Tuesday, March 24, 2009
It points out the flaws and unconsious biases found even in academic research. I think it's always interesting to see things from a different point of view, and this is a point of view of someone who has actually worked in Big Pharma.
Among other things, he says, "Moreover, since academic success is determined almost exclusively by the number and prestige of research publications. . . " When I was an undergraduate, I spent a year studying "Zoologie" at a German university.
One lab instructor had spent several years working as a postdoctoral fellow at Yale. He said he wrote up his research in order to publish a paper, and his lab leader told him no, he shouldn't write just one paper. He should break it up into five different papers, so he could have more publications on his resume.
He also says, ". . . many researchers tend to pursue the trendiest technologies and explore topics that happen to be associated with the most generous levels of research support." I agree with that too. When I was in grad school, the trendy topic was molecular biology, especially something called "phage lambda."
I was more interested in oddball things no one else was interested in. I'm now a sheep farmer and some of the people following trendy topics have Nobel Prizes and prestigious academic positions, which suggests that following trendy avenues of research does pay off.
In that respect, those of us with diabetes are "lucky," because diabetes research is now pretty trendy. Very few people are doing research on obscure diseases that only affect a few people.
We may distrust Big Pharma, which wants to find new drugs they can sell us at high prices, but at least in the process of looking for new pathways that would be responsive to drugs, they're learning more about how diabetes works.
It's a very complex disease, and as one commenter to the Washington Post piece noted, "Many questions in health, behavioral and environmental sciences (e.g.) are so complex - specifically multidimensional - that meaningful measurement is phenomenally difficult."
There will be a cure for diabetes some day. We just don't know when that will be.
Friday, March 20, 2009
As with so many things relating to our health, it's a balancing act.
Most people who eat meat get sufficient iron. Some foods these days are also supplemented with iron. The chocolate syrup Bosco was designed to get children to consume more iron. Cooking in iron pots, especially cooking acid foods, adds iron to our diet. Multivitamins designed for younger people contain iron (especially those for pregnant women, as the fetus consumes a lot of iron).
Hence nonpregnant Western people who aren't vegetarians usually get enough iron from their diet. People in Third World countries who don't get much meat, however, are often iron deficient.
Heme iron, or the iron that is in hemoglobin, the oxygen-carrying molecule in red blood cells, is absorbed even more efficiently than the nonheme iron that you get when you eat vegetables or take an iron-containing multivitamin pill. So eating meat, especially red meat and liver, should ensure that you get enough iron.
Vitamin C will increase the absorption of iron, and large amounts of calcium or whole grains will decrease it.
Those of us over 60 probably remember all those ads for "tired blood" in the 1950s and 1960s that implied that older people were tired because they didn't have enough iron and needed to supplement with Geritol.
So should we all try to get as much iron as possible?
There is some evidence that high iron levels contribute to heart disease, and most "senior vitamins," designed for people who are at an age at which heart disease is more likely, don't have any added iron. Some people think that losing blood every month helps to protect younger women from heart disease. This protection is lost after menopause.
Iron levels have other interesting effects on our health.
Like us, most bacteria require iron in order to grow. Our bodies are smart, and they apparently know this. So when we get an infection, our bodies start reducing the iron in our blood, especially when we have a fever.
The bacteria, in turn, try to develop ways to snatch the iron away from the proteins that carry it around and store it in our cells. Hence taking iron supplements when you have an infection is probably not a great idea.
So why am I babbling on about iron? Because there are two different iron-level conditions that are relevant to diabetes. The first is hemochromatosis, a genetic disease found most commonly among people with Celtic ancestry.
Hemochromatosis makes you absorb too much iron, and the high iron levels attack many organs in the body, including the beta cells. So people with the hemochromatosis gene are at very high risk of getting diabetes. Some people absorb enough iron that their skin turns slightly brown, and if they develop diabetes, it's sometimes called bronze diabetes because of the bronzed color of the skin.
The other condition is the exact opposite, a form of anemia, or too little hemoglobin in your blood. It occurs when you don't absorb enough iron or when you lose iron because you've lost a lot of blood. Without iron, you can't make hemoglobin, and without hemoglobin, you can't make enough red blood cells.
This condition is called, not surprisingly, iron-deficiency anemia.
A test for both these conditions is the ferritin test. Ferritin is the protein that the body uses to store iron, and it's a good indicator of overall iron levels in the body. Low ferritin could mean iron-deficiency anemia. High ferritin could mean hemochromatosis.
There's another wrinkle to the iron story and diabetes. Iron-deficiency anemia can make your hemoglobin A1c test higher than it should be on the basis of your daily blood glucose measurements. A recent study showed that increases in A1c levels often found in late pregnancy are in fact caused by iron-deficiency anemia rather than by increases in blood glucose levels.
Conversely, if you find you have iron-deficiency anemia and you treat it with iron supplements, your A1c will go down.
The reason that iron-deficiency anemia makes the A1c decrease is not clear. It may be related to the red blood cell lifespan. Some people think it's related to oxidative stress.
And although iron-deficiency anemia makes the A1c go up, hemolytic anemias make the A1c go down. Hemolytic anemia is any kind of anemia that destroys the red blood cells, as this reduces the lifespan of the cells and hence results in abnormally low A1cs.
The interpretation of the A1c test assumes the red blood cells live an average of 120 days. In fact, the actual lifetime of red blood cells even in healthy people can vary from person to person, which may be one reason some people seem to get A1c results that are either higher or lower than what they expect on the basis of their home blood glucose readings.
So many things can affect our health, and so many things can affect the lab tests we use to monitor our health.
I think the important thing is to remember that no lab test is 100% accurate for all patients under all conditions. If you get an abnormal lab test, don't panic. Sometimes it helps to have the test repeated, just in case it was lab error. Other times it's simply a suggestion that something might be wrong. Then you can work on what you think might have caused the positive lab test and see if that fixes the problem.
If you have reasons to think you might have hemochromatosis (Celtic or Scandinavian ancestry; relatives with hemochromatosis), it would be a good idea to get a test for ferritin. If you have reasons to think you might be anemic (fatigue, pale skin, rapid heartbeat, especially if you're vegetarian), it wouldn't hurt to ask your doctor for the same test.
If you don't have either and your A1c continues to differ from what you think it should be, you might just be someone whose red blood cells live longer or for a shorter time than average.
Tuesday, March 10, 2009
Monday, March 9, 2009
Someone who calls him/herself "Primary Health Care Physician" is on my side. Other WSJ readers are blaming fat people and smokers for their problems.
Saturday, March 7, 2009
In the old days, when people with diabetes wanted to add sweetener to their food or drink, they had a choice of saccharin, saccharin, or saccharin.
Gradually new sweeteners, including Acesulfame K, cyclamate, and aspartame were added to the pot. Cyclamate was later prohibited in the United States, although it continued to be sold in Canada, because a study suggested that it increased cancer rates in rodents.
Saccharin was also reported to increase cancer rates in rodents when used in huge quantities, but it remained on the market. Many people said they had problems when they used aspartame; others said it didn’t bother them. Aspartame does break down when it is heated and isn’t recommended for cooking.
More recently, sucralose, marketed as Splenda, was added to the repertoire. And stevia, which comes from a South American plant, has been used as a sweetener although it wasn’t approved for such use in the United States and was sold instead as a “supplement” in the vitamin sections of stores. It has been used as a sweetener in Japan for some time.
You can also add a sweet taste with sugar alcohols, which are metabolized differently from regular sugars. Most of them reach the colon undigested, and bacteria in the colon digest them and produce gas, which you (and your friends) may notice if you eat a lot of these sugars. They are also good laxatives.
The names of the sugar alcohols end with “itol,” as in maltitol, lactitol, sorbitol, xylitol. Some people find these sugar alcohols don’t make their blood glucose (BG) levels go up very much; others say they do. It depends on your personal metabolism.
Unfortunately, maltitol, the sugar alcohol that is used most commonly in “sugarfree” products like candies, consists of 50% glucose, so it will raise the BG levels in most people as much as table sugar (sucrose), which is also 50% glucose.
The sugar alcohol erythritol is a little different from the others. Instead of going through the intestine undigested, much of it is absorbed into the bloodstream and then excreted unchanged by the kidneys. For this reason, it does not cause gas like the other sugar alcohols, and it has fewer calories.
I’ve described all these sugars in more detail in my book The First Year Type 2 Diabetes, and I won’t repeat that information here. Instead I’ll focus on a few of the newer sweeteners.
I never used much Splenda, primarily because it was all “cut” with maltodextrin (which is a carbohydrate made of glucose that is digested to glucose and makes your blood glucose [BG] levels increase just like starch) or glucose (listed as “dextrose” on the individual packets), or both. I did use it for a few weeks in the summer when my raspberry bushes were bearing to beat the band, as I consider it sinful to leave fresh raspberries uneaten. Uncut sweeteners like stevia are difficult to sprinkle evenly on the berries.
But now, Splenda has come out in a new formulation emphasizing fiber. Instead of maltodextrin, they’re using soluble corn fiber as a “bulking agent.” This is good news for all of us, because not only are we no longer required to add glucose or maltodextrin with the sweetener, but soluble fiber also helps keep BG levels down. Each packet contains 1 g of corn fiber.
And in 2008, the FDA began approving stevia products as GRAS (generally recognized as safe) when used as sweeteners if the manufacturers provided research results showing their safety. And a lot of manufacturers have jumped on the stevia bandwagon.
Two big boys on the sugar shelf are products combining stevia extracts with erythritol. The major new ones are made by Cargill for Coca Cola (Truvia) and the Whole Earth Sweetener Company for Pepsi Cola (Purevia). I found both these products at a grocery store in the small town where I shop.
Truvia contains only erythritol, stevia extract (rebiana), and “natural flavors,” which they don’t indicate. Purevia contains erythritol, stevia extract (which they call Reb A), isomaltulose , a little cellulose, and “natural flavors,” which they also don’t indicate. Truvia seemed a little sweeter to me, but they’re both basically the same except that Truvia doesn’t contain the isomaltulose.
Isomaltulose is made from sucrose (table sugar) and has the same number of calories. It is digested in the intestine to produce glucose and fructose, but the digestion is slower than that of sucrose, which also produces glucose and fructose, so it should have a lower glycemic index.
Some time ago I bought a similar erythritol/stevia combination (Stevita) at a local health food store. At the time, it was marketed as a “dietary supplement.”
And another stevia product, Sweet Leaf, has been on the shelves for some time. This one isn’t cut with erythritol, but with with inulin, a fiber.
Inulin is a polymer of fructose found in Jerusalem artichokes, and, like the sugar alcohols, it isn’t digested until it reaches the colon. There bacteria can break it down to release gas. It is said to stimulate the growth of “good” bacteria in the colon and some people supplement with it for that reason. Although it is made up of fructose, it doesn’t increase triglycerides as fructose does.
For some time, I’ve used the KAL brand of uncut stevia. I like it because it comes with tiny spoons that are the equivalent of 1 tsp of regular sugar. I find it sweeter than other brands of pure stevia I tried, so I need to use less. Like many other fake sugars, it becomes bitter when you use too much, so you have to be careful, but I’ve had good success with it.
Some people say they get an oregano taste when they eat stevia. I’ve found that with the unpurified stevia leaves, but not with the purified forms. But every manufacturer may purify the stevia extract slightly differently so the resulting product contains slightly different things. To me, different brands of stevia have different levels of sweetness. One kind I got in bulk at my local Coop was cheaper than the KAL brand, but about half as sweet, so I needed to use twice as much and it ended up being more expensive.
One problem with any of the supersweet sugar substitutes becomes apparent when you make a product like ice cream, which relies on the sugar to lower the freezing point as well as to sweeten. Because you use so little stevia or sucralose or saccharin if you use those to make ice cream, you end up with something that is brick hard when you put it into the freezer.
Erythritol works like sugar in this respect. I made some ice cream with pure erythritol, and it was soft and creamy even after being frozen for several days. Success at last! The new erythritol/stevia blends may work almost as well as the pure erythritol, perhaps less because the sweet stevia means you use less of the erythritol. Time will tell.
Unfortunately, erythritol is expensive. A pound of table sugar costs about $1 at the supermarket. A pound of erythritol costs about $9, a little less on the Internet, but then you also pay high shipping costs.
Another sugar that would act like table sugar for cooking is tagatose. It would also brown when cooked, like table sugar. However, the one manufacturer of tagatose decided to stop production after a short time, saying there wasn’t sufficient market for the product.
People will argue until the cows come home about which sweetener tastes the best and is the safest. Some people seem to be allergic to aspartame, for example, and others aren’t. We really won’t know the long-term effects of any of these sweeteners until they’ve been on the market for a long time. In that respect, saccharin, which has been sold for many decades, probably has the best record.
What is nice about these new products is that they give us more choice to find a sweetener that works for us. Read labels before you buy any sweetener so you know exactly what you’re buying. If you’re on a high-carbohydrate diet, the 1 g of glucose in a packet of sweetener won’t make much difference, but if you’re on a very low carb diet it could.
I think I’ll stick to pure stevia for now, but the erythritol products may be useful when I want to make my own sugarfree ice cream. I hear rumors that summer is just around the corner, and the occasional dish of homemade ice cream is pretty appealing when the weather is hot.
Monday, March 2, 2009
Those days are gone, and now I send e-mail instead. I also write for fun. I've published a few books related to diabetes, and more unfinished books and stories are sitting in my files waiting for me to have the time to polish them up and find homes for them.
In the past few years, I've been doing some blogging for Health Central's diabetes pages, and I will continue doing this. But I thought it would be fun to branch out a bit with my own blog, which would give me more freedom to branch out a bit in what I say, to post occasional pictures, and mostly just to try something new.
I'm calling this blog "Wildly Fluctuating" because I'm planning to tackle wildly fluctuating topics from the very serious to the very absurd; from basic information that everyone needs to more technical stuff that might be of interest to us old timers to simple musings on the diabetes news of the week. Maybe occasionally something that has nothing whatsoever to do with diabetes. We all need a break.
Diabetes is a serious disease, and we all need to take it seriously. But we also need to take a break from time to time: we need to laugh. Thus I'll try to write something humorous from time to time.
I'll also occasionally discourse on the science of diabetes. When we have diabetes, it's nice to understand the scientific basics of topics like digestion, food composition, drug absorption, and so forth.
Health professionals, including physicians and certified diabetes educators, can provide general guidance and one-size-fits all treatment plans. But we're not all one size, and a treatment plan that works great for me might not work well at all for you. The health care people won't be at our side when we want to eat that chocolate eclair that looks so tasty. We've got to understand how food affects our health ourselves.
I tried to explain the diabetes basics in my book The First Year: Type 2 Diabetes, and the basics of diabetes prevention in Prediabetes. But new material comes out every day, and it never hurts to review what we already know.
I will give my views on the numerous diabetes news items that seem to surface every week, if not every day. The news media tend to simplify things and tell us that type 2 can be prevented by eating some food or type 1 has been cured, when in fact some food or other has been had a slight effect on the incidence of type 2 or type 1 has been cured in mice.
In fact, diabetic mice have been cured zillions of times, and at the current time, your best bet for a diabetes cure would be to be reincarnated as a lab rodent.
I've had type 2 diabetes myself for 13 years now. And I'll occasionally write about my own experiences living with this dragon, both good and bad. However, I do hope I don't become so self-focused that my blog turns into an off-topic daily diary about my favorite toothpaste or a great buy in hamburger at the local grocery store.
And one thing is certain: I promise I'll never, ever upload photos of Spot and Fluffy.
.*Only because my cats all died on the highway near my house and they haven't been replaced.