Diabetes Month Day 3--Know Your Risk Factors

Question

Who is at risk for Type 2 diabetes? What about Type 1 diabetes?

Answer

I think it is also important to embed a little lesson on risk factors versus causality before moving on to a discussion of risk factors: Here is one tutorial.


Even though we don’t fully understand why some people develop Type 2 diabetes and others do not, we do know that there are some factors that increase the risk:

1. Being overweight (as determined by you and your primary care provider)—the more excess fatty tissue you have, the harder it is for your cells to use insulin.  Please remember that not everyone who is overweight will develop diabetes, and some people develop diabetes even though they are not overweight. You cannot tell if a person has diabetes or will develop diabetes just by looking at them; and their health is between them and their doctor, period.
2. Having fat distribution in the abdomen vs. fat distribution in the hips/thighs. If you are visiting with a dietitian who is qualified in doing a Nutrition Focused Physical Exam (NFPE) they might do a waist circumference measure/ratio to help determine your risk.
3. Being inactive or less active—less active people will have cells that are more resistant to the action of insulin. Again, people may have reduced activity levels for a lot of reasons and not all lower activity folks will develop diabetes.
4. Family history—your risk is higher if your parent or sibling has diabetes.
5. Race/Ethnicity—African Americans, Hispanics, American Indians, and Asian-Americans are at higher risk of developing type 2 diabetes. 
6. Previous diagnosis of pre-diabetes, gestational diabetes, or polycystic ovary syndrome.
   Type 1 diabetes risk factors seem to be related to a family history and genetics, although other causes are being investigated.
   Want to keep reading? Click on the link!
   http://www.joslin.org/info/Type_2_Diabetes_Know_Your_Risk_Factors.html

Diabetes Month Tip of the Day--Day 2

Question
How is diabetes diagnosed?

Answer
Let’s start by talking a little bit about what “non-diabetic” parameters are. If you get blood drawn and lab work done by at your primary care clinic, you will hopefully get a printout (or an online version) of your results and what are considered “usual” values (and hopefully the opportunity to talk to your doctor about them). A “non-diabetic” fasting (nothing to eat for 8-12 hours before the blood test) blood glucose level is 70-99 mg/dL, and if you don’t have any issues with blood glucose regulation, your blood glucose levels won’t budge over that even if you’ve eaten something high in carbohydrate the night before. Over the years I’ve had many patients “deny” that anything was wrong because they “indulged” the night before the lab test; and I’ve had to be the one to point out that if everything was working as usual that the body would be able to regulate the blood sugar levels despite the birthday cake (or whatever) it was that you ate.


If you have an “out of range” fasting blood glucose, your primary care provider might send you for an Oral Glucose Tolerance Test (OGTT) to diagnose pre-diabetes or overt diabetes.  Details of this procedure are listed here (http://www.joslin.org/info/diagnosing_impaired_glucose_tolerance_IGT.html).  This particular test does involve more time and money so insurance coverage and the person’s ability to go through the test will come into play. If someone is not willing or able to do the OGTT, the primary care provider will likely order additional lab work to try to determine the diagnosis of diabetes. If your fasting blood glucose level is between 100-125 mg/dL, this level is called “pre-diabetes,” which is pretty serious as you have a 25% chance of progressing to diabetes in 3-5 years.  At the same time, if someone has two consecutive fasting blood glucose levels of 126 mg/dL or greater, or a random blood glucose level of 200 or greater, that is enough for us to diagnose diabetes.  

We can also do a lab test called an Hemoglobin A1c (A1c) to monitor those we suspect are at risk for Type 2 diabetes.  I list this one last because when I started my career 20 years ago this lab test was not standardized and could not be used to “diagnose” diabetes.  I'm glad that we have this available to us now as having one blood test to help diagnose you is way less time intensive and expensive than taking the glucose drink for an OGTT (although I hear it doesn’t taste as awful as it used to). An A1c is a measure of the average concentration or percentage of glucose “clinging” to the red cells in our blood.  Think of it this way—picture your red blood cells as M & M’s and the A1c is a measure of the “thickness” of the candy coating. Some people have called in an “average blood sugar over 3 months” but that really isn’t an accurate description. A “non-diabetic or non-pre-diabetic” A1C is between 4.2-5.8%.  If someone’s A1C is over 6.5% that cause to diagnose someone with diabetes.  We will then try to keep their A1C less than 6.5-7% unless they are other circumstances at play like advanced age or an advanced chronic condition (e.g. advanced heart disease). (A good “goal” A1c is something that every diabetic should discuss with their doctor).


Some of you might be old enough to remember the term “borderline diabetes;” and you might still hear this thrown around. This was never an actual diagnosis even though it was often used to refer to either pre-diabetes or diet/exercise controlled type 2 diabetes.  The main problems with that term was that no one could ever tell you what that really meant (i.e. criteria for diagnosis) or feel that they should take their diabetes seriously as they were not in need of medicine.  If you use this term today (and you know who you are), someone (me) will probably remind you that that’s analogous to being “borderline pregnant.”  You either are, or you aren’t diabetic .

Want to keep reading? Click on the link! http://www.joslin.org/info/all_about_a1c.html

Diabetes Month Day 1

For the month of November, I will be doing informational blog posts for diabetes awareness month on most of the working days. Typically I do a short blurb at my workspace for co-workers, but I thought my friends in cyberspace might want some information too. Most of the information presented here is an expansion of what I want to say at work.

Question

What is diabetes? Are there different kinds?  Is one worse than another?


Answer
Diabetes, or diabetes mellitus, is the name given to a group of diseases in which a person has high blood glucose (blood sugar).  The blood glucose becomes high either because the body does not make enough of the hormone insulin, or because the body’s cells do not respond properly to insulin, or some combination of the two.   The three types of diabetes that I see the most often in my practice are:

Type 1:  Type 1 diabetes only makes up about 5-10% of the cases of diabetes in the United States.  In this form of diabetes the body does not produce insulin at all.  People with Type 1 diabetes must take insulin to survive and follow a carbohydrate controlled diet to “match” the amount of insulin they take. People with Type 1 are usually diagnosed before their 40^th year and usually present with the symptoms of weight loss, frequent urination, increased thirst, and increased hunger.  Type 1 diabetes used to be called “insulin dependent diabetes” or IDDM, “juvenile diabetes,” “or early-onset diabetes.”  These terms were discontinued by the medical community because they are too confusing and not accurate, however, in popular culture it is hard to get rid of this terminology. (Actually, in the medical community it is hard for some of us old farts to get rid of these terms too, come to think of it).

Type 2:   This is the most common form of diabetes (about 90% of cases) in the United States and the form that I deal with the most since I work with an older and elderly adult population.  In Type 2 diabetes the cells in the body do not react to insulin (called “insulin resistance”), or the body does not produce enough insulin, or some combination of both. If caught early enough this form of diabetes can be treated with a carbohydrate controlled diet and exercise alone.  For those who are diagnosed “later” or who are unable to follow a carbohydrate controlled diet plan, they may need to be treated with medications that help sensitize the body to insulin or help the body make more insulin.   Type 2 diabetes is progressive and many people do wind up having to take insulin to control blood glucose levels. (Some people think they have “converted” to Type 1 and this is simply not true).  This form of diabetes used to be called “non-insulin dependent” diabetes (NIDDM) or “Adult Onset Diabetes.” Again, these terms were discontinued because they are too confusing and not accurate; people can be diagnosed with Type 1 diabetes in their 20’s, 30’s, and 40’s and children have been diagnosed with Type 2.

Gestational: This form of diabetes is used to describe elevated blood glucose levels in pregnancy when the woman’s body becomes resistant to insulin.  Some women are able to control this with a carbohydrate controlled diet alone and others may require insulin during that time.  Gestational diabetes usually resolves after giving birth, but some women are more at risk for Type 2 diabetes in the future.

Is Type 1 “worse” than Type 2? No, both forms of diabetes are equally serious and can result in complications, such as blindness or kidney failure, if left uncontrolled.

Want more information. Click on the link! https://www.joslin.org/info/an_overview_of_diabetes.html

Do vegetarians have poorer health?

I spend a lot of time, probably more than I should, skulking around in nutrition related forums where people share the successes and failures they've had with various weight loss plans and/or change of eating habits for a variety of health conditions.  If someone has had good success with one way of eating, chances are they will talk smack about other plans that are in opposition to their way of eating, and sometimes the points they are making are evidence based, sometimes they are not.  The last blog post I did was based on an article that a vegan friend was using to try to talk people out of their "paleo" diet; now it looks like the more omnivorous types could potentially fire back after reading an article like this one: Study: Vegetarians Less Healthy, Lower Quality of Life than Meat Eaters.  So do they have any evidence to truly turn the tables?  Let's apply the same Double X Double-Take to this news article.

1) Skip the Headline. Step away from the Appeal to Emotion Fallacy.

2) What is the Basis of the Article? This one was easy, click on the link in the article and ta-da!  Looks like we have access to the full article!  Now you get to read it, I'll wait.....
Did you see the "lots of people, lots of data, lots of analysis" to indicate that this is original research that has undergone a peer review.

3) Look at the words in the article.  You did read the article?  All the way through?  Including the part that has "limitations" printed in bold?  Here, I'll help:
"Potential limitations of our results are due to the fact that the survey was based on cross-sectional data.  Therefore, no statements can be made whether the poorer health in vegetarians in our study is caused by their dietary habits or if they consume this form of diet due to their poorer health status. We cannot state whether a causal relationship exists, but describe ascertained associations. Moreover, we cannot give any information regarding the long-term consequences of consuming a special diet nor concerning mortality rates. Thus, further longitudinal studies will be required to substantiate our results. Further limitations include the measurement of dietary habits as a self-reported variable and the fact that subjects were asked how they would describe their eating behavior, with giving them a clear definition of the various dietary habit groups." (Emphasis mine).
In other words, based on the people sampled we can't necessarily extrapolate to the larger population, correlation does not equal causation, we need more studies, and we can't rely of people's memory and subjective description of what they ate to determine treatment. 

4) Look at the original source of the information. As I said before, you will want to ensure that the journal and the article are peer reviewed and not just commentary by an "expert." Experts are human and can be prone to some not so scientific idea.  In this particular case a Google search about the journal indicates it is peer reviewed.

5) Remember that every single person involved in what you're reading has a dog in the hunt.  Once again, be careful that your speculations about what dog is in the hunt doesn't devolve into a variation of the ad hominem fallacy, so hold off on the inflammatory language for a bit.

6) Ask a scientist. Once again, I'm so glad you asked!  Some other points to ponder:
1) This study was done in Austria, and the news article was geared to people living in the United States.  Just because the majority of people in each country speak English doesn't mean they have the same eating habits and access to food. A typical vegetarian diet in Austria is likely different than in the US, I personally would have to research that more so I'm not going on assumptions.
2)  As it states above, we don't know if the vegetarians in this group were already in poor health before they changed their diet.  I can remember doing a rotation on the oncology ward as an intern and seeing people that were trying a variety of different diets, vegetarian and otherwise in the hopes that they would be able to cure their cancer.  Perhaps some of these people were having similar struggles with their physical and/or mental health and were making dietary changes that they thought might help.
3) The term vegetarian and vegan mean that you eschew animal flesh and all animal products respectively, these terms actually don't say anything about the quality of a person's diet.  As one friend of mine said about her husband, "He's more of a "sugartarian" than anything else..."  So perhaps these vegetarians weren't actually eating vegetables and were surviving on rice and chocolate and we can't extrapolate their data to a greater population of vegans who spend time planning their meals to include vegetables, soaking their beans to extract more nutrition, etc.  And before some of you start sputtering about how "that's not a vegetarian diet" you might want to study up on the No True Scotsman fallacy.  And remember, you can take just about any eating plan and make it unhealthy (I'm looking at you, people who survive on Atkins company diet products!)

So what do we do with this information?
1) Don't smoke (sound familiar?).
2) Moderate alcohol intake.
3) Include lots of vegetables and some fruit.
4) Don't over or under do your protein intake.

Edited to correct Australia to Austria thanks to alert reader Eve.  My spell-check needs spell-check.

Smoking Meat?

One of the fun parts about blogging is trying to think up catchy titles for blog posts, particularly since "news" writers get to think up scary sounding titles like Diet High in Meat and Cheese Can Be Bad as Smoking and The Scary News about the Paleo Diet.  Of course, since my sense of humor runs toward the teenage variety, that first title make me think of someone lighting up a sausage and smoking it like a cigarette, hence my title.  (I was probably the only one who thought was funny, unless you are also twelve years old).  So, if you thought I was going to talk about various culinary techniques, thanks for reading so far, but I'm actually going to be talking about whether or not we should be as fearful of eating animal protein as these articles imply.

I think this calls for a review of Emily Willingham's excellent post on how to read science and medical news over at Double X Science: Science, health, medical news freaking you out? Do the Double X Double-Take first!  So let's apply this to some of the article about this topic, shall we?

1) Skip the Headline.  This one is hard (for me anyway), but remember that these titles often employ the Appeal to Emotion fallacy to get your attention.  (I think a lot of your friends that post these articles on social media use this appeal as well!).

2) What is the Basis of the Article? Some news articles will make it easy to find the original article (like this one), with other articles you will need Google as your friend to input as much detail as you can find--I used the author's name, the journal, and protein.  We also lucked out in that the entire article was available for viewing online and you didn't have to sidle up to one of your friends with access to a particular journal and/or seek out your nearest medical library to see if they had a copy of that journal.  Now if you read the article (you did, didn't you?  If not, we'll be here while you do) you can see that this article "lots of people or mice or flies, lots of data, lots of analysis, a hypothesis tested, statistics done–is considered “original research.”  So it looks like this was original research that has undergone a peer review.

3) Look at the words in the article.  Here you see words like "risk" and "association" tossed around, so, you are going to see a "correlation" here, but not necessarily a "causation."

4) Look at the original source of the information. You will also want to make sure that the journal and the article are peer reviewed and not just commentary by an "expert" as even some of the experts can have some not so scientific ideas!  In this particular case you can go to the "about" or "journal information" section to see that this is a peer reviewed journal.

5) Remember that every single person involved in what you're reading has a dog in the hunt.  Fairly self explanatory, except sometimes the speculation about what dog you have in the hunt can launch into quite the ad hominem fallacy where suddenly a person who just wants to find out about protein intake finds themselves labeled as a grant whore (and that was one of the nicer terms I've seen), etc. Michael over at Skeptical Raptor sums up his frustration with this statement quite nicely: "The problem with actually trying to dismiss these accusations is that it’s nearly impossible to dismiss the accusations with evidence, because as we know, proving the negative is almost impossible."

6) Ask a scientist.  What do I think about this?  I'm so glad you asked!  Other than the "correlation does not equal causation statement I found some other points to ponder:
--The human data was observational and appeared to rely on people reporting intake, meaning that people could have over or under reported their protein intake.  Do you remember exactly how much you ate yesterday?  Last week?  Last year?
--The study didn't appear to take into account how much or what type of carbohydrate the people ate.  If they ate a bunch of white flour with their protein, and therefore consumed extra calories and/or increased your risk of blood glucose related issues, that could increase your mortality.  At the same time, the people eating less animal protein could have been eating less sugar and engaging in the other healthy behaviors as well.
--I didn't see mention of taking the amount and/or type of fat into account either.
--What about fruit and vegetable intake?
--What about exercise?
--What about the different between feedlot beef and grass-fed, or farm raised fish vs. wild caught, etc?
--Human beings aren't the same as rats, although you can use the info from the animal studies as the basis for future human studies.
--If you actually look at some of diets pointed out as being problematic, like the Atkins', they don't usually advocate "high protein" as even too much protein can cause problems with blood glucose levels, etc.   Loads of cheese isn't part of the Paleo plan either.
--A lot of the news article neglected to mention that a higher protein intake can be beneficial for older adults.
--Going overboard on anything will probably hurt you.

So what should we do with this information?
1) Don't smoke tobacco.
2) Figure out what your protein needs really are.  (0.8-1 gm protein per kg body weight on average, and for older adults it might be more like 1-1.2 gm protein per kg body weight).  The very overweight/obese might need to use a "lean body mass calculator" to get an estimate on what "weight" to use to calculate protein needs (some need more protein at the beginning of their weight loss plan to maintain lean body mass and then it will reduce as you lose weight)
3) Find out how much protein in is the food that you are eating.  If you are reading this, you probably have regular or semi-regular access to the Internet and can easily access sites like calorieking.com.  Keep a record of how much you're eating for at least 3 days.
4) Limit or avoid added sugars and processed carbohydrates, choose fresh fruit and tubers for your starches as often as you can.  If you tolerate grains, choose unprocessed ones. (Hint, most bread products are "made with whole grain" and not actually whole grain.)
5) Consume vegetables at every meal.
6) Avoid deep fried foods and trans fats.
7) If you tolerate vegetable protein sources, find ways to incorporate them (legumes aren't part of my low FODMAPS plan), but that doesn't mean other people can't include them.
8) Find ways to be as active as possible.

Take home message--Always question the news articles you read, particularly if they appeal to emotion.  Finding out how much protein you are eating, from any source, and not overdoing can help you meet your health goals.

Opinion: New Food Label

Last night I had the privilege to chat with dentists Jason and Grant of the Prism Podcast about diabetes, nutrition and pseudoscience, and my favorite gluten free beer (It's Omission by the way).  I was asked about my thoughts on the new nutrition label, and I thought I would expand on my thoughts in writing (which has always been my preferred medium of expression over the spoken word anyway).

Currently there are two different label formats that are proposed, as shown in this graphic from the Washington Post:

What I like about the proposed changes to the "new" label:

1) I like to have easy access to basic information about food, and I like for my patients/clients to have the same access.  Not everybody is equipped with smart phones to be able to look up information in the grocery store, and not everyone has Internet access at home to make up their grocery list either.

2) I like the bigger print for the serving sizes and calories, particularly since I work with a population that tends to have diminishing eye sight.

3) I like the addition of the mineral "potassium" to the food label.  One of the unfortunate consequences of being a diabetes educator is that you wind up working with people who have already developed kidney failure (usually from uncontrolled diabetes, uncontrolled blood pressure, or both)and they have to be cognizant of how much potassium they take in since the kidneys can no longer filter any excess potassium.

4) There has been an effort to make the serving sizes more in line with what
people might actually eat.

What I don't like about the proposed changes/wish they would have done differently:

1)  I wish they would leave the percentages off, as I have never found them useful in teaching people how to read a food label.  Who wants to calculate a percentage while they are in the grocery store anyway?  Many people already don't have a framework for how many calories, carbohydrate grams, etc they should have--and those that do have a framework are going to look at the calories/grams, etc and not look at the percentage.

2) I wish they would do away with the serving sizes and give the information for the entire container.  It would remove one more way that food companies can manipulate the serving size to cause a product to look healthier than what it really is, and I think more people would rather adjust for their own serving size.

3) I hope they don't go with proposal 2, as it's a more crowded format, they are still emphasizing saturated fat as a problem (when it's not really) while ignoring the added sugars, and once again I don't think people respond well to being "told" what to do either.

For those of you who are wanting to establish a good framework for how many calories you need, etc, I recommend the use of the Body Weight Simulator as it uses the most up to date info on how much to cut back over time and what to do to maintain your weight.  For those of you with diabetes/re-diabetes/insulin resistant conditions who are trying to figure out your carbohydrate intake, your ball park intake will be no more than 100 grams of carbohydrate per day if you are trying to lose weight and no more than 150 grams per day if you are trying to maintain (and that's just ball park, if you have diabetes you will only figure out your optimum intake by testing your blood glucose before and after meals when trying new foods.  Try not to aim for more than a 30 mg/dL increase 2 hours after eating).

For other info on label reading and portion control from this blog:
Label reading: Carbohydrate Edition
Portion Distortion
Grocery Shopping with Radio Lab

On My Reading List: The Diet Fix

I have been asked before to do a blog post about "diet books that don't contain a lot of woo."  I've avoided doing that post because even though I can think of books that have good information, I have trouble finding ones that also do not contain a lot of ad hominem fallacies or that promote enough flexibility to keep the plan sustainable.  Today, as I was catching up on blog postings from ScienceBasedMedicine.org I found one that looks promising: The Diet Fix, by Yoni Freedhoff, MD.

I say "looks promising" because it won't be published until tomorrow (I have pre-ordered), and because I like the highlights that Scott Gavura gave over at this this blog post.  I am also happy because it looks like we might finally have a book that does not ascribe demonic powers to either saturated fat (yay bacon and coconut oil!) or all carbohydrates for all people.  I also like his (seeming) focus on sustainability and self awareness (i.e. a diet plan only works as long as you have a plan for that pasta taking a leap into your shopping cart).  I'm also looking forward to reading a book that doesn't contain references to toxins/detoxing/cleansing.

I'm still waiting, however, to check out his references and look at the kind of language he uses.  I'm already wishing he hadn't used the term "Post Traumatic Dieting Disorder" as many of my patients with Post Traumatic Stress Disorder (PTSD) have eating problems that are tied up with their PTSD and I would really hate to draw a false equivalency.

Will report back with my findings/thoughts.  Meanwhile, if your reading list isn't long enough, check out this Goodreads list of recommended books:  Science Based Medicine Recommends.