Health for life

People with diabetes experience depression more often than people without diabetes.

Does having diabetes raise your risk of developing depression? Or is it the other way around ... Does experiencing depression raise your risk of developing diabetes?

No definitive answer to that question exists. In fact, the two may be inextricably intertwined. That did not deter a group of Johns Hopkins researchers from seeking to tease the two conditions apart. Their findings were reported in the June 18 issue of JAMA:

Examining A Bidirectional Association Between Depressive Symptoms And Diabetes

The study had two parts. The cohort used was the Multi-Ethnic Study of Atherosclerosis (MESA study), a group of US adults followed for about 3 years.

The first part involved 5201 participants without diabetes. Their findings:

"The crude incidence of type 2 diabetes over 3.2 years was 22.0 per 1000-person years for those with elevated depressive symptoms and 16.6 per 1000 person-years for those without elevated depressive symptoms."

So, there was a small increase in risk for diabetes in individuals experiencing depression. This difference, however, was partially lessened when lifestyle factors (smoking history, caloric intake, alcohol use, physical activity level) were considered. It is possible that the same lifestyle factors that put someone at risk for depression (physical inactivity, higher caloric intake with weight gain), also increase their risk for diabetes.

The second part involved 4847 participants without depressive symptoms. Their findings:

"Individuals with untreated type 2 diabetes were not at increased risk of developing elevated depressive symptoms, those with treated type 2 diabetes were at increased risk of developing elevated depressive symptoms. ... Treated type 2 diabetes was associated with a 52% higher odds of developing elevated depressive symptoms."

That last finding, where untreated patients did not experience depression but treated patients did, led the authors to conclude:

"Clinicians should be aware of increased risk of elevated depressive symptoms in individuals with treated type 2 diabetes and consider routine screening for depressive symptoms among these patients."

What is it about treatment for diabetes that raises risk for depression?

The authors speculate that psychological stress associated with diabetes management may contribute. Also, if youre being treated, youre likely to have a number of complications which by themselves could increase the risk for depression.

Pharmaceuticals are not the answer to cure or treat diabetes. Avandia is the latest drug to be questioned for its efficacy and side effects that increase the risk of heart attack by a whopping 43%. The Commission on Human Medicines in Great Britain has recommended pulling the drug because its risks outweigh the benefits.

The results of two studies published in Diabetes Care, one in 2006¹, and one in 2007², both led by Dr. Duk-Hee Lee, reveal a significant association between environmental pesticides and type 2 diabetes.

The first study was a cross sectional analysis involving 2,016 adult participants from the National Health and Nutrition Examination Survey of 1999–2000. It examined the relationship between toxic persistent organic pollutants (POPs) and diabetes.

After adjusting for age, sex, race/ethnicity, poverty income ratio, BMI, and waist circumference, the odds ratios (ORs) were 1.0, 16.9, 15.8, 36.7, and 38.0 (P for trend < 0.001), for five categories of exposure. That means there was a 38-fold greater odds of having diabetes for those in the highest exposure group compared to those in the lowest exposure group.*

Another interesting finding of this study was that being obese was not associated with having diabetes if the subjects blood levels of POPs were low. So, being thin but having high levels of POPs could place you at greater risk for diabetes than being overweight but having low levels.


* This study cited the source of many of these toxins: "Greater than 90% of POPs comes from animal foods in the general population without occupational or accidental exposures."
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The second study was a cross-sectional analysis involving 749 nondiabetic adults. It examined the relationship between POPs and insulin resistance.

The adjusted odds ratios were 1.8 for being equal to or above the 50th percentile for insulin resistance, 4.4 for the 75th percentile, and 7.5 for the 90th percentile. So, there was almost an 8-fold greater odds of having insulin resistance for those in the highest exposure group than the lowest.

The strongest associations were found for organochlorine (OC) pesticides or nondioxin-like polychlorinated biphenyls (PCBs).

An interesting finding of this study was that the association between OC pesticides and insulin resistance strengthened as waist circumference increased, suggesting that POPs may interact with obesity to increase the risk of type 2 diabetes.
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Finally, a commentary that appeared in the January 26th edition of The Lancet³ drew attention to Dr. Lees findings:

"This result was a surprise for many people working in diabetes research, because most studies to date have focused on the effects of genetics and the westernisation of dietary habits and lifestyle, while ignoring the potential effect of xenobiotics."

And note that:

"... an increasing number of reports suggest that chronic dietary exposure to, and accumulation of, low concentrations of environmental pollutants within the body might also be associated with diabetogenesis."

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¹ A Strong Dose-Response Relation Between Serum Concentrations of Persistent Organic Pollutants and Diabetes

² Association Between Serum Concentrations of Persistent Organic Pollutants and Insulin Resistance Among Nondiabetic Adults

³ Environmental Pollution And Diabetes: A Neglected Association, The Lancet, Vol. 371, No. 9609, 26 January 2008.

This is a great fact sheet on diabetes from the Centers for Disease Control (CDC). It would be handy for anyone doing a school project or giving a presentation. At 12 pages, its more of a brochure than a sheet:


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I dont keep track of all the designated days for things... and in fact, often, various organizations just randomly make up a day, out of the blue, whenever they want to promote something... (Not necessarily a bad thing, really.)

So, apparently, today is Type 2 Diabetes Alert Day. 

The American Diabetes Association wants to create awareness of the risks a person might have for developing Type 2 Diabetes... by having them answer some basic, simplistic questions. Yeah, pretty basic and simplistic:

• Are you old?
• Are you a man or a woman (because apparently men are more screwed than women)?
• Do you have high blood pressure?
• Did you have gestational diabetes (which should be a big DUH, right)?
• Did you have a mother or father with Type 2 Diabetes (another big DUH)?
• Are you a fat, couch potato? 

Dear American Diabetes Association,  

When I was diagnosed with Type 2 Diabetes, the first thing I did (like any other person newly diagnosed), was to go visit your site. I studied it quite a bit... and gleaned some buzz words like "tight control," and goals of keeping my blood glucose under 180 mg/dL.  

Then I thought to myself... wait a minute? 180 mg/dL is awful close to 200 mg/dL. That sounds... quite dangerous and irresponsible. That cant be right...  

So I googled, more, and more... and even the American Association of Clinical Endocrinologists suggests keeping blood glucose levels under 140 mg/dL, and perably, as close to normal as possible. 

I understand blood glucose goals are individual, and should be consulted with ones doctor, ADA... (Some of us have other illnesses and hurdles that might make tighter blood glucose control difficult.) But you are giving people a very risky, and low MINIMUM hurdle to shoot for, without much other guidance!! WHY???? Please excuse me if I dont immediately reject the theories that you have deep conflicts of interests with big pharmaceutical representatives lining your pockets.  

Now, dear ADA... you claim you dont embrace any particular diet, but say we should ALL just eat healthy as healthy should be considered for ANY person without diabetes, without further explanations... Honestly, ADA, shame on you. We all know thats just veiled talk for telling people they ought to eat a diet made up of 60% carbohydrates, rich in fruit, starchy grains, and vegetables. (Yes, a world in which corn is good for your health.) It sounds charming, and wise... But even to my mind, back then, that was just hogwash. Normal people dont have a BUSTED pancreas... If this were the case, then hey! Everyone, throw your glucose meters, oral medications, and your insulin away. 

So through more research of my own, I found out I could eat following the guidance of my glucose meter, instead. The way it SHOULD be. Oh, imagine that...?! I should eat meals, and use my glucose meter to TEST those meals, to see if they exceed 140 mg/dL! And OMG, instead of just eating whatever because its "healthy..." Wow, what a concept! Im sorry, but oatmeal, for my diabetes, is NOT healthy. Hope Warshaw might lie -- but my glucose meter NEVER will.

Dont get me wrong, ADA... some people DO need meds, as their poor pancreases are too pooped out... But why the hell should I put the BURDEN of my care and how well I do, on just meds and insulin? Requiring more and more meds as time goes on, and more and more insulin... and then, oh no... developing complications I could have delayed, or reduced a risk for? I would be just accelerating the damage, and pancreatic beta cell failure, by willingly keeping myself at 180 mg/dL goals all the time.. when I could help it.

Its not easy, ADA... but why should we lie to people and make them believe it is? You know whats harder? DIALYSIS. NEUROPATHY. AMPUTATIONS.  

Then I thought to myself... "Hey? Who the hell are the American Diabetes Association, anyway? Theyre not even endocrinologists! What THE fructose!"  

Yeah, thats right...  Just a bunch of six figured salaried talking heads for big pharma sponsored researchers.

So, in essence, American Diabetes Association... here is my success story: I went and read your site, and then I did the opposite. 

Its such a no-brainer, right?  If persons at risk for diabetes would only eat right and exercise more, theyd avoid the disease.  And for those who develop diabetes, diet and exercise will reduce death rates and complications.

Yes and no, say Elizabeth Sumamo Schellenberg and colleagues at the University of Alberta.  Their review of the mixed published scientific evidence on the topic appears in the October 15 issue of the Annals of Internal Medicine.  The purpose of their study was to ascertain the impact of diet and exercise on the prevention of "Type 2 diabetes," as well as lowering complications among persons with who had established Type 2 diabetes. 

To be included, studies had to be prospective and compare the outcomes from an intervention versus a randomly selected control group. The study could only be included if it examined the impact of exercise plus diet and "one other component," such as "counseling, smoking cessation and behavior modification."  The outcomes had to include the development of Type 2 diabetes (in the prevention trials) or complications (in the treatment trials).

1289 candidate studies were found but only 20 made the grade. Nine were prevention trials and 11 were treatment trials.

For the prevention trials:

The interventions lasted from 6 to 72 months, with follow-up going for 3 to 20 years for between 39 to 3234 participants.  The counseling varied and included group and/or individual with or without tobacco cessation, telephony, goal setting, cooking classes or pills involving a range of physician and non-physician professionals.

Results?

Seven of the nine studies showed that diabetes can be delayed. When the results were pooled, compared to the control patients, the risk of developing diabetes over 10 years was only a third and the difference was statistically significant.

But, there was no detectable impact on cardiovascular disease events or on eye, kidney or nerve damage. That may have been due to not all the studies including these outcomes as well as the time it takes for these complications to occur once diabetes develops.  With more patients or more time, a difference could have become apparent.
 
For the treatment trials:

The interventions lasted from 6 to 48 months with follow-up for 6 to 93 months. The counseling was as varied as the prevention trials but included glucose and blood pressure monitoring as well as stress management and, in one instance, a three day residential retreat. There was likewise the range of professionals who provided the interventions.

Results? 

Compared to the control patients, there was no statistically significant difference in all-cause mortality.  Some individual studies had beneficial outcomes involving cardiovascular events or diabetes complications, but they included the aggressive use of medications.  There were no sustained impacts on weight or dietary intake.  And if pills were not included, there was also no real improvement in measures of blood glucose control.

The Disease Management Care Blogs take?

The good news is that there is good evidence that exercise and diet can prevent diabetes.  The bad news is that it takes years for that "return on investment" to declare itself and typically involves interventions that fall outside the traditional health care delivery system.  Its unlikely, thinks the DMCB, that current iterations of payment orm (value based purchasing, bundled payments or upside risk) can be marshaled to make this a reality.  That being said, population health management (PHM) companies like Omada Health are making their evidence-based services available to, for example, employers who have a longer term commitment to the well being of their "human capital" outside of the traditional insurance market.

The bad news is that once diabetes declares itself, diet and exercise dont result in life extension, and control of complications as well as overall blood sugar levels is more a function of pills than lifestyle. Accordingly, expectations need to be realisitically shared with patients and PHM should emphasize taking the pills as prescribed.

Image from Wikipedia

Researchers from New England found that men who slept either less than 6 hours, or greater than 8 hours, increased their risk for type 2 diabetes. That risk remained after adjustments were made for age, hypertension, smoking status, self-rated health status, education, and waist circumference.

These results suggest that even though you have a handle on your weight, blood pressure and smoking, you may still court a diagnosis of diabetes if your sleep is consistently short-changed, or over-indulged.

The study included 1564, primarily white men, aged 40 to 70, who were enrolled in the Massachusetts Male Aging Study (MMAS), and who did not have diabetes at baseline. The men were followed for up to 15 years. Similar, although less marked results were found in women who partook in the Nurses Health Study.

The study appears in the March 2006 issue of Diabetes Care.

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For the MMAS study:
Sleep Duration as a Risk Factor for the Development of Type 2 Diabetes

For a summary of the MMAS study:
Diabetes Risk Raised By Too Much Or Too Little Sleep

For the Nurses Health Study:
A Prospective Study of Self-Reported Sleep Duration and Incident Diabetes in Women

If youre having difficulty keeping your resolution to exercise 30 minutes a day, 5-days-a-week, then youre going to like this study.

Researches put young men through some very brief, but strenuous, workouts and found their sensitivity to insulin (and so their blood sugar levels) improved:

Extremely Short Duration High Intensity Interval Training Substantially Improves Insulin Action In Young Healthy Males, BMC Endocrine Disorders, January 2009

A total of 16 men, average age 21, underwent 6 sessions of exercise over 14 days.

A session of exercise consisted of:

• 30 seconds of cycling as fast as possible
  
• 4 minutes of rest
  
• The above repeated 4 to 6 times

An exercise session lasted 17 to 26 minutes, but only 2 to 3 minutes of that was actual exercise.

Compared to before training (baseline):

• Postprandial glucose levels declined 12% (measured by AUC: Area Under the Curve)
  
• Postprandial insulin levels declined 37% (AUC)
  
• Postprandial free fatty acid levels declined 26% (AUC)
  
• Insulin sensitivity improved 23% (measured by Cederholm index)
  
• Aerobic cycling performance improved 6%

The authors concluded:

"The efficacy of a high intensity exercise protocol, involving only ~250 kcal of work each week, to substantially improve insulin action in young sedentary subjects is remarkable. This novel time-efficient training paradigm can be used as a strategy to reduce metabolic risk factors in young and middle aged sedentary populations who otherwise would not adhere to time consuming traditional aerobic exercise regimes."

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This coming Tuesday, March 28^th, has been designated American Diabetes Alert Day by the ADA. Its a day devoted to drawing attention to the disease, spreading the word about who is at risk, and finding those people who have it but dont know it.

Are you at risk? Take the ADAs free, online risk test:
Diabetes Risk Test

Do you suspect someone you know may be at risk? Send them an ADA Diabetes Alert E-card that includes a link to the risk test:
Diabetes Alert E-card

Drinking three to four cups of coffee per day may help to prevent type 2 diabetes according to research highlighted in a session report published by the Institute for Scientific Information on Coffee (ISIC), a not-for-profit organisation devoted to the study and disclosure of science related to coffee and health.

Recent scientific evidence has consistently linked regular, moderate coffee consumption with a possible reduced risk of developing type 2 diabetes. An update of this research and key findings presented during a session at the 2012 World Congress on Prevention of Diabetes and Its Complications (WCPD) is summarized in the report.

The report outlines the epidemiological evidence linking coffee consumption to diabetes prevention, highlighting research that shows three to four cups of coffee per day is associated with an approximate 25 per cent lower risk of developing type 2 diabetes, compared to consuming none or less than two cups per day1. Another study also found an inverse dose dependent response effect with each additional cup of coffee reducing the relative risk by 7-8 per cent2.

Whilst these epidemiological studies suggest an association between moderate coffee consumption and reduced risk of developing diabetes, they are unable to infer a causal effect. As such, clinical intervention trails are required to study the effect in a controlled setting. One prospective randomized controlled trial3, tested glucose and insulin after an oral glucose tolerance test with 12g decaffeinated coffee, 1g chlorogenic acid, 500 mg trigonelline, or placebo. This study demonstrated that chlorogenic acid, and trigonelline reduced early glucose and insulin responses, and contribute to the putative beneficial effect of coffee.

The report notes that the association between coffee consumption a reduced risk of type 2 diabetes could be seen as counter intuitive, as drinking coffee is often linked to unhealthier habits, such as smoking and low levels of physical activity. Furthermore, studies have illustrated that moderate coffee consumption is not associated with an increased risk of hypertension, stroke or coronary heart disease4 ,5, 6. Research with patients with CVD has also shown that moderate coffee consumption is inversely associated with risk of heart failure, with a J-shaped relationship7.

Finally, the report puts forward some of the key mechanistic theories that underlie the possible relationship between coffee consumption and the reduced risk of diabetes. These included the Energy Expenditure Hypothesis, which suggests that the caffeine in coffee stimulates metabolism and increases energy expenditure and the Carbohydrate Metabolic Hypothesis, whereby it is thought that coffee components play a key role by influencing the glucose balance within the body. There is also a subset of theories that suggest coffee contains components that may improve insulin sensitivity though mechanisms such as modulating inflammatory pathways, mediating the oxidative stress of cells, hormonal effects or by reducing iron stores.

The Basics of a Healthy Diabetes Diet

Contrary to what you may have heard, there is no "diabetes diet," per se -- and thats good news! The foods recommended for a diabetes diet to control blood glucose (or blood sugar) are good for those with diabetes -- and everyone else. This means that you and your family can eat the same healthy foods at mealtime. However, for people with diabetes, the total amounts of carbohydrates consumed each day must be monitored caully. Of the different components of nutrition -- carbohydrates, fats, and proteins -- carbohydrates have the greatest influence on blood sugar levels. Most people with diabetes also have to monitor total fat consumption and protein intake, too.


To keep your blood sugar levels in check, you need to make healthy food choices, exercise regularly, and take the medicines your health care provider prescribes. A dietitian can provide in-depth nutrition education to help you develop a personalized meal plan that fits your lifestyle and activity level, and meets your medical needs.
Learn the ABCs of a Diabetes Diet

The goal of nutrition for people with diabetes is to attain the ABCs of diabetes. The A stands for the A1c or hemoglobin A1c test, which measures average blood sugar overthe previous three months. B is for blood pressure, and C is for cholesterol. People with diabetes should attain as near as normal blood sugar control (HbA1c), blood pressure, and healthy cholesterol levels.
Alcohol and Diabetes

Use discretion when drinking alcohol if you have diabetes. Alcohol is processed in the body very similarly to the way fat is processed, and alcohol provides almost as many calories as fat. If you choose to drink alcohol, only drink it occasionally and when your blood sugar level is well-controlled. Its a good idea to check with your doctor to be sure drinking alcohol is acceptable.

Diabetes and Glycemic Index

For years, researchers have tried to determine what causes blood sugar levels after meals to soar too high in those with diabetes. Potential culprits have included sugar, carbohydrates, and starches, among other foods. The glycemic index is a ranking that attempts to measure the influence that each particular food has on blood sugar levels. It takes into account the type of carbohydrates in a meal and its effect on blood sugar.

Foods that are low on the glycemic index appear to have less of an impact on blood sugar levels after meals. People who eat a lot of low glycemic index foods tend to have lower total body fat levels. High glycemic index foods generally make blood sugar levels higher. People who eat a lot of high glycemic index foods often have higher levels of body fat, as measured by the body mass index (BMI).

Talk to your doctor, a registered dietitian, or a diabetes educator and ask if the glycemic index might work to help gain better control of your blood sugar levels.

The glycemic load takes into account the effect of the amount of carbohydrates in a meal. Both the type of carbohydrate and the amount have an effect on blood sugar.
Eating Right With Diabetes

If you have diabetes, its important to eat right every day to keep your blood sugar levels even and stay healthy. Heres some easy tips:

    * Be sure to eat a wide variety of foods. Having a colorful plate is the best way to ensure that you are eating plenty of fruits, vegetables, meats, and other forms of protein such as nuts, dairy products, and grains/cereals.
    * Eat the right amount of calories to maintain a healthy weight.
    * Choose foods high in fiber such as whole grain breads, fruit, and cereal. They contain important vitamins and minerals. You need 25 to 35 grams of fiber per day. Studies suggest that people with type 2 diabetes who eat a high fiber diet can improve their blood sugar and cholesterol levels. Similar results have been suggested in some studies in people with type 1 diabetes.

Serving Sizes and Diabetes

Be sure to eat only the amount of food in your diabetes meal plan. Excess calories result in excess fat and excess weight. In people with type 2 diabetes, excess body fat means less sensitivity to insulin. Weight loss in overweight and obese people with type 2 diabetes helps improve blood sugars and reduces those risk factors which lead to heart disease. Your dietitian can help you determine the appropriate serving sizes you need, depending on if you need to maintain your weight, gain weight, or lose weight, and if you have high or low blood sugar levels.

    * In women with gestational diabetes, its important to eat multiple meals and snacks per day as recommended.
    * Do not skip meals.
    * Eat meals and snacks at regular times every day. If you are taking a diabetes medicine, eat your meals and take your medicine at the same times each day.

Note: If you are taking some of the newer diabetes drugs, some of these tips may not apply to you; ask your health care provider the tips you should follow.
The Sweet Truth about Food and Diabetes

You might have heard that, as a person with diabetes, you shouldnt have any table sugar. While some health care providers continue to promote this, many -- realizing that the average person lives in the real world and will probably indulge in a bit of sugar every now and then -- have adopted a more forgiving view. Most experts now say that small amounts of sugar are fine, as long as they are part of an overall healthy meal plan. Table sugars do not raise your blood sugar any more than similar amounts of calories from starches, which is found in many foods that we consume. It is important to remember that sugar is just one type of carbohydrate.

When eating sugar, keep these tips in mind:

    * Read food labels. Learn how to determine how much sugar or carbohydrates are in the foods that you eat.
    * Substitute, dont add. When you eat a sugary food, such as cookies, cakes, or candies, substitute them for another carbohydrate or starch (for example, potatoes) that you would have eaten that day. Make sure that you account for this in your carbohydrate budget for the day. If it is added to your meal for the day, then remember to adjust your insulin dose for the added carbohydrates so you can continue to maintain glucose control as much as possible. In other words, readjust your medications if you do add sugars to you meals.
    * Sugary foods can be fattening. Many foods that have a lot of table sugar are very high in calories and fat. If you are watching your weight (and many people with diabetes must), you need to eat these foods in moderation!
    * Check your blood sugar after eating sugary foods and talk to your health care provider about how to adjust your insulin if needed when eating sugars.
    * Ultimately, the total grams of carbohydrates -- rather than what the source of the sugar is -- is what needs to be accounted for in the nutritional management of the person with diabetes.

Diabetes Diet Myths

Before you start a diabetes diet, get the facts. So many people believe that having diabetes means you must avoid sugar and carbohydrates at all cost, load up on protein, and prepare "special" diabetic meals apart from the familys meals. Wrong! Most individuals with diabetes can continue to enjoy their favorite foods, including desserts, as long as they monitor the calories, carbs, and other key dietary components and keep a regular check on their blood glucose levels.

Get the facts and start enjoying the foods you love on a diabetes diet.

What Is the TLC Diet for Diabetes?

People with diabetes who have abnormal cholesterol levels will likely be placed on a diet known as a "TLC" diet. The TLC diet will help reduce the intake of cholesterol-raising nutrients. As part of this diet you may be asked to lose weight and increase physical activity levels -- all of these are components that will help lower bad LDL cholesterol. Looking at food labels will help you become more knowledgeable about your intake of fats and cholesterol.

Specifically, the TLC diet calls for the following:

    * Total fat consumption should be 25%-35% or less of total calories eaten per day.
    * Saturated fats should be less than 7% of total calories eaten in a day.
    * Polyunsaturated fats (from liquid vegetable oils and margarines low in trans fats) should be up to 10% of the total calories per day consumed.
    * Monounsaturated fats (derived from vegetable sources like plant oils and nuts) should be up to 20% of total calories per day eaten.
    * Carbohydrates should be 50%-60% of total calories per day eaten
    * We should eat 20-30 grams of fiber per day. These can be derived from oats, barley, psyllium, and beans.
    * The amounts of protein in the diet should equal about 15%-20% of total calories eaten per day.
    * Cholesterol content of the diet should be less than 200 milligrams per day.

How Much Fat Is Acceptable on a Diabetes Diet?

People with diabetes have higher than normal risk for heart disease, stroke, and disease of the small blood vessels in the body. Controlling blood pressure and limiting the amount of fats in the diet will help reduce the risk of these complications.

Limiting the amounts of saturated fats, increasing the amount of regular exercise, and receiving medical treatment can lower bad LDL cholesterol. This has been repeatedly shown in medical studies to help people with diabetes reduce their risk of heart disease and reduce the risk of death if a heart attack does occurs in a diabetic person.

Artificial Sweeteners and Diabetes

Artificial sweeteners can be added to a variety of foods and beverages without adding more carbohydrates to your diabetes diet. Using non-caloric artificial sweeteners instead of sugar also greatly reduces calories in your favorite foods.

Keep in mind that foods with artificial sweeteners are not necessarily zero carbohydrates foods. Many have carbohydrates; theore, you must read the food labels to determine the gram amounts per serving that these have in order to take into account the effect that these carbohydrates have on your glycemic control. Foods labeled with artificial sweeteners can affect your blood sugar.

As long as you are aware of the content of carbohydrates you can adjust your meal or medication to maintain blood sugar control. "Sugar free" means no sugar has been added, but you must remember these foods still contain carbohydrates which does affect your blood sugars.

Examples of artificial sweeteners you can use include:

    * Aspartame
    * Acesulfame-k
    * Saccharine
    * Sucralose
    * Other non-nutritive sweeteners

Pregnant or breastfeeding women should avoid saccharine, and people who suffer from phenylketonuria should not use aspartame. People with phenylketonuria are unable to metabolize phenylalanine, an amino acid thats a common part of many proteins.

Some artificial sweeteners -- such as xylitol, mannitol, and sorbitol -- have some calories and do slightly increase blood sugar levels.

The American Diabetes Association cautions that eating too much of any artificial sweetener can cause gas and diarrhea.

A large diabetes study was interrupted yesterday because of an unexpected number of deaths. Whats notable here is that only one arm of the study was halted, that involving participants who were undergoing aggressive blood glucose lowering strategies. The less intensive treatment arms are ongoing.

The study in question is the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which enlisted 10,251 patients with type 2 diabetes who were at high risk for heart disease. After about 4 years, there were 257 deaths in the intensive treatment arm and 203 deaths in those receiving standard BG treatment ... a difference of 54 deaths.

Elizabeth Nabel, director of the National Heart, Lung and Blood Institute (NHLBI) which is sponsoring the study, said, "The harm of the very intensive treatment outweighed the potential benefit."

Intensive Treatment

All participants received the same dietary and lifestyle recommendations. However, since the goal for those in the intensive treatment arm was to achieve an HbA1C < 6.0%, a fasting BG of 100 mg/dl or less, and a 2-hour postprandial BG of 140 mg/dl or less, several drug therapies were aggressively employed. The protocol stated:

"Most intensive group participants will likely be on 3 or more injections of insulin per day in addition to 2 or 3 oral agents." All patients in the intensive arm received a minimum of 2 oral agents.
- ACCORD Protocol, May 11, 2005

Those in the standard treatment groups used a combination of dietary, lifestyle and drug therapies to achieve an HbA1C of 7.0 to 7.9% and a fasting BG of 90 mg/dl or more. Postprandial BGs were not routinely used to guide therapy in this group, and healthcare contacts were less frequent and less intense.

ACCORD researchers have not yet determined the cause of the excessive deaths.

Dr. Steven Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic speculated that patients may suffer unintended consequences from taking so many drugs, which might interact in unexpected ways.
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News summaries:
Deaths Halt Part of Diabetes Study, Scientists Fear Heart Attacks, Strokes Were Tied to Treatment, Washington Post
Diabetes Study Partially Halted After Deaths, New York Times

NHLBI press release:
For Safety, NHLBI Changes Intensive Blood Sugar Treatment Strategy in Clinical Trial of Diabetes and Cardiovascular Disease

ACCORD Trial online:
ACCORD

"Well, my husband is a board certified endocrinologist, and he told me that whenever a Type 2 patient is good, and gets their numbers normalized, that he removes the Type 2 Diabetes diagnosis, and changes it to a Metabolic Syndrome diagnosis, instead, to help them out." -- Misinformed Mrs. Know-It-All.

The woman was very angry at me. How dare I suggest Type 2 Diabetes has no cure. And furthermore, I could go get a gastric bypass surgery, if I wanted. That, for certain, was also a cure. This, of course, was followed by a few "You people will never be like us; you need to stop comparing yourselves to us... You keep trying to act like we are the same, or have it worse than us, or that your disease is just as bad as ours" type of comments. I cant say that I blame her entirely for her misinformed, self righteous attitude. (Okay, I know she was being kind of a bitch. Im just trying to be nice, here.)

This is the every day bread of Type 2 Diabetes awareness. Raising Type 2 Diabetes awareness is not easy. In fact, its one of the most painful things Ive ever had to do in my life. My husband certainly doesnt understand it, sees a redundant theme in it, and wonders why I dont just get out of it... since its obvious I cant change the world. Ive gone to bed crying, on more than a few nights.

The comment above, is of course, ridiculous. If there is a board certified endocrinologist out there, doing this, he needs to have his license revoked. Simple as that. He is doing NO ONE any favors. He is hurting his patients a lot more than he knows. I understand that insurance companies love judging us -- hey why not, the media has done a great job of misinforming the world, and insurance companies get their news just like the rest of us, and want to use that to safeguard their old, mighty dollar -- but the value of a small defense against an insurance company does NOT outweigh the psychological harm and denial you feed into a person by acting like their diagnosis doesnt exist. Would these people dream of telling someone who had AIDS "If youre good, and your labs come back good, Ill change your diagnosis to HIV positive, instead?" Yeah, I dont think so! (Its not entirely a perfect analogy, but you get the idea...)

But people dont GET the permanence of Type 2 Diabetes. Whats worse is that, while we preach day and night that this is an epidemic of epic proportions, our medical establishment does not act like it! (Oh, lots of people are acting like it, dont get me wrong... but its, mostly, the people who want to scam us, and take advantage of us...) If this is such a serious threat, why isnt the American Medical Association, and the American Association of Clinical Endocrinologists, making it a priority to get doctors educated, and prepared, for diagnosing, and empowering patients? Why are they not working hard to give patients the weapons to fight back, and effectively not feel themselves the hopeless victims of this disease? (I know someone out there will claim that they are... but the proof, or lack of proof, is in the pudding, folks.)

• Patients are out there, going undiagnosed, not because they dont regularly see a doctor (though some, undeniably dont...), but because doctors dont know how to recognize the signs of diabetes, or are UNWILLING to mark down a "diabetes diagnosis" in a patient record, thanks to insurance company scheming. More and more Type 2 Diabetes patients are being diagnosed by other medical professionals, such as gynecologists, urologists, dentists, and eye doctors. Often, a patient even gets misdiagnosed based on ridiculously old knowledge, like assuming that an adult could not be a Type 1 Diabetic, instead, leaving the patient vulnerable to Diabetic Ketoacidosis, and Diabetic Coma.  
• Most doctors, especially Primary Care Physicians (or Family Doctors), get a MINIMAL amount of diabetes education in medical school, and NO extended diabetes education throughout their careers. Diabetes information, care, and knowledge is growing about as fast as technological advances are... why should doctors remain in the dark, if we, as patients, cant afford to do so? Some doctors are going by on 20, and 30 years of OLD diabetes education! As a consequence, when a diabetic patient gets diagnosed, thanks to this lack of knowledge and insurance company scheming, patients get denied access to specialists, denied access to certified diabetes educators, denied access to dietitians, denied access to insulin, etc. Doctors, ROUTINELY, give NO information or direction to a newly diagnosed Type 2 Diabetes patient, leaving them vulnerable to whatever might be out there, on the internet. There is something vastly wrong with an insurance company that denies access to a dietitian, or certified diabetes educator, but is happy to approve gastric bypass surgery. In other scenarios, doctors give patients extreme misinformation, such as "STOP eating ALL fruit because they are high in carbs." Ummm, hello, not all fruit is made the same... We need to learn to MANAGE food, not put the fear of God in people.   
• The medical establishment is allowing itself to be ruled by the treatment guidelines of the American Diabetes Association -- an Association with clear conflicts of interest, per a recent study done by the Mount Sinai School of Medicine, and which has been SLOW AS MOLASSES in embracing the future of diabetes tight control, and management. Whats worse, they have GREATLY contributed to diagnoses getting delayed and delayed. This is WRONG and unacceptable. Doctors and Endocrinologists need to be educating the ADA, and not the other way around! 
• Instead, more and more "doctors" and "medical professionals" are taking advantage of the serious need for diabetes patient education, as a door to write books, push supplements, spread their own pseudoscience, and MAKE MONEY. 

 

Nature often plays a delicate balance, like these two bugs holding on against the wind, behind these delicate, white blooms.  Its a rainy, cold, and wet  day, in Iowa.  Fall is just around the corner. (September 11, 2008)

One of the biggest challenges, when helping newly diagnosed persons with diabetes, is finding balance in the information provided. Helping create a positive environment, which encourages a person to learn the scope of the disease and its complications, but still keeping their heads above water. No matter the diabetes community -- this is a struggle that I have found almost everywhere. Even in my own diabetes groups.

Whenever I share any information, my hope is for you, the patient, to be able to make your OWN decisions -- and not make MY decisions as yours. I have this crazy idea that, when empowered with basic information, people will tailor their diabetes regimes to their own circumstances, and find balance. That I dont need to tell anyone what to do, and that since this is diabetes were talking about, what has worked for me... will definitely, and not necessarily, work for you.

The problem is that diabetes is a dick. Diabetes doesnt play fair, and it doesnt give two shits about our feelings. It doesnt. It doesnt care that the news of the things it can do, can scare us, nor does it politely pass us over when we decide to close our eyes against it. So... sometimes, this harsh bit of reality might lead people to behave in one of two ways: either by becoming inflexible with their ideas of control, or by becoming completely lax in their control. Neither of these two ideas is good, even if one of them has much, much better numbers.

Inflexible Control

Laxed Control