The best diet for optimal blood sugar control & health
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Over 40% of new type one diabetics are over the age of 30 at the time of diagnosis.
Richard Oram from Exeter University said, “The assumption among many doctors is that adults presenting with the symptoms and signs of diabetes will have type two, but this misconception can lead to misdiagnosis which can have serious consequences”.
Clues to the person having type one can be failure to control blood sugar with tablets and the person being of a slim build.
The study was done by looking at the genetic biomarkers of over 13 thousand patients who had developed the disease before the age of 60.
BMJ 9 December 2017
I’ve joined the Fitbit world. Having dipped my toe in the water via the Jawbone Up Activity tracker, I’m now the proud owner of a Fitbit.
My Up activity tracker vanished in January when the device fell out of the wristband. It must be somewhere in the house. Maybe the system thinks I’m dead thanks to my lack of movement. Hey ho! Anyway, by that point I reckoned I knew what you needed to do to cover 10,000 steps a day, and I was quite happy to live tracker-free.
I didn’t stare at my phone so much. My health didn’t take a nosedive, and the world didn’t end.
On Valentine’s Day, however, my husband gave me a Fitbit Charge 2, the reward for staying alcohol-free so far this year. To be honest, when he hinted the other week that he’d got me a pressie for my teetotal efforts, I thought he was talking about champagne. It always makes sense to reward your giving up something with the very substance you’ve been avoiding, hmm?!
And I was grateful and touched that he’d bothered. He’d done the research, he told me happily. This tracker is the all-singing, all-dancing one! It counts your steps, how often you climb up stairs (you should climb ten flights a day for good health, apparently), checks your heart beat, auto-recognises different exercises and monitors your sleep. You can add in a food tracker and monitor your calorie intake if you want to lose weight.
For someone who tends to obsessiveness, this is good and bad news. To prevent myself repeatedly checking my phone, I downloaded the app for Fitbit onto my tablet instead.
Exercise is very good for we folks with diabetes if you are able to be active. If you have type 2, you might be able to control the condition through diet and exercise alone. If you have type 1, exercise will mean you can reduce how much insulin you need to take overall, and it can be used with diet and insulin to keep your blood sugar levels in range.
At some point, perhaps activity trackers will be prescribed for people with diabetes? In the future, the Fitbit could include blood glucose monitoring, as a story earlier this year reported that Fitbit has just invested in a company that’s developing a minimally invasive glucose tracker. Imagine having all that information available in one place.
I, for one, would love that capability, so fingers crossed.
Adapted from an article by Richard A. Friedman’s article, “Yes, your sleep schedule is making you sick” published in the New York Times March 10 2017
Jet lag makes everyone miserable and here is what you can do about it.
We have a circadian rhythm that is 25 hours long and it is almost in synchronicity with the 24 hour day. Jet lag messes this up big time. Everyone who has experienced it knows that jet lag makes you feel tired, out of sorts, renders concentration difficult and makes you moody.
If you are flying from New York to Rome for instance and arrive early in the morning Rome time, the best way to reduce jet lag is to keep on eye shades in the plane and dark glasses on the ground till your New York 7am has been reached. This will be about lunch time in Rome.
Melatonin is also an important factor. As it starts getting dark your pineal gland starts to produce melatonin around 2 or 3 hours before your sleep time. If you take a melatonin supplement earlier than this is can become possible for you to fall asleep earlier than you otherwise would.
Surprisingly, if you take melatonin in the early morning, it can fool your brain into thinking it slept longer, at least to some extent, and does not make you more tired during the day.
So this is the fix for jet lag. Travel east and you’ll need morning light and evening melatonin. Go west and you’ll need evening light and morning melatonin.
If you are a night owl, who can’t sleep at midnight because it’s too early for you, take a small dose of melatonin a few hours before the desired bedtime. They can also try exposure to bright lights at progressively earlier times in the morning, which also should make it easier to fall asleep earlier. You
should also avoid the blue light that smartphones and computers emit in the evenings. You can wear special glasses that block blue light if this is a problem.
Richard A. Friedman is a professor of clinical psychiatry and director of psychopharmacology clinic at the Weill Cornell Medical College.
From Diabetes in Control May 2017. Cheapest treatment associated with increased risks of cardiovascular events and death.
After the cardiovascular issues with rosiglitazone, cardiovascular safety trials had to be conducted for all new anti-hyperglycemic agents. However, approval for older medications was based simply on evidence of a reduction in glucose parameters; cardiovascular safety was not a concern back then. But, data from the UKPDS trial shows that metformin reduces CV events, so, it was never in doubt. The ORIGIN trial has shown no increased harm with early initiation of insulin. However, some questions linger regarding the cardiovascular safety profile of sulfonylureas.
Data exist on the weight gain and risk of hypoglycemia associated with sulfonylureas, but the associated cardiovascular events have not been well-quantified. Sulfonylureas are used commonly across the world and are very effective in lowering HbA1C, but often the effect wears off, as shown in the ADOPT study.
Recent randomized trials have compared the newer antidiabetic agents to treatments involving sulfonylureas, drugs associated with increased cardiovascular risks and mortality in some observational studies with conflicting results. They reviewed the methodology of these observational studies by searching MEDLINE from inception to December 2015 for all studies of the association between sulfonylureas and cardiovascular events or mortality.
Sulfonylureas were associated with an increased risk of cardiovascular events and mortality in five of these studies (relative risks 1.16–1.55). Overall, the 19 studies resulted in 36 relative risks as some studies assessed multiple outcomes or comparators. Of the 36 analyses, metformin was the comparator in 27 (75%) and death was the outcome in 24 (67%). The relative risk was higher by 13% when the comparator was metformin, by 20% when death was the outcome, and by 7% when the studies had design-related biases.
The lowest predicted relative risk was for studies with no major bias, comparator other than metformin, and cardiovascular outcome (1.06 [95% CI 0.92–1.23]), whereas the highest was for studies with bias, metformin comparator, and mortality outcome.
In summary, sulfonylureas were associated with an increased risk of cardiovascular events and mortality in the majority of studies with no major design-related biases. Among studies with important biases, the association varied significantly with respect to the comparator, the outcome, and the type of bias. With the introduction of new antidiabetic drugs, the use of appropriate design and analytical tools will provide their more accurate cardiovascular safety assessment in the real-world setting.
So this study reviewed over 19 trials looking at sulfonylureas, specifically studying cardiovascular events and mortality. The problem with some studies is that they don’t take into account the duration of diabetes et cetera; so, they may end up comparing sicker patients with those who aren’t as sick. This group looked at potential biases such as exposure misclassification, time-lag bias, and selection bias, and, of the 19 studies, 6 did not have any of these biases. Of those 6 studies, 5 showed that sulfonylureas were associated with an increased risk of cardiovascular events and mortality, with relative risks ranging from 1.16 to 1.55.
It is not possible to tease out what the cause of the increase in events is based on this type of analysis. Is it hypoglycemia? Is it a direct drug effect? However, regardless of the mechanism, the consistent finding of increased cardiovascular risk may have an impact on selection of agents for our patients. Newer agents have been shown not to increase events, and recently some have even shown reduction in events. So, perhaps our algorithm of selecting medications for our patients may have to change to focus on the cardiovascular effects first and then the glycemic benefits because, in the end, our goal is preventing cardiovascular events from happening in our patients with diabetes.
Practice Pearls:
Sulfonylureas are associated with increased risks of cardiovascular events and death.
Sulfonylureas also associated with hypoglycemia events.
Data exist on the weight gain and risk of hypoglycemia associated with sulfonylureas.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-853.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)07019-6/fulltext
The ORIGIN Trial Investigators. Basal Insulin and Cardiovascular and Other Outcomes in Dysglycemia. N Engl J Med. 2012;367(4):319-328. http://www.nejm.org/doi/full/10.1056/NEJMoa1203858
Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies. Diabetes Care 2017 May; 40(5): 706-714. http://care.diabetesjournals.org/content/40/5/706
Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies. Diabetes Care. 2017 May;40(5):706-714. doi: 10.2337/dc16-1943. https://www.ncbi.nlm.nih.gov/pubmed/28428321
My comments: The health issues of sulphonylureas have been known about for at least a decade or two, but because they are cheap and effective in blood sugar lowering they continue to be promoted as the next drug to use after Metformin for type twos. The Scottish Government have produced a paper which I reviewed a few weeks ago. It is their “new” strategy to deal with diabetes. Mainly, they wanted to limit the expenditure on the newer gliptans eg Linagliptan, Sitagliptan, the flozins eg Empagliflozin and the injectibles such as Victoza and Byetta. These are a lot more expensive than metformin and gliclazide. They propose that lifestyle measures are first line. This means promoting exercise and “Healthy Eating” first. Yes, this means a high carb, low fat diet, with lots of starch, limited sugar, salt, and whatever fat you eat should be the good monounsaturated type and also the inflammatory vegetable oil/margarines. As we know this actually increases obesity for most people and worsens diabetes control. You then get put on metformin and then before you get put on drugs that actually lower your weight, blood sugar and blood pressure and cardiovascular risk, you get put on a sulphonylurea which wears out your pancreas, makes you fatter, makes you more prone to hypos and increases your cardiovascular risk. In my view sulphonylureas should be AFTER the newer drugs and given as a choice if someone does not want to use insulin. I put in my comments regarding diet to the editorial board but they have done nothing saying that the remit of the paper was really about drugs, not diet. Yet, without the right diet, diabetes management is doomed to failure.
The delivery firm DPD hit the headlines this week – for the wrong reasons.
One of the firm’s drivers died from diabetes-related causes. According to his wife, he’d started missing hospital appointments because the company fines you £150 for not working, if you can’t find someone to drive on your behalf. As a franchisee, the onus is on the driver to find his or her replacement if that person needs to take time off for medical reasons.
Don Lane worked through the busy Christmas period, despite feeling ill. He collapsed in late December and died on 4 January.
Mr Lane’s story was widely reported. An article in the Independent said Mr Lane had worked for 20 years for the company at its Bournemouth depot. His widow Ruth told the Guardian that he’d missed appointments because he was worried about being fined, having previously been fined for taking time off for an appointment in July when he visited a specialist about the damage to his eyes caused by diabetes.
Labour MP Frank Field, the chair of the Commons Work and Pension Select Committee, said the loss of life represented a new low for the gig economy. In a statement, DPD emphasised that Mr Lane was “self-employed”, and said it was “devastated” by Mr Lane’s death, but that self-employed couriers are contracted to provide a service, and they can provide a substitute if they can’t carry out the job.
They added that they were wrong to charge him for attending his appointment in July.
Horrifying, isn’t it? If you feel strongly about this, and would like to do something about it, you can choose not to use DPD for parcel delivers where possible. This might mean changing your shopping habits or asking companies you regularly buy goods from which courier firms they use. You can also make your feelings known via social media – @DPD_UK on Twitter.
Out of Insulin, Too Early to Renew — What To Do?
Disasters Averted Diabetes in Control August 30th, 2016
It is not unusual for people to have difficulty keeping insulin from freezing or getting overheated. A patient, with type 1 diabetes for 17 years, had glucose that did not respond to his rapid-acting insulin as it usually does.
He had two new vials in the refrigerator. He took a new vial out of his refrigerator earlier in the day, and started using it a few hours after he took it out. Had high post prandials that did not respond as usual to correcting. He had enough experience to wonder if perhaps something was wrong with his new insulin, so he thought he’d try another vial. He saw it was frozen. He had put the two vials at the back, where for many refrigerators it is colder. He thought back and wondered if the first vial looked any different, but remembered, he did not look closely at it.
He then went to get a new prescription filled at his pharmacy, but was told insurance would not cover it at this date; it was too early. It was cost prohibitive for him to pay out of pocket ~$300.00/vial. He contacted a diabetes health care provider (hcp) who offered him two sample vials to cover him until his prescription would once again be covered. He corrected and his glucose lowered. Disaster averted! (Thank heavens we don’t have this problem in the UK!)
Not everyone has the luxury of having a hcp who has samples available in such a timely manner. If their hcp even had them, what if it were a weekend, or another time that the hcp did not have access to the samples? I reached out to certified diabetes educator, Laurie Klipfel, RN, MSN, BC-ANP, CDE, to see if she could offer any pearls of wisdom.
“This was a recent discussion on an AADE list serve with many good suggestions. The best suggestion was asking the healthcare provider if samples were available. My next option would be to see if the insurance would make an exception under the circumstances (but this may take time).
Someone with type 1 needs their insulin and cannot wait a day or two. The next option is to see if a diabetes educator could contact a rep for samples (their prescribing healthcare provider would also need to be involved). My next option would be to see if there were coupons available online from websites like: http://www.rxpharmacycoupons.com, or other websites. As a last resort (but may be the fastest option in a pinch), if a patient was not able to afford the analog insulins such as Novolog, Humalog, or Apidra, I might suggest discussing with the healthcare provider if using regular insulin instead would be an option. Though the analogs match insulin need to insulin much better than regular insulin, taking regular insulin (especially when using a generic brand such as Walmart’s ReliOn brand) can be a much cheaper option and would be much better than not taking any meal dose insulin at all.
It would be beneficial to explain the differences in action times and suggest taking regular insulin 15-30 min. before the meal and beware of potential hypoglycemia 3-5 hours after injection due to longer action of regular. Of note, you do not need a prescription for regular, NPH or 70/30 insulin.
“I would also agree with suggestions made on the list serve for keeping the insulin in the door of the refrigerator and using a thermometer in the refrigerator. If the temperature in the refrigerator is not stable, it may be helpful to have the thermostat of the refrigerator checked.“
Lessons Learned:
Teach patients:
People who have diabetes, especially type 1 diabetes, need to have and take insulin that is effective.
If you have type 1 diabetes, you are in danger of DKA. Know what it is, how to prevent, recognize, and get help for DKA.
A back-up plan for insulin gone bad or not available.
To double check insulin when taken out of the refrigerator for the “feel of the temperature” of the insulin. Do not use if hot, warm, or frozen.
To know what their insulin should look like, clear or cloudy. Avoid it if crystals, clumps or anything unusual is noted.
The onset, peak, and length of action of insulins they are taking, as well as replacements if needed.
If insulin is not available and can’t get insulin within hours, to visit the nearest ED or urgent care center.
Anonymous
Anonymous
Gavin Routledge is an osteopath from Edinburgh who seeks to raise awareness of health issues in the general population. He treats all kinds of musculo-skeletal problems but particularly low back pain. Most of us will have this at some point in our lives and for many it makes their life miserable for long periods of time.
Gavin recognises that a lot of illness is lifestyle related and that includes low back pain. If you can tackle these aspects you are less likely to get a multitude of illnesses. We understand the importance of lifestyle in the development of obesity and many cases of type two diabetes but as a GP I agree with him that back pain isn’t thought of in those terms to any degree.
By the time most people are calling on a doctor or osteopath with acute back pain, they have been sweeping a lot of issues under the carpet for a long while. Usually there is some last straw that breaks the camel’s back. Often bending down and rotating at once, often first thing in the morning is the trigger for severe pain that can take weeks to settle.
The book, Active X backs describes how your back works, how tissues respond to injury and how pain works. He describes many factors that you may need to address in your life and helps to tailor an action plan to deal with acute pain and more importantly sort out the problems that make you more likely to experience pain in the first place.
Although physical factors such as trauma, burden overload, and poor levels of physical fitness make perfect sense, many of us are oblivious about the effects of low mood, work related stress and smoking on our backs. He gives structured advice and exercises to deal with all of these and more.
The book is spiral bound so you can access the relevant exercises which are photographed and the book ends with advice on best postures to adopt for sitting, standing, sleeping and bending.
The book is £20 and the online course £39.
MY SELF STUDY OF MORNING HIGHS →
HOW TO HANDLE MORNING HIGHS and DON’T SKIP BREAKFAST
Posted on June 18, 2015
by Anna
I have posted about this issue on June 6 but now I’ve found a website that not only provides a better explanation but offers the solutions as well. It’s Diabetes Forecast. Boy, am I glad I stumbled upon it.
You wake up to blood sugar spike, as if you were eating cookies all night. This is not uncommon in people with diabetes but there are ways to get those numbers down. There are two possible things that can cause that: dawn phenomenon and waning insulin. The third possibility is Somogyi effect but this one is controversial, Diabetes Forecast states.
Whatever the cause is, the source of the BG spike is your liver. The liver is where glucose is produced and stored, and then hormones signal the liver to release glucose into the bloodstream for energy. This usually happens between meals and overnight.
With diabetes however, there is a hormone imbalance because of either an impaired insulin production by pancreas or too much of the hormones that counteract insulin. Either way, chances are that a wrong signal is sent to the liver that prompts it to pump out more glucose than it should, hence we’re having a case of an overproductive liver.
DAWN PHENOMENON or dawn effect
It takes place when your liver releases glucose in between 3 to 6am, in people with typical sleep schedule. I found out that if I go to sleep at around 10 or 11pm, this happens to me at around 3am. This is supposed to be counteracted by insulin produced by the pancreas. People with diabetes however, might not have enough insulin or they’re having an insulin resistance so their blood sugar stays elevated and continues this way into the morning.
WHY YOU SHOULDN’T SKIP BREAKFAST
Eating breakfast helps to normalize blood glucose levels; it signals to the body that it is day and time to rein in the anti-insulin hormones. It’s very important not to skip breakfast.
Some folks believe that it’s the dinner in the night before to blame for the morning spike but it’s actually a dawn effect.
WANING INSULIN
This applies to those who are taking insulin as a medication. What happens is that an evening meal could lead to higher than normal blood glucose levels in the morning after. I think by ‘evening meal’ they mean a bedtime snack. The cause may be too little mealtime insulin, waning long-acting insulin from an evening injection, or not enough overnight basal insulin through a pump. So the blood glucose levels may creep as you sleep. With waning insulin, the rise in blood glucose is typically more gradual than with the dawn effect.
SOMOGYI EFFECT
Another name for this is “hypoglycemia rebound”. It was named after a researcher who first described it.
The theory is that if a person with diabetes experiences hypo overnight, the body produces anti-insulin hormones to counteract this and bring blood glucose levels back up, the body can overdo it which leads to a morning high. It is usually described as blood glucose level taking a dip (hypo) at around 3am, and then a morning high follows.
There is a split opinion as to the mere existence of this effect. Diabetes Forecast states that it’s controversial and unproven. However some other sites claim that it does exist and back it up with their personal experiences.
WHICH ONE IS IT?
This involves some ‘detective work’ as Diabetes Forecast puts it. I personally did this for a few days. I would check my glucose at bedtime which was around 10 or 11pm, then wake up at 3am, check blood sugar, back to sleep and checked it again in the morning. It’s important to sleep about 4 to 5 hours in between blood sugar checks. Comparing the changes in blood sugar levels will help you to figure out which effect takes place.
bedtime blood sugar 3am blood sugar morning blood sugar
normal normal high DAWN EFFECT
normal high high WANING INSULIN
normal low high REBOUND (Somogyi)
WHAT ELSE YOU CAN DO
You need to discuss your morning highs with your doctor and see if he / she advises to adjust your diabetes medication or physical activity. For those using insulin pumps, you can adjust your basal rates. I don’t use a pump so can’t elaborate further.
Diabetes Forecast further states that to overcome Somogyi Effect, you should either eat a bedtime snack with some carbs and protein in it. Also discuss your target blood glucose range with your doctor.
WHAT I DID
In my case it was none of the above but a DISORGANIZED LIFE that I will discuss in my next post. After having adjusted my testing times, my morning numbers were doing fine for a while. And then boom, a spike, 111 for absolutely no reason. I figured maybe my bedtime snack was a culprit, and switched to the one with protein & low carbs. I had half a cup each of ricotta cheese and cold milk that I love. Comes next morning, my number is 103. Yay.
Gian Franco Bottazzo was born in Venice in 1946. He died there on 15 September 2017.
After graduating at the University of Padua he moved to London in 1973 to study immunology with Deborah Doniach. A year later they published their paper in the Lancet proving that type one diabetes is associated with the development of antibodies to the insulin producing pancreatic beta cells. This paper stimulated a wave of research into the immunological basis of thyroid and pituitary diseases.
Bottazzo enjoyed speaking about his research, and gave his talk the title, ” Death of a beta cell: homicide or suicide?”
As a young man, Bottazzo, nearly missed out on his medical career as he was a promising football player and came close to signing for Venezia, which was in the Premier League at the time. Fortunately he completed his studies.
For many years Bottazzo held professorial appointments in London and published on the HLA antibodies. In 1998 he returned to Italy to work as scientific director to the Baby Jesus Hospital in Rome. He leaves a wife and daughter.
BMJ 9 December 2017
Diabetes Diet 