BMJ: Why don’t we encourage and register the diabetics who achieve remission?

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Weighing up the benefits of registering those in remission from type two diabetes

Adapted from BMJ Louise McCombie et al 16 Sept 17

Type two diabetes now affects between 5 -10% of the UK population. This is 3.2 million people in the UK. 10% of the NHS budget is spent on treating diabetes and costs are between two and three times that of age matched individuals without diabetes. Life expectancy is six years less for people with type two diabetes.
Remission is attainable for some patients but is rarely achieved or recorded. (My comments: except in the low carbing community) The trend is for diabetes management to focus on reversible underlying disease mechanisms rather than treating symptoms and multisystem pathological consequences.
Lowering blood glucose remains the primary aim of management and drugs are the main method of doing this rather than diet and lifestyle advice. (My comment: because high carb/low fat dietary advice is counterproductive).
It has been found that weight loss of 15kg often produces biochemical remission of type two diabetes, restoring beta cell function. The accumulation of fat in the liver and pancreas impairs organ function to cause type two diabetes but is potentially reversible. If remission is achieved, the person no longer requires diabetes drugs.
The American Diabetes Association describe a partial remission as below the threshold for diabetes diagnosis. This is a hba1c of less than 6.5%/48 mmol/mol and a fasting blood sugar less than 6.9 without diabetes drugs. A full remission is described as the elimination of the criteria for impaired glucose tolerance. This means a hba1c less than 6%/42 and a fasting blood sugar under 5.6 again without the use of diabetes drugs.
A full remission will completely remove the cardiovascular risk associated with diabetes but partial remission removes a great deal of the risk and is still very much worthwhile.
We suggest that whether hba1c or fasting blood sugars are used to detect remission that these are repeated twice at two month intervals. Once in remission, a patient should be tested annually.
No study has yet been done that has reported the outcomes for diabetics in remission, but you would expect their outcomes to be much better than it otherwise would.
If a patient achieves remission, and if the Read code C10P is applied to them, they would still be scheduled for annual reviews and retinal screening programmes but would be considered non-diabetic for matters such as insurance, driving, and employment. But so far, in Scotland, only 0.1% of diabetics have been coded as being in remission.
Perhaps there are coding errors, but the possibility that type two diabetes can be reversed may not be fully understood by both doctors and patients. If patients achieve either a 10% body weight loss or 15kg, then 75-80% of them can expect to go into diabetes remission.
Physical and social environments, emotional states and self- regulatory skills are important factors affecting adherence to a weight management intervention.
It costs around £5,000 for the medical care of a person with type two diabetes but this almost doubles over the age of 65. The patient also has increasing holiday insurance costs. This is around double the usual rate for type twos and more for insulin users. Could knowledge of the advantages of weight loss act as an incentive for patients?

 

Start ’em young

 

kid

 

A survey of UK school children has shown that children as young as nine and ten are already showing signs of markers for type two diabetes.

It is known that the more screen time a child has, whether this is computer games, video games or television, the fatter they get. There is a dose / response effect.

Insulin resistance also increases and also shows a dose / response effect. The surprise is how early the changes occur.

Achiv Dis Child doi:10.1136/archdischild-2016-312016

Eric Barker: 5 Questions that will make you emotionally strong

wonder woman

5 Questions That Will Make You Emotionally Strong

Click here to read the post on the blog or keep scrolling to read in-email.

Ever been caught in the grip of extreme emotions? I’m gonna guess whatever decision you made next probably wasn’t a good one.

When we’re anxious, angry, or sad, we rarely do the smart thing. And that can seriously mess up our lives. At work, in love, or pretty much anything we do, we need emotional strength to stay cool and do the right thing.

Now dealing with the ups and downs of feelings isn’t anything new. And nor are some of the best solutions. So let’s look at what some ancient wisdom has to say about dealing with difficult emotions.

Studying Buddhist mindfulness or Stoicism can take a heck of a long time. So we’ll prune their insights down to 5 questions that can help you when emotions hijack your brain and send you into a tizzy.

First up: worrying. When your mind is filled with anxious concerns and doubts, what question do you need to be asking yourself?

“Is This Useful?”

Face it: your brain can be a pretty crazy place. All kinds of things bounce around in there. And you’re usually pretty good at culling the wacky thoughts. But then you get worried…

And your brain starts multiplying negative possibilities like crazy. And you make the mistake of taking them seriously. Every. Single. One.

Remember: you are not your thoughts. Neuroscientist Alex Korb made an interesting distinction when I spoke to him. If you were to break your arm you would not tell people, “I am broken.” But when we feel worry we’re quick to say, “I am worried.”

Your brain produces thoughts. That’s its job. But that’s not directly under your control. So just because something is in your head, doesn’t mean it’s “you”, and should therefore be taken seriously.

When I spoke to Buddhist mindfulness expert Sharon Salzberg, she said this:

I think one of the issues that we have is that we don’t necessarily recognize that a thought is just a thought. We have a certain thought, we take it to heart, we build a future on it, we think, “This is the only thing I’ll ever feel”, “I’m an angry person and I always will be”, “I’m going to be alone for the rest of my life”, and that process happens pretty quickly.
If you acted on every crazy thought that popped into your head, I can guarantee you two things:

  • There’s a blockbuster reality show in your future.
  • And not a lot of happiness.

So if you are not your thoughts, who are “you”? You’re the thing that decides which thoughts are useful and should be taken seriously.

The ancient Stoics believed that you are just your reasoned choice; because that’s the only thing fully under your control. So those worried thoughts aren’t you. The decisions you make regarding them are.

You’re not your brain; you’re the CEO of your brain. You can’t control everything that goes on in “Mind, Inc.” But you can decide which projects get funded with your attention and action.

So when a worry is nagging at you, step back and ask: “Is this useful?”

When I spoke to Buddhist mindfulness expert Joseph Goldstein he said:

This thought which has arisen, is it helpful? Is it serving me or others in some way or is it not? Is it just playing out perhaps old conditions of fear or judgment or things that are not very helpful for ourselves or others? Mindfulness really helps us both see and discern the difference and then it becomes the foundation then for making wiser choices and why the choices lead to more happiness.
If the worry is reasonable, do something about it. If it’s irrational or out of your control, recognize that. Neuroscience shows that merely making a decision like this can reduce worry and anxiety.

(To learn the 7-step morning ritual that will make you happy all day, click here.)

But maybe you’re not worried. Maybe you’re furious. But what is anger? Where does it come from? And what question can make these HULK SMASH feelings go away?

“Does The World Owe Me This?”

Anger comes from entitlement. You feel you’re entitled to something, reality doesn’t bend to your expectations and boom — you’re punching things. Or people.

Traffic is bad. You get angry. Let me translate that thought process for you: “Traffic should never cause me problems. The world owes me that.” Sound reasonable? Hardly.

Or someone doesn’t do what they said they’d do. You get angry. Now you might reply, “People should do what they say they’ll do! I have a right to be angry!”

Yes, it would be nice if people always followed through, but is that a reasonable expectation? Of course not. You know people don’t always do what they say. Now you can definitely call them out on it. You can decide to do something in response. But the anger?

That awful feeling is all yours. You had an unrealistic expectation (“People will always do what they say”) and now you’re shocked — SHOCKED! — that they didn’t.

Famed psychologist Albert Ellis (whose work was inspired by the Stoics) led a war against the words “should” and “must.” Anytime you use those words, you’re probably in for some unhappiness because you’re saying the universe is obligated to bend to your will. Good luck with that.

So the solution to anger is to ask yourself: “Does the world owe me this?”

Yeah, it’s a trick question. Because the world doesn’t owe you anything. And the more you think the world owes you, the angrier you will be. Again, it’s all about reasonable expectations. And that’s why Marcus Aurelius said:

Begin each day by telling yourself: Today I shall be meeting with interference, ingratitude, insolence, disloyalty, ill-will, and selfishness…
Not a pleasant way to start the day — that I grant you. But he was on to something. Expecting everything to go your way, let alone insisting on it, is a prescription for anger.

I know what some people are thinking: feeling you’re entitled to nothing in life seems unfair and sad. But don’t forget that you take for granted what you are owed. Not being entitled makes every good thing in life a prize. You either achieved it or you were lucky, and those lead to feelings of pride or gratitude.

When you’re entitled, you don’t appreciate anything, and you’re frequently disappointed. Not a good combo. And when psychologists are evaluating if someone is a narcissist, guess what one of the four criteria is? Yeah, entitlement.

(To learn how mindfulness can make you happy, click here.)

Maybe you’re not worried or angry. Maybe you’re just overwhelmed by sadness about something. Well, I have a question for you…

“Must I Have This To Live A Happy Life?”

Plenty of people have a lot less than you and live a very happy life. If happiness was all about money then every single person in the developing world would be miserable. People who have lost a loved one, who have become handicapped, or heaven forbid, had a bad hair day, are all capable of living happy lives.

What do you truly need to live a happy life? (Hint: the longer your list, the more miserable you will be.)

As Marcus Aurelius said:

Very little is needed to make a happy life; it is all within yourself, in your way of thinking.
So next time you don’t get something you want and it makes you sad, ask yourself, “Must I have this to live a happy life?”

Yeah, yeah, forgive me — it’s another trick question. The answer is almost always “no.”

Maybe you didn’t get that promotion. And when you ask yourself the question, your first thought is “But my career is important to my happiness!”

Hey, I underlined the word “this” for a reason, pal.

Yes, your career is important. But is this promotion, right now, vital to the happiness of your life? No. Who knows what the future holds? And some of that is under your control. There are many ways to live a happy life and very rarely will this one thing make or break you.

(To learn the four rituals neuroscience says will make you happy, click here.)

Now when you’re consumed by negative emotions it can be very hard to make good decisions. Which means more bad stuff happens, which means more bad feelings. So how do you make smart choices when you feel awful? Just ask…

“Is This Who I Want To Be?”

News flash: there is no singular, concrete “you.” Neuroscientists have poked around at plenty of grey matter and there’s no spot in there that contains a stable “you.” And Buddhists were saying this over a thousand years ago.

Neuroscientist and Buddhism practitioner John Yates explains:

We often believe we should be in control, the masters of our own minds. But that belief only creates problems for your practice. It will lead you to try to willfully force the mind into submission. When that inevitably fails, you will tend to get discouraged and blame yourself. This can turn into a habit unless you realize there is no “self” in charge of the mind, and therefore nobody to blame.
Tons of things affect your decisions every day. Context, friends, and moods all affect what you do and who you are. This is a good thing, because it means you can change.

But it presents a challenge because it means you need to decide which person you will be today, Sybil. And this isn’t something you want to get wrong. What is the #1 regret people have on their deathbeds?

I wish I’d had the courage to live a life true to myself, not the life others expected of me.
Yow. So who should you decide to be? We can turn to modern science for this answer: Be you on your best day. So when making tough choices think about whether what you plan to do is aligned with the “you” you’re most proud of.

Merely thinking about your best possible self makes you happier:

Results generally supported these hypotheses, and suggested that the [Best Possible Self] exercise may be most beneficial for raising and maintaining positive mood.
And don’t worry about seeming inauthentic either. When you act like your best self, you end up showing people what you’re really like:

…positive self-presentation facilitates more accurate impressions, indicating that putting one’s best self forward helps reveal one’s true self.
(To learn the schedule very successful people follow every day, click here.)

Alright, this has all been very focused inside your head. How can you be emotionally strong when someone you’re dealing with is being emotionally weak or difficult? If someone else is anxious, angry, or sad, and it’s making your life rough, that can bring you down. How do you help both of you? Ask yourself…

“Have I Ever Felt That Way?”

Whatever they are going through, you’ve probably felt something similar. So be compassionate.

Both Buddhism and Stoicism believe in doing your best to reduce the suffering of others. Buddhism has the four divine abodes: loving-kindness, compassion, sympathetic joy, and equanimity. And on the Stoic side, good ol’ Marcus Aurelius said:

Be tolerant with others and strict with yourself.
Compassion sounds nice, but does it really produce results? Absolutely. And you get bigger benefits if you do it when you are least likely to want to — during an argument.

Via 100 Simple Secrets of Great Relationships:

People who maintain a compassionate spirit during disagreements with their partner, considering not just the virtue of their position but the virtue of their partner, have 34 percent fewer disagreements, and the disagreements last 59 percent less time. – Wu 2001
(To learn how to have more grit — from a Navy SEAL — click here.)

Okay, we’ve learned a lot. Let’s round it up and learn the most important part of being emotionally strong…

Sum Up

Here are the 5 questions from ancient wisdom that will make you emotionally strong:

  • “Is it useful?”: Most worrying isn’t. Make a decision to do something or to let it go.
  • “Does the world owe me this?”: No. Don’t be entitled. Have realistic expectations and you won’t get angry.
  • “Must I have this to live a happy life?”: Probably not. It takes little to make a happy life and there are many ways to get those things.
  • “Is this who I want to be?”: Act the way you do when you’re at your best.
  • “Have I ever felt that way?”: Respond to others’ problems with compassion and you’ll both have fewer problems.

The most important part of emotional strength is not calming your mind. It’s being resilient. It’s trying again after you’ve been shaken by negative feelings.

There are plenty of areas of your life where this is critical, but none is more important than your relationships — research shows 70% of your happiness comes from relationships.

You will be hurt. You will feel bad at times. That’s life. Sorry, there’s no avoiding it. So the question is: who is worth it? Who is most meaningful to you?

So when things are hard, have the emotional strength to still give to them and help them and care for them. You now have tools to weather the storm. Earlier I mentioned the biggest regrets that people had when they were dying. Know what #3 was?

I wish I’d had the courage to express my feelings.
So go first. Let someone know how much they mean to you. Who are we most likely to love? Research says it’s the people who first show us love.

Recently, I have been lucky enough to have this happen to me. And I can tell you nothing feels better.

Enough reading, time for doing. Right now, have the emotional strength to tell someone important how you feel, to forgive someone, to let someone back into your life, or to reconnect with someone you miss.

Don’t wait around for something negative to develop emotional strength. Flex some now and see how happy it can make you.

Please share this on Facebook or save it to Pocket. Thank you!

 

 

Thanks for reading!
Eric
PS: If a friend forwarded this to you, you can sign up to get the weekly email yourself here.

 

Stephan Guyenet: Why your brain makes you fat

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In this interview, which you can listen to or read,  neuroscientist Stephan Guyenet discusses various topics related to a big issue with a lot of people, how we get fat and what we can do about it, with Kris Kresser.

 

https://chriskresser.com/why-your-brain-makes-you-fat-with-stephan-guyenet/?utm_source=activecampaign&utm_medium=email&utm_term=rhr-why-your-brain&utm_content=&utm_campaign=blog-post

Susan Pierce Thompson: How to be happy, thin and free

the-3-huge-mistakes-report

This March, Susan’s first book, Bright Line Eating: The Science of Living Happy, Thin & Free, arrived in bookstores.

Here’s what she had to say:

Susan, in Bright Line Eating, you argue that the reason so many people struggle with their weight is that the human brain blocks weight loss. How so?

The human brain was designed to keep us stable in a right-sized body. But modern processed foods and the modern pace of life have hijacked various systems in the brain, and the result is that now, in the present-day environment, the brain does indeed block weight loss.

Here’s how: willpower is a finite resource in the brain. And it doesn’t just help us resist temptations or persevere in the face of challenges – it helps us do all kinds of things, like make decisions (e.g., checking email, going shopping), regulate our emotions (e.g., having kids, being in traffic), and regulate our task performance (e.g., working in Excel, giving a presentation).

After a brief period of time doing any of these things, if we start to think it might be a good time to get something to eat, we’re likely to fall into the Willpower Gap.

This is why so many of us order out for pizza or take-out on a Friday night after a long week, irrespective of how sincere we were when we pledged that this time we would stick with our diet until we lost all our excess weight.

In our modern society, the Willpower Gap is waiting for us, nearly always. Most plans of eating implicitly ask you to rely on your willpower to stick with the plan over the long term. The truth about your brain is that that will never work. You need a plan of eating that assumes you have no willpower at all (because, at any given moment, you may not), and works anyway.

To avoid relying on willpower, you suggest people adopt 4 “bright lines” into their eating habits. What are they?

Bright lines are clear, unambiguous boundaries that you don’t cross, no matter what–similar to how a smoker who wants to quit and get healthy throws up a bright line for cigarettes. The four bright lines I recommend are:

  1. No added sugar or artificial sweeteners
  2. No flour of any kind
  3. Eating only at meals–no snacking or grazing
  4. Bounding quantities of food, both to make sure you get enough vegetables, and to make sure you don’t eat too much of everything else.

What’s one thing everyone reading this can do right now to improve their chances of maintaining a healthy weight?

To really bridge the Willpower Gap, start writing down what you’re going to eat for the day in a little journal, ideally right after dinner the night before. Do it religiously until it becomes a habit. The next day, your job is to eat only and exactly that, no matter what. Make sure there’s no sugar or flour in your food plan for the day, and, ideally, stick with three meals a day, because three meals are much more automatizable than five or six.

Within a few weeks these habits will be automatic, and eating the right things, and not the wrong things, will start to be as easy as brushing your teeth.

 

(From original interview by Ron Friedman)

Planning a pregnancy: the importance of getting slim before you get started

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In Europe the World Health Organisation estimate that more than 50% of men and women are overweight or obese and 23% of women are obese.

In a pregnant woman obesity raises her chances of gestational diabetes and pre-eclampsia. She is also more likely to get metabolic syndrome and type two diabetes later in life. The resulting children are more likely to come to harm in utero and at birth and also more likely to become fat children. They are then more likely to develop higher blood pressure and excess weight in early adulthood.

Despite the push to improve the outcome for the babies in utero, lifestyle changes and medical interventions have largely proved unsuccessful.

Women with a BMI over 25 find it more difficult to conceive in the first place and then are more likely to miscarry compared to their slimmer sisters. The miscarriage rate is 1.67. Congenital abnormalities become more common.

The placenta responds to maternal insulin levels. In normal weight women they become 40-50% less sensitive to insulin but this bounces back within days of delivery. Obese women show greater decreases in insulin sensitivity, this affects lipid and amino acid metabolism. African Americans and Southern Asians get these changes at lower body masses than Europeans.

Obese women are more likely to go into labour early. They also may need to be delivered early. They have a higher rate of failed trial of labour, caesarean sections and endometritis and have five times the risk of neonatal injury.

Anaesthetic complications are more common. The Royal College of Obstetrics and Gynaecology recommend that women with a BMI over 40 see an obstetric anaesthetist before going into labour. Epidural failure is more common. The woman may have lower blood pressure and respiratory problems and the baby may have more heart rate decelerations in labour.

Broad spectrum antibiotics are recommended for all caesarean sections. Despite this, overweight women get more post- operative infections. The wounds are also more likely to come apart.

Obese pregnant women are obviously at even more risk.

Babies of obese mothers are usually fatter at birth compared to other babies. Obese mums tend to put on more weight than average during the pregnancy and then find it even harder to lose weight after delivery.

Recent randomised controlled trial  have shown that interventions started after pregnancy have little or no effect. These include increasing the mum’s physical activity and cutting the dietary glycaemic load. These things reduced the weight gained in pregnancy a little but did not affect adverse pregnancy outcomes and the birth of fat babies. Thus there is now a bigger push to intervene before pregnancy.  

Currently between ten and twenty percent of obese women lose weight between pregnancies. This has been found to reduce weight gain in the next pregnancy and also the risk of pre-eclampsia.  Supervised intensive lifestyle interventions can be done, work and are safe, even in breast feeding mothers. Pre-pregnancy classes to get women fit for pregnancy would help improve the outcome for the babies of the future.  The metabolic environment, a mixture of inflammation, insulin resistance, lipotoxicity, and hyperinsulinemia,  can then be optimised prior to conception. After this, it is really too late.

 

Adapted from Obesity and Pregnancy. Patrick M Catalano and Kartik Shankar from Cleveland Ohio and Little Rock Arkansas Universities.  BMJ 18 February 2017 BMJ 2017;356;j1

Obesity raises the risk of cancer

cancer

Obesity is strongly associated with eleven different cancers.

These are: oesophageal, multiple myeloma, stomach, colon, rectum, biliary tract, pancreas, breast, endometrium, ovary and kidney.  For many cancers there seems to be a dose response.

This was found by Kyrgiou and colleagues by studying over 95 meta-analyses from various sources.

The BMJ reports, “The unavoidable conclusion is that preventing excess adult weight gain can reduce the risk of cancer. Furthermore, emerging evidence suggests that excess body fat in early life also has an adverse effect on the risk of cancer in adulthood. Clinicians, particularly those in primary care, can be a powerful force to lower the burden of obesity related cancers, as well as the many other chronic diseases linked to obesity such as diabetes, heart disease and stroke. The data are clear. The time for action is now.”

As a GP, I don’t really think that I am a “powerful force” that can turn the obesity epidemic round. It is amazing what faith the authors Yikyung Park and Graham Colditz have regarding our abilities.

 

Adapted from Adiposity and cancer at major anatomical sites BMJ 2017; 356:j477 and BMJ 2017;356:j908