Dietary gluten in pregnancy is related to an increased risk of type one diabetes in the child

Adapted from Antvorskov JC et al. Association between maternal gluten intake and type one diabetes in offspring. BMJ 22 September 2018

This research was based on a study of Danish women’s food frequency questionnaires completed 25 weeks after their first pregnancies ended. The incidence of diabetes in the children was then noted from January 1996 till May 2016 from the Danish Registry of Childhood and Adolescent Diabetes. After certain exclusions had been made over 63,500 were analysed.

The mean gluten intake per day was 13g ranging from 7g to more than 20g per day.

The incidence of diabetes in the child increased proportionately according to gluten intake. The women who had  20g or more intake had double the type one diabetes in their offspring compared to those who ate 7g or less.

As type one diabetes has risen seemingly inexplicably over the last few decades, there has been a lot of consideration into possible environmental triggers. Gluten is a storage protein found in wheat, rye and barley.  In animal studies, a wheat free diet in the mother has been found to dramatically reduce the incidence of diabetes in the child.

It has been suggested that gluten can affect gut permeability, gut microbiotica and cause low grade inflammation.

Although there is this association between gluten and type one diabetes it could be that other factors, for example the advanced glycation products from the baking process, that are to blame.  Unwanted additives to grain  could also be a factor eg mycotoxins, heavy metals, pesticides and fertilisers.

Mothers who eat a lot of gluten may similarly feed their children a lot of gluten. They also may pass gliadin from wheat into the breast milk.

Although this research suggests that high amounts of gluten may be problematic in pregnancy, further research will need to be done before dietary recommendations are likely to be changed.

CrossFit: exercise, diet and research

CrossFit is a website which you may enjoy visiting.

In one site you can find detailed exercise advice, often in the form of videos, for strength training, recipes, and research findings related to health and dietary composition.

There is information on the low carb diet, which is particularly helpful for those with diabetes, who wish to lose body fat, or who wish to reduce their cardiovascular risk.

Lectures by a wide variety of speakers are also included.

https://www.crossfit.com/essentials

Metformin improves side effects of steroid treatment

From Pernicova I et al. Lancet Diabetes Endocrinol 25 Feb 2020

Long-term glucocorticoids, most often prednisolone, are prescribed for about 3% of European adults. The long term exposure can raise metabolic, infectious and cardiovascular risks.

This was a trial of 53 adults who had inflammatory disease treated with prednisolone but did not have diabetes, who were given either 12 weeks of metformin or a placebo.

The dose of prednisolone was 20mg or more for the first month and then 10mg or more for the next 12 weeks. The dose of metformin given was up to 850mg three times a day.

What improved:

Facial fatness was in seen in 52% of the placebo group but only 10% in the metformin group.

Increased blood sugar was seen in 33% of the placebo group and none of the metformin group.

There was improvement in insulin resistance, beta cell function, liver function, fibrinolysis, carotid intima media thickness, inflammatory parameters and disease activity severity markers in the metformin group.

There were fewer cases of pneumonia, moderate to severe infections and all causes of hospitalisation for adverse events in the metformin group.

What got worse:

Diarrhea was worse in the metformin group.

What didn’t get better:

Visceral to subcutaneous fat ratio was unchanged between the groups.

My comment: Looks like a clear winner for adding metformin to long term prednisolone treatments.

Should you get tested for coeliac?

From Allergy and Autoimmune Disease for Healthcare Professionals October 9 2019

Apparently 70% of people who have coeliac have yet to be tested for it.

Who may have it?

4.7% of those with irritable bowel syndrome.

20% of those with mouth ulcers.

8% of infertile couples.

16% of type one diabetics.

7.5% of first degree relatives of people with coeliac.

About 50% of people who are diagnosed have iron deficiency diagnosis  at the time of coeliac diagnosis.

Other people who need to be tested may have:

Pancreatic insufficiency

Early onset osteoporosis or osteopenia

vitamin and mineral deficiencies

gall bladder malfunction

secondary lactose intolerance

peripheral and central nervous system disorders

Turner’s syndrome

Down’s syndrome

Dental enamel defects

persistent raised liver enzymes of unknown cause

peripheral neuropathy or ataxia

metabolic bone disorders

autoimmune thyroid disease

unexplained iron, vitamin D or folate deficiency

unexpected weight loss

prolonged fatigue

faltering growth

second degree relative with coeliac disease

My comment: I had years of  the mouth ulcers, iron deficiency anaemia and irritable bowel symptoms which all resolved completely on a wheat free diet. The problem is that if I did want tested I would need to go back on wheat for a minimum of six weeks to give my antibodies a chance to build up sufficiently to test positive.  Thus, best to get a test BEFORE you go on a wheat free diet.

 

 

Dr Michael Eades: Omega 6 fats make you fat way beyond their caloric value

There is a hypothesis gaining ground which is that the omega 6 fats in vegetable oil disrupt metabolism and promote fat gain way beyond their simple caloric value.

Dr Michael Eades explains the epidemiology which suggests that this is the case and then the biochemistry which provides a plausible explanation.

This video is 45 minutes long and is quite technical in parts.

 

Abstract and video here:

https://denversdietdoctor.com/dr-michael-eades-a-new-hypothesis-of-obesity/

 

 

 

 

NICE: Blood Pressure Update

From Diagnosis and management of hypertension in adults. NICE guideline update 2019

BJGP Feb 2020 by Nicholas R Jones et al.

The last update by NICE was in 2011. The key changes are explained in this article.

High blood pressure is blood pressure over 140/90 if measured in the clinic.

Home measurements can be more reliable due to a natural rise in blood pressure in the clinic setting. Ambulatory monitoring can be done, but it is not always available or tolerated. My comment: The machine can be very uncomfortable and disrupts sleep. 

To take your blood pressure at home, take two readings, one minute apart, twice a day for 4 to 7 days.  Don’t count the first days readings. Then take the average of the others.

Hypertension is diagnosed if the average of home or ambulatory monitoring is over 135/85.

The BP should be taken standing for those people over 80, who have type two diabetes and if you have postural hypotension. You need to stand for at least a minute before taking the blood pressure and it is best to avoid talking. 

A blood pressure difference between the arms of over 15 mmHg is a marker for vascular disease. Thereafter the arm with the highest measurements should be chosen for monitoring.

Urgent admission is needed if the bp is over 180/110.

Target organ damage is assessed with looking at the retina, urine testing, U and E and eGFR, ECG and a cardiovascular risk score such as QRISK. Check up should be annually.

Lifestyle advice should be emphasised as this can result in taking fewer drugs.

People with blood pressures over 140/90 at the clinic or 135/85 who are aged 60 to 80 are currently advised to have treatment for their blood pressure. People over the age of 80 are fine with blood pressure targets lower than 150 systolic.

The treatment target for people with diabetes is now 140 systolic which is now the same as the general population.

The drugs to treat hypertension are:

ACE or ARB if type 2 diabetes, age under 55 or African or Caribbean origin.

The next step is to add a calcium channel blocker or thiazide like diuretic.

The next step is a combination of ACE or ARB, CCB and Thiazide.

If the potassium is less than 4.5, Spironolactone can be added as a next step.

If the potassium is over 4.5 then an alpha or beta blocker.

For all other patients the first step is a CCB or Thiazide. 

The next step is an ACE, ARB or Thiazide.

Then any combination of these.

If the potassium is under 4.5 then spironolactone can be added.

If the potassium is over 4.5 then an alpha or beta blocker can be added.

 

Fitter, better, sooner

From BJGP May 2020 by Hilary Swales et al.

Having an operation is a major event in anyone’s life. There is a lot a patient can do to improve their physical and mental health before surgery that will improve their recovery and long term health.

Fitter, better, sooner is a toolkit was produced by the Royal College of Anaesthetists with input from GPs, surgeons and patients.

The toolkit has, an electronic leaflet, an explanatory animation and six operation specific leaflet for cataract surgery, hysteroscopy, cystoscopy, hernia, knee arthroscopy and total knee joint replacement.

These can be seen at: https://www.rcoa.ac.uk/patient-information/preparing-surgery-fitter-better-sooner

The colleges want more active participation with patients in planning for their care.

The most common complications after surgery include wound infection and chest infection. Poor cardiorespiratory fitness worsens post op complications. Even modest improvement in activity can improve chest and heart function to some extent.  Keeping alcohol intake low can improve wound healing. Stopping smoking is also important for almost all complications. Measures to reduce anaemia also reduce immediate and long term problems from surgery and also reduce the need for blood transfusion. Blood transfusion is associated with poorer outcomes particularly with cancer surgery. HbA1Cs over 8.5% or 65 mmol/mol causes more wound complications and infections.  Blood pressure needs to be controlled to reduce cardiovascular instability during the operation and cardiovascular and neurological events afterwards.

This toolkit is already being used in surgical pre-assessment clinics but access to the materials in GP practices will also help. After all, the GPs are the ones who are initially referring the patients for surgery, and improving participation early can only be helpful.

It is hoped that this initiative will result in patients having fewer complications, better outcomes from surgery but also from their improved lifestyle.

 

Take your blood pressure pills at night

Adapted from BMJ Take anti-hypertensives at night says study. Susan Major 2 Nov 19

Taking your blood pressure medication at night gives you better blood pressure control and nearly halves cardiovascular events and deaths compared to taking them in the morning.

This study was done on nearly 20 thousand patients with an average age of 60 for six years. The reductions in events included cardiovascular death, heart attacks, coronary artery revascularisation, heart failure and stroke.

Professor of cardiovascular medicine at Sheffield, Tim Chico said, ” As taking medications at bedtime poses little risk there is enough evidence to recommend that patients consider taking their medication at bedtime.”

Bariatic surgery doubles congenital abnormalities in babies

From BMJ 30 Nov 19

A retrospective analysis from Quebec of 2 million pregnant women who had delivered between 1989 and 2016 showed that offspring of women who had become pregnant after bariatric surgery had roughly twice the risk of birth defects compared to women who were not obese or who were obese but had not had surgery.

The defects were mainly heart and musculoskeletal defects.

My comment: This short report does not go into possible causes for this. You would have thought that the risk would have been reduced to the level of the non obese women. I wonder if nutritional issues have a part to play as after bariatric surgery long term vitamin supplements need to be taken. 

Your brain needs 50g of glucose a day

Adapted from Richard Feinman’s Nutrition in Crisis 

We have all heard NHS dieticians and diabetologists telling us that we will die of brain failure or get severe brain damage when we go on low carb diets because the brain needs 130g of glucose a day.

We will typically remind them that the glucose does not need to be ingested since our livers are perfectly able to manufacture well over 130g of glucose a day, the process called gluconeogenesis.

Richard Feinman is a cell biologist and he has an even finer retort.

The 130g of glucose a day necessity was discovered by George Cahill. This was the amount of glucose that a brain uses in normal nutritional states. It is indeed the case that this glucose can be ingested or manufactured in the liver or both.

Under starvation conditions however, the brain will only use 50g of glucose a day.  In starvation, the utilisation of ketone bodies becomes more important for brain function.

Unfortunately, nutritionists picked up on the 130g of glucose a day message and have been repeating it ever since. Cahill is reported to have said that by the time he was aware of the simplified but inaccurate message, it was too late to stop it.

Thus, it is not always true that you need 130g of glucose a day for brain function and it is never true that this must be from dietary carbohydrate.

So, if you get the old chestnut thrown at you, you know what to say now!