Are you physically active and do you have diabetes (of any type)? Now is your chance to share how you manage your diabetes regimen while doing a variety of activities! A new edition of Dr. Sheri Colberg’s book, Diabetic Athlete’s Handbook, is coming out in Spring 2019. Please complete the diabetic athlete survey at the link below no later than […]
Adapted from BMJ 27 Jan 2018 from a study reported in PLOS Med
The UK Food Standards Agency uses a scoring system of their own devising to determine whether a food is “healthy” or not. Fruit, vegetables, fibre and protein get top marks and saturated fat, sugar and salt get a fail.
When 25 thousand participants in the European Prospective Investigation of Cancer study completed a seven day food diary at the start of the study, and their food choices were marked on perceived health benefits, there was no difference in the incidence of cardiovascular disease over the next 16 years.
Time to lay the Eatwell Plate advice in the bin?
This post belongs to Yummy Lummy – I cook, photograph and eat food with the occasional restaurant review!. Whisky flavoured chicken blue cheese casserole Whisky flavoured chicken and blue cheese casserole may sound weird but the taste is amazing, especially with some nice Danish blue cheese melted throughout the chicken and vegetable mix. 34 more…
I’ve joined the Fitbit world. Having dipped my toe in the water via the Jawbone Up Activity tracker, I’m now the proud owner of a Fitbit.
My Up activity tracker vanished in January when the device fell out of the wristband. It must be somewhere in the house. Maybe the system thinks I’m dead thanks to my lack of movement. Hey ho! Anyway, by that point I reckoned I knew what you needed to do to cover 10,000 steps a day, and I was quite happy to live tracker-free.
I didn’t stare at my phone so much. My health didn’t take a nosedive, and the world didn’t end.
On Valentine’s Day, however, my husband gave me a Fitbit Charge 2, the reward for staying alcohol-free so far this year. To be honest, when he hinted the other week that he’d got me a pressie for my teetotal efforts, I thought he was talking about champagne. It always makes sense to reward your giving up something with the very substance you’ve been avoiding, hmm?!
And I was grateful and touched that he’d bothered. He’d done the research, he told me happily. This tracker is the all-singing, all-dancing one! It counts your steps, how often you climb up stairs (you should climb ten flights a day for good health, apparently), checks your heart beat, auto-recognises different exercises and monitors your sleep. You can add in a food tracker and monitor your calorie intake if you want to lose weight.
For someone who tends to obsessiveness, this is good and bad news. To prevent myself repeatedly checking my phone, I downloaded the app for Fitbit onto my tablet instead.
Exercise is very good for we folks with diabetes if you are able to be active. If you have type 2, you might be able to control the condition through diet and exercise alone. If you have type 1, exercise will mean you can reduce how much insulin you need to take overall, and it can be used with diet and insulin to keep your blood sugar levels in range.
At some point, perhaps activity trackers will be prescribed for people with diabetes? In the future, the Fitbit could include blood glucose monitoring, as a story earlier this year reported that Fitbit has just invested in a company that’s developing a minimally invasive glucose tracker. Imagine having all that information available in one place.
I, for one, would love that capability, so fingers crossed.
From Diabetes in Control May 2017. Cheapest treatment associated with increased risks of cardiovascular events and death.
After the cardiovascular issues with rosiglitazone, cardiovascular safety trials had to be conducted for all new anti-hyperglycemic agents. However, approval for older medications was based simply on evidence of a reduction in glucose parameters; cardiovascular safety was not a concern back then. But, data from the UKPDS trial shows that metformin reduces CV events, so, it was never in doubt. The ORIGIN trial has shown no increased harm with early initiation of insulin. However, some questions linger regarding the cardiovascular safety profile of sulfonylureas.
Data exist on the weight gain and risk of hypoglycemia associated with sulfonylureas, but the associated cardiovascular events have not been well-quantified. Sulfonylureas are used commonly across the world and are very effective in lowering HbA1C, but often the effect wears off, as shown in the ADOPT study.
Recent randomized trials have compared the newer antidiabetic agents to treatments involving sulfonylureas, drugs associated with increased cardiovascular risks and mortality in some observational studies with conflicting results. They reviewed the methodology of these observational studies by searching MEDLINE from inception to December 2015 for all studies of the association between sulfonylureas and cardiovascular events or mortality.
Sulfonylureas were associated with an increased risk of cardiovascular events and mortality in five of these studies (relative risks 1.16–1.55). Overall, the 19 studies resulted in 36 relative risks as some studies assessed multiple outcomes or comparators. Of the 36 analyses, metformin was the comparator in 27 (75%) and death was the outcome in 24 (67%). The relative risk was higher by 13% when the comparator was metformin, by 20% when death was the outcome, and by 7% when the studies had design-related biases.
The lowest predicted relative risk was for studies with no major bias, comparator other than metformin, and cardiovascular outcome (1.06 [95% CI 0.92–1.23]), whereas the highest was for studies with bias, metformin comparator, and mortality outcome.
In summary, sulfonylureas were associated with an increased risk of cardiovascular events and mortality in the majority of studies with no major design-related biases. Among studies with important biases, the association varied significantly with respect to the comparator, the outcome, and the type of bias. With the introduction of new antidiabetic drugs, the use of appropriate design and analytical tools will provide their more accurate cardiovascular safety assessment in the real-world setting.
So this study reviewed over 19 trials looking at sulfonylureas, specifically studying cardiovascular events and mortality. The problem with some studies is that they don’t take into account the duration of diabetes et cetera; so, they may end up comparing sicker patients with those who aren’t as sick. This group looked at potential biases such as exposure misclassification, time-lag bias, and selection bias, and, of the 19 studies, 6 did not have any of these biases. Of those 6 studies, 5 showed that sulfonylureas were associated with an increased risk of cardiovascular events and mortality, with relative risks ranging from 1.16 to 1.55.
It is not possible to tease out what the cause of the increase in events is based on this type of analysis. Is it hypoglycemia? Is it a direct drug effect? However, regardless of the mechanism, the consistent finding of increased cardiovascular risk may have an impact on selection of agents for our patients. Newer agents have been shown not to increase events, and recently some have even shown reduction in events. So, perhaps our algorithm of selecting medications for our patients may have to change to focus on the cardiovascular effects first and then the glycemic benefits because, in the end, our goal is preventing cardiovascular events from happening in our patients with diabetes.
Sulfonylureas are associated with increased risks of cardiovascular events and death.
Sulfonylureas also associated with hypoglycemia events.
Data exist on the weight gain and risk of hypoglycemia associated with sulfonylureas.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-853.
The ORIGIN Trial Investigators. Basal Insulin and Cardiovascular and Other Outcomes in Dysglycemia. N Engl J Med. 2012;367(4):319-328. http://www.nejm.org/doi/full/10.1056/NEJMoa1203858
Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies. Diabetes Care 2017 May; 40(5): 706-714. http://care.diabetesjournals.org/content/40/5/706
Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies. Diabetes Care. 2017 May;40(5):706-714. doi: 10.2337/dc16-1943. https://www.ncbi.nlm.nih.gov/pubmed/28428321
My comments: The health issues of sulphonylureas have been known about for at least a decade or two, but because they are cheap and effective in blood sugar lowering they continue to be promoted as the next drug to use after Metformin for type twos. The Scottish Government have produced a paper which I reviewed a few weeks ago. It is their “new” strategy to deal with diabetes. Mainly, they wanted to limit the expenditure on the newer gliptans eg Linagliptan, Sitagliptan, the flozins eg Empagliflozin and the injectibles such as Victoza and Byetta. These are a lot more expensive than metformin and gliclazide. They propose that lifestyle measures are first line. This means promoting exercise and “Healthy Eating” first. Yes, this means a high carb, low fat diet, with lots of starch, limited sugar, salt, and whatever fat you eat should be the good monounsaturated type and also the inflammatory vegetable oil/margarines. As we know this actually increases obesity for most people and worsens diabetes control. You then get put on metformin and then before you get put on drugs that actually lower your weight, blood sugar and blood pressure and cardiovascular risk, you get put on a sulphonylurea which wears out your pancreas, makes you fatter, makes you more prone to hypos and increases your cardiovascular risk. In my view sulphonylureas should be AFTER the newer drugs and given as a choice if someone does not want to use insulin. I put in my comments regarding diet to the editorial board but they have done nothing saying that the remit of the paper was really about drugs, not diet. Yet, without the right diet, diabetes management is doomed to failure.
Gavin Routledge is an osteopath from Edinburgh who seeks to raise awareness of health issues in the general population. He treats all kinds of musculo-skeletal problems but particularly low back pain. Most of us will have this at some point in our lives and for many it makes their life miserable for long periods of time.
Gavin recognises that a lot of illness is lifestyle related and that includes low back pain. If you can tackle these aspects you are less likely to get a multitude of illnesses. We understand the importance of lifestyle in the development of obesity and many cases of type two diabetes but as a GP I agree with him that back pain isn’t thought of in those terms to any degree.
By the time most people are calling on a doctor or osteopath with acute back pain, they have been sweeping a lot of issues under the carpet for a long while. Usually there is some last straw that breaks the camel’s back. Often bending down and rotating at once, often first thing in the morning is the trigger for severe pain that can take weeks to settle.
The book, Active X backs describes how your back works, how tissues respond to injury and how pain works. He describes many factors that you may need to address in your life and helps to tailor an action plan to deal with acute pain and more importantly sort out the problems that make you more likely to experience pain in the first place.
Although physical factors such as trauma, burden overload, and poor levels of physical fitness make perfect sense, many of us are oblivious about the effects of low mood, work related stress and smoking on our backs. He gives structured advice and exercises to deal with all of these and more.
The book is spiral bound so you can access the relevant exercises which are photographed and the book ends with advice on best postures to adopt for sitting, standing, sleeping and bending.
The book is £20 and the online course £39.
MY SELF STUDY OF MORNING HIGHS →
HOW TO HANDLE MORNING HIGHS and DON’T SKIP BREAKFAST
Posted on June 18, 2015
I have posted about this issue on June 6 but now I’ve found a website that not only provides a better explanation but offers the solutions as well. It’s Diabetes Forecast. Boy, am I glad I stumbled upon it.
You wake up to blood sugar spike, as if you were eating cookies all night. This is not uncommon in people with diabetes but there are ways to get those numbers down. There are two possible things that can cause that: dawn phenomenon and waning insulin. The third possibility is Somogyi effect but this one is controversial, Diabetes Forecast states.
Whatever the cause is, the source of the BG spike is your liver. The liver is where glucose is produced and stored, and then hormones signal the liver to release glucose into the bloodstream for energy. This usually happens between meals and overnight.
With diabetes however, there is a hormone imbalance because of either an impaired insulin production by pancreas or too much of the hormones that counteract insulin. Either way, chances are that a wrong signal is sent to the liver that prompts it to pump out more glucose than it should, hence we’re having a case of an overproductive liver.
DAWN PHENOMENON or dawn effect
It takes place when your liver releases glucose in between 3 to 6am, in people with typical sleep schedule. I found out that if I go to sleep at around 10 or 11pm, this happens to me at around 3am. This is supposed to be counteracted by insulin produced by the pancreas. People with diabetes however, might not have enough insulin or they’re having an insulin resistance so their blood sugar stays elevated and continues this way into the morning.
WHY YOU SHOULDN’T SKIP BREAKFAST
Eating breakfast helps to normalize blood glucose levels; it signals to the body that it is day and time to rein in the anti-insulin hormones. It’s very important not to skip breakfast.
Some folks believe that it’s the dinner in the night before to blame for the morning spike but it’s actually a dawn effect.
This applies to those who are taking insulin as a medication. What happens is that an evening meal could lead to higher than normal blood glucose levels in the morning after. I think by ‘evening meal’ they mean a bedtime snack. The cause may be too little mealtime insulin, waning long-acting insulin from an evening injection, or not enough overnight basal insulin through a pump. So the blood glucose levels may creep as you sleep. With waning insulin, the rise in blood glucose is typically more gradual than with the dawn effect.
Another name for this is “hypoglycemia rebound”. It was named after a researcher who first described it.
The theory is that if a person with diabetes experiences hypo overnight, the body produces anti-insulin hormones to counteract this and bring blood glucose levels back up, the body can overdo it which leads to a morning high. It is usually described as blood glucose level taking a dip (hypo) at around 3am, and then a morning high follows.
There is a split opinion as to the mere existence of this effect. Diabetes Forecast states that it’s controversial and unproven. However some other sites claim that it does exist and back it up with their personal experiences.
WHICH ONE IS IT?
This involves some ‘detective work’ as Diabetes Forecast puts it. I personally did this for a few days. I would check my glucose at bedtime which was around 10 or 11pm, then wake up at 3am, check blood sugar, back to sleep and checked it again in the morning. It’s important to sleep about 4 to 5 hours in between blood sugar checks. Comparing the changes in blood sugar levels will help you to figure out which effect takes place.
bedtime blood sugar 3am blood sugar morning blood sugar
normal normal high DAWN EFFECT
normal high high WANING INSULIN
normal low high REBOUND (Somogyi)
WHAT ELSE YOU CAN DO
You need to discuss your morning highs with your doctor and see if he / she advises to adjust your diabetes medication or physical activity. For those using insulin pumps, you can adjust your basal rates. I don’t use a pump so can’t elaborate further.
Diabetes Forecast further states that to overcome Somogyi Effect, you should either eat a bedtime snack with some carbs and protein in it. Also discuss your target blood glucose range with your doctor.
WHAT I DID
In my case it was none of the above but a DISORGANIZED LIFE that I will discuss in my next post. After having adjusted my testing times, my morning numbers were doing fine for a while. And then boom, a spike, 111 for absolutely no reason. I figured maybe my bedtime snack was a culprit, and switched to the one with protein & low carbs. I had half a cup each of ricotta cheese and cold milk that I love. Comes next morning, my number is 103. Yay.