Kris Kresser: Lesser known symptoms of wheat intolerance

The Symptoms of Gluten Intolerance You Haven’t Heard About
by Chris Kresser
Last updated on April 18, 2019

Brain fog, skin issues, depression, and even anemia are all symptoms of gluten intolerance.
You just don’t feel good. You’re tired and get frequent headaches, have ongoing skin issues, or struggle with depression—or all of the above. Maybe you’ve wondered if gluten could be the culprit, but because you don’t experience gastrointestinal upset, you’ve since put the thought out of your mind and haven’t mentioned anything to your doctor. Or perhaps you’ve shared your suspicion, but conventional testing ruled out celiac disease (CD) and thus, supposedly, any issues with gluten. In either case, your diet has likely stayed the same … and so have these often-overlooked symptoms of gluten intolerance.
Yes, all of the symptoms mentioned here—and many others you may not have heard about—can be signs that you have a significant degree of gluten intolerance. Even if you don’t run to the bathroom right after enjoying a plate of pasta, and even if standard lab work says otherwise, your body (and brain) may be having serious problems with gluten. Let’s explore these lesser-known symptoms and discuss if going gluten free is right for you.
You’ve heard of the havoc gluten can wreak on your digestive tract, but did you know that gluten intolerance can cause skin problems, depression, and frequent headaches? Check out this article for more symptoms of gluten intolerance you’ve never heard of.

Undiagnosed Intolerance Is More Common Than You May Think
First off, I want you to know that if you eat gluten and you feel lousy but you don’t have digestive issues—and you have tested negative for CD and been told it’s all in your head—you are not alone. In fact, undiagnosed cases of gluten intolerance are incredibly widespread. Here’s why.
As I’ve written before, wheat contains several different classes of proteins: gliadins (of which there are four different types, including one called alpha-gliadin); glutenins; agglutinins; and prodynorphins. Once wheat is consumed, enzymes in the digestive tract called tissue transglutaminases (or tTGs) help break down the wheat compound. During this process, additional proteins are formed, such as deamidated gliadins and gliadorphins (also called gluteomorphins). Stick with me here—these terms are worth knowing so that you can understand the pitfalls of conventional testing for CD.
CD is a serious form of gluten intolerance, one that can do real damage to the tissues in the small intestine (though its symptoms aren’t merely gut related). CD is characterized by an immune response to one specific gliadin (the aforementioned alpha-gliadin) and one specific type of transglutaminase (tTG-2). But people can—and very much do—react to several other components of wheat and gluten.
Therein lies the problem, because conventional lab testing for CD and gluten intolerance only screens for antibodies to alpha-gliadin and tTG-2.
If your body reacts to any other wheat protein or type of transglutaminase, even severely, you’ll still test negative for CD and intolerance.
Statistics suggest that for every one case of CD that is diagnosed, 6.4 cases remain undiagnosed—the majority of which are atypical forms without gastrointestinal symptoms; even many patients who are eventually diagnosed don’t experience an upset stomach after consuming gluten. (1)
What’s more, the distinct autoimmune response to wheat proteins and transglutaminase enzymes in the gut that defines CD is just one possible expression of gluten intolerance. The many other ways a sensitivity to gluten can affect the body are collectively referred to as non-celiac gluten sensitivity, or NCGS. Cases of gluten intolerance classified as NCGS involve both intestinal and non-digestive reactions to gluten that are not autoimmune or allergic in nature and that resolve when gluten is eliminated from the diet.
There is no definitive diagnostic test for NCGS, making it difficult to put a number on its prevalence. By some estimates, it may occur in as many as one in 20 Americans. (2) And although your doctor and plenty of others out there might still insist that NCGS doesn’t truly exist, several studies have validated it as a distinct clinical condition. (3) As I’ve explained previously, gluten sensitivity is very real. Stories painting NCGS as a collective delusion have gotten it wrong.
Decoding Your (Real) Symptoms
Gluten intolerance can affect nearly every tissue in the body, including the brain, skin, endocrine system, liver, blood vessels, smooth muscles (found in hollow organs such as the intestines), and, yes, stomach.
That’s why it can manifest either in the classic presentation of digestive distress—abdominal pain, bloating, gas, and diarrhea or constipation—or in any of the following, likely surprising, non-digestive symptoms.
Anemia
Although it’s discussed infrequently in popular articles, iron-deficiency anemia is well documented as a symptom of gluten intolerance in scientific studies. (4, 5) In fact, research suggests that it may often be the first noticeable symptom of CD and that up to 75 percent of those with an anemia diagnosis may be gluten intolerant. (6, 7) Gluten intolerance can interfere with the uptake of iron from food, causing malabsorption of this important nutrient. (8) What’s more, because anemia generally saps one’s energy, it can trigger or worsen the next non-digestive sign of gluten intolerance on this list.
Fatigue
Many gluten-intolerant individuals report feeling tired and fatigued, especially right after eating, you guessed it, gluten. (9) Research has linked NCGS to chronic fatigue symptoms in some people. (10) As with chronic fatigue syndrome, symptoms of gluten intolerance can also include muscle fatigue and muscle and joint pain.
Brain Fog
This type of cognitive dysfunction can be a sign of gluten sensitivity. Those affected often describe experiencing “foggy mind” symptoms such as an inability to focus and concentrate; some also describe feeling mentally fatigued. (11, 12)
Headaches
Headache is a frequent finding in NCGS, with one recent study reporting the symptom in more than half of its participants. (13, 14, 15) Migraine in particular is an associated symptom. (16, 17)
Eczema and Other Skin Disorders
As with fatigue, brain fog, and headaches, people with NCGS may notice a worsening of skin symptoms such as eczema, rash, and undefined dermatitis after ingesting gluten-containing foods. The most commonly reported skin lesions include those similar to subacute eczema, as well as the bumps and blisters indicative of dermatitis herpetiformis, or Duhring’s disease—to which CD is closely linked. Those who are gluten intolerant may also experience scaly patches resembling psoriasis. Lesions are typically found on the muscles of the upper limbs. (18, 19, 20)
Depression and Anxiety
One of the main reasons gluten sensitivity often goes unrecognized and untreated, researchers theorize, is because mental health issues can be a hallmark of this condition. Data suggests that up to 22 percent of patients with CD develop such dysfunctions, with anxiety and depression occurring most commonly. One study found that CD patients were more likely than others to feel anxious in the face of threatening situations, while additional research has linked conditions such as panic disorder and social phobia to gluten response. Depression and related mood disorders appear to occur with both NCGS and CD. (21, 22)
Here’s the good news: The majority of studies cited here not only investigated whether or not these symptoms are signs of gluten intolerance, but also whether or not they can be addressed by going gluten free. And it turns out, these problems improved or completely resolved with adherence to a gluten-free diet.
But more on that in a minute.
Beware These Surprising Consequences of Intolerance
While the symptoms mentioned above are what will most likely clue you in to your body’s negative response to gluten, they aren’t the only effects of intolerance to be aware of. In fact, a variety of chronic diseases may develop due to long-term CD or NCGS, including: (23, 24)
Epilepsy
Attention-deficit hyperactivity disorder, or ADHD
Autism spectrum disorders
Schizophrenia
Type 1 diabetes
Osteoporosis
Multiple sclerosis
Hashimoto’s
Peripheral neuropathy
Amyotrophic lateral sclerosis, or ALS
In one study, researchers found a strong link between gluten sensitivity and neurological complications—especially those in which the cause was unknown. (25) Research has even shown that, for some people with gluten sensitivity, the primary symptom they experience is a neurological dysfunction. (26) The data suggests that nearly 60 percent of people with neurological dysfunction of unknown origin test positive for anti-gliadin antibodies. (27)
Challenge Yourself: Do You Feel Better on a Gluten-Free Diet?
If you’re currently experiencing any of the symptoms of gluten intolerance I shared in this article and can’t seem to find relief, or if you have received a diagnosis of any of the above linked diseases or disorders and you and your doctor have not found a probable cause or resolution, gluten could very well be a trigger for you.
Because of the limitations of current testing for CD and the lack of diagnostic options for NCGS, the most reliable test for gluten intolerance is a “gluten challenge.”
This involves removing gluten from your diet completely for a period of at least 30 days—60 days is best—then adding it back in after that time has elapsed. If your symptoms and/or diagnosis improve during the elimination period and return when gluten is reintroduced, let your healthcare provider know. You have NCGS or atypical CD.
Though I consider this to be the gold-standard test for gluten intolerance, Cyrex Laboratories does offer a comprehensive blood panel that screens for all of the wheat and gluten proteins and transglutaminase enzymes discussed earlier. It can be a helpful diagnostic tool, but it shouldn’t replace a gluten challenge. (Note: It must be ordered by your physician or another healthcare provider.)
How Will You Deal with Your Symptoms of Gluten Intolerance?
If you experience improvement on a gluten-free diet and plan to continue eating this way, you can feel confident that there is no risk in terms of nutrient deficiencies to removing gluten from your diet. (28) If anything, my experience has shown me that people who eat gluten-free are more likely to increase their intake of essential nutrients, especially if they replace breads and other flour products with whole foods.
Have you experienced any of these symptoms? Are you planning a gluten challenge to determine once and for all if gluten is the culprit? Let me know below in the comments!

My comments: My anaemia, post wheat meal fatigue and brain fog, irritable bowel, and mouth ulcers all went away when I stopped wheat. And they recurred after four days of eating wheat after a long period of abstinence.  We discuss how you can meal plan and bake without wheat on this blog site and in our book.

Kris Kresser: The Carnivore Diet, is it really healthy?

The Carnivore Diet: Is It Really Healthy?
by Chris Kresser
Published on February 6, 2019

 

My comment: There has been a lot of publicity about the benefits of an all meat diet, the opposite end of the spectrum from veganism.  Dr Jordan Petersen’s daughter has overcome considerable health problems and she puts it down to an all beef diet. In this post Kris shares information, the good and the not so good about such an extreme diet.
The carnivore diet is a hot eating trend, and many people have reported significant benefits from adopting an all-meat diet. But is consuming only meat healthy in the long term? Read on to understand the mechanisms behind the diet, the potential consequences of not eating plant foods, and a few alternatives to going pure carnivore.

Is an all-meat, carnivore diet healthy? 
In my recent debate on the Joe Rogan Experience with Dr. Joel Kahn, I touched briefly on the carnivore diet. I’m a huge believer that meat is an essential part of a healthy diet, but eating an all-meat diet is an entirely different subject, and I think we need to be very careful about assuming that an intervention that works well in the short term will also be safe and effective in the long term.
In this article, I’ll discuss the diets of ancestral populations, how the carnivore diet affects the body, my concerns about the potential consequences of such a restrictive diet in the long term, and alternative dietary approaches that might offer the same benefits without having to go pure carnivore.
Are you considering going carnivore? The all-meat diet is trending, but completely dropping plant-based food off your plate could have a significant impact on your health. Check out this article for a breakdown on the strengths and weaknesses of the carnivore diet. #chriskresser

What Is the Carnivore Diet?
The carnivore diet is pretty straightforward: eat only animal foods and stay away from all plant foods. This means that you are primarily getting your energy from protein and fat and are consuming close to zero carbohydrates.
Many people who have adopted the carnivore diet report faster weight loss, improved mental clarity, healthier digestion, and even improved athletic performance. I certainly don’t doubt the anecdotal reports of people that have found remarkable relief from debilitating chronic health problems with this diet. For many of these people, nothing else they had tried worked.
However, when considering the health of a dietary or lifestyle intervention, I’ve long believed that we should look at the big picture: historical evidence from other populations, plausible mechanisms that explain its effect on our bodies, and scientific data regarding outcomes.
Were Any Ancestral Populations Carnivores?
Let’s start with a brief look at the diets of some supposedly “carnivorous” ancestral populations. Indeed, many ancestral groups thrived on large quantities of animal products. However, every single one of these groups also took advantage of plant foods when they were available:
The nomads of Mongolia nourished themselves on meat and dairy products, but also gained nutrients from their consumption of wild onions and garlic, tubers and roots, seeds, and berries. (1)
Gaucho Brazilians consumed mostly beef, but they supplemented their diet with yerba mate, an herbal infusion rich in vitamins, minerals, and phytonutrients. (2)
The Maasai, Rendille, and Samburu from East Africa primarily ate meat, milk, and blood. Young men almost exclusively ate these animal products but also occasionally consumed herbs and tree barks. Women and older men consumed fruit, tubers, and honey. (3)
The Russian Arctic Chukotka subsisted on fish, caribou, and marine animals but always ate them with local roots, leafy greens, berries, or seaweed. (4)
The Sioux of South Dakota ate great amounts of buffalo meat, but they also ate wild fruit, nuts, and seeds that they found as they followed the buffalo herds. (5)
The Canadian Inuit lived primarily on walrus, whale meat, seal, and fish, but they also went to great lengths to forage wild berries, lichens, and sea vegetables. They even fermented some of these plant foods as a way of preserving them. (6)
Every culture we know of that has been studied ate some combination of animal and plant foods. This does not necessarily mean that animal or plant foods are required to remain healthy, but it does speak to the ancestral wisdom of these cultures.
Five Reasons Why the Carnivore Diet Works
When any diet, drug, or other intervention “works,” it’s important to try to understand the mechanism behind it. In the case of the carnivore diet, there are several reasons that might explain the benefits people report.
1. The Carnivore Diet Can Restrict Calories and Mimics Fasting
Ever felt stuffed after you ate a huge steak? Protein is very satiating, meaning it fills you up and sends signals to your brain that you’ve consumed enough food. It’s no surprise that people report not feeling very hungry and start eating less frequently when they adopt an all-meat diet.
Food habituation may also play a role here. When you eat the same thing day after day, your brain doesn’t get as much reward value from food, so you start to eat less food overall—even if the food is usually something you find rewarding, like a big juicy steak.
The ultimate result is unintentional caloric restriction. Caloric restriction sets off a number of changes. When caloric intake drops, the concentration of insulin, insulin-like growth factor 1 (IGF-1), and growth hormone are significantly reduced. This condition triggers autophagy, which literally means “self-eating”—an internal process of cleaning up old cells and repairing damaged ones. Autophagy is also induced during fasting.
This may be why caloric restriction is so effective at reducing inflammation and alleviating symptoms of autoimmune disease. (7) Of course, caloric restriction also results in weight loss. These are arguably the two primary reasons that people seem to be drawn to the carnivore way of eating, but these effects might also be achieved through simple caloric restriction.
2. The Carnivore Diet Is a Low-Residue Diet
“Residue” is essentially undigested food that makes up stool. A low-residue diet is a diet that limits high-fiber foods like whole grains, nuts, seeds, fruits, and vegetables. It is often prescribed for people with inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS) to alleviate symptoms like diarrhea, bloating, gas, and abdominal pain. (8)
Meat is made primarily of protein and fat, which are absorbed high up in the GI tract, leaving little residue leftover to irritate or inflame the gut. In other words, an all-meat diet is effectively a very low-residue diet and gives the gut a rest.
3. The Carnivore Diet Is Often Ketogenic
If you’re eating large amounts of meat but are only eating once or twice a day and adding extra fat to the meat, your diet is likely ketogenic. A ketogenic diet is a high-fat, moderate-protein diet, with:
60 to 70 percent of energy from fat
20 to 30 percent of energy from protein
5 to 10 percent of energy from carbohydrates
While the carnivore diet has no such macronutrient ratios, it’s likely that some of the benefits that come with eating meat alone are due to the body being in a state of ketosis.
Ketogenic diets have been shown to be helpful for a wide variety of conditions, including multiple sclerosis, diabetes, and neurological conditions like Parkinson’s disease and Alzheimer’s. (9, 10)
4. The Carnivore Diet Changes the Gut Microbiota
Switching to an all-meat diet can also rapidly alter the gut microbiota. A 2014 study found that putting healthy human volunteers on an animal-based diet resulted in significant changes to the gut microbiota in less than 48 hours. (11) The animal-based diet increased the abundance of bile-tolerant organisms and decreased the levels of microbes known to metabolize different plant fibers.
The gut microbiota has been linked to virtually every chronic inflammatory disease that has been studied, so it’s no surprise that an intervention that drastically changes the gut microbiota could have significant implications for health. (12)
The Biggest Potential Problem with This Diet: Nutrient Deficiencies
Now that we’ve established some of the mechanisms involved, the big question is: is the carnivore diet safe?
The short answer is that we really don’t know, since there are no long-term studies that have tracked large groups of individuals on carnivore diets for any significant length of time. One of my chief concerns about it is that it lacks several nutrients that are crucial for health.
There are four micronutrients that are especially difficult to obtain on a meat-only diet. Based on a typical carnivore diet and the Dietary Reference Intakes (DRIs) established by the Institute of Medicine, these include:
Vitamin C: An antioxidant that boosts immune cell function and is important for stimulating collagen synthesis
Vitamin E: An antioxidant that prevents the oxidation of lipids and lipoproteins
Vitamin K2: A fat-soluble vitamin that reduces the calcification of blood vessels
Calcium: A mineral required for healthy bones, muscle contraction, and nerve transmission
If dairy is included in the diet, this will cover vitamin K2 and calcium. However, if you don’t like organ meats, the number of potential micronutrient deficiencies increases significantly. In that case, you can add to the list:
Vitamin A: A fat-soluble vitamin important for proper vision and maintaining immune defenses
Folate: A B vitamin important for cell growth, metabolism, and methylation
Manganese: A trace mineral needed for the proper function of the nervous system, collagen formation, and protection against oxidative stress
Magnesium: A mineral that supports more than 300 biochemical reactions, including energy production, DNA repair, and muscle contraction
It’s also important to note that vitamin C is extremely heat sensitive, so only fresh or very gently cooked organ meats will have appreciable amounts.
Many carnivore dieters claim that the nutrient requirements for the general population simply don’t apply to them. Anecdotally, I know of several individuals who have consumed a carnivore diet for three or more years without any overt signs of nutrient deficiencies.
Still, we’re lacking data. Currently, the DRIs are the best we have to go off of, and I don’t think we have enough evidence to unequivocally say that this diet has no risk of producing nutrient deficiencies in the general population.
Should We Be Aiming Higher Than the Daily Recommended Intake?
Even if the carnivore diet were sufficient to prevent outright deficiency, we should also consider metabolic reserve. Metabolic reserve is the capacity of cells, tissues, and organ systems to withstand repeated changes to physiological needs. In other words, it’s having enough nutrients “in the bank” to be able to deal with a major stressor, injury, or environmental exposure. (13) So if an all-meat dieter manages to meet a recommended nutrient intake, it still may not be enough for optimal health.
Other Reasons an All-Meat Diet May Not Be Healthy
It Lacks Beneficial Phytonutrients
Phytonutrients are chemicals that are produced by plants to protect against environmental threats, such as attacks from insects and disease. They can also have major benefits for our health. Curcumin, beta-carotene, quercetin, and resveratrol are all examples of common phytonutrients.
Some proponents of the carnivore diet suggest that phytonutrients are toxic to humans, and that it’s best to eliminate them completely from our diet. However, many of these “toxins” act as acute stressors that actually make us stronger through a process called hormesis.
Much like resistance training is an acute stressor that leads our muscles to adapt and get stronger, exposure to small amounts of phytonutrients is a hormetic stressor that activates several different pathways in the body, ultimately serving to reduce inflammation, enhance immunity, improve cellular communication, repair DNA damage, and even detoxify potential carcinogens. (14, 15)
It Might Affect Hormones, Fertility, and Thyroid Function
We have zero long-term data about how an all-meat diet impacts hormones, thyroid function, and fertility. I have written before about why carbohydrates are particularly important for female fertility and why very-low-carb diets may not be the best choice during pregnancy.
Carbohydrates are particularly important for supporting thyroid function since insulin stimulates the conversion of inactive thyroid hormone T4 to active T3. In fact, traditional cultures that ate largely animal products and had little access to plant foods often went to great lengths to support fertility, including eating the thyroid glands of the animals they hunted. (16)
My guess is that most modern “carnivores” are not consuming the thyroid glands of animals and are therefore at risk for suboptimal thyroid function and (at least temporary) infertility.
It Could Overtax Your Liver (If You’re Eating Lean Meat)
When you don’t eat sufficient carbohydrates and fat, your liver can make glucose from protein via a process called gluconeogenesis. This process creates nitrogen waste, which must be converted to urea and disposed of through the kidneys.
While this is a normal process that occurs in every human being, there is a limit to how much protein the liver can cope with safely. More than 35 to 40 percent of total calories as protein can overwhelm the urea cycle, leading to nausea, diarrhea, wasting, and, potentially, death. For pregnant women, this threshold may be as low as 25 percent of total calories. (17)
Interestingly, anthropological evidence suggests that hunters throughout history avoided consuming excess protein, even discarding animals low in fat when food was scarce. (18)
In short: When eating meat, it’s important to have a good amount of healthy fats or quality carbohydrates as well.
Is the Carnivore Diet the Ideal Human Diet?
In the last section, I outlined several potential concerns with the carnivore diet. But this leads me to another important question: even if the carnivore diet is safe, is it really the best diet for optimal health?
While you might be able to get away with a vegetarian or carnivorous diet for a short while, the evidence suggests that the ideal diet includes both animal and plant foods. Dr. Sarah Ballantyne broke this down in part three of her series “The Diet We’re Meant to Eat: How Much Meat versus Veggies.”
While you can theoretically get all of your nutrients from one group alone (and potentially supplement with any missing nutrients from the other group), we need both sets of nutrients to be optimally healthy, and consuming animal and plant foods in their whole form is the best way to accomplish this.
Five Alternatives to the Carnivore Diet
Here are some options that might provide the same therapeutic benefits that the carnivore diet can offer—but without as much potential risk.
1. A Low-Carb Paleo Diet
Some people trying a carnivore diet are going straight from the Standard American Diet to pure carnivore. Oftentimes, a low-carbohydrate Paleo template might provide some of the same benefits, including weight loss, improved insulin sensitivity, and an alleviation in autoimmune symptoms. (19, 20, 21)
2. A Fasting Mimicking Diet
A fasting mimicking diet can reverse type 1 and type 2 diabetes, alleviate age-dependent impairments in cognitive performance, and protect against cancer and aging in mice. (22, 23, 24) In humans, the fasting mimicking diet was found to significantly reduce body weight, improve cardiovascular risk markers, lower inflammation, and potentially improve symptoms of multiple sclerosis. (25, 26)
3. Periodic Prolonged Fasting
Undergoing a 72-hour fasting once every few months could also achieve many of the benefits boasted by the carnivore diet. Prolonged fasting causes organs to shrink and then be rejuvenated as damaged cells are cleared out and stem cell pathways are activated. (27)
4. A Ketogenic Diet
The ketogenic diet has been very well studied and has documented benefits for epilepsy, neurodegenerative disease, and autoimmune disease. Ketones themselves are potent anti-inflammatories. (28, 29)
5. Addressing Gut Pathologies
If a healthy lifestyle coupled with the dietary approaches above is insufficient to control your symptoms, consider working with a Functional Medicine practitioner who is knowledgeable about gut health. If you’re thinking about becoming a strict carnivore because you’re experiencing adverse reactions to even very small amounts of plant foods, that’s likely a sign of an underlying gut infection that should be addressed.
Share this with friends and family who might be considering an all-meat diet, and be sure to leave your thoughts in the comments below.
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BMJ: Flu jag timing matters

From BMJ May 2019: Minerva BMJ 2019;365:1993

A review in Science indicates that vaccines for mumps, whooping cough and yellow fever lose their effectiveness more quickly than those for measles, diptheria, tetanus and flu.

The flu vaccine at best only protects about 60% of the people given it in any given year. Its effectiveness also declines after just a few months. If you are first in the queue to get it towards the end of September, much of its effects will be lost by January and February which are the peak months for flu infection.

My comment: Maybe you should plan to get the jag any time from mid November to mid December  if you are very keen on getting maximum effectiveness to prevent flu?

 

BMJ: Flozin effects in type one diabetes

 Adapted from BMJ 13 April19 Efficacy and safety of dual SGLT 1/2 inhibitor sotagliflozin in type one diabetes Musso G, Gambino R. Cassader M, Pascheta E. BMJ 2019:365:1328

Flozins are increasingly used for patients with “double diabetes” in practice. The authors of this study searched for randomised controlled trials for the drug Sotagliflozin to find out how effective they were and what safety issues were apparent. Over three thousand patient responses were studied. There were six trials that were of moderate to good quality and they ran between four weeks and a year. The relative pluses and minus are listed.

lowered HbA1c by  0.34% (small)

reduced fasting and post meal blood sugars

reduced daily total, basal and meal insulins

reduced time in target blood sugar range

reduced body weight by 3%

reduced systolic blood pressure by 3 mmHg

reduced protein in the urine

reduced the number of hypoglycaemic events

reduced the number of severe hypoglycaemic events

On the other hand these factors were increased:

Ketoacidosis increased by a factor of x 2 to x 8 depending on the study looked at

genital tract infections increased by a factor of x 2 to x 4.5

diarrhea increased up to x 2

volume depletion events increased by up to x 4

Patients got better blood sugar results from the higher dose of 400mg Sotagliflozin compared to the 200mg dose without increasing the risk of adverse events.

Most DKA episodes occurred as the drug was being started and patients cut their insulin dose too much, in anticipation of reduced blood sugars.

My comment: The risk of DKA in type twos is not very common but is a known effect of flozins, so it is not that surprising that this is increased in type ones too. The reduction in hypoglycaemia events and severity is a new finding and suggests an increasing role for flozins in type one management.

 

 

 

Vitamin D shown to improve blood sugar control in gestational diabetes

From Ojo O et al. The effect of vitamin D supplementation in women with gestational diabetes mellitus. A systemic review and meta-analysis of randomised controlled trials. Int J Environ Res Public Health. 2019:16(10)

A meta-analysis has indicated that various factors relevant to improved blood sugar control are likely to be improved by vitamin D supplementation in  a total of 173 women with gestational diabetes.

Fasting blood glucose decreased by a mean of 0.46 mmol/L

Glycated haemoglobin decreased by a mean of 0.37%

Serum insulin reduced by a mean of 4.10 uIU/mL.

 My comment: Although the improvements are small, vitamin D supplements are inexpensive, easy to take and do not have the side effects of other medications.

 

 

Lower cholesterol may not better if you have neuropathy

From Jende JME et al. Peripheral nerve damage in patients with type 2 diabetes. JAMA Netw Open. 2019;2(5);e194798

In type two patients who had diabetic neuropathy affecting the legs, low total cholesterol and low density lipoprotein cholesterol had more nerve lesions, impaired nerve conduction and more pain and disability than those with higher cholesterol levels.

Almost all type two diabetics will be advised to take statins to keep the cholesterol level down as this is generally accepted as improving the outlook for cardiac and circulatory conditions.

One hundred participants with type two diabetes were tested using magnetic resonance neurography. 64 had diabetic neuropathy and 36 did not.

My comment: Although this was not discussed in the abstract, I wonder whether those people with more advanced complications were being more intensively treated all round and thus had more/higher doses of statins, and so the relationship between low cholesterol and neuropathy severity was simple association, or whether there is a causative factor here. I am aware that statin neuropathy is believed to exist.

Higher blood pressure is linked to LESS cognitive decline

From Streit S et al. Ann Fam Med 1 March 2019 and reported by Sarfaroj Khan UK Clinical Digest 13 March 2019

In my GP career treatment of blood pressure for the general population has become more intensive as time has gone on. This hasn’t always resulted in better long term outcomes overall. Indeed, the target systolic blood pressure, the upper measurement, has been moved from 130 to 140 in the last few years because of this.

A Dutch study of over a thousand patients over the age of 75 showed that those with a systolic blood pressure under 130 showed more cognitive decline than those with a blood pressure over 150 when they had mental functioning tests a year later.

Those with higher blood pressures had no loss of daily functioning or quality of life.

As aggressive blood pressure control in those with diabetes is standard treatment, it is worth knowing this. Perhaps further studies in this subgroup of patients would be worth doing. I have seen reports of impaired kidney function when blood pressure levels are “optimal” but low too.

Another study regarding blood pressure management reported in the British Journal of Sports Medicine indicates that blood pressure reduction of almost 9mm Hg in hypertensive patients when regular structured exercise is undertaken. This is of a degree similar to most anti-hypertensive medications. (Reported in BMJ 5 Jan 2019)