Dr Sheri Colberg: Why insulin does not always work predictably

Nov 21, 2016Oct 9, 2016 kaitiscotland1 Comment

Head Scratching Days with Insulin Action Changes

From Diabetes in Control
August 6th, 2016

by Dr. Sheri Colberg, Ph.D., FACSM
The topic of insulin action (resistance and sensitivity) has come up multiple times over the years in my articles, but it is admittedly much more complex than I often make it out to be.

In a DIC article last summer, you can find a short list of all the factors that can potentially improve insulin action (basically insulin sensitivity). In reality, though, sometimes it is impossible to know exactly what is causing your reduced insulin action from day to day and how to easily and consistently manage it.
Recently, I spent the majority of two days traveling in a car and not exercising, and I reached the point where I could barely eat anything without my blood glucose rising over 200 mg/dl, even when giving twice or three times my usual insulin dose for the same food.

Just sitting in a car and not exercising resulted in full muscle glycogen stores, with no room to store more carbohydrate—hence the resulting muscular insulin resistance.

Although I have an extensive working knowledge of nutrition, exercise, and diabetes overall, even I was frustrated by dealing with my lack of immediate control, even though I knew that physical inactivity was the cause. It was hard to anticipate how large of an impact it would have and how much insulin it would take to overcome it.
Based on my personal experience, I want to take some of the burden of always being on top of blood glucose levels off of people with diabetes (PWD). You have to realize that sometimes you can do everything right and your insulin action can still less (or more) than expected. It’s not necessarily your fault, nor can you always anticipate how to best combat it.
Here is my short list of factors from my personal experience that can make people insulin resistant one day and insulin sensitive the next—and not always as you would expect. I call those the “head scratching days,” but sometimes it’s more like hair pulling!
If you’ve had a prior hypoglycemic event
Going too low and staying there for a while (such as during sleep) may increase insulin resistance more than just having a simple hypo event and treating it quickly. Morning insulin resistance is the most variable anyway (higher levels of cortisol then). It is admittedly my most frustrating time of day since often the same exact breakfast and starting blood glucose level will result in a different rise in blood glucose levels. Sometimes an overnight low explains it, but sometimes it doesn’t.
If your blood glucose has been running high
Hyperglycemia begets more hyperglycemia because it causes insulin resistance. That is why sometimes it takes way more insulin than you would expect just to get back to a normal level, and it may take hours. Try not to overdose on insulin in the meantime (especially at your bedtime) or you’ll end up low and back on the blood glucose rollercoaster.
If you’ve drastically changed your normal exercise patterns
Heightened insulin action due to your last workout is fleeting, and sitting in a car for two days is a dramatic change for me, particularly since my basal and other insulin doses are set for being active, not for being inactive. Even a week of detraining (due to injury, vacation, sickness, or other life event) can cause insulin resistance to rise rapidly in everyone, not just in people with diabetes. If you start working out more overall or just more regularly, your overall insulin needs (including basal) may also decrease. Just try to be as consistent as possible to make it easier for yourself to manage.
If you ate more calories, fat, or protein than you realized
Eating out at restaurants is really hard for me because no matter what I order, it seems like it takes two to three times my usual insulin doses to cover it. It is likely because protein and fat kick in and affect blood glucose levels later on (3-6 hours after a meal) and restaurant meals have more calories in them than most home-cooked meals. Fat, sugar, and salt keep people coming back to the restaurant for more! You can strategically use protein and fat intake overnight or after exercise to help prevent later-onset lows, though.
If you’re stressed, mentally or physically
It is truly amazing how much of an impact that stress has on blood glucose levels. Just try going to court (if you’re not an attorney) and keep your blood glucose in check while your adrenaline is pumping. Your cortisol levels also go up and raise blood glucose. So, just being stressed out during the day, or being exhausted or sick (physical stress), can cause insulin resistance. Try to take deep breaths and get some exercise during the day to combat both the stress and the resulting insulin resistance. Getting sick and running a fever or having an infection can also drive your blood glucose and insulin needs up.
If you’re lacking on sleep
Not getting enough sleep is physically (and often mentally) stressful. I knew an oceanography professor who had to harvest samples at sea, sometimes for days at a time, on no sleep. The longer he went without sleeping, the higher his insulin resistance became. Lack of sleep may be causing some of your unexplained highs since more cortisol (a stress hormone) is released when you are sleep-deprived.
If you’ve had some alcohol to drink
Alcohol interferes with the normal function of the liver in making and releasing glucose. While it can lead to hypos, it can also be used strategically to relieve insulin resistance or to keep it in check—and luckily it does not take much alcohol to have an effect. An older guy called me on a diabetes hotline I was manning for a TV station once and explained that he usually had two shots of whiskey at night and woke up with good blood glucose levels, but that if he ever had to skip the whiskey, he would wake up too high. He wanted to know what he should do. I said, “Keep drinking the whiskey!” No more than one drink daily for women or two for men is recommended, though, so do not overdo it or you raise your risk of other health problems.
If it’s a certain time of the month (women only)
You may have everything else accounted for and your blood glucose levels are still skyrocketing for apparently no reason—except that you’re either ovulating (and releasing extra hormones that promote insulin resistance) or in the few days or week leading up to your period when insulin resistance is highest. This has been a bigger issue for me later in life since my cycles seem to be more extreme, although I do not know if this is the case for all women. I helped a diabetes educator recently figure out that she was actually pregnant when she simply could not figure out why her blood glucose levels were so whacked out; it can be as simple an explanation as that (and hopefully a desired one, if you are pregnant).
Regardless of what is causing your (unexplained) insulin resistance, just try to control your blood glucose levels the best you can and lose the guilt over not knowing exactly why it is high and not being totally in control of your blood glucose levels 24/7. Even the most knowledgeable of us have our head scratching and/or hair pulling days trying to figure it out!

In addition to my educational web site, Diabetes Motion (www.diabetesmotion.com), I also recently founded an academy for fitness and other professionals seeking continuing education enabling them to effectively work with people with diabetes and exercise: Diabetes Motion Academy, accessible at http://www.dmacademy.com. Please visit those sites and my personal one (www.shericolberg.com) for more useful information about being active with diabetes.

Jovina cooks Italian: Swordfish Messina Style

Nov 18, 2016Oct 8, 2016 kaitiscotlandLeave a comment

Pesce Spada alla Messinese (Swordfish Messina style)

Ingredients (serves 4)

1 lb (600 gr) swordfish cut into palm-sized pieces slices
2 cloves of garlic, chopped
2 spring onions, chopped
20 capers (if salted, rinse well first)
10 black olives, chopped
4 anchovy fillets
1 cup white wine
2 cups tomato passata (sauce)
15 oz can chopped tomatoes
Extra virgin olive oil
Salt and pepper
A pinch of crushed dried chili pepper
Parsley, chopped

Directions

Brush the swordfish slices with olive oil and set aside.

In a skillet heat enough olive oil to cover the bottom of the pan. Add the spring onions, garlic, capers, olives, chili pepper and anchovy fillets and cook until the anchovies melt into the oil and the onion is soft.

Put the slices of swordfish in the skillet and add the white wine. Burn off the alcohol and then add the tomatoes. Mix well, cover and cook for 30 minutes on very low heat.

When ready to serve, sprinkle with parsley.

PUBLIC HEALTH COLLABORATION: WHAT TO LOOK OUT FOR WHEN STARTING A LOW CARBOHYDRATE DIET

Nov 15, 2016Oct 9, 2016 kaitiscotland2 Comments

PHC-Space-Top

FOR EVERYONE

As you start a low carbohydrate diet your kidneys get better at excreting salt thus you will usually find that you lose a lot of water from the tissues of the body. This can make you instantly slimmer, particularly around the legs, but also can give some cramps in the muscles when you exert yourself. Be aware of this and add extra salt to your food, and drink plenty of water. When you are on a low carbohydrate natural foods diet you will be consuming considerably less sodium chloride, which is present in many processed foods including sweet ones. Bread for instance has a lot of added salt that most people are completely unaware of, therefore feel free to be liberal with the salt cellar.

BLOOD PRESSURE

Blood pressure comes down, partly due to less water retention, but also due to lowered natural insulin levels in the body. As the weight comes down as well, blood pressure tends to drop. For most people who are not on any antihypertensive drugs they may feel slightly lightheaded from time-to-time. This can be abolished by adding more salt to the diet.

For people who are on medication to reduce their blood pressure they should have their blood pressure measured by their general practitioner and cut back on medication on embarking on a low carbohydrate diet if their blood pressure is under 140/90. After a few weeks on a low carbohydrate diet they will be adjusted to a lower level of blood pressure. Thereafter blood pressure only requires to be checked on several occasions with each extra half stone of fat loss.

It is helpful to buy your own blood pressure monitor as measurements done when you are relaxed at home tend to be more accurate than those undertaken in a surgery.

As many blood pressure medications have more than one use, and different effects on the body, it is worth discussing with your general practitioner which ones would be better to cut out altogether or which ones could be reduced in dose. This is because certain drugs such as ACE inhibitors and sartans have an extra protective effect on the kidney and this can be important for diabetic patients. They also help improve heart function in cardiac failure.

Beta-blockers are sometimes given to people with atrial fibrillation, or who have had a heart attack, or who suffer from angina, and continuing these may be a priority for some individuals.

BLOOD SUGAR REDUCTIONS

Blood sugar reductions happen rapidly with a low carbohydrate diet. This is mainly due to the lack of sugar and starch being turned into blood glucose. This has several effects.

The most pronounced and rapid effect could be on the eyesight. The lens of the eye adjusts to a particular blood sugar and if the level goes suddenly up, or suddenly down, your vision can become blurry, particularly for reading print. It is worthwhile avoiding getting new spectacles for about 6 months to give time for the lens of your eye to adjust otherwise you can end up having to get another pair of spectacles at a very short interval and this can be rather expensive.

INSULIN and ORAL HYPOGLYCAEMIC DRUG USERS NEED TO TAKE EXTRA PRECAUTIONS

Type 1 diabetics will have been using insulin from the time of diagnosis. Increasing numbers of Type 2 patients are going on insulin as their pancreas needs more support as time goes on. A rapid change in pattern of sugar and starch intake can give dangerously low levels of blood sugar unless the insulin dose is proportionately reduced from the outset of the diet. The amount of reduction will depend on how high your blood sugars run normally, and how strict your low carbohydrate diet is.

For many people who are taking insulin, or sulphonylurea drugs which also have a marked blood sugar reduction effect, starting on a moderately low carb diet of 100g or so a day may cushion the effect somewhat.

Most diabetics will need to cut their insulin quite dramatically, particularly if they go on less than 50g of carbohydrate a day. It is normal to have to cut insulin by a half or even two thirds in some individuals.

A close eye on blood sugar monitoring needs to be done and we would recommend that, for particularly people who are operating machinery or driving, they start a low carbohydrate diet over a period of holiday when there are other people around who can assist them should they have low blood sugars, and also people to undertake driving on their behalf.

Your own general practitioner or hospital endocrinologist is the best person with whom to discuss your planned reduction in insulin or sulphonylurea medications.

Many patients on sulphonylureas are able to stop these drugs completely prior to starting a low carbohydrate diet and thus remove the risk of low blood sugars completely. People who use insulin however are not able to do this and must have a degree of background insulin to prevent them developing dangerously high blood sugars and ketoacidosis.

The normal blood sugar ranges between 4 and 7 at most times. Drivers must not drive unless their blood sugar is at least 5, and they should re-check their blood sugar after every 1-2 hours of driving. To treat a hypo use 15-20g of glucose and do not drive till blood sugars are completely normal and you have fully recovered.

Setting an alarm to check blood sugars in the middle of the night, and taking blood sugars at 2½ hourly intervals through the day is advised in the first few days for insulin users.

The normal correction dose is one unit of rapid acting insulin for every 2.5 units of blood sugar elevation. This can be helpful to know if you have cut down your insulin doses a bit too much.

Aiming for blood sugars between 6 and 8 mmol can be a safe strategy in the first 2 weeks after starting a low carbohydrate diet. Thereafter the blood sugars can be tightened up when insulin requirements are more predictable. To prevent blood sugars going up and down unpredictably it is best to stick to 3 main meals a day and avoid snacking.

EDUCATIONAL COURSES

For insulin users and people on sulphonylureas it is best to fully understand the implications of a low carbohydrate diet and know how to control your blood sugars and insulin as well as having a good grasp of carb counting prior to undertaking a low carbohydrate diet. There are many educational resources on the web to do this. Some of these resources are Dr Bernstein’s Diabetes University on you tube, diabetes.co.uk website and Low Carbohydrate Course which is web based, and diabetesdietblog.com which has two written courses.

LONG TERM

Although it can be daunting to think about the initial difficulties that can occur with a low carbohydrate diet, the long term benefits of improved blood sugars, weight, blood pressure and lipids make the outlook for pre-diabetics, the overweight and people suffering from diabetes much brighter indeed. It is worth educating yourself about your condition and how to effectively use a low carbohydrate diet to change your health destiny. The extra planning that you need to do for meals, more frequent shopping for fresh ingredients and often increased expense are worth the long term health benefits.

ALCOHOL

Alcohol can be a pleasant part of life. Many alcoholic drinks are high in sugar, such as beer and sweet wines, and also cocktails. These need to be eliminated for success in a low carbohydrate diet. Spirits such as whisky, gin and vodka have less impact on the blood sugar, and dry red and white wines are also suitable.

For insulin users, and particularly Type 1 insulin users however, alcohol can tip them into unexpected hypoglycaemia if they are consuming more than 1-2 units of alcohol without a corresponding increase in dietary carbohydrate. This is because alcohol limits the ability of the liver to manufacture glucose, and also blood sugars tend to run much more towards the normal range, around 4.6, when diabetes undergoes an apparent reversal on a low carbohydrate diet.

EXERCISE

Exercise is a very beneficial and pleasant adjunct to a low carbohydrate diet for increased mood and health. For insulin users and those on medication such as sulphonylureas, adding exercise into the regime early on in the stages of a low carbohydrate diet add an increasing layer of complexity to blood sugar management. We therefore recommend that unaccustomed exercise is avoided for the first 2 weeks until blood sugar stability is achieved.

Dr Katharine Morrison

Public Health Collaboration: Free booklets

Nov 12, 2016Oct 9, 2016 kaitiscotlandLeave a comment

This is the link to the Public Health Collaboration site where you can download for free or order print versions, at a modest cost, of illustrated health booklets that will help you:

know what to eat for a wide variety of good health outcomes

plan your meals

count your carbohydrates

lose fat

https://www.PHCuk.org/booklets/

Hopefully you will end up somewhere between the extremes of our sisters up there!

Jovina cooks Italian: Summer eating

Nov 9, 2016Oct 8, 2016 kaitiscotland1 Comment

Influenza vaccine reduces total mortality in diabetics

Nov 6, 2016 kaitiscotland6 Comments

From Diabetes in Control

Could Influenza Vaccination Prevent More Than Just the Flu?

September 10th, 2016

Influenza vaccination may reduce cardiac-related hospital admissions and all cause mortality in patients with diabetes.

Currently, only low-quality evidence exists to support efficacy of influenza vaccination to prevent seasonal influenza in patients with diabetes. There is even less information regarding the impact of influenza vaccination on cardiovascular events or all-cause mortality in this population. A recent study published in the Canadian Medical Association Journal was designed to evaluate the impact of seasonal influenza vaccination on admission to the hospital for acute myocardial infarction, stroke, heart failure, or pneumonia, and all-cause mortality in patients with type 2 diabetes.

Conducted over a 7-year time period from 2003 – 2009, the study analyzed retrospective patient data from the Clinical Practice Research Datalink in England. The analysis included 124,503 adult patients diagnosed with type 2 diabetes. At baseline, characteristics such as age, sex, smoking status, BMI, cholesterol labs, HbA1c, blood pressure, medications, and comorbidities were compared between patient groups. Vaccination rates of the included participants ranged from 63.1% to 69.0% per year. In general, unvaccinated participants were younger, had lower rates of pre-existing comorbidities, and were taking fewer medications.

The baseline characteristics of subjects enrolled in this retrospective analysis showed that sicker subjects received the flu vaccination more frequently. Given this observation, and seasonal confounding of flu outbreaks, data adjustments favored fewer cardiovascular events and lower rates of all-cause mortality during the influenza season spanning 7 years of data. While other studies have shown that influenza vaccination can reduce the risk of cardiovascular events in high-risk patients, this study is the first to demonstrate a reduction in cardiovascular events associated with influenza vaccination in patients with diabetes. This study is notable for its large sample size and long duration. However, given the retrospective nature of the study, further trials are warranted to offer conclusive evidence about the benefits of influenza vaccination in patients with diabetes.

Practice Pearls:

Previous clinical trials aimed at studying the effectiveness of the flu vaccine in patients with diabetes are often small, inconclusive, and have not investigated cardiovascular outcomes.
When data was adjusted for baseline covariates and seasonal residual confounding, patients who received the influenza vaccination had significantly reduced rates of hospital admissions for stroke, heart failure, pneumonia or influenza, and all-cause mortality.
Large experimental or quasi-experimental trials are needed to establish a causal link between influenza vaccination and clinical endpoints in patients with diabetes.

References:

Vamos EP, Pape UJ, Curcin V, Harris DPhil MJ, Valabhji J, Majeed A, et al. Effectiveness of the Influenza vaccine in preventing admission to hospital and death in people with type 2 diabetes. CMAJ. 2016 July 25.

Remschmidt C, Wichmann O, Harder T. Vaccines for the prevention of seasonal influenza in patients with diabetes: systematic review and meta-analysis. BMC Med 2015;13:53.

Researched and prepared by Alysa Redlich, Pharm.D. Candidate, University of Rhode Island, reviewed by Michelle Caetano, Pharm.D., BCPS, BCACP, CDOE, CVDOE

Could Metformin be useful to prevent Alzheimer’s?

Nov 6, 2016Oct 8, 2016 kaitiscotland3 Comments

From Diabetes in Control.
July 16th, 2016
The diabetes drug may have a beneficial effect on neurodegenerative diseases.
Metformin, a biguanide, is an oral diabetes medicine used to improve blood glucose levels in people with type 2 diabetes. There have been various studies on other uses of metformin. It may be beneficial in Alzheimer’s disease, stroke and other degenerative brain cell diseases. An animal study found that metformin helps neurogenesis and enhances hippocampus, a key pathway (aPKC-CBP).

Type 2 diabetes doubles the risk of having dementia; though some studies show metformin helps reduce risk, other studies show antidiabetic medications like insulin are linked to increased risk of having dementia.

Animal studies show that metformin recruits endogenous neural stem cells and also promotes the genesis of new neurons. Metformin, however, needs to have been used for a longer period before a drastic reduction in neurodegenerative disease and its neuroprotective nature is seen.
The purpose of this study is to find a link between antidiabetic medications, especially metformin and other neurodegenerative diseases. Also, to know how long one has to be on these antidiabetics before the neuroprotective nature kicks in.

A cohort study of type 2 diabetes patients who are 55 years and above and being managed on a monotherapy antidiabetic drug of either metformin, sulfonylurea (SU), thiazolidinedione (TZD) or insulin were observed in a period of 5 years.

In the course of 5 years, dementia was identified in 9.9% of the patients. Comparing those taking metformin to those taking sulfonylurea, there was a 20% reduction in dementia in those taking metformin. The hazard ratio 0.79%, a 95% confidence interval of 0.65-0.95.

For TZD, metformin had a 23% reduction in having dementia as compared to TZD with hazard ratio of 0.77, 95% confidence interval of 0.66-0.90.

Whereas those on SU as compared to metformin had a 24% increased risk for dementia with a hazard ratio of 1.24, 95% confidence interval of 1.1-1.4.TZD had an 18% increased risk, hazard ratio of 1.18, 95% confidence interval of 1.1-1.4.

Insulin had the highest risk of 28% with hazard ratio of 1.28, 95% confidence interval of 1.1-1.6.

These findings proved that metformin use has neuroprotective benefits while insulin has an increased risk of one having dementia.
In yet another study, patients 50 years and older from Veterans Affairs, diagnosed with type 2 diabetes, were recruited. Those on insulin were followed from the time they started insulin. The exclusion criteria were neuropathy, vitamin B12 deficiency, cognitive impairment, cerebrovascular disease, renal disease, and those who took insulin for less than two thirds of the study period. The sample size after all exclusions was 6,046 patients with 90% of them being male and a median age of 5.25 years.

334 cases of dementia were diagnosed, 100 of them had Parkinson’s, 71 had Alzheimer’s disease and 19 had cognitive impairment during the follow up period. The incidence of developing neurodegenerative disease was lower (2.08) for those who never used metformin as against those who used it for less than a year, which was (2.47). Metformin usage for 4 years was 0.49, 2 to 4 years was 1.30 and 1.61 for less than 2 years. This proves that the longer one stays on metformin the better the neuroprotective benefits take effect.

This study was significant for dementia (0.567 at 2-4 years and 0.252 for more than 4 years), but for Parkinson’s and Alzheimer’s disease it was 0.038 and 0.229 respectively, which happened from four years and beyond. For future studies, a larger scale prospective cohort study is needed to approve the connection between metformin use and the risk for neurodegenerative disease.

A spatial learning maze test performed on mice showed those given metformin (200mg/kg) were significantly better to be able to learn the location of a submerged platform as compared to those given a sterile saline solution.

Other studies have also proposed that metformin could stimulate neurogenesis from human neural stem cells.
Metformin is known to cross the blood-brain barrier, and has pleiotropic effects. It is known to have other possible preventive roles in cancer and heart disease. From all these various studies, one can conclude that metformin does have a therapeutic potential for mild cognitive impairment and dementia.
Practice Pearls:
Metformin use for more than 2 years has a significant reduction in neurodegenerative disease; it is neuroprotective as well as promoting neurogenesis.
Though the mechanism between metformin and neurodegenerative disease is uncertain, it is known to cross the blood brain barrier and has pleiotropic effects.
Growing evidence suggests that neural stem cells play a role in the repair of injuries or a degenerated brain.

Shi Qian, Lui Shuqian, Foseca Vivian, et al. “The effort of Metformin Exposure on Neurodegenerative disease among Elder Adult Veterans with Diabetes Mellitus”. American Diabetes Association-76th Scientific session 2016. Web June 19 2016.
Wang Jing, et al. “Metformin Activates an Atypical PKC-CBP Pathway to promote Neurogenesis and Enhance Spatial Memory Formation”. Cell Stem Cell. Vol 11(1) July 2012. Web June 19 2016.
Knopman David S et al. “Metformin Cuts Dementia Risk in Type 2 Diabetes”. Alzheimer Association International. July 2013. Web 19 2016.

When is the best time of day to exercise?

Nov 3, 2016Oct 8, 2016 kaitiscotland5 Comments

From Diabetes in Control 14th July 2016
Is there a best time to work out, based on circadian rhythms?

Circadian rhythms are estimated 24 –hour biological cycles that function to prepare the organism for daily environmental changes. There is a molecular clock mechanism found in most cell types including skeletal muscles. Disturbances in the circadian rhythms have been shown to have harmful impacts on health, which may lead to metabolic syndrome.
Experiments in mice suggest that the timing of exercise may be critical for the maintenance of molecular rhythms. Scheduled exercise functioned to enhance the stability of both activity and heart rate rhythms.
Another study determined the significant differences in circadian rhythms in healthy non-diabetic young men. 59 subjects between the ages of 20-34 were recruited and studied for 60 days. They were grouped based on their BMI as healthy weight, overweight or obese and all were free from cardiovascular disease, diabetes, pulmonary disease and many diseases.

Resting heart rate and blood pressure were measured, so was their body composition and a maximal graded exercise test performed. Their circadian rhythm parameters were measured by noninvasive wrist temperature rhythm monitoring and recording devices.

Subjects recorded daily questions concerning sleep, frequency and timing of nutritional intake, alcohol use, and smoking, and removal times of wrist skin temperature monitor.

There was no association between body fat and peak wrist temperature during night time hours (r= -0.05; P= 0.79). The poor % fat group (109.10 ± 14.12) had significantly lower circadian temperature stability than the optimal % fat (166.52 ± 17.84) or fair % fat group (175.21 ± 23.96).
Another recent study was performed to determine the exact time one needs to work out, based on circadian rhythm, to obtain a better outcome. In this study it was found that the various times one exercises give different outcomes.

For instance, when one exercises from 7 to 9am, their pain tolerance is higher but they have poorer flexibility since their body temperature is low and therefore more likely to sustain an injury. (My comment: so not great for yoga or running but maybe better for walking, meditiation or weight training?)

Exercising from 10 am to 12 p.m. is good for any skill based sports that require alertness and short term memory peaks. (Anyone for tennis?)

Meanwhile from 4 to 8 pm showed an overall performance peak since it coincides with the peak body temperature. Body temperature is normally high at that time since there is a higher lung capacity, blood flow to muscle and flexibility. (So good for a run and yoga and indeed most sports and activity)
In conclusion the best time for one to work out is whenever is appropriate for and suits that person since many things affect the circadian rhythms.
Practice Pearls:
Circadian rhythms is a molecular clock mechanism found in most cell types including skeletal muscles.
Presence of a molecular clock is argued to be a necessary timekeeping mechanism to prepare the cell for daily changes in environmental conditions
The best time to work out is when it is convenient for one since every time frame has its advantages and disadvantages.

Comment from Dr. Sheri Colberg, Ph.D., FACSM, Advisory Board Member:
It has been suggested that many different things affect circadian oscillations, and in people with diabetes and in aging, some of these normal controls fail to work effectively. For example, alterations in the release of melatonin, a critical hormone that regulates sleep and central nervous system balance, occur in both states (diabetes and aging) that lead to more imbalances. Exercise of any type helps reset autonomic function, or the balance between sympathetic and parasympathetic branches of the autonomic nervous system. For management of diabetes and successful aging both, being physically active on a regular basis is likely more important than the time of day that activity is undertaken.

References:
Colino Stacey “What is the best time of the day to exercise? The answer is complicated”. US News 6 July 2016. Web. 14 July 2016.
Schroder, Elizabeth A., and Karyn A. Esser. “Circadian Rhythms, Skeletal Muscle Molecular Clocks and Exercise.” Exercise and sport sciences reviews 41.4 (2013): 10.1097/JES.0b013e3182a58a70. PMC. Web. 14 July 2016.
Tranel, Hannah R. et al. “Physical Activity, and Not Fat Mass Is a Primary Predictor of Circadian Parameters in Young Men.” Chronobiology international 32.6 (2015): 832–841. PMC. Web. 14 July 2016.

Jovina cooks Italian: Neapolitan Ragu

Oct 31, 2016Oct 8, 2016 kaitiscotland2 Comments

Neapolitan ragù is one of the two most famous varieties of Italian meat sauces called ragù. It is a specialty of Naples, as its name indicates. The other variety originated in Bologna.

The Neapolitan type is made with onions, meat and tomato sauce. A major difference is how the meat is used, as well as the amount of tomato in the sauce. Bolognese versions use very finely chopped meat, while the Neapolitan versions use large pieces of meat, taking it from the pot when cooked and served it as a second course. Ingredients also differ.

In Naples, white wine is replaced by red wine, butter is replaced with olive oil and lots of basil leaves are added. Bolognese ragù has no herbs. Milk or cream are not used in Naples. Neapolitan ragù is very similar to and may be ancestral to the Italian-American “Sunday Gravy”; the primary difference being the addition of a greater variety of meat in the American version, including meatballs, sausage and pork chops.

Ingredients

1 pound rump roast
1 large slice of brisket (not too thick)
1 pound veal stew meat
1 pound pork ribs
2 large onions, sliced
6 tablespoons of extra virgin olive oil
2 tablespoon butter
1 tablespoon tomato paste
1 cup of red wine
1 1/2 pounds tomatoes, pureed
Salt and pepper to taste
Fresh basil leaves

Directions

Season the meat with salt and pepper. Tie the large pieces with cooking twine to help them keep their shape. In a large pot heat the oil and butter. Add the sliced onions and the meat at the same time.

On medium heat let the meat brown and the onion soften. During this first step you must be vigilant, don’t let the onion dry, stir with a wooden spoon and start adding wine if necessary to keep them moist.

Once the meat has browned, add the tomato paste and a little wine to dissolve it. Stir and combine the ingredients. Let cook slowly for 10 minutes.

Add the pureed tomatoes, season with salt and black pepper and stir. Cover the pot but leave the lid ajar. (You can place a wooden spoon under the lid.)

The sauce must cook very slowly for at least 3-4 hours. After 2 hours add few leaves of basil and continue cooking.

During these 3-4 hours you must keep tending to the ragú, stirring once in a while and making sure that it doesn’t stick to the bottom. Serve with your favorite pasta.

Ghost pills: has it happened to you?

Oct 29, 2016Oct 9, 2016 kaitiscotland1 Comment

From Diabetes in Control: Disasters averted series
August 2nd, 2016

When it comes to metformin, when appropriate, I recommend the extended release version.

Last week my patient, female, 56 years of age, type 2 diabetes, visited. A1C was elevated, and she gained 5 pounds. She had been on metformin ER for the last 6 months and doing well. She said she recently noticed a bean-looking/pill-looking thing in her stools that seemed to be related to her metformin. (She hadn’t looked before this).

She stopped her metformin and said she didn’t see it after that. “If it was coming out of me, it must not have been working, so I stopped it.” She refuses to check her glucose or weigh herself, therefore she did not notice the increase in her glucose levels. She did mention noticing her pants being tighter around her waist.
I informed her that the bean-looking/pill-looking thing in her stool was the metformin, but that did not mean it wasn’t working, it was. It was just a different method of delivery to be a slower release than other medications she takes or has taken. Some call the remains…ghost pills.
She resumed her metformin. Sure enough, she saw them again, but she did not stop taking her metformin. Three months later, her A1C and weight returned to the levels before stopping.
Lessons Learned:
Understand that some controlled or extended release medications may look like they haven’t been “digested,” but that’s the formulation of the medication. The active ingredient has been released.
When starting your patients on medications that seem to not be “digested” such as extended release metformin, teach they may see this.
Learn more at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847989/ and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110830/

My comment: As a GP I have come across this. At least I know what to say about it now.

Author: kaitiscotland