Tag Archive for: diabetes

Want Fewer Medications? Change Your Lifestyle

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The study that we examined on Tuesday showed that a regular exercise program can help reduce the number of medications related to cardiovascular disease and type 2 diabetes. We’re not talking about youngsters; 51 subjects completed the study with an initial mean age of 54. There were some outcomes that were likely unexpected; for example, waist circumference did not change between the experimental group and control group over the five years. There was a significant decrease in body fat in the exercise group that explained the difference in body weight. Still, the control group lost about two pounds in five years while the exercise group lost about six pounds. That actually turns out to be a good thing, as I’ll explain a little later.

The Exercise Program

The high-intensity interval training was just as advertised: intense. It included a 10-minute warm up, followed by four 4-minute intervals at 90% of maximum heart rate (HRMax) interspersed with 3 minutes of active recovery. They finished with a 5-minute cooldown. They used percentage of HRMax as assessed in the exercise test, because that’s an intense level. The focus is on the 4 minutes but those 4 are brutal. You do get to rest, but then you have to do it over again, and that’s a significant challenge to the cardiovascular system. As people got fitter, the intensity would be changed to sustain the 90% level.

What surprised me was that there was no organized exercise activity in the other eight months of the year; they just kept track of activity levels using the activity monitors. There were no differences between the control group and the exercise group in the eight months with no organized activity. That’s interesting.

Most Variables Didn’t Change

This probably surprised the researchers, but it was a desirable outcome. There were no significant differences in body fat, waist circumference, BMI, or overall percentage of body fat. While the subjects probably would have liked to have lost more weight, the fact that they didn’t shows that the changes that occurred in the risk factors for cardiovascular disease, such as high blood pressure and low HDL cholesterol as well as a lower insulin levels, showed that the difference was the actual exercise program itself. The differences in distribution of nutrients in the diet and in the total caloric intake were insignificant. As I mentioned earlier, the number of steps per day and other activities were still even. That means, again, the changes could be attributed to the exercise program alone.

The Bottom Line

What is abundantly clear is that if you really want to reduce medications, you have to pay the price by changing your lifestyle. In this study they focused on one variable: exercise. If you add a change in dietary intake, and or a change in the distribution nutrients, you may get even more benefits. But for me, it answers the question that I started with. You want to reduce medications? Change your lifestyle.

Is it worth it? That’s your call. But that’s what Aging with a Vengeance is all about.

What are you prepared to do today?

        Dr. Chet

Reference: MSSE. 2021. 53(7):1319-1325.

Can You Reduce Your Medications?

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One of the questions that I get asked frequently goes something like this: “Dr. Chet, how can I reduce the medications I’m taking?” Along with that question is, “I don’t want to have to take medications for blood pressure or cholesterol or diabetes. What can I do?” As we proceed with a focus on Aging with a Vengeance, a recently published study illustrated at least a partial answer to these questions.

Researchers in Spain recruited 64 subjects for an exercise program. The exercise program was a high-intensity interval training (HIIT) program, three days a week, that ran for four months under staff supervision. The rest of the year these subjects were given activity monitors that automatically uploaded data on activity, sleep, etc. The researchers also took a variety of blood samples for testing metabolic variables, tested the subjects’ fitness levels, assessed anthropomorphic measures such as body weight and waist circumference, and recorded medications related to blood pressure, cholesterol, triglycerides, and blood sugars. The subjects were retested after two years and again after five years.

Over the period of five years, an amazing 51 subjects completed the exercise sessions and all the testing required. That, in and of itself, is remarkable—I’ve done this type of study, and holding on to the subjects is one of the main challenges.

The primary question was answered: those who exercised as the study required took fewer medications for blood pressure, cholesterol, and blood sugar control. As you might expect, that isn’t the entire story, so we’ll wrap this up on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: MSSE. 2021. 53(7):1319-1325.

COVID-19 Attacks the Whole Body

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Our look at diseases associated with COVID-19 continues in this pre-4th of July memo. Let’s turn to diabetes. We know, based on prior reports, that people with type 2 diabetes as well as other comorbidities are susceptible to getting the worst symptoms of COVID-19. But now, there are also some reports that COVID-19 infections may cause diabetes; people diagnosed with COVID-19 with minor symptoms have developed type 1 diabetes later.

How could that happen? The first way may be a direct attack on the pancreas because it also contains many ACE2 receptors. Or it may be that as the virus stays in the body, it triggers an autoimmune response. Or it may somehow stimulate other dormant viruses due to the inflammation and immune response.

One of those is the Epstein-Barr virus; almost 90% of us have been exposed to it. Epstein-Barr impacts the nervous system in a significant way. Perhaps the challenge to the immune system somehow triggers the activation of Epstein-Barr to cause neurological dysfunction from mild to severe.

In doing the background research for these Memos, I found that scientists are looking at every organ for potential consequences of the COVID-19 virus infection. We already knew of cardiovascular problems as well as kidney damage; lung damage was significant whether the patient was on a ventilator or not. The impact on blood vessels, which are full of ACE2 receptors, are the root cause of many of the problems. With the loss of taste and smell, it may be that the virus causes the death of enough of those organelles that we are permanently impacted. We’re learning some patients develop problems in their brains such as strokes, psychosis, and altered mental state, and we’ll discover more conditions that are impacted by the virus as time goes on. And we haven’t even begun to discuss the microbiome.

The Bottom Line

As I wrote several weeks ago, I don’t want you to fear this virus but you’d better respect it. That means you do your best to avoid getting it and avoid spreading it.

This is the beginning of the major holiday of the summer. Being restricted in what we can do and where we can go has worn on people, perhaps even you. So let me leave you with two thoughts.

First, if getting into a pool is part of your holiday plans, go ahead. The chlorine in a well-maintained pool or hot tub will kill the virus and sunshine helps, so have some fun; but if you’re just socializing while wet and not social distancing, wear a mask.

Second, I’ll finish where I began this series: with wearing a mask in public. You don’t have to like it. Who does? Science clearly shows it reduces the risk of catching or spreading the virus which, as we’ve seen, has far more implications then just a little fever and cough. So if you’re going into public places, do what I do and wear the damn mask. Please.

What are you prepared to do today?

        Dr. Chet

Reference: Nature. 2020. doi: 10.1038/d41586-020-01891-8.

Does Fiber Improve Your Microbiome?

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Now let’s look at the results of increasing dietary fiber for people with diabetes. Researchers recruited over 50 type 2 diabetics (T2D) for a 12-week study. The control group was given standard recommendations for a healthy diabetic diet. All current medications were maintained and both groups received acarbose, a starch blocker. The experimental group was put on a diet of prepared high-fiber foods and a diet higher in vegetables and fruits. Stool samples were collected periodically to assess the impact of the diet on the microbiome.

While the variables were straightforward, the analytic techniques were extraordinarily complex. It’s easy to say you want to examine the microbiome, but that’s not simple to do with thousands of types of microbes to analyze. Several types of bacteria from different species responded to the increase in fiber: bacteria that produced short-chain fatty acids (SCFA). The SCFAs are important because they feed the cells in the gut that do all the work during digestion and absorption.

HbA1c levels decreased faster and in a higher percentage of subjects in the experimental group than the control group. The fiber group also lost more weight and their blood lipids improved more than controls.

This was a small study, limited by the complexity of analyzing the microbiome, but the improvement in T2D simply due to an increase in fiber from foods is important. One more thing: this was a Chinese study, so typical high fiber foods from China were used. Is that important? We’ll find out Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: Science. 2018. 359:1151–1156.

Health Headline: Ketogenic Diet and Type 1 Diabetes

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Researchers wanted to examine the blood sugar control of type 1 diabetics who use a very low carbohydrate, high-protein, moderate fat ketogenic diet. The diet was developed by Dr. Richard Bernstein, himself a type 1 diabetic. They used a unique study design: they requested volunteers from a Facebook group of children and adults who adhere to the Bernstein Diet. Over 300 volunteers completed an online survey about their diagnosis and diet. The diagnosis of type 1 diabetes was confirmed from medical records from a follow-up survey of medical staff.

This was a rigid ketogenic diet with no more than 30 grams of carbohydrate allowed per day. The average intake was 36 grams carbohydrate per day. The better the control of carbohydrate intake, the better the HbA1c score, with a mean of 5.7%. Remember, these were type 1 diabetics; there are many type 2 diabetics who don’t control their HbA1c that well. I think this study illustrated the potential of nutrition in affecting a disease system. One interesting aside was the healthcare professionals treating the patients seemed indifferent to the dietary approach regardless of the results.

Headline worthy? Yes, in context. Close to half the subjects did not provide access to medical personnel so the researchers relied on the initial subject surveys for information. They also had no access to any dietary records to confirm the diet. Still this was a unique way to use social media to gather information. The study has to be confirmed using traditional research design to assess the variables. But this approach examined people who live this diet on their own or with their children. That can provide insights that might be missed if the study were conceived by a group of research professionals discussing the question around a table.

What are you prepared to do today?

Dr. Chet

 

Reference: Pediatrics. 2018. doi: 10.1542/peds.2017-3349.

 

Guidelines for Type 2 Diabetes: EBM in Practice

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The American College of Physicians (ACP) has established guideline statements for the management of HbA1c in non-pregnant adults using medication. They considered the research behind guidelines set by four other major physician organizations for treating type 2 diabetes. After reviewing that data, they have proposed four guidelines for use when treating patients. These are non binding guidelines; the choice is always left to the physician and the patient. But I think they get back to what evidence-based medicine should have always been about: use the best science and research and work with the patient to see what they want to do. Let’s take a look.

ACP Guideline Statements

These are the statements:

Guidance Statement 1
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.

Guidance Statement 2
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

Guidance Statement 3
Clinicians should consider de-intensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

Guidance Statement 4
Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

EBM and Guideline Statements

I think the Guideline Statements reflect what EBM was always supposed to be about: consider the patient and what they want. I have spoken to many adults with type 2 diabetes who become frustrated with their inability to reach the HbA1c goals their physician has set. If they can’t reach it, more medication seems to be the only solution, and that’s not what they want.

I think these guidelines bring the patient or their caregiver into the equation. What price does the patient have to pay with their body? How much will it affect their life positively or negatively? Are there real improvements in quality of life if the HbA1c is 6.5% versus 7.0%? What is the cost of emotional stress?

The new guideline statements are a great addition to a physician’s repertoire: treat the patient as an individual. The patient comes before statistics and hazard ratios.

The Bottom Line

While not all organizations are going to adopt these guidelines, they’re important. There has been significant pushback from other organizations, all suggesting that there are new medications that may prevent some of the negative effects of prior treatment. “New medications”—they’ve learned nothing.

The one opportunity I see is that there’s hope for all of us who want to work at getting control of our lifestyle and reduce the dependence on medications as recommended by statement three. You say you don’t want to take medication? Excellent! Here is your chance to prove it.

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.

 

A New Approach to HbA1c

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Type 2 diabetes is a significant problem in North America and it’s spreading throughout the entire world. The treatment standard has always focused on controlling blood sugar, especially HbA1c. Normal is less than 5.7%. For most individuals, reducing the HbA1c to under 6.5% has been the goal for pharmacologic treatment.

HbA1c is a protein found on red blood cells that indicates blood glucose levels over the past 90 days. It develops when hemoglobin, a protein within red blood cells that carries oxygen throughout your body, bonds with glucose in the blood. Think of it as the sugar you ate over the last three months getting stuck to your red blood cells; the higher your HbA1c, the worse your control of your blood sugar has been. For a prediabetic, that means your days of diabetes meds and finger pricks is getting closer. For a diabetic, that opens the door to many of the worst consequences of diabetes, such as heart and kidney disease, blindness, and nerve damage.

Recently, the American College of Physicians published new guidance statements for the use of medications for controlling HbA1c. A committee of physicians examined the data behind the current standards of treatment for four of the major physician organizations including the American Diabetes Association. In the simplest terms, they wanted to know what benefits or hazards occur when treating adults with type 2 diabetes with medications. Should the goal be to get the HbA1c as low as possible with drugs? Or should the individual be part of the treatment equation?

This is an important issue and the topic for this week. I’m going to review evidence-based medicine on Thursday. You can get the entire story by listening to the Straight Talk on Health on evidence-based medicine, normally available only to Members and Insiders; I cover the entire concept of how EBM began and what it was intended to be. For those of you who haven’t chosen a membership yet, get more info here.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.

 

The Bottom Line on “What the Health”

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“What the hell is going on around here?” That’s one of my favorite sideline videos of Vince Lombardi as he’s talking to his players, and that’s the way I felt after watching this movie. As I said, I’m going to cover one of the studies that was cited several times, but there’s a whole lot more science that warrants explanation; it’s available for Members and Insiders as a Straight Talk on Health audio. Now to the study.
 

“A Vegan Diet Is Better Than ADA Diet”

One of the films experts may be recognizable to some readers: Dr. Neal Barnard, president of the Physicians Committee for Responsible Medicine. He’s a leading proponent of a vegan diet. He led a research group that conducted a study to compare a vegan diet with a diet based on the American Diabetes Association diet guidelines (2). In the film, there were several references to the study that claimed it was more effective than the ADA diet—in fact, twice as powerful at controlling or reversing diabetes as the ADA diet, which included meat and dairy.

Researchers gave both groups dietary guidelines to follow for each diet as well as training with a registered dietician; 49 subjects began in the vegan group while 50 began in the ADA group. The study went 22 weeks and then continued through 74 weeks with the subjects tested periodically. I don’t know the significance of the 22 weeks; those results were not included in the paper.

Here are the results that didn’t quite make the movie:

  • There were no differences in the decrease in blood sugar; both diets reduced fasting blood sugar a similar amount.
  • Fewer than half the people in both groups completed the study.
  • The subjects in both groups claimed to reduce their caloric intake over 400 calories per day. However, weight loss was just ten pounds in the vegan groups and seven pounds in the ADA group. Really? In 74 weeks? Those results are simply not possible unless the subjects did not accurately report what they ate.
  • Finally, this study didn’t show that a vegan diet was twice as beneficial as the ADA diet; it showed that they were both ineffective at achieving reasonable goals for weight loss and a reduction in HbA1c over an extended period of time. While it was statistically significant, a reduction from 8.1% to 7.7% in over a year is not much improvement. Yes, it was better than the ADA diet in which the HbA1c stayed the same, but I wouldn’t start touting the benefits for diabetics just yet.

 

What the Movie Did Right

The only expert who comes through this movie unscathed is Dr. Caldwell Essylstein, the physician from the Cleveland Clinic who has demonstrated in a large clinical trial that severe CVD can be reversed using a low-fat vegan diet. I’m a fan of his work and education program. He was in only a couple of scenes and did not corrupt science in anything he said.

No so for many others in the movie. I just don’t understand why these medical and healthcare professionals would say the things they said. I have more to say, and it’s in the Straight Talk on Health audio for Members and Insiders.

What the movie got right was to provide the research that the experts cited in the movie. It was done scene by scene and makes it easy for anyone to check where the experts got their research facts. Unfortunately, that didn’t stop the research from being misinterpreted by people who know better.
 

The Bottom Line

“What the Health” is a mess of a documentary. It’s not an objective examination of what constitutes a healthy diet; it’s a critique of the food industry and health organizations that get funding from that industry. The problem is that it’s not done very well and never quite gets around to proving what it claims. Maybe they’ll do better next time.

I know a vegan diet is a very healthy way to eat if you do it right. We must move to a more plant-based diet if we’re going to be healthy, and it’s better for the planet as well. While I don’t think it’s the only healthy diet, it’s certainly great if you take the time to learn how to follow it correctly. The problem is that the plants we count on for nutrients may continue to have fewer of them. That’s the topic for next weeks Memos.

What are you prepared to do today?

Dr. Chet

 

References:
1. What the Health. Directed by K. Andersen and K. Kune. 2017.
2. Am J Clin Nutr 2009;89(suppl):1588S–96S

 

“What the Health”: False Sugar Claims

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“Sugar doesn’t cause diabetes!” So says just about every expert in the film “What the Health.” Of all the misstatements in the film, this one is the worst and most dangerous. It isn’t because the statement is false; it’s because of the way it’s presented. Expert after expert looks into the camera and says that excess sugar intake does not cause type 2 diabetes. On top of that, the explanations that they give to justify their position are misleading.

One expert said that sugar will be stored as glycogen in the liver and the muscles and the rest used for energy. That’s correct. Another talked about the Duke University Diet which included rice, sugar, and some fruit and fruit juices; one physician used it to help many people who were too sick for other treatments. All the experts filmed agreed that neither sugar nor carbohydrate caused type 2 diabetes. It just couldn’t.

They are stopping short of telling the truth or intentionally misleading the audience. Sugar doesn’t cause type 2 diabetes if the person does not overeat. The statement about glycogen? True, as I said, but when a person overeats carbohydrates, the liver stores as much glycogen as it can and then converts the rest to fat.

Excess carbohydrates lead to insulin resistance and eventually, type 2 diabetes. The Duke University Diet? That was from the 1940s. It was an ultra low-fat diet with no salt, and was used to treat the sickest patients but only under the care of a physician.

The section on sugar and diabetes was by far the worst. It intentionally misleads people to think that overeating is fine as long as it’s carbohydrates. But there was one study that was cited over and over that’s even worse in my opinion. I’ll cover that on Saturday.

What are you prepared to do today?

Dr. Chet

 

Reference: What the Health. Directed by K. Andersen and K. Kune. 2017.

 

Chelation Therapy: Too Soon to Judge

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The results of the study on chelation therapy in subjects with diabetes showed a reduction in cardiovascular incidents during the follow-up time. No single event dominated, ranging from heart attack to stroke to death, but overall there were fewer incidents. Subjects who did not have diabetes did not experience a benefit in v incidents during the same follow-up time.

That led the researchers to speculate why. They couldn’t come up with any specific reason other than the chelation must involve a mechanism that was not yet identified. They carefully suggested that while the results were positive, this study could only suggest that larger clinical trials were necessary and the findings do not constitute enough evidence to be recommended as a treatment.


Should You Do It?

Here a few more things to consider:

  • The cost: each session costs $90 to $150 and there should be at least 30-40 of them. Add office visits and the total price could be around $5,000; none of it is covered by insurance.
  • All the subjects continued to use their typical medications for diabetes, cholesterol, and blood pressure. This was not replacing traditional treatments, it was in addition to the treatments.
  • The investment of time was significant at three-plus hours once a week or on whatever schedule the patient and doctor agree upon.


The Bottom Line

This study demonstrated a small cardiovascular benefit to the patients, reducing the risk of a cardiovascular event from 35% to 25%. In my opinion, the results are too small to justify the cost of money or time.

I know people who swear by chelation therapy, and I’m happy it worked for them, but there’s too much we don’t know. Nobody tracks what is actually changed in the body during chelation. Where do the heavy metals go? What if someone doesn’t process metals the same way to eliminate them? At this point, there are more questions than answers.

Here’s an idea. Spend the money on more vegetables and fruit for your diet. Invest the three hours per week in additional exercise. Both of those things will give you a better return on your investment than chelation therapy.

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2014;7:15-24