Tag: Diabetes

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Alcohol in Diabetes

Alcohol’s effect on body systems

Alcohol on it’s own can have negative effects on the body but the effects on some one with diabetes can be augmented by the interaction of alcohol and medications. Patients with diabetes should be counselled regarding the negative effects of alcohol on diabetes and possible interactions. Alcohol in diabetes should be avoided and patients should be advised of abstaining from alcohol.

Cardiovascular and Gastro Intestinal

Chronic alcohol use is associated with negative cardiac health events including:
● nonischemic dilated cardiomyopathy (3)
● ventricular dysfunction (3)
● atrial fibrillation (5)
● hypertension (4)
● increased caloric intake and weight gain (4)
Interestingly, alcohol exhibits a “J”-shaped dosing curve for many of these events, where lower risk is observed at approximately 2 drinks/day, but steeply rises beyond this (8) Chronic alcohol is associated with negative GI health events, including:
● injury to gastric mucosa, leading to an increased risk of GI bleeds (12)

Liver/Pancreas

Chronic alcohol is associated with negative hepatic and pancreatic health events, including:
● increased triglyceride secretion which increases the risk of pancreatitis(7)

●increased TGs (>1000 mg/dL) are associated with increased chylomicrons which can obstruct pancreatic capillaries, supporting ischemia and inflammation (16)
● promoting hepatic fibrosis and cirrhosis via fatty acid breakdown mechanisms (8)
● increasing hepatic production of LDL (8)
● decreasing atheroprotective efficacy of produced HDL (8)

Managing Diabetes:  Chronic alcohol use dramatically limits the ability to use ADA recommended antidiabetic agents.

Metformin

Mechanism: AMP kinase activation, decreasing hepatic glucose production Problems raised with chronic alcohol use:
● Both metformin and alcohol have individually demonstrated a risk of causing lactic acidosis (10,11)
● Concurrent use of metformin and alcohol has demonstrated an increased risk of developing lactic acidosis (9). Limiting use in patients with chronic or binging alcohol intake.
● Would probably think twice about starting metformin in this patient given the risk of lactic acidosis, but if other medication classes are problematic, the patient will still need at least some therapy to manage diabetes.

Sulfonylureas

Mechanism: Blocks K+ channels on pancreatic beta cell membranes, increasing insulin secretion Problems raised with chronic alcohol use:
● Concurrent use of alcohol and sulfonylureas is associated with an increased risk of delayed hypoglycemia (19)
● Chronic alcohol use is associated with decreased insulin secretion response in the presence of elevated blood glucose levels (2)      Use in these patients?
● Probably not, given the added risk of delayed hypoglycemia
● Additionally, starting a medication in this class might not be very effective in managing chronic diabetes anyway, given the decreased insulinogenic response.

Thiazolidinediones

Mechanism: PPAR-gamma activation, increasing insulin sensitivity and glucose uptake in peripheral tissues Problems raised with chronic alcohol use:
● Pioglitazone has been reported in post-marketing surveillance to cause hepatic failure, but actual risk remains unknown (18)
● Chronic alcohol use is known to be associated with hepatic injury.  Use in these patients?
● Probably not, given multiple risk factors for liver injury
● If given, would have to closely monitor hepatic function tests

DPP4 Inhibitors

Mechanism: Inhibits DPP enzyme, prolonging effects of endogenous GLP1/GIP to increase insulin secretion and decrease glucagon secretion Problems raised with chronic alcohol use:
● Sitagliptin has been reported in post-marketing surveillance to cause acute pancreatitis, but actual risk remains unknown (0.1 per 100 patient years in both study and placebo) (17)  ○ Pancreatitis was reversible

● Chronic alcohol use is known to be associated with increased risk of pancreatitis via increased triglyceride levels (16) Use in these patients?
● Probably not, considering multiple risk factors for pancreatitis, but possible with monitoring
● Also, the value of this class (post-prandial control) in a patient with an A1c close to 9% would seem limited.

SGLT2 Inhibitors

Mechanism: Inhibits SGLT2 in nephrons, reducing renal glucose reabsorption Problems raised with chronic alcohol use:
● Empagliflozin can induce diabetic ketoacidosis even at glucose levels

GLP1 Receptor Agonists

Mechanism: Activates GLP 1 receptors to increase insulin secretion, decrease glucagon secretion, slow gastric emptying and promote longer satiety Problems raised with chronic alcohol use:
● Liraglutide has been observed to cause more cases of pancreatitis than control groups (2.2 vs. 0.6 cases per 1000 patient-years), but this has not been fully studied (17) ○ Pancreatitis was reversible, however
● Chronic alcohol use is known to be associated with increased risk of pancreatitis via increased triglyceride levels (16) Use in these patients?
● considering multiple risk factors such as pancreatitis,  possible with monitoring

Insulin

Mechanism: supplements endogenous insulin production Problems raised with chronic alcohol use:
● Concurrent use of alcohol and insulin is associated with an increased risk of delayed hypoglycemia (1)
● Chronic alcohol use is associated with decreased insulin secretion response in the presence of elevated blood glucose levels( (2) Use in this patient?
● patients  already on insulin, are more likely to grow more resistant to insulin as doses increase – higher doses and/or adding bolus dosing might temporarily improve glycemic control, but also contribute to weight gain
● Additionally, compliance with bolus dosing may be unlikely

Statins

Mechanism: inhibits function of HMG-CoA reductase, increasing hepatic LDL breakdowns. Also reduces endothelial inflammation. Problems raised with chronic alcohol use:
● Although statins are rarely causative in hepatic injury or failure (Out of 1188 cases reported to the US Drug Induced Liver Injury Network, only 22 cases could be clearly linked to hepatic injury), a fatality was associated with alcoholic liver disease and statin use (20)  Use in this patient?
●  a statin but is indicated per ADA guidelines for CV mortality reduction. Chronic alcohol use and possible hepatic injury would warrant caution if this class were used, but still possible.

Aspirin

Mechanism: inhibits platelet COX 1 and 2, reducing platelet aggregation and prostaglandin effects Problems raised with chronic alcohol use:
● Aspirin has demonstrated an increased risk of GI bleeds (22)
● Alcohol causing injury to gastric mucosa, leading to an increased risk of GI bleeds (12) Use in these patients?
● aspirin for primary CV prevention, but could be considered per ADA guidelines, considering hypertension and dyslipidemia.
● However, the multiple risk factors for bleeding (including concomitant use of NSAIDS such as naproxen or ibuprofen) would probably make aspirin a poor choice.

References

1. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2017; 40 Suppl 1: S1-S135.
2. Nguyen, Lee, & Nyomba. (2011). Ethanol causes endoplasmic reticulum stress and impairment of insulin secretion in pancreatic β-cells. Alcohol, 46(1), 89-99.
3. Mozaffarian, D. (2016). Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity A Comprehensive Review. Circulation, 133(2), 187-225.
4. Núñez-Córdoba, J., Valencia-Serrano, F., Toledo, E., Alonso, A., & Martínez-González, M. (2009). The Mediterranean diet and incidence of hypertension: The Seguimiento Universidad de Navarra (SUN) Study. American Journal of Epidemiology, 169(3), 339-46.
5. Larsson, Drca, & Wolk. (2014). Alcohol Consumption and Risk of Atrial Fibrillation: A Prospective Study and Dose-Response Meta-Analysis: A Prospective Study and Dose-Response Meta-Analysis. Journal of the American College of Cardiology, 64(3), 281-289.
6. Sacks, F., Svetkey, L., Vollmer, W., Appel, L., Bray, G., Harsha, D., . . . Cutler, J. (2001). Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. The New England Journal of Medicine, 344(1), 3-10.
7. Berglund, Lars, Brunzell, John D, Goldberg, Anne C, Goldberg, Ira J, Sacks, Frank, Murad, Mohammad Hassan, & Stalenhoef, Anton F H. (2012). Evaluation and treatment of hypertriglyceridemia: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism,97(9), 2969-89.
8. Brinton, E. (2010). Effects of ethanol intake on lipoproteins and atherosclerosis. Current Opinion In Lipidology, 21(4), 346-351.
9. Krzymień, J., & Karnafel, W. (2013). Lactic acidosis in patients with diabetes. Polskie Archiwum Medycyny Wewnetrznej, 123(3), 91-7.
10. Müssig, Schleicher, Häring, & Riessen. (2008). Satisfactory Outcome After Severe Ethanol-Induced Lactic Acidosis and Hypoglycemia. Journal of Emergency Medicine, 34(3), 337-338.
11. Glucophage (metformin). [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; August 2008. 17
12. Macmath, T. (1990). Alcohol and gastrointestinal bleeding. Emergency Medicine Clinics of North America,8(4), 859-72.
13. Handelsman, Y., Henry, R., Bloomgarden, Z., Dagogo-Jack, S., Defronzo, R., Einhorn, D., . . . Weir, M. (2016). AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON THE ASSOCIATION OF SGLT-2 INHIBITORS AND DIABETIC KETOACIDOSIS. Endocrine Practice, 22(6), 753-762.
14. Kitabchi, A., Umpierrez, G., Miles, J., & Fisher, J. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 32(7), 1335-43.
15. Mcguire, L., Cruickshank, A., & Munro, P. (2006). Alcoholic ketoacidosis. Emergency Medicine Journal, 23(6), 417-420.
16. Yadav, D., & Pitchumoni, C. (2003). Issues in hyperlipidemic pancreatitis. Journal Of Clinical Gastroenterology, 36(1), 54-62.
17. Januvia (sitagliptin). [prescribing information]. Whitehouse Station, NJ: Merck & Co. Inc.; August 2018.
18. Actos (pioglitazone). [prescribing information]. Deerfield, IL: Takeda Pharmaceuticals America; July 2011.
19. Glucotrol (glipizide). [prescribing information]. New York, NY: Pfizer Inc.; October 2016.
20. Victoza (liraglutide). [prescribing information]. Princeton, NJ: Novo Nordisk Inc.; January 2010.
21. Russo, M., Hoofnagle, J., Gu, J., Fontana, R., Barnhart, H., Kleiner, D., . . . Bonkovsky, H. (2014). Spectrum of statin hepatotoxicity: Experience of the drug‐induced liver injury network. Hepatology,60(2), 679-686.
22. Pignone, M., Alberts, M., Colwell, J., Cushman, M., Inzucchi, S., Mukherjee, D., . . . Kirkman, M. (2010). Aspirin for primary prevention of cardiovascular events in people with diabetes: A position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Diabetes Care, 33(6), 1395-1402.

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To Check or Not to Check Blood Sugars.

The question is: To Check or Not to Check Blood Sugars.

For patients on insulin the answer is that we always recommend checking blood sugars. For patients on only oral medications, there is an ongoing clinical debate about the benefits of Self-monitoring of blood glucose (SMBG). There are Health Systems and insurances that limit quantity due to high cost. Many practitioners do not see the need or benefit for patients to monitor unless they are on insulin, I don’t agree as many of those patients can benefit from SMBG to better control their blood sugars.

In a recent article published in JAMA Internal Medicine, a randomized study of 450 individuals originally enrolled, 418 completed the study. The objective of the study was to look at hemoglobin A1C levels and health-related quality of life (HRQOL) of the enrolled patients based on their randomization to one of three groups: no Self-monitoring of blood glucose (SMBG) once-daily SMBG or once-daily SMBG with enhanced messaging feedback on the blood glucose meter. The measured outcomes were change in hemoglobin A1C and HRQOL at 52 weeks. The results of the data were no significant difference in the three groups hemoglobin A1C and HRQOL. Leading the authors to conclude that regular testing of the blood glucose by patients with non-insulin treated type 2 diabetes is not necessary. Here is the citation for the study: Young, L et al. “Glucose Self-monitoring in Non–Insulin-Treated Patients with Type 2 Diabetes in Primary Care Settings: A Randomized Trial”, JAMA Intern Med. 2017;177(7):920-929.

Many insurances like Medicare B will cover strips for patients with diabetes on oral medications but just one strip per day. Choosing carefully when to ask patients to test becomes very important to get the information and patterns needed to maximize treatment.

In practice, I manage patients whose blood sugars are very uncontrolled diabetes which for my Health System means any patient with an A1C greater than 9. While an A1C can give us a lot of information, it cannot give us detail information such as how high blood sugars are going in the morning or after meals. I often ask patients to check fasting blood sugars first in the morning and work on controlling these sugars first. Once the morning fasting blood sugars are under control, I will ask to ROTATE time of finger stick check (before meals, at bedtime) over the course of 1-2 weeks. This allows reducing testing frequency while allowing me to see patterns over time. At every visit re-assess the need for continue SMBG, frequency and timing.

Why Test?

Testing for the sake of testing does no one good. For the patient, testing can help see what certain foods do to their blood sugars, what helps or make the blood sugars worst and when to act. For this to happen, patients need to be educated and shown how SMBG can help them manage their diabetes.

For the Health Care professional, SMBG can give feedback regarding daily choices such as foods, alcohol, exercise, illnesses and stress. SMBG can also help make informed decisions about foods, activity level and medications. It can help see what the impact of stress, injury, illness and disruption in routine do to the patient’s blood sugars. The use of data to know when to advanced therapy and when to stop certain therapies that might not be right for the patient.

Data shows that in type 1 diabetes, patients who test tend to have a lower A1C and a lower number of acute complications. Data also shows that patients who do SMBG have better control regardless of treatment or type of diabetes.

Other reasons why to consider SMBG, it can emphasize the importance of medication adherence for the patient. Another thing is that we want patients to be familiar with the process, and able to accurately self-monitor, once they are using insulin. Learning how to use the glucometer, insulin injection techniques, storage, and when to inject tend to be too much to spring on a patient all at once. Introducing the concepts more gradually may help them adopt the information easier and not feel overwhelmed.

When to Check

• Before and after exercise: can help prevent low blood sugars and it can show the patient the benefits of exercise in lowering blood sugars.

• Before and after meals: to determine insulin to carb ratios, adequacy of meal time insulin dose, effects of foods or portion size on blood sugars.

• Illnesses: patients should check more frequent when they are sick, patients should be educated about a sick day plan.

• Pregnancy: will need to check more frequent before, after meals and before bedtime; to avoid complications for the unborn baby.

What if the Patient is Resistant to checking Blood Sugars?

Sometimes patients who are VERY resistant to checking, it could be because they don’t see the need for SMBG, they dislike needles, checking hurts, they don’t want to check when they are outside the house, they work overnight or financially checking can be a burden. Trying to find out the barriers to checking is the first step, then working closely with the patient to problem solve those barriers and get them to check their blood sugars.

Sometimes I can only convince the patient to check 3 times per week. Once SMBG readings and A1C are at goal, I advise the patient to continue to check BG 2-3x/week and contact me if pre-meal BG rises above a certain level (150mg/dl OR 180mg/dl if elderly or higher A1C goal). I also encourage them to continue to learn what the different foods do to their blood sugars by checking after meals.

Patients who “fall off the wagon” and glycemic control worsens is usually because they stop testing, taking their medications and managing their diabetes. If you don’t know how high your blood sugars are going, you can not do anything about it. For these patients not being motivated has a lot to do with it. Sometimes patients are depressed, ashamed of not being able to manage their blood sugars, have social barriers such as financial barriers, homelessness, job loss and food insecurities.

It is my belief that SMBG is a very good tool in self management of diabetes, when used correctly can help patients and their Health Care providers manage blood sugars. SMGB should be part of every diabetes plan to get blood sugars to goal. To the question to check or not check? When ever possible educate and motivate patient to use this tool to get their blood sugars under control.

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Vitamin D and Diabetes

Vitamin D and Diabetes

There is evidence between the relationship between vitamin D and Diabetes. Patients who are vitamin D deficient are at higher risk of developing diabetes.  The question remains weather or not Vitamin D deficiency worsens the markers of diabetes.

Vitamin D

Vitamin D is a fat soluble vitamin that helps maintain enough calcium and Phosphate levels in the blood. Vitamin D is also needed in bone growth, remodeling and helps promotes calcium absorption from the gastrointestinal tract.

Chronic insufficient levels of vitamin D can cause osteoporosis and in severe cases rickets or osteomalacia. Other functions of vitamin D in the body include cell growth, neuromuscular, immune function and reduction of inflammation.

What is Vitamin D Deficiency?

Vitamin D is most accurately measured by 25(OH)D as it has a long half-life, reflects both vitamin D produced by the skin and obtained through diet.  It is hard to get enough vitamin D from food alone, most of the vitamin D is absorbed through the skin from sun light.

Vitamin D levels are categorized as follows:

  • < 10 ng/ml = severe deficiency
  • 10–24 ng/ml = mild-mod deficiency
  • 25–80 ng/ml = optimal
  • > 80 ng/ml = toxicity possible

Who is at risk of Vitamin D deficiency:

  • Have either liver or kidney dysfunction
  • GI disorders (ex. celiac disease, pancreatitis, low bile levels)
  • Aging skin
  • Darker skin color
  • Living at a higher latitude with less yearly sun exposure
  • Obesity (BMI >/=30)

Vitamin D deficiency can lead to consequences such as heart attack, poor immune function nd diabetes.  Vitamin D also has a protective role in breast cancer, prostate and colon cancer.  Your doctor can test you vitamin D level and tell you if you are vitamin D deficient.

Nutritional Vitamin D

Put this foods in your plate: wild cold-water salmon, mackerel, tuna, sardines, cod, and halibut. Also try milk, liver, egg yolks and fortified cereal.

Other ways to get Vitamin D

Sunshine: 15 to 30 minutes of sunlight without any sunscreen, can be done in small doses and not at high noon to avoid sun burn.

Vitamin D supplements for adults: try 4,000 to 5,000 IU daily of vitamin D3 (Cholecalciferol) which is the equivalent of fortified milk.  Excessive sun exposure does not cause vitamin D toxicity. Excessive intake in foods that contain large quantities of vitamin D are also very unlikely to cause toxicity. Toxicity is usually the result of high intake of vitamin D containing supplements.

How can Vitamin D deficiency lead to diabetes?

There are vitamin D receptors on different immune cells as well as the beta cells of the pancreas which are responsible for insulin secretion. There are a few different proposed mechanisms of how vitamin D is related to diabetes:

  • Active form of vitamin D, 1,25-dihydroxyvitamin D works by:
    (1) Improving insulin sensitivity of target cells in the liver, skeletal muscle, and adipose (fat) tissue.
    (2) Enhancing and improving B cell function in the pancreas.
    (3) Protecting B cells from immune cells by influences proliferation and differentiation of immune cells such as macrophages, dendritic cells, and T cells.
  • Vitamin D binding proteins, vitamin D receptors and 1alpha-hydroxylase (CYP1alpha) may affect insulin release and result in insulin resistant.
  • Affects glucose homeostasis through these mechanism:
    (1) Vitamin D helps to maintain adequate calcium levels. When calcium levels are low there is less glucose stimulated insulin secretion that occurs from the B cells.
    (2) Inadequate vitamin D can lead to increased PTH levels. This causes decreased glucose uptake by liver, muscle and adipose cells as well as suppression of insulin release.
  • Vitamin D may stimulate insulin secretion by the vitamin D receptors when there is enough calcium.

**Pancreatic Beta cell make insulin.

Studies finding a correlation between vitamin D Deficiency and type 2 Diabetes (T2DM).

(a) Randhawa F et al. Pak J Med Sci 2017;33:881-885: The purpose of this study was to access the effect of vitamin D supplementation on A1C for patients recently diagnosed with T2DM. Results: There was no significant difference between both groups’ A1C at 1, 3 and 6 months.
(b) Dalgard C et al. Diabetes Care 2011;34:1284-1288: This study looked at 668 participants who were all between the ages of 70-74. They lived in a North Atlantic fishing community where a large part of their diet consisted of fatty fish.
Of the 668 patients 24% had type 2 diabetes mellitus (T2DM) and >50% were considered vitamin D deficient (25(OH)D3 level <20 ng/ml).  There were not correlations found between vitamin D deficiency and plasma glucose levels (rs = -0.01; P = 0.78).  Vitamin D deficiency was associated with having an 80% increase in sex-adjusted odds of having diabetes compared with sufficient vitamin D levels (OR 1.8, 95% CI 1.23-2.64, P = 0.002). This was also adjusted to take BMI, serum triacylglycerides, serum HDL, PCB exposure, smoking & month of blood sampling into account (OR 1.67, 95% CI 1.11-2.50, P=0.013). Conclusion: Vitamin D deficiency (25(OH)D <20 ng/ml) doubles the risk of newly diagnosed diabetes. This data suggests that vitamin D may play a protective role preventing the development of T2DM.
(c) Pittas AG et al. Diabetes Care 2006;29:650–65: This study consisted of 83,779 women who were all greater than 20 years of age. They found that patients who had low vitamin  were at an increased risk of T2DM. When patients were treated with a combination of vitamin D 800 IU and calcium 1,000 mg they found their risk for T2DM was reduced by 33%.
(d) NHANES group (2003– 2006): This group evaluated 9,773 U.S. adults who were greater than 18 years old and had T2DM. They found that there was a correlation between serum vitamin D levels, glucose homeostasis, and the evolution of diabetes.  They concluded that patients with an elevated A1C should be evaluated for vitamin D insufficiency.
(e) Talaei A et al. Diabetol Metab Syndr 2013;5:8: This study looked at 100 patients with T2DM between 30 and 70 years old. Of all the patients, 24% had a vitamin D deficiency (25(OH)D ≤20 ng/m). All of these patients were given 50,000 unit of vitamin D3 orally per week for eight weeks. When comparing these patients baseline results to the results at the end of the study they found: Their conclusion was that vitamin D supplementation could reduce insulin resistance in patients with T2DM.
(f) Zhang J et al. Can J Opthalmol 2017;52:S39-44: This study looked at the correlation between diabetic retinopathy (both T1DM and T2DM) and vitamin D deficiency. This was a meta-analysis of 14 observational studies with a total patient population of 10,007. They found a statistically significant association between diabetic retinopathy and vitamin D deficiency. There were statistically significant lower serum vitamin D levels in patients with diabetic retinopathy than in the control group. The higher the degree of vitamin D deficiency, the higher the grade of diabetic retinopathy. Studies finding a correlation between vitamin D Deficiency and diabetes (T1DM)4.  Overall there is a lack of studies to support that vitamin D supplementation would improve treatment of T1DM after diagnosis.
(g) Hypponen E, et al. Lancet 2001;358:1500–1503. This study observed that children who took 2,000 IU of vitamin D daily were 80% less likely to develop T1DM.

Conclusion:

There is evidence to the relationship between vitamin D and diabetes.  Patients who are vitamin D deficient are at a higher risk of developing diabetes. There is also sufficient evidence showing a positive correlation between vitamin D deficiency and increased insulin resistance, decreased insulin production and higher A1Cs.

Patient with prediabetes and vitamin D deficiency can benefit from Vitamin D supplementation. Patients with diabetes who are obese, have a high A1C and have vitamin D deficiency, can also benefit from Vitamin D supplementation.

***A very special thanks to M. Langton PharmD candidate for her help in gathering information for this topic.

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Weight Loss in Diabetes

There is a known connection between obesity and Type 2 diabetes. It is known that the obesity epidemic is driving the Type 2 Diabetes epidemic world wide. There is strong evidence that modest weight loss can delay the progression from pre-diabetes to type 2 diabetes (1,2,3).  Weight loss in diabetes is beneficial in managing type 2 diabetes. Why lose weight question, for many type 2 diabetics is an important one to get their diabetes under control.
Studies have shown that reduction in calories lead to a reduction in A1C of 0.3% to 2.0% in adults with type 2 diabetes, leads to reduction in medication doses and improvement in quality of life (1). Maintaining weight loss is challenging (4) but offers long-term benefits. For example, maintaining weight loss for 5 years is associated with sustained improvements in A1C and cholesterol levels (5). Weight loss in diabetes can be attained with lifestyle programs that offer a 500–750 calorie energy deficit or offer 1,200–1,500 calorie for women and 1,500–1,800 calorie for men. For many obese individuals with type 2 diabetes, losing >5% can produce beneficial outcomes in sugar control, cholesterol, and blood pressure, and sustained weight loss of ≥7% is optimal (4).

Definition of Obesity

Body Mass Index, or BMI, is used as a screening tool for overweight or obesity.
• If your BMI is less than 18.5, it falls within the underweight range.
• If your BMI is 18.5 to <25, it falls within the normal.
• If your BMI is 25.0 to <30, it falls within the overweight range.
• If your BMI is 30.0 or higher, it falls within the obese range.
To calculate BMI, see the Adult BMI Calculator or determine BMI by finding your height and weight in this BMI Index Chart.

How does Obesity Lead to Type 2 Diabetes?

Increase weight leads to increase fat (adiposity), increase adiposity leads to insulin resistance which eventually will lead to diabetes.
To have weight loss in diabetes, there are three modalities: bariatric surgery, weight loss medications (pharmaceuticals) and energy deficit. A combination of any of the three modalities with behavior modification can help patients achieve weight loss.

Bariatric surgery

Bariatric surgery is indicated for patients with a BMI equal or greater than 40 or a BMI equal or greater than 35 with co-morbidities such as diabetes. The two most popular types of bariatric surgery are Roux-en-Y gastric bypass and Gastric sleeve surgery also known as vertical sleeve gastrectomy. Gastric sleeve is more popular because the number of side effects are less than with the Roux-en-Y bypass but is not as effective.

Weight loss Medications (Pharmaceuticals)

Prescription weight loss drugs: Belviq, Contrave, Saxenda, phentermine, and Qsymia. Over the counter you can find orlistat. Lifestyle intervention plus pharmacotherapy intervention lead to better response to calorie restriction. For patients on weight loss medications see an increase magnitude of response, average percentage of weight loss is greater. Overall pharmaceuticals can help extend weight loss sustained response. SEQUEL study data showed amount of weight loss group on pharmaceutical treatment lead to greater weight loss more than the placebo group.

Who can benefit from the use of Pharmaceuticals for weight loss?
Patients who report early hunger shortly after eating, patients who tend to have more than one plate of food to feel full, Patients with persistent food thoughts, strong emotional response to food or eating, and less than robust response to dietary plan. For some, pharmaceuticals can be use indefinitely or in maintenance can be use when needed.

Calorie Restriction

Type 2 diabetes is potentially reversible via an 8-week, very low-calorie diet followed by careful weight management for up to 6 months, new research shows. The findings were published online March 21, 2016 in Diabetes Care by Dr Sarah Steven of Newcastle University, United Kingdom, and colleagues.

The best weight loss response was seen in Younger age patients, in those with shorter duration of diabetes and not on insulin. STAMPEDE trial followed 150 patients with a BMI of 27-43 1 for five years 1 out of 3 patients were in remission after 5 years after bariatric surgery. Look AHEAD and DIRECT trial achieve 50% remission on an average weight loss of 10 kgs.
Calorie restriction paired with exercise provides patients with type 2 diabetes with a plan to lose weight and control blood sugars. Before starting any exercise, program consult your Primary care physician.
Lifestyle is always recommended to manage diabetes, for some patients with type 2 diabetes it may not be enough. Pharmaceuticals and bariatric surgery are other tools that can help. For patients who are morbidly obese bariatric surgery maybe the best alternative. Talk to your Primary Care Physician to find out what they recommend for you.
Weight loss in type 2 diabetes can lead to remission or well control diabetes at the levels of prediabetes leading to decrease complications from diabetes. Make weight loss part of your diabetes action plan.

References
  1. https://jandonline.org/article/S2212-2672(17)30333-7/abstract
  2. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002095
  3. http://annals.org/aim/fullarticle/2395729
  4. https://jandonline.org/article/S2212-2672(15)00259-2/fulltext
  5. http://drc.bmj.com/content/5/1/e000259
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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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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.

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Exercise Recommendations for Patients with Diabetes

Why is Exercise Important in Patients with Diabetes?

Exercise is a very important part of getting blood sugars under control and one that is often overlooked, put aside or not done at all.

The American Diabetes Association exercise recommendations are:

  • For most adults with type 1 and type 2 diabetes: 150 or more minutes per week of moderate-to-vigorous activity over at least 3 days per week with no more than 2 consecutive days without exercise.
  • Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals.
  • Adults with type 1 and type 2 diabetes should perform resistance training in 2-3 sessions/week on nonconsecutive days.

What if You Don’t Exercise but Want to Start?

For those who do not exercise at all but want to start, it is important to start slowly and safe. It is always a good idea to check with your doctor before starting any exercise routine.

It is important to start by being more active, slowly adding exercise like walking. The key is to be less sedentary and start moving more.

Start by Moving More

Research found that sitting too much for long periods of time is harmful to our health especially related to heart health, mental health and increased risk for becoming disabled.

Just getting up once every 30 minutes to stretch or walk around the house or workplace is better than sitting for hours. Take every opportunity you can to get up and move.

If you don’t exercise at all, getting motivated is half the battle. Once you start being more active, you’ll find that it isn’t as hard to keep going — you’ll feel better and have more energy.

Aerobic exercise, strength training, flexibility exercises/stretching, balance exercises, and activity throughout the day are the types of activities recommend for people with diabetes.

Exercise should be part of your Diabetes Action Plan and you can make it one of your Health goals.

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Can I Eat Eggs?

Eggs are a good source of protein, but they have dietary cholesterol. The cholesterol we eat does not necessarily raise blood cholesterol for most people. Our bodies make all the cholesterol we need, we do not need dietary cholesterol. What has a big impact on cholesterol is the amount of fat you eat.  For patients with cardiovascular disease or cardiovascular risk lowering dietary cholesterol is important.

What is Cholesterol?

Cholesterol is a type of fat in the body. Cholesterol helps form the lining (membrane) of the body’s cells and it plays a role in hormone production. Two subtypes of cholesterol we care a lot about are:

HDL (the “good” cholesterol) and LDL (the “bad” cholesterol).

  • LDL can get trapped in the lining of the artery. Over time, leading to a heart attack or stroke.
  • HDL’s job is to help remove LDL from the body.

Can I eat eggs or not?

Yes, but in the right way. If you regularly have an egg, reduce saturated fat in other areas of your diet.  Eating moderate amounts of eggs will have little impact on blood cholesterol for most people.
However, if you are adding a lot of saturated fat (bad fat), such as preparing eggs with butter, cheese, bacon, sausage, or eating excessive amounts of eggs a day, you are going to run into issues.
Are there other satisfying breakfast or snack choices that won’t impact cholesterol? Absolutely! Oatmeal, low-fat plain yogurt, egg whites, fruit with modest amounts of nuts, avocado and whole wheat toast, or peanut butter on whole wheat toast are excellent choices. But taste preferences, cultural differences, allergies, and time constraints make some of these challenging.

Reasons to Choose Eggs

• Good source of complete protein. If you don’t eat much red meat or high-fat dairy, eggs are a good addition to the diet. At seven grams of protein per whole egg, it’s a more efficient, readily absorbed protein option (more so than beans or lentils).
• Keep you fuller for longer and are satisfying! The fat and protein content of eggs will keep you fuller longer, prevent overeating later compared to options like bagels, toast, cold cereal, pancakes, or waffles.
• Eggs won’t raise blood sugar. This is a big for patients with diabetes, especially those who don’t eat much poultry or fish. While lentils and beans have protein, they are primarily carbohydrate (which raises blood sugar).
• Easy to prepare. They take a few minutes to cook. Hard-boiled eggs make meal and snack time simple.
Overall, yes, eggs can raise your cholesterol but not as much as saturated fat. It’s about your dietary balance in general.
Eggs can be part of your diet if you don’t over due the amount of fats you eat, egg whites are also a healthy alternative. For patients with diabetes one egg per day is OK to eat but should refrain from frying or adding a lot of butter and cheese. For patients with diabetes there is no diabetic diet, we recommend a healthy diet low in starchy carbohydrates. Using the plate method can help make sure you get enough protein in your diet.