Saturday, April 4, 2020

Support Groups, Good or Bad?

This article recently appeared on Eurekalert. The title, "Patients with type 2 diabetes belonging to online support groups have poorer health" makes it sound as if belonging to an online support group causes you to have poorer health, which doesn't make sense.

It also contradicts other studies like this one, titled "Joining a Support Group Improves Diabetes Treatment." The authors of this study wrote that "men and women who were enrolled in an online support program were nearly twice as likely to take their medication as prescribed and less likely to discontinue it."

So what's going on here? To try to figure it out, I read the full text of the article, "Participation of Patients With Type 2 Diabetes in Online Support Groups is Correlated to Lower Levels of Diabetes Self-Managemen."

In this study, 307 patients were recruited through an online survey. Then they were asked about their diabetes self-care management (glucose management, healthcare, dietary restrictions, and physical activity) and complications related to the disease, as well as their participation in online social groups and forums (duration, time, and intensity).

The researchers found that type 2 participants involved in online support groups had lower scores in "healthcare and self-management of diabetes." They also reported more diabetes complications.

I can think of several reasons for these results.

First, we know that correlation doesn't mean causation. A patient who follows medical advice and has wonderful control would be less apt to scour the internet looking for information about diabetes. But a patient who follows medical advice and is having problems controlling blood glucose might go online seeking more information. So the online support groups wouldn't be causing the lower scores for diabetes control, but the lower scores for diabetes control would be causing the people to join online support groups.

The authors also mention this, saying, "We cannot predict the direction of effects between using online support groups and the disease’s self-management, that is, we do not know whether the self-management complications are the cause or the consequence of such a type of online support group."

But many readers would just read the headline and conclude that participation in a support group caused the poor control.

Second, the study relied on self-reports, which may not be accurate. I might think my self-management was wonderful when it wasn't or vice versa.

Throughout the article, it's clear that the authors think patients need to have medical professionals in charge of information. For example, "it is likely that intervention or assistance is required for those patients to select and critically analyze the information they encounter in online support groups,"  "Hence, misinformation about diabetes, including its “cure”, has been found" [in the online support groups], and "information shared and consumed in online support groups may not be 100% rigorous and veracious."

It is true that online support groups can contain misinformation. But so can professional advice. The members of various groups must decide which information is credible and which is snake oil. When I was diagnosed almost 25 years ago, the professional view (with a few exceptions like Dr Richard Bernstein) was that low-carb diets are dangerous and one should follow a Food Pyramid that prescribed a lot of white bread and rice. Since then, the tide has turned, and now many, if not most, professionals are supporting low-carb diets.

But the point of this blog is not to criticize medical professionals. Rather, the point is that the headlines describing diabetes research, written by journalists trained to find interesting stories, not physicians, may be misleading.

So if you see a headline that sounds too good to be true ("Eating food X will cure your diabetes") or unlikely ("Just 30 minutes of exercise a day will make your diabetes go away"), make sure you read as much of the article as you have access to and decided if the headline is really supported by the evidence.

Monday, March 9, 2020

Coronavirus

Diabetes Daily has a blogpost on coronavirus as it relates to people with diabetes.

There's no reason to panic. But this is a good time to be extra careful with your blood glucose levels, as high levels increase the risk of various infections.

One benefit of having diabetes is that it almost forces you to eat a healthy diet. I'm sure that someone who eats a whole-foods diet for diabetes is in better shape to fight off infections than a nondiabetic who lives off fast food and boxed dinners.






Friday, March 6, 2020

More Reasons to Eat Low Carb

Several recent studies have supported the consumption of low-carbohydrate diets, especially, of course for people with diabetes but also for people without the disease.

The first study showed that although artificial sweeteners by themselves don't affect metabolism or the brain's sensing of a sweet taste, when these sweeteners are eaten along with carbs, they do, causing insulin resistance and a decrease in the brain's response to a sweet taste. These changes increase the risk of obesity.

In other words, it's OK to drink a diet soda with some steak, but not with french fries.

The mechanism of this effect is not clear, but it could explain seemingly contradictory results of studies of artificial sweeteners. Some studies may have given the sweeteners along with carbs, say adding them to yogurt, whereas others did not.

The full text of the study is available. I found it a bit confusing. For example, they say, ". . . in healthy human adults we observed reduced insulin sensitivity and blunted brain response to sucrose following consumption of seven 355 mL beverages over 2 weeks," but they don't say what the beverages contained.

Nevertheless, the overall conclusions are interesting: "consuming sucralose with, but not without, a carbohydrate rapidly impairs glucose metabolism." Of course, if you're on a low-carb diet, you're less apt to be using a sweetener with significant amounts of carbohydrate.

Another study suggests that low-carb diets may help prevent age-related changes in the brain. The authors say that communication between brain regions destabilizes with age, starting in the late 40s, and destabilization correlates with poorer cognition and accelerates with insulin resistance.

The researchers found that glucose decreases, and ketones (which are formed when glucose ingestion is low) increase, the stability of brain networks. 

The authors say that as people get older, "their brains start to lose the ability to metabolize glucose efficiently, causing neurons to slowly starve, and brain networks to destabilize." Hence a ketone-producing low-carb diet could provide the energy the brains need.

They used functional MRI to image the brains of 1000 people aged 18 to 88 and found that destabilization was associated with impaired cognition and was accelerated with type 2 diabetes, which affects the neurons' ability to metabolize glucose. They found that either a low-carb diet or a ketone-rich drink stabilized the networks.

The last study found that mice fed a ketogenic diet were better able to fight off the influenza virus than mice on high-carbohydrate diet. The authors said that the diet enhances the production of a certain type of T cell that produces mucus in the lungs that helps to trap the virus.

This study was done with the flu virus, and there is no evidence that a ketogenic diet would protect against coronavirus. But perhaps it could. We know that high blood glucose levels weaken your immune system, and people on low-carb diets tend to have lower glucose levels, so it could help in that way as well as possibly triggering lung changes.

Not everyone is happy on a low-carb diet long term, but it's certainly worth trying.


Sunday, February 23, 2020

More Misleading Headlines

A recent article in Eurekalert says in the headline, "University of Minnesota researchers discover Mediterranean diet ingredient may extend life." This illustrates two problems with popular science articles.

First, the authors emphasize the university where the research was done more than the research itself. Of course, this is the job of the PR people who write press releases, as sites like Eurekalert and Science Daily simply print the press releases as they come in, without editing them.

Second, and more important, the headline mentions "Mediterranean diet ingredient," which turns out to be olive oil. If they mean olive oil, why don't they say olive oil. People on a lot of different diets use olive oil. But seeing something in a headline tends to make people remember it. So many will see this headline and think, "Oh yes. If I follow a Mediterranean diet, I'll live longer."

That might be true if they're currently on a fast-food diet or a diet with lots of processed foods. For someone without diabetes, I think the so-called Mediterranean diet is healthy, even though it doesn't represent what many people in that part of the world actually eat. But the diet emphasizes whole grains, which make blood glucose (BG) go up in people with diabetes. Of course, whole grains are better than highly processed grains, but better doesn't mean best. And many people don't really understand what a whole grain is.

Corn and rice are whole grains, but in people with diabetes they'll make BG levels soar.

Health writers, and even some researchers, tend to get on the Diet du Jour bandwagon. You're more apt to get funding if you're researching the popular Mediterranean diet, looking at it from some new angle, than if you're researching the Blubber and Kale diet, which no one eats.

I'm all for informing nonscientists about research results. But not if the publicity is misleading. In this case, the original article was titled "Lipid Droplet-Derived Monounsaturated Fatty Acids Traffic via PLIN5 to Allosterically Activate SIRT1," and although it mentioned that the Mediterranean diet is high in monounsaturated fats (olive oil is monounsaturated), the focus of the research was on how olive oil helps, not on any life extension of that diet.

They write, "While undoubtedly a plethora of components in the Mediterranean Diet contribute to its positive effects on health, the data presented herein provide at least one feasible biological mechanism that may underlie these well-established benefits."

Almost any whole-food diet will show benefits when compared to the Standard American Diet. Maybe the mechanism of the benefits of the Mediterranean diet is simply eliminating chicken nuggets, cheeseburgers, french fries, and doughnuts rather than using more olive oil.




Thursday, February 20, 2020

Physician Reviews

The internet allows us to see reviews of our physicians, or of physicians we're thinking of seeing.

However, we're all aware of the dangers of believing online reviews of anything. It's very easy for people to hire people to write positive reviews. Or a disgruntled reader can write negative things. When the book The Four Corners Diet," which advocated low-carb eating, came out, someone didn't like something I said online (I think it was a suggestion that they should count the carbs in coffee) and proceeded to write negative reviews of the book, for which I was a coauthor.

The same applies to online reviews of physicians. Irl Hirsch, an endocrinologist who has had type 1 diabetes for most of his life, wrote this in an article titled "Ranting in 2020: Reflecting About the Past and the Future (with Concerns About the Present)":

"There are other frequent venues to evaluate physicians, particularly on the Internet. I was not even aware of physician evaluations on Yelp until I was emailed that I received a low grade (1 star out of 5) from a dissatisfied patient. I went to the site and indeed, I was a horrible disrespectful man, saying derogatory things about a woman's weight. Not only that, I had horrible body odor (at least no mention was made of my bad breath). In the email I received, I was told the poor review could be removed from the website for $3000. After checking with a few people, I learned this is a common scam and many of these evaluations are posted by swindlers looking to make a quick dollar."

I knew about negative reviews by disgruntled patients. But I'd never heard of review scams.

One more reason to not trust online reviews. If you do read them, see if there are at least several reviews that make similar points, but not so similar that they're probably written by the same person. Then if you decide to try that physician, keep the criticisms in mind and see if they seem to be valid.

The internet offers us a chance to get a lot of information with very little effort. It also offers us a chance to read lies.

Caveat emptor, buyer beware.

Thursday, February 13, 2020

Big Pharma and Research

I'm hardly a big fan of big pharma (understatement). But I think we sometimes don't think of how difficult it is to develop an effective drug that is also safe. Derek Lowe is a chemist who used to work in drug development, and I follow him to see how such people think. I found this recent blog interesting.

Management puts pressure on their chemists to develop profitable drugs in a minimum amount of time. But that means they sometimes don't have time for rigorous testing. He cites a trial in France in which 2 of 9 patients in a phase 1 trial (which is supposed to test safety) died.

PK = pharmacokinetic, and PD = pharmacodynamic.

Sunday, February 9, 2020

Is Dietary Protein Dangerous?

A currently popular diet is a low-carbohydrate diet, often high fat with normal amounts of protein. But some people call low-carb diets high-protein diets. So recent headlines disparaging high-protein diets may cause worry to people on low-carb diets even if they're not eating an especially high amount of protein.

Two examples of such headlines are

High-protein diets boost artery-clogging plaque, mouse study shows.

And Lower-protein diet may lessen risk for cardiovascular disease.

If you just read headlines like this, you might worry that you're eating too much protein.

But we need protein. And as we get older, we need more protein because our muscles tend to lose strength and the dietary protein helps to slow this decline.

So how much protein do we need? A rule of thumb is 0.8 grams of protein per kilogram of body weight, or 0.36 grams per pound. An ounce of meat has about 7 grams of protein.

If you're math-phobic, Jenny Ruhl has a calculator that will estimate how much protein you need on the basis of size and age, and you can find other calculators online. Some use lean body mass, rather than weight, for the calculations because it's muscle mass, not fat, that determines how much protein  you need.

Note that all these calculations refer to a minimum amount needed for good health. Especially if you're getting older, you should eat a little more than the minimum, and recommendations increase to 1.2 to 1.5 grams per kilogram weight or lean body mass. I weigh about 50 kg, and different calculators say I need from 31 to 71 grams of protein a day, so don't take the results as totally accurate.

When I was first diagnosed in 1996, I was told to follow the ADA low-fat diet, which prescribed an average of less than 2 ounces of meat per meal. I felt very deprived and not satisfied. I now try to eat 3 or 4 ounces of meat or other protein per meal, and that satisfies me.

But the real question here is what the authors of the papers I've cited mean by "high protein" or "low protein." The mice in the first study were fed 46% protein. This is indeed high. Normal protein intake in humans is 12% to 20% of calories from protein. And except for people on the Carnivore Diet (nothing but meat), I doubt that many people, even those on low-carb diets, are eating 46% of calories as protein. 

However, with protein, the amounts rather than the percentages are the important factors, because as you reduce one nutrient, like carbohydrate, the percentages of the other nutrients go up even if the amounts stay the same.


In addition, this study was done in mice, and mouse results often don't translate to  human results. In the wild mice eat mostly seeds, grains, and small fruit, although they'll eat almost anything they can get their paws on.

However, people seeing "high protein" and "artery clogging" linked in the headline might cut back on their protein intake and end up protein deficient.

The second study, citing "lower protein diet," focussed on sulfur-containing proteins, and their intake is difficult for the average person to estimate. But again, the headline is misleading. It doesn't refer to sulfur-containing proteins but proteins in general.

And just to confuse patients even more, a 2015 study was titled "High protein foods boost cardiovascular health, as much as quitting smoking or getting exercise."


Nutrition is a very fuzzy science. Many studies are done with food-frequency questionnaires. I sometimes can't remember what I had for lunch, much less how many chicken legs I ate last month. Sometimes people don't mention foods they think are unhealthy. Or they'll overestimate or underestimate the amounts they ate.

So when you see headlines like the ones cited here, take them with a grain of salt (unless, of course, you're on a low-salt diet). If they worry you, try to read the papers themselves to find out what they mean by fuzzy terms like "high protein," and ask your doctor for another opinion.

If you eat real foods, not fast foods or boxed foods, in reasonable portions, you probably have a healthy diet. If your blood glucose and hemoglobin A1c levels are good, you're following a diet that is good for your diabetes. Keep it up and don't obsess about sensational headlines.