The best diet for optimal blood sugar control & health
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!
From Diabetes in Control
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:
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
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.
Hear, hear!
It seems after declaring my commitment to running a half marathon in my post last week, the world knew I would be in need of some inspiration. Devastatingly it came in the form of a press release from Beyond Type 1, a juvenile diabetes charity I recently became involved with. “In 2017 funding for Type 1 diabetes clinics in Uganda and neighboring African nations will stop flowing.” I don’t know why this took me by surprise, cuts have been happening in low developed countries for years now, this is just another government cut. However, I then saw a campaign flyer from The Sonia Nabeta foundation, a charity which works to raise money for these much needed cases.
The post put it simply that $40 would provide a child with access to 3 HbA1c, Creatinine and Lipid profiles a year. This test shows your average blood sugar over a period of time. These numbers…
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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.
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.
What apps do you use to help you with your diabetes? There are specialised apps you can use (free and paid for) created for diabetics and other general health apps that are useful.
I’m a bit of an app nerd. Gathering data on yourself is fascinating. And it can be very revealing. Here are the apps I use:
This is primarily a food diary that allows you to track macros, micros and calorie counts. You can also use it to look up carbohydrate values. It is useful because the database of food it has is huge. If you mainly eat unprocessed, home-made food it will require more work, but you can enter recipes and it will give you a calorie/carb count for them. Ignore the silly numbers (1,200 calories!) they suggest and customise your numbers to suit.
Created especially for diabetics (and run by them too), this app allows you to log blood sugar levels, how much insulin you take, exercise, how you feel and more. I use it intermittently as inputting all the information can get tedious. If you forget to log for a day or so, it’s difficult to remember. Some blood testing meters can be connected, which would make logging easier.
Thanks to mysugr, I worked out how to fine tune how much insulin I need to cover food (it varies depending on the time of day) and the best time for me to take my bolus insulin.
Pacer is a pedometer. My main form of exercise is walking and it’s great to know that I can achieve the recommended 10,000 steps relatively easily. It also tells you the distance you walk or run every day and you can use it to see weight loss goals. Be warned: this app drains your battery quickly.
All the above apps are free – though you can upgrade to premium versions. The free versions give enough information for this not to be necessary.
If you are in the slightest OCD, an app will encourage such behaviour so check yourself if you get uptight when you’re in an area where there no coverage or wi-fi… When that absence is too upsetting, step away from the app for a while.
What apps do you use for your health?
Dr Lois Jovanovic from Santa Barbara is an expert in getting great results with diabetic women in pregnancy. This video series from Diabetes in Control covers in depth interviews with Lois. Even if you are not pregnant or intending to be you can pick up information on how to get excellent blood sugar control in these videos.
Lois Jovanovic, MD, is Clinical Professor of Medicine, University of Southern California-Los Angeles Medical Center. Consultant: Hyperglycemia in Pregnancy. Dr. Jovanovic is an international expert, multiple award winning endocrinologist, in the research and clinical management of diabetes. She specializes in the ages and stages of women with diabetes, and hyperglycemia in pregnancy.
If you prefer to view the entire video, click here.
To view other segments in this video:
Part 1; Taking Care of Diabetes in Utero
Part 2: Low Carb Diets for Pregnant Women
Part 3: Insulin Dosage During Pregnancy
Part 4: What’s Healthy for Mothers and Babies
Part 5: Prevalence of Glucose Intolerance in Pregnancy
Part 6: One-Step Test for Glucose Intolerance
Part 7: The Artificial Pancreas and Pregnant Women
Part 8: Use of Insulin Pumps in Pregnancy with Type 1
Part 9: Managing Blood Sugar During Pregnancy
Part 10: What is “Normal” A1C in Pregnancy?
Part 11: Think Pregnancy First
Part 12: Prediabetes and Gestational Diabetes
Part 13: Limitations of Fasting Bloodwork
Part 14: Centers of Excellence for Diabetes and Pregnancy
Part 15: Risks of Poor A1C Control in Pregnancy
Part 16: Exercise During Pregnancy
For many years, I have focused on aspects of lifestyle and health management that can enhance quality of life, especially when living with a chronic disease like diabetes, rather than simply on living a long time (longevity). Much of my motivation is derived from the personal experience of watching my maternal grandmother suffer through six (long) years of severe disability related to cardiovascular complications of diabetes starting at the age of 70 that left her unable to feed herself or communicate, bed bound, and with almost no quality of life for her final six years of life. Really, what is the point of simply being alive when you’re really not experiencing life under such conditions?
This topic has come up again recently. New research published online ahead of print in Diabetologia in Spring 2016 (1) presented results showing that the life expectancy and disability-free life expectancy (with 95% uncertainty interval) at age 50 years were 30.2 and 12.7 years, respectively, for men with diabetes, and 33.9 and 13.1 years for women with diabetes. Really think about what those estimates mean: If you’re female and have diabetes at age 50, you would be expected to live almost to age 84, but likely be disabled in some way from the age of 71 forward. If the disability is severe (as in the case of my stroked-out grandmother), then that is a lot of pointless years of being alive without really living, not to mention the cost of caring for someone with medical disabilities that could be a huge burden to your family and the health care system.
Admittedly, that’s pretty discouraging. The best solution may be to focus on what we can do to prevent disability as we age rather than simply living longer, especially with diabetes. Here are three proven ways to improve your quality of life with diabetes (and likely your longevity):
1. Exercise regularly and be more physically active overall.
Even if you already have some diabetes-related health issues like peripheral neuropathy, which can negatively impact quality of life, exercising regularly can help. In a small study on older adults with diabetes and neuropathy, engaging in just 8 weeks of moderate-intensity aerobic exercise was shown to be a cornerstone in improving their quality of life, including experiencing less pain, more feeling in their feet, less restriction in their activities of daily living, better social interactions, and a greater overall life quality—just after 8 weeks of training (2). Other types of physical activity have similar and profound effects on living well with neuropathy (3), so choose the activities that you enjoy doing the most and start with those.
2. Eat more fiber, found abundantly naturally in plant-based foods.
We all know we should be eating more fiber, but where can you find it (besides in Metamucil, which may not have the same health benefits)? Look for it in plant-based foods, mainly fruits, vegetables, grains, beans, and nuts and seeds. Why can it enhance your health and quality of life? Dietary fiber and whole grains contain a unique blend of bioactive components including resistant starches, vitamins, minerals, phytochemicals, and antioxidants, all of which are critical to healthy living. A higher fiber intake helps prevent or protect against many of the health issues that can decrease both quality of life and longevity, including certain gastrointestinal diseases, constipation, hemorrhoids, colon cancer, gastroesophageal reflux disease, duodenal ulcer, diverticulitis, obesity, diabetes, stroke, hypertension, and cardiovascular diseases (4). It also keeps the healthful gut bacteria in your digestive tract more abundant, which directly can benefit health and even prevent obesity. Aim for as much as 50 grams of fiber in your daily diet for optimal health.
3. Improve the quality and quantity of your sleep.
Both sleeping better and sleeping adequate amounts (7 to 8 hours a night for most adults) lower insulin resistance and can help improve diabetes control; alternately, not getting enough good sleep can make your blood glucose levels much harder to manage effectively. As you age, it may require taking a melatonin supplement to help you fall asleep and may help improve diabetes control (5), but exercising regularly certainly assists in both as well, so try taking your daily dose of exercise to optimize sleep.
Get started on these three easy changes today to improve your chances for living longer without disabilities. Remember, there’s more to life than living a long time. What’s the point of living longer if you can’t live well and feel your best every day of your life? It really is your choice to make because you can affect the outcome.
References cited:
1.Huo L, et al. “Burden of diabetes in Australia: life expectancy and disability-free life expectancy in adults with diabetes” Diabetologia 2016; DOI: 10.1007/s00125-016-3948-x.
2.Dixit S, Maiya A, Shastry B: Effect of aerobic exercise on quality of life in population with diabetic peripheral neuropathy in type 2 diabetes: a single blind, randomized controlled trial. Quality of Life Research 2014;23:1629-1640
3.Streckmann F, Zopf EM, Lehmann HC, May K, Rizza J, Zimmer P, Gollhofer A, Bloch W, Baumann FT: Exercise intervention studies in patients with peripheral neuropathy: a systematic review. Sports Med 2014;44:1289-1304
4.Otles S, Ozgoz S: Health effects of dietary fiber. Acta Scientiarum Polonorum Technologia Alimentaria 2014;13:191-202
5.Grieco CR, Colberg SR, Somma CT, Thompson A, Vinik AI: Melatonin supplementation lowers oxidative stress and improves glycemic control in type 2 diabetes. International Journal of Diabetes Research, 2(3): 45-49, 2013 (doi: 10.5923/j.diabetes.20130203.02)
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.
by Dr. Sheri Colberg, Ph.D., FACSM
Published in Diabetes in Control 2nd July 2016
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