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HOW MANY FACTORS AFFECT BLOOD GLUCOSE?

Posted by Randall W Brown on September 1, 2014 at 11:35 AM Comments comments (0)

HOW MANY FACTORS ACTUALLY AFFECT BLOOD GLUCOSE?

ADAM'S CORNERAUGUST 19, 2014

by Adam Brown

 

twitter summary: Adam identifies at least 22 things that affect blood glucose, including food, medication, activity, biological, & environmental factors.

 

short summary: As patients, we tend to blame ourselves for out of range blood sugars – after all, the equation to “good diabetes management” is supposedly simple (eating, exercise, medication). But have you ever done everything right and still had a glucose that was too high or too low? In this article, I look into the wide variety of things that can actually affect blood glucose - at least 22! – including food, medication, activity, and both biological and environmental factors. The bottom line is that diabetes is very complicated, and for even the most educated and diligent patients, it’s nearly impossible to keep track of everything that affects blood glucose. So when you see an out-of-range glucose value, don’t judge yourself – use it as information to make better decisions.

 

As a patient, I always fall into the trap of thinking I’m at fault for out of range blood sugars. By taking my medication, monitoring my blood glucose, watching what I eat, and exercising, I would like to have perfect in-range values all the time. But after 13 years of type 1 diabetes, I’ve learned it’s just not that simple. There are all kinds of factors that affect blood glucose, many of which are impossible to control, remember, or even account for.

 

Based on personal experience, conversations with experts, and scientific research, here’s a non-exhaustive list of 22 factors that can affect blood glucose. They are separated into five areas – Food, Medication, Activity, Biological factors, and Environmental factors. I’ve provided arrows to show the general effect these factors have on my blood glucose (a sideways arrow indicates a neutral effect), but emphasize that not every individual will respond in the same way (and even within the same person, you may be different from day-to-day or over time). Certain factors may also apply more to type 1 vs. type 2 diabetes (or the other way around). The best way to see how a factor affects you is through personal experience – test your blood glucose more often or wear a CGM and look for patterns. Please email me at adam.brown(at)diaTribe.org with your thoughts on this article or any factors you would add.

 

FOOD

 

Factor

 

Typical Effect on Blood Glucose

 

Comments

 

More Information

 

1. Carbohydrates

 

 

(rapidly)

 

Of all the three sources of energy from food (carbohydrates, protein, and fat), carbohydrates affect my blood glucose the most. Accurately counting carbs is very difficult, and getting the number wrong can dramatically affect blood glucose. The type of carbohydrate also matters – higher glycemic index carbs tend to spike blood glucose more rapidly.

 

Adam’s Corner in diaTribe #58

 

2. Fat

 

 

 

Fatty foods tend to make people with diabetes more insulin resistant, meaning more insulin is often needed to cover the same amount of food relative to a similar meal without the fat. On my pump, I typically use temporary basals or extended boluses (square and dual-wave) to cover high-fat meals. This effect is most notable if you eat a lot of fat at one time – for instance, when snacking on nuts, I’ll observe a steady rise in blood glucose over many hours.

 

Wolpert et al., Diabetes Care 2013

 

3. Protein

 

 

or

 

 

 

If you’ve ever eaten a protein-only meal with very few carbs (e.g., salad with chicken), you may have seen a noticeable rise in blood glucose (~20-50 mg/dl). Though protein typically has little effect on blood glucose, in the absence of insulin, it can raise blood glucose. When I’m eating a carb-free, protein-only meal, I still take a bit of insulin to cover it (usually an equivalent of about 10-15 g of carbs)

 

Franz, Diabetes Educator 1997

 

 

Smart et al, Diabetes Care 2013

 

 

4. Caffeine

 

 

or

 

 

 

Many studies have suggested that caffeine increases insulin resistance and stimulates the release of adrenaline. Personally, I know that if I have a cup of coffee, I’ll see at least a 20-30 mg/dl rise in blood glucose, particularly in the morning when I’m more insulin resistant.

 

Lane, Journal of Caffeine Research 2011

 

5. Alcohol

 

 

or

 

 

Normally, the liver releases glucose to maintain blood sugar levels. But when alcohol is consumed, the liver is busy breaking the alcohol down, and it reduces its output of glucose into the bloodstream. This can lead to a drop in blood sugar levels if the alcohol was consumed on an empty stomach. However, alcoholic drinks with carbohydrate-rich mixers (e.g., orange juice) can also raise blood sugar. When drinking alcohol, make sure you test your blood glucose often and that someone responsible nearby knows you have diabetes.

 

American Diabetes Association

 

 

UCSF

 

 

Joslin

 

 

MEDICATION

 

Factor

 

Typical Effect on Blood Glucose

 

Comments

 

More Information

 

6. Medication dose

 

 

or

 

 

 

For those of us with diabetes on any medication (pills or insulin injections), the dose of medication directly impacts blood glucose – in most cases (but not always), taking a higher dose of a diabetes medication means a greater blood glucose-lowering effect

 

Your medication’s label and package insert

 

7. Medication timing

 

 

or

 

 

 

In addition to dose, medication timing can also be critical. For instance, taking rapid-acting insulin (Humalog, Novolog, Apidra, and Afrezza) 20 minutes before a meal is ideal for me - it leads to a lower spike in glucose vs. taking it at the start of the meal or after the meal has concluded. Note that this works best for me, although this can vary among individuals – please consult your health care provider to discuss the optimal timing of insulin. The timing of many type 2 diabetes medications matters a lot – some can consistently be taken at any time of day (e.g., Januvia, Victoza), while others are most optimally taken at meals (e.g., metformin).

 

Your medication’s label and package insert

 

8. Medication Interactions

 

 

or

 

 

 

Non-diabetes medications can interfere with your diabetes medications and blood glucose. Consult the information included in both your diabetes and non-diabetes medications.

 

ADA’s My Medicine Tracker

 

 

ACTIVITY

 

Factor

 

Typical Effect on Blood Glucose

 

Comments

 

More Information

 

9. Light exercise

 

 

 

Light activity can have a surprising glucose-lowering effect – I find that walking tends to lower my blood sugar by about 1 mg/dl per minute. I have seen drops as large as 46 mg/dl in 20 minutes, more than 2 mg/dl per minute and others see even more.

 

Adam’s Corner in diaTribe #51

 

10. High-intensity and moderate exercise

 

 

or

 

 

 

Exercise is often positioned as something that always lowers blood glucose; however, high-intensity exercise, such as sprinting or weight lifting, can sometimes raise blood glucose. This stems from the adrenaline response, which tells the body to release stored glucose. Often, I find this happens when I’m exercising in the morning on an empty stomach. But this is not a reason to avoid high intensity exercise – studies show it can improve blood glucose for one to three days post-exercise! Note that in some cases high-intensity exercise can also drop blood glucose very rapidly (2-3 mg/dl per minute), especially if you have insulin on board in your pump. The best way to see how individual exercise sessions affect your blood glucose is to test prior and after activity.

 

“The Impact of brief, high-intensity exercise on blood glucose levels” (Diabetes Metab Syndr Obes 2013)

 

 

BIOLOGICAL

 

Factor

 

Typical Effect on Blood Glucose

 

Comments

 

More Information

 

11. Dawn phenomenon

 

 

 

The “dawn phenomenon” occurs in people with and without diabetes. The term refers to the body’s daily production of hormones around 4:00-5:00 AM. During this time, the body makes less insulin and produces more glucagon, which raises blood glucose. The best way to figure out how dawn phenomenon affects you is to wear a CGM or wake up and test your blood glucose early in the morning. If you take insulin, you may need to time your dose to cover this early morning rise in glucose. Note that not everyone experiences dawn phenomenon, but it is common!

 

Dawn phenomenon (ADA)

 

12. Infusion set issues (e.g., length of wear, occlusions, air bubbles)

 

 

 

Infusion sets are not as well understood as we would like, and a huge number of factors can lead to higher glucose levels: air bubbles in the tubing, an occluded cannula, an infected site, or even the location of the set. If you wear a pump and your glucose is unexpectedly high, a good first step is to change your set out. I find that my glucose always tends to run higher on the third day of wearing an infusion set. In addition, I tend to get the best absorption wearing sets in my buttocks and the worst absorption in my legs – yet again, this varies among patients.

 

“Insulin Infusion Set: The Achilles Heel of Continuous Subcutaneous Insulin Infusion” (JDST 2012)

 

13. Scar tissue and lipodystrophy

 

 

 

Using the same sites on the body for injections or infusion sets can lead to lipodystrophy and scar tissue buildup – these result in erratic absorption of insulin, leading to glycemic variability and making it harder to spend more time in range. To avoid these issues, rotate your injection/infusion sites and don't reuse needles.

 

Common Insulin Injection Challenges (BD)

 

 

Insulin Pump Therapy (AADE)

 

14. Insufficient Sleep

 

 

 

In my experience, I have found that I need nearly 25% more insulin on days following less than seven hours of sleep; my highest blood glucose of the day is even higher on days following little sleep; and my glucose is 21% more variable when I do not sleep enough. These findings are consistent with many studies, which have found that not getting enough sleep leads to worse diabetes control, insulin resistance, weight gain, and increased food intake.

 

Adam’s Corner in diaTribe #53 – see my full length article on sleep and glucose control for a more comprehensive list of related research studies

 

15. Stress and illness

 

 

 

Stress and illness can cause the body to release epinephrine (adrenaline), glucagon, growth hormone, and cortisol. As a result, more glucose is released from the liver (glucagon, adrenaline) and the body can become less sensitive to insulin (growth hormone, cortisol). In some cases, people are much more insulin sensitive right before getting sick and can tend to run low blood sugars. Personally, I have found exercise, time outside, and meditation to be most helpful against combatting stress.

 

UCSF Diabetes Education

 

 

ADA

 

16. Allergies

 

 

 

Though I have not found any studies on this topic, some patients report higher glucose levels when they have allergies. Some have speculated that it’s due to the stress hormone cortisol.

 

Can allergies raise glucose level? (Diabetes Forums)

 

 

Allergies and Blood Sugar (TuDiabetes)

 

 

17. A higher glucose level (“glucotoxicity”)

 

 

 

Hyperglycemia can lead to a state known as “glucotoxicity,” which can actually cause insulin resistance. Have you ever needed to correct a very high blood sugar with much more insulin than your correction factor would suggest? I find that simply having a high blood glucose for many hours makes me appear much more insulin resistant.

 

Vuorinen-Markkola et al., Diabetes 1992

 

 

Kim et al., Circulation 2006

 

18. Periods (Menstruation)

 

 

or

 

 

 

There is not a definite answer to the question of how periods affect women’s blood sugars. Many women report having higher blood sugar levels a few days prior to their period starting, but some women notice a sharp drop in sugar levels. To figure out how you respond, your best bet is to test your blood glucose often during this time of month.

 

Periods (Menstruation) and Diabetes (Diabetes UK)

 

 

Why are my blood sugars affected by my period? (DiabetesSisters)

 

19. Smoking

 

 

 

Some studies suggest that smoking can increase insulin resistance, and people with diabetes who smoke are more likely than nonsmokers to have trouble with insulin dosing and managing their diabetes. Smokers also have higher risks for serious complications.

 

CDC

 

 

Chiolero et al, AJCN 2008

 

 

 

ENVIRONMENTAL

 

Factor

 

Typical Effect on Blood Glucose

 

Comments

 

More Information

 

20. Insulin that has gone bad

 

 

 

I’ve fried my insulin by exposing it to direct sunlight or leaving it in the car on a hot day. If your insulin is normally clear, but suddenly turns cloudy, that could signal it has gone bad (note: NPH is always cloudy). Aside from a change in appearance, it can be hard to know if a vial of insulin has actually gone bad unless you try a new one. I’ve found that insulin that has “gone bad” will typically still work, but just not as well – I may need more insulin than I think to bring my glucose down, and the insulin may work unpredictably. Unopened insulin should be stored in a refrigerator at approximately 36-46 °F. According to the FDA, insulin can be left unrefrigerated at a temperature from 59-86 °F for up to 28 days.

 

Information regarding insulin storage (FDA)

 

21. An accurate blood glucose reading

 

 

 

While this seems fairly obvious, I often find myself testing multiple times in a row, since I do not believe the initial value – in many cases, the second time I get a much lower value, and it’s because I failed to wash my hands. For a meter that needs a tiny 0.3 microliter blood sample (the smallest currently on the market), a speck of glucose on the finger the weight of a dust particle will increase the reading by 300 mg/dl! I recommend retesting if you don’t believe the value on the meter; if you wear CGM, it’s great to reality check the meter value against your sensor reading. The diabetes online community has also done a lot of work advocating for more accurate blood glucose testing supplies – you can read more about their campaign here.

 

Glucose Monitoring After Fruit Peeling (Diabetes Care 2011)

 

22. Altitude

 

?

 

Though most studies related to diabetes and altitude concern the accuracy of blood glucose meters, there are some reports that altitude can increase insulin resistance. I’ve found that when I go to high altitude regions like Colorado, I need about 20-30% more basal insulin. However, if you go to a high altitude place to do activity (e.g., skiing), you may find that you need less insulin.

 

High Altitude Diabetes (A Sweet Life)

 

 

Blood Glucose and Altitude (Diabetes Forecast)

 

Postscript: Following publication, many readers have written me with additional factors that seem to affect blood glucose: sunburn, allergic reactions, administration of steroids, niacin, celiac disease, ambient temperature, hydration.

 

[Editor’s Note: Adam is a patient with diabetes and not a health care provider. Please consult with your health care provider before making any changes to your diet, insulin, or medication regimen.]

 

Adam is Senior Editor of diaTribe and Chief of Staff/Head, Diabetes Technology at Close Concerns. He is a graduate of the University of Pennsylvania and serves on the board of the San Francisco branch of JDRF. He was diagnosed with type 1 diabetes at the age of 12 and has worn an insulin pump for the last 12 years and a CGM for the past four years. Adam is passionate about exercise, nutrition, and wellness and spends his free time outdoors and staying active. He can be contacted at adam.brown(at)diatribe.org or @asbrown1 on twitter.

 

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DIABETIC NEUROPATHY INPROVED WITH VEGAN DIET

Posted by Randall W Brown on September 1, 2014 at 11:30 AM Comments comments (0)

Diabetic Neuropathy Improved with Vegan Diet

A randomized controlled trial indicates that a vegan diet may be beneficial in relieving diabetic nerve pain....

Diabetic peripheral neuropathy, which occurs in about half of all patients with type 2 diabetes, is underdiagnosed, and this is partly because physicians aren"t able to offer anything to treat the underlying cause of this condition, and the current treatments provided to these patients only treat the pain. The vegan diet is a plant-based diet, and studies show that it can help ease the pain caused by diabetic neuropathy. In an earlier observational study conducted by Crane and Sample, 21 type 2 diabetes patients with nerve pain were put on a low-fat, high-fiber vegan diet for 1 month, and 81% of the participants achieved complete pain relief and lost around 11 lbs on average. Additionally, the diet enabled most of these patients to reduce their diabetes medications and blood pressure medications.

 

Anne Bunner, PhD, and Caroline Trapp, MSN, of the Physicians Committee for Responsible Medicine, sought to see whether these same benefits could be seen in a randomized controlled trial. They conducted the Dietary Intervention for chronic diabetic Neuropathy pain (DINE) study, in which 15 patients with type 2 diabetes and diabetic neuropathy were randomized to either a low-fat, high-fiber, vegan diet and B12 supplementation or B12 supplementation alone. The patients had a mean age of 57, half of them were female, and half had a college education or higher. Bunner noted that there tended to be a deficiency in B12 in diabetic patients, especially those taking metformin. The participants who were put on the diet had to attend 20 weekly nutrition classes involving nutrition education, social support, cooking demonstrations, and food product sampling, eat plant-based foods that had a low glycemic index, get at least 40 grams of fiber per day, and limit their consumption of fatty foods, such as oils and nuts, to 20-30 grams per day. Since high-fiber foods were low in calories, there were no portion limits.

 

Five out of the seven patients that were put on the vegan diet were fully adherent. According to Bunner and Trapp, with good adherence, the participants that were put on the diet along with the vitamin reported greater improvements in McGill Pain Questionnaire pain scores (p=0.04) and significantly greater reductions in body mass index (p=0.01) when comparted with the control group.

 

The results of the study indicated that there were also improvements in cholesterol, HbA1c, neuropathy symptom scores (NTSS-6), and quality-of-life scores in which the changes differed significantly from the baseline, but these improvements were not significantly greater in the diet group when compared to the control group. There was a greater decrease in cholesterol and HbA1c in the diet group, but many of the patients in the diet group discontinued their lipid medications and diabetes medications, while those in the control group were put one more lipid medications and diabetes medications, so the graphs were artificially lowered. Participants on the vegan diet had significant improvement in NTSS-6 and similar changes in quality-of-life scores not matched by the control group, but at the end of the trial, the differences among both groups were not significant, which Bunner believes may have possibly been due to the small number of patients or maybe even the effect of participating in the study on the control group. The researchers plan to follow their study participants for 1 year to examine the long-term effects exhibited in these patients. They believe the study has shown that a dietary intervention can provide promising potential for treating diabetic nerve pain.

 

Practice Pearls:

In this study, the patients with type 2 diabetes and diabetic neuropathy that were randomized to a low-fat, high-fiber, vegan diet and B12 supplementation reported greater improvements in McGill Pain Questionnaire pain scores and significantly greater reductions in body mass index than the patients receiving the B12 supplementation alone.

The control group also resulted with improvements in cholesterol, HbA1c, neuropathy symptom scores (NTSS-6), and quality-of-life scores in which the changes differed significantly from the baseline, but these improvements were not significantly greater in than the control group.

The researchers believe that the results of this study have shown that a vegan diet can provide promising potential for treating diabetic nerve pain.

 

 

40 OF AMERICANS WILL DEVELOPE DIABETES

Posted by Randall W Brown on September 1, 2014 at 11:30 AM Comments comments (0)

CDC: 40% of American Adults Will Develop Diabetes

In Hispanic men and women, and non-Hispanic black women, the projected increased risk is even higher, over 50%....

Researchers from the CDC incorporated data about diabetes incidence from the National Health Interview Survey, and linked data about mortality from 1985 to 2011 for 598,216 adults, into a Markov chain model to estimate remaining lifetime diabetes risk, years spent with and without diagnosed diabetes, and life-years lost due to diabetes in three cohorts: 1985-89, 1990-99, and 2000-11. Diabetes was determined by self-report and was classified as any diabetes, excluding gestational diabetes. They used logistic regression to estimate the incidence of diabetes and Poisson regression to estimate mortality.

 

On the basis of 2000-11 data, lifetime risk of diagnosed diabetes from age 20 years was 40.2% (95% CI 39.2-41.3) for men and 39.6% (38.6-40·5) for women, representing increases of 20 percentage points and 13 percentage points, respectively, since 1985-89. The highest lifetime risks were in Hispanic men and women, and non-Hispanic black women, for whom lifetime risk now exceeds 50%. The number of life-years lost to diabetes when diagnosed at age 40 years decreased from 7.7 years (95% CI 6.5-9.0) in 1990-99 to 5.8 years (4.6-7.1) in 2000-11 in men, and from 8.7 years (8.4-8.9) to 6.8 years (6.7-7.0) in women over the same period. Because of the increasing diabetes prevalence, the average number of years lost due to diabetes for the population as a whole increased by 46% in men and 44% in women. Years spent with diabetes increased by 156% in men and 70% in women.

 

The researchers concluded that continued increases in the incidence of diagnosed diabetes combined with declining mortality have led to an acceleration of lifetime risk and more years spent with diabetes, but fewer years lost to the disease for the average individual with diabetes. These findings mean that there will be a continued need for health services and extensive costs to manage the disease, and emphasize the need for effective interventions to reduce incidence.

 

Practice Pearls:

Approximately 40% of American adults will develop diabetes in their lifetime

Obesity is the main factor behind the rise of diabetes development

Hispanic men and women and non-Hispanic black women have the highest risk of developing diabetes.

Hackethal V. 2 in 5 American Adults will develop diabetes. The Lancet, Diabetes & Endocrinology

 

http://www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70161-5/fulltext

 

 

 

LOW CARB DIET RECOMMENDED

Posted by Randall W Brown on September 1, 2014 at 11:30 AM Comments comments (0)

Low-carb Diet Recommended for Type 1 and 2 Diabetes Patients

Low-carbohydrate diets should be the first line of attack for treatment of type 2 diabetes, and should be used in conjunction with insulin in those with type 1 diabetes...

Conducted by a consortium of 26 physicians and nutrition researchers, the study suggests the need for a reappraisal of dietary guidelines due to the inability of current recommendations to control the epidemic of diabetes. The authors point to the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk or general health, and to the persistent reports of serious side effects of commonly prescribed diabetes medications. By comparison, the authors refer to the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects.

 

Barbara Gower, Ph.D., professor and vice chair for research in the UAB Department of Nutrition Sciences and one of the study authors, stated that, "Diabetes is a disease of carbohydrate intolerance." "Reducing carbohydrates is the obvious treatment. It was the standard approach before insulin was discovered and is, in fact, practiced with good results in many institutions. The resistance of government and private health agencies is very hard to understand."

 

The authors say their review of the medical literature shows that low-carbohydrate diets reliably reduce high blood sugar and at the same time show general benefit for risk of cardiovascular disease.

 

Richard David Feinman, Ph.D., professor of cell biology at SUNY Downstate Medical Center and lead author of the paper, added that, "We've tried to present clearly the most obvious and least controversial arguments for going with carbohydrate restriction." "Here we take a positive approach and look to the future, while acknowledging this paper calls for change. The low-fat paradigm, which held things back, is virtually dead as a major biological idea. Diabetes is too serious a disease for us to try to save face by holding onto ideas that fail."

 

Gower added that, "For many people with type 2 diabetes, low-carbohydrate diets are a real cure," said Gower. "They no longer need drugs. They no longer have symptoms. Their blood glucose is normal, and they generally lose weight."

 

The authors caution that people with diabetes who are already on drugs for type 2 diabetes or are on standard amounts of insulin should undertake conversion to a low-carbohydrate diet only with the help of a physician. Because the diet may have a similar sugar-lowering effect, it is critical that drug doses be tapered off in order to avoid dangerous low blood sugar.

 

Practice Pearls - As with all diabetes clinical recommendations, these should be tempered to meet the individual needs and circumstances of the patient. The 12 points of evidence from the study backed up by clinical studies are:

 

High blood sugar is the most salient feature of diabetes. Dietary carbohydrate restriction has the greatest effect on decreasing blood glucose levels.

During the epidemics of obesity and type 2 diabetes, caloric increases have been due almost entirely to increased carbohydrates.

Benefits of dietary carbohydrate restriction do not require weight loss.

Although weight loss is not required for benefit, no dietary intervention is better than carbohydrate restriction for weight loss.

Adherence to low-carbohydrate diets in people with type 2 diabetes is at least as good as adherence to any other dietary interventions and frequently is significantly better.

Replacement of carbohydrates with proteins is generally beneficial.

Dietary total and saturated fats do not correlate with risk of cardiovascular disease.

Plasma-saturated fatty acids are controlled by dietary carbohydrates more than by dietary lipids.

The best predictor of microvascular and, to a lesser extent, macrovascular complications in patients with type 2 diabetes is glycemic control (HbA1c).

Dietary carbohydrate restriction is the most effective method of reducing serum triglycerides and increasing high-density lipoprotein.

Patients with type 2 diabetes on carbohydrate-restricted diets reduce and frequently eliminate medication. People with type 1 usually require less insulin.

Intensive glucose-lowering by dietary carbohydrate restriction has no side effects comparable to the effects of intensive pharmacologic treatment.

Nutrition July 2014

 

 

TCOYD CONFERENCES

Posted by Randall W Brown on August 20, 2014 at 8:25 PM Comments comments (0)

Mark your calendars for September. TCOYD Conferences coming to Missoula, Mt on September 6th, then to Des Moines, Iowa on September 27th.

These have lots of info, speakers and ono on one with the experts.

You can inform yourself by attending a conference. It will help you take control of your diabetes.

Very low costs for what you get!

Come to one conference and you will be hooked. It will change your life.

TYPE 2 Diabetes PATIENT BENEFIT FROM VIDEO GAMES

Posted by Randall W Brown on August 20, 2014 at 8:20 PM Comments comments (0)

Type 2 Diabetes Patient Benefit from Video Games

Playing Nintendo's Wii Fit Plus led to improvements in many diabetic measurements....

In a recent randomized controlled trial, German researchers analyzed the effects of playing an interactive exercise video game would have on diabetic patients. By asking 120 type 2 diabetic patients to participate in a 12 week video game program on the Nintendo Wii called 'Wii Fit Plus' and then comparing their diabetic measurements to 100 type 2 diabetic patients who did not play the video, researchers were able to see if there was a health improvement for the intervention group. The age range for all participants was 50 – 75.

 

After the 12 weeks, the group that played the game was found to have improved A1C levels (from 7.1% to 6.8%; P=.0002), reductions in fasting blood glucose (from 135.8 mg/dL to 126.6 mg/dL; P=.04), reductions in weight (from 97.6 kg to 96.3 kg; P<.001), and reductions in BMI (from 34.1 to 33.5; P<.001) compared to the control group. In addition to improvements in diabetic parameters, the intervention group was found to report higher improvements in well-being and quality of life as compared to the control group.

 

This study demonstrates that interactive video games could provide type 2 diabetic patients with activities that are fun and convenient as well as healthy.

 

Practice Pearls:

Playing Nintendo's Wii Fit Plus for 12 weeks lead to lower A1C measurements, lower fasting blood glucose levels, weight reductions, and BMI reductions in type 2 diabetic patients.

Diabetic patients reported improvements in quality of life and wellbeing after playing Nintendo's Wii Fit Plus for 12 weeks.

Interactive video games may be an effective and convenient way to improve the health of type 2 diabetic patients.

BMC Endocrine Disorders, December 2013

 

 

 

BARIATRIC SURGERY vs Intensive medical Thereapy

Posted by Randall W Brown on August 20, 2014 at 8:20 PM Comments comments (0)

Weight Loss Surgery More Successful Than Usual Care in Treatment of Type 2 Diabetes

Diabetic patients who received bariatric surgery saw greater weight loss and fewer macrovascular and microvascular complications than those treated with usual care....

 


Swedish researchers reported in a study that fifteen years after having bariatric surgery, 30% of patients were no longer considered diabetic compared to only 7% of patients who received usual care.

 

Of patients recruited between September 1987 and January 2001, 260 of 2,037 control patients and 343 of 2,010 bariatric surgery patients had type 2 diabetes at baseline. The bariatric surgery patients had either vertical banded gastroplasty, non-adjustable or adjustable banding, or Roux-en-Y gastric bypass. The patients had a mean age of 50, a BMI of 41, 60% were women, and all participants chosen had had type 2 diabetes for an average of 3 years. Primary endpoints measured were diabetes remission, relapse, and incidence of diabetes related complications. Remission was characterized as having a fasting blood glucose level below 110mg/dL and not taking any antidiabetic medications. Study limitations were lack of randomization and a significant loss of participants after 15 years.

 

Patients in the control group received normal lifestyle and pharmacological treatment for both obesity and diabetes at their primary health facility. Both groups had identical follow-up throughout the study.

 

Those patients who received bariatric surgery had higher remission rates (30% vs 7% at 15 years) and greater weight loss (22.5kg vs 4.4kg at 10 years) as compared with those who received usual care. However, one thing to note was that 2 years post-surgery, 72% of patients were in remission. This tells us that a significant number of patients relapsed.

 

Bariatric surgery was also associated with a decreased risk for macrovascular (31.7 vs 44.2 in 1000 patients) and microvascular complications (20.6 vs 41.8 per 1000 patients). The study cited that bariatric surgery was associated with a 20 year reduced incidence of myocardial infarction. Tight glycemic control with lifestyle changes and pharmacologic treatment may reduce the incidence of microvascular disease but this kind of control is hard for many patients to achieve. Lifestyle changes have not statistically reduced diabetes-associated macrovascular disease.

 

Dr. Anne Cappola, from the Perelman School of Medicine at the University of Pennsylvania and an associate editor for JAMA believes these findings


"validate the expectations of bariatric surgery."

 

Practice Pearls:

Bariatric surgery was associated with more frequent remission and fewer complications in patients with type 2 diabetes than usual care.

Due to ethical considerations a randomized design was not approved because of high post-op mortality rates in preceding bariatric surgeries and therefore brings in some questions as to the validity of the study.

Data on complications associated with diabetes was limited in the study and only included complications severe enough to be treated by a specialist and not more minor complications that were treated by primary care.

Sjostrom, Lars MD, Peltonen, Markku PhD, Jacobson, Peter MD, et al. Association of Bariatric Surgery With Long-term Remission of Type 2 Diabetes and With Microvascular and Macrovascular Complications. JAMA. 2014;311(22):2297-230

EARLY INSULIN DELAYS DIABETES

Posted by Randall W Brown on August 20, 2014 at 8:15 PM Comments comments (0)

Early Insulin Delays Diabetes But Are There Negative Consequences?

One researcher comments, "Please don't fall into this trap that you can prevent diabetes with insulin."…

 


For patients with impaired glucose tolerance or early diabetes, use of insulin glargine (Lantus) was the best predictor of maintaining a lower hemoglobin A1c (HbA1c) level over 5 years, according to a subanalysis of the ORIGIN trial.

 

Patients on the long-acting insulin had a nearly threefold higher likelihood of maintaining a lower HbA1c over that time (OR 2.98, 95% CI 2.67 to 3.32, P<0.001), Matthew Riddle, MD, of Oregon Health & Science University, reported during a symposium at the European Association for the Study of Diabetes meeting.

 

But Thomas Pieber, MD, of the Medical University of Graz in Austria, warned that clinicians shouldn't necessarily start patients on insulin early in the disease process just to maintain glycemic control.

 

Pieber offered several criticisms of the study, noting that annual mortality rates were about twice as high in ORIGIN as they were in similar large diabetic trials -- including ADDITION, ADVANCE, ACCORD, and PROactive -- which weren't explained by differences in age, diabetes duration, smoking, or hypertension.

 

The ORIGIN trial did have a large proportion of patients with cardiovascular disease at baseline, at about 60%, he said, but that wasn't the highest rate. All patients in the PROactive trial had prior heart disease, but they still had a much lower mortality rate than seen in ORIGIN.

 

Pieber also noted that patients on insulin in the ORIGIN trial had a threefold increase in severe hypoglycemia – a "substantial side effect without any clinical benefit" in mortality or cardiovascular events, he said.

 

And while ORIGIN investigators have touted a 30% relative risk reduction in new diabetes cases, Pieber said the absolute risk reduction is only on the order of 6.5%, with a number needed to treat of 15.

 

"I don't think this is really preventing diabetes," he said. "Please don't fall into this trap that you can prevent diabetes with insulin."

 

Top-line results of the ORIGIN (Outcome Reduction with an Initial Glargine Intervention) trial were reported at the American Diabetes Association meeting in Philadelphia last June, showing no increased risk of cancer or cardiovascular disease with long-term insulin use in patients who had early signs of or had recently been diagnosed with diabetes.

 

Riddle and colleagues conducted a sub-analysis of data from the trial, characterizing patients by their diabetes status, and looking at predictors of maintaining target HbA1c levels.

 

Of 12,537 patients enrolled in the study, 88% had diabetes, while the rest had impaired fasting glucose or impaired glucose tolerance. They were randomized to once-daily insulin glargine or to standard care.

 

Standard care for those without diabetes involved yearly screening for the disease, and diabetic patients were managed by clinician judgment with no insulin until they were uncontrolled on at least two oral antidiabetic agents.

 

As expected, Riddle said, diabetic patients randomized to insulin glargine had a higher HbA1c at baseline than those without diabetes who went on insulin, and the same pattern held for those given standard therapy.

 

He and colleagues found that all patients on insulin glargine had better drops in fasting plasma glucose and HbA1c, both of which were more pronounced in diabetic patients. And more patients in both groups maintained an HbA1c below 6.5% at 5 years with insulin use (87% versus 79% for nondiabetics, 60% versus 45% for diabetics).

 

Having diabetes and a higher baseline HbA1c both independently predicted a lower chance of being able to achieve an HbA1c below 6.5% at 5 years, they found (OR 0.31, 95% CI 0.24 to 0.40, P<0.001 and OR 0.19, 95% CI 0.18 to 0.21, P<0.001, respectively).

 

On the other end of the spectrum, using insulin glargine was associated with a nearly threefold higher likelihood of maintaining the target HbA1c over that time (OR 2.98, 95% CI 2.67 to 3.32, P<0.001).

 

Oddly, Riddle said, moderate alcohol intake -- at least two drinks a week -- also made it more likely to hit that HbA1c target (OR 1.61, 95% CI 1.41 to 1.84, P<0.001).

 

He concluded that giving insulin early in dysglycemia – whether it's impaired glucose tolerance or early diabetes -- can help patients achieve target HbA1c levels in the long term.

 

Practice Pearls:

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Explain that a subanalysis of the ORIGIN trial found that use of insulin glargine in dysglycemia was associated with a higher likelihood of achieving a low target hemoglobin A1c (HbA1c) level.

Note that critiques of the study questioned whether use of insulin to achieve lower HbA1c levels is safe, cost-effective, and appropriate to be considered prevention of the development of type 2 diabetes.

European Association for the Study of Diabetes; Riddle MC, et al "Unpublished results from the ORIGIN trial" EASD 2012.

 

 

 

LOW CARB DIET RECOMMENDED

Posted by Randall W Brown on August 20, 2014 at 8:15 PM Comments comments (0)

Low-carb Diet Recommended for Type 1 and 2 Diabetes Patients

Low-carbohydrate diets should be the first line of attack for treatment of type 2 diabetes, and should be used in conjunction with insulin in those with type 1 diabetes....

 


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Conducted by a consortium of 26 physicians and nutrition researchers, the study suggests the need for a reappraisal of dietary guidelines due to the inability of current recommendations to control the epidemic of diabetes. The authors point to the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk or general health, and to the persistent reports of serious side effects of commonly prescribed diabetes medications. By comparison, the authors refer to the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects.

 

Barbara Gower, Ph.D., professor and vice chair for research in the UAB Department of Nutrition Sciences and one of the study authors, stated that, "Diabetes is a disease of carbohydrate intolerance." "Reducing carbohydrates is the obvious treatment. It was the standard approach before insulin was discovered and is, in fact, practiced with good results in many institutions. The resistance of government and private health agencies is very hard to understand."

 

The authors say their review of the medical literature shows that low-carbohydrate diets reliably reduce high blood sugar and at the same time show general benefit for risk of cardiovascular disease.

 

Richard David Feinman, Ph.D., professor of cell biology at SUNY Downstate Medical Center and lead author of the paper, added that, "We've tried to present clearly the most obvious and least controversial arguments for going with carbohydrate restriction." "Here we take a positive approach and look to the future, while acknowledging this paper calls for change. The low-fat paradigm, which held things back, is virtually dead as a major biological idea. Diabetes is too serious a disease for us to try to save face by holding onto ideas that fail."

 

Gower added that, "For many people with type 2 diabetes, low-carbohydrate diets are a real cure," said Gower. "They no longer need drugs. They no longer have symptoms. Their blood glucose is normal, and they generally lose weight."

 

The authors caution that people with diabetes who are already on drugs for type 2 diabetes or are on standard amounts of insulin should undertake conversion to a low-carbohydrate diet only with the help of a physician. Because the diet may have a similar sugar-lowering effect, it is critical that drug doses be tapered off in order to avoid dangerous low blood sugar.

 

Practice Pearls - As with all diabetes clinical recommendations, these should be tempered to meet the individual needs and circumstances of the patient. The 12 points of evidence from the study backed up by clinical studies are:

 

High blood sugar is the most salient feature of diabetes. Dietary carbohydrate restriction has the greatest effect on decreasing blood glucose levels.

During the epidemics of obesity and type 2 diabetes, caloric increases have been due almost entirely to increased carbohydrates.

Benefits of dietary carbohydrate restriction do not require weight loss.

Although weight loss is not required for benefit, no dietary intervention is better than carbohydrate restriction for weight loss.

Adherence to low-carbohydrate diets in people with type 2 diabetes is at least as good as adherence to any other dietary interventions and frequently is significantly better.

Replacement of carbohydrates with proteins is generally beneficial.

Dietary total and saturated fats do not correlate with risk of cardiovascular disease.

Plasma-saturated fatty acids are controlled by dietary carbohydrates more than by dietary lipids.

The best predictor of microvascular and, to a lesser extent, macrovascular complications in patients with type 2 diabetes is glycemic control (HbA1c).

Dietary carbohydrate restriction is the most effective method of reducing serum triglycerides and increasing high-density lipoprotein.

Patients with type 2 diabetes on carbohydrate-restricted diets reduce and frequently eliminate medication. People with type 1 usually require less insulin.

Intensive glucose-lowering by dietary carbohydrate restriction has no side effects comparable to the effects of intensive pharmacologic treatment.

Nutrition July 2014

 

 

Join Your Local MOVE Program at the VA

Posted by Randall W Brown on August 9, 2014 at 1:20 PM Comments comments (0)

Do you need to lose weight? Learn how to take control of your diet, diabetes. See your Doctor about getting in the MOVE program at your VA.


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