Month: April 2018

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In Diabetes, think lower carbs

Lower Carbohydrate diet

My advice in diabetes, think lower carbs. Eating fewer carbohydrates with every meal is one of the most important changes in your diet that you can make to control blood sugars. Eating fewer carbohydrates sounds restrictive but meals can be made tasty and think about the benefits that come with it.

How many carbohydrates should you eat per day

While reducing carbohydrates will help with blood sugars, it is a very personal journey to find what foods work for you. Based on a 2500 calorie per day diet, I would recommend 100-150 gm of carbohydrate per day. If you want to lose weight reduce not only your calorie intake but also your carbohydrate intake down 75-110 per day.

Is there a diet that is better for diabetes?

The best diet is the one that works for you, your goals and activity. Everyone is different, the diet that works for you might not work for someone else, and vice versa. If you are trying to build strength and muscles, you shouldn’t follow the same diet as when you are trying to lose weight.
In the same way, someone who runs every day has different dietary requirements than someone who sits in an office all day and doesn’t exercise.

Moderate carbs

The general recommendation for a non-diabetic person is to get 40-60% of their daily calories from carbs. If you eat 2,000 calories a day, that’s between 200 and 300 grams of carbs a day.
For people with diabetes, this is generally too many carbs, but for people with diabetes that exercise a lot and/or are trying to build muscle mass 30-50% might be better than low carb.
One possible problem is that if you do not maintain the high level of exercise your blood sugars can go out of control easily.

Low carbs

There is no clear definition of exactly what a “low carb” means, low carb can be approximately 50-90 grams of complex carbs a day (not including vegetables). Patients with diabetes go this low when they want to slim down, like when wanting to drop a few pounds.

The benefits of lower carbs

The benefits of lower carbs are not surprising, Carbs raise blood sugars far more than fat and protein do. Limit the amount of carbs to get blood sugars under control, to use less insulin, avoid weight gain and avoiding the complications of diabetes.
Eating less carbs is one of the most important changes patients with diabetes can make. Lower carbs can make their blood sugars steady and will help avoid the roller coaster ups and downs that come with eating a high carb diet. For patient s with Type 2 diabetes this should be the first approach to manage high blood sugars effectively. For type 1 diabetes is the best way to manage it along with insulin.
Eating fewer carbs will lead to less insulin and less oral medications use. Eating just one low carb meal per day can make a difference, especially if it is the largest meal of the day. Reduce carbs slowly and be patient, it takes your body about 2-3 weeks to get used to it.
Other benefits are lower cholesterol, lower triglycerides, lower weight, and reduction in cardiovascular disease. For a place to start healthy eating refer to the plate method. Combine lower carbs with lean protein and good fats, to see low or no blood sugar fluctuations after meals.

The negatives of low carbs

Low carb is great for weight loss and can help with blood sugar control, but it also decreases your metabolism and energy levels. If you live an active lifestyle (and especially if you do resistance training), the moderate carb diet provides you with the energy you need to fuel your workouts, while still allowing for great blood sugar control.

The no-carb (ketogenic) diet

The theory behind the ketogenic diet is that by consuming almost no carbs (less than 5% of your total calories), your body will start converting fat into fatty acids and ketones.

Benefits of no-carb

Ketones can replace glucose as your body’s main energy source, meaning that your body mainly relies on fat for energy. In theory, this should make it very easy to lose excess body fat if you limit your calorie intake at the same time. By eating almost no carbs, you also, in theory, need very little insulin, making blood sugar control easier.

The negatives of no-carb

For most insulin dependent patients their insulin sensitivity fluctuates. Since he theory is that fat is released more slowly into the bloodstream than complex or refined carbs, there should be no blood sugar fluctuations. Insulin resistance is based on the amount of fat you have specially in your abdomen, for those with little or no fat the increase in fat intake can lead to fluctuations in insulin needs.
Many patients also experience weight gained from the increase fat intake. For patients with type 2 diabetes wanting to lose weight this maybe an alternative for a short term. Long term will lead to little energy level and can induce patients to end up eating more because they feel hungry all the time.

As I wrote in the beginning, what the optimal diet depends on your goals.

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What is prediabetes?

What is Prediabetes?

Prediabetes is when your, blood sugar levels are higher than normal but not high enough to say you have diabetes. People develop prediabetes before they are diagnosed with diabetes.

Normal “fasting blood sugar”

Normal Fasting blood sugar is between 70 and 99 mg per dL.

What is Fasting blood sugar?

Fasting blood sugar is your blood sugar level you before you have something to eat in the morning.
• Fasting blood sugar between 100 and 125 mg per dL suggests prediabetes.
• Fasting blood sugar higher than 126 mg per dL is considered diabetes.

Causes

Who is at risk?

You are at risk for prediabetes if any of the following are true:
• You are age 45 years old or older
• You are overweight or obese.
• You have a parent, brother or sister who has diabetes.
• You had diabetes during pregnancy (called gestational diabetes) or had a baby who weighed more than 9 pounds at birth.
• You belong to any of the following ethnic groups: African American, Native American, Latin American or Asian/Pacific Islander.
• You have High blood pressure (above 130/80 mm Hg).
• Your high-density lipoprotein (HDL) cholesterol level (“good” cholesterol) is less than 40 mg per dL (for men) or less than 50 mg per dl (for women), or your triglyceride level is higher than 250 mg per dL.
• You are a woman who has polycystic ovary syndrome (PCOS).

Diagnosis

How can my doctor tell if I have prediabetes?

Your doctor can give you a blood test to check for prediabetes.

Tests

There are several tests your Doctor can give you to find out if you have prediabetes or diabetes:

Test                                                          Normal                      Pre-diabetes                 Type 2 diabetes
Hemoglobin A1C%                                   <5.7                           5.7-6.4                          ≥6.5
Fasting Plasma Glucose (mg/dL)            <100                          100-125                        ≥125
Oral glucose tolerance test (mg/dL)       <140                         140-200                        ≥200

Fasting plasma glucose is how much sugar is in your blood after not eating for 8 hours (often first thing in the morning).
Hemoglobin A1C helps your physician figure out your average sugar control over the past 3 months.
Oral Glucose Tolerance Test blood sugar is measured after not eating for 8 hours and 2 hours after drinking a sugar rich beverage.

Prevention

If I have prediabetes, can I avoid developing diabetes?

You can lower your risk of developing diabetes by making changes in your lifestyle. If you are overweight, losing weight can help. Losing weight also helps lower your blood pressure and cholesterol levels.
Exercise is also important. Your exercise routine should include 30 minutes of moderate physical activity (such as brisk walking or swimming) at least 5 times a week. Ask your doctor what exercise level is safe for you.
Follow a healthy diet. Eat foods such as vegetables, fruits, whole grains, fish, beans, poultry and other meats. Don’t eat a lot of processed foods or sweeteners such as sugar, honey, maple syrup, agave syrup, or molasses. Eat foods made with whole grains instead of white flour.
Your doctor might refer you to a dietitian or diabetes educator to help you change your eating and exercise habits.

Treatment

Can medicine help prevent or delay diabetes?

Diabetes medicines are not as effective as diet and exercise. However, your doctor might prescribe medicine such as metformin, if you are at high risk for diabetes and have other medical problems, such as obesity, a high triglyceride level, a low HDL cholesterol level or high blood pressure.

Questions

Questions to Ask Your Doctor

• If I have prediabetes, will I get diabetes?
• What is the best step I can take to avoid getting diabetes?
• My father has diabetes. Should I be screened for prediabetes on a regular basis?
• I have diabetes. Should I have my children screened for prediabetes?
• I had gestational diabetes. Should I be screened for prediabetes regularly?
• Are there any foods I should eat that will help me to avoid prediabetes?
• Should I speak with a dietitian about changing what I eat?

What does having pre-diabetes mean for my health in the future?

Having pre-diabetes is your early warning system. Make changes and avoid the problems that diabetes and heart disease could bring. Small steps can make a big difference in your health. Choose 2 or 3 small steps—start today to reverse your pre-diabetes.

Visit our patient corner for more information for patients.

 

 

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What is an A1C?

What is an A1C or a Hemoglobin A1C? Why is it important?

An A1C is a blood test done at your doctor’s office to tell you how well you are managing your blood sugar over time. Your A1C number tells you your average blood sugar for 2-3 months before the test or how well your diabetes is being controlled.

These are some ways the A1C test can help you manage your diabetes:

• Confirm self-testing results or blood test results by the doctor.
• Judge whether a treatment plan is working.
• Show you how healthy choices can make a difference in diabetes control.

How often should you have an A1C test?

A1C tests should be done at least every 3 to 6 months. Ask your doctor what your last A1C was and when you should have your next test.

The American Diabetes Association (ADA) A1C goal:

The recommended level is Less than 7% but goals should be individualized for each patient.

•You and your doctor will set an A1C goal or Hemoglobin A1C. This goal may change over time.
•Work with your doctor or health care providers to reach a final goal less than 7%.

The goal A1c will help reduce or minimize complications from diabetes.

How often should you get your A1C Check?

Get an A1C or Hemoglobin A1C checked every 3 months if your blood sugars are not at goal but if your blood sugars are controlled, you can get an A1C checked every 6 months. Keep track of your A1C numbers.

Talk to your doctor about:

•If your A1C is not at goal Talk to your Doctor to agree on a plan to get your blood sugars under control
•If you reach your A1C goal, do you need to set a different goal or just stay where you are? what else do you need to do to avoid complications.

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Is Coffee Bad or Good for You?

Millions of people around the world depend on a cup of coffee to start their day. We treat ourselves to a nice, hot, smooth cup and enjoy our vice even if it’s bad for you. Or… is it?
Is Coffee bad or good for you? Recent studies have evidence that coffee has potential health benefits. While more research is needed to validate the results, the evidence does show potential benefits to drinking coffee.

Lowers risk of Death

Several studies suggest an association between coffee consumption and a lower risk of death. A trial of 185,000 individuals who identified as African American, Latino, Native Hawaiian, white, or Japanese American, and aged 45-75, were followed over a period of 16.2 years. Coffee was associated with a lower risk of death even after adjusting for confounders. The association was found for both decaffeinated and caffeinated coffee, as well as anywhere from 1 cup per day to 4 cups per day.

In one cohort study, more than 500,000 individuals from 10 countries were followed over a mean period of 16.4 years. Compared to nondrinkers, men who drank the most coffee had a 12% lower risk of death (OR 0.88; 95% CI 0.82-0.95, P<0.001) and women had a 7% lower risk of death (OR 0.93; CI 0.87-0.98, P=0.009). Unfortunately, this study had potentials problems that made the evidence less cleared such as the authors noted that coffee drinking habits were only assessed once, and reverse causality might have affected the findings. However, the large numbers enrolled in the trial and exclusion of those who died within 8 years after the start of the trial certainly strengthen the findings.

Lower risk of developing Diabetes

The Nurses Health Study group had a combined follow-up for individuals of 1,663,319 years and found that those who drank coffee had a lower risk of developing diabetes. Those who decreased their coffee intake by more than 1 cup per day increased their risk for developing diabetes by 17%. They investigated tea drinking but found no association. Diet was reassessed every four years using a questionnaire.

Decrease Mortality in Chronic Kidney Disease (CKD)

Because the caffeine in coffee can transiently increase blood pressure, there are concerns that CKD or heart patients should not drink non-decaffeinated coffee. One group followed more than 2,300 patients with CKD and coffee drinking was associated with a decrease in mortality in that group, independent of many potential confounders (eGFR, smoking status, race, income, hypertension, BMI, and others). Those who drank the most coffee had a 24% lower risk of death compared to nondrinkers. This study at least demonstrates that coffee is safe in this population and that it might be beneficial. It would be interesting to see a similar design with a larger number of people to see if that same association holds true.

Lower risk of Colon cancer

A group studied the association between coffee consumption and colorectal cancer among 5,145 cases and 4,097 controls. In one of the strongest associations of any of these trials, coffee was associated with a 26% overall lower risk of developing colorectal cancer. Among the highest group of consumption (>2.5 servings per day), coffee was associated with a 54% lower risk (OR 0.46; 95% CI 0.39-0.54, P<0.001). Coffee data was collected using a validated questionnaire and the researchers controlled for race. The findings held true for both colon and rectal cancers.

Drink it black and don’t drink it scalding hot. Sugar is associated with numerous health problems and could be ruining the benefits you are receiving, while WHO’s International Agency for Research on Cancer issued a statement in 2016 that there is some limited evidence consuming drinks hotter than 200 degrees Fahrenheit might increase the risk for esophageal cancer.

 

Why do some think coffee is not good for you?

There have been some concerns that coffee might be bad for you, but these are based on limited evidence or taken out of context. For example, there is an ongoing court battle in California about whether coffee should be labeled a carcinogen due to trace amounts of acrylamide. This is based on the effect of acrylamide alone in animal studies. Other concern is cafestol, a compound removed by paper filters but not by other methods (French press, Turkish coffee), which increases cholesterol. Based on current evidence, the presence of this compound does not appear to negatively affect outcomes.
For people with borderline or high blood pressure, I would cautious and recommend limiting the number of coffee cups to two per day of noncaffeinated coffee. More research is needed to conclusively state some of the above benefits but for now the data is showing that there might be some benefit.

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What is Medication Therapy Management (MTM),

What is Medication Therapy Management? Medication Therapy Management (MTM) is a covered benefit for many Medicare patients, some commercially insured patients, and is available for others on a cash paying basis.
MTM is an ongoing process to ensure that medications are prescribed safely, used correctly, and sometimes de-prescribed or discontinued. MTM is a patient-centered health-care service focused on helping people get the most benefit from their medication therapy.  Patients with multiple medications and chronic diseases such as diabetes, hypertension, asthma, COPD and congested heart failure will benefit greatly from MTM.

Medication Therapy

“The use of medications to treat or prevent diseases”. And it’s not just prescription medications that are important. Nonprescription medications, vitamins, and dietary supplements each can play a part in treating and preventing disease. An individual who takes medications in any of these four categories is using Medication Therapy.

The goal of MTM:

The goal of Medication therapy management is to identify, prevent and resolve medication related problems to improve patient outcomes and decrease the total cost of care for our patients.

Services provided:

Medication Counseling

• Sharing drug product information
• Generally, occurs when dispensing medications at point of sale

Disease Management

• Management of diseases using standard guidelines
• Often team-based or can be part of a pharmacist–physician protocol

Medication Therapy Management (MTM)

• Optimization of medication use
• May be a comprehensive review of entire medication regimen or focused on one specific aspect
• Appointment-based service

The American Pharmacists Association (APhA) and the National Association of Chain Drug Stores (NACDS) put out an official framework for the components of an MTM Service Model. There are 5 core elements that make up an MTM service model in pharmacy practice.

 The Pharmacist’s Role

 Monitor individual medications:

o Drug efficacy
o Adverse events and drug interactions
o Cost

    Monitor patient:

o Understanding of regimen
o Adherence
o Self-management of condition

   Streamline medication therapies:

o Identify duplicate therapies
o Simplify drug and dosing regimens

Benefits to the Patient:

Medication therapy. MTM empowers people to take charge of their own medication use by helping them understand:
• How prescription medicines work
• How and when medicines should be taken
• How incorrect use of medications can result in poorer health
• How age changes the way medicines work, or the risk of side effects
• How vitamins and supplements may add or detract from the effects of medications
• What side effects or problems to watch for.

Medication Therapy Management can improve outcomes and lower the total cost of care for our patients. Clinical Pharmacists in Clinics and in Hospitals provide some of the same services, they provide Pharmacotherapy to patients nd as part of the healthcare team help improve patient outcomes and prevent medication problems.

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Antibiotic Duration in Sinusitis

Current recommendations:

Current guidelines from the Infectious Diseases Society of America (IDSA) recommend only antibiotic treatment duration of 5 to 7 days in uncomplicated sinusitis. Recent findings from a research letter published in JAMA Internal Medicine, show that a significant number of antibiotic prescriptions for acute sinusitis are written for greater than10 days.

How the researches arrive at this conclusion:

Using the 2016 National Disease and Therapeutic Index (IQVIA), researchers identified an estimated 3,696,976 physician visits in which antibiotics were prescribed for a sinusitis. Patients were excluded if they had a concurrent antibiotic prescription for other conditions.

Results:

Results showed that the median duration of therapy for all antibiotics was 10.0 days with 69.6% of prescriptions given for ≥10 days (95% CI, 63.7%–75.4%). IDSA explicitly recommends against using azithromycin to treat sinusitis. After excluding azithromycin, the percentage of antibiotic courses that were given for over 10 days in duration jumped to 91.5%; 7.6% (95% CI, 4.1%-11.1%). Although the IDSA guidelines recommend against the use of azithromycin, 22.6% of prescriptions (95% CI, 17.2–28.0%) were for a 5-day course of azithromycin.
For patients at high risk or those who have failed initial treatment, 7 to 10 day courses of therapy may be appropriate, however it is unlikely those types of cases made up most patients in the study.
Based on their findings, the authors concluded that “the durations of most courses of antibiotic therapy for adult outpatients with sinusitis exceed guideline recommendations.

What is sinusitis?

Sinusitis an infection of your sinus that can cause by either a virus or a bacteria. For Viral sinusitis, antibiotics should not be use.

Why should we worry about duration of antibiotics in uncomplicated Sinusitis?

Because the number of antibiotic resistant infections is growing, and we do not have new antibiotics to treat those resistant infections. A recent article shows that inappropriate prescribing of antibiotics has remained the same.

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Metformin

Metformin is a medication for type 2 diabetes, decreases the liver’s glucose output and increases the muscles’ glucose uptake. Metformin remains not only first line therapy but one of the most used medications for Type 2 Diabetes.

Possible side effects: nausea, upset stomach, diarrhea (can sometimes be avoided by taking with food or by using the extended-release formulations).

Should not be taken by persons with decreased kidney function or certain other medical conditions.

Medications available: metformin (Fortamet, Glucophage, Glucophage XR, Glumetza, Riomet).

Metformin is an inexpensive medication considered first-line therapy for treatment of glucose control in individuals with type 2 diabetes. It is also widely used to improve cardiovascular risk in adults with type 2 diabetes.

Reducing with Metformin Vascular Adverse Lesions in Type 1 Diabetes (REMOVAL)

This study examined if similar benefits could be expected for people with type 1 diabetes. Metformin may be prescribed for people with type 1 diabetes who are also overweight, to help control blood sugar and weight, allowing a lower daily insulin dose.

This multi-center, international clinical trial enrolled patients at 23 centers across the United Kingdom, Australia, Canada, Denmark and the Netherlands. Researchers investigated three years of treatment with metformin reduces heart disease in middle-aged adults with type 1 diabetes who are at increased risk for cardiovascular disease (CVD).

REMOVAL studied 428 middle-aged adults with longstanding type 1 diabetes–on average for 33 years. The patients had three or more risk factors for cardiovascular disease, including BMI over 27; A1C greater than 8.0; known CVD/peripheral vascular disease; current smoker; high blood pressure; high cholesterol or triglycerides; strong family history of CVD; or duration of diabetes more than 20 years.

Patients who received metformin lost weight, and their insulin doses were able to be reduced during the study.

However, A1C levels showed reduction only during the first three months of metformin treatment. Cholesterol was also reduced, even though more than 80 percent of trial participants were already taking statins. Weight reduction and lowering of cholesterol may therefore have played a role in reducing atherosclerosis.

The Diabetes Prevention Program Outcomes Study (DPPOS)

Was an extension of the Diabetes Prevention Program (DPP) to determine the longer-term effects of the two interventions, reduction in diabetes development and reduction of development of the diabetes complications. Complications like blindness, kidney failure, amputations and heart disease. Funded largely by the NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the new findings show that the lifestyle intervention and metformin treatment have beneficial effects, even years later, but did not reduce microvascular complications.

Metformin long term use:

Metformin treatment was associated with a modest degree of long-term weight loss. There is also a small increase in vitamin B-12 deficiency, overall metformin treatment has been extremely safe and well-tolerated.

Metformin Works Better in African Americans

In a study of electronic health records of 19,672 people with type 2 diabetes, starting on metformin led to a 0.90 percentage-point drop in A1C—a measure of blood glucose control for two to three months—in black participants versus just 0.42 in whites. The researchers took factors such as age, sex, body mass index, and starting A1C into account, so the difference more likely has to do with genetics.

Metformin may help fight off brain and nervous system diseases

Those taking metformin for two to four years had a 40 percent lower risk of developing Alzheimer’s disease, Parkinson’s disease, and other brain and nervous system problems, while those taking the medication for longer than four years had an 80 percent lower risk. The brain benefit remained even after the investigators accounted for factors such as age, gender, race, and obesity.

Polycystic ovary syndrome (PCOS)

The cause of PCOS is still unclear, but researchers know one thing for sure: There’s a link between PCOS and diabetes. Women with PCOS are often insulin resistant, a condition that’s an important trigger for type 2 diabetes. The insulin resistance of PCOS is often treated with metformin.

Metformin is a very safe medication, that doesn’t cause low blood sugars, can lead to a modest reduction in weight and the most important, a reduction in cardio vascular risks.