Monday, September 23, 2013

Cinnamon for Diabetes?

Controlling diabetes takes work.  If you do all you are supposed to do between checking your blood glucose, exercising, preparing healthy food, checking your feet, etc, it takes up a large chunk of time.  (One very small study estimated that doing all your self care tasks takes up to three hours per day).  So it is not surprising that people who really do want to decrease their blood glucose levels will find ways to try to minimize the amount of work that they are doing.   Often they are hoping that there is a supplement that they can take, and one of the supplements I get questioned about a lot is cinnamon.  But is there any evidence that taking cinnamon helps?

A meta-analysis released in this months Annals of Family Medicine, indicated the answer was "well maybe."  Even though there have been some good randomized studies conducted, the studies are often still too small to be extrapolated to a general population.  And there is also the problem that we still don't have enough evidence to tell people how much to take for them to have a benefit, or how long they have to take it, or even how long it is safe to take it.  I was also interested to see that while there seemed to be a reduction in the fasting blood glucose levels, there wasn't an overall reduction in hemoglobin A1C levels.  Usually when a person has "good" fasting blood glucose levels but a high A1C they are eating something that is causing their blood glucose levels to spike after a meal (often called elevated post prandial levels), so the ingestion of the cinnamon was likely not counteracting whatever they were eating during the day.

Now I do know that there are some of you who are still going to try this, or already trying this at home so to speak, so here are some safety guidelines using what we do know.

1) Taking cinnamon while eating a crappy diet isn't going to help you.  (You laugh, but I get to witness this sort of magical thinking on a daily basis).

2) Cinnamon seems to be safe if taken for up to 6 grams daily for up to six 6 weeks. 

3) If you are using this as a supplement, you will probably want to use capsules.  6 grams per day is roughly about 1.5 teaspoons per day (1/2 teaspoon = 2 grams if I did my math correctly) .  Now think about the last time you put just a 1/8-1/4 of cinnamon on your food, and how that small amount actually gave it flavor without burning like Red Hot Cinnamon candy.  Now think about what putting 6 times that amount on your food would do (feeling the burn yet?).  And as much as I like cinnamon, I only have a limited amount of foods that I want to eat it on (Note to self, try cinnamon bacon tomorrow).  So you will probably get what we call a "therapeutic dose" if you use capsules.

3) Since you are using cinnamon as a drug, it might interfere with certain drugs you are taking, like blood thinners.  Please discuss your medications with a doctor and/or pharmacist before trying this.  This advice applies to all supplements.

4) If you are taking medicine or insulin to control your blood sugars, please inform your provider and/or qualified diabetes educator because cinnamon combined with your other medications could cause your blood sugar to drop too low.  (Ask any person with diabetes why you don't want a low blood sugar.  Death is one reason).

5) If you are taking medicine for blood pressure, please inform your provider as cinnamon combined with those drugs could cause your blood pressure to drop too low.

5) If you have liver disease, seizure disorder, auto-immune diseases, or abnormal heart rhythm, use caution and discuss with your provider.

6) Hopefully the above stated guidelines remind you that "natural medicines" are still medicines and can have some bad side effects if you take too much, take them for too long, or take them with other things.

7) The amount you use in your Cincinnati style chili shouldn't interact with medicines; use it as you would any spice/seasoning to help your new and improved diet actually include food that is tasty.

Take home message--cinnamon shows promise for helping some people with diabetes, but discuss it with your health care team first.

References: Natural Standard Database

Friday, September 20, 2013

What about intermittent fasting?

Before I answer that question, I want to admit from the beginning that talking about fasting elicits a not so rational response in me (i.e. makes me wince).  One of the reasons is, as have mentioned before, I grew up religious, and though fasting was not a requirement, it was often highly encouraged during times of crisis (aka "imploring God to change His mind), as a way of controlling "impure" thoughts (aka "if you fast you won't think about sex as much"), or even as a way of showing solidarity with the poor (In college we would have specified meals where we would donate the cost of that meal from our meal plan to a local cause.  I don't have a problem with the concept, but most of us ate elsewhere and didn't experience hunger).   The second reason is that as a female student in her late teen's/early 20's during the 1990's I was exposed to my fair share of people starving themselves to excessive thinness, a condition know as anorexia nervosa (Hat tip to those who work with people with this problem, it is not my cup of tea).  The third reason is the link between poverty and obesity, a situation fueled by the availability of high caloric food that doesn't actually provide any nutrition (Link), and it reminds me of quote attributed to Eusebius Sophronius Hieronymus (aka St. Jerome, yeah I studied my church history) that states "When the stomach is full, it is easy to talk of fasting."

OK, now that's over with.  Deep breath.

So you are wondering about Intermittent Fasting, are you?  Possibly because of the publication of the The Fast Diet and a similar book called The 2 Day Diet?    Or maybe you have heard about one of the variations where you consume 20% of your usual caloric intake on fasting days or just don't eat in between meals?  Or cutting down to 2 meals per day?  Is there any benefit to all of this when it comes to shedding extra pounds?

Well, maybe.  I have already written two somewhat related posts, a few weeks ago I talked about how it might benefit some people to skip breakfast and how the advice about eating six smaller meals a day is more fallacy than fact.  Basically the concept of intermittent fasting is another technique to get people to 1) eat less (Thank you, Captain Obvious) and 2) not have readily available sources of energy so their body will be forced to draw from the stores (sounds good).  And I am putting the emphasis on technique here, because even though we all know that weight loss comes from reducing your intake of calories, and for those with insulin resistant related problems you need to make sure that you reduce your level of carbohydrate, all the while making sure you get enough protein, fat, etc; how you actually get there is easier said than done.  (Remember the quote from St. Jerome?)   A weight loss plan and weight-gain prevention plan are only as good as they are sustainable, and for some people the thought of cutting out certain things for the foreseeable future seems impossible, so the idea of varying "moderate" eating with "restrictive" eating sounds more doable.

As far as the research is concerned, the human studies are small but positive looking when it comes to helping people lose weight and reduce lipids, improve insulin resistance, etc (One here and another here).  Now, intermittent fasting has also been touted as a way to live longer (particularly if you are a lab rat), but when it comes to studies done in primates, it looks like diet quality and your genetics have the upper hand there. 

So should you practice intermittent fasting to lose weight?  I am going to point you back to this post and this post where I basically discuss the caveats.  I will add that apparently people who have trouble with blood glucose regulation do not do well with this, and men and post-menopausal women tend to fare better than women in their reproductive years.  And this will still require some pre-planning and discipline.  If you know that your co-workers always bring the doughnuts on Tuesday mornings, then maybe that is not the best day to do this.  If your co-workers bring in snacks every single day, then you might have to avoid certain areas of the workplace.  If you live with another person/other people, you will have to have a frank discussion about the support you can expect from them.  This might be an "easier than" technique for you to reduce your intake/help your body use up reserves, but it still requires effort.

Other notes:

1) Yes, I know, some people do have to cut out certain foods for the foreseeable future when they have allergies or huge increases in blood glucose after eating them.

2) Some people have adopted a particular diet that severely limits certain foods groups and still find it sustainable (congratulations, you have worked hard to do so).  That doesn't mean everyone can or will.

3) Make sure that your fasting days are based on healthy protein/fat and vegetables.  Getting all your calories from junk food will be more likely to keep you feeling miserable and hungrier sooner.

Take home message--Intermittent fasting could be a useful technique for loosing weight but it still requires planning.

Thursday, September 19, 2013

More in weight loss supplements--Green Tea Extract

I didn't have to spend too much time talking with Dr. Oz's followers (told you this was a gold mine of blog material!) before the supposed "metabolic boosting" properties of Green Tea Extract came up.   But is there any evidence to support this or are you just back to spending your money?  Let's find out.....

First, let's make sure we are all on the same page when it comes to the word "metabolism."  If you ask for a definition from those of us who work in a medical related field what the definition of metabolism is, you will likely see something similar to this one from the National Institutes of Health: Metabolism refers to all the physical and chemical processes in the body that convert or use energy to keep you running.  So your ability to breathe, have a heart beat, contract a muscle to pick up a fork to pierce that steak, process that steak, poop out the steak, etc is all the result of your metabolism.  Now, usually when all the non-medical people talk about metabolism, they are usually wondering how they can burn off extra body fat/increase their ability to burn calories.  (Usually with minimal effort; you know who your are.)  So if you ask your provider about how to "boost your metabolism," and they wince a little bit, it is because sarcasm took over and she probably thought "Really?  You want to increase muscle contractions and cause cramps?" before she remembered you were talking about burning fat/losing the extra poundage.

Now that my sarcasm bout is temporarily over, let's talk about metabolism as your ability to burn calories, and whether or not green tea/green tea extract increases it.    And in this situation, somebody might actually be on to something.  I had already been doing some research this week, but a Pharmacist co-worker gave me a very helpful website called Natural Standards that covers a lot of alternative therapies including dietary supplements.  When you type in "green tea extract" you will, um, probably see a listing for an article about genital warts (sorry about that), but if you click on "evidence table" you should get to a table with all the different conditions that green tea extract is supposed to help, and if you keep scrolling you will find "obesity." (Link)  You will see that 1) while some studies showed modest weight loss, there wasn't much indication that there was a change in metabolism, 2) where there was change the researchers manipulated the levels of catechins (also called flavanoids) so there was more than the caffeine in the tea at work, and 3) if you were able to go in and read some of those studies that looked more positive you would notice that they are pretty small and/or done in one segment of the population (Link), so we don't know if there will be the same effect in women as in men, elders vs. children, etc.  So the end result is, if you think that taking green tea extract might "boost your metabolism" there is a very qualified maybe.

And of course this type of supplement will usually appeal to those of you are have actually reduced your intake and exercised more but you just....can't....lose...that...last...ten...pounds.  Even if you consider yourself pretty rational and skeptical you might be tempted, so I am going to leave these other considerations here:

1) My new favorite website does give an overview of products studied (here), as it is tough to know whether or not your product actually contains the catechins in the amount that you might want to try.

2) Make sure you look at the amount of caffeine that is in the product and think about what other sources of caffeine  you might consume.  Caffeine consumption over 500-600 mg per day could up your risk for dehydration, insomnia, heart rhythm problems, etc.  In other words, it is a drug, even if it is "natural" and can cause problems if you consume too much.  And if you already have a condition, like Irritable Bowel Syndrome, that is aggravated by caffeine, the capsules will likely aggravate that too.

2a) Keep in mind that the studies that showed promise indicated that the combination of the catechins and the caffeine were what helped the weight loss, not just the caffeine itself.

3) Make sure that you are not taking any medications that could interact with this supplement (Link).

4) Do not overestimate how many more calories you might be burning.  In the study I linked above the participants burned about 180 more calories a day, which might sound like a lot.  Until you realize that 180 calories equals a little over half a cup of ice cream or one of my dairy free desserts.  So if you've got the spoon and that pint out and you think that the green tea extract is going to help, think again.  (You know who you are).

Take home message--green tea extract might have modest impact on weight loss if you have already been following a satisfactory weight loss plan including change of diet and exercise.

Tuesday, September 10, 2013

Garcinia Cambogia: This again?

I apparently don't watch enough TV or visit enough supplement shops (which is probably a good thing).  The other day I was driving home and saw an advertisement for this particular weight loss supplement, garcinia combogia, advertised for 25% off.  Since it was something recommended by Dr. Oz I was already suspicious, and an Internet search confirmed my suspicions.  Once I started to write a blog about it, however, I realized that 1) this "new/amazing" supplement has actually been promoted for more than 15 years and 2) other writer's and bloggers have beaten me to pointing out the lack of evidence. 

So with that, I give you this excellent article written by Julia Belluz and Stephen J. Hoffman over at Slate: Can you trust Dr. Oz?  (Hint, the answer is no).

Let me highlight here that the 1998 study that indicated that the garcinia extract was no better than a placebo for weight loss was a randomized-controlled trial, also known as the gold-standard for a clinical trial.    So if you go on or your other favorite supplement retailer you get to spend about $20-$30 a month for something that works no better than a placebo.  That should be a deterrent to any good skeptic.

I also want to put in a reminder to watch out for the logical fallacy known as the Appeal to Ancient Wisdom.  Just because something is billed as having been "used for hundreds of years" in "insert country that seems exotic to those who live in Western societies here" does not mean that it has any practical medical application today.

Take home message--if you use garcinia extract to lose weight you are spending money that you could put toward your healthy food budget.

Now excuse me, I will go stalk Dr. Oz's website for more blog material.  I might be awhile.

Wednesday, September 4, 2013

Take care of yourself: Get a flu shot

It's September, and if you work in the healthcare like I do, you know that that flu season is fast approaching.  If you are a Skeptic, you probably also know that flu season is prime time for a lot of anti-flu vaccine and "boost your immunity" woo, and so you are creating that special place on the wall for you to bang your head.    As I've said before, I'm sure I will be getting questions about various "alternative" methods of preventing the flu and/or the common cold, although I have already written about many of those before.  But as I was reading one of Dr. Harriet Hall's take down of one anti-flu shot purveyor, I realized that many of the Masters of Woo try to sell you on their product or regimen by pretending that "Get your flu shot" translates into "we don't care about anything else."  Fortunately you have me to remind you that those of us who really want people to stay well are fully aware that there are other evidence-based practices that you can follow to stay well and avoid infectious diseases, such as:

1) Eat a healthy diet with adequate protein, plenty of vegetables, and don't overeat on starches and sugars so that you can keep your usual state of health.  If you have a condition, like diabetes for example, where following a particular diet plan is critical for you to maintain control of your condition, then stay on your plan as much as you can.  If your condition is not controlled, you will be more vulnerable to whatever contagious disease is going around.  Keep in mind too that there is no evidence that anyone specific food will keep you from getting the flu.

2) Wash your hands after using the restroom, before eating, and before touching your face/nose.  This is especially important when you come into contact with what I call "shared equipment," like the handles on a grocery store cart or the handles on the weights at the gym.  I've noticed that some public places actually have hand-sanitizing stations and wipes for cleaning equipment placed at strategic intervals.

3) If you are sick, stay home.  If your kids are sick, keep them out of school (I think this translated into "stay away from children" in the linked post).  If you are feeling ill, and you have friends/co-workers/loved ones who have a condition that causes them to be immunocompromised, stay away from them until you are no longer contagious or have them done masks, etc.  (Easier said than done for people who don't have paid sick days at work, I know.  I wish I had an easy answer for that one).

4) Get adequate sleep as poor sleep can cause you to have a less than optimal immune system.  (Again, easier said than done, although this discussion does sound familiar).

5) If you have a known vitamin deficiency, such as low vitamin D levels, you might need supplementation until your levels are back to normal.

6) Don't overdo the neti-pot, just use it temporarily if your sinuses are irritated.  Overuse can actually deplete the mucus layer in the nasal passages--the reason you have that mucus layer is so it can actually serve as a barrier to infectious agents.  (And keep in mind that a neti-pot will cost you on average about $10-22 depending on what comes with it, and a bottle of saline nasal spray costs you $3.88).

And of course.....

7) Get a flu shot.  Sometimes we don't always get sleep, eat properly, etc and it helps to build up antibodies to an actual illness.  And even if you have an adequate immune system, the people around you may not, so do it to keep them from getting sick as well.

I know, I know, some of you are still thinking, "But the flu shot doesn't cover all strains of flu!"  Of course not, which is why you wash your hands, etc.   And you should also read this thorough, excellent blog post by Dr. Mark Crislip which contains this lovely quote:

 "If you realize that medicine is subtle and nuanced, and often the answers are filled with qualifiers and uncertainty, that the practice of medicine is messy, I think the answer is that the flu vaccine is of benefit. And that the more people who get the vaccine, the greater the benefit for everyone. You do not know how much it pains me to quote Donald Rumsfeld , but he was partly right when he said “You go to war with the army you have, not the army you might want or wish to have at a later time.”

It is true in medicine as well. My army is the vaccine and the data used to support it."

Take home message--Use all the tools you can to stay healthy, including a flu shot.

Tuesday, September 3, 2013

CLA for weight loss?

As I've said before, losing weight is hard work.  Most educated adults know by now that they have to make some pretty radical changes in their diet and exercise routine, and sustain them, in order to reach their goals, but that doesn't necessarily stop them from looking for those supplements that might help them lose those last 5 or more pounds.  And one of those supplements that has recently come up again, thanks to Master of Woo Dr. Mehmet Oz, is conjugated linoleic acid, or CLA.
I say "come up again," as this was popular in the late 1990s when I first started practicing (and I'm feeling a little old).  But can taking this as a supplement really help us achieve our lose fat/build muscle goals?

CLA is actually a type of omega-6 fatty acid, one of those essential fats that our body needs to obtain from the diet as we cannot make it on our own.  It is also a type of trans fat, which immediately scares some people because they know that the trans fats found in margarine, etc are associated with inflammation, insulin resistance, etc.  Fortunately, these type of naturally occurring trans fats acutally have the double bond in a different place (better living through chemistry), and have being showing some promise as far as inhibiting tumor growth/certain kinds of cancers at least if you are a rat (in other words, this might benefit humans, or it might not, depending on what future research shows).  The best sources of this type of fat is from the meat and milk of grass fed ruminant animals (cows, sheep, deer, etc), and second best would be the milk and meat of silage fed ruminants, as well as eggs from chickens fed CLA.  Vegans sources of CLA would be safflower oil and common/white mushrooms.

That's all well and good, but when it comes to losing weight, the amount of CLA recommended is well over what most people would get from eating food.  This should raise a red flag, as there is already signs of a "more is better" philosophy that we are so fond of in the United States (usually to our detriment), and the studies are conflicting.   There are some studies that indicate that this supplement might help people lose weight--to the tune of a person losing an average of one pound of fat over an average of 5 weeks (Link), and that doesn't sound very promising to me.  Other studies indicated that there was no net loss of body fat at all.    Even more troubling was indicators of increased insulin resistance in some overweight individuals, increasing the risk of developing diabetes and altering cholesterol levels in a non-favorable way, although the studies are conflicting here as well (Link).

And then of course there is the price.  When I looked on you are usually going to pay about 10-15 cents per capsule (which is cheaper than what Dr. Oz sells on his website), so you will average about $10-14 per month.  If it were me, I could think of other ways to spend that money for something that is probably not going to help me lose much fat, and might even be harmful given that I have a strong family history of insulin resistance already.

Take home message--consuming conjugated linoleic acid from naturally occuring food sources does not seem to be a problem, and might even be beneficial for protecting against certain cancers (take caution).  Using it as a weight loss supplement might cause problems for those already at risk for diabetes, cardiovascular disease, and spending money on things you don't need.