The Wisdom to Know the Difference

Sometimes people ask me why I spend so much time reading, researching, and writing about Diabetes, which is, after all, a disease. I've given this some thought, and come to an interesting realization.

I focus on diabetes because it is the only physical condition I have where it is possible for me to made a difference in my health with what I do.

I was diagnosed with two chronic conditions before diabetes. Both had in common that there was nothing I could do to relieve the symptoms or influence the way that the disorder progressed. I pretty much had to wake up each morning and pray that it was a "good day" instead of a bad one. If it was a bad day, I had to just get through it. If it was a good day, I had to hope the pain and disability would end sooner rather than later. I learned a lot about mental techniques for pain control and about doing what I could with what I have left. But if I wasn't in crisis I did not dwell on these conditions. I did what I could to forget I had them until they worsened again.

So when I finally was diagnosed with diabetes, what a thrill it was to discover that I had finally gotten a diagnosis where I could do something. If my blood sugar was high, I could change what I ate and bring it down. If that didn't work, there were drugs that might help. If they didn't help, there was insulin which, dosed properly, always works.

I did not have to just sit around hoping something bad wouldn't happen. I could keep it from happening!

If you have to have a chronic disorder, what a good one to have!

With my other conditions, if I spent any time reading about them, I'd end up feeling worse. One book even told me that people with one of my conditions frequently committed suicide. When I ventured into online support boards, invariably there would be people posting who were in more pain than I was, or who had had heroic surgeries that didn't work, or who had developed mental illness dealing with intolerable symptoms. I considered joining a support group for one of these other diagnoses years ago but the woman who ran the group scared me so much during our initial phone call when she described how her symptoms had kept her housebound for a decade, that I never went to a meeting.

With diabetes, support groups are full of people who have eliminated symptoms and figured out how to live reasonably normal lives.

With the other conditions, I'd hope some doctor somewhere would come up with some treatment that might work for me. And over the years, I've noticed that the treatments that were prescribed decades ago--including two surgeries I was strongly urged to have, but refused--have been discredited.

With diabetes I learned that doctors were often way behind the patients in understanding what the most recent research was finding about causes and cure. Even better, I learned there that there was even a very powerful treatment--limiting carbs in my diet--that didn't require a doctor's prescription at all.

So over time, I found I was spending a lot of time thinking about diabetes even when it was not dominating my life in other ways. When I do research, instead of finding more cause for dispair, I find more cause for hope. And I love that I can write about something I've experienced or turned up in my research and have perfect strangers write to me that reading what I wrote gave them not only hope, but actual techniques to use that they are finding will work for them.

So far from being a morbid fascination with disease, my time spent on diabetes is time spent on changing one of the very few things that I can. And it definitely takes my mind off the many other things in life I cannot change.

Taking a Drug Holiday

Every year I go off my metformin for a week or two, usually because my digestive system gets upset enough that it makes sense to cut out a drug notorious for causing stomach issues.

Since I am using insulin at mealtime now, going off metformin does not pose a danger to my health as long as I adjust my insulin dose to match the higher blood sugars I get without metformin in my system.

This past week, off the metformin, has been very interesting. As expected, my digestive system got a lot happier very quickly. No heartburn or weird feelings in the heart region that turn out to be signals from the esophagus or top of the stomach. (If you take Metformin, you probably know what I'm talking about.)

But after stopping, I was surprised at how much more energy I got. I'd been very sleepy in the evenings the last couple months but now, after almost a week without met, I'm bright and alert at 10 PM. My mind feels clearer during the day, too. Interesting!

My insulin needs have gone up, though my carb/insulin ratio is still that of a non-insulin resistant person--1 unit to 11 or 12 grams rather than 1 unit to 15. It took me a few days to adjust my dosage up, very carefully, a half unit at a time. Now I'm using 4.5 or 5 units, instead of 2.5 or 3 per 40-50 gram meal.

I do find it easier to go low with the higher amount of insulin, hence the higher carb intake. I'm not eating those 50 grams all at once, but instead eating a some at 2 or 3 hours to prevent lows. I'm using R, which hits hardest between 2-3 hours. Novolog would require a different approach, but I haven't had the time to work it out.

I'm also hungrier--which is one reason I started taking metformin, because without it I can be hungry and that pushes up my intake and weight. I consider hunger a symptom, not a moral failing, and for years metformin has been helpful in giving me normal hunger patterns. That's one reason I might go back to taking it.

Metformin also lowers my triglycerides dramatically, and since they are one of the more predictive elements in the lipid profile, I see that as good reason to take it. I'm sure my triglycerides are nastier now as I'm eating a bit more carb than usual, reworking the insulin dosing.

Finally, for some reason, taking metformin also lowers my blood pressure enough that when I take a blood pressure pill along with metformin, I can have serious problems with BP going very low. Now that I'm off the Met, I'm taking my blood pressure pills more frequently. I can't take the Diovan every day, never could. For years one Diovan would last me 2 days, and when I'm on Metformin it often controls my blood pressure very well for four! Any more Diovan and I'm likely to find myself flat on my back in the garden seeing stars if I bend over to pick a weed.

But I'm wondering, now that I feel so much more alert and awake without metformin, what this tells me about potential side effects. Is it subtly poisoning me in ways I didn't know about? We know it acts on the liver, and, well, I'm fond of my liver and would really like to keep it around for years to come. Metformin has been used for decades, so it has a pretty good safety record, but even so, the old "listen to your body" thing is telling me that maybe a little less Metformin might be in order.

I'm going to stay off the Metformin for a while longer and then go back on it and see if the sleepiness comes back. This kind of "challenge test" is what my endo instructed me to do years ago when I expressed other concerns about metformin side effects.

All in all, I think it probably is a very good idea to go off any drug we are taking day in and day out after we've taken it for years, to see if 1) it is still actually doing anything--many drugs don't after a while and 2) whether the drug has been causing side effects we haven't connected with it.

Obviously, if you stop a drug you need to closely monitor the area it impacts. You don't stop a blood pressure medicine without testing your blood pressure several times a day. Ditto blood sugar meds and blood sugar.

A Word of CAUTION

For many meds you can't stop cold turkey, because, although doctors often fail to mention this, the drugs are physiologically addictive and you'll have very nasty rebound symptoms or even, in the case of beta blocker blood pressure meds, a heightened risk of heart attack. If you feel a drug vacation is in order discuss your particular drug with your doctor before you stop taking it.

But it is well worth reviewing the rationale behind any drug you've been taking for a few years or more. Your condition changes, other drugs you have added since starting a drug may be duplicating the effect of that older drug, or the drug you have been taking may have become ineffective over time. A good doctor will take these concerns seriously and help you understand how to audit what you are taking and decide if it's time for you to try a drug holiday.

Coke Adds Death?

A disturbing little study published recently in the journal, Epidemiology, received no coverage at all by the media. It found that drinking as little as two "cola drinks" a day could double the risk of "chronic kidney disease."

This was true for both regular and diet sodas. The study also found that drinking non-cola sodas did not appear have any impact on the incidence of chronic kidney disease.

The culprit appears to be the phosphoric acid found in cola drinks but not other kinds of sodas, which usually contain citric acid. Before this study was done, phosphoric acid was already known to promote the formation of kidney stones.

But this study was not reporting the incidence of kidney stones, it was reporting the risk of developing "chronic kidney disease" among people who drank various beverages. The study involved 932 people, half with newly diagnosed kidney disease and half controls.

Chronic kidney disease is the condition that leads to dialysis. It seems pretty clear to this Diet Cherry Pepsi addict that it's time to make a change. No one with diabetes can afford to do anything that further challenges our kidneys.

Carbonated Beverages and Chronic Kidney Disease

Why Didn't this Story Hit the Media?

You do have to wonder. Those of us who are a bit cynical about the power of money to affect our media might wonder if the reason you didn't see this result all over the press is because the companies that produce cola drinks are huge advertisers that no media outlet can afford to alienate.

Even more telling, this isn't the first bad news about phosphoric acid, and cola drinks, that has come and gone without any significant attention being paid to it by the media. Good research (part of the Framingham Study) associates the drinking of sodas with phosporic acid with osteoporosis in older women, because phosporic acid apparently disturbs the mineral balance of the bones.

Here's a Medscape "Medical News" release that describes the osteoporosis findings and a more technical abstract describing the same findings.

Regular Cola Consumption Linked to Lower Bone Density in Women

Carbonated Beverages and Bone Mineral Density

One web site calls these sodas, "Osteoporosis in a can." The sodas that contain phosporic acid include Coke, Pepsi, and Dr. Pepper. There may be others. Read the label to be sure. And don't expect to see this reported on any of the networks each of which runs mind-numbing amounts of advertising for all these dangerous drinks.

Why Type 2s have 3 Times More Neuropathy than Type 1s

A very interesting study presented at the recent ADA Scientific Sessions, which did not get picked up by the media, found that Type 2s have three times as much neuropathy as Type 1s.

http://www.diabetesincontrol.com/results.php?storyarticle=4928

From the Diabetes in Control report:
"Factors associated with higher diabetic neuropathy in a multivariate analysis were male gender (P=0.02), increasing age (P<0.0001), type 2 diabetes (P=0.02), increasing duration of the disease (P=0.0006), and HDL cholesterol at or below 40 mg/dL for men or 50 mg/dL for women (P<0.0001)."

The researchers concluded that "neuropathy and painful neuropathy are mainly associated with type 2 diabetes, potentially via the metabolic syndrome, which encompassed the majority of the strong predictors found."

When I read this, it occurred to me that there may be another, much better, explanation for why Type 2s have so much more neuropathy than Type 1s, and one that has nothing to do with "metabolic syndrome".

The explanation may lie in the fact that doctors consider it normal for Type 2s maintain blood sugars that are well over 140 mg/dl (7.7 mmol/L) all the time. In contrast, Type 1s tend to seesaw between highs and lows, and so while they may go quite high they rarely stay high for more than a short time, because they use corrective boluses to get their blood sugars back down.

Doctors give Type 1s the tools needed to reduce exposure to very high blood sugars: intensive insulin regimens and pumps. A Type 1 who is high will use a corrective bolus to bring down the very high blood sugar as soon as it is noticed.

In contrast, Type 2s mostly are given oral drugs which are incapable of reducing their very high blood sugars to levels anywhere near those that would prevent neuropathy. So they spend the entire day at levels a Type 1 would immediately correct.

Even when they put Type 2s on insulin, doctors rarely instruct Type 2s in how to use bolus insulin to correct highs. Most Type 2s, in fact, are only given basal insulin, which leaves them very high hours each day after eating the low fat/high carb meals they are still instructed to eat.

Most Type 1s are also instructed to keep their fasting blood sugar well under 140 mg/dl, where many, if not most Type 2s have doctors who do nothing when their fasting blood sugars is 160 mg/dl (8.9 mmol/L) or even higher.

We know, based on the research I've explored on my Research connecting organ damage with blood sugar page, that the incidence of neuropathy rises very swiftly as soon as people's 2 hour GTT test result goes over 140 mg/dl. This finding has been duplicated in several studies. This suggests that several hours of exposure to a blood sugar over 140 mg/dl promotes the development of neuropathy.

So it is very clear to me that the real explanation for why Type 2s have so much neuropathy is not likely to be anything intrinsic to their disorder. It is, instead, the result of the extremely poor blood sugar control that their doctors consider normal.

One reason that doctors allow Type 2s to maintain such damaging blood sugars is that they relay so heavily on A1c, which reflects a mean glucose, rather than looking at peaks. In addition, thanks to the ADA's recommendation, they still consider the 7% A1c "safe."

The research shows that for Type 1s a 7% A1c will significantly reduce complications. But UKPDS showed that the reduction for Type 2s at the same A1c is much less.

That is because of how that A1c is achieved.

Type 1 with a 7% A1c may have a fasting bg of 110 mg/dl and spend many hours at a near normal blood sugar, punctuated by hour long excursions to 300 mg/dl now and then that raise the A1c from the normal range.

In contrast, the Type 2 controlled on oral meds alone, as most are, or on an inadequate does of Lantus, may have that same 7% A1c but will be more likely to have achieved it by having blood sugars that are much closer to the mean--172 mg/dl (9.6 mmol/L) all day long. That is why Type 2s have many more complications than Type 1s at the same A1c. For a Type 2, the "safe" A1c--no matter what the number--is one that is achieved by being under 140 mg/dl as much of the day as is possible.

If you are a Type 2 and want to avoid neuropathy--the condition that leads to amputation--do what you can to keep your blood sugars under 140 mg/dl (7.7 mmol/L) If you spend many hours a day with blood sugars over that level you will develop neuropathy.

The tools that will let you keep your blood sugar at that level are these:

1. Avoid eating carbs. There is nothing "healthy" about a food, no matter how good for someone without diabetes that raises blood sugar, and carbs--including whole grains and pasta--do raise blood sugar, often very high.

2. If your current drug regimen is leaving you over 140 mg/dl (7.7 mmol/L) for hours at a time, and you have tried all the currently available oral drugs, ask your doctor to prescribe insulin for you and, if possible, ask to see a Certified Diabetes Educator who can teach you how to use insulin properly. If you are still going high on Lantus, Levemir, or NPH, ask to be taught how to use meal time insulin too.

Chocolate and BP--Another Stupid Study!

If you have diabetes, controlling your blood pressure is the next most important thing you can do to keep yourself healthy after controlling your blood sugar.

So you probably were thrilled this morning when you saw some version of this headline in today's paper: "Dark Chocolate lowers blood pressure!" But before you hit the Hershey's, it's worth taking a look at those pesky details.

Here are two different online versions of the story you can refer to, each includes only part of the data released to the press:

Dark chocolate in a medicinal light

Dark Chocolate Lowers Blood Pressure, New Study

In the words of the first article: The study took "44 adults ages 56 to 73 who had untreated pre-hypertension or mild, stage 1 hypertension. Test participants were divided into two groups. One consumed a daily dose of dark chocolate; the other the same amount of white chocolate."

The second version includes an important fact ommitted in the first: "Every day for 18 weeks, the volunteers were instructed to eat one-square portions of a 16-square Ritter Sport bar, or a similar portion of white chocolate. White chocolate doesn't contain cocoa."

So, after consuming their square of Ritter Sport dark chocolate every day "Systolic blood pressure, the top number, fell an average of nearly three points and diastolic dropped almost two points in the group that ate dark chocolate, compared with no change in blood pressure readings in the group eating white chocolate."

Sounds pretty good doesn't it?

But here's the kicker. In over half the versions of the story which I read online the following piece of information was omitted:
Average blood pressure at the start of the 18-week test was 147 over 86.

This means that at the end of the study the average blood pressure was 144 over 82, which I'm sure your doctor will confirm is much too high!

So here's what the journalists should have been asking, but didn't ask.

1. Why were people with damagingly high blood pressures allowed to maintain those damagingly high blood pressures for 18 weeks without being put on one of the many effective drugs that could have lowered them rather than being subjected to what turned out to be a feeble and mostly ineffective treatment?

2. Why didn't anyone ask whether German candy manufacturer, Ritter Sport, whose candy was used exclusively in this study funded this German study? If they did, why didn't someone point out the ethical issues involved in delaying treatment for high blood pressure for 18 weeks in order to promote the dubious health benefits of their candy?

I like chocolate as much as the next woman, possibly more. So, trust me, if dark chocolate had healing properties, I'd be healed!

But this study, contrary to the headline, really shows that eating chocolate, whatever its benefits, does not provide enough improvement in blood pressure to make chocolate an alternative to one of the more effective methods available for getting blood pressure control. And when the chocolate companies are rolling out $3 chocolate bars plastered with health claims, this is worth keeping in mind.

Here are a couple of tried and true methods for controlling your blood pressure that you should be aware of:

1. Cut your carbs. A large proportion of those who adopt a lower carbohydrate diet sees their blood pressure drop.

2. Cut your salt intake. Many people are salt sensitive, and if you are one, cutting down on salt can make a huge difference. Try to keep your daily intake under 1 gram. Hint: one half can of canned soup has an entire day's worth of salt in it. You don't even want to know about what's in "snack" food.

3. Exercise regularly.

4. Lose weight if you are able.

3. If you are still running a blood pressure higher than normal (which tops out at 120/80) talk to your doctor about starting what would be the appropriate blood pressure medication for you. If you have diabetes, it should NOT be a diuretic (hydrocholorothiazide) as these drugs raise blood sugars. Lisinopril or another ACE inhibitor is the recommended drug. A month's worth of Lisinopril can be bought for $4 at Wal-Mart so cost shouldn't be a problem. If you can't take an ACE inhibitor, an ARB is recommended. Both these classes of drugs fight insulin resistance and also protect the kidneys.

Should you Avoid Injected Insulin when Natural Insulin Levels are High?

If you are a Type 2 who is having a tough time getting normal blood sugars using oral drugs, your doctor may tell you that injecting supplemental insulin would be a bad idea as you already are producing high natural levels of insulin.

This sounds like a compelling argument--except if you also, despite those high levels of natural insulin--are experiencing consistently high blood sugars.

That is because the higher your blood sugar, the more insulin resistant your cells will become. This nasty effect appears to kick in as blood sugars go over 180 mg/dl (10 mmol/L). So if you you are routinely walking around all day with blood sugars of 250 mg/dl (14 mmol/L) or more, no matter how much insulin your body is pumping out, your cells will have a tough time using it, which means your blood sugar will tend to go even higher. Even worse, these blood sugar levels are high enough to poison your remaining beta cells, making your diabetes permanently worse.

Some people can reverse this vicious cycle by cutting carbohydrates out of their diet to the point where the post-meal blood sugars no longer go high enough to increase insulin resistance. If you can do this, it is a very good way to deal with the problem. But this approach, though it often works, is one that few doctors currently recommend, since their orientation is to prescribe heavily marketed pharmaceutical drugs and they may be influenced by outdated nutritional research and not know that current research backs the safety of cutting carbohydrates to control diabetic blood sugars.

But if this approach doesn't work for you, and if, despite taking two or even three oral drugs and making a trial of Byetta, your A1c is higher than the 7% level that even the ADA admits cause the dreaded complications of diabetes, then insulin is the only drug that can bring your blood sugar back to safer level.

That is because, no matter how insulin resistant you may be, with enough supplemental insulin, properly dosed, your blood sugars will come down. And if you can get your blood sugars under the level at which insulin resistance increases, your response to insulin, including your own homemade insulin, will improve. Most importantly, by using insulin to get your blood sugar down to a safer level, you will cut way down on your likelihood of developing life-ruining complications.

It is tough to understand why so many doctors take a lackadaisical approach to doing something about the over 7% A1cs of their Type 2 patients, but sadly, many do, standing by while patients experience year after year of blood sugars that are continually in the very high range guaranteed to cause complications.

This lackadaisical attitude is even harder to justify when you realize that science has found that as long as your blood sugars are very high glucose molecules are continually flooding into your nerves and retinas which is a major explanation of what causes the damaging complications of diabetes. It turns out that these key tissues--the nerves and the retinas--do not require functioning insulin in order to take in glucose. If glucose levels are high in the blood stream, glucose is drawn into these tissues and over time it destroys the nerves and causes the changes in the blood vessels in the retina that lead to blindness.

Your doctor may argue that exposure to very high insulin levels for a prolonged period of time may not be good for you. This may be true, since insulin is a growth hormone and there is concern that very high levels of it may cause some tissues to grow at unhealthy rates--though the evidence on this is mixed. But whatever the longer term effect of exposure to extra insulin there is no dispute in the scientific community that long-term exposure to extremely high blood sugars results in outcomes that are a lot worse.

So if you have tried cutting way back on your carbohydrates and taking drugs that are supposed to lower insulin resistance or lower blood sugar itself, and you still have an A1c over 7%, or if your post-meal blood sugars are routinely over 180 mg/dl despite taking a variety of drugs, and your doctor hasn't suggested that you supplement insulin, you should demand that your doctor explain to you why he or she is withholding the only drug that can normalize blood sugars and allowing those high blood sugars to ravage your body.

The answer better be a good one.

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Note: One last point that is often missed is that doctors may conclude you are making high levels of insulin based on faulty interpretation of lab data. The C-Peptide test, for example, only shows whether you are making insulin at all. The measurement of C-peptide does not correlate well with how much insulin you are making.

Though many type 2s are insulin resistant, after years of being exposed to very high blood sugars their beta cells may have been destroyed or have lost the ability to respond properly to high blood sugars, so their insulin production, while enough to register on a C-peptide test, may actually be much less than they need to control their blood sugar. In that case insulin supplementation will be the only treatment that can normalize that blood sugar.

Happy birthday to this blog!

It's been a year since I started this blog and almost exactly a year to the day after I started this blog, it got chosen as a Diabetes Information "Top Ten" site by healthcenteral.com. Gotta love that!

The other major development has been that, for some reason beyond human understanding, the Wall Street Journal has been featuring a link to this blog on all its health-related articles, even when they have nothing to do with the subject of the blog.

This, of course, means that I'm getting a lot of traffic from people whose only interest in health is financial, and that investors, like those who participate on the discussion board, "Investors Village," regularly denounce me for what has to be the delusional belief that my blog postings are sending the value of their Amylin or Pfizer stocks lower.

The upside of this kind of exposure is that there are just as many people with diabetes investing in stocks as there are in every other area of endeavor, and who knows? Maybe some of them might learn something that will help improve their health.

But it does depress me that the people paying the most attention to health news seem to be those who are eager to profit off of the chronic illnesses of others. It's also sobering to encounter the anger of the investors whose pet companies have been caught indulging in the kind of patient-harming behavior we'd like to believe happens only in distant lands filled with people very different from ourselves.

Their anger is directed not at the companies who profit from hiding evidence of patient harm, or manipulating data to obscure damaging information, or by influencing doctors with huge and often questionable cash payments, but at those who uncover these abuses. In a world where people are willing to put antifreeze in cough medicine intended for toddlers in order to earn a few bucks, this shouldn't shock me, but it does.

Fortunately, I also hear from a lot of people with diabetes who tell me they've read things here that they haven't seen before that are very helpful to them. They also tell me that they appreciate the fact that I back up the statements I make here and on my Main Web Site with references to relevant research studies and to reports by investigative journalists so that they can evaluate any statement they read here for themselves.

It's those people I write for, and their enthusiasm and encouragement--reflected in the Top 10 citation and in the email that I get--makes it worth doing.

One reason I've been focusing so much on the malfeasance of the drug industry in the past couple months is because without an understanding of how far these companies are willing to go to earn a buck and how effective they are in pitching their drugs to doctors in a way that completely obscures possible problems those doctors should be informed of you aren't going to understand why your doctor may be prescribing drugs that aren't in your best interest.

If you trust your doctor without understanding the environment in which he or she works, you may end up just taking a handful of not-very-effective pills each day in the belief that your health has been taken care of and not look into other treatments which are more effective, but which you doctor doesn't know about because they are not being publicized by drug companies with many billions of dollars invested in marketing.

My main problem with all the expensive much-hyped new drugs is not that I have a ravening hatred of the Free Enterprise System. It is that for most people with Type 2 Diabetes these drugs don't work. We know what blood sugar levels damage organs and none of the drugs on the market get blood sugars below those levels for any but a very small percentage of those who take them.

If there were no other treatments available, well, these drugs would be better than nothing. But there are treatments that work much better for most people with Type 2 diabetes--carb restriction and insulin, properly prescribed--that can give all these people blood sugars low enough to avoid complications completely. But these treatments are more complex than taking a pill and doctors do not hear about them because they will not earn billions of dollars for anyone.

So that's why I'm here, pointing out what the health establishment won't. If I can save only one person from amputation, blindness, or dialysis, the time I've put into this blog will be worth it. My email suggests I am having that kind of effect and there are people who now have A1cs in the 5% range who might not have had them if they hadn't read my stuff.

But of course, I'm greedy. I want to save hundreds or even, maybe thousands of people from complications. My dream is that someday the information I'm trying to get out to people with Diabetes about what normal blood sugars are and how they can achieve them will become so well known that doctors and drug companies will be ashamed to publish studies where hundreds or thousands of patients with A1cs of 8% are labeled "well controlled."

Then I can go back to enjoying my garden and let the people who get paid for providing health care do all the work!