egg mix. Use the same fork to gently move the liquid from the edges to the centre and vice-versa and as soon as it is not quite set fold it over and serve it. The whole process should take less than five minutes from opening the pantry door to sitting down to eat.

If you have the time add extras like chopped herbs, or grated cheese, or sautéed veges. All those can be pre-prepared the night before to save time.

CASSEROLES

Make up a large batch of your favourite casserole. Choose one (or more) that is high in protein and reasonably low in carbs, so that an individual breakfast-sized serve won't spike your blood glucose levels. When it is cooled after cooking store individual serves in appropriate containers in your freezer.

For a quick breakfast grab a serve from the freezer, decant it into a bowl and re-heat it in the microwave while you have your morning shower.

Try a few ideas of your own; far tastier and healthier than expensive "shakes".

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter

Aspartame

On the subject of aspartame, never in the field of human diet has so much nonsense been so credulously believed by so many (with apologies to Winston Churchill).

Do some searching on the web or just listen to your well-meaning friends next time you reach for a diet drink. It happened to me again yesterday. I opened the fridge and took out a Coke Zero and my friend immediately said "Don't drink that - it's got that poisonous aspartame stuff in it!" Regardless of my answer, I was unable to change his conviction that he was saving me from a terrible fate.

If you are a type 2 diabetic and that hasn't happened to you yet, rest assured, it will. The sweetener police are a Special Squad of the Diet Police, always out to save us from ourselves.

Let me put it politely and succinctly. It is ALL utter nonsense.

We can thank a few individuals for this myth. The truth is lost in the mists of time.

(2017 note. Many of the old links are gone since I first wrote this; where necessary I have used wayback machine links to resurrect those pages).

This anti-aspartame web-page claims that a certain Betty Martini was the originator, but this equally anti-aspartame page is dedicated to Nancy Markle who is more often accredited with the "discovery." Some believe they were the same person. There are several disciples on the web these days, busily spreading the gospel according to Nancy Markle (note added 11th March 2011. That Nancy Markle page has disappeared and the various Betty Martini web-pages now claim Markle never existed).

If you do some searching on the web you will find that the followers of these kooks are very web-savvy and have ensured they will be on the first page of your search results. If you have the time, read some of them. You will find a web of inter-woven "supporting" research papers, some real, some not, most quoting each other, rarely peer-reviewed by any reputable journal and most performed using unlikely levels of aspartame on unrepresentative rodents.

On the other hand, if you go to more reputable sites such as the US National Cancer Institute, a division of the US national Institutes of Health, you will find some more credible references. Their summary (the emphasis is mine) is as follows:

"A study of about half a million people, published in 2006, compared people who drank aspartame-containing beverages with those who did not. Results of the study showed that increasing levels of consumption were not associated with any risk of lymphomas, leukemias, or brain cancers in men or women.

Researchers examined the relationship between aspartame intake and 1,888 lymphomas or leukemias and 315 malignant brain cancers among the participants of the NIH-AARP Diet and Health Study from 1995 until 2000. Development of these cancers was not associated with estimated aspartame consumption, refuting a recent animal study with positive findings for lymphomas and leukemias and also contradicting claims regarding brain cancer risk."

As a person with leukemia, those conclusions were of direct interest to me. I should note that I rarely consumed aspartame in any form before my double-diagnosis in 2002; I have consumed it daily since. Both conditions have improved; I don't credit that to aspartame, I am just making the point that neither got worse.

2017 note: that report is no longer directly available on the web. This is the orginal study underlying the assessment (pdf): Consumption of Aspartame-Containing Beverages and Incidence of Hematopoietic and Brain Malignancies 

Results: During over 5 years of follow-up (1995-2000), 1,888 hematopoietic cancers and 315 malignant gliomas were ascertained. Higher levels of aspartame intake were not associated with the risk of overall hematopoietic cancer (RR for z600 mg/d, 0.98; 95% CI, 0.76-1.27), glioma (RR for z400 mg/d, 0.73; 95% CI, 0.46-1.15; P for inverse linear trend = 0.05), or their subtypes in men and women.  

Conclusions: Our findings do not support the hypothesis that aspartame increases hematopoietic or brain cancer risk. (Cancer Epidemiol Biomarkers Prev 2006;15(9):1654 – 9)

Similarly, another organisation that gives credible support using reputable studies for their conclusions about aspartame is Green Facts. You can read their reports here: Scientific Facts on Aspartame. For further reading, begin with Snopes: Kiss my Aspartame

No matter what food substance you test someone, somewhere will have problems with it. Of course some people will have problems with aspartame. Some people have deadly problems with peanuts, or fish, or gluten or even lactose. But that does not mean that any of those substances necessarily have any dangers, if ingested in moderation, for the rest of us.

I have also consumed almost all of the other artificial sweeteners available to us these days, including Splenda, saccharine, and several others. None have harmed me in any way.

I repeat, I never drank diet sodas until AFTER my cancer and diabetes diagnoses and the only effect it has had on me has been to let me enjoy soft drinks without harming my blood glucose levels.

You must make your own judgement and test for yourself.

Cheers, Alan
Everything in Moderation - Except Laughter

PS. Comments from the kooks will not be published, so don't waste the effort of typing.

Stuffed Mushrooms

Breakfast for one, low carb.

Ingredients

½ a small onion
Two or three medium to large, or one very large, mushrooms
Two or three tablespoons of Napoli Sauce or chopped canned tomatoes
Cheddar and grated parmesan cheese
A little olive or canola oil for cooking.


Skillet method.

I use a 6" cast-iron skillet.

Remove the stalks from the mushrooms, peel the mushrooms if appropriate.

Pre-heat the skillet and your grill (broiler if you are American).

Chop the onion and the stalks and sauté them in the skillet in a little oil.

When the onion is translucent spoon the vege mix into the mushrooms and add a spoonful of Napoli Sauce or tomatoes to each mushroom, adjusting to slightly overfill each cap.

Place the mushrooms in the skillet, add a few tablespoons of water to the exposed area of the skillet to provide instant steam and also deglaze juices, cover and cook over low heat for two or three minutes until the mushrooms have wilted. The stuffing will leak or spread a little and mix with the water to make a rich sauce.

Remove the lid and lightly cover the mushrooms with grated or sliced cheese. Sprinkle a little parmesan over the top. Place the skillet under the grill (broiler) until the cheese is bubbling and browning.

You can transfer it to a plate, but I usually eat it direct from the skillet on a trivet.


Oven Method.

Preheat oven to 200 C (390-400 F)

Prepare the mushrooms in the same way, but don't pre-cook anything. Assemble the mushroom caps, chopped onion and stalks, Napoli sauce and cheese in a suitable size ramekin or small baking dish. Add sufficient water to give a depth of about 6mm (1/4") in the ramekin after the mushrooms are placed in it.

Cook for approximately 15 minutes.

After the first time, you may need to adjust the time to suit your own oven.

I like this method for a fast breakfast because I can prepare it the night before and leave it in the oven pre-set to cook in the morning; ready when I wake. Allow a few minutes additional cooking time for the oven to reach the right temperature.

Nutrition.

This is very approximate. The fat is from the olive oil and cheese, cut back on those if it worries you.

Calories................335
Protein.............12 gm
Total Fat.........25 gm
Sat. Fat..............9 gm
Mono. Fat........14 gm
Poly. Fat............2 gm
Carbohydrate..13 gm
Fiber...............4.5 gm

Bon Appetit

Cheers, Alan
Everything in Moderation - Except Laughter.

Are Carbs Really Necessary?

I wrote about the The Diabetes Diet Wars and the continuing controversy over low-fat versus low-carbohydrate late last year. Although I do not consider myself to be following a low carbohydrate way of eating I certainly eat less carbs than I did pre-diagnosis and a lot less than the average type 2 diabetic in a Western country.

I spend the first couple of hours each day reading and posting on several diabetes forums. Daily I see newly diagnosed type 2s reporting the advice they have received from dieticians, diabetes educators or doctors. Far too often that advice is to eat to a formula. The formula is usually 45 to 60 grams of carbohydrate at each of the three main daily meals and 15 grams for snacks. That gives 180 to 225 grams of carbohydrate daily as a minimum level. I have discussed the problems inherent in that advice in several previous posts. However, when I, or others, suggest to new people that they could benefit from eating less carbs we find they have been told horror stories of the dangers of inadequate carbohydrate input.

The most common warning is the need to eat a minimum of 130 grams of carbohydrate per day or the brain will lack sufficient energy to function, but there are others such as the dangers of fatigue from lack of energy or just the generalised warning "but your body NEEDS carbs!"

This is just one of many examples: What Should I Eat? New ADA Guidelines Can Help
"ADA does not recommend a specific mix of carbohydrates, fats, and protein. Rather, it refers people to the guidelines of the Institute of Medicine. These recommend that healthy adults get 45 to 65 percent of their calories from carbohydrates, 20 to 35 percent from fats, and 10 to 35 percent from protein.
[snip]
ADA discourages low-carb diets (diets that limit carbohydrate to fewer than 130 grams per day). Carbohydrates are major sources of fiber, vitamins, minerals, and phytochemicals (health-promoting chemicals in plants). People who overly restrict carbohydrates can miss out on these benefits as well as the good flavors of carbohydrate foods".

Despite statements like that, whether or not carbohydrates are essential is still a matter of differing opinions. Far too many health authorities accept that "carbohydrates are a necessary dietary component" is a given fact that needs no support. I can only offer my own opinion, supported by reading, personal experience and discussions with many people on the web and the net.

Carbohydrates are not essential to energy or cognition. Before I go on, I want to stress that although I eat carbohydrates myself my point is that I don't need carbohydrates for good health.

To meet our energy and cognition needs there is nothing that carbohydrates provide that can not be provided by protein or fat via gluconeogenesis, aided by glycogen storage in the liver and muscles. The oft-repeated need for a minimum intake of 130gms of carb per day for brain energy is nonsense. Ask a traditional Inuit. Or read Vilhjalmur Stefansson's story.

The issue is confused by the other factors mentioned in that ADA quote: fibre, vitamins, minerals, and phytochemicals. That is correct, the body needs all those and other micronutrients and flavonoids for good health. Some of those things, especially fibre, are available in most abundance in starchy foods like grains and root vegetables, so people tend to presume that is the best way to get them. Unfortunately it's not necessarily the best and certainly not the only way, it's just a convenient way. Adequate fibre is available in other, non-starchy vegetables; fibre is also readily available as a supplement in natural forms such as psyllium husk. The same logic applies to fruits; flavonoids, vitamins and other micronutrients are available from other vegetable sources with less effect on blood glucose levels. Again, note that I eat fruit, but with care and in small portions. Not because I have to but because I choose to.

There is no doubt that carbs provide quick energy. There is definitely a use for higher carbohydrate input before exercise or heavy activity for an athlete or a worker in a highly active job. But for the rest of us that does not usually apply. I have no energy problems in the mornings despite a simple breakfast that never exceeds 10gms carb; nor do I have energy problems after lunch despite rarely having eaten more than 25 gms total by that time.

Many people lead long, productive and healthy lives on ultra-low-carb diets. It may not be the way you would choose, but you only need to drop in on the Bernstein forum to meet a lot of people who do.

Personally I choose a middle ground. I used my meter to find, over time, how much I needed to reduce carbs at different meals to meet my blood glucose goals. But within those limits I include a significant level of carbs (by my standards) to add variety and flavour. My main focus is blood glucose control; for the micronutrients I consciously try for maximum variety in my vegetable input to try to cover the field.

To me carbohydrates are not essential, they are a luxury food that I treat similar to chocolate or scotch. Nice to eat and beneficial in moderation, but with specific limits which I should not exceed.

But, of course, if you believe the experts my brain will die before dinner from the lack of carbs. I had dire warnings from the dieticians seven years ago that one day I would hear a little voice in the back of my mind...

"I'm afraid. I'm afraid, Alan. Alan, my mind is going. I can feel it. I can feel it. My mind is going. There is no question about it. I can feel it. I can feel it. I can feel it. I'm a... fraid. Alan, please eat more carbs..."

I'm still waiting for that little voice (apologies to HAL 9000)

Cheers, Alan
Everything in Moderation - Except Laughter

Test, Test, Test

The best advice I received from any source, professional or otherwise, since I was diagnosed with type 2 diabetes was written by a lady named Jennifer. I first met her in cyber-space posting on the alt.support.diabetes usenet group where she regularly greeted newly diagnosed people with the advice I repeat below. It appeared as Jennifer's Information for the Newly Diagnosed on the a.s.d. home page and has now been repeated on many other web-sites. Some years ago she graciously gave me permission to spread it far and wide. I have been doing that ever since by providing a link to that a.s.d page.

The web-master made some improvements to the site which I just noticed today so I will be revising the link wherever it appears in earlier blog posts. It occurred to me that this may happen again, so I have decided to repeat Jennifer's original advice here in full so that it will always be available for me to reference.

Jennifer's Information for the Newly Diagnosed

"Sounds like you're planning a move to take control of your diabetes... good for you.

There is so much to absorb... you don't have to rush into anything. Begin by using your best weapon in this war, your meter. You won't keel over today, you have time to experiment, test, learn, test and figure out just how your body and this disease are getting along. The most important thing you can do to learn about yourself and diabetes is test test test.

The single biggest question a diabetic has to answer is: What do I eat?

Unfortunately, the answer is pretty confusing. What confounds us all is the fact that different diabetics can get great results on wildly different food plans. Some of us here achieve great blood glucose control eating a high complex carbohydrate diet. Others find that anything over 75 - 100g of carbs a day is too much. Still others are somewhere in between.

At the beginning all of us felt frustrated. We wanted to be handed THE way to eat, to ensure our continued health. But we all learned that there is no one way. Each of us had to find our own path, using the experience of those that went before, but still having to discover for ourselves how OUR bodies and this disease were coexisting. Ask questions, but remember each of us discovered on our own what works best for us. You can use our experiences as jumping off points, but eventually you'll work up a successful plan that is yours alone.

What you are looking to discover is how different foods affect you. As I'm sure you've read, carbohydrates (sugars, wheat, rice... the things our Grandmas called "starches") raise blood sugars the most rapidly. Protein and fat do raise them, but not as high and much more slowly... so if you're a T2, generally the insulin your body still makes may take care of the rise.

You might want to try some experiments.

First: Eat whatever you've been currently eating... but write it all down.

Test yourself at the following times:

Upon waking (fasting)
1 hour after each meal
2 hours after each meal
At bedtime

That means 8 x each day. What you will discover by this is how long after a meal your highest reading comes... and how fast you return to "normal". Also, you may see that a meal that included bread, fruit or other carbs gives you a higher reading.

Then for the next few days, try to curb your carbs. Eliminate breads, cereals, rice, beans, any wheat products, potato, corn, fruit... get all your carbs from veggies. Test at the same schedule above.

If you try this for a few days, you may find some pretty good readings. It's worth a few days to discover. Eventually you can slowly add back carbs until you see them affecting your meter. The thing about this disease... though we share much in common and we need to follow certain guidelines... in the end, each of our bodies dictate our treatment and our success.

The closer we get to non-diabetic numbers, the greater chance we have of avoiding horrible complications. The key here is AIM... I know that everyone is at a different point in their disease... and it is progressive. But, if we aim for the best numbers and do our best, we give ourselves the best shot at heath we've got. That's all we can do.

Here's my opinion on what numbers to aim for, they are non-diabetic numbers.

Fasting............................Under 110
One hour after meals.......under 140
Two hours after meals.....under 120

or for those in the mmol parts of the world:

Fasting............................Under 6
One hour after meals......Under 8
Two hours after meals....Under 6.5

Recent studies have indicated that the most important numbers are your "after meal" numbers. They may be the most indicative of future complications, especially heart problems.

Listen to your doctor, but you are the leader of your diabetic care team. While his /her advice is learned, it is not absolute. You will end up knowing much more about your body and how it's handling diabetes than your doctor will. Your meter is your best weapon.

Just remember, we're not in a race or a competition with anyone but ourselves... Play around with your food plan... TEST TEST TEST. Learn what foods cause spikes, what foods cause cravings... Use your body as a science experiment.

You'll read about a lot of different ways people use to control their diabetes... Many are diametrically opposed. After awhile you'll learn that there is no one size fits all around here. Take some time to experiment and you'll soon discover the plan that works for you.

Best of luck!
Jennifer"

As an engineer, when I read that, it made sense immediately. So simple, yet so powerful. And it has certainly worked for me. Thanks again Jennifer.

Post-script. I've been musing on Jenny's comment below and decided to add this.

I used Jennifer's wonderful advice to gain control of my numbers fairly quickly. Once I understood it I did not mess about and I used a lot of test strips in those early days. I fairly rapidly achieved the goals she set and I realised that I could do better. At the time, despite their poor advice on carbs and goals the ADA recommended something that stuck in my mind "Keeping your blood sugar (glucose) as close to normal as possible helps you feel better and reduces the risk of long-term complications of diabetes." That sounded logical to me so eventually I changed Jennifer's goals for myself to my present ones of:

Fasting............................Under 100
One hour after meals.......under 126
Two hours after meals.....under 100

or for those in the mmol parts of the world:
Fasting...........................Under 5.5
One hour after meals......Under 7.0
Two hours after meals....Under 5.5

Cheers, Alan
Everything in Moderation - Except Laughter.

I Ate Nothing! Why Are My BGs high?

Most of us discover fairly quickly after we start testing after meals that eating carbs leads to a rise in our blood glucose levels. That seems logical, and it is, so managing those carbs and the resulting spikes becomes a cornerstone of home treatment.

But pretty soon we also discover that logic has limitations. We go to bed at night with good numbers and wake with high numbers. But we didn't eat in our sleep. Or we make the mistake of thinking 'food = spike, fasting = no spike' and find that after eating nothing for six hours we might be normal or even high when we expected to be low.

It doesn't seem to make sense, does it? "I Ate Nothing! Why Are My BGs high?".

I am no expert on this, but I am pretty good at looking things up and then testing the things I read against my own results. My body, my science experiment. So I checked this out a long time back when I first came across the term "liver dump". Here is my rough version, based on the best explanation I've seen (or that I could understand at my level:-) . This is the medical-speak version:

"Stores of readily available glucose to supply the tissues with an oxidizable energy source are found principally in the liver, as glycogen. Glycogen is a polymer of glucose residues linked by a-(1,4)- and a-(1,6)-glycosidic bonds. A second major source of stored glucose is the glycogen of skeletal muscle. However, muscle glycogen is not generally available to other tissues, because muscle lacks the enzyme glucose-6-phosphatase.
*snip*
The major site of daily glucose consumption (75%) is the brain via aerobic pathways. Most of the remainder of is utilized by erythrocytes, skeletal muscle, and heart muscle. The body obtains glucose either directly from the diet or from amino acids and lactate via gluconeogenesis. Glucose obtained from these two primary sources either remains soluble in the body fluids or is stored in a polymeric form, glycogen. Glycogen is considered the principal storage form of glucose and is found mainly in liver and muscle, with kidney and intestines adding minor storage sites. With up to 10% of its weight as glycogen, the liver has the highest specific content of any body tissue. Muscle has a much lower amount of glycogen per unit mass of tissue, but since the total mass of muscle is so much greater than that of liver, total glycogen stored in muscle is about twice that of liver. Stores of glycogen in the liver are considered the main buffer of blood glucose levels."

For the really detailed version click on the links.

Below I put that in words that I understand. I am no biochemist, so if any experts are reading this please correct any errors I make or omissions from over-simplification.

Liver Dumps.

We need glucose for energy. When we eat a meal it is usually a mix of carbohydrates, protein and fats. Carbohydrates are an easily converted source which quickly appear as glucose in our blood. We also, more slowly, obtain glucose by gluconeogenesis from protein or even fats and also from the stored energy in our liver and other organs.

When we create more glucose than our immediate needs some is stored. Some is stored as fat, especially if we have excess insulin floating around, and some is converted to glycogen. Glycogen is stored mainly in the liver and the muscles. The muscles are selfish because the glycogen stored in the muscles can usually only be used for the muscles, but the glycogen stored in the liver is our supply for any glucose needed by the rest of the body. When the body needs it the right amount is automatically released to the right places. As a result there is always a steady flow of energy to meet a person's needs, regulated to demand, regardless of when or what they eat.

At least, that is how it works in non-diabetics. It is the body's version of a fuel tank. Unfortunately, for type 2s, the system can be flawed. Type 2s on the internet use the term "liver dump" for the release of excessive glycogen fr0m the liver to become blood glucose at times when it wasn't really needed or wanted.

For example, one cause of the Dawn Phenomenon is thought to be the body sensing our need for energy when we are about to wake, leading to excessive glycogen release until we eat and send the signal to stop the release. That's why a breakfast soon after we wake is an essential meal for many of us. Similarly, fasting, exercise or heavy physical activity can lead to a liver dump if the body senses the reduction in blood glucose levels and over-compensates with excessive glycogen release.

Preventing liver dumps is complex and I know no general solution. For dawn phenomenon the most common treatment is to eat a late night snack; but the reports of successful snacks vary widely so it's best to perform your own experiments until, hopefully, you find the one that works for you. A minority never does, and others find that the only solution for them is basal insulin.

For those who experience liver dumps after fasting the solution is easy. Don't fast for long periods. Eat something every few hours, even if it is only a small snack.

For those who get them during or after exercise, I have seen reports of success from people who spread small carby snacks across the period of exercise, including a snack before starting.

Sorry I can't be more specific with answers on this one, just suggestions. Once again it's your body, your science experiment

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter

Postscript: Another good comment on the "Dawn Phenomenon can be found in the Misc.Health.Diabetes FAQs. Click on the link and scroll down to "Why is my morning bg high? What are dawn phenomenon, rebound, and Somogyi effect?".

Travelling With Type 2

Up-dated 16th February 2022. Please advise me in the comments if amendment is needed.


Air travel

Travel by air has become a bit more complicated since 9/11 and covid. I was travelling through the USA on my first rtw trip in March 2003 when the Iraq war started. Security went nuts and within a week we missed a flight from St Louis to Atlanta because we spent two hours in security. TSA took a long time to find a way to secure air travel without grossly inconveniencing passengers. However, after the initial over-reaction things have settled a bit now.

COVID 

The rules for COVID vary for different countries and airlines. Always check those before you pay for a ticket and be wary of airline refund policies. Check vaccination rules and what tests (PCR, RAT etc) are required and their timing, check whether self-isolation or quarantine will be required on arrival and whether that will affect your access to needed medical supplies, food or drinks.

Food

Hypo protection

For the possibility of lows, I just carry jelly beans. Simple and not bulky, which is important these days for carry-ons with many airlines strictly enforcing size limits.

Mid Air Snacks.

Making some snacks up in advance is best because you can choose exactly what they are. You aren't restricted to the over-priced limited range available at the airport. I usually make up a small sealed plastic container of mixed nuts and raisins. It keeps well, can be kept in a pocket or purse for a quick nibble to stave off hunger and gives a good mix of protein, fats and carb. If that is not possible, I seek out something suitable in the air-side shops. Things like beef jerky (check the carb count), nuts, cheese-'n-crackers or similar. Not for meals, but for those times when you need something to nibble on during a long flight. I don't try for very low carb, but a mix of carbs, protein and fat, including about 5-10 gms carb in a snack.

I never go on a flight without sufficient for two or three snacks in my carry-on. It may be scheduled as a one-hour hop. But, after the first time you've waited three hours in the gate lounge and then sat in a delayed plane on the taxi-way for several hours without food, air-conditioning or information you realise that travelling in those conditions without snacks is not wise. It may only ever happen to you once, but that will be too often if you don't have food available every few hours.

In-flight Meals.

This is becoming a hypothetical subject, but there are still a diminishing number of Airlines that provide meals in cattle class.

Never, ever, ring in advance to advise that you have diabetes and wish to have a "diabetic" meal. If you do, be ready to eat a meal that will commence with a bread roll, followed by a main of low-fat starch, with sides of starch, washed down with fruit juice, followed by a piece of fruit and a dessert of low-sugar rice pudding or similar.

Instead, I have a standard procedure. I wait until the initial boarding rush is over and I can catch the attention of the steward. I advise the steward that I have diabetes that I manage with a strict diet. Then I patiently nod and smile through the set "you should have advised us in advance so we could have provided a special diabetic meal for you". I apologise for not doing so and request a look at the menu of the day. I then choose the least bad choice. Failure to do this means you are risking no choice at all when they run out of the beef casserole and you find that pasta and rice is the only choice left. On two notable occasions, when there were no remotely acceptable choices, the senior steward suggested that I might prefer something from the business class menu. You get a different class of service on Qantas and Air New Zealand.

For longer flights I carry a cooler pack with me. This thing wandered around the world twice with me:

It doubles as my carry-on for medications and other things I need to get at quickly. Most airlines will allow something like that as a second carry-on, but check if your airline has a one-bag limit.

I often prepare a salad the night before, usually with some cold cuts or similar, and pack it in an appropriate small plastic lunch container. The dry food will get through the TSA security, but liquids won't; I haven't tried a freezer brick through security since those rules changed, so I would transfer the food from the fridge to the pack as late as possible. After passing through security buy a cold drink which can also act as a cooler for the insulated section. If you don't want to pre-prepare you can nearly always buy a prepared salad, or jerky or something similar on the "air" side of security.

Don't try to get drinks through airport security - they will probably be confiscated. Buy your cans or bottles after the security check if you need them; I usually have a coffee instead. On board, I have never travelled on an airline that did not provide water or diet soda on demand, sometimes free.

Medications and Diabetes Supplies

When I fly I always carry a letter from my doc listing my ailments and medications. I have only rarely needed that letter, but on those rare occasions it saved me a lot of stress and hassle. For diabetes supplies read the current rules on the TSA web-site - they apply to all US airports and many overseas airports also use them as a general guide. 

This is a copy of TSA's blog Travel Tip: Traveling with Diabetes, updated 16th February 2022.

heck or Carry-on

We know that traveling with medical supplies can be a nerve-wracking experience, especially when your medication includes needles and other sensitive equipment. So here are some tips to help make your trip as smooth as possible.

Notify the Officers

When you arrive at the checkpoint, let our officers know about your medical device and any other equipment prior to screening. If you have an insulin pump, glucose monitor or other medical device attached to your body, inform the officers where it is located before the screening process begins. Although not required, you can provide them with a TSA notification card prior to screening to discreetly describe the medical condition.

If you have questions or concerns at any time during the screening process, please ask to speak to a supervisor.

Screening Process

Passengers in standard lanes may be screened by advanced imaging technology, metal detector or a pat-down. If the standard lane does not have advanced imaging technology, or if you are eligible for expedited screening through TSA PreCheck®, you may be screened by a walk-through metal detector. If you do not wish to go through screening by technology, inform the TSA officer and they will conduct a pat-down. Pat-downs are conducted by a TSA officer of the same gender, and you may request private screening at any time.

You will not be required to remove any medical devices attached to your body.

Medical Supplies

If you are traveling with medical equipment or supplies, they will need to undergo separate screening. The TSA officer will check the supplies and conduct any necessary testing. If your medical condition requires it, you are allowed to travel with a juice box or other liquid over 3.4oz., but be prepared for the liquid to receive additional screening.

In the event that your insulin pump or glucose monitor is attached to your body, the device is subject to additional screening, including visual inspection. You may be required to conduct a self pat-down of the actual device, followed by a test of your hands for any trace of explosives.

Still have questions? Visit our website for additional information.

TSA Cares

If you have any additional questions or need assistance at the checkpoint, reach out to TSA Cares at 855-787-2227. Simply call 72 hours prior to your trip or visit our TSA Cares website. Knowing more about the process may help to relieve any stress and anxiety!

See also US TSA rules for Disabilities and Medical Conditions. This mentions that the 3-1-1 gels and liquids rule is eased for Medications. That was a very useful tip explained to me by the TSA supervisor at DFW. It helped that I had my letter from my doc, but items not on the doc's list such as mosquito repellent, antiseptic and similar were also allowed.

Road Trips

 

When possible I prepare exactly the same snacks as I do for an air trip and carry the cooler pack on board. That gets a lot of use in the car, because there will always be a bottle or two of diet soft drinks, a bottle of wine and some cheese, crackers or similar. I add a couple of freezer bricks to keep things cold and fresh. Each night I put those in the room fridge, if it has one, or ask the hotel staff to keep them in the restaurant freezer. I've never had that request rejected but I have occasionally forgotten to collect them in the morning. No big deal, they only cost a couple of bucks. I also store small containers of olive oil for salad dressing or cooking oil, vinegar, salt and pepper in the side pockets.

If the accommodation I am using has cooking facilities I always prefer to cook my own simple breakfasts. While on the road it is easy to pick up some eggs, maybe an onion, mushrooms, cheese (or whatever you like) to make a simple omelette or scrambled eggs in the morning.

I look for diners and Mom and Pop restaurants when I'm on the road. The sort of place where I can get bacon and eggs for breakfast, or they will listen when I ask them to hold the fries and double the salad.

Breakfasts

Hotel breakfasts can vary from wonderful buffet choices to disastrous "continental" breakfasts of a tired croissant and grey cold imitation coffee. They can also be incredibly expensive, with minimum prices in the restaurant or high extras and tips on room service. I refuse to pay $20+ for some watery scrambled eggs and a coffee. If the hotel choice is OK or I can cook my own, wonderful. If not I have a standard routine on arrival at a hotel.

I ask at reception where the nearest diners, cafes and restaurants are and for recommendations. At an appropriate time after I check in, usually after dinner, I take a walk around the district. If I arrived by car I will have already been watching for restaurants as I drove in. I use the walk for exercise and also to check out an appropriate place for breakfast. It is rare that there are no diners or similar within a reasonable walk - which also doubles as my morning exercise.

Eating Out

When I am travelling with my wife, eating out is much simpler. On two trips around the world with her we left a reputation behind us as Aussie cheapskates because, wherever we went, we would order one main course and a spare plate for the two of us. It took some cheek, but we didn’t put the weight back on. We also saved some cash, but that was a bonus, not the intention. Where it wasn’t possible because of language or embarrassment of others, we would order a main course and a side salad or starter – just to get the plate – then mix between the two. This allowed me to leave the high carb items for my non-diabetic wife.

We often found that we still left food on the plate, even when we shared. The food is actually the smallest cost in running most restaurants; many chefs provide enormous serves to attract customers.

When I travelled alone, it was more difficult. I, like many, was raised in an environment where waste was frowned upon - waste not, want not. As a post-WWII child I was taught to clean my plate before leaving the table.

It takes discipline to break the habits of a lifetime and leave over half the food on the plate when you know you are paying for it. But if you eat it, you will pay much more eventually. Specify that you absolutely, definitely do NOT want chips/fries. Many restaurants add them automatically.

For dinners, when travelling alone, I found the method I used most often was to order an appetiser and a side salad instead of a main course. If that was too small I would order a second appetiser. That led to some marvellous and delicious meals; often the appetisers are more varied than the main course and aren't accompanied by piles of potato, rice or fries.

My most common lunch when travelling is "Soup of The Day". But be a little careful of thick "cream" soups; they will often be thickened with cornstarch, flour or potato. In 2006 I happened to be wandering through Germany in Spargelsuppe season. Bliss.

I'm sure I'll recall other tips after I post this, so I'll probably return regularly and up-date it.

Bon Voyage

Cheers, Alan

Everything in Moderation - Except Laughter.

ADA Accomplishments in 2008

The ADA has just posted this review of their achievements in 2008 on their web-site:

In Diabetes Today 08-JAN-2009
American Diabetes Association Reflects on 2008 Accomplishments in the Fight Against Diabetes and Looks Ahead to Challenges in 2009

I read the whole thing through carefully. Unfortunately, the accomplishments I was looking for weren't in it. I read it twice to be sure.

What they did include as headlines were:

Research Funding
Fighting Discrimination Against People with Diabetes
Health ReformCreating A Healthy Environment
Those are all necessary and highly laudable achievements. I have nothing but praise for all of those involved in those areas. But that is a very limited list to my mind.

These are the headlines I missed:

"America's average A1c of diagnosed diabetics reduced significantly."or "Mortality rate of diabetics reduced."or "Rates of long-term complications reduced in diabetics."or "Fewer people with metabolic syndrome or pre-diabetes progressing to type 2 diabetes."

I didn't see anything remotely like those. Those, or similar accomplishments, are the headlines that would indicate to me that the ADA is making a real and significant difference to the diabetics of the world, or at least of America.

I searched again, but all I could find was:

"Since 1987, the death rate due to diabetes has increased by 45 percent"

Maybe I'm too simple to understand these things, but isn't that trend heading in the wrong direction? And at a rather high rate?

If beating the medical afflictions of the world was a team sport and the ADA was the most highly funded team in the Diabetes Division, don't you think that by now the fans would be screaming for a review of the team's aims, methods and tactics? Hopefully the recent change in coach will bear fruit.

They note that in "in 2008, the American Diabetes Association provided $42.5 million toward funding research to combat type 1 and type 2 diabetes in people of all ages and races."
How much of that money came from big Pharma ? Most. How much of that money went to discover the optimum SMBG testing and dietary regimen for type 2 diabetes? Any? I doubt it.

On a more optimistic note, back when I wrote Money, Medications and Motives, the ADA FY06 Corporate Recognition Program included several major grains, food and beverage companies. That link no longer works and I could not find the same level of sponsorship from that industry group on the present Become a Corporate Supporter page (although it is still top-heavy with Big Pharma). I hope that is a sign from the new coach of things to come and not just poor search techniques on my part.

In that case I applaud the changes that are occurring and I hope they continue into other areas such as the focus for research funding. Maybe some day I will start to see the headlines I missed today.

Cheers, Alan

Diabetes and Dental health

A couple of years ago I wrote about the two-way relationship between Diabetes and Periodontal disease in Teeth, Gums, Diabetes and Death .

My main intent at that time was to emphasise that dental hygiene and blood glucose levels seem to be closely related. Poor dental hygiene causes poor blood glucose levels and poor blood glucose levels exacerbate dental problems. The reverse is also true, with improvements in either leading to improvements in the other. For more discussion on that read the earlier article.

One of the cites I provided, Periodontitis and diabetes interrelationships, had an interesting comment: "Thus, there is potential for periodontitis to exacerbate diabetes-induced hyperlipidemia, immune cell alterations, and diminished tissue repair capacity. It may also be possible for chronic periodontitis to induce diabetes." Induce diabetes? I noted that further research should be done there.

Further research has now been done and that possibility is becoming a little more plausible. This paper was published online on April 4, 2008 in Diabetes Care 31:1373-1379, 2008: Periodontal Disease and Incident Type 2 Diabetes

OBJECTIVE—Type 2 diabetes and periodontal disease are known to be associated, but the temporality of this relationship has not been firmly established. We investigated whether baseline periodontal disease independently predicts incident diabetes over two decades of follow-up.

RESEARCH DESIGN AND METHODS—A total of 9,296 nondiabetic male and female National Health and Nutrition Examination Survey (NHANES I) participants aged 25–74 years who completed a baseline dental examination (1971–1976) and had at least one follow-up evaluation (1982–1992) were studied. We defined six categories of baseline periodontal disease using the periodontal index. Of 7,168 dentate participants, 47% had periodontal index = 0 (periodontally healthy); the remaining were classified into periodontal index quintiles. Incident diabetes was defined by 1) death certificate (ICD-9 code 250), 2) self-report of diabetes requiring pharmacological treatment, or 3) health care facility stay with diabetes discharge code. Multivariable logistic regression models assessed incident diabetes odds across increasing levels of periodontal index in comparison with periodontally healthy participants.

RESULTS—The adjusted odds ratios (ORs) for incident diabetes in periodontal index categories 1 and 2 were not elevated, whereas the ORs in periodontal index categories 3 through 5 were 2.26 (95% CI 1.56–3.27), 1.71 (1.0–2.69), and 1.50 (0.99–2.27), respectively. The OR in edentulous participants was 1.30 (1.00–1.70). Dentate participants with advanced tooth loss had an OR of 1.70 (P <>

CONCLUSIONS—Baseline periodontal disease is an independent predictor of incident diabetes in the nationally representative sample of NHANES I."

What that means in layman’s terms was clarified in Endocrine Today online in November when an interview with one of the authors, Ryan T. Demmer, PhD, MPH was published. He said that these findings add a "new twist" to the association, suggesting that periodontal disease may lead to diabetes.

"It has been generally accepted that periodontal disease is a consequence of diabetes despite the fact that this association has not been studied with the same methodological rigor applied to coronary and stroke outcomes," he told Endocrine Today. "We found that over two decades of follow-up, individuals who had periodontal disease were more likely to develop type 2 diabetes later in life when compared to individuals without periodontal disease." For more details read that Endocrine Today issue where it is discussed with several other researchers in this field.

I still suspect that type 2 has a genetic cause, but I now believe that periodontal disease can be a trigger for type 2 diabetes in the same way that a poor diet or lifestyle can be. There is also the possibility the genetic tendency to type 2 diabetes may also be the initial cause of the precursor conditions of periodontal disease or obesity.

I already knew that it was important to have very good dental hygiene as a type 2 diabetic. Now it seems that it may be equally important for those of us who have offspring following in our genetic foot-steps to pass that message on loud and clear to them.

Cheers, Alan