Catering For Different Tastes When Cooking

I see variations on this question asked many times on the various forums I am on:

Being head cook and bottle washer, I have a question. Having D, I need certain foods, my son has become a meat and potatoes guy, my wife eats most anything, except a variety of veggies. I do not want to have to cook 3 separate plates to satisfy all. How do you cater to each taste, or do you? Is there a happy middle?

The same problem occurs for the person who is not the cook but does not want to offend the person who is. This may help those people: Cooking as a Survival Skill. But I realise that is not possible or practical for some.

Here is my own method for dealing with the situation. I am the cook in our household, mostly just for the two of us. Mum is invited for dinner a couple of times a week.

It is important to keep in mind that I am the only person with diabetes. Although I may believe others would benefit from my way of eating it is not my role or place to force them to eat as I do. We each have our own food likes, dislikes, aversions or allergies.

I am diabetic and careful about carbohydrates but otherwise omnivorous. My wife has a very limited menu, by choice, and a long list of foods she detests. For example, she will not eat fish or seafood, eggs, steak, many vegetables, milk, the list goes on. Her likes are basically meat (other than steak), starchy vegetables, peas, tomatoes and silverbeet (chard). My mother is omnivorous but, like most people, has a few foods she prefers to avoid.

If I restricted myself to cooking only the foods we all like my menu would become very limited and boring. I also actively seek to include fish and a wide range of seasonal vegetables in my diet. Therefore, at most meals for the two of us I cook three types of foods. Those I can eat, those my wife will eat, and those we both eat. The other night was a typical example. In the steamer I had potato and pumpkin (winter squash) simmering in the bottom section with silverbeet, carrots, cabbage and broccoli in the top. I cooked two loin lamb chops under the grill (broiler) for her and when they were almost cooked I seared and fried a fillet of Atlantic Salmon in a small skillet for myself.

At the table I put the salmon on my plate, the lamb chops on hers, and all the vegetables on a platter in the middle. We served ourselves from the platter. She had most of the potato and silverbeet; I took most of the rest.

When my mother or other people are dining with us I use the same method. I find out whether anyone has specific protein likes or dislikes and serve that appropriately, letting them select their own vegetables and starches from the centre of the table. For major feasts such as Christmas dinner everything is served buffet-style for diners to select as they wish.

It really isn't as difficult as it sounds, with a small amount of extra thought and effort keeping everyone at the table happy and healthy.

Taxes For Our Own Good

Recently there have been disquieting moves by social engineers in several countries proposing use of taxes to force the public to eat healthier. Examples are: Denmark introduces food fat tax and from the UK: Fat tax' on unhealthy food must raise prices by 20% to have effect, says study.   

I didn't worry much about it when those proposals were in far-off places; I was confident that Aussies were much too sensible to let that happen here. But now our media are starting to join the push: Chew the fat on a sugar tax to trim waistlines.

I should have seen it coming when the “Traffic Lights” concept was first proposed: The WA Health Traffic Light System and Green Light, Eat Right. 

It appears that those who wish to save us from ourselves - and from overloading the public health system - are resolved to make us eat healthier whether we like it or not.

There are a lot of things I dislike about that concept, not the least being the idea that the government or its agencies has any right to direct me on a matter as basic as the food I choose to put in my mouth, apart from ensuring that it is not actually poisonous and is safely and humanely produced. I'll leave that philosophical side of the discussion for now and concentrate on the practical aspects.

There are two separate parts to the question:

1. Does prohibitively taxing items based on their impact on health have a significant effect on public use of those items?
2. If taxes or public education programmes are used with the intention of improving public health are the right food groups being taxed, promoted or discouraged? 

Do Taxes Work To Change Bad Habits?

There are two clear examples in this country. In Australia the Federal government has been steadily increasing taxes and excise on tobacco and alcohol over the past century. Our taxes are quite heavy on those items when compared to many other countries. For example, a packet of 20 Marlboro is over $16 and a 700ml (24oz US) bottle of cheap whisky starts at $28. Our dollar and the US dollar are close to parity at the moment.

Historically each time taxes or excise were increased on either commodity there were short-term reductions in use, but time shows those were just temporary blips. Changes in alcohol taxes sometimes led to changes in preferences from beer to spirits or wine or vice versa, but had little effect on overall consumption or consequent health problems such as youth drunkenness or adult alcoholism.

We had a recent specific example with the alcopops tax. The government was concerned with drinking problems in teenagers. They decided that the root cause was alcopops, a form of popular alcoholic soft drinks. They decided that drastically increasing the taxes on those was the way to fix the problem.

Effect of the increase in “alcopops” tax on alcohol-relatedharms in young people: a controlled interrupted time series

Med J Aust 2011; 195 (11): 690-693. doi:10.5694/mja10.10865

Objective: To measure alcohol-related harms to the health of young people presenting to emergency departments (EDs) of Gold Coast public hospitals before and after the increase in the federal government “alcopops” tax in 2008.

Design, setting and participants: Interrupted time series analysis over 5 years (28 April 2005 to 27 April 2010) of 15–29-year-olds presenting to EDs with alcohol-related harms compared with presentations of selected control groups.

Main outcome measures: Proportion of 15–29-year-olds presenting to EDs with alcohol-related harms compared with (i) 30–49-year-olds with alcohol-related harms, (ii)15–29-year-olds with asthma or appendicitis, and (iii) 15–29-year-olds with any non-alcohol and non-injury related ED presentation.

Results: Over a third of 15–29-year-olds presented to ED with alcohol-related conditions, as opposed to around a quarter for all other age groups. There was no significant decrease in alcohol-related ED presentations of 15–29-year-olds compared with any of the control groups after the increase in the tax. We found similar results for males and females, narrow and broad definitions of alcohol-related harms, under-19s, and visitors to and residents of the Gold Coast.

Conclusions: The increase in the tax on alcopops was not associated with any reduction in alcohol-related harms in this population in a unique tourist and holiday region. A more comprehensive approach to reducing alcohol harms in young people is needed.

Similarly, taxes on cigarettes have had only a marginal effect.

Smoking prevalence and tobacco excise revenue

1991-92 to 2007-08 (2007-08 dollars)

Note that smoking was relatively unchanged when taxes were increased in the early '90s but dropped significantly later despite steady taxes from the mid-90s on. The significant reductions in cigarette smoking in this country came from better public education and various new State laws such as restriction of advertising, labelling changes, restricting sales to minors and drastically reducing the public places where people could legally smoke; allied to a paradigm shift in public acceptance of smoking in social situations. For example: 

Tobacco Control in New South Wales

5 CONCLUSION

The current focus of the anti-tobacco lobby on the rights and health of non-smokers has led to a proliferation of smoking bans in enclosed public places. The NSW Parliament only recently passed the Smoking Environment Amendment Act 2004 which will gradually phase-in an extension of smoking bans to include licensed premises in NSW. The support for such smoking bans has been growing and the implementation of similar restrictions in Ireland and New York appears to have been successful.

Smoking bans are only one method of tobacco control. The use of tobacco is also controlled through restrictions on the way it is packaged and advertised. Particular strategies are applied to minors such as prohibiting the manufacture and sale of toys and confectionery that resemble tobacco or the act of smoking, as well as prohibiting the sale of tobacco to persons under the age of 18. Health warnings have been included on tobacco packages for thirty years but have continued to adapt to contemporary requirements with graphic warnings the most recent development. The price of tobacco may be influenced by taxation policies and smoking cessation can be encouraged through media campaigns, and the availability of nicotine replacement therapy and telephone counselling. Litigation may also affect the activities of tobacco companies.

Tobacco continues to be the cause of much death and disease not only in Australia but also worldwide. The damage attributed to tobacco has been recognised by the World Health Organization and by the numerous countries to have signed and/or ratified the Framework Convention on Tobacco Control. Accordingly, governments continue to seek strategies that will encourage the minimisation, prevention and cessation of tobacco use.

I write as a long-term heavy smoker, who became increasingly annoyed as those changes occurred over the past few decades but eventually gave up in 2001. Now I look back and wonder why I took so long to wake up to the harm it was doing to me.

Will They Tax The Right Foods?

In my opinion this question is actually more important. If we accept the dubious hypothesis that taxes will work to solve the problem, to have any chance of success those taxes should target the right foods. Similarly any public education initiatives should be providing valid and useful information.

Based on the present proposals the foods to be targeted are fats, sugar and salts. The West Australian "Traffic Light" system clearly indicates what we could expect:

Green Foods and Drinks

Foods and drinks classified as Green are the healthiest choices. They are excellent sources of important nutrients needed for health and wellbeing, and low in saturated fat, added sugar and salt, and are lower in energy density.

Can be eaten every day or at every meal.

Examples include: Plain or whole grain breads and cereals, vegetables and salads, fruit, low fat milks and dairy products, lean meats, fish and poultry, eggs, and nuts and legumes.

Amber Foods and Drinks

Foods and drinks classified as Amber are mainly processed foods. They have some nutritional value but contain moderate levels of saturated fat, added sugar and/or salt and can, in large serve sizes, contribute to excess energy intake.

Should be carefully selected and eaten in moderation.

Examples include: Full fat milk and dairy products, some breakfast and cereal bars, some un-iced, plain, lower fat cakes and muffins, some processed meats (e.g. ham, pastrami), poly- or mono-unsaturated spreads, breakfast cereals with no added sugar or fat.

Red Foods and Drinks

Foods and drinks classified as Red are energy dense and nutrient poor foods and drinks that are high in saturated fat, sugar and/or salt. They can contribute to excess energy intake if consumed in large amounts or on a frequent basis.

Red foods also include deep fried foods, confectionary and chocolate (energy size limit), crisps, corn chips and similar salty snacks (energy size limit), sugar sweetened soft drinks, energy and sports drinks (energy size limit).

Should only be eaten occasionally.

Examples include: Fried foods, savoury commercial products such as pies and sausage rolls, snack bars, sweet biscuits, cakes and sweet pastries, small size confectionary and packets of crisps, some sweetened drinks and processed meats such as salamis.

Logically, taxes would be highest on the "Red Foods" and education would be focused on promoting the "Green Foods". In other words, we would be taxed and educated to eat in a way that is extreme low-fat and high-carbohydrate.

I can't imagine many programmes likely to lead to worse results. That would entrench the terrible low-fat high-whole-grains doctrine of the 20th century that I am becoming convinced is a significant factor in the so-called obesity epidemic occurring in the 21st.

Fat consumption in moderation is a trivial part of the problem and sugar is only part of the problem. My definition of moderation in that context is very different to the dieticians who advise governments; it is more like my Grandma, who wasted very little of the sheep when Grandfather killed it. She lived to 102.

The real problem is excessive carbohydrate consumption; sugar is only part of the carb load. A tax on sugar, even if it worked to cut sugar consumption, would have only a minimal effect as the nation continued to start its day with a wonderful 'healthy' bowl of highly processed cereal, drenched in milk, accompanied by some low-sugar spread on multigrain toast and margarine, washed down with a glass of 'healthy' fruit juice. Then, after a 'healthy' breakfast the day continues with an overload of 'healthy' multigrain breads and loads of fruit, spuds, corn, rice and pasta. All, of course, fat-free and low-sugar; so wonderfully healthy. Yeah, right.

Taubes puts it together better than I can; I agreed with him long before I had heard of him: Why We Get Fat and Good Calories, Bad Calories.

I believe that the suggestions to tax foods for public health reasons are misguided at best and may be counter-productive at worst.

Cheers, Alan, T2, Australia

Everything in Moderation - Except Laughter

PS See also this follow-up post: The Fat Tax: Dare I say I Told Them So?

Free Radicals and James Bond

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

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.

Good Targets, Bad Methods

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.

Food, Farmers and Factories

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What criteria do you use?

Cheers, Alan
Everything in Moderation - Except Laughter.

Swine Flu, Diabetes and Good Sense

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cheers, Alan
Everything in Moderation - Except Laughter.

Diabetes and Dental health

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

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

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

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

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

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

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

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

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

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

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

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

Cheers, Alan

Smoking and Diabetes

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

So why should you?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cheers, Alan
Everything in Moderation - Except Laughter.

Further reading:
Cigarette smoking and health. American Thoracic Society Cigarette smoking remains the primary cause of preventable death and morbidity in the United States.
--------------
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.
-------------------
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.
----------------
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.
----------------
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.
--------------
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.
------------------
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.
-------------------
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.
-----------------
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.

Analysis of a Day's Meals, Day 2

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

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

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

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

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

Cheers, Alan

Analysis of a Day's Meals

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

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

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

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

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

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

Here are the numbers for the macronutrients:

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

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

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

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

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

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

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

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

Cheers, Alan
Everything in Moderation - Except laughter

What to Eat at First

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

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

Minimise:

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

Be wary of:

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

Maximise

All vegetables, apart from root vegetables.

Use in appropriate portions:

Fish
Meats
Eggs
Beans
Nuts
Avocado

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

Cheers, Alan

Psyllium, Fibre, Muesli and Nuts

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. "

Red, Red Wine

I am a believer in the value of a modest intake of alcohol in the form of red wine.

Some people cannot drink alcohol because they have addiction or other medical/ideological reasons for abstinence. For the rest of us the evidence is becoming fairly clear that a moderate regular intake of alcohol is beneficial, particularly for type 2 diabetics. The benefits appear to be enhanced if the alcohol of choice is dry red wine.

At the foot of this post I have given a brief sample of a search on HighWire using the following terms: "red wine" diabetes "type 2". Even I was surprised at the result, particularly with the findings of more recent research. So I've included the links for those who are interested, as well as some excerpts from some selected papers. (2019 note. The highwire search no longer works. Try a Scholar search on all words: "red wine" "type 2" diabetes)

I usually drink dry red wine. I have found that many people don’t understand the term "dry". It simply means "not sweet". Fortified wines such as port, or dessert wines such as sherry or tokay, or sweet fruity wines such as lambrusco or most white wines, aren’t suitable for me because the sugars in them raise my blood glucose. The only white wines I can drink are the very dry Sauvignons Blanc or Chablis styles.

In essence I drink dry red wine for the following reasons:

1. I like it. That’s important. If you don't like wine, don't start. I shudder at the thought of having to "take it as a medicine".
2. It appears to assist in blood glucose control when taken with meals.
3. It appears to improve my cardiovascular health, based on my own lab reports since I added it to my menu after diagnosis.
4. Red wines include some specific benefits over other alcoholic drinks and white wines because of their unique resveratrols and flavinoids.

The studies I’ve included in the links below tend to support the possibility that I’m not unique in seeing those benefits.

Any proposed changes in your alcohol consumption should be discussed with your doctor first. There may be other reasons for abstinence, apart from addiction, that your doctor is aware of. However, don’t automatically accept warnings against alcohol on medication packets - metformin is just one example – discuss those with your doctor to see if it applies in your individual situation.

The various studies aren't in agreement on "moderation". The definition appears to lie between one and three "standard" glasses daily for a male and half that for a female; personally I imbibe about a half-bottle of dry red daily which equates to 300-400ml. If in doubt your doctor will advise on that.

Cheers Alan, T2, Australia.
 A PS, added 24th April '07.

I also have CLL, a type of leukemia. 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.”

PPS, added 20th March 2013: The Relationship Between Alcohol Consumption and Vascular Complications and Mortality in Individuals With Type 2 Diabetes Mellitus 

"RESULTS During a median of 5 years of follow-up, 1,031 (9%) patients died, 1,147 (10%) experienced a cardiovascular event, and 1,136 (10%) experienced a microvascular complication. Compared with patients who reported no alcohol consumption, those who reported moderate consumption had fewer cardiovascular events (adjusted hazard ratio [aHR] 0.83; 95% CI 0.72–0.95; P = 0.008), less microvascular complications (aHR 0.85; 95% CI 0.73–0.99; P = 0.03), and lower all-cause mortality (aHR 0.87; 96% CI 0.75–1.00; P = 0.05). The benefits were particularly evident in participants who drank predominantly wine (cardiovascular events aHR 0.78, 95% CI 0.63–0.95, P = 0.01; all-cause mortality aHR 0.77, 95% CI 0.62–0.95, P = 0.02). Compared with patients who reported no alcohol consumption, those who reported heavy consumption had dose-dependent higher risks of cardiovascular events and all-cause mortality. 

CONCLUSION In patients with type 2 diabetes, moderate alcohol use, particularly wine consumption, is associated with reduced risks of cardiovascular events and all-cause mortality"

Once again moderation is the key.

Further reading:


Links to papers and articles for those who want to read further:

Am J Physiol Heart Circ Physiol 288: H2023-H2030, 2005.
First published January 14, 2005; doi:10.1152/ajpheart.00868.2004
Antiatherogenic potential of red wine: clinician update
http://tinyurl.com/zpt5m
"Complications of atherosclerosis remain the leading cause of morbidity and mortality in industrialized countries. Epidemiological studies have repeatedly demonstrated that
moderate alcohol intake has a beneficial effect on cardiovascular disease. The purpose of this review is to examine the epidemiological and biological evidence supporting the intake of red wine as a means of reducing atherosclerosis. On the basis of epidemiological studies,
moderate intake of alcoholic beverages, including red wine, reduces the risk of cardiovascular, cerebrovascular, and peripheral vascular disease in populations. In addition to the favorable biological effects of alcohol on the lipid profile, on hemostatic factors, and in reducing insulin
resistance, the phenolic compounds in red wine appear to interfere with the molecular processes underlying the initiation, progression, and rupture of atherosclerotic plaques. Whether red wine is more beneficial than other types of alcohol remains unclear. Definitive data from a
large-scale, randomized clinical end-point trial of red wine intake would be required before physicians can advise patients to use wine as part of preventative or medical
therapies."
*********

Diabetes Care 28:2933-2938, 2005
Alcohol Consumption and Risk of Type 2 Diabetes Among Older Women
http://tinyurl.com/nmo4q
"CONCLUSIONS-Our findings support the evidence of a decreased risk of type 2 diabetes with moderate alcohol consumption and expand this to a population of older women."
********

Diabetes Care 27:1369-1374, 2004
Acute Alcohol Consumption Improves Insulin Action Without Affecting Insulin Secretion in Type 2 Diabetic Subjects
http://tinyurl.com/g6wyc
"CONCLUSIONS-Acute alcohol consumption improves insulin action without affecting ß-cell secretion. This effect may be partly due to the inhibitory effect of alcohol on lipolysis. Alcohol intake increases insulin sensitivity and may partly explain both the J-shaped relationship between the prevalence of diabetes and the amount of alcohol consumption and the decreased mortality for myocardial infarction."
*******

The Journal of Clinical Endocrinology & Metabolism Vol. 90, No. 2 661-672 doi:10.1210/jc.2004-1511
Beneficial Postprandial Effect of a Small Amount of Alcohol on Diabetes and Cardiovascular Risk Factors: Modification by Insulin Resistance
http://tinyurl.com/jylqx
"Alcohol enhanced the postprandial increase in energy
expenditure 30-60 min after the LC meal (increase, 373 ± 49 vs. 236 ± 32 kcal/d; P = 0.02) and HC meal (increase, 362 ± 36 vs. 205 ± 34 kcal/d; P = 0.0009), but suppressed fat and
carbohydrate oxidation. Some of our findings may be mechanisms for lower diabetes and cardiovascular risks in moderate drinkers."
**********

Diabetes 50:2390-2395, 2001
A Prospective Study of Drinking Patterns in Relation to Risk of Type 2 Diabetes Among Men
http://tinyurl.com/gjs22
"Using data from a 12-year prospective study, we determined the importance of the pattern of alcohol consumption as a risk factor for type 2 diabetes in a cohort of 46,892 U.S. male health professionals who completed biennial postal questionnaires. Overall, 1,571 new cases of type 2 diabetes were documented. Compared with zero alcohol consumption, consumption of 15-29 g/day of alcohol was associated with a 36% lower risk of diabetes (RR = 0.64; 95% CI 0.53-0.77).

This inverse association between moderate consumption and diabetes remained if light drinkers rather than abstainers were used as the reference group (RR = 0.60, CI 0.50-0.73). There were few heavy drinkers, but the inverse association persisted to those drinking >=50 g/day of alcohol (RR = 0.60, CI 0.43-0.84). Frequency of consumption was inversely associated with diabetes. Consumption of alcohol on at least 5 days/week provided the greatest protection, even when less than one drink per drinking day was consumed (RR = 0.48, CI 0.27-0.86). Compared with infrequent drinkers, for each additional day per week that alcohol was consumed, risk was
reduced by 7% (95% CI 3-10%) after controlling for average daily consumption. There were similar and independent inverse associations for beer, liquor, and white wine. Our findings suggested that frequent alcohol consumption conveys the greatest protection against type 2 diabetes, even if the level of consumption per drinking day is low. Beverage choice did not alter risk."
*******

(Circulation. 2000;102:494.)
Moderate Alcohol Consumption and Risk of Coronary Heart Disease Among Women With Type 2 Diabetes Mellitus
http://tinyurl.com/gwkal
"Conclusions-Although potential risks of alcohol consumption must be considered, these data suggest that moderate alcohol consumption is associated with reduced CHD risk in women with diabetes and should not be routinely discouraged."
********

Diabetes Care, Vol 15, Issue 4 546-548, Copyright (c) 1992 by American Diabetes Association
Short-term effect of red wine (consumed during meals) on insulin requirement and glucose tolerance in diabetic patients
http://tinyurl.com/f6bfk
"CONCLUSIONS--Moderate prandial wine consumption has no adverse effect on the glycemic control of diabetic patients. Thus, it appears unnecessary to proscribe the consumption of
red wine in moderation with meals to diabetic patients. Wine contains tannins and phytates that can explain its action."
********

DIABETES CARE, VOLUME 22, NUMBER 12, DECEMBER 1999 p2084
Meal-Generated Oxidative Stress in Diabetes
The protective effect of red wine
http://care.diabetesjournals.org/cgi/reprint/22/12/2084
"Our data show that red wine is able to preserve plasma from meal-induced oxidative stress in diabetes, suggesting that moderate consumption of red wine during meals may have a beneficial effect in decreasing the risk of cardiovascular disease in diabetic patients."
********

JAMA Vol. 282 No. 3, July 21, 1999
Alcohol Intake and the Risk of Coronary Heart Disease Mortality in Persons With Older-Onset Diabetes Mellitus
http://tinyurl.com/g4x87
"Conclusion. Our results suggest an overall beneficial effect of alcohol consumption in decreasing the risk of death due to CHD in people with older-onset diabetes."
*********

"Am J Physiol Heart Circ Physiol 288: H2023-H2030, 2005.
First published January 14, 2005; doi:10.1152/ajpheart.00868.2004
Antiatherogenic potential of red wine: clinician update
http://tinyurl.com/zpt5m
"Complications of atherosclerosis remain the leading cause of morbidity and mortality in industrialized countries. Epidemiological studies have repeatedly demonstrated that moderate alcohol intake has a beneficial effect on cardiovascular disease."
********

Finally, an interesting one specifically on resveratrol, a red wine component, and the insulin system.
Am J Physiol Endocrinol Metab 290: E1339-E1346, 2006. First
published January 24, 2006; doi:10.1152/ajpendo.00487.2005
Resveratrol, a red wine antioxidant, possesses an insulin-like effect in streptozotocin-induced diabetic rats
http://tinyurl.com/evxtp
"Aberrant energy metabolism is one characteristic of diabetes mellitus (DM). Two types of DM have been identified, type 1 and type 2. Most of type 2 DM patients eventually become insulin dependent because insulin secretion by the islets of Langerhans becomes exhausted. In the present study, we show that resveratrol (3,5,4'-trihydroxylstilbene) possesses hypoglycemic and hypolipidemic effects in streptozotocin-induced DM (STZ-DM) rats."

Note that I prefer to wait for the human trials confirmation - but it is the first time I've seen this effect of resveratrol noted anywhere.

Teeth, Gums, Diabetes and Death

First, the personal background.

I was first diagnosed with periodontal disease just before I left the RAAF 22 years ago. I had the same cleaning routine, every three months for a year, with the service paying. I didn't continue after that, because everything seemed good.

Nobody had mentioned that it is an incurable disease, at least while you still have teeth. Of course, if you don’t treat it that isn’t forever.

Over the next ten years, I had some minor dental work, but no serious problems. Then, quite suddenly, I got a major infection and abscess and was told that I needed treatment by the periodontist again. That was the first time I was told that it was an incurable disease, and that I should have been getting regular periodontal cleaning treatment ever since the first diagnosis.

Over the next five years, under an excellent periodontist in Melbourne, I managed to retain most of my teeth (lost four) and had several flare-ups. One of those I ignored for a few days because I was travelling; that one nearly killed me when it got out of control and I was treated just in time. I now carry Amoxycillin when I travel, just in case.

Now for the good news. At the time I was diagnosed with diabetes in 2002 I was seeing my new and also excellent periodontist on the Gold Coast every three months. He commented that I had improved significantly after a year of no smoking. But the improvement a year later when I had reduced my A1c and gained some control over my BGs was even better.

I now only attend every four months, and on two of those appointments I now only see the dental hygienist because I've improved too much to justify the periodontist's time.

Now – the serious bit for other diabetics.

Below I’ll list some links for those that want to read further, but I’ll summarise briefly here. I haven’t read all of the hundreds of papers – but skimming through the conclusions there is a gradual trend to general agreement on the following:

The bad news:

Periodontal disease and diabetes mellitus is a two-way relationship. Poor control of either degrades control of the other. See Periodontitis and diabetes interrelationships
That paper concludes with a quite unexpected additional possibility:
"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? Further research should be done there.

Postscript January 2009. See Diabetes and Dental health for more comment on causality.

Mortality (that word has a sense of finality) is significantly increased in diabetics with Periodontal Disease. http://care.diabetesjournals.org/cgi/reprint/28/1/27

The good news:

The two-way relationship can work in your favour. Improved control of Periodontal disease can assist with glycemic control and vice-versa. See http://www.medscape.com/medline/abstract/16584339

So - look after your pearly whites, folks. We all get lazy at times, as my periodontist is quick to remind me, but as a diabetic bad teeth and gums can literally be the death of us.

Cheers, Alan,

Everything in Moderation - Except Laughter.

If you are interested in further reading, this is a link to over 100 papers listed in PubMed:
http://tinyurl.com/y92tbs
And a similar link for medline (with some duplications)
http://tinyurl.com/t69s8

A post-script, posted 5th October 2010

A friend of mine, who is a Type 1 diabetic in the UK, just posted this report of a dental problem. Although not directly related to periodontitis I thought it may reinforce the need for dental health and also includes some sound advice on what to do if you ever have the same extraction need.

Here is Patrick's post, slightly edited:

I've had one very rotten wisdom tooth taken out and I'm a complete WIMP when it comes to dentists, that's why I hadn't been in years and is also why I've had the problems I've had.

Anyhooo I'm sure there's a few of you out there who are as nervous as me so here's a link to a very good site.

http://www.dentalfearcentral.org

There is a wealth of info for scaredy cats and also a list of NICE friendly dentists.

My thread is here http://www.dentalfearcentral.org/forum/showthread.php?t=13006

Now I'm aware there's more than a few food gurus in here, I'm not and never will be one of them so if you're one of those lazy low maintenance T1 like me then I hope the following is of some use.

Bearing in mind we're at a higher risk of dry sockets, we are more prone to infection and we take longer to heal I think stuff like this is worth paying attention to.

1. Follow your dentists advice on post tooth removal care.

Do NOT smoke. ( diabetics shouldn't anyway but I know some of us do)
Do NOT drink alcohol
DO rinse with warm salt water after each meal ( half teaspoon of salt per glass of warm water)
DO buy some Corsodryl and use that to rinse the salt taste away
DO drink lots of water
DO brush carefully but avoid the gum where the tooth was - the salt rinse and Corsodryl will see to that.

The longer you can stomach a liquid diet ( tomato soup for me as it has no bits in it) the better then you don't run the risk of getting food stuck in the gum.

Be aware that if you're used to a high carb diet, switching to just soup is going to present liquid problems at the other end

Breakfast has been either microwaved scrambled eggs mixed with sliced hot dog sausages. Or one crumbled weetabix mixed with half a sliced banana ( sliced into quarter of the round slices) and full fat milk but wait till it goes all soft before you eat it. I switched to egg on the basis that it tends to bind the gut up - a good thing when all you've really had in there is soup

Lunch has been soup mixed with more sliced hot dog sausages and buttered bread, the butter helps to keep the bread in one piece so you can keep it away from the gum.

Evening meal - more soup. bread and sausage.

I have also invested in low fat yoghurt for between meals to ensure there's plenty of good bacteria kicking around - this seems to have really sped up the healing process.

All the above foods do NOT fall to bits in your mouth and therefore do not get stuck in the gum as it heals - avoid rice and nutty breads etc for this reason.

Two things are going to happen, firstly you're going to lose any excess weight you had and secondly you're going to hate the taste of soup I'm ok with the latter on the basis of the former!

Lastly and for a rare few this will help. I'm T1 diabetic so the reduction in carb means a massive reduction in insulin requirements, be aware that Ibuprofen / Neurofen will remove your low blood sugar physical warning signs. Test more frequently and if like me, you're on a basal / bolus DAFNE system, you'll really need to work out what you're going to do with insulin.

Remember no two T1 diabetics are the same but my basal insulin was split 18u and 18u morning and evening. At the moment due to diet changes, i'm running 12u morning and 8u evening - this also due to the weight loss which makes you less insulin resistant.

Before you go in for the tooth out, please bear in mind you may not want to eat for up to 24 hours - to do that safely as a diabetic you need to ensure you reduce your basal insulin BEFORE you have the tooth out. Also ensure you eat a good meal before going in so that your blood sugar can be kept high enough to be safe. 24 hours of running a little higher than normal won't kill you. Knowing what I know now, I'd have changed over to this diet a week or so before the tooth came out so that I was better prepared for it.

Lastly and I can't stress this enough, I haven't needed any painkillers since the day the tooth came out - I've had no swelling at all and on day 5 it looks like my appetite has returned. I have lost approximately 1.5 stone in a little under a month ( I cut out coffee and tea with sugar, chocolate of any kind, ALL wine etc ) and I think I've got another 2 or 3 weeks of this diet to go so I'm guessing another half stone will drop off. I've gone from a 35" waist down to a 32" waist. [note for US readers. One stone is 14 pounds.]

The point I'm getting at is simply that losing middle body fat is a GOOD thing, I just didn't expect to have this many positive side effects after having something done I was very very nervous about. All of a sudden I'm hitting the exercise bike on Monday with a figure worth fighting for

So if you're out there and nervous, you can't be any more than I was and I'm fine, as is my diabetes control which has been almost perfect for the entire period.

Cheers

Patrick

Cheers, Alan