Eating carbs last gives lower blood sugar spikes

From IDDT newsletter December 2018

A report in BMJ Open Diabetes Research and Care Sept 2017 shows that in type two diabetes, eating sugar and starch later in the meal halved the blood sugar spike after the meal compared with those who ate the sugar and starch first.

This study was done on 16 people who ate test meals of protein, vegetables, bread and orange juice. Those who were instructed to eat the bread and juice last also had 40% lower post meal glucose levels compared to those who ate all of the meal components in a mixed fashion.

My comment: This is a small study but easily reproducible with yourself and your blood glucose meter. If you do wish to eat sugar and starch best have these last, unless you are treating a hypo.

 

 

More fat = more kidney failure

From BMJ 12th January 2019

Chang AR et al The CKD Prognosis Consortium BMJ 2019;364:k5301

Between 1970 and 2017 a huge number of people were assessed for fatness using body mass index, waist circumference and waist to height ratio. The outcome was that the fatter you get, the more your kidney function declines. This was true whether you started off  with normal or impaired kidney function.

The lowest kidney disease was seen in those with a BMI of 20 and this barely changed till a BMI of 25 was reached. After this was a linear progression. By the time your BMI is 40, you have double the risk of kidney function impairment.

The results were adjusted for age, sex, race and current smoking.

My comment: This is a new risk factor for obesity as far as I know.

 

 

 

Hypoglycaemia: the neglected complication

Adapted from Hypoglycaemia: the neglected complication by Sanay Kalra et al.

Indian J Endocrinol Metab. 2013 Sep-Oct; 17(5): 819-834

Hypoglycaemia is an important complication of glucose lowering therapy in patients with diabetes mellitus. Attempts made at intensive glycaemic control invariably increases the risk of hypoglycaemia. A six fold increase in deaths due to diabetes has been found in patients with severe hypoglycaemia compared to those not experiencing severe hypoglycaemia.

Repeated episodes can lead to hypoglycaemia unawareness. Complications  of hypoglycaemia include stroke, heart attacks, cognitive dysfunction, retinal cell death and loss of vision. Apart from this there are the effects on quality of life regarding sleep, driving, employment, exercise and travel.

To maintain good glycaemic control, minimize the risk of hypoglycaemia and thereby prevent complications, there are steps that need to be taken: recognise risk factors for hypoglycaemia, use appropriate self monitoring of blood sugar, select treatment regimens that have little or no risk of incurring hypoglycaemia and teach health care professionals and patients how to avoid hypoglycaemia.

Although the DCCT showed that complications were reduced when blood sugars were brought under a HbA1C of 7%, other trials have noted a three fold risk of hypoglycaemia when the level is reduced under 6.5%. This tends to negate any improvements in long term complications.

Insulin users are most at risk. Those who have had diabetes for more than 15 years are particularly at risk. The DARTS study showed that the risk of severe hypoglycaemia was 7.1% for type one patients, 7.3% for type two patients and 0.8% for type twos on sulphonylureas. This causes increased cost for their healthcare as hospitalisation for around a week is needed in the average case.

The majority of hypos are due to medications but there are other potential causes such as: pancreatic or islet cell tumours, dietary toxins, alcohol, stress, infections, sepsis, starvation and excessive exercise.

In diabetics not eating enough food was the most common cause. Others were physical exercise, insulin miscalculation, stress, overtreating a high blood sugar, and impaired glycaemic awareness.

Nocturnal hypoglycaemia is seen in half of diabetic children, particularly under the age of 7. Dead in bed syndrome causes 5-6% of all deaths in type one youngsters.  Contributory factors are increased exercise that day or delayed meals.

In type two patients additional causative factors are alcohol ingestion and liver disease and duration of insulin over ten years. As in type ones there tends to be more hypoglycaemic unawareness as the person ages. In type twos  there is a 9 fold increase in deaths in those with hypoglycaemic unawareness.

Severe hypos in elderly patients increase the risk of dementia, functional brain failure and cerebellar ataxia. There are clear signs of neuronal death in specific brain areas at post mortem in these patients and a history of fits make these more extensive.

Hypos in elderly patients promote cardiac ischaemia. Arrhythmias are more likely due to catecholamine release during hypos. Prolonged QT intervals lead to increased heart rate, fibrillation and sudden cardiac death.  Inflammatory cytokines are released during hypos, abnormalities of platelet function and the fibrinolytic system occur.

Hypos can cause double vision, blurred vision and dimness of vision.  Blindness can occur due to retinal cell death.

Recurrent hypos make people feel powerless, anxious and depressed. Acute hypos cause mood swings, irritability, stubbornness and depression.  Quality of life scores are worse in patients with recurrent hypos.

Driving ability is affected by hypos. The affected driver can inadvertently cross lanes and speed and generally drive worse.

Hypos at night may be recognised by sleep disturbance, morning headaches, chronic fatigue and mood changes. In young children fits and bed wetting may occur.

Hypos at work can be awkward, embarrassing and frightening. Hypos are particularly dangerous for those who work at heights, underwater, on railway tracks, oil rigs, coal mines, handling hot metals or heavy machines.

Expert medical advice and planned action counselling can help workers. So can self blood glucose testing, healthy food options in canteens, flexible meal times, arrangements to carry and use emergency glucose/sugar, storage and disposal sites for medications and sharps, and time off for medical appointments. Work time and productivity due to hypos can be reduced and nocturnal hypos can also have a knock on effect the next day.

Hypos in children tend to be increased in summer months when they are more active. In adults, intense prolonged exercise following an episode of recent severe hypoglycaemia can damage skeletal muscle and the liver and can cause severe neurological symptoms.

Travelling long distances, particularly over times zones can cause insomnia, tiredness, stress, reduced appetite, nocturia,  gastric disturbance, muscle aching and headaches. Psychological symptoms include low mood, irritability, apathy, malaise, poor concentration. These deficits in both physical and mental performance can profoundly affect decision making.

The fear of hypos can affect patients more profoundly than the fear of long term complications.  Withholding of insulin can occur. Sometimes patients refuse to start it when they need it and sometimes they miss out their doses.

About 30% of type one patients are affected by hypoglycaemia unawareness and under 10% of type two patients are thus affected. Duration of insulin use is the main common factor.

Educating patients about how to detect, treat and prevent hypoglycaemia must be understandable to the patient and their family.

In 2013 the ADA recommended that insulin users test their blood sugars 6-8 times a day.

Basal insulin needs to be matched to the patients needs. If hypos persist, particularly overnight, switching to pump therapy may help.

Newer diabetic medications, which do not cause low blood sugars such as the gliptans and gliflozins, may be preferable in type two patients who have multiple co-morbidities, are elderly,  who live alone, are at high risk of falls, and who have hypoglycaemia unawareness or who otherwise could not effectively deal with a hypo.

 

 

 

Dietary calcium doesn’t make your bones stronger after all

Although it is current practice to prescribe vitamin D and calcium together, particularly in post menopausal women, a six year study shows that the added calcium has no value.

The women were all over the age of 65 and had osteopenia. This is the stage before osteoporosis. 1,994 women were randomised to take zolendronic acid or placebo.  Bone mineral density was measured at the spin, total hip, femoral neck and total body three times at intervals.

The baseline BMD was unrelated to dietary calcium after controlling for age, height, weight, physical activity, alcohol intake, smoking and past HRT use when a cross section of women were studied.

Loss of BMD over the next six years was not related to the amount of dietary calcium ingested.

Bristow SM et al. Dietary Calcium intake and bone loss over six years in osteopenic post menopausal women. J Clin Endocrinol Metab. 2019 Mar 21.

My comment: Maybe time to ditch the calcium?

And while we are on the subject of bones, I’m pleased to say that another study has shown that high dose vitamin D supplementation does NOT increase kidney stone risk.

Over just over 3 years of taking 100,000 iu of vitamin D3 each month did not increase excess calcium in the blood or the onset of kidney stones in adults aged between 50 and 84 years.

This dose is equivalent to 3300 iu vit D3 a day, similar to what many of us in the know take.

158 people took part in the randomised trial. The number of people developing kidney stones was similar in each group and no one in the intervention group developed hypercalcaemia.  The groups self reported stones. No ultrasound was done which the authors say could have been more accurate.

Malihi Z et al. Monthly high dose vitamin D supplementation does not increase kidney stone risk or serum calcium: results from a randomised controlled trial. Am J Clin. Nutr. 2019 Apr 21

 

Matthew’s Friends: a lifeline for epileptic patients

The charity Matthew’s Friends was set up by Emma Williams whose son Matthew got a great improvement in his epilepsy which did not respond to drugs but did respond to a ketogenic diet.

The charity aims to promote the ketogenic dietary option as an adjunct or alterative to drugs in children or adults whose epilepsy control is sub optimal. The hassle of following the diet often becomes much more preferable to facing a daily struggle with unpredictable and dangerous fits.

The website, Matthew’s Friends#KetoKitchen You Tube channel gives free ketogenic recipes, demonstrations and tutorials, which can be a great help to those embarking on ketogenic or low carb diets, including many diabetics. 

Professor Helen Cross from Great Ormond Street Hospital writes: Epilepsy affects 1% of all children, and in 25% of cases  there are continued fits despite considerable effort with medication. This can affect physical and mental ability, learning and behaviour. This not only affects the child but their family. The ketogenic diet has been used for almost one hundred years to treat epilepsy. There are different versions of the diet. The long chain triglyceride diet, the more liberal medium chain triglyceride diet, the modified Atkins and Low Glycaemic index diet. The best diet for an individual will be developed with the help of qualified and trained ketogenic dieticians in conjunction with the family. Such help is essential. In 60% of people who are resistant to anti-epileptic drugs, they respond, at least  to some extent to a ketogenic diet.

A three month trial of the ketogenic diet is advised to see if there is a response or not.In many cases, the response is so marked that medication can be stopped entirely. Obviously, direct clinical supervision is mandatory.

Matthew’s Friends can advise parents or people who would like to improve their epilepsy and provide contacts and materials to get started on an appropriate ketogenic diet. They are always grateful for donations to further their work.

Chief Medical Officer Scotland: Vitamin D supplementation

From letter from Dr Catherine Calderwood Chief Medical Officer Scotland 
24 November 2017

New Recommendations on Vitamin D Supplementation

Vitamin D plays an important role in maintaining bone health throughout life. Vitamin D deficiency impairs the absorption of dietary calcium and phosphorous. This can lead to:
 Infants having muscle weakness and bone softening leading to rickets;
 Adults having muscle weakness and osteomalacia, which leads to bone pain and tenderness.
The most recent National Diet and Nutrition Survey shows that a proportion of the UK population has low vitamin D levels, which may put them at risk of the clinical consequences of vitamin D deficiency.
Last year, the Scientific Advisory Committee on Nutrition (SACN) made new recommendations on vitamin D and health.  The full report is available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/537616/SACNVitamin_D_and_Health_report.pdf

SACN considered all relevant evidence suggesting links between vitamin D and various health conditions and concluded that the risk of poor musculoskeletal health (e.g. rickets, osteomalacia) is increased with low vitamin D levels. SACN found insufficient evidence to draw firm conclusions on the impact of low vitamin D levels for non-musculoskeletal health outcomes.
The Scottish Government has now updated its advice on vitamin D in line with the new SACN recommendations as follows:

Everyone age 5 years and above should consider taking a daily supplement of 10μg of vitamin D, particularly during the winter months (October – March). Between late March/early April and September, the majority of people aged 5 years and above will probably obtain sufficient vitamin D from sunlight when they are outdoors, alongside foods that naturally contain or are fortified with vitamin D.
From October to March, everyone aged 5 and over will need to rely on dietary sources of vitamin D. Since vitamin D is found only in a small number of foods, it might be difficult to get enough from foods that naturally contain vitamin D and/or fortified foods alone.

Children aged 1 to 4 years of age should be given a daily supplement containing 10μg vitamin D. We recommend Healthy Start vitamin drops for all children in health.

A new-born baby’s vitamin D level depends on their mother’s levels near the birth and will be higher if the mother took a vitamin D supplement during pregnancy. Some mothers and babies have a higher risk of vitamin D deficiency, including those born to mothers who habitually wear clothes that cover most of their skin while outdooors and those from minority ethnic groups with dark skin such as those of African, African-Caribbean and South Asian origin.
However, as a precaution, we are now recommending that all babies from birth up to one year of age should be given a daily supplement of 8.5 to 10μg vitamin D. Babies who are formula fed do not require a vitamin D supplement if they are having at least 500ml per day, as infant formula already has added vitamin D.
We recommend Healthy Start vitamin drops for infants. Neonatologists and paediatricians may recommend alternatives for premature infants, children with clinical conditions or clinical presentations of vitamin D deficiency.
Advice for parents on vitamin D supplementation for breastfed babies must be carefully considered as there is a risk that infant formula could be viewed as superior to breastmilk. Breastfeeding is the normal way to feed infants. It has an important and lasting impact on the public health of the population and it is vital that we protect and support breastfeeding. It is recommended that you emphasise that the potential problem is related to a lack of sunlight in the UK, and that it affects the whole 
population, not just breastfed babies.
It is recommended that those at greatest risk of vitamin D deficiency take a daily supplement all year round. These groups include:
pregnant and breastfeeding mothers
 children under 5 years of age
 people who are not exposed to much sunlight, such as frail or housebound individuals, or those that cover their skin for cultural reasons; and
 people from minority ethnic groups with dark skin such as those of African, African-Caribbean and South Asian origin, because they require more sun exposure to make as much vitamin D.
General information leaflets on vitamin D for both the public and healthcare professionals have been updated to reflect these new recommendations and are available online at: http://www.gov.scot/Topics/Health/Healthy-Living/Food-Health/vitaminD
New guidance has been developed for parents and healthcare professionals to support parents to follow this new recommendation. This includes advice on how to administer vitamin D drops to young babies. It is available at:
http://www.gov.scot/Topics/Health/Healthy-Living/Food-Health/vitaminD
From April 2017, Healthy Start vitamins for women (which provide Vitamin D, folic acid and Vitamin C) are provided free of charge to all pregnant women in Scotland for the duration of their pregnancy, regardless of their entitlement to the Healthy Start scheme.
Breastfeeding women and children up to age 4 who are eligible for Healthy Start can also get free supplements containing vitamin D. Further information on the Healthy Start scheme can be found at http://www.healthystart.nhs.uk
Healthy Start vitamin drops for babies and children currently contain 7.5μg per 5 drops of vitamin D, as well as vitamin A and vitamin C. The new recommended dose for vitamin D is 8.5-10μg and vitamins containing the new recommended dose will be available from October 2018. In the meantime, parents should be advised to continue to give the current dosage of 5 drops per day.
In Scotland, NHS Boards are responsible for supplying Healthy Start vitamin supplements universally to pregnant women and to breastfeeding women and children who are eligible for the Healthy Start scheme. NHS Boards are also able to sell Healthy Start vitamins to families who are not eligible for Healthy Start. Some Health Boards have chosen to provide additional free vitamins for infants.
We are not currently in a position to extend universal provision of vitamin supplements to the whole of the Scottish population or to additional at risk groups including the elderly, women in the pre-conception period, infants or young children.
Vitamin D supplements for adults and children are also available to buy from most major supermarkets, high street pharmacies and health food stores.

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Liraglutide can improve fatty liver damage as well as blood sugars

Adapted from Glucagon like peptide-1 receptor agonists for the management of obesity and non-alcoholic fatty liver disease: a novel therapeutic option. 

Gauri Dhir and Kenneth Cusi  Endocrinology/Metabolism Review Volume 66 Issue 1 2018

Obesity is a major risk factor for type two diabetes and a cluster of metabolic factors that lead to poor cardiovascular outcomes.  The amount of fat stored in the liver tissue closely mirrors insulin resistance and metabolic health.

Non alcoholic fatty liver disease (NAFLD) is now the commonest form of liver disease in the western world and can lead progressively to non alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma.

NAFLD is present in two thirds of obese people and promotes type two diabetes.  NASH is present in half of these. NAFLD is expected to become the most common cause of liver transplantation by 2020.

Pioglitazone and the newer drugs such as Liraglutide (Victoza) can be used, as well as various dietary therapies.

If a weight loss of 10% can be achieved, there is a significant improvement in the inflammatory process that results in cell death and fibrosis in NASH. But weight loss is difficult to achieve and maintain.  Pioglitazone can improve  NASH in two thirds of non- diabetic patients and by around half in those with diabetes or pre-diabetes.  Vitamin E has also been shown to have some success in non diabetic patients.

Liraglutide and drugs of the same class affect insulin secretion in response to meals, beta cell proliferation, inhibition of glucagon secretion, delayed gastric emptying, and making you feel fuller with less to eat.

These effects result in worthwhile clinical outcomes in overweight or obese patients whether they have diabetes or not. Body weight is reduced by at least 5% in 30% of patients and by at least 10% in 30% of patients. Over three years this can result in complete remission of the diabetes or pre-diabetes in 30% of the patients. Cardiovascular outcomes are also improved.

Triglyceride accumulation in the liver cells is the mechanism that has been recently shown to cause insulin resistant adipose tissue.  After 48 weeks of high dose Liraglutide (1.8 mg a day), resolution of NASH was seen on biopsy samples in 39% of the treated group compared to 9% in the placebo group.

The main side effects are nausea and diarrhea.  There could possibly be more gallstone development but no increase in pancreatitis.