Type 2 Diabetes - A Personal Journey

ADA Standards of Medical Care in Diabetes 2012

2012-02-03T09:56:00.000+11:00

The ADA has just released their 2012 Position statements on several issues. A clickable set of pdf files can be found in the latest Diabetes Care Table of Contents page.

The most important document is probably the overall position paper: Standards of Medical Care in Diabetes 2012

I am posting the links immediately for those who wish to read the ADA documents for themselves in detail. I will post more detailed comments later after I have had time to analyse the full document.

A quick skim found that there are some significant changes, especially in acceptance of low-carbohydrate diets in the Medical Nutrition Therapy section. Unfortunately, they tend to still qualify that with statements like:

For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short term (up to 2 years). (A)
c For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed. (E)

With no direct acceptance that low-carb may be better for blood glucose levels, not just weight. There is some oblique acceptance:

115). A meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets (116).

and earlier in the paper:

Macronutrients in diabetes management

The mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes. (C)
Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control. (B)
Saturated fat intake should be <7% of total calories. (B)

Of course, that final comment can make low-carbing difficult for some. Not for me; I simply ignore that :)

There are also some other significant changes in non-dietary areas, such as very qualified acceptance of the value of post-prandial home testing.

One of the changes that may be of concern to those who believe that diet and exercise should be tried first and medication should only be added if d&e is inadequate is this:

2. Therapy for type 2 diabetes

Recommendations
At the time of type 2 diabetes diagnosis, initiate metformin therapy along with lifestyle interventions, unless metformin is contraindicated. (A)

There is a lot more; take a little time to read the papers in depth.

Cheers, Alan, T2, Australia

Everything in Moderation - Except laughter

What on Earth Can I Eat? Now out as an eBook!

2011-10-25T15:45:00.000+11:00

WhenI reached my '50s I mistakenly thought that my learning years werelong behind me.

How mistaken I was. My double diagnosis in 2002 ledto a whole new world where I was a naïve ignorant student learningabout a host of mysterious things neglected from my education in myvarious earlier stages of life. Things like carbohydrates, insulin,blood glucose, lymphocytes and all that.

Some of those subjects were vital to my continued health. In many of thosefields I will be a student for the rest of my life.

Other things I had to learn were less directly important but stillnecessary to assist my search for knowledge; thus I became net-savvyand learned how to use the web and usenet to get the information Ineeded. Later, further learning was needed to allow me to find waysto pass on to others the knowledge I had gained. As a consequence Ispent a lot of time in 2010 researching self-publishing;. That led tome eventually publishing What on Earth Can I Eat? late last year.

Originally that was going to be the only form of the book, but after publicationI received many requests from people to produce an ebook. Thatinvolved another learning curve, as I tried to re-work the manuscriptfor the various e-reading options. I floundered around until I wasdirected to Smashwords. That made it so much easier.

So now, responding to popular demand, the ebook is out there on the web!

I have to admit I'm still an old fogey and tend to prefer printed books, but for those modern people who prefer to download and read on their Kindle (or any otherebook reader) please click here:What on EarthCan I Eat? Food, Type 2 Diabetes and You. As a service to my blog readers, a $1.00 discount is available if you include coupon numberJP52U when you get to the checkout.

The Discovery of Insulin

2011-10-20T10:37:00.007+11:00

A couple of years after I was diagnosed I spent a fascinating few hours reading a Canadian web-site titled “The Discovery of Insulin”. Recently I went looking for it again and was sorry to see it was no longer directly available on the web.

However, all is not lost! The marvellous way-back machine was able to find it again for me. I don't know how long such archives are kept, so I suggest you don't delay if you are interested in reading this wonderful story.

Begin here: The Discovery of Insulin

Use the site as you would any other, clicking on icons as appropriate. The way-back bar at the top is not too intrusive. I suggest you start by clicking “Enter” then click on “Introduction” before reading the rest. Click on the “Home” button at the top or your “back” button if “Home” is missing to return to the index page after you finish each section.

The dLife web-site also has a three-part video series on the discovery of insulin. I was unable to find the code to show them directly here so you will need to click on the links. The "non-intrusive" ads for Novo-Nordisk are worth wading through for the story.

The Story Of Insulin, Part 1

The Story Of Insulin, Part 2

The Story Of Insulin, Part 3

For those in the Tampa area tomorrow or in the Tyler, Tx, region next month, this exhibition may also be worth attending: Breakthrough: The Dramatic Story of the Discovery of Insulin

After reading and watching all of that information I was reminded again how remarkable this achievement was and how close it came to not occurring. There are millions of diabetics alive today as a direct consequence of the discovery; the story of Dr Lois Jovanovic's grandmother gives the perspective of those living under a death sentence back in the 1920s. As a lateral thought, one has to wonder whether it would have ever been discovered if there had been the same strict rules for using animals like dogs in lab experiments then as there are now.

At the moment I do not need insulin, but I am very grateful that it is available for that possible day in the future when I may need to.

Cheers, Alan, T2, Australia

Everything in Moderation - Except laughter

Kitchen Essentials: Steamer Saucepan

2011-10-18T10:25:00.008+11:00

For those who are discovering cooking as a survival skill for the first time this is the first in a short series of tips for new cooks.

I first started using a steamer saucepan set when I was wandering around in a caravan in 1997-98. I discovered a set in an op-shop while we were wandering and found it to be a wonderful tool for cooking a full balanced meal with several vegetables on a tiny two-burner caravan stove.

After I was diagnosed I found it became an essential tool in my kitchen as I increased the range of vegetables on my menu. I use it daily; often cooking five or more different vegetables at a time. I believe in the KISS rule (keep it simple) in most things; for cooking there are few things simpler than steaming. You really have to try hard to over-cook steamed veges, so you can concentrate on other foods where timing is more critical.

Apart from the obvious advantages of steaming vegetables to retain most of the vitamins and minerals, a steamer takes a lot of the work out of cooking regular meals.

I thought about polishing mine up for the pictures, but decided to show it as it is, because this battered old saucepan set has been in constant use for many years now:

Over the years we have added bits to it; not all match:

We use those extra sections for big family dinners. Usually we only need the base and one steamer section when cooking for three or four. For example, for dinner last night I put potato and Aussie pumpkin (Winter Squash) to be boiled in the bottom in just enough water to cover them; in the steamer section was 1/3 cob corn, peas, sliced carrot, broccoli and cabbage with chopped bacon. Each vegetable was placed separate from the others so that they could be easily served later without mixing together excessively. Here is how it looks with the boiled veges moved to the top section to keep warm while my fish cooks beside it and my wife's chops cook under the griller:

Some tips when using one.

1. Put root vegetables that need to be boiled, such as potatoes, in the bottom section and leafy/watery veges in the top for steaming.

2. If the veges in the bottom section cook before the rest of the meal is ready, transfer them to the top section to remain warm without over-cooking.

3. If the veges are cooked before your other foods are ready, remove the steamer set from the heat and transfer any veges in the bottom section to the steamer section. The residual heat in the hot water will act as a bain-marie and keep the veges warm without over-cooking them.

4. Don't overfill the base with water; use just enough to do the job with a little extra for safety so that you never boil dry. When the water comes to the boil, reduce the heat until it is just simmering. Retain that water after cooking for an excellent stock if you like to cook vegetable soups or stews.

5. As you gain experience, don't restrict the concept to just vegetables. Experiment with other foods, especially fish and seafoods.

Cheers, Alan, T2, Australia

Everything in Moderation - Except laughter

Free Radicals and James Bond

2011-08-09T11:24:00.003+10:00

I enjoyed this brief moment immensely yesterday while watching an old movie.

With all due respect to Ian Fleming and Sean Connery, "Never Say Never Again" was not the greatest Bond movie ever made. But it had one sterling moment:

For those unable to load youtube:

M: Too many free radicals. That's your problem.

James Bond: "Free radicals," sir?

M: Yes. They're toxins that destroy the body and the brain, caused by eating too much red meat and white bread and too many dry martinis!

James Bond: Then I shall cut out the white bread, sir.

A very wise decision, James.

I drank a toast to that with a glass of Shiraz after my steak without white bread last night.

Cheers, Alan
Everything in Moderation - Except laughter

The 600 Calorie Diet for Type 2 Diabetes

2011-07-28T11:05:00.002+10:00

A British research group reported the following a few weeks ago. I had hoped the results would be a brief news report which would shortly go the way of many similar reports and disappear again. I was wrong. Suddenly new people are appearing on every forum I am on. They are either enthusiastically trying this new "miracle" diet or seriously considering it.

First, please take a moment to read the article:

Diabetologia
DOI 10.1007/s00125-011-2204-7

Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol

E. L. Lim & K. G. Hollingsworth & B. S. Aribisala & M. J. Chen & J. C. Mathers & R. Taylor

It becomes obvious on reading the article that it does not seem to have occurred to the worthy researchers that their extreme low-calorie diet was also a moderate low-carb diet.

"After the baseline measurements, individuals with type 2 diabetes started the diet, which consisted of a liquid diet formula (46.4% carbohydrate, 32.5% protein and 20.1% fat; vitamins, minerals and trace elements; 2.1 MJ/day [510 kcal/day]; Optifast; Nestlé Nutrition, Croydon, UK). This was supplemented with three portions of non-starchy vegetables such that total energy intake was about 2.5 MJ (600 kcal)/day."

Allowing for the variations in choices of non-starchy fresh veges that works out to be a little over 70gms carb, 50 gms protein and 15 gms fat daily. To me that is extremely low-fat and moderately low in carbs and protein - but also about half the level of 130 gms carb that too many food scientists continue to suggest will cause our brains to starve of energy. They don't appear to have mentioned cognition in the paper.

One has to wonder if their results would have been similar and the individuals healthier if they had simply reduced the carbs and left the fat and protein levels of the participants alone.

Instead, by concentrating on calories rather than a specific macronutrient such as fat, carbs or protein their research is interesting but hardly news. Gannon and Nuttall showed years ago that an iso-caloric diet can have very significant results for improved diabetes control when carbs are reduced and fat and protein increased; see their LoBAG series. This is the LoBAG30 paper. There is also a later paper on LoBAG20.

In short, the low-cal paper shows some promise but has too many confounders. Finally, can any type two reading this seriously consider eating 600 calories daily for the rest of their lives? You will find an excellent critique (as usual) of this nonsense on Jenny Ruhl's blog.

Even if it is only applied for a short period there are other dangers no-one has mentioned. An acquaintance of mine on alt.support.diabetes went on a similar starvation diet a few years ago and reported on progress on that newsgroup. A dramatic A1c drop ensued. So did a major eye damage problem. That is a known but thankfully rare danger. It can happen when there may be existing retinopathy (which the patient may be unaware of) and very sudden changes in blood glucose levels occur.

In brief, I have always counselled against extreme regimens in type 2 diabetes management, regardless of whether that extreme method involves diet, exercise, medications or anything else. I consider a 600kcal regimen very dangerous for any significant period of time and advise strongly against trying it. If you must try it, then only do so under strict, close medical supervision.

In my opinion a balanced regimen over a lifetime, refined by post-prandial testing and adjusted when required, is a better course to follow.

Cheers, Alan, T2, Australia

Everything in Moderation - Except Laughter.

Tight Control. When Will They Ever Learn?

2011-07-15T14:01:00.008+10:00

Yet another meta-study implying that tight blood glucose control is dangerous for us was published this month. Here is the Press Release: Benefit of blood glucose lowering to near-normal levels remains unclear

The study is published by a German group called IQWiG, the Foundation for Quality and Efficiency in Health Care, a private law foundation with legal capacity. IQWiG's function according to its charter includes:

"(1) The Institute will work on issues of fundamental importance for the quality and efficiency of the services performed within the framework of the statutory health insurance (SHI) system as an independent scientific institution of the Foundation, in particular in the following areas:

1. Search for, assessment and presentation of current scientific evidence on diagnostic and therapeutic procedures for specific diseases;

2. Preparation of scientific reports and expert opinions on quality and efficiency issues of SHI services, taking age, gender, and personal circumstances into account;

3. Appraisal of evidence-based clinical practice guidelines on the epidemiologically most important diseases;

4. Issue of recommendations on disease management programmes;

5. Assessment of the benefits and costs of drugs;

6. Provision of easily understandable information for all citizens on the quality and efficiency of health care services, as well as on the diagnostics and treatment of diseases of high epidemiological relevance.

Its task is to support the Federal Joint Committee in fulfilling its statutory duties in these areas by the submission of recommendations (§139b [4] SGB V)"

Bearing in mind that the German health-care system is mainly funded by the government, they don't look just at the medical aspects but also at efficiency and costs. That is something to keep in mind when considering these reservations about the efficacy of tight control. Costs are very important when you run a government health-care system, but costs should have no bearing on the medical aspects of whether or not tight control of diabetes is good for patients.

The IQWiG news release includes this:

"Indications that patients with type 2 diabetes benefit from intensive blood glucose control were found only for the outcome "non-fatal heart attacks”. However, at the same time the data provide indications that severe hypoglycaemic episodes as well as other serious events in part occurred considerably more often in the intensive-therapy group than in the group with less intensive lowering of blood glucose levels.

Overall, the results of the current IQWiG report are consistent with those of reviews and meta-analyses recently conducted and presented by other researchers.

Question as to which treatment strategy is better still remains unanswered

The IQWiG Director Jürgen Windeler comments on the current report: "It is quite astonishing: individual interventions, particularly drugs, have in part been well investigated in studies; however, we know relatively little about the advantages and disadvantages of treatment strategies. If doctors are faced with the question as to what they can specifically offer to their diabetes patients, whether they should lower blood glucose levels as much as possible, and in which patients this a promising (or less promising) approach, they still do not receive satisfactory answers.” Even though this is a key question in the care of people with type 2 diabetes, the few studies available do not allow reliable conclusions."

The full IDWiG pdf report is here: Benefit assessment of long-term blood glucose lowering to near normal levels in patients with type 2 diabetes mellitus

They've missed the target again. There are many benefits of lowering blood glucose levels in diabetics to near-normal levels. But there are also many dangers in the intensive use of medications and insulin to achieve that goal.

The problem is not the goals but the methods.

Sadly, all they have done is confirm something that has been discussed by type 2 diabetics on diabetes forums ever since ACCORD and ADVANCE (both are included in this meta-study) were published. Those papers did not show that tight control is harmful, instead they showed that intensive use of oral medications and/or insulin to push A1c or FBG down can be hazardous to the health of a diabetic.

The factor missing from all of these studies is use of lifestyle changes, particularly diet and exercise, to achieve near-normal A1c and blood glucose levels. Repeatedly in all these studies the subjects were advised to follow the traditional (since Keyes) extremely low-fat high-carbohydrate diet and to then use medications and insulin to combat the results of that way of eating. I wrote some brief comments on the ACCORD and ADVANCE trials back in 2008 when they came out; nothing has changed since then.

Easily overlooked in the detail of this IQWIG paper is an even sadder acceptance of very poor targets:

"The goal in the test intervention group had to be long-term BG adjustment to near-normal levels (long-term lowering of HbA1c to levels at least lower than 7.5%, or long-term lowering of fasting BG to levels at least lower than 126 mg/dl or 7 mmol/l). Comparator interventions were those with no goal or a less intensive goal of long-term BG adjustment to near-normal levels."

We have already seen ACCORD used by the UK NHS and some other national diabetes authorities to discourage patients from trying for less than 7%; now they will probably use this to raise it to 7.5%.

One of the more enjoyable parts of being an active participant on several diabetes forums is that I get the opportunity to frequently offer congratulations to excited people reporting dramatic improvements in their diabetes indicators such as HbA1c, or significant improvements in the severity of complications. Often those congratulations are for joining the 5% club for achieving an A1c of less than 6%. Invariably those happy people report that their great results are from their efforts in making changes to their menu, usually as a consequence of post-meal testing, or their increases in exercise or both. Very rarely do they mention it was due to increasing meds but even then the diet and exercise usually changed first.

Those people do not seem to be encountering any of the problems warned about in meta-studies like this or ACCORD and ADVANCE.

To repeat myself, they've missed the target again. But I'll keep aiming for 6% or less.

Cheers, Alan, T2, Australia

Celebrating An Anniversary

2011-04-30T12:56:00.004+10:00

I have a terrible memory for birthdays and anniversaries. I usually have to use memory aids such as calendars and computers to remind me of them. But there is one I never forget. Today is the last Saturday in April. That is a day I need no reminders for.

On the last Saturday in April 2002, exactly nine years ago as I write this, I was having a lazy weekend morning in bed and the bedside phone rang.

A couple of months before that I had been tentatively diagnosed with CLL from a routine blood test showing a high white count. That led to lots of confirming blood tests and a bone marrow aspiration. Apparently they can be painless, but no-one seems to have told the haematologist that performed mine. He remained my haematologist until a couple of years later when he wanted to do another one to “check on progress”. That guy was never going to laboriously drill holes in in my “strong” bones ever again; I found another haematologist that was happy to state that I did not need one. Time has proved him right.

I spent that two months searching for something I could do about my CLL and finding I could do nothing at all but “Watch and Wait”. Wonderful. I was well into the depths of diagnosis depression.

So, when the phone rang my mood was hardly bright and cheerful. It was about to get worse.

Caller: "Hi Alan, this is Dr ............ 's reception here. The Doctor wants me to make an appointment for you for Tuesday."

Me: "That's fine. I presume it's to discuss the latest test results for the leukaemia?"

Caller: "No, it's about your diabetes."

Me: "......stunned silence......."

Caller: "Hullo - are you there?"

Me: "About what?"

Caller: "Your diabetes."

Me: “I don't have diabetes, are you sure you have the right person?”

Eventually she convinced me that she did.

I have learned to like and respect my doctor. He is the best doctor I have ever encountered. If not for his knowledge and expertise my CLL and diabetes might not have been diagnosed for another five or more years. Less competent doctors had missed some very obvious signs, such as fasting blood glucose levels of 7.9 mmol/L (140 mg/dL) for at least five years before that. He certainly gained my attention; if he had not made it clear that if I did not gain control of the diabetes I may not live long enough to worry about the cancer, I might not have maintained the discipline to achieve control. But at that time we did not really know each other and I was also unaware of the stress on that very overworked small village practice.

So I hope he won't mind me mentioning this. When I received that call he had left for the day. I'm pretty resourceful when I'm scared. I'm sure he didn't appreciate the call at his home a few hours later after I tracked down his number, but I'm also sure that phone advice by the receptionist of diagnosis of a major chronic condition has not happened often since.

Waiting for that Tuesday appointment was one of the worst weekends of my life. In hindsight, my ignorance of anything to do with type 2 diabetes and everything associated with it such as complications, diet, exercise and the myriad other things we need to know to take control of this condition was abysmal. Much of my fear and worry over that terrible weekend was caused by that ignorance.

I have made up for that ignorance since; see my story here: Turning Points

If a diabetes diagnosis seems an odd thing to celebrate, look at it from my different perspective. It has been a bit of a bumpy ride at times, but I reckon the simple fact of being here, moderately fit and well for a 64 year old, to write this nine years later without any diabetes complications at all is well worth celebrating.

I think I'll open one of the better bottles of Shiraz from the "cellar" in my back bedroom cupboard tonight.

Salud!

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

What on Earth Can I Eat? - The Book

2010-12-17T08:18:00.002+11:00

Life is full of unexpected surprises. There is no way in the world I could have envisaged ten years ago that one day I would publish a book. Even less credible was the possibility that it would be a book to help people with type 2 diabetes find a way of eating to assist in individually managing their condition.

But that is exactly what I have done today. If you look at the side-bar, there it is. I can hardly believe it myself. How on earth did that happen?

A little over eight years ago I was just like many of the people who are reading this right now. I had just left the doctor's surgery with a handful of diet brochures, a new blood glucose test meter and a new diagnosis of type 2 diabetes to add to my various afflictions. But, unlike many newly diagnosed people, I was determined to conquer this one. I hit the ground running. I started seeking information and I haven't stopped since.

In the eight years since then I have learned from every source I could, commencing with my doctors, dieticians and educators but not limited to those and continuing with usenet and the web. I turned my affliction into my hobby. I learned to use the various medical search engines on the web and subscribed to email alerts from sites such as the New England Journal of Medicine, the American Diabetes Association, Journal of the American Medical Association, Heart, Endocrine Today, Diabetes in Control and many others. I read everything I could find. I learned to understand “Medi-speak” and how to pick a valid research paper from a poor one; and believe me, there are far too many poor ones.

I started on usenet's misc.health.diabetes, back when it was very active (usenet is fading these days), and later added more diabetes groups and web forums. I learned a lot from many good people who helped me. Over time I started trying to help others as they arrived, shocked and scared, on those forums. If their situation sounded like mine and I felt I could suggest a way to help, I did. And slowly, over time, I found that many people started to experiment for themselves using my suggestions and they worked for them too. Often we both learned from the mutual feedback of advice and experiment.

Over time I found that I am a good coach. Like many coaches, I found that some of those I helped achieved better results than the coach. I respect them but I do not envy them, because we each have to choose the right balance for ourselves. I could work harder and achieve tighter goals, but I balance that with my enjoyment of life. My signature on the web is “Everything in Moderation – Except Laughter”. I keep that in mind when making lifestyle decisions. But I never forget that the laughter may become a bit strained if the terrible diabetes complications start to appear in my life. So I try to make sure I work just hard enough to ensure they do not. That can never be guaranteed but after more than eight years they have not arrived yet.

After a while I added other forums and groups to my morning and the number of new arrivals I responded to started to grow, especially on the American Diabetes Association Forum. I found that I was repeating myself daily. So I looked for a way to store the “standard” suggestions and discovered blogging. This blog started in 2006 as a type of archive; a way to give a new person a link to more information without typing it several times daily. Then it started to grow, as I answered more questions and posted some of those answers to the blog.

The book I have published today grew out of that experience, partly to help those who are more comfortable with a book than a computer screen. I finally made the decision to write the book when many of those who had followed my suggestions over the years urged me to write it for their relatives and friends.

That is the story behind the book. I'm a good coach, but not much of a salesman because I tend to be too honest and "tell it like it is".

I do not promise a cure. I don't have a magic bullet. I don't sell herbal mixtures, special potions or promise reversal of your diabetes in 30 days. After buying the book you don't get follow-up mail to buy anything or join a program or start a business. All you get is a book that is easy to read, easy to understand and offers clear and simple ideas to help you take control of your diabetes.

What I can promise is that following the suggestions in my book will help you understand much more clearly the relationship between the foods you eat and the consequences for your long term health. I can teach you a way to find an enjoyable way of eating that suits you. My hope is that this information may help you take control of your own diabetes management, just like many others who have reported back to me, and may help you delay the progression of your diabetes towards those terrible complications.

If you're really quick - you might even get delivery before Christmas :)

Seasons greetings to all. I just received my Christmas present; I hope you receive what you wish for.

Cheers, Alan, Australia

Low Carb Crustless Quiche

2010-10-26T20:34:00.003+11:00

I experimented for a while with various quiche recipes, but almost all included either flour or milk leading to carbohydrate content higher than my goal .

Eventually I made this simple version myself tonight from basic ingredients. It was intended to be the next in a series of new experiments. I was quite surprised to find that it set well and tasted delicious. Even better, my spouse, who will not eat eggs in any other form, loved it.

Ingredients.

4 whole eggs, free range if possible
200ml reduced cream
¼ tsp baking powder
2 rashers bacon, chopped (one rasher is 3 or 4 American strips)
1 medium onion, sliced
1 cup sliced swiss chard or spinach (1/4 cup if frozen)
30gm (1oz) of grated or sliced cheddar cheese
¼ tsp cayenne pepper
A grating of black pepper
Salt to taste – remember that the bacon will add salt too.

Method.

Four eggs and 200ml cream was the right quantity for my quiche dish, but if you have a larger dish add an extra egg and cream in proportion. Beat the eggs with a whisk until smooth. Add the cream, cayenne and baking powder and beat again until smooth. Set aside.

If you do not have reduced cream use your local equivalent. The cream I used is 35% milk fat, which is a little less than UK double cream or US heavy cream. I will try it with fresh cream next, which is a little lower in fat but I see no reason why that should not work OK. The fat content will be slightly lower and the carb content slightly higher.

Turn the oven on to let it heat up to 170C (340F) . In a suitable pan or skillet cook the bacon and onion until the onion is starting to caramelise. Add the chard or spinach, remove from the heat and set aside for a moment for the chard to wilt while you prepare the dish.

Use olive oil or butter to grease a suitable quiche baking dish well. Place it in a larger baking tray and add enough water to that tray to surround the quiche dish without causing it to float. Drain any excess liquid from the vegetable mix then spread the vegetables over the base of the quiche dish. Pour the egg and cream mix over the vegetables and spread the cheese over the top. I pressed the cheese down, but if you prefer a crusty top leave it on the surface.

Bake for about 30 minutes, but test with a skewer in the centre at 25 minutes in case your oven cooks more quickly than mine. When it is almost, but not quite, set in the centre it is time to remove it from the oven; it will finish cooking from residual heat.

Let it sit for a few minutes after you remove it from the oven. Don’t be disappointed if it goes flat – that is normal, it is a quiche, not a souffle.

We cut it into four serves, but double that would still be a very low carb meal. This is not a low fat meal. We had a simple lettuce, cherry tomato and onion salad with it. Delicious.

Nutrition Table
for one serve:

Energy 340 kcal
Protein 11 gm
Carbs 5.5 gm
Fat 31 gm

Bon Appetit

Up-date added 14th January 2011. I now use 5 eggs and cook it a little longer, about 40 minutes. It provides four substantial main meal serves.

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

To Medicate - Or Not?

2010-09-23T14:50:00.003+10:00

Quite often type 2 diabetics appear on forums that I read announcing that their goal is to become medication-free or to avoid needing insulin.

Although that sounds like a good goal, and for some individuals it may be, I think they may be confused about the true goal. To me the true goal is to delay or defer the terrible complications of diabetes for as long as possible; preferably to a date about ten years after I die in my sleep as a very old man.

I do not fear medications. If medications are needed to achieve my true goal I will take them. I added metformin a few years back for that reason. However, and it is a very important however, I will use them if, and only if, reasonable application of diet and exercise cannot achieve the desired result. There is an enormous difference between fearing medications and having a healthy and informed respect for the full implications of adding drugs to our bodies.

In my opinion medications should be used to complement a healthy lifestyle, not to attempt to compensate for an unhealthy lifestyle. If the diabetic's circumstances are such that further changes in lifestyle are unreasonable, impossible or not capable of producing the same benefits as medication, then medications are appropriate and valuable. But, if that is not the case, medications may be adding to their problems instead of solving them. Nor am I in favour of prophylactic medication, prescribed because some study somewhere showed a statistical benefit for some people. I'm interested in the effects on me as an individual, not a percentage of a study group who may or may not represent me.

There are no side-effects-free medications. As with all things in life a risks-benefit analysis is needed when considering adding medications or insulin.

I am unapologetically selfish about testing of new drugs. When new medications appear, often with lots of fanfare and research papers supported by the manufacturer of the new wonder drug, I have decided to wait for a decade or two of human experience before I will add that to my regimen. I will let others be the human guinea pigs over that period unless there is an urgent need that no other course of action can meet. Selfish? True. But sensible.

The history of many drugs makes salutary reading. First the euphoria, then the glowing reports, then the doubts, then the reaction. Some recent relevant cases for the drugs commonly prescribed for type 2s include the statins, Byetta, Avandia, Actos and even insulin. All may be beneficial to a large number but have significant risks for minority. The difficulty is knowing whether you are in the majority or the minority in advance. Nothing is risk-free.

Medications should not be feared. They are a valuable tool for us - but they should be respected and used only when needed.

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

Privacy On Forums And The Web

2010-08-11T12:12:00.004+10:00

I've been wandering around the internet since Netscape and Internet Explorer first appeared. I've seen it grow and change. Lately it has changed again with the dramatic increase of activity by multitudes of people posting overwhelming volumes of their most intimate personal details on places like MySpace, Facebook, Twitter and the constantly expanding range of other social net-working sites.

That trend is now reaching older sites such as the diabetes web forums I have been reading and posting on for a few years. The ADA Forum was re-vamped last November to add social networking and dLife added it a couple of years earlier.

I'm continually fascinated that people who would not tell their most intimate personal secrets to their own family, and certainly not to those who may not be their friends, happily post everything from their sex lives to their bathroom problems on the web. It becomes patently clear that the vast majority are blissfully unaware that not only can almost all of their writing be seen by anyone who cares to but it is being stored for readers decades from now. Many also appear to believe that forums and sites which require registration can only be seen or used by those who are registered.

Some years ago, when I only posted on usenet's alt.support.diabetes and misc.health.diabetes groups I googled my sig "Alan, T2, Australia" and was quite surprised to find that my posts were appearing on over 40 different forums; everything from bicycling to low-carbing. Some of those forums required registration - but my posts still appeared.

For one example of many, I am not a member of MedKB: http://www.medkb.com/Uwe/Forum.aspx/dia ... k-Diabetes

These days I also write on several other forums and my blog. I just googled that sig again and got 237,000 responses. Now, I know I write too much - but not THAT much!

Registration may help - but that depends on the software of the web-site and the integrity of the web-master or group owner. Try an experiment yourself. If you are a member of a group or forum that you need to register for, select a unique part of one of your old messages, place it in quotes and google or bing for it. You may get a rude surprise.

Even if your message does not appear in that sort of simple search, remember that any-one can register on ANY forum and "mine" the forum until the moderator or web-master ejects them. That includes anyone who may have a grudge against you or may be looking for information about you. To be honest, the only thing protecting the vast majority of the personal information posted on the web's social networking sites is the fact that 99.99% of it is utterly and incredibly boring to anyone but the writer.

Long ago I made the decision that I would never write anything on the net or web that I would be embarrassed to find was read by my mother, my wife, my children or my grand-children. Those are the important ones; I couldn't care less what the rest of the world thinks of me. Although I do keep in mind things like copyright law and that not all readers may have my best interests in mind.

I write on the assumption that there is NO privacy on the web regardless of the site I write on. Always write with that in mind and you will make the web a much safer place for yourself.

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

I'm Type 2! What Should I Eat?

2010-07-22T08:30:00.005+10:00

I often see these questions, in one form or another, on the various diabetes forums I read:

"How many carbs can I eat in a day?" or "What ratio of fat to carbs to protein should I eat?".

I think that is the wrong way to approach the subject for us as individual type 2 diabetics. Very few of us will actually sit down and work out the calories and fat:carbohydrates:protein ratios we are eating on a daily basis, nor does a daily limit for carbs work very well when our response to those carbs may be quite different at different times of day.

I do not deliberately plan to consume any particular proportion of daily fats, protein and carbs, nor any set daily carbohydrates level or limit. Instead, when I slowly developed my present way of eating I followed a simple process to work out what suited me.

My logic is fairly basic. I need to get all the appropriate nutrients for good health, but I need to get them in a way that does not jeopardise any of my various afflictions, including diabetes. I learned very soon after diagnosis that eating excessive carbohydrates caused blood glucose spikes, so I used this technique to adjust my carbohydrate levels until that did not happen: Test, Review, Adjust.

But other people, including my doctor, were then concerned that I may be missing out on vital nutrients. So I used a diet analyser to check what I actually ate to see if that was true. This is the most recent analyser I have found for that purpose: CRON-o-meter; there are others on the web if you do some searching. I also have regular blood tests; those can also show if I am deficient in various vitamins and minerals. If analysis or blood tests showed that I was missing something I then used the USDA nutrients guide to see what foods I could use to include those missing nutrients without increasing blood glucose levels.

In general terms, I found that eating a variety of proteins such as meat, fish and eggs in normal serve sizes, and replacing most of my starchy carbs, such as breads, potatoes, corn, pasta and similar with a wide range of colourful vegetables, such as cabbage, spinach, celery, onions, peppers, cauliflower, egg-plant and similar meant that there were very few nutrients I missed out on. In fact the increased variety of foods, especially vegetables, in my diet improved my nutrient intake in several areas.

If, and only if, I could not obtain a nutrient by adding a food to the menu I then added a supplement. At the moment my only supplements are vit D3, fish oil and magnesium.

When I do take the trouble to work out my fat:carbohydrates:protein ratios I find they are usually surprisingly close to those suggested in these interesting papers by researchers Mary C Gannon and Frank Q Nuttal:

Effect of a High-Protein, Low-Carbohydrate Diet on Blood Glucose Control in People With Type 2 Diabetes

Control of blood glucose in type 2 diabetes without weight loss by modification of diet composition

I did not use those as a guide, but it is reassuring to see that there is some science supporting my present way of eating.

Cheers, Alan

Everything in Moderation - Except laughter

Serendipitous Cajun Chicken

2010-07-11T17:33:00.002+10:00

Last night I had some chicken pieces to cook but I didn't feel like baking them, so I made the following up as I went along. I'm not sure this could really be called a recipe because the quantities and directions are not exactly quantified or normal, but the result was delicious.

I started with a chicken maryland (drumstick and thigh) and two wings. I jointed all those and ended up with eight small bits of chook, to be cooked for two.

I browned all those in a wok in a decent splash of peanut oil. When they were browned but not fully cooked I removed them to be returned later.

I sliced or chopped one red onion, a stalk of celery and a medium carrot and sautéed those in the chicken-flavoured oil; adding a minced clove of garlic when they were nearly cooked. Then I added a half teaspoon of cayenne, a half-teaspoon of turmeric, a half-teaspoon of paprika, a half-teaspoon of salt and a grating of pepper. The measurements were by calibrated eyeball. I also added just a few flakes of my ultra-hot dried birds-eye chili from the garden and some dried oregano, also from my garden.

I returned the chicken to the veges in the wok, gave it a good stir, then covered it all with chicken stock. I brought that to the boil and then reduced it to simmer and went off to upload some movies to my travel blog. That turned out to be an essential and serendipitous part of the cooking technique.

The up-loading took a little longer than I expected. Some time later (probably about a half-hour) I returned to find the wok had boiled almost dry and the veges on the bottom were starting to stick to the pan and going rather black. On tasting, the flavour had developed a slightly charred characteristic (hence the cajun tag) but still seemed edible.

I added a little water and gave it a good stir to de-glaze the wok and to mix the black flecks into the mass of veges; just enough water to result in a nice gravy consistency. I did not use any thickener in the recipe; no flour or guar gum. Then I returned it to the simmer for about ten minutes; this time under supervision.

I served it with some trepidation. The tasting judge, my better half, thought it was wonderful. She claimed it was the best chicken she had eaten for a long time. Surprisingly, so did I. Of course, she may have just been trying to ensure that the cook continues to cook for her...

I'm not quite sure how to write that down as a recipe technique: "cook until just charred but not burnt".

I haven't worked out a nutrition count but the only significant carbs would have been the carrot. It hardly caused a blip on my peak post-meal BGs.

Bon appetit,

Alan

Everything in Moderation - Except Laughter

Banting's Diet

2010-04-14T00:44:00.004+10:00

Just a quick post-script during my travels.

The title does not refer to the Banting who wrote the "Letter on Corpulence" but to the Banting who discovered insulin. Although both Bantings appear to have had some similar dietary views.

I was re-reading the fascinating story of Lois Jovanovic's grand-mother, which I refer to in SMBG - A Doctor Who Understands when something I missed earlier caught my eye.

Read again the letter an 8-year-old girl wrote to Dr Banting.

In addition to marvelling at the courage of that little girl giving herself injections with the size and type of syringe available in 1922, note this section on diet:

"I have been sugar-free for the last five days and getting about 1900 calories consisting of Pro 60 Fat 163 Ch 44."

Those numbers do work out close to 1900 calories. The percentages of calories from macronutriuents are approximately:

Protein 13%
Fat 78%
Carbohydrates 9%

That was the diet Banting, the discoverer of insulin, appears to have prescribed to his patient.

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

A Brief Interlude

2010-03-19T20:12:00.005+11:00

Among my various afflictions I am one of those unfortunates afflicted with wanderlust, a terrible condition (according to SWMBO) that causes me to become increasingly crabby and difficult to be around if I am confined to one locality for any extended period.

For that reason there will be a temporary hiatus on this blog until early May while I wander all over South America seeking a cure for it. If I am lucky, I'll fail in my quest...

In the interim I will post occasional trip reports, subject to the whims of internet cafes, wi-fi availability and upload speed on my travel blog for anyone interested.

I look forward to returning refreshed and relaxed.

Cheers, Alan

SMBG - A Doctor Who Understands

2010-03-14T22:24:00.006+11:00

Over time I must admit to developing a certain degree of cynicism about researchers and doctors in the medical research field. I get a little jaded and dispirited about the entrenched attitudes in the fields of diabetes research, especially concerning diet.

Recently, in SMBG Research, Or The Lack Of It, I wrote “There are so many areas of diabetes crying out for research. There are some that have never been studied at all, including those dealing with diet modified by structured testing or similar methods which can lead to minimal medication or insulin needs.”

A friend from the Netherlands has gently chided me by sending me a copy of a paper that shows I may have been a little harsh. Time is the enemy and I only read it in full for the first time today. It's not a research study, more a position or discussion paper, but it is the closest statement from a qualified doctor that I have seen yet to Jennifer's Test, Test, Test advice or my own version of Test, Review, Adjust.

The paper is written by Dr Lois Jovanovic and includes references to other studies in support. Not a lot of other studies, most are small and some are only obliquely relevant, but at least there is some research happening in the field. It is so pleasant, after years of reading so many doctors ignoring so many patients on this subject, to finally read a paper like this one. They can ignore diabetics like me and dismiss us as unqualified; but Lois Jovanovic is someone who may be harder to ignore.

I think two unique factors make this particular doctor more aware of the close relationship between carbohydrate input and post-prandial hyperglycemia than most doctors. First, she has a depth of experience especially in gestational diabetes and pregnancies in patients already diagnosed as type 2. That has led to experience in trying to attain and manage normoglycemia much tighter than the levels usually expected for most type 2s. Her bio, in part reads:

Dr. Jovanovic has authored over 240 articles, including 135 for refereed journals, and 25 books on the topic of diabetes and pregnancy and islet cell transplantation. She serves as an Associated Editor of Diabetes Care and is on the editorial boards of Clinical Pharmacology and Therapeutics and the American Journal of Perinatology and is a contributing editor for the Journal of the American College of Nutrition and special editor for Endocrine Practice, the official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. In addition, Dr. Jovanovic serves on the national board of directors of the Society for Experimental Biology and Medicine.

Not someone whose opinions on diabetes can be lightly dismissed.

Second, Lois Jovanovic is a type 1 diabetic. Uniquely, she is the grand-daughter of an 8-year-old type 1 girl in the original group treated by Banting when insulin was discovered. I found this fascinating article on her story here: Dr. Lois Jovanovic's Story. The discovery of insulin did not just save her life as a Type 1; she would never have existed at all without it.
The abstract of the paper can be found here: Using Meal-Based Self-Monitoring Blood Glucose (SMBG) Data to Guide Dietary Recommendations in Patients With DiabetesLois Jovanovic, MD, MACE
The Diabetes Educator, Vol. 35, No. 6, 1023-1030 (2009)DOI: 10.1177/0145721709349587

The purpose of this article is to describe how self-monitoring of blood glucose (SMBG) data is a useful tool for identifying and managing postprandial hyperglycemia (PPHG).

PPHG and postprandial glucose excursions occur frequently in patients with diabetes even when hemoglobin A1C is controlled below 7.0%, and convey increased risk of cardiovascular morbidity and mortality. Consequently, effective management of diabetes must include control of postprandial glucose levels. Postprandial plasma glucose (PPG) depends on the composition of meals, specifically the amount of carbohydrates.

Reduced-carbohydrate diets offer short-term improvements in glycemic control and other metabolic parameters, but await the support of long-term efficacy and safety studies. Glucose profiling and paired-meal SMBG are useful tools for detecting PPHG and glucose excursions. They provide immediate feedback to patients on the effect of foods and meals, thereby allowing appropriate food and medication adjustments to improve postprandial glycemic control.

But that abstract does not give an inkling of the specific recommendations in the full text or the pleasant shock I received when I read this marvellous “To Do” list for guiding dietary recommendations that is included as Table 1:

Educate your patients on the risks associated with high peak-postprandial glucose concentrations (≥150 mg/dL)

Ensure patients understand that postprandial glucose concentrations are determined by the total amount of carbohydrates consumed

•• Encourage patients to measure their carbohydrate consumption

•• Recommend that patients keep a food diary

Remind patients of the benefits of monitoring their blood glucose levels with SMBG and construct a testing plan that optimizes these benefits

•• Have patients determine the best time for postprandial SMBG by testing 45, 60, 75, 90, 105, and 120 minutes after a meal to detect their peak postprandial glucose concentration

•• Using preprandial and postprandial SMBG, together with a food diary, patients can understand how certain foods influence their glucose concentrations

•• If preprandial glucose concentrations are already high, there is no room for carbohydrates in the upcoming meal

Review recent SMBG and food diary data with your patients to help them recognize trends in out-of-target readings

•• Use this information to recommend a specific SMBG testing schedule including number of tests per day and appropriate testing times

•• Have patients meet with a nutrition specialist if they are having trouble identifying or controlling their carbohydrate consumption

Personally, I was particularly pleased to read the recommendation to find the post-prandial peak and use that as the best time.

I could hardly have asked for a better list of advisory guidelines from a doctor. I hope her paper is widely distributed among her peers. It should be required reading on the boards of organisations such as the ADA, NHS, CDA and Diabetes Australia.

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

Should Detectives, Not Just Academics, Review Drug Research?

2010-02-26T17:02:00.002+11:00

The different reports I intend to comment on may seem a bit disconnected as you read this; however, I think you will see the common thread.

A little while ago I wrote Money, Medications and Motives, related to this report of a corrupt doctor who strongly promoted prescription of powerful antipsychotic medicines to children while receiving un-declared income of over $1.6 million from drug-makers. That New York Times article goes on to describe other doctors acting similarly and implies a systemic problem in the relationship between practicing physicians, academia and the massive medical industry.

This perspective was published in the New England Journal Of Medicine today (Volume 362:669-671 February 25, 2010 Number 8): Serving Two Masters — Conflicts of Interest in Academic Medicine, by Bernard Lo, M.D.

He comments on the recent introduction by Boston-based Partners HealthCare, which includes some of the nation's leading teaching hospitals, of strict limitations on the level of compensation appropriate for their officials for serving on boards of directors of biomedical companies or similar situations. I must admit, from my perspective, a limit of "$5,000 per day for the time spent at board meetings" seems a trifle loose; it certainly causes one to wonder what the unlimited compensation has been. He includes this comment in his conclusions:

The public grants the medical profession considerable discretion in setting its own standards because it trusts that physicians will place patients' interests ahead of their own or those of third parties. To maintain this trust, AHCs (academic health centers ) should take the lead in addressing conflicts of interest in medicine, rather than merely responding to government requirements and adverse publicity about troubling cases. Taking the initiative will promote a culture of accountability and a commitment to professionalism.

I could not agree more. Unfortunately, I think the gate has been left open too long and the horse has well and truly bolted. It is now time for agencies beyond academia and the medical profession to take a keener interest.

A couple of days ago an article was reported in TheHeart.org about an analysis performed by Dr Mohammed Hassan Murad (Mayo Clinic, Rochester, MN) and colleagues of 202 papers or articles authored by medical professionals concerning Avandia. Coincidentally, an article in the UK Guardian newspaper reports that, after a two-year inquiry, the US Senate finance committee concluded that Glaxo Smith Kline knew of the link between Avandia and heart problems in 2004 but intimidated scientists to ensure favourable reports. You might note in that Guardian report "Glaxo firmly rejected the committee's findings, saying that 164 independent clinical trials have failed to find an association between Avandia and heart attacks."

Coincidence is a strange thing. Independently, as far as I can determine, Dr Murad and his colleagues examined the links some authors of papers and reports had with antihyperglycemic agent manufacturers and with rosiglitazone's manufacturer which may have conflicted with an unbiased report on the medication. Please read the full article; I don't wish to infringe copyright so I'll just mention the bare facts.

The analysts found that 107 of 202 papers or reports included a conflict-of-interest statement and 90 (45%) indicated a conflict existed.

Of the authors who concluded that no risk of heart problems are posed by rosiglitazone, 91% had financial relationships with antihyperglycemic agent manufacturers and 86% had relationships with rosiglitazone's manufacturer.

On the other hand, of authors who stated unfavourable opinions, only 25% had financial relationships with antihyperglycemic agent manufacturers and only 18% had relationships with rosiglitazone's manufacturer.

I don't think it takes a statistician to realise those numbers are significant. Who pays the piper calls the tune.

Earlier this month this brief statement appeared in the FDA news Drug Daily BulletinFeb. 2, 2010 Vol. 7 No. 22

Researcher Reaches Plea Agreement on Charge of Fabricating Data

A former influential pain drug researcher has reached a plea agreement with the Justice Department on a charge that he fabricated patient data. Federal prosecutors accused Scott Reuben, former chief of acute pain at Baystate Medical Center in Springfield, Mass., of falsifying patient data in trials of painkillers, including Merck’s Vioxx (rofecoxib) and Pfizer’s Celebrex (celecoxib). Reuben agreed to plead guilty to one count of healthcare fraud.

News reports on that appeared in several places, this is a brief extract from Medpage Today:

A Massachusetts anesthesiologist accused of fabricating data in studies of pain drugs will plead guilty to federal criminal charges under an agreement with prosecutors.

Scott Reuben, MD, a well-known pain researcher at Baystate Medical Center in Springfield, Mass., was charged with one count of healthcare fraud.

Early last year, the hospital announced that an internal audit had revealed that Reuben had made up research data out of whole cloth, affecting at least 21 published studies over a 15-year period. (See Special Report: Few Gaps in Analgesic Practice After Reuben Retractions) The criminal charge arose from one of those studies, funded by Pfizer and published in Anesthesia & Analgesia in 2007.

If you refer back to that article of mine on Money, Medications and Motives you will find that Celebrex was not Pfizer's big money maker. This is from 2007 figures:

"Pharmaceutical revenue from 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.

Overall, the company’s domestic revenue dropped 11 percent to $21.74 billion in 2007. Lipitor (atorvastatin calcium) had revenue of approximately $7.2 billion in the U.S. last year compared with approximately $7.85 billion in 2006. Worldwide Lipitor revenues were approximately $12.7 billion, a 2 percent decrease from 2006."

There are many countries in the UN that don't have a gross revenue like that. In 2007, if Pfizer was a country and not a manufacturer of pharmaceuticals, $48.4 billion would have positioned Pfizer 72nd out of 190 countries on the world rankings, just below Belarus and just above Luxembourg.

Until the FDA, TGA and other regulatory agencies can be absolutely confident that research studies are not only scientifically sound but are also not fraudulent, it appears to me that there is a case for agencies such as the FBI in the USA and equivalents in other countries to be involved in following the money trail during the process of approval of a medication for prescription by physicians.

There is the possibility that drugs like Lipitor and Celebrex save lives. But there is also the possibility that they kill people. All medications have side effects. Medications scientifically and honestly researched and trialled which provide detailed advice to regulators, physicians and patients of both the benefits and the risks can be a boon to mankind. For example, the risk of type 2 diabetes from Prednisone is well known, but the benefits for patients undergoing chemo are also significant. If a phsyician and patient decide to use that medication when fully aware of the risk, that is acceptable.

However, in my opinion, if a person deliberately falsifies or distorts influential reports on medications which lead to killing people who would not otherwise have died, and if others become aware of that consequence but deliberately falsify or suppress that information to profit from the sales of that medication, that person and those people should be charged with homicide, not just fraud.

Big fines will not cause a blip in the balance sheet of companies with resources like Pfizer. However, the possibility of being charged with murder may cause some second thoughts before repeating or facilitating actions such as the Celebrex scandal.

Resources such as the FBI are limited so their allocation needs to be targeted. An obvious starting point, in my opinion, would be to review ALL of the papers used by the FDA when making their decisions on statins, including Lipitor, Crestor, Zocor and all of othes presently approved.

Follow the money trail...

Cheers, Alan

Everything in Moderation - Except Laughter

SMBG Research, Or The Lack Of It

2010-02-16T22:26:00.001+11:00

Nearly three years ago I challenged the authors of a particularly poor paper titled "Impact of self monitoring of blood glucose (SMBG) in the management of patients with non-insulin treated diabetes: open parallel group randomised trial" in the British Medical Journal to conduct a study based on Test, Review, Adjust.

When I first read Jennifer's Test, Test, Test I used to wonder why a study of that method had never been performed.

Of course now, with a little more experience, the reasons are fairly obvious to me. To start with, no researchers are even vaguely aware of the technique. That is apart from the fact that the results are unlikely to lead to increases in medication sales. Over five years ago, back when I naively thought someone would listen, I rang the Australian offices of Roche and Lilly to suggest it. They were polite and totally uninterested. I thought that at least the major test-strip manufacturers may have a vested interest. Apparently not.

My response to that paper was another small attempt to interest somebody in the appropriate field in the concept. But I have to be realistic; not many researchers read the "Rapid Responses" and Farmer et al certainly were not going make any attempt to prove themselves wrong.

The idea surfaced again today when Stuart, a Type 1 diabetic on the dLife forum, posted this very interesting question:

"If you wanted someone to explore something, to do a STUDY on a subject(s) about our diabetes, what do you want them to research? What areas do YOU want to know far more about that don't seem to be being done??? "

He had some very interesting replies. You can read them here. I would like to expand slightly on my answer there.

There are so many areas of diabetes crying out for research. There are some that have never been studied at all, including those dealing with diet modified by structured testing or similar methods which can lead to minimal medication or insulin needs. At the moment research tends to be focused on finding new medications or new ways to use old medications. In the real world "who pays the piper calls the tune".

No researchers are asking us, the diabetics, "what should we be researching?"

My own area of interest is just one of many possibilities. Despite understanding the reasons I still find it hard to believe that after more than three decades of home self-testing of blood glucose by diabetics no medical researcher, anywhere, has researched the use of structured self-testing for dietary modification to reduce blood glucose excursions.

Thousands of type 2 diabetics like myself have been "researching" the method personally and reporting their individual successes on many different forums since before I was diagnosed eight years ago, but we don't count in professional medical and research terms. We are diabetics, not scientists and our reports are anecdotes, not data.

I will offer the basic idea. Who knows, maybe there is a bright scientist out there looking for a PhD subject who has the ability to find a grant or research funds.

I propose a study comparing two groups of type 2 diabetics, all within their first 12 months of diagnosis. The only exclusion criteria would be that none should be using insulin or an insulin-stimulating medication such as a sulfonylurea at the commencement of the study.

Group 1, control, would be treated as individuals by their physicians and other specialists in exactly the same way as the present guidelines for their country. For example that would be the ADA or AACE and American Dietetic Association guidelines in the USA, Diabetes Australia here, or the NICE/NHS guidelines in the UK.

Group 2 would would also be treated as individuals by their physicians and other specialists in exactly the same way as the present guidelines for their country with the exception of dietary and testing guidelines. Instead, they would be given basic dietary guidelines to understand the differences between carbohydrates, fats and protein and their effect on blood glucose levels, and would also receive training and support in using feedback from peak post-prandial blood glucose testing to modify diet and lifestyle. The method taught would be based on the technique described in Test, Review, Adjust. If that needs clarification I am available as a consultant :)

The period of study would be three months initially, with weekly support and review to record indicators for both groups for the first four weeks, then monthly for the next two months with a preliminary report prepared after three months. Periodic follow-up review and reports would be performed at 12 months, five years and ten years. Indicators recorded would include A1c, fasting and peak post-prandial blood glucose levels, lipids, weight, blood pressure and any others the researchers felt valuable.

The five year and ten year reports would follow up all the earlier results and also include morbidity and mortality and any differences in progression to, or of, diabetes complications.

An inexpensive pilot study would not need very large populations and could be restricted to the first three months. The results of that could support further study over the longer period with a larger population.

I can also see other possible studies. For example, the possibility of combining Gannon and Nuttall's LoBAG20 or LoBAG30 diet with the above study as the starting diet for Group 2 is one that intrigues me. But it may be unwise to put too many variables in the mix. One thing at a time.

My area of interest may be quite different to yours. If you were the person asked by the researchers "what do you want us to study?" what would your answer be?

Cheers, Alan

Everything in Moderation - Except Laughter

Good Targets, Bad Methods

2010-02-03T09:08:00.003+11:00

There has been a lot of discussion in the media and the blogosphere about an Early Online Publication in the Lancet on 27 January 2010.

Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study

"Methods
Two cohorts of patients aged 50 years and older with type 2 diabetes were generated from the UK General Practice Research Database from November 1986 to November 2008. We identified 27 965 patients whose treatment had been intensified from oral monotherapy to combination therapy with oral blood-glucose lowering agents, and 20 005 who had changed to regimens that included insulin. Those with diabetes secondary to other causes were excluded. All-cause mortality was the primary outcome. Age, sex, smoking status, cholesterol, cardiovascular risk, and general morbidity were identified as important confounding factors, and Cox survival models were adjusted for these factors accordingly

[snip]

Interpretation

Low and high mean HbA1c values were associated with increased all-cause mortality and cardiac events. If confirmed, diabetes guidelines might need revision to include a minimum HbA1c value."

What has saddened but not surprised me is that the reaction in on-line medical discussions has been much the same as that when the ACCORD and ADVANCE studies appeared. No-one has questioned the methods used to attain targets, all appear to accept that there may be a problem with attempting to aim for tight targets for type 2 diabetics. Thus, the targets are bad and should be eased.

I was not going to write about it because so many others have, but eventually I responded in Present where a doctor posed the following question based on this study: "Are we treating our patients to death?"

This was my response to the doctors.

The answer depends, of course, on the method of treatment and the individual nature of your patient's diabetes.

All of these studies, including ACCORD, ADVANCE and these recent ones have a common thread. They presume that the only way the physician can reach lower A1c and blood glucose goals in a patient is by medication. None of them consider using lifestyle – diet and exercise - changes to complement minimal medication or insulin to achieve those goals.

You all presume that a patient would not use diet and exercise. And, of course, to some degree you are correct, especially when the most generally prescribed diet is directly counter-productive for achieving better A1cs and blood glucose levels.

So you prescribe diet and exercise, the numbers go up, you presume non-compliance and prescribe metformin or a sulf or add insulin, they keep going up so you increase those and add more meds. But you also stress that the patient should eat more carbohydrates – and less fat - to be absolutely sure there are no hypoglycemic episodes as a result of the sulfs or the insulin and so the cycle continues, chasing it's tail.

Lower blood glucose and A1c targets do not cause higher mortality and morbidity. I have read success stories from many thousands of pro-active diabetics of all types on many forums since I was diagnosed eight years ago who have clearly demonstrated the opposite is true.

On the other hand, over-medication to attempt to counter poor dietary advice DOES cause higher mortality and morbidity; that is the consequence these studies are showing.

The solution? First, stop promoting the terrible “heart-healthy” high-carbohydrate AHA diet to your patients, or allowing the dieticians you send your patients to to do so. Instead, suggest that the patient use their meter at their post-prandial peak blood glucose timing to find out what foods are killing them and they will quickly reduce those foods, and their levels, and substitute others. The technique is described here: http://loraldiabetes.blogspot.com/2009/04/test-test-test.html

Some patients will do that and succeed; some will need further medication, but much less than you usually prescribe. And others will be non-compliant whatever you prescribe. They are the ones to prescribe higher medication to – but they are also the ones you should set easier targets for. Because they are the ones dying from over-medication.

Cheers, Alan.

Everything in Moderation - Except Laughter.

Cholesterol, Fats, Carbs, Statins and Exercise

2009-10-31T12:58:00.003+11:00

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 assessment Effect 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

2009-09-15T14:23:00.004+10:00

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

2009-08-13T14:54:00.007+10:00

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

2009-07-15T16:49:00.005+10:00

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

2009-06-29T12:18:00.010+10:00

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

2009-06-22T15:36:00.004+10:00

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

2009-06-12T15:36:00.009+10:00

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.

The annual cost to the Federal taxpayer works out at about AU$3,400 per person. That is about US$2,800 or £1,700 at today's rate of exchange. 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 1.5%. 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, these three links give an insight from slightly different viewpoints:

Medibank: from conception to delivery and beyond

The Australian Health Care System: An Outline - September 2000

Medicare - Background Brief

Breakfast On The Run

2009-05-24T11:45:00.002+10:00

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

2009-05-04T18:55:00.004+10:00

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. 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.

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, start 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

2009-05-01T09:39:00.003+10:00

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?

2009-04-25T22:24:00.008+10:00

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

2009-04-17T18:57:00.007+10:00

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 120
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 6.5
Two hours after meals....Under 5.5

Cheers, Alan
Everything in Moderation - Except Laughter.

I Ate Nothing! Why Are My BGs high?

2009-02-16T14:33:00.005+11:00

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

2009-02-07T13:40:00.007+11:00

Air travel

Travel by air has become a bit more complicated since 9/11. 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.

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. Click here and scroll down to "Diabetes". Also, note that the 3-1-1 gels and liquids rule is eased for Medications. They do not need to go in that quart zip-loc bag. For the specific rules scroll down to "Additionally, we are continuing to permit prescription liquid medications and other liquids needed by persons with disabilities and medical conditions." and subsequent paras. 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.

Further recent reading from the ADA: Fact Sheet: Air Travel and Diabetes (PDF)

That notes that drinks for diabetics are now allowed through security based on the doctor's letter. That worked for me when I left Noumea recently, but I would not rely on it.

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

2009-01-09T16:19:00.006+11:00

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 Reform
Creating 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

2009-01-03T15:02:00.001+11:00

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

Inspiration

2008-12-28T08:57:00.003+11:00

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

2008-12-17T06:41:00.000+11:00

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

2008-11-27T12:40:00.002+11:00

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

2008-11-25T14:17:00.002+11:00

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

2008-11-24T16:01:00.002+11:00

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

2008-11-22T13:44:00.001+11:00

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.

Roll-mops and similar fishy treats.
Not for all – but a great snack for those who like them.

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.

Cheers Alan
Everything in Moderation - Except Laughter

Experts

2008-11-16T22:47:00.003+11:00

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 signicant. 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

2008-10-24T20:22:00.002+11:00

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

2008-10-12T10:31:00.005+11:00

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

2008-10-02T09:13:00.014+10:00

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

2008-09-26T09:02:00.004+10:00

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

2008-08-18T09:26:00.008+10:00

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?

2008-07-30T23:17:00.005+10:00

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 educate the patients in their use.

Cheers, Alan

Everything in Moderation - Except Laughter

Past, Present and Future

2008-07-21T18:16:00.003+10:00

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

2008-07-16T14:46:00.005+10:00

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

2008-06-18T13:37:00.007+10:00

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

2008-06-10T08:26:00.010+10:00

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.

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

2008-06-07T22:38:00.009+10:00

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

2008-06-06T09:19:00.005+10:00

"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

2008-05-06T19:19:00.005+10:00

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 (trimmed well of fat)
Eggs
Beans
Nuts
Avocado

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

Cheers, Alan

Is Testing Worthwhile?

2008-04-30T11:13:00.003+10:00

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

Valderee, Valderah. Or, I love To Go A-wandering...

2008-03-06T08:43:00.004+11:00

G’day Everyone

This blog is meant for all the newly diagnosed type 2’s out there who are still getting over the shock of diagnosis.

Please use the Contents list on the sidebar to access information. Start here: Getting Started

Treat this place as a smorgasbord; use what is helpful to you, ignore what isn’t. And please read the bit in Red at the head of the page before trying any of the ideas here.

If you have added a comment and are annoyed it hasn’t been approved, my apologies. I’m off on my wanders around the world for a couple of months. I’ll be placing a few trip reports on the World Travel Blog at some stage, but there will be no new entries here for a while and approvals will have to wait a while.

Cheers, Alan

The Quality of ADA Dietary Advice

2008-02-29T17:05:00.009+11:00

I was asked this question today on the ADA forum.

"Just what is low-fat/high-carb? My dietitian suggested 45-60 carbs per meal. That does seem like a lot sometimes. "

This was my reply on the Type 2 board.

"The USDA and the owners of this web-site (at least, they are again this week:-) have defined it pretty well here: Using the Diabetes Food Pyramid. Notice that fats of all types are right at the top, to be used minimally, and "bread grains and other starches" are at the base to be used in abundance.

That is associated with this other ADA web-page The Diabetes Food Pyramid: Grains & Starches which includes "The message today: Eat more whole grains! Whole grains and starches are good for you because they have very little fat, saturated fat, or cholesterol. They are packed with vitamins, minerals, and fiber. Yes, foods with carbohydrate -- starches, vegetables, fruits, and dairy products -- will raise your blood glucose more quickly than meats and fats, but they are the healthiest foods for you. Your doctor may need to adjust your medications when you eat more carbohydrates. "

I am departing for two months in a few days, so I will depart from my usual reticence on this subject on this forum.

In my lay opinion as a type 2 diabetic I think that the dietary information for type 2 diabetics on those pages, and on several associated pages, is the most dangerous and disgraceful dietary advice for type 2's that it is possible to give. In effect, it says that it's OK to eat food that you know will cause blood glucose spikes as long as you medicate to correct it. In fact, not just that it's OK but that it's healthier for you to do that.

It is made even more dangerous because the source is the most influential major authority in the world. I wrote about that a long time back, and little has changed since.

There has been a change of leadership at the ADA and many of the diabetics I know are hoping for changes in those guidelines."

Well, time will tell. I just hope that the changes occur within my lifetime; they may come too late for many.

Motivation, Likes and Dislikes

2008-02-28T09:32:00.006+11:00

On all the various forums I read there is a recurring theme from newly diagnosed people of grief over a lost lifestyle. And not just from newly diagnosed people.

How many times do we read "I hate testing" or "I can't exercise" or "I don't like vegetables" or "I don't eat breakfast" or "I couldn't give up my [insert your favourite treat]" or "I only ever eat one big meal a day" or "I don't like cooking" or "I haven't got time to cook/exercise/whatever" or just "I don't like...".

Motivation is a strange thing. The carrot and the stick. Some of us say we do best on the positive; others find the negative more effective. In reality it's a mix of both. Many of us have found that the improvement in our overall health once we took control of our diabetes was quite dramatic and we promote that as a positive. It is. But let's be honest, how many of us used that as the motivator when we started?

"Hey! I've just been diagnosed with diabetes! Ain't it great! Now I can get fit!" Yeah, right. That wasn't me.

If we're honest, the real motivator for me, and I suspect for most of you, was fear. We each have our own phobias, but diabetes gives us such a wide range of choices that there is something there for all.

Stop here if you don't like nasty reminders.

Consider why you are reading about diabetes. The experienced people on all forums try to mainly be up-beat and supportive, but support can sometimes mean that a jolt of reality is appropriate.

Just a few for starters:
o Death from many possibilities, the most likely being heart attack.
o Blindness, usually from retinopathy.
o Neuropathy, including associated wound healing problems and possible gangrene and salami surgery or amputation.
o Nephropathy, kidney disease, dialysis.

Positive motivation is great. But the reality is that if we don't take control of our own diabetes management the negatives can creep up on us all too quickly. My personal negative motivator is blindness; as a leukemiac death no longer scares me; I think I can live with amputation, and from what I've read dialysis is not an enjoyable long-term lifestyle.

But I love reading, I love seeing the beauty and grandeur of nature, I enjoy watching TV, I love watching my grand-daughter grow and I enjoy writing so blindness scares the shit out of me.

It took me a while to accept that my past lifestyle likes and dislikes were no longer relevant. I had to discover new likes and dislikes, because I am in this for the long haul.

It's amazing what you can learn to like once you realise that your life, and the quality of that life, depends on it.

ACCORD, Foxes and Grapes

2008-02-10T10:06:00.000+11:00

Of the stories I learnt as a child, the ones by an ancient writer named Aesop have often proven to be full of wisdom over the years.

Remember this one?

'One hot summer's day a Fox was strolling through an orchard till he came to a bunch of Grapes just ripening on a vine which had been trained over a lofty branch. "Just the thing to quench my thirst," quoth he. Drawing back a few paces, he took a run and a jump, and just missed the bunch. Turning round again with a One, Two, Three, he jumped up, but with no greater success. Again and again he tried after the tempting morsel, but at last had to give it up, and walked away with his nose in the air, saying: "I am sure they are sour."'

Going by the popular press and various responses in medical literature ACCORD appears to indicate to the experts that achieving normal HbA1c levels in long-term diabetics is obviously too hard for modern pharmacology without dangerous side-effects.

So obviously it can't be done. And obviously it isn't important any more.

Normal HbA1c has become a sour goal.

It never occurred to the fox to build a ladder or pile up some rocks.

It never seems to occur to the experts to review the traditional diet and lifestyle guidelines to see whether different ones may assist the HbA1c goal and reduce the medication levels and thus the side effects.

Years ago I also learnt a different lesson about goals. Good goals are set in concrete; plans to achieve them are drawn in sand.

I'll write more on ACCORD and it's interpretation in a few days.

Cheers, Alan

Everything in Moderation - Except Laughter

LuckyKat

2008-02-01T07:48:00.000+11:00

G'day All

Too often we see new people in denial. And sometimes we hear from others seeking motivation.

I read an inspirational story yesterday on the ADA forum that really brings home both the best and the worst in the way people handle this disease. The thread was started by a diabetic asking for "horror stories" for negative motivation and this was one of the replies.

I asked permission to post it in other forums and was told I can "post it anywhere you want." So here is Kat's Story.

Hi allow me to introduce myself. My name is Kathy and I am both a horror story and a diabetic survivor.
Let me start with my family history. My mother was a Type 1.5 diabetic. My Father is a type 2 diabetic. My brother is a type 2 diabetic. Me --I am a type 2 We have it covered! LOL

My Mothers story

My Mom was a Type 1.5. She was born in 1938. She was diagnosed in 1957. She decided for whatever reason to ignore the diagnosis. Until she was pregnant with me in 1963. Well I was born 13 weeks premature. Spent the first 3 months of my life in Baby ICU.

My Mom controlled her disease for years and gave birth to my brother in 1965. After that she suffered 4 miscarriages and tried no more -- she tried no more for babies and she once again decided not to fight the disease. In 1970 I stood by her hospital bed as she cried about them cutting of her leg. I was 7. In 1973 she suffered a major stroke. At 10 I learned to change diapers of the shell that used to be my Mother. In 1977 2 days before Christmas a 14 year old child (me) and a 12 year old son buried their 39 year old Mother. A 37 year old husband was left to raise a teenage daughter and his son.

When I get to Heaven my first question to my Mother will be why I wasn't important enough for her to give up Twinkies?

My Fathers Story

Raising 2 children he was diagnosed in 1984. He took a different approach -he controlled the disease. He did a wonderful job raising 2 children and controlling his disease. Today he is still only on oral meds. His last A1c was5.2. He walks over 5 miles a day-oh and he is 67 years old.
He has welcomed into this world 2 grandchildren and just 4 months ago his 1st great Grandchild.

My Brothers story

Type 2 diagnosed 6 years ago. Oral meds only. Last A1c 6.9. Up from a 6.3 last time. In fact his 6.9 is his highest in the last 4 years. Has 2 great kids. A good job and is happy and as healthy as he can be.

Kathy's Story- (this is me) LOL

From the time I was 21 I had blood work done every year. Jan to be exact. Never a problem. Just keeping an eye on the Beast . Until 2007. I was too busy to go get it done. Put it off for 2 months.

March 2,2007. Can't move my right arm. Trip to the ER. The next thing I remember is waking up in the ICU at St. Luke's -3 days later. Can't move my right arm or leg. Can't speak.
Husband says " honey you had a stroke." Now you think that would be the end of Kathy. After all look at Mother's Story.

Fast forward to March 16th 2007. Dr. says Kathy you are a diabetic. Sugar at admission was 384. Got me am A1c of 15.24.

Kathy decides to follow Dad's example with this disease and not Mom's. Sometimes a girl just can't be like her Mom. She also decided to fight, fight, fight to get her life back. She was not going to have her husband changing her diapers!

Fast forward to Dec 15th 2007. Kathy A1c 6.5. She is still aiming for 6.0!

Fast forward to 1/30/2008. Kathy can talk, Kathy can walk, Kathy can use her right arm. Okay Kathy still has a couple of fingers being stubborn-but she refuses to give up on them! In fact Kathy starts a part time job next week. Not only that but she gets the nerve to finally introduce herself to the great people on the ADA board. After all she was reading you guys before she could even move her right arm.

Hi My name is LuckyKat!!!
(Stroke Survivor and Diabetes Fighter!)

And also a very courageous and inspirational lady. Thanks Kat.

The Other Side of the Revolution

2007-12-09T15:36:00.000+11:00

Hi All

Shortly after writing my comment on the USA Today "Diabetes revolution" article, I had cause to re-visit a report by the US National Committee for Quality Assurance.

It's worth browsing through. Although it is specifically about the USA, I doubt that other Western nations, such as mine, are significantly different:

THE STATE OF HEALTH CARE QUALITY 2007

Scroll down to page 35 for some details on diabetes.

For example:

ABOUT DIABETES

• Almost 2 in 3 Americans living with diabetes will die from heart disease or stroke.

• For every 1 percent reduction in blood sugar level (HbA1c), the risk of developing eye disease, nerve disease and kidney disease is reduced by 40 percent.

• Every 10 millimeters of mercury reduction in systolic blood pressure in diabetics results in a 12 percent reduction in diabetic complications.

• In the U.S., diabetes accounts for almost 45 percent of new cases of kidney failure.

• About 65 percent of people with diabetes have mild to severe forms of nervous system damage. Long-term effects include impaired sensation in the feet and hands, carpal tunnel syndrome and other nerve problems.

• Diabetics are more likely to die from acute illness such as pneumonia or influenza than those who do not have diabetes.

• Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness annually.

That doesn't sound much like a revolution in diabetes to me. More reports are available here: NCQA Newsroom

Cheers Alan

The Diabetes Revolution?

2007-12-09T15:26:00.000+11:00

This article has just appeared in USA Today: Diabetes 'revolution' is cutting both ways

I won't quote it because I don't want to infringe copyright. So I'll wait while you slip away and read it.

Back already? :-)

I wouldn't get too excited just yet. Have another look at those graphs that are at the top and on the left sidebar again. I hope I'll be forgiven for copying those. They may have changed the curve but the changes are rather un-dramatic.

The graph at the top shows diagnosis numbers tripling over a 25 year span. Despite changes in diagnostic criteria and populations that is still a giant increase at a time when we were being told by all dietary authorities that fat is evil and starch was good for us.

The other charts show:

o Lower extremity amputations are exactly where they were,after a terrible peak in the '90s.

o Eye damage has dropped from 26% to 21%; still terribly high and hardly encouraging considering much of that drop could be related to improvements in eye treatment such as laser surgery over that time.

o The chronic kidney disease rate increased by 40% over that 25 years despite coming down from a peak in the '90s.

Despite all the feel-good words in the report, I have difficulty accepting the up-beat tone. The only thing I get out of it is the thought that they should be studying what changed in the mid-90s in diet and lifestyle in the American population.

I can think of a few things that may, or may not, be significant. Think about these for a while, and maybe you can add some of your own.

1. There has been almost no change in the dietary advice pushed by the major professional medical advisory bodies.

2. The diagnostic criteria change has led to earlier treatmentfor many.

3. Low-carb diets, whether you like them or hate them, led to a new awareness of the dangers of excess carbs in diet and may have had an effect on the consumption of carbs as a proportion of the Standard American (or Australian) Diet (SAD), particularly of those diagnosed with type 2 diabetes.

4. Home testing meters became much more available and easier to use.

5. The internet has empowered patients of all afflictions to gain knowledge to add to their doctor's advice.

Just thoughts. But I'm not rushing out to celebrate the 'revolution' in diabetes just yet.
Cheers, Alan

Psyllium, Fibre, Muesli and Nuts

2007-10-19T11:41:00.001+10:00

Back when I started following Jennifer’s testing advice I gradually cut the starchy and high GI carbs in my daily menu significantly. I replaced them with other veges but on analysis I found I needed to add some fibre back into my menu. I found that the most readily available supplement to do that was psyllium husk; a food that is 80-85% dietary fibre.

If you do a little searching on psyllium you will find a lot of scientific papers on it’s various benefits. However, it’s not easy to eat the stuff directly. That’s why commercially available forms such as Metamucil have other flavours and ingredients added to make them palatable.

Separate to that, I also found that I could eat more carbs in the evening and that a small bowl of muesli at bedtime helped with my dawn effect numbers in the morning. Additionally, I try to eat some nuts regularly as part of my menu.

As a result of all those different factors I gradually developed this simple recipe for my bedtime snack.

Ingredients:

750gm or 1 Kg (1 1/2 to 2 lbs) pack of Muesli from the supermarket.
For those who haven’t eaten Muesli, it is usually a mix of rolled oats, other grains, dried fruits
etc. High in whole grains and fruits, so high carb but also high fibre. Usually about 65% carb and 10-14% fibre.

400-500 gms of mixed nuts, roasted but not salted.

My usual mix is brazils, walnuts, almonds, cashews; I vary it occasionally with pecans or other real nuts. No peanuts.

200-250gm psyllium husks from the local health food store.

The result is roughly a 4:2:1 ratio of Muesli:nuts:psyllium.

Method.

I chop the nuts coarsely in a food processor, but not to the point where they are a powder. I like the crunch when I eat them. Then I just mix all the ingredients together and store them in a large air-tight container.

Use.

At bedtime I put two or three tablespoons of the mix in a bowl and cover it with enough whole milk to wet it; I experiment to find the quantity needed to overcome the psyllium's tendency to set the mix solid:-)

Occasionally I use water instead of milk, or a combination of both.

For my most recent mix I worked out the actual numbers (US style, subtract fibre) for a 40gm serve with 100ml whole milk. Obviously these numbers will vary according to your muesli ingredients and choice of nuts:

Calories ................ 220__cal
Carbohydrate..........27__gm
Fiber........................8.5__gm
Protein .....................8__gm
Total Fat..................12__gm
Sat. Fat.....................3__gm
Mono. Fat.................5__gm
Poly. Fat....................3__gm
Cholesterol ..............13__mg

I eat that at bedtime 3-4 nights per week.

One other beneficial side effect was to improve my morning regularity.

Cheers, Alan

Everything in Moderation - Except Laughter.

A post-script, 16th May 2008.

This was brought to my attention today, published in the American Journal of Clinical Nutrition in 1999:

Effects of psyllium on glucose and serum lipid responses in men with type 2 diabetes and hypercholesterolemia

"Results of this study suggest that the addition of psyllium to a standard diet for diabetes is safe, is well tolerated, and offers an additional dietary tool to improve metabolic control in individuals with type 2 diabetes and hypercholesterolemia. "

Cinnamon, Spices, Herbs and Similar

2007-10-06T08:46:00.002+10:00

On the various diabetes groups I read there is a perennial question as to the benefits of cinnamon for reducing blood glucose peaks. Many of the stories about cinnamon can be traced back to a limited study in Pakistan a few years ago and some US follow-ups. I won't argue about their validity but I've seen no credible in-depth studies on the subject. However it keeps recurring almost weekly on places like the ADA forum and was discussed last month on the ADA web-site and last April on David Mendosa's excellent web-site. [see the post-script at the foot, added 18 February 2009

The minimal, if any, effect that cinnamon had on me was trivial. Reducing my carb input by just a few grams had a much greater effect. I still use cinnamon as a spice frequently and infuse it in my morning coffee - but for taste, not BGs. It did affect my post-breakfast BG peak indirectly, because I no longer add milk to my morning coffee as a consequence.

I use many other herbs and spices in my menu. Some for taste, some for medicinal purposes, some for both. Some have proven benefits, such as turmeric for some cancers, some are anecdotal. My attitude is that if it is not harmful I have nothing to lose and a possible gain by adding such things to my menu. However, I do NOT buy capsules or pills of cinnamon, or turmeric, or garlic or anything. I eat them by including the herbs, spices and specific foods regularly in my normal way of eating. Sometimes by spicing up an existing recipe, such as a sprinkle of turmeric and black pepper (the two are complementary) in a morning omelette; sometimes by adding new spicy dishes to my menu, such as Asian stir-fries etc.

So I have tiny amounts of many things almost every day.

As I wrote this I started reviewing the herbs and spices in my menu over the last few days. Just normal days, nothing unusual. Turmeric, cinnamon, nutmeg, grated black pepper, cumin, paprika, thyme, mint, basil, rosemary, hot chili, fresh garlic, grated ginger and the broad combination spices of garam masala and commercial curry powder. That's in addition to ensuring my menu also included items like avocado, nuts, psyllium husks, leafy greens, onions, capsicum (peppers) etc. And, of course, a modicum of red wine. Most of my herbs are grown fresh at home. When the crop is over-abundant I dry it, chop it and store it for future use out of season.

As to which of those, if any, is helping my diabetes or CLL, who knows. But I'll follow my docs' advice and keep doing what I'm doing.

Because, even if they don't improve my health, they definitely help a slightly restricted menu taste good.

Post-script, 18th February 2009
I just became aware of this paper published in Diabetes Care in January 2008:

Effect of Cinnamon on Glucose Control and Lipid Parameters. "CONCLUSIONS— In this meta-analysis of five randomized placebo controlled trials, patients with type 1 or type 2 diabetes receiving cinnamon did not demonstrate statistically or clinically significant changes in A1C, FBG, or lipid parameters in comparison with subjects receiving placebo."

Cheers, Alan

Good Advice, Bad Advice - Nicky's Experience

2007-09-24T08:54:00.000+10:00

I have a friend in the UK named Nicky. We met in cyberspace on alt.support.diabetes and then I was privileged to meet her in person in London on my travels. Nicky is one of those who is not just trying her best to manage her diabetes but who has become active in trying to improve the situation in her own system.

Recently on a.s.d she was asked about her experiences with doctors and other patients over there. This was her reply. To see it in context it was here on alt.support.diabetes.

My doctor is adamant that I shouldn't test, and that I should base my diet on whole grains.

OTOH, I have an A1c of 5.5% (down from, I think, about 10.3% at dx), have come off all meds
(except thyroxine), and have reversed the neuropathy the doc missed at dx. The doc is quite surprised now that I don't see him very often - most of his other patients have progressed to needing insulin by this stage; the last time I needed a doc for me was last year's flu jab.

When I go to Diabetes UK meetings, I am the only one eating a low carb diet. I'm frequently the only one with a bg meter handy. Last weekend was a regional meeting where I hadn't seen some folks for a year. They looked a heck of a lot more than a year older, and two of them had got that neuropathy walk - leaning forward to see where their feet were, over their stomachs, stiff-legged from the pain. They had biscuits with their tea at breaks, and rice and a crumble pudding with their meal.

I'm 46, and if I follow my Dad's family pattern, I might make it to 100. Damned if I want to be blind or in a wheelchair for any part of that. Jennifer's advice, and the low-spike diet resulting from that, has given me a new lease of life, and improved my health enormously. I have no doubt that had I followed the doc's guidance, or that of the dietician who recommended oatmeal and bananas, I would be one of the folks who had seriously deteriorated. No, thanks.

I spend a fair bit of my time campaigning against Diabetes UK's dietary advice. However, they are handy people to know if you're fighting a battle for test strips.

Nicky.
T2 dx 05/04 + underactive thyroid
D&E, 100ug thyroxine
Last A1c 5.6% BMI 25

Read that sig again. It's amazing what can be achieved with the RIGHT diet and exercise. Incidentally, when we meet up again I will be agreeing with everything she says; one of her preferred exercises is Karate:-)

Cheers, Alan

Everything in Moderation - Except Laughter

Self-Testing and Type 2 Management

2007-07-01T20:14:00.000+10:00

A paper denigrating the value of patient self monitoring of blood glucose (SMBG) was published in the British Medical Journal a few days ago. Once again I am mystified that highly qualified medical researchers can spend tens of thousands of dollars (or, in this case, Pounds) to come up with a worthless result.

BMJ, doi:10.1136/bmj.39247.447431.BE (published 25 June 2007)
research-article

Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial

Read the full paper here: http://www.bmj.com/cgi/content/full/bmj.39247.447431.BEv1

Their conclusions:

Conclusions
Evidence is not convincing of an effect of self monitoring blood glucose, with or without instruction in incorporating findings into self care, in improving glycaemic control compared with usual care in reasonably well controlled non-insulin treated patients with type 2 diabetes.

How did they arrive at that conclusion? In my opinion they failed to understand how to use SMBG systematically and had no concept at all of the process of using test results as feedback to change input for better results.

Rather than say it all twice, I'll repeat below my post to the BMJ "rapid response" section after the article. Hopefully, they will publish it; if not, at least it will appear here:

***
Response to BMJ

I am not a doctor. I am a type 2 diabetic patient who has a keen interest in patient self-management of diabetes, and who has spent far too much time over the past four years discussing this with other diabetics around the world on the net and personally. My only relevant publication is a patient's view online at http://loraldiabetes.blogspot.com/

This is not the first poorly performed study of blood glucose testing techniques published in the past twelve months, including one in my own country. All have suffered from the same basic flaw. SMBG is pointless – as is any testing of any sort – if the results are not used to either confirm that things are as expected or to assess what changes need to be made to improve the results next time.

However, if SMBG is used systematically to assess the success of past treatments and to then make changes in those treatments, in a continuously iterative method, it can be spectacularly successful. I accept that BMJ readers will consider anything I say as anecdotal; however I have seen it happen hundreds of times over the past five years.

This study was a waste of time and effort because the patients in the "most intensive" group were given no training in evaluating their test results with a view to improvement. In fact the basic premises of their training doomed them to failure: "They were also given training and support in timing, interpreting, and using the results of their blood glucose test to enhance motivation and to maintain adherence to diet, physical activity, and drug regimens." That was the worst thing they could have done - to maintain adherence to their present regimens, particularly diet. In fact they maintained it so well that they hardly changed their poor HbA1c levels at all.

As an aside, for the authors to consider A1c's in the mid 7's as "reasonably well controlled" is appalling to me. I would refer the authors to the EPIC Norfolk study which found that "HbA1c was continuously related to subsequent all cause, cardiovascular, and ischaemic heart disease mortality through the whole population distribution, with lowest rates in those with HbA1c concentrations below 5%. An increase of 1% in HbA1c was associated with a 28% (P<0.002) increase in risk of death " BMJ 2001;322:15 [Full] ( 6 January )

Now, back to SMBG. The single most important thing that the patient can do at home is modify diet. They should not change medications without doctor’s advice, there are realistic limits to the exercise they can add to their routine – but they can make dramatic changes in blood glucose levels with a diet modified by feed-back from post-prandial peak blood glucose levels.

I, and many of my friends around the world, have been following a systematic testing regimen that works for some years now. It is intensive in the initial stages, then becomes much more relaxed once individuals have created their own personal databases of foods and activities, so we know what foods and activities will cause blood glucose spikes (at the peak, not necessarily at two hours), and which won’t. It’s as simple as that.

I challenge the authors of this paper – or any other researchers for that matter, to repeat the study but train the "most intensive" group as follows:

Eat, then test after eating at your peak spike time and if blood glucose levels are too high then review what you ate and change the menu next time. Then do that again, and again, and again until what you eat doesn’t spike you. You will get some surprises, particularly at breakfast time. The so-called "heart-healthy" breakfast is NOT for most type 2's. Similarly, you will find variations through the day - the same thing will have different effects at breakfast, lunch, dinner and supper

As you gradually improve your blood glucose levels, review the resulting way of eating to ensure adequate nutrition, fibre etc are included and adjust accordingly. Test, review, adjust until you have a flexible and interesting menu that is nutritious but does not "spike" your post-prandial blood glucose; a menu you can follow for the rest of your life.

Studies such as the one in question are meaningless if the SMBG is not performed systematically and with a defined purpose.
***

Cheers, Alan

Ki Si Ming

2007-06-28T16:41:00.000+10:00

This is one from my better half. Despite using a commercial Chicken Noodle Soup as part of the base it is surprisingly low in carbs and calories.

As usual, all quantities are very approximate and should be adjusted to your own taste.

Ingredients

Chicken Noodle Soup: One 50gm packet
Water: 5ooml (1pint) (use half the soup pack recommendation)
Mince steak (ground beef): 500gm (1lb)
Cabbage, shredded: 2 cups
Carrot, shredded: one medium
Onion, chopped: one medium
Curry powder: flat tablespoon
Olive oil or melted butter: 2 tablespoons
Salt and pepper to taste

Method

Fry the chopped onions in the oil or butter in a small saucepan until translucent and stir in the curry powder. Mix the packet of soup thoroughly with the water, then add it to the onions and bring to a gentle boil. Simmer for 15 minutes.

While the liquid is simmering fry the meat in a larger saucepan until browned, breaking up any lumps. Add the shredded carrot and cabbage, mix thoroughly and then pour the soup and onion mix in when it is ready.

Bring to a simmer and cook for 20-30 minutes, stirring occasionally. The result should be moist, with a light curry gravy, not soupy. Adjust by adding extra water if too dry, or cooking longer to reduce it if it's too liquid.

Serve with brown rice or noodles if your carb limit can handle that, or for your non-diabetic partner. Personally, I eat it as is without sides.

Serves 4 on it's own, 6 with rice or noodles.

Nutrition Count, will vary slightly depending on your packet soup.
Based on 4 serves.

Calories 210
Protein 8.2 gm
Total Fat 11.2 gm
Carbohydrate 13.5 gm
Fibre 2 gm
Sodium 800 mgm

Jennifer's Story

2007-06-09T15:27:00.001+10:00

Five years ago when I started searching the net for advice on type 2, after I realised that the standard Diabetes Australia advice wasn't working for me, I discovered misc.health.diabetes on usenet. A guy from the UK calling himself Flying Rat sent me to his web-page to read "Jennifer's Advice". Since then I've found that advice in several other places.

It was the single most important thing I read after diagnosis. Jennifer's advice changed my life and I will always be grateful. I now repeat it to every newby I meet who stands still long enough:-)

Today, on a different forum, Jennifer posted the story of her first eight years after diagnosis. Here it is.

From Jennifer.

Eight years ago today I was diagnosed with T2 diabetes. I was very afraid...but fortunately for me I turned to this list and others for a shoulder and advice. And I found all of that and more. I utterly appreciate the patience and help I got in those first months/years, and can't fathom where I would have been without the internet, this list and you people. Truly.

So on my 8th diabetic anniversary I thought I'd look back. Here's my story... long but hopefully interesting. (Some of you may already know most of this, I ask your indulgence).

First a disclaimer. These are just my experiences. I believe with all my heart that each of us will respond to different things. Some folks do just perfectly on an ADA food plan... others find that low carb is the only thing that keeps their BG stable. The only way to know what works for you is to test, try, test, try. The idea of one size fits all NEVER works... in pantyhose or in health. ;-)

Now you should know, I am a decorated veteran of the diet wars... until age 36 when I decided never to diet again. I worked very hard at accepting my body and my life and I was finally able to let go of all that wasted mental energy I spent worrying and obsessing about diets and fat. It was wonderful.

So at 40, when I was dx'd with DM. I was petrified... I just knew I would walk into the doctors office and they'd take one look and say, "Well, just lose weight". And I would try and I would fail. As I had on every diet known to man since the beginning of time. But this time failure would mean blindness, amputation and other horrible complications, not just a bigger dress.

I immediately dove into the internet searching for any shred of hope. Everything I read said that carbohydrates raised your glucose levels. Atkins was not yet the total fad (that would happen a year or two later)... but there were a few books out and I read them all.

I started out with a very low carb approach. I didn't use any one plan, but read a number of books and took something from each of them. Including Protein Power, Dr. Bernstein and Atkins. At first I just (just! as though it was a snap... it wasn't!) cut out all "classic" carbs... bread, rice, pasta, cereal, sugar, beans, corn, potato, fruit etc. My BG dropped dramatically and quickly.

My A1c at dx 6/99 was 15.3
By 7/99 it was 8.5
By 9/99 it was 6.6
By 12/99 it was 4.9

I hovered in the 4's for awhile, but then chose to add back in some high fiber - non-white carbs and I've been in the 5's ever since. (with a small detour upward due to some urological problems)

Interestingly, I found something else occurred as well. I found an amazing correlation for me with regards to low carb and cravings and binges. I've spent my whole life fighting cravings and bingeing. I could eat a pound of pasta (with the "regulation" fat free sauce) and an hour later be standing in the kitchen in front of the fridge, starving. Needing to eat something, anything. Unable to stop thinking about food.

I grew up believing it was me. Something was wrong with me. I must have low self esteem or I was eating to fill up an "emotional hole". However, none of the rest of my life supported those theories. I was happy... except with my eating and my size. The low carb approach worked very well controlling my diabetes, But more amazing to me was that those almost daily crave attacks disappeared completely. Entirely. And so far they have never returned.

I must believe that for me, has to be some sort of metabolic disorder. Some kind of carbohydrate malfunction within me. It was the first time in my 40 years that I had not had these cravings. It's been wonderful. If they discovered a "cure" tomorrow for diabetes I would still eat this way.

After six months or so of very low carb, I used my meter to help add in other carbs at specific meals. I found, through testing, that I could eat a piece of whole wheat toast at breakfast with no appreciable rise in BG... I could eat some corn with a meal... On the downside: Pasta doesn't work for me at anytime... (until I found Dreamfields) Neither does rice.

I don't count carbs... I don't count calories... I don't count fat or protein grams. I eat whenever I'm hungry, I just restrict my carbs. I think the reason I've been able to maintain good BG numbers is because I didn't go on any one eating plan. I read many many books and took information from each. I was not going to sit down and write out a food plan for the week. That was too diet-like. I was not going to count anything, not portions, not calories, not anything. That was too diet-like. I wasn't going to weigh anything, not me or my food. That was too diet-like. I knew if I headed down those paths I would never survive. I had to find a way that fit my current life and yet would keep my BG in line. My personal history with dieting necessitated this for me.

I used my meter like a mad fool. Testing testing testing. I learned how my body used food. I learned which foods I could eat in great abandon, and which I had to limit. My meter is still a constant companion. When I stop testing I find my control slips. Using my meter keeps me aware and connected to my diabetes. The number I see isn't there to judge me, but to give me valuable information. Information is power.

Now I can walk into any restaurant, party, or other food situation and know what foods will raise my BG and what won't. It's enabled me to travel to Italy for a friends wedding which included three big dinners and many many other "eating" events and survive. It's enabled me to continue eating out many many times a week. And because it's not a DIET, I don't feel like I'm on something, therefore when I do eat a food that may spike my BG, I haven't gone "off"
something, so no guilt.

Giving myself permission to eat when I feel hungry, is a big difference from every diet I've ever been on. Where I netted out is that if I had to add them up I'd say I eat between 80g - 150g of carbs a day. Spaced out over 3 meals and 2 - 3 snacks. I have found that I can handle about 30g of carbs at any one "eating moment".

You may have noticed that I haven't mentioned exercise. I am a firm believer that exercise is vital to all bodies. Thin, fat, diabetic, not... I am a believer, but I have a hard time putting into practice what I believe ; ) It is my achilles heel. I feel so much better when I get regular movement, but can always find a "reason" to put it off. Since this is a journey that will last a lifetime (a long lifetime I hope)...exercise is something I will continue to work on.

All of this works for me! The answers all lie in an individuals blood glucose testing. Use any method that works. Keep hunting until you find one that does. Between food, exercise, oral meds and insulin, you can strike a balance to acheive numbers you can live with.

And I'm off to start my next 8 years.

Jennifer

Thanks Jennifer, for being there. Alan

Useful Info

2007-05-17T23:42:00.007+10:00

An index page for posts on a variety of miscellaneous topics.

Test, Test, Test
Teeth, Gums, Diabetes and Death
Cooking as a Survival Skill
Red, Red Wine
Millimoles and Milligrams
The Other Side of the Revolution
Eating Out
The Price of Eating Healthy
Analysis of a Day's Meals
Travelling With Type 2
I Ate Nothing! Why Are My BGs high?
Swine Flu, Diabetes and Good Sense

Breakfast Stew, Low Carb

2007-05-17T22:56:00.000+10:00

I make this up every few weeks and use the results for breakfast once or twice a week.

All measurements are approximate; it's one of those "make it up as you go along" type of dishes. The main thing is to not add too many high-carb veges to it - no spuds for example. Carrots are OK for me, but they do spike some people, so adjust to suit yourself. Replace with something like cabbage or capsicum - or any vege you like in season. It's a sort of combined vege stew and beef burgundy.

Ingredients

1.5-2kg (3.5-4lbs) approx of stewing beef - or any red meat.
2 cups celery, chopped
2 large carrots, sliced
one medium/large onion, chopped
4 cloves garlic, minced or crushed
1 rasher back bacon, chopped (about 4 American strips)
Chopped herbs to your taste; I use basil, mint and thyme.

Method

Fry the onions, garlic and chopped bacon in a little olive oil until the onion is starting to lightly brown; add the celery, carrots and herbs and stirfry over high heat until the veges have started to "sweat" but aren't fully cooked. Transfer to a bowl temporarily.

Trim the beef carefully of fat and gristle and cut into smallish cubes of 1-2cm, or 1/2"-3/4".
Fry the meat on high heat in a little olive oil in the same pan in small batches until they are sealed and brown but not cooked. Transfer to an appropriate sized casserole container for your oven. Don't do too much at once or they will release too much liquid and not brown correctly.

When all the meat has been fried and is in the casserole container, deglaze the pan with a cup or two of dry red wine. Sprinkle a teaspoon of guar gum over the reserved veges and mix together to spread it, then add to the casserole dish and mix with the meat. Add sufficient stock (or water and stock cubes) to the wine so that the result will be just enough to cover the mixture of meat and veg, bring to the boil, then pour into the mix and stir. Press down the mixture with a large spoon so that the liquid just covers the meat and veg.

Cook in a 140-160C (285-320F) oven for about 90 minutes (longer if it's a really cheap cut of meat) and leave it in the oven another 20 minutes after you turn off the heat. About half-way through, season with salt and pepper to your taste.

I also add a few sliced mushrooms to the mix sometimes.

Let it cool in the fridge overnight. Put 7-10 small individual serves in plastic containers in the freezer. When you want a quick no-fuss breakfast decant it into a bowl, zap it in the microwave while making your coffee or having your shower - and presto - breakfast.

Based on those ingredients and 8 serves, this is an approximate nutrition breakdown:

Calories________400__cal
Protein________38__gm
Total Fat_______20__gm
__Sat. Fat______9__gm
__Mono. Fat____10__gm
__Poly. Fat______1__gm
Carbohydrate____6__gm
__Fiber________2__gm
Sodium_______250__mg
Cholesterol_____125__mg

Cheers, Alan

Millimoles and Milligrams

2007-04-28T20:54:00.001+10:00

I live in a country that uses mmol/L (mmol per litre) as the units for measurement of blood glucose and cholesterol levels, the most common lab numbers used for diabetes management. Most of the world uses that system – but the USA does not. The USA and several other countries use mg/dl (milligrams per decilitre). I havent the faintest idea why, but it can be very useful to be able to convert from one to the other.

My source for the conversion numbers is GlobalRPh.com.

Cholesterol

To convert from mmol/L to mg/dl for Cholesterol (total, LDL, HDL, VLDL) divide by 0.0259 or multiply by 38.6.

For Triglycerides divide by 0.0113 or multiply by 88.5.

Lipids ratios are mentioned in several papers discussing their relevance to cardiac risk and insulin resistance; remember to use conversions before applying US numbers. For example, based on those papers the triglycerides/HDL ratio should be under 1.3 for mmol/L and under 3.0 for mg/dl.

Blood Glucose

The conversion rate can be done either by multiplying by 18 (so 5.5 mmol becomes 99, but I usually round to the nearest 5, so 5.5 => 100) or divide by .0555 if you want to get totally accurate. The exact multiplier is 18.018. When accuracy is not critical, using a multiplier of 20 can be quick and useful.

Finally, a quick ready reckoner to convert blood glucose meter readings:

mg/dl mmol/L
100.........5.6
105.........5.8
110.........6.1
115.........6.4
120.........6.7
125.........6.9
130.........7.2
135.........7.5
140.........7.8
145.........8.0
150.........8.3
155.........8.6
160.........8.9
165.........9.2
170.........9.4
175.........9.7
180.......10.0
185.......10.3
190.......10.5
195.......10.8
200.......11.1
250.......13.9
300.......16.7
400.......22.2
500.......27.8

Cheers, Alan

Wine and Serendipity

2007-04-24T12:13:00.000+10:00

I added a PS to my entry on Red, Red Wine today. Sometimes things have totally unforeseen side benefits:-)

I also have CLL, a type of leukemia. Nothing to do with diabetes. But, after I made the changes I mention in this blog, something odd happened. Purely serendipity according to my haemotologists, and maybe it will change tomorrow and Damocles Sword will drop. My CLL numbers improved as my diet and fitness changed and as my diabetes numbers improved.

I became aware of this report today: http://www.physorg.com/news96550822.html
“Antioxidant found in many foods and red wine is potent and selective killer of leukemia cells
A naturally occurring compound found in many fruits and vegetables as well as red wine, selectively kills leukemia cells in culture while showing no discernible toxicity against healthy cells, according to a study by researchers at the University of Pittsburgh School of Medicine.”
I believe that this is the original study:
http://www.jbc.org/cgi/reprint/M610616200v2
CYANIDIN-3-RUTINOSIDE, A NATURAL POLYPHENOL ANTIOXIDANT, SELECTIVELY KILLS LEUKEMIC CELLS BY INDUCTION OF OXIDATIVE STRESS
“These results indicate that cyanidin-3-rutinoside have the promising potential to be used in leukemia therapy with the advantages of being wildly available and being selective against tumors.”

Not just wine, also vegetables. Just serendipity - but the haemotologists tell me to keep doing what I'm doing.

Cheers, Alan

Testing on a Budget

2007-04-20T12:55:00.001+10:00

I'm very lucky to be in a country where diabetics in the past have successfully lobbied for specific support within the government health system to assist good diabetes control. I'm eternally grateful for the pioneers who created Australian medicare and the NDSS.

However, I'm daily reminded that others overseas are not so fortunate. Consequently, some have difficulty following the full Test, Test, Test regimen as Jennifer suggests because of strip cost.

For them, I suggest a "one strip a day" method. This works more slowly than following Jennifer's advice completely - but it can still work. When I say "one strip a day" I'm not counting the FBG or other tests the doctor wants - discuss with the doc if you can cut back there. In hard economic circumstances I can't see that doing FBG every second or even third day is going to be a problem for the doc - but check to be sure. Let's face it, the "average" type 2 out there is testing FBG maybe once per week, doing absolutely nothing with the result, and wondering why their A1c goes up every 3-6 months.

This other daily test strip is purely to let YOU know what's happening when you eat.

First, it will take a few extra BG tests for two or three days to discover when your peak timing is. Once you know that for each meal, you can focus on that timing. Some reckon you also need to test before meals to see what the rise was; in these circumstances I would see the pre-meal test as a waste of a strip. Just concentrate on the absolute peak level. Target one meal per week. Most of us have problems with breakfast, so I'd recommend starting there.

Test at the peak spike time, just for breakfast, until you have modified your breakfast to the point where the spikes are acceptable to you. I use Jennifer's guidelines, which are similar to the AACE, but check with your doctor if in doubt. Concentrate on that meal for one week, by that time you should have something workable. I've given some alternative breakfast ideas here, but think outside the square and find what works for you. There is no law that decrees cereal, juice, milk or toast before noon. I just finished a kransky sausage with one dry-fried egg before typing this (it's 7:40am here:-) That will be followed with black, cinnamon-infused coffee.

Then concentrate on Lunch for week two, Dinner for week three and so on. Then repeat over the next three weeks. Over time you will find a range of foods that are OK - and a range of foods that aren't - and slowly build a safe menu base.

Cheers, Alan

Dieting for Life - What's in a Name?

2007-04-14T08:53:00.000+10:00

Hi All

Well, the news is out, here is the headline: Dieting Does Not Work! The scientists are sure of it. It mystifies me that research dollars needed to be spent to discover that. All they needed to do was ask me.

Part of the problem is the definition of that word: "dieting". It's fascinating how a word can change in meaning. A diet used to be just the description of what you eat. You can see the gradual change in the progression of Webster's definitions:
Diet
a : food and drink regularly provided or consumed
b : habitual nourishment
c : the kind and amount of food prescribed for a person or animal for a special reason
d : a regimen of eating and drinking sparingly so as to reduce one's weight

Dieting as described in "a" or "b", to regularly or habitually consume food and drink, obviously does work or we'd all starve to death. So in that sense the sensational headline is wrong. But slowly we've come to think of dieting as definition "d" and eating "sparingly" doesn't work because it is unnatural for the human animal to do that as a way of life forever.

I think "way of eating" is a better term for how I intend to eat for the rest of my life, not just to achieve a short-term goal. I think I first saw it used by Bernstein in his book on diabetes. I slowly changed my way of eating continuously since diagnosis; first to lose weight, then to minimise BG spikes, then to ensure that I was getting the best nutrition possible without gaining back the weight or jeopardising blood glucose control.

But to be sustainable, the way of eating has to not only satisfy nutritional needs but our other social and psychological needs: to be able to eat in company comfortably; to be able to munch absently on something while we think; to have "comfort food" occasionally without guilt. The only way to achieve that is to train oneself over time to the point where we like what is appropriate for our needs and no longer crave what is inappropriate. That does not happen overnight and may never happen for some - but, in my opinion, it is the only way to change a way of eating permanently.

I'm only part of the way there myself. But it's amazing what I learnt to like, and dislike, once I accepted that my life does depend on it. Just as an example, I now look on something like mud-cake in the same way that someone with a sea-food allergy would look on lobster. Not that I think it's bad food - just bad for me. So I no longer want it and I don't feel deprived at all. As Jennifer puts it - it's not that I can't have it, it's that I don't want it.

Mind games? Maybe; but possibly life-saving mind-games if you can learn to play them over time.

Cheers, Alan

Chili Crab

2007-03-24T18:44:00.000+11:00

I developed this after I ate a wonderful Chili Crab in an apartment block cafeteria in Singapore on the way home in 2003 from our first trip. I kept experimenting until I came up with something with a similar flavour - but without the sugar.

Sauce:
½ cup water
½ cup ketchup (I use Napoli Sauce ) or 1/4 cup tomato paste
2 tbsp soy sauce
1 tsp chili flakes or 1 small chopped chili (adjust to taste)
1 tbsp vinegar
1 tbsp splenda

Cooking:
About 1 kg of live crab (2-3 lbs) or half that weight dressed.
1 tbsp of peanut or olive oil
2 or 3 cloves of garlic, minced
grated ginger to taste
1 chopped hot chili to taste
1 sliced medium onion
1 tsp cornflour (cornstarch) or a little guar gum as a carb-free alternative.
¼ cup water

Pre-cook the crab in boiling water. Divide the crab into appropriate portions, cracking legs and claws with the back of a heavy knife and set aside.

Mix sauce ingredients, set aside.
Heat the oil in a wok or heavy pan and stir-fry the onion and chili. Add ginger and garlic, fry briefly. I often add some chopped celery or carrots or greens at this stage as a variation.

Add the crab and stir-fry for two minutes then add the sauce and stir while heating for another five minutes or until crab is heated through.

Mix cornflour and water and add to the pan. If you are using guar gum you will need a little practice to get the quantity right for consistency; if in doubt start with too little. Cook and stir until the sauce is set and ready to serve.

Serve as is or with basmati rice if carbs are OK. Supply damp towels for diners - they will need them. This is not a dish to serve to a food snob who won't use their fingers.

You can separate the crab-meat out before cooking; but in that case make sure you still put some of the shell into the wok when stir-frying for the flavour that infuses into the sauce. Then you can remove the shell before serving for the more "genteel" diners.

Bon Appetit.

Cheers, Alan

Lasagna

2007-03-20T20:58:00.001+11:00

Don't let the name scare you off. The blood glucose effect depends on serve size. Eat a little less, add some salad.

Originally on the back of a "Zafarelli" pack, modified somewhat. You'll need a lightly oiled lasagna baking dish, approximately 325x225x50 mm or 13" x 9" x 2".

Ingredients

Basic:
250 gm ( ½ lb) of lasagna sheets. Most no longer need pre-cooking, but check the label just in case.
250 to 300 gms ( ½ to ¾ lb) grated mozzarella cheese.
Grated parmesan cheese.

Meat Sauce:
2 to 3 tablespoons Olive oil
2 chopped medium onions
125 gm ( ¼ lb) roughly chopped bacon or ham
250 to 300 gms ( ½ to ¾ lb) of minced (ground) beef
1 ½ cups water
3 cloves garlic, minced
2 x 400 gm (14 oz) undrained cans of chopped peeled tomatoes, or equivalent in ripe fresh tomatoes
¼ cup tomato paste
salt, pepper to taste
1 teaspoon chopped dried basil, 1 teaspoon oregano or chopped fresh equivalent to taste.

Bechamel Sauce:
2 tablespoons olive oil
2 tablespoons plain flour
600 mls (1 pint) milk
½ teaspoon of grated nutmeg
salt, pepper to taste

Method, including meat fat reduction

In a large saucepan, gently fry the onion and bacon in a little olive oil until onion is translucent and most of the fat has rendered out of the bacon. Add the minced beef and stir over moderate heat until the meat has browned and separated. Add the water and simmer for ten minutes. Reserve the liquid by pouring through a strainer. Put the meat aside, and store the liquid in the fridge to let the fat rise to the top. Add an ice cube or two if you want to speed the process up. Use a "fat/oil separator" if you have one.

Gently fry the garlic in a little oil over moderate heat, stirring until just browned. Add the chopped tomatoes with their juice and bring to a slow simmer. Then add herbs and seasoning. Simmer for 30 - 40 minutes, stirring occasionally. Add just a little water if it starts to get too thick.

Skim the fat from the reserved liquid and combine the liquid with the tomatoes and the reserved meat. Add the tomato paste and simmer for another thirty minutes, stirring occasionally.

While it's simmering, prepare the Bechamel sauce. Stir the flour and oil together over low heat. Increase the heat slightly, and continue stirring while gradually adding milk. Add the nutmeg and seasoning, continuing to stir until the sauce is smooth and thick.

Assembly

Spread a thin layer of the meat sauce over the base of the lasagna dish and cover with one layer of lasagna. Then spread about 1/3 of the remaining meat sauce, followed by 1/3 of the bechamel sauce, and 1/3 of the mozzarella. Repeat the lasagna/meat/bechamel/cheese process until you have three layers. And remember it doesn't have to be perfect. Liberally sprinkle the final cheese layer with grated parmesan.

Bake in a moderate (180 C, 360 F) oven for about 40 minutes or until cooked when tested with a skewer. If the top browns too quickly, loosely cover with aluminium foil. Let stand for 10 - 15 minutes before serving. I cut it into 12 serves; non dieters/diabetics usually make it 6 or 8.
Serve it with a side green salad. I freeze individual serves in plastic containers for later use. When re-heating, add a little water or chopped tomatoes and sprinkle some fresh cheese on the top.

Calories per serve: 350
Protein..............15gms
Total fat............21gms
Carbs................25gms (more than I thought when I worked it out - it's the milk and tomatos) Fibre.................1gm

Bon Appetit

Cheers, Alan