Letter to Editor Sees Light of Day...

Last week The Oregonian published A Jazz Man's New Groove, about Thara Memory, a jazz trumpeter who lost a leg and finger to complications of diabetes "but not his fire to make music."

It wasn't an article that caught my attention in my daily review of the news; in fact, I probably wouldn't have known of it if it weren't for a reader of my blog bringing it to my attention. Vivki A. emailed me because she'd sent a letter to the editor of the Oregonian about the article. That was last week. The editors have not indicated they'll be publishing her letter, so I decided I'd publish it for her.

Dear Editor,

Your story headlined "Diabetes steals Thara Memory's [a well known local trumpet player] lower leg and fingertip" make me feel so sad - and angry. It would better have been headlined "Memory hands his lower leg and fingertip to diabetes".

No, I'm not blaming Thara Memory for the loss of his lower leg and fingertip. I'm blaming his doctors, who gave him such bad advice about diabetes management that he had no alternative but to lose those limbs, plus his kidneys, forcing him on dialysis and making him an invalid with a severely restricted lifestyle.

These diabetic-related complications could have been entirely avoided had his doctors given him the proper tools - which they obviously did not.

If his doctors were like the vast majority, they probably gave him some pills, told him to lose weight, gave him a copy of the ADA diabetic diet plan and sent him on his way. They might have told him to test 2 or 3 times a day without telling him what to do with the results of that testing. And maybe even told him he had "excellent" control when his A1C(an average of blood glucoses over a 3-month period) was 7 or even anywhere near that number.

What they probably didn't tell him was that if he could get his A1C to under 6.5 he very likely wouldn't have lost the use of those limbs. Or the use of his kidneys. Or be wheelchair bound. Nor did they tell him how to do this.

Although it takes some effort, it can be done. I have, and I know many diabetics who have.

I blame the American Diabetic Association, whose diet plans almost all doctors give their diabetic patients. The same ADA who advise diabetics that they can eat like regular people, just cut down on portion size and use artificial sweeteners. Sure, you can have that slice of pie, crust made with flour, under the filling - just be sure to use artificialsweetners in the filling.They don't tell diabetics that any grain, such as rice, or foods made with grain - such as breads, pasta, cereals, and yes, that pie crust - will raise BGs alarmingly.

The ADA actually advocates eating breads, pasta, rice and cereals. That's quite clear from the food you mentioned in the article that Memory was eating. Rice? Rice will for SURE raise BGs.

My point is, the diabetic "epidemic" could be well tamed if people were told how they could live a diabetic life and reach its end with all their limbs and body parts intact. It could be that they aren'tmotivated to make the effort. But doctors never even give their diabetic patients the information that this is possible. Sadly, they probably weren't even taught this in medical school.

In closing, I would refer you to a letter to the editor that appeared in the NYTimes last week in response to an article they printed about the ADA and its sponsors. For your convenience, I'll paste it on here. And you might be interested in reading the original article, which is referred to.

New York Times Letter to the Editor December 4, 2006

To the Editor:

"In Diabetes Fight, Raising Cash and Keeping Trust" (front page, Nov.25) points out the conflict of interest in the American Diabetes Association's relationship with drug and food companies that makedonations to the association.

Indeed, you even quote an official of the association as saying that sugar ingestion is of little consequence for prediabetics.

I have been a Type 2 diabetic since 1999.

The article claims that "obesity and inactivity are the key risk factors" for Type 2 diabetes.Perhaps for some, but I was neither obese nor inactive, yet my bloodsugar levels were off the chart.

I was fortunate in finding a doctor who advised me to cut back significantly on carbohydrates. By doing so, I am able to achieve normal blood sugar numbers without using drugs or insulin.Perhaps someone should inform the American Diabetes Association that carbs turn into sugar when digested. But there's no money to be madefrom such advice, which I have never seen from the American Diabetes Association.

Irwin LevineHastings on Hudson, N.Y., Nov. 25, 2006
---------------

Feel free to do any editing necessary to make the segue graceful (if you can, smile)

Vicki A.

True Believers

Science at its best is all about curious wonder, investigation and discovery. Those who follow a career path to research are often inquisitive, interesting people who have a strong desire to get to the bottom of things, to search for answers and to challenge long-held beliefs. I've had great opportunities to meet many researchers over the last five years and am always struck by their desire to take their knowledge and understanding one more step, repeatedly questioning if what they believe is true or not.

Often when a researcher holds a dissenting view on an issue - interprets data differently than others or reaches contrary conclusions - they find themselves ridiculed, ostracized and sometimes even censured! But, they often remain steadfast because they are sure something isn't right with the popular interpretation or use of the data.

Through the years we've seen a number of researchers eventually vindicated - last year two Austalian scientists were awarded the Nobel Prize in medicine after decades of ridicule over their discovery "that ulcers weren’t caused by stress, but rather by the bacterium Helicobacter pylori." That discovery turned medical dogma on its head but not without years of fighting the entrenched belief that ulcers were caused by stress.

Yesterday, as I was reviewing the latest issue of the American Journal of Clinical Nutrition, I wasn't surprised to read Dr. Martijn Katan's reply to Dr. Uffe Ravnskov's Letter to the Editor about Katan's editorial in May about the findings of a study by Krauss et al.

Now, while I could write all about it here, I think it's best to let you read all about it over at Dr. Mike Eades blog - he notes the same type of issues with the reply that struck me when I read it.

Enjoy!

UK Solution to Childhood Obesity - Surgery & Drugs

In a stunning decision this week, reported in This is London, the National Health Services approved weight loss surgery for children as young as 14; those younger will be offered "anti-obesity" drugs.

They claim dramatic action is needed to save a generation from dying before their parents. More than a quarter of children are overweight or obese, with obesity rates of 14 per cent in those aged between two and 10 years.

At the same time, levels of inactivity have soared as many children no longer take part in competitive sport at school and playing fields have been closed.The Government has set a target to halt the year-on-year rise in obesity among children under 11 by 2010.

For the first time the Government's watchdog, the National Institute for Health and Clinical Excellence (NICE), has proposed guidelines for preventing and treating obesity in children.Surgery - which costs around £10,000 - would be an option for children who had reached an age of "psychological maturity", thought to be between 14 and 16 years.

Gastric surgery is a risky procedure - even for adults - which needs lifelong monitoring for potential complications.

What types of complications are we talking about subjecting these children to?

Short Term Complications (in the first 3 to 14 days)

• Bleeding Leak
• Abscess and Infection
• Pulmonary Embolus
• Death
• Severe Nausea and Vomiting
• Narrowing or ulceration of the connection between the stomach and the small bowel has been reported in one series in about 20% of all patients undergoing gastric bypass.
• Bile Reflux Gastritis occurs when bile flows back into the stomach.
• Fistulas, (an abnormal passage leading from one hollow organ to another) abscess and infection have been seen in gastric bypass operations.
• Dumping Syndrome
• Gallstones
• Adhesions, scar tissue caused by healing after surgery
• Diarrhea

Long Term Complications

• Vitamin and Mineral Deficiencies - Decreases in iron, vitamin B12, and/or Folate levels were detected eight months to eight years (median, two years) after the operation.
• Peripheral neuropathy (disorders resulting from injury to the peripheral nerves) has been reported after operation.
• Osteoporosis and Bone Loss.
• Gastric bypass procedures carry the highest risk of multiple micronutrient deficiencies, that may supervene despite close medical follow-up.
• Patients with a gastric bypass have a greater frequency of microcytosis and anemia, more frequent subnormal serum levels of vitamin B12, and impressive failure to absorb food vitamin B12.
• Gastrointestinal bleeding from a duodenal ulcer four years after having a gastric bypass procedure for obesity
• Symptomatic gallstones requiring cholecystectomy
• Abdominal Wall Hernia
• Pregnancy Complications

Oh, let's not forget the drugs!

Weight loss drugs Xenical and Reductil could also be prescribed for teenagers, and even children under 12 if doctors think their lives are at risk. NICE accepts the drugs are not licensed for use in children but says doctors are legally permitted to do so if it will benefit their patients.

Professor Colin Waine, chairman of the National Obesity Forum, said "We believe there is a small group of obese children at significant risk who could benefit, once a child has finished growing and has achieved maximum height, and where there has been a failure of medical treatment.

"We wish it wasn't necessary but the risks are so great of not helping these children that surgery has to be be an option."This is because these children are at risk of developing type 2 diabetes in later life, they have significant risk factors for premature cardiovascular disease, and they are more at risk of developing cancer."

Nailing the Cause of Childhood Obesity

It seems these days there is a lot of finger pointing about the cause of the alarming rise in the incidence of childhood obesity.

It's the advertising children see...

No, wait, it's a lack of public parks...

No, really it's the fast food...

No, no, no, they don't have enough places to exercise...

Oh, wait, it's the inability to maintain a healthy balance between calories and activity...

No, they just eat too many calories...

Gosh darn it, it's the loss of physicial education in schools!

No, it's probably the school lunches...

Hey, what happened to recess?

Forget that, it's lazy parents...

Kids just need to learn to eat right...

They need to stop skipping breakfast...

They're eating the wrong snacks!

No, really, it's stranger danger keeping them from being active!

If they have a fitness magazine they'll lose weight...

Stop selling soda in schools, that's the ticket...

It's living in the suburbs...

We should hike up the tax on junk food to stop them from buying it...

They eat too much fat...

Damn those cupcakes...

Lay off the juice drinks...

Nah, they watch too much television...

Wait, it's too many hours surfing the internet and playing video games...

It's the trans-fats...

Give them more whole grains and less Lunchables!

They need healthy snacks!

They're too picky so parents just feed them what they'll eat...

It starts when they're toddlers....

No, it's their birth weight...

No, no, no...it's their mother's eating too many calories before they're born...

Oh, if only they were breastfed...

Wow - and that is just a sample from the results this morning in Google searching the phrase "childhood obesity."

Oh, and let's not forget, Cookie Monster is now singing "cookies are a sometimes food," schools have banned parties, and Candyland is being evaluated to determine if it's contributing to childhood obesity!

So, what do you think is causing childhood obesity?

The Obesity Crusaders

Earlier this year I wrote "Waiting for the government, schools, daycare, health organizations, politicians, doctors, the food industry or others to fix the problem for you is no longer an option any parent should consider viable for the long-term health of their child. It's time we parents step up to the plate and take responsibility for what we're feeding our kids, what messages we allow marketers to ingrain in their minds, and what activities we encourage them to engage in each day."

Problem now? As the laws of unintended consequences go, now everyone is jumping in the game trying to solve the problem and what we're heading for isn't a solution, but a nanny-state!

In the United States we're not quite there yet, but consider this - Britain is establishing a database to track all children, their habits and behaviors, and investigate families whose children are flagged in the database as "at risk," based on particular behaviors - including failure to eat the government recommended five servings of fruits and vegetables each day!

The index - or those computer systems linked to it - will carry details of everything from vaccinations to whether a child is eating enough fruit and vegetables, or is struggling in the classroom...Doctors, schools and the police will have to alert the database to a wide range of "concerns". Two warning flags on a child's record could trigger an investigation.

Today, Britain's Daily Mail reported Sainsbury's (a retail grocery chain) will roll out a program of "Nutrition Nannies" to walk the aisles of their supermarkets and "advise families about what to buy to lose weight and stay fit."

Can you imagine?

It seems these obesity crusaders believe that the state has the right to define and enforce a single vision of what constitutes healthy living and a good life. The establishment of the "Children Index" database assumes the government's judgment is inherently superior to any individual's judgment - if you stray from the accepted vision, expect a knock at your door as you will be investigated; afterall you are putting your child at risk!

Think it can't happen here in the United States?

Let it Snow, Let it Snow, Let it Snow!

That's the snow on our back deck from the storm!

A bit more perspective on the depth of the snow:

Shut Up and Eat Your Carbohydrates!

"Words are, of course, the most powerful drug used by mankind"
-- Rudyard Kipling

Listen closely.

Read between the lines.

You are being convinced, slowly and deliberately that any dietary approach or course of treatment that deviates from the American Diabetes Association position for medical nutrition therapy, even when scientifically valid and supported by hard data, is dangerous; be afraid, be very afraid.

Add doublespeak to the mix and what was healthful is now "dangerous"; what is inherently toxic is now good for you; and remember, you can just medicate any nasties away with a handful of drugs.

The mission of the ADA is to "prevent and cure diabetes and to improve the lives of all people affected by diabetes."

As data mounts from longer term studies, the number of researchers and physicans challenging the ADA Medical Nutrition Therapy recommendations, and the media points to contradictions in the standards of care, we're seeing intensified attempts at damage control by the ADA; the latest message being one of fear.

Fear that simply writing about the success some patients have with treatment, by physicians, who are not towing the party-line and following the ADA recommendations, well, it's blasphemy! - just writing about it, highlighting the success of an alternative dietary approach, is endangering the lives of millions of Americans!

The message to those interested in preventing or managing diabetes must be clear and maintained - pharmaceutical drugs are necessary, that no one wants to or can follow a diet without sugar, that carbohydrate-rich foods are necessary for health, and that only "proper consultation" with a dietitian can help one acheive their goals in managing their disease with lifestyle modification and pharmaceuticals.

Perhaps you've become aware of this upside-down logic?

If not, I offer you a few examples of how the ADA is working hard to create a state of fear in those at risk for or diagnosed with diabetes, who even think a low-carbohydrate diet may work for them after reading about significant improvements in the media about research studies or in clinical practice. The ADA has slowly moved from discouraging anyone from thinking they can follow a low-carb diet to implying any communication that they might see improvement if they do follow a carbohydrate restricted diet is dangerous and will not be tolerated.

WebMD: Do Low-Carb Diets Help Diabetes?

While agreeing that carbohydrate restriction helps people with type 2 diabetes control their blood sugar, ADA spokesman Nathaniel G. Clark, MD, tells WebMD that the ADA does not recommend very low-carb diets because patients find them too restrictive.

"We want to promote a diet that people can live with long-term," says Clark, who is vice president of clinical affairs and youth strategies for the ADA. "People who go on very low carbohydrate diets generally aren't able to stick with them for long periods of time."

Message - low-carb diets work, but no one can do it anyway.

MedScape: Revised Nutrition Guidelines for Diabetes Prevention Stress Weight...

Pearls for Practice:

• Type 2 diabetes may best be controlled through diet by lowering total caloric intake to achieve weight loss. The best mix of macronutrients in this diet may depend on the individual patient, but low-carbohydrate diets are not recommended for all patients.
• The current recommendations state that healthy patients with diabetes may consume the same amounts of protein, alcohol, and nonnutritive sweetener as the general population.

Message - have your cake and eat it too; why follow low-carb, you can have sugar just like anyone else.

ADA Letter to the Editor, Men's Health Magazine:

"...your publication printed dangerous information that could potentially jeopardize the lives of millions of Americans with diabetes or at risk for diabetes."

Message - writing about patients who effectively control their diabetes with a carbohydrate restricted diet is dangerous, a public health threat, it endanagers the lives of millions!

The ADA Letter to the Editor is nothing more than an attempt at damage control - every time someone in the media, a physician in practice, or researchers and their data challenge the ADA dogma and expose the contradictions (especially the "you have high blood sugars, a disorder of blood sugar metabolism, but keep eating sugar"), the ADA must respond and must do all it can to preserve itself as the authority of what is "right" and "wrong" for someone with diabetes.

Rudyard Kipling was right: Words are, indeed the most powerful drug used by mankind!

The ADA has made it abundantly clear, it's dangerous - a public health threat - to even write about patients' that have successfully managed their diabetes with a carbohydrate restricted diet; forget about the existence of hard data, ignore the mountain of studies piling up, and don't even think of exploring the potential of carbohydrate restriction as an alternative - just shut up and eat your carbohydrates!

ADA Responds to Men's Health Magazine Article

Reprinted with permission, The Fitness Insider, Adam Campbell, November 29, 2006. I have added "ADA" in red to clarify what was from the ADA letter since my formatting is different from Adam's.

The ADA Responds... And So Do I

As expected, the American Diabetes Association responded to my diabetes story.
I've posted it here, along with a few responses of my own. (Click the link for a PDF of the letter: Download ADA_Response.pdf)

ADA: Dear Editor,
In fairness to Men’s Health readers, we would like to clarify some of the issues presented in your December 2006 article, “The Cure for Diabetes.” This article was an opportunity to educate your readers about the greatest health crisis of the next quarter century – the alarming growth of diabetes. Unfortunately, your writer presented an unbalanced story on a disease that affects 10.5 percent (10.9 million) of all men aged 20 or older - with nearly one-third of them not knowing they have it.

AC: In fairness to people with diabetes, we wanted to clarify some of the issues presented in your 2006 Nutrition Recommendations, published in the September issue of Diabetes Care. You had an opportunity to provide diabetes and healthcare providers with unbiased, scientific recommendations, yet you presented an unbalanced report on the efficacy of low-carbohydrate diets in the prevention and treatment of diabetes. Our story intended to raise awareness on this relevant and important topic, and encourage physicians, scientists, and major health organizations to enter into a serious and objective discussion on the use of low-carbohydrate diets as a potential medical nutrition therapy for diabetes.

For instance, in your 2006 report, you stated, "Although there are no data specifically in patients with diabetes, diets restricting total carbohydrate to <130 href="http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16318637">Duke University study in our story, which concludes, "The [low-carbohydrate diet] improved glycemic control in patients with type 2 diabetes such that diabetes medications were discontinued or reduced in most participants." Does this not qualify as "data?" If your answer, is "No," then that begs the question, "Why not?" It's one thing to acknowledge that data exists, but doesn't meet your qualifications; it's another to simply deny its existence.

Perhaps you should have said, "There's no data over 22 months on people with diabetes." Otherwise, you've also denied the existence of this study from Jorgen Vestin Nielsen and Eva Joensson, which found that advising patients to consume a low-carbohdrate diet resulted in improved measures of long-term blood sugar, and that there was no occurrence of heart disease in these patients (23 patients in all). Unfortunately, heart disease did occur in 3 out of 5 patients who didn't adopt the diet.

In addition, this study, from Guenther Boden and colleagues at Temple University, found that “In a small group of obese patients with type 2 diabetes, a low-carbohydrate diet followed for 2 weeks resulted in...much improved 24-hour blood glucose profiles, insulin sensitivity, and hemoglobin A1c; and decreased plasma triglyceride and cholesterol levels. The long-term effects of this diet, however, remain uncertain.” As you would no doubt point out, the authors stress that this was short-term, but there’s another way to think about this: If you can achieve these benefits in just 2 weeks on a low-carbohdyrate diet, what are the potential long-term benefits? While we whole-heartedly agree that more research is needed in are of medical nutrition therapy for diabetes, we can't understand why there isn't a movement by the ADA to better understand low-carbohdyrate diets.

ADA: The article glosses over the difference between type 1 and type 2 diabetes. Between 5-10 percent of Americans have type 1 diabetes, which occurs when the body does not produce insulin. Patients with type 1 must take insulin for the rest of their lives in order to survive. Because it is an autoimmune disorder, type 1 diabetes is not preventable – an important distinction from type 2 diabetes.

AC: We certainly understand this, and by no means intended to trivialize the seriousness of type 1 diabetes. However, this story was about type 2 diabetes. That said, many physicians have effectively used low-carbohydrate diets along with adequate insulin as a therapy for type 1 diabetes. Just ask Richard Bernstein, M.D., who has had type 1 diabetes for 55 years, and has not only successfully treated himself, but also thousands of patients. But again, like Mary Vernon, M.D., the doctor featured in my story, the ADA has chosen to disregard this observational evidence from practicing physicians.

Here are a few additional studies, including a couple that are based on patient data from Dr. Bernstein and Dr. Vernon. Again, according to the ADA, these data don't count.

Gannon MC, Nuttall FQ: Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes.Diabetes 2004, 53:2375-2382.

The Effects of a Low-Carbohydrate Regimen on Glycemic Control and Serum Lipids in Diabetes MellitusDaniel F. O'Neill, Eric C. Westman, Richard K. BernsteinMetabolic Syndrome and Related Disorders Dec 2003, Vol. 1, No. 4: 291-298.

A Pilot Trial of a Low-Carbohydrate, Ketogenic Diet in Patients with Type 2 DiabetesWilliam S. Yancy Jr., Mary C. Vernon, Eric C. Westman.Metabolic Syndrome and Related Disorders Sep 2003, Vol. 1, No. 3: 239-243

Clinical Experience of a Carbohydrate-Restricted Diet: Effect on Diabetes MellitusMary C. Vernon, John Mavropoulos, Melissa Transue, William S. Yancy Jr., Eric C. WestmanMetabolic Syndrome and Related Disorders Sep 2003, Vol. 1, No. 3: 233-237

ADA: For the past five years, the cornerstone of ADA’s message has been that lifestyle modifications are the first line of defense against the development of type 2 diabetes and diabetes complications. The landmark Diabetes Prevention Program study (DPP) in 2001, funded in part by the ADA, showed a 58 percent reduction in progression to type 2 diabetes among people who had maintained a healthy lifestyle, compared to the control group. This healthy lifestyle includes physical activity and weight loss.

AC: It's interesting that you bring up the Diabetes Prevention Program. It's a great example of how lifestyle intervention (diet and exercise) can be more effective than even medication for the prevention of diabetes. In fact, the conclusions from the DPP state: "The lifestyle intervention reduced the incidence [of diabetes] by 58 percent, and metformin [reduced it] by 31 percent... [so] the lifestlye intervention was signifcantly more effective than metformin."
Now, there are a couple of points to make in regard to this.

1. The first is that the DPP doesn't support the ADA's recommendations for a low-fat diet, particularly for people with diabetes. That's because although all participants were at high risk for diabetes when the study started, they were still all non-diabetic. And 4.8 percent of the people on the ADA's lifestyle intervention developed diabetes while on the program, compared to 7.8 percent of those taking metformin, and 11 percent who did nothing.

2. The DPP study states that participants were encouraged to lose 7 percent of their body weight through a low-fat diet and by engaging in exercise for 150 minutes a week. The results: Overall, the dieters ate, on average, 249 fewer calories a day, while 58 percent (does this number look familiar? See above) adhered to the 150-minute/week exercise quota, and 50 percent lost 7 percent of their body weight. So what can we conclude? That exercising and dieting for weight loss reduces your risk of diabetes. Wow! Fascinating stuff. I guess I'm not sure why this is being brought up in response to my story. I clearly pointed out in the story that the ADA recommends to "cut calories and add exercise to reduce insulin resistance." I can't say that anyone in the world debates this advice. Which is why it wasn't the point of the story. My story centered on the specific nutrition recommendations which encourage people with diabetes to eat a diet that features carbohydrates, the only nutrient that signficantly raises blood sugar, the defining marker of the disease. In fact, if you're diagnosed with diabetes, one of the first things they do is teach you to count carbohydrates. Why? So that you can adjust your medication. More carbohydrates equals more medication. And as I wrote in the story, the need for more medication usually indicates that a disease is worsening.

3. It seems to me that the DPP is an informative academic study, but not really relevant in practical terms because it's what the ADA has been recommending for years, and yet we still have an "epidemic" of diabetes. Shouldn't the ADA take some responsibility for what's happened? The ADA's Dr. Buse told me that ultimately, exercise and dieting won't work long-term, so it's best to go ahead and get them on medication right away. (You can read about it in this position statement.) This is well meaning, as the idea is to help people lower their blood sugar even if they won't help themselves (through diet and exercise). But overall, it's a bit like they're blaming the patients for the fact that their therapy isn't working. True, not everyone who develops diabetes is going to change their diet or start exercising, but shouldn't they be given all of their options first? I would have thought that because of the seriousness of this disease, the ADA would be looking for alternatives to the current recommendations, since clearly they aren't working. Especially an alternative as logical as reducing carbohydrates, which automatically reduces the need for some, if not all, medication in many cases.

ADA: It is important for a person with diabetes to consult with a dietitian to develop a food plan that will reflect the needs, tastes, preferences, and lifestyle of the individual. Proper consultation can result in the achievement of desired goals for weight loss or maintenance, blood pressure, blood cholesterol and blood glucose.

AC: You're preaching to the choir on this one. However, just because a person with diabetes might have a "taste" for sugar, doesn't mean they should be encouraged to go ahead and eat it. That seems to be the gist of the ADA's recommendations when they state, "Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucoselowering medications."

ADA: The scientifically-based meal plan recommended by the ADA includes a variety of foods containing carbohydrates from whole grains, legumes, fruits, vegetables, and low-fat milk. These foods are important sources of fiber, vitamins, and minerals.

AC: Sure, but it's based on high-starch foods like grains. And as I pointed out in the story, and you in your 2006 position statement (although worded differently), starch is no better than sugar when it comes to controlling blood glucose. It's also hard to accept the vitamin and mineral argument when compared to medication. For instance, perhaps a person would rather take a multi-vitamin instead of metformin or an insulin shot.

ADA: While low-carbohydrate diets have been a popular and controversial topic, current research does not support the long-term effectiveness and safety of low-carbohydrate diets for the treatment and management of diabetes. Diabetes is a progressive, life-long disease that must be managed long-term. It is not wise to rely on short-term study results for a disease that will always remain a part of that person’s life. The effects of such diets on kidney and cardiovascular disease risks are especially concerning, considering these are two of the biggest diabetes-related complications.

AC: Please show me the research that raises the concern. I understand that the ADA practices evidence-based medicine, so please produce the evidence that shows low-carbohydrate diets increase kidney and cardiovascular disease risk in patients with type 2 diabetes. In fact, it would be enlightening to see the evidence that shows the increase in kidney and cardiovascular risk in non-diabetics. For instance, Ron Krauss' work (1, 2, 3, 4, 5) shows that eating more carbohydrate and less fat increases the risk of cardiovascular disease. And as I showed in the story, more than a dozen studies over the last 5 years have shown that low-carbohydrate, high-fat diets are as effective or, in most cases, more effective at lowering overall heart disease risk than low-fat diets (which are high-carb by nature)--particularly because they raise HDL (good) cholesterol while simultaneously lowering triglycerides. Not to mention that lead to greater weight loss.

Here are several of those studies (many of the links include full text of the study):

Brehm, B. J., Seeley, R. J., Daniels, S. R. & D’Alessio, D. A. (2003) A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women.

J. Clin. Endocrinol. Metab. 88:1617-1623. Sondike, S. B., Copperman, N. & Jacobson, M. S. (2003) Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents.

J. Pediatr. 142:253-258. Samaha, F. F., Iqbal, N., Seshadri, P., Chicano, K. L., Daily, D. A., McGrory, J., Williams, T., Williams, M., Gracely, E. J. & Stern, L. (2003) A low-carbohydrate as compared with a low-fat diet in severe obesity.

N. Engl. J. Med. 348:2074-2081 Foster, G. D., Wyatt, H. R., Hill, J. O., McGuckin, B. G., Brill, C., Mohammed, B. S., Szapary, P. O., Rader, D. J., Edman, J. S. & Klein, S. (2003) A randomized trial of a low-carbohydrate diet for obesity.

N. Engl. J. Med. 348:2082-2090 Volek, J. S., Sharman, M. J., Gomez, A. L., Scheett, T. P. & Kraemer, W. J. (2003) An isoenergetic very low carbohydrate diet improves serum HDL cholesterol and triacylglycerol concentrations, the total cholesterol to HDL cholesterol ratio and postprandial pipemic responses compared with a low fat diet in normal weight, normolipidemic women.

J. Nutr. 133:2756-2761 Volek, J. S., Sharman, M. J., Gomez, A. L., DiPasquale, C., Roti, M., Pumerantz, A. & Kraemer, W. J. (2004) Comparison of a very low-carbohydrate and low-fat diet on fasting lipids, LDL subclasses, insulin resistance, and postprandial lipemic responses in overweight women.

J. Am. Coll. Nutr. 23:177-184 Sharman, M. J., Gomez, A. L., Kraemer, W. J. & Volek, J. S. (2004) Very low-carbohydrate and low-fat diets affect fasting lipids and postprandial lipemia differently in overweight men.

J. Nutr. 134:880-885 Brehm, B. J., Spang, S. E., Lattin, B. L., Seeley, R. J., Daniels, S. R. & D’Alessio, D. A. (2005) The role of energy expenditure in the differential weight loss in obese women on low-fat and low-carbohydrate diets.

J. Clin. Endocrinol. Metab. 90:1475-1482 Meckling, K. A., O’Sullivan, C. & Saari, D. (2004) Comparison of a low-fat diet to a low-carbohydrate diet on weight loss, body composition, and risk factors for diabetes and cardiovascular disease in free-living, overweight men and women.

J. Clin. Endocrinol. Metab. 89:2717-2723 Stern, L., Iqbal, N., Seshadri, P., Chicano, K. L., Daily, D. A., McGrory, J., Williams, M., Gracely, E. J. & Samaha, F. F. (2004) The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial.

Ann. Intern. Med. 140:778-785 Yancy, W. S., Jr, Olsen, M. K., Guyton, J. R., Bakst, R. P. & Westman, E. C. (2004) A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial.

Ann. Intern. Med. 140:769-777 Aude, Y. W., Agatston, A. S., Lopez-Jimenez, F., Lieberman, E. H., Marie, A., Hansen, M., Rojas, G., Lamas, G. A. & Hennekens, C. H. (2004) The national cholesterol education program diet vs a diet lower in carbohydrates and higher in protein and monounsaturated fat: a randomized trial.

Arch. Intern. Med. 164:2141-2146Seshadri, P., Iqbal, N., Stern, L., Williams, M., Chicano, K. L., Daily, D. A., McGrory, J., Gracely, E. J., Rader, D. J. & Samaha, F. F. (2004) A randomized study comparing the effects of a low-carbohydrate diet and a conventional diet on lipoprotein subfractions and C-reactive protein levels in patients with severe obesity.

Am. J. Med. 117:398-405 McAuley, K. A., Hopkins, C. M., Smith, K. J., McLay, R. T., Williams, S. M., Taylor, R. W. & Mann, J. I. (2005) Comparison of high-fat and high-protein diets with a high-carbohydrate diet in insulin-resistant obese women.

Diabetologia 48:8-16 Dansinger, M. L., Gleason, J. A., Griffith, J. L., Selker, H. P. & Schaefer, E. J. (2005) Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial.

J. Am. Med. Assoc. 293:43-53 Daly, M.E., Paisey, R. Paisey, R. Millward, B.A., Eccles, C., Williams, K., Hammersley, S., MacLeod, K.M., Gale, T.J. (2006) Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes--a randomized controlled trial.

As for kidney disease, the concern you voice has never been shown, and it's inappropriate for the ADA to state this, especially since carbohydrate restriction leads to an improvement in blood glucose levels, which REDUCES the risk for kidney disease.

ADA: As a result of improperly addressing these crucial components of diabetes management, not only did your publication provide a disservice to your readers by suggesting that a low-carbohydrate diet is the only safe solution to the prevention and treatment of type 2 diabetes, your publication printed dangerous information that could potentially jeopardize the lives of millions of Americans with diabetes or at risk for diabetes.

AC: We didn't suggest that a low-carbohydrate diet is the only safe solution. But we did present another side to the story--that many people with diabetes have had and are having great success in controlling their blood sugar with a low-carbohydrate diet, despite the fact that the ADA doesn't recommend this as a therapy. The truth is, we think patients who can be successful with ADA recommendations should follow them, but we don't see any great success. In fact, we see a worsening of the problem.

ADA: Larry C. Deeb, MDPresident, Medicine & Science, American Diabetes Association
Richard R. Rubin, PhD, CDEPresident, Health Care & Education, American Diabetes Association
John B. Buse, MD, PhD, CDE, FACEPresident-Elect, Medicine & Science, American Diabetes Association

AC: So that's one letter. I've gotten a bunch of other letters, too. Here are a few:


Your article accurately reflects the rapidly changing scientific understanding of diet and diabetes, as well as the "oral tradition" of diet therapy before medications were available. Congratulations on a job well-done.

Eric C. Westman, MD MHS
Associate Professor of Medicine Duke University Medical Center
----------------------------------------------------------------------

I am living proof of Mr. Campbell's conclusion about carbs and diabetes. I feel very fortunate that I was able to discover this relationship and not rely on the information provided by the ADA. If his article saves one person it would, in my opinion, accomplish more than the $51,000,000.00 spent last yr. by the ADA. Keep up the great work!

Steve Miller
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That was a great article about diabetes. I identified with it completely. At 32 extremely overweight 220#, 5'9'' and lazy as hell I developed insulin dependant diabetes. The starches have to go, but that's OK there's a world of great alternatives out there to eat, which will actually make you look and feel like new again. Stop poisoning yourself one mouthful at a time. Now at 48 a 27 year civil servant at @165# and an 8 pack, I run 15 or so 5K?s and 2, 1/2 marathons a year, additionally I routinely place in weight lifting competitions at the local YMCA and the MWR gyms on the Navy Base where I work. That?s' 1st - 4th place in pull-ups, dips, pushups, sit-ups and bench. By the way that's against college students, mid twenties sailors and marines. There are worse hobbies!

Richard Dollar
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I just finished reading the article on diabeties and agree wholeheartedly with the doctor 3yrs ago I was told I was diabetic my glucose count was 320, my acia blood test was 9 and i tipped the scale at 364 I went on a low carb diet and got immediate results Today my glucose is always between 80 and 100 my acia test is between 5 and6 which is normal and i have lost 120pounds i also include a daily exercise routine in my program and do not take any meds at all This diet plan definetly works!!

Thomas Urbanek
----------------------------------------------------------------------

You are right on! We work with Dr. Bernstein and produced the Secrets to Normal Blood Sugars by Dr. Bernstein. As a pharmacist and diabetes educator, I have seen time and time again, that by reducing carbs, blood sugars go down and people get off of meds. And if you add a little phyical activity to the mix, the results are even greater. It will probably take another 5-10 years for the medical community to accept the obvious. But it will happen!Your Friend in Diabetes Care,
Steve Freed
Publisher
www.diabetesincontrol.comhttp://www.diabetes911.net/

Out Sick....

Fatally Flawed Health & Risk Paradigms: Part 2

On Friday I wrapped up the first of two posts with:

The fatal flaw in the dietary recommendations is that it's not the fat - it's the excessive carbohydrate and sugar in our diets that is causing our chronic, degenerative diseases.

The fatal flaw is that we're specifically recommended a dietary pattern that increases the risk of higher than optimal blood sugars - advising the population that such a diet is going to reduce their risk, when it is increasing their risk!

I've written many times that the dietary recommendations to the population at large are flawed; I honestly cannot believe that it's intentional, but they're flawed nonetheless, and until we go back to the drawing board and tackle the flaws we're not going to see much change in the rates of obesity or alarming prevalance of diabetes.

How did we get so entrenched in the notion that dietary fat is the critically important macronutrient to modify in our diet to reduce risks?

For that history, an article by Gary Taubes, The Soft Science of Dietary Fat, is a good place to start.

Since its publication in 2003, two large, long-term studies have been published that found no increased risk in those who consumed more total fat and/or more saturated fat than recommended. The first was the Women's Health Initiative study, published earlier this year; the second was just published and examined the data from the Nurses' Health Study.The response to the findings in both were eye-opening. In various articles reporting the WHI findings, the mainstream experts contended the null findings were because dietary fat intake was not lowered enough to make a difference; the response to the Nurses' Health Study data contended that neither dietary pattern (low-carb or low-fat) was healthy.

For whatever reason, those deeply committed to the diet-heart theory cannot accept the idea the foundation of the theory is flawed, that perhaps it isn't dietary fat per se, but the total context of diet that really matters most.

In the last few years we have witnessed some very subtle massaging of the message about what we should eat though, although it is often stated as if this were what we've been told all along! The most obvious changes in the message are two things: dietary fat isn't all bad, in fact you can consume up to 35% of total calories from fat as long as you limit intake of saturated fat to less than 7% of calories and keep intake of trans-fat as low as possible (1% of total calories or less) and concentrate on vegetable sources of fat instead of animal sources; and we're now told about "good carbs" and "bad carbs" and told we should eat complex, low glycemic index carbohydrates and limit refined carbohydrates.

Evidence for these changes to the message? Scant, but that didn't stop anyone in the past from perpetuating the idea a low-fat, predominantly plant-based diet is optimal, so why would it now?How do we keep getting it wrong?

Let me say this - changing the message about quality of carbohydrate isn't an all bad thing, it's just incomplete.

That's because it really doesn't matter if you eat complex carbohydrate or refined carbohydrate when it comes to rising blood sugars and release of insulin. Oh, to be sure, complex carbohydrate works in the metabolism slower, but 100g of carbohydrate - complex or refined - is still 100g of carbohydrate to convert to blood glucose. As noted in previous posts, blood glucose, HbA1c, high insulin, high triglycerides and such are all correlated with poor health outcomes over the long-term.

Yet we continue to preach dietary advice that raises blood sugars, triglycerides and insulin, and over time increases percentage of HbA1c when an individual has become insulin resistant.

The flaw is our focus on dietary fat and the belief we require the majority of our energy from carbohydrates.

What to we keep dismissing as critical in the equation of good health and diet?

Protein, specifically complete protein that provides for our essential amino acid requirements.

Now many counter that protein stimulates insulin too, thus protein is a moot arguement in the dietary debate; besides we eat too much protein anyway!

But do we?

Data published from the NHANES surveys tell us something really interesting - over the last few decades our intake of protein has remained stable, level, not increased; and deficiency in critical nutrients is increasing amongst the population, with too many Americans failing to meet requirements for Vitamin E, C, A and D, selenium, magnesium and potassium.

A study published in May 2006 analyzed the newly updated food pyramids and found they were nutritionally deficient.

How does that happen? Everything these days is fortified or enriched to protect against nutrient deficiency!

It happens because the guidelines are not adequately designed to meet nutrient requirements, they're not focused on essential nutrients, but macronutrients as a percentage of calories; designed to promote reducing fat intake, choosing plant-based proteins over animal foods and convincing you to consume carbohydrates as the major source of your calories.

Did you know protein requirements are based on your weight, not a fixed gram intake that meets everyone's needs like other nutrients?

How often have you heard or read you only need 54g of protein each day? That's what it works out to if you do the math based on the Nutrition Facts panel on every packaged food and are targeting a 2,000-calorie per day diet. (2,000-calories, total fat 65g or 585-calories, total carbohydrate 300g or 1200-calories - leaves 215-calories from protein, or just 53.75g).

If we actually look at the recommendations from the Institutes of Medicine, we find protein intake is not based on a percentage of calories, but on an individuals body weight. So, 53.75g is adequate when you weigh 148-pounds. If you weigh more, you need more each day. The RDA is set at 0.8g/kg of body weight; the IOM acknowledges "much less than most people are typically consume," yet government agencies claim "Americans eat too much protein" in educational documents, including ones that target children.

What gives?

It comes back to the deeply entrenched fear of dietary fats - if you want to reduce fat intake, specifically saturated fat, you have to promote the idea to consume less meat, whole dairy, eggs and other animal foods. What happens, at the same time though, is that both the quality of protein intake and the absolute grams of intake is impacted - both are reduced.

But hey, you did reduce fat intake!

Even with the recent concession that it isn't necessarily total fat intake in the diet, the concurrent reduction in limits on satutated fat means an absolute need to reduce animal foods which come neatly packaged with saturated fats, monounsaturated fats and polyunsaturated fats. Oh, yeah, few highlight the fact that meat, like beef, has a majority of its fat calories from monounsaturated fat, not saturated fat.

Plant-based foods can be complete when consumed together to get over the limiting protein in one or the other, but they're simply not as rich with nutrients as animal-based proteins. Meats, eggs, liver, fish, whole dairy - excellent sources of not only complete protein (essential amino acids), but also zinc, selenium, vitamin B-12, potassium, magnesium and other B-vitamins.

When you choose plant-based proteins you're also eating more calories to consume the same amount of protein - that's because plant-based foods are not rich with protein, they're rich with carbohydrate.

So, what happens when you miss your daily requirement for essential amino acids (EAA)?

Well, if it's a day here or a day there, it probably won't have much impact on your health in the long-term. But, if it's the norm, not an occasional miss, it will have an effect since amino acids are the building blocks to repair and build throughout your body. As the Biology Project at University of Arizona highlights, "Failure to obtain enough of even 1 of the 10 essential amino acids, those that we cannot make, results in degradation of the body's proteins—muscle and so forth—to obtain the one amino acid that is needed. Unlike fat and starch, the human body does not store excess amino acids for later use—the amino acids must be in the food every day."

Our dietary guidelines specifically encourage a diet that is deficient in adequate protein and complete amino acids. Each time a study is released finding protein is critical in satiety, hunger regulation, ease of calorie restriction, and weight management - it is pooh-poohed and we're cautioned too much protein is bad for us and to stick with the recommendation to choose plant-based protein!

This leads us to consume excess carbohydrates, even when we think we're eating healthy. Excess is any level of intake above and beyond what we actually need each day.

Now answer this honestly - do you really think we need to consume 500g of carbohydrate each day for energy?

That's what we're currently averaging in the United States; who is consuming the 400g+ that I'm not?

The fatal flaw is in our fear of fat, we are not meeting our protein requirements, thus we keep eating in an attempt to do so, and the foods we're choosing are poor sources of complete protein and often littered with unnecessary calories from fats and oils.

The beauty of a carbohydrate restricted diet is this - isuch a diet forces you to make protein your focus each day and strictly limits the carbohydrate foods you do it to non-starchy vegetables, low sugar fruits, nuts, seeds - all rich sources of vitamins, minerals and trace elements; and when tolerated, whole grains and legumes as desired and within calories consumed.

A carbohydrate restricted diet is not making you eat more fat or more protein; in fact, odds are better than good that you'll be eating exactly the same amount of protein and fat as you did before you limited carbohydrate! What you're eliminating isn't vegetables, fruits, nuts or seeds - in fact, you'll most likely increase your intake of non-starchy vegetables; what you are eliminating is the nutrient-poor higher carbohydrate foods that provide too much carbohydrate and too little nutrition for those calories.

Many wring their hands trying to figure out what you replace carbohydrate calories with when you're on a carbohydrate restricted diet.

The answer is - you don't replace them with anything, you simply swap out the nutrient-poor carbohydrates for the nutrient-rich ones; and encourage non-starchy vegetables, nuts, seeds and low-sugar fruits as the foods to replace the potatoes, rice, beans, pasta and other high-carbohydrate foods.

A simple example is, the typical American lunch might include a cheeseburger on a bun, french fries with ketchup and a soda. A carbohydrate restricted lunch would instead be a cheeseburger sans the bun, a salad with ranch dressing and water or iced tea with a slice of lemon, no sugar.

Both will satisfy the appetite; both are providing identical complete protein; one is significantly less calories and less carbohydrate - all because a salad is swapped for the french fries and water/iced tea replaces the soda.

Now to be fair, we're told the standard American diet (burger, fries and a soda) is unhealthy; but we're also told the carbohydrate restricted meal is just as bad, if not worse for us.

If Americans aren't going to stop eating burgers, why are we not encouraging them to at least eat them in a way that provides a better nutritional profile with less calories?

It all comes back to the fatal flaw - the dietary fat.

Until we get past the fear of dietary fat, not much is going to change. :::sigh:::

Sidebar Updates

Let me take a moment to highlight additions to the list of resources in the sidebar:

Welcome to Dr. Briffa, Dr. Davis, Alan and Lou Schuler - they each have a blog you may be interested in visiting and reading.

Two new links to support forums are also among the additions - Beyond Low-Carb and Dr. Bernstein's Diabetes Forum.

Blogs and support forum links that no longer appear in my sidebar were removed, for the most part, for lack of timely updates. It should be noted that I don't always agree with those I link to - keeps things interesting! - but each blog or forum I do provide a link to does have compelling content and is a good read!

If there is a blog you host or know of that you think others might enjoy, email me for consideration - I update my sidebar about once a month.

Physicians don't address diabetes the right way

A letter to the editor in the Kennebec Journal (Maine) had this gem:

Physicians don't address diabetes the right way

On Nov. 4, the Kennebec Journal discussed the epidemic of diabetes. Diabetes is a nutritional disease. Dr. Sears said that this was a "societal problem" due to less activity and bigger portions.

But the Centers for Disease Control Health Report shows we are more active and many of us eat fewer calories than we did in 1994. Clearly calories in, calories out is oversimplified. Eating equivalent calories from carrots or coke will do profoundly different things to the body. Doctors must address the individual needs of patients, checking thyroid levels, stress levels, sleep deprivation and simple carbohydrate intake. But 72 percent of overweight patients are never even told by their doctors to lose weight (Nov. 7, KJ).

On Nov. 9 in the newspaper, we learned a low-carb diet is "not a risk" for heart disease. Protein sparing fasts have been shown to lower: "Fasting plasma glucose and HbA1c." In clinical practice, I have seen blood sugars drop into the normal range when patients change their diets. In effect, we have the cure for type II diabetes and we are not training our doctors to use it. Even in 2006, only 30 percent of medical doctors have ever taken a separate course on nutrition. These are the specialists who are trying every drug possible when the diet of their patients is literally killing them.

Dr. Christopher Maloney

The Cure for Diabetes?

Way back in July 2002 Gary Taubes article in the New York Times, What if its All Been a Big Fat Lie, was a big fat headache for those deeply commited to the decades old dietary dogma.

Well, get ready for another firestorm of controversy about dietary recommendations! In the December 2006 issue of Men's Health magazine, Adam Campbell takes on the American Diabetes Association in his special report The Cure for Diabetes.

He teases us with his opening sentences...

What if the American Heart Association endorsed the trans-fat diet? Problem, right?

Look at what the American Diabetes Association is spoon-feeding people with diabetes: sugar.

Not to worry: We've got the solution right here.

...and leads in with the controversial approach to managing and reversing diabetes of one small town doctor in Kansas, Mary Vernon, MD.

Her secret weapon against the disease? A low-carb diet.

There's no question Dr. Vernon is trouble - but for whom? Not her patients, that's for certain. They just won't stay sick. People walk into her office afflicted with type II diabetes and, by every objective medical measure, walk out cured. There's $51-million that says that isn't supposed to happen, not in a clinic in Kansas, and definitely not the result of cleaning out the refrigerator.

[...]

If Dr. Vernon and a growing cadre of researchers are correct about carbohydrates, we may be looking at an epic case of ignorance on the part of the medical community. That, however, pales next to the implications for the American Diabetes Association, namely that the very organization dedicated to conquering diabetes is rejecting what could be the closest thing we have to a cure.

This is one of those must read articles!

Go on.....go and read it now!

Part 2 of Fatally Flawed Health & Risk Paradigms is rescheduled for posting tomorrow!

Fatally Flawed Health & Risk Paradigms: Part 1

Hardly a day goes by without the media hounding us to lose weight, lower our cholesterol and keep our blood pressure in check! Why? Conventional wisdom says if we can modify these things - make lifestyle changes - we can modify our risk for chronic health problems like cardiovascular disease, stroke, cancer and diabetes.

A sampling of today's headlines include:

Nurturing Students' Healthy Lifestyles a Priority for UCF

Nurturing Students' Healthy Lifestyles a Priority for UCF[Preeti] Wilkhu [UFC Dietitian] added that “high blood pressure, high cholesterol and diabetes don’t know if you’re healthy, or unhealthy, skinny or fat, white or black, or male or female. Just because you are skinny, it doesn’t give you the right to eat all the junk food you want.”

Group hears about heart disease

"Although genetics and age can't be controlled, women should address risk factors such as smoking, high cholesterol and high blood pressure. A woman should eat a balanced diet and maintain a healthy weight. She should exercise regularly to stay in shape. If a woman has diabetes, doctor visits are important, too," said [Beth] Close.

Eat Your Way to a Healthy Heart

According to the American Heart Association, a healthy diet can help alleviate three major risk factors for heart disease: high blood cholesterol, high blood pressure, and excess body weight.

Not a day goes by without numerous articles and segments on the news to remind us of the message we must make lifestyle modifications - diet and exercise - to reduce our risk of disease. A noble undertaking, no doubt; what's wrong with helping people help themselves, right?

But, what if the message is flawed?

Clearly the experts believe more than adequate evidence supports their recommendations. They tell us that multiple studies, of multiple type, across multiple research methods point to cholesterol, blood pressure and weight. And, I'll even tell you they often do.

The only problem is that consistent and convincing weight of the evidence remains lacking, much to the dismay of those who continue to preach a low-fat diet, reducing calories and restrict fat, cholesterol and sodium intake. The other problem is that a large and growing body of evidence implicates something else is more critical in our long-term health - our blood sugar levels; more specifically our blood sugar trends over time, most easily measured in our percentage of Hemaglobin A1c.

Earlier this week I touched on the findings that show how critical blood sugar levels are in our long-term health. Today, let's take a look at data that points directly to the relationship between HbA1c and coronary heart disease, cardiovascular disease and all-cause mortality.

Hemaglobin A1c is the measure of the percentage of red blood cells that are "damaged" by gycation in our blood. It is formed in a non-enzymatic pathway by hemoglobin's normal exposure to high plasma levels of glucose. The higher your HbA1c, the more your red blood cells are carrying around glycated hemoglobin. That's because once a hemoglobin molecule is glycated, it remains that way.

A buildup of glycated hemoglobin within the red cell reflects the average level of glucose to which the cell has been exposed during its life cycle. The normal range is said to be between 4% to 5.9%. While diabetic patient treatment goals vary, many include a target range of HbA1c values. A diabetic with good glucose control has a HbA1c level that is close to or within the reference range of normal. The International Diabetes Federation and American College of Endocrinology recommends HbA1c values below 6.5%, while the range recommended by the American Diabetes Association extends to 7%.

A very high HbA1c represents poor glucose control in those with diabetes.

But, what about those who are not diabetic - what does the data tell us about the vast majority in the United States who do not have diabetes?

First, let's lay out what the HbA1c values mean. When HbA1c is found to be at the following percentage, the average blood sugar level is: **

5% = 100mg/dL
6% = 135mg/dL
7% = 170mg/dL
8% = 205mg/dL
9% = 240mg/dL
10% = 275mg/dL
11% = 310mg/dL
12% = 345mg/dL

This average is the full, 24-hour average, over a period of 120-days with the lows and highs associated with waking in the fasting state, eating, and expected post-prandial rise. So if your HbA1c is 7%, that basically means your blood sugars averaged - lows to highs - 150mg/dL over the last 3-months.

Now let's take a look at a study published two years ago.

In it, researchers investigating risks for cancer stumbled upon a critically important finding. In their research to explore the relationship between blood sugars and cancer growth, they found a linear relationship between HbA1c and CHD, CVD and all-cause mortality in their study of 10,232 men and women over a period of six years. The statistically significant finding was published in the Annals of Internal Medicine in the paper Association of Hemoglobin A1c with Cardiovascular Disease and Mortality in Adults: The Eurpean Prospective Investigation into Cancer in Norfolk. (PDF)

The finding was an eye-opener - even at "normal" levels of HbA1c, risk started a steady linear rise at 4.8%. Those with an HbA1c of less than 5% had a very low risk for CHD, CVD and all-cause mortality. But, at each incremental increase in HbA1c, the risk of heart disease and death increased significantly. Keep in mind "normal" is considered less than 6%, and this study found increased risk once HbA1c rose above 4.8%.

The researchers published their data in an easy to understand, gender segmented set of tables. In it they reported that the:

Percentage of men with CHD events at, with relative risk at:

• Less than 5% = 3.8% (95% CI; RR = 1)
• 5% to 5.4% = 6.4% (RR 1.56 [1.09-2.24])
• 5.5% to 5.9% = 8.7% (RR 2.00 [1.39-2.88])
• 6% to 6.4% = 10.2% (RR 2.13 [1.35-3.35])
• 6.5% to 6.9% = 14% (RR 3.34 [1.78-6.63])
• 7% or higher = 28.4% (RR 7.07 [3.96-12.62])

Percentage of men with CVD events at, with relative risk at:

• Less than 5% = 6.7% (95% CI; RR = 1)
• 5% to 5.4% = 9% (RR 1.23 [0.92-1.64])
• 5.5% to 5.9% = 12.1% (RR 1.56 [1.16-2.09])
• 6% to 6.4% = 15.2% (RR 1.79 [1.24-2.60])
• 6.5% to 6.9% = 25% (RR 3.03 [1.73-5.31])
• 7% or higher = 34.8% (RR 5.01 [2.95-8.51])

All-cause mortality (death within the six years of the study) in men at:

• Less than 5% = 3.8% (95% CI; RR = 1)
• 5% to 5.4% = 5.5% (RR 1.25 [0.88-1.82])
• 5.5% to 5.9% = 7.5% (RR 1.57 [1.08-2.29])
• 6% to 6.4% = 9.9% (RR 1.80 [1.13-2.86])
• 6.5% to 6.9% = 19% (RR 3.49 [1.83-6.66])
• 7% or higher = 18.5% (RR 3.38 [1.74-6.53])

Percentage of women with CHD events at:

• Less than 5% = 1.7% (95% CI; RR = 1)
• 5% to 5.4% = 2.1% (RR 0.96 [0.58-1.59])
• 5.5% to 5.9% = 3% (RR 1.04 [0.62-1.63])
• 6% to 6.4% = 7.3% (RR 2.29 [1.34-3.96])
• 6.5% to 6.9% = 9.6% (RR 3.06 [1.25-7.49])
• 7% or higher = 16.2% (RR 4.73 [2.16-10.34])

Percentage of women with CVD events at:

• Less than 5% = 3.3% (95% CI; RR = 1)
• 5% to 5.4% = 3.8% (RR 0.89 [0.62-1.29])
• 5.5% to 5.9% = 5.4% (RR 0.98 [0.68-1.29])
• 6% to 6.4% = 9.8% (RR 1.63 [1.05-2.52])
• 6.5% to 6.9% = 13.7% (RR 2.37 [1.13-2.52])
• 7% or higher = 36.8% (RR 7.96 [4.38-14.5])

All-cause mortality (death within the six years of the study) in women at:

• Less than 5% = 2% (95% CI; RR = 1)
• 5% to 5.4% = 2.7% (RR 1.02 [0.65-1.60])
• 5.5% to 5.9% = 4.4% (RR 1.28 [0.82-2.01])
• 6% to 6.4% = 6.4% (RR 1.61 [0.94-2.75])
• 6.5% to 6.9% = 6.8% (RR 1.70 [0.63-4.60])
• 7% or higher = 25% (RR 6.91 [3.50-13.67])

Relative risk tells us the likelihood of adverse outcomes - when the RR is less than 1, adverse outcomes are less likely; when they are greater than 1, adverse outcomes are more likely. So, when the RR range remains above the 1, ie. 1.23-1.99, it is a statistically significant risk for all within the group because in the group everyone had between a 23% to 99% higher incidence of an adverse event when compared to the lowest risk group.

Go back and look at those numbers again!

This study was not the only one to find blood sugars and HbA1c to be critically important either.

Last year a paper, Glycemic Control and Coronary Heart Disease Risk in persons with and without diabetes, was published in the Archives of Internal Medicine. The data from it is almost identical to the findings in 2004. The researchers concluded "In nondiabetic adults, HbA1c level was not related to CHD risk below a level of 4.6% but was significantly related to risk above that level (P = greater than 0.001). In diabetic adults, the risk of CHD increased throughout the range of HbA1c levels. In the adjusted model, the RR of CHD for a 1–percentage point increase in HbA1c level was 2.36 (95% CI, 1.43-3.90) in persons without diabetes but with an HbA1c level greater than 4.6%."

But instead of educating the population about the dangers of elevated, even within the normal range, blood sugars, the crusade continues to beat the drum to reduce cholesterol. You would never know it from the statin ads, but half of all people who have heart attacks have no known risk factors - translated - they have completely normal cholesterol that isn't alerting their healthcare team to impending doom. Add to this fact, the oft-cited Framingham Study couldn't find the ever important connection between LDL - the popular target for reduction - and heart attack either. In fact the Framingham data clued us in that it isn't total cholesterol, LDL, or HDL alone, but the ratio of total cholesterol to HDL and triglycerides that matter most if we're going to focus on cholesterol as a target.

In addition to the above cited studies finding blood sugars and/or HbA1c significant for risk, we have clear evidence that higher than optimal blood sugars are deadly over the long-term; that non-diabetic hyperglycemia is a risk factor for cardiovascular disease; and that there is a linear relationship between blood glucose levels and coronary mortality over the long-term.

And yet, the dietary advice we're given specifically increases the potential for chronically higher than optimal blood sugars - all because the dietary dogma is based on the assumption that dietary fat and cholesterol raise the risk of cardiovascular disease.

The fatal flaw in the dietary recommendations is that it's not the fat - it's the excessive carbohydrate and sugar in our diets that is causing our chronic, degenerative diseases.

The fatal flaw is that we're specifically recommended a dietary pattern that increases the risk of higher than optimal blood sugars - advising the population that such a diet is going to reduce their risk, when it is increasing their risk!

Come back Monday, as Part II of this article will continue...

**Correction from original post: I inadvertantly cut & paste incorrect "HbA1c - blood glucose values" from a chart I compiled from various sources as I researched to provide accurate information. The revised data comes from consensus of two sources - LifeScan (OneTouch glucose meters) and the University of California San Franscisco.

Blood Glucose Testing - Lost Opportunities

During the three day Institute of Health Economics conference, taking place this week in Edmonton, Canada, experts are debating the efficacy of daily testing of blood sugars for those with type II diabetes reports CBC News.

Canadian diabetes experts are revisiting the idea that people with Type 2 diabetes need to monitor their blood-sugar levels daily.

Such frequent testing is valuable for people with Type 1 who take insulin many times a day. But for people with Type 2, who aren't on insulin, the benefits are less clear and are contentious.

[...]

A six-month study by institute fellow Dr. Jeff Johnson concluded the test strips don't offer much benefit to Type 2 diabetics in the long run, and the money governments pay out may be better spent."

There's a number of research studies conducted in the last few years since the time that our guidelines were written that suggest that the long-term benefit of doing more frequent tests for people with Type 2 diabetes has very little impact on their blood-sugar control," Johnson told CBC News on Tuesday.

With my experience as a corporate strategist it boggles my mind how these experts miss the point so often.

In the corporate world, profits are driven by performance and strategists are employed to review business processes and find ways to improve performance to enhance productivity and profits. Folks, it always comes down to money!

And, that's not necessarily a bad thing - enhanced productivity can lead to growth that not only improves the bottomline for a company, but also enhances innovation, employment opportunities and even safety. But, as any strategist will tell you, you cannot make improvements without establishing performance measures, accountability, and ensure that return-on-investment data is being used to find where improvements will make a difference.

It is a continuous cycle of gathering data, learning, tweaking, implementation, testing, and analysis of outcome as you apply changes trying to enhance productivity and profits; and when the data for return-on-investment is impressive, you move forward to implement those process changes system wide that are found to have the best bang for the buck.

If I had a project under way and spent time and money to set up a review of process, then measured various potential changes with the influence of each and then did nothing with the results, it would be a waste of my time, corporate executives time and a lot of money.

Measuring and then not doing anything with the results is simply a waste of time.

Various studies investigating the efficacy of blood sugar testing continue to find that it does little to improve glycemic control in those with type II diabetes.

Now the burning question seems - is it worth all this money to provide meters and test strips when testing doesn't result in improvement in those with type II diabetes?; when the question should be - is there improvement to be made in how results are used to improve glycemic control in those with type II diabetes?

The problem isn't that testing does nothing to improve glycemic control; the problem is nothing is done with the data to effectively make changes that will result in improved glycemic control.

Those with diabetes are told to test; they're given a very powerful tool for data gathering that is reliable, real-time and specific to direct inputs/outputs; what they're not provided is the one thing they require - what to do with the data?

Measuring and then not doing anything with the results is simply a waste of time.

Testing blood sugar, in and of itself, does absolutely nothing to improve blood sugars. Instead testing is a "return on investment" proposition for a person with type II diabetes; if they are going to use the data, it is worth the investment; if they're not, it's a waste of time and money.

Measuring is knowing (as I learned, a saying from Holland - "meten is weten"); simply knowing however is only the very first step; knowing cannot make your blood sugars improve; knowing cannot make your blood sugars decline; but we all knowledge is power.

Power to do what?

Power to change the inputs to see what affect those inputs have on the outcome.

"Eat to your Meter" is a saying often expressed by those who, through trial-and-error, tweaking, testing, measuring, and modifying their diet along the way, have found their meter to be the single most important tool in their control over their disease. The don't just measure their blood sugars, they do something when they see less than desired results.

Measuring and then not doing anything with the results is simply a waste of time.

Those debating the issue of testing, testing supplies and usefulness of testing for the individual miss the point that it's not the testing that is a problem - it's that nothing is done to effectively use the data at hand to make improvements.

The problem is one of perspective not performance.

Rather than evaluate why daily testing is not leading to significant or sustained improvement, the thinking is testing is obviously a waste of time; and with nothing gained, then nothing is to be lost if testing is reduced or eliminated by the individual.

What is lost is opportunity.

Not only the opportunity to evaluate the current assumptions, but also opportunity to really understand how diet affects blood sugars; how changes impact glycemic control in the short and long-term; and how real-time feedback from the meter is invaluable in the decision making process as one learns how to improve glycemic control as they modify their diet.

Rather than ask why testing is not leading to improvement - asking the difficult question, what are we doing wrong here? The assumption is nothing is wrong, diabetes simply is progressive and there is little one can do, so with nothing wrong with the process, there's no benefit to gathering data, which really is what testing is - gathering data.

Measuring and then not doing anything with the results is simply a waste of time.

Until these experts step back from their assumption that the present guidelines are the best we have, testing will remain a useless endeavor for someone with diabetes who follows the guidelines.

For those who understand the concept of actually using their data - testing and re-testing with modifications to see what the result is - it is and will remain an invaluable tool to help make improvement not only possible, but a reality as their blood sugars improve and their HbA1c goes down.

Those individuals who "get it," that testing means having to make changes to see the results also "get it" that with each small improvement they can manage, they also make a parallel improvement to reduce the risk of complications.

That's because those with diabetes who measure and DO SOMETHING with their results know it is possible to achieve normal or near-normal blood sugars and HbA1c when they use the tool - the meter with daily testing is a tool - to do what it takes to gain control and thus reduce the risk of complications.

Just don't wait for the experts, the ADA or the IDF to jump on that bandwagon and promote the idea that daily testing is the single most effective way to gain control. That would mean having to tell the truth about carbohydrates in the diet of those with type II diabetes.

I don't expect that to happen any time soon - instead we'll keep seeing the advice move in the direction of medicating the problem away, and now, leave it all up to the healthcare team, don't inconvenience the patient - just take your medications and come in every few months for tests so we can adjust them.

Makes you wonder whose bottomline benefits most, doesn't it?

When "Normal" isn't Optimal for Health

Add one more study to the growing mountain of data that points directly at higher than optimal blood sugars as a major cause of death.

A study in the November 11 issue of the Lancet - Global and regional mortality from ischaemic heart disease and stroke attributable to higher-than-optimum blood glucose concentration: comparative risk assessment, concluded "Higher-than-optimum blood glucose is a leading cause of cardiovascular mortality in most world regions."

In the WebMD article on the study, High Blood Sugar a Global Killer, the staggering number of deaths annually is laid out - Worldwide, high blood sugar is linked to 3,160,000 deaths each year.

Three million deaths annually!

Are we talking about blood sugars in the pre-diabetic (100-125mg/dL) or diabetic (126+/mg/dL) range?

No, this study demonstrated that even levels considered "normal" may be deadly over the long-term - as the WebMD article noted "High blood sugar is one sign that a person is on the road to diabetes. But it kills many people long before they ever get diabetes, note Goodarz Danaei, MD, of Harvard School of Public Health, and colleagues.

Moreover, blood sugar levels start causing problems once they pass the higher-than-normal level. It's not a matter of getting disease at a certain point. It's a matter of ever-increasing disease risk."

In this study risk started to increase at 4.9mmol - just 88.2mg/dL; well below the ADA "normal" of less than 100mg/dL; much less than the 100-125mg/dL for a diagnosis of pre-diabetes and much, much lower than the 126mg/dL used as the level to diagnose diabetes.

Quite frankly, this isn't news - we've had hard data for years warning us about the dire consequences of even a minor elevation in blood sugars within the normal range.

Archives of Internal Medicine, October 2004: Is nondiabetic hyperglycemia a risk factor for cardiovascular disease? A meta-analysis of prospective studies

CONCLUSION: Blood glucose level is a risk marker for CVD among apparently healthy individuals without diabetes.

Diabetes Care, December 2004: Blood glucose and risk of cardiovascular disease in the Asia Pacific region

CONCLUSIONS: Fasting blood glucose is an important determinant of CVD burden, with considerable potential benefit of usual blood glucose lowering down to levels of at least 4.9 mmol/l.

Archives of Internal Medicine, September 2005: Glycemic Control and Coronary Heart Disease Risk in Persons With and Without Diabetes

"...the RR of CHD for a 1–percentage point increase in HbA1c level was 2.36 (95% CI, 1.43-3.90) in persons without diabetes but with an HbA1c level greater than 4.6%. In diabetic adults, the RR was 1.14 (95% CI, 1.07-1.21) per 1–percentage point increase in HbA1c across the full range of HbA1c values."

"Our results also suggest that in persons without diabetes, a "high normal" HbA1c level predicts elevated CHD risk and that, in addition to diabetes prevention, strategies to lower glucose levels should be investigated for reducing heart disease risk."

Diabetes Care, 2006: Relation Between Blood Glucose and Coronary Mortality Over 33 Years in the Whitehall Study

"All-cause, cardiovascular, and respiratory mortality were elevated among participants with glucose intolerance...There was no evidence for a dose-response relationship below 2hBG = 4.6 mmol/l. Between this level and 11.1 mmol/l (200 mg/dl), the age-adjusted hazard ratio was 3.62 (95% CI 2.3–5.6)."

Add to this, impaired fasting glucose may not even begin to rise enough to alert clinicians before damage is occurring.

In 2003, the ADA journal Diabetes published a study, The Natural History of Progression From Normal Glucose Tolerance to Type 2 Diabetes, researchers found that of the 437 people who started out with normal glucose tolerance only 48% remained normal. Of the rest, 52% developed abnormal blood sugars during the course of the study. Critical in this data is the finding that 31% of the original group of 437 participants had impaired glucose tolerance though they still had "normal" fasting blood glucose. In fact, abnormal post-challenge blood sugar with normal fasting glucose was the most common pattern for developing type II diabetes in the study.

As noted on the What they Don't Tell You About Diabetes website - the difference in the range of "normal" blood sugar tests in telling. "At the outset of the study the average fasting plasma glucose of the people who remained normal was 82 mg/dl with a narrow standard deviation reaching up to 92 mg/dl. But the average fasting plasma glucose of the "normal" people who went on to develop diabetes was 10% higher--at 90 mg/dl but the standard deviation extended all the way up to 139 mg/dl, the pre-1998 ADA cut off for "normal." (The standard deviation is a measure of how tightly values in a range cluster around the mean.)"

It's difficult enough to grasp the ever increasing risk if you have diabetes; when you don't, it boggles the mind how your "normal" blood sugars might be killing you!

The take home message of this new study, when taken with others with similar findings is this - it isn't whether you have diabetes that decides your long-term risk for diabetes or cardiovascular disease, it's whether you have blood sugars above optimal, even within the normal range; the higher they are, the more the risk. As the data shows, higher than optimal blood sugars are those that doctors now treat as normal.

Expert Says Children Should be Aggressively Treated with Statins

MSNBC reported (via Reuters) U.S. children showing hardening of arteries which included a grim report from a presentation at the annual American Heart Association meeting - "Children with risk factors for heart disease, including high cholesterol and diabetes, are showing signs of narrowing and hardening of the arteries, conditions normally associated with adults...[a]n increasing number of children suffer from these and other risk factors for cardiovascular disease, including obesity, but testing for future heart conditions is not standard practice."

At the center of the article is this easily glossed over tidbit - "Testing should include regular blood lipid and glucose level testing, said the report’s lead author, Sanaz Piran, a resident at McMaster University in Hamilton, Ontario, Canada. Earlier treatment could include more aggressive use of cholesterol-lowering drugs called statins, she said."

Have we lost our minds?

Let's just medicate the problem away instead of getting at the real cause - a poor diet.

:::sigh:::