Thursday, October 22, 2015

New Book Is Out

This is blatant self-promotion, which I hate, but I thought I should let people know that the third edition of my book "The First Year: Type 2 Diabetes" is out. Official publication date is November 1, but it seems to be shipping from Amazon now.

I'm now recommending that people with type 2 diabetes try a low-carb diet first, as it helps with both blood glucose control and weight loss, and they'll find less opposition from their health care team today than they would have in 2007, when the second edition was published. Then if for some reason the LC diet doesn't work for a particular person, that person can try other approaches. But the LC diet should be, as Richard Feinman says, "the default diet."

Other updates include discussion of the new drugs now available, insurance availability because of the Affordable Care Act, discussion of ketosis-prone diabetes (Flatbush diabetes), networking via social media, new sweeteners, and updated references. David Mendosa's chapter "Searching the Internet is completely new.

Saturday, October 10, 2015

Does Insulin Resistance Protect the Heart?

We think of insulin resistance as a bad thing. But could it sometimes be a good thing?

Christopher Nolan and colleagues think so. And some others agree.

These researchers argue that under conditions of "overnutrition," meaning eating more than your body requires, insulin resistance (IR) is a protective mechanism that keeps the heart cells from taking up too much glucose. We need glucose, but we also know that glucose can be toxic when it's present in excess.

However, we tend to think of blood glucose (BG) levels as being the only important factor. In fact, the glucose levels inside cells are also important. In general, when BG levels are high, the levels inside the cell are also higher than normal because of mass action. Hence the body has evolved a mechanism to protect some tissues, mostly skeletal and cardiac muscle, from taking up too much glucose when the BG levels in the blood are high. This is insulin resistance, and it means the extra energy is diverted to fat instead.

However, not all cells require insulin to take up glucose, and hence IR won't protect these tissues. Such tissues include the endothelial cells that line our blood vessels and may be one reason high BG levels contribute to vascular disease. Thus reducing BG levels when they're too high is essential for good health.

But how we reduce BG levels may also be important. Some treatments like the drug metformin reduce the amount of glucose the liver produces through gluconeogenesis and ships out into the blood. This should be beneficial.

Some drugs like the glitazones seem to increase the number of new and active fat cells, which can take fatty acids and glucose out of the blood. This reduces the BG levels but also can lead to weight gain.

However, other drugs like insulin, or the sulfonylureas that make us secrete more of our own insulin, overcome the IR and hence force more glucose into the muscle cells. This will reduce our BG levels and make us and our physicians happy. But in the long run, is it damaging the heart cells? That's what Nolan and colleagues argue. And it could be one reason that reducing BG levels doesn't have a huge effect on heart disease.

In other words, treatments designed to overcome what is believed to be the primary cause of type 2 diabetes (in addition to genetics) may not be the best for everyone. And research into new drugs that would reduce IR might not be as useful as research into other types of treatment.

Nolan and colleagues argue that such treatments are especially harmful for people with massive IR who require massive amounts of insulin to overcome it. And if this subset of patients are harmed by intensive treatment with IR-reducing drugs, then the results of clinical studies that included such patients would be unclear. Some patients would be helped and others would be harmed.

This could explain the results of the ACCORD trial, which some interpreted to mean that aggressive BG lowering was harmful. Later analysis showed that those who were harmed were those who got aggressive treatment but it wasn't effective. In other words, the harm caused by the drugs was not offset by the benefit of lower BG levels.

Unfortunately, the best approach, according to Nolan and colleagues, is to focus on the other cause of type 2 diabetes: overnutrition. This is not good news for those of us born with excessive appetites. It's very difficult to eat less when your body is screaming for more food. But it's one reason many people with huge appetites find that low-carbohydrate diets are useful. Such diets tend to reduce appetite because the high fat content slows down gastric emptying so you feel satisfied for hours after eating. This doesn't happen to everyone, but it does occur with most. It did with me.

Unfortunately, too many people diagnosed with type 2 diabetes want to be able to take a pill and continue to eat the standard American diet that everyone else eats. This may work in the short term, but Nolan and colleagues argue that such an approach causes harm in the long term.

What if a new drug that reduced IR to normal came on the market. Would I take it? I used to think this would be my dream drug, letting me eat like all my friends and neighbors. But now I'm having second thoughts. As so many research papers conclude, "More research is needed." Let's hope some of that research addresses the question of IR as harmful or protective.

Researchers don't routinely measure glucose levels inside cells, but technology is advancing so quickly that this might become feasible and affordable in the future. Also useful would be techniques for measuring IR in different tissues. For example, IR in fat would keep you thinner, but it would also reduce fat's ability to take up some of the excess glucose for storage as fat.

More research is needed.

Monday, October 5, 2015

Low Carbohydrate Diet and Fiber

A recent blogpost at Optimising Nutrition pointed out that it's difficult for some people to get enough fiber on low-carbohydrate diets. Many people do well on very low carb diets without added fiber, but some do not.

I thought it would be relevant to point out that the Four Corners Diet, previously the GO Diet, was designed to emphasize fiber as well as monounsaturated fats and low carbohydrate levels. The original name of the diet stems from the names of the two physicians who worked it out, Jack Goldberg and Karen O'Mara. They tried it on a small group of patients, with good results.

Back in the early part of this century, I felt the diet was the healthiest one out there for people with type 2 diabetes, so I worked with them to add some comments about the beneficial effect of the diet for type 2, and it was published as the Four Corners Diet, emphasizing low-carb, high-fiber, high-mono fat, and what we called pharmafoods, foods with health benefits beyond their macronutrients. These include fermented foods like yogurt or kefir as well as foods containing antioxidants, cancer-inhibiting compounds, phytoestrogens, and cholesterol reducers.

Goldberg was the first person to point out that yogurt and kefir have less carbohydrate than the milk from which they're made, and he even tested the carb count in yogurt and showed that you can subtract 1 gram of carb for every ounce, so a cup of milk, with about 12 grams of carbs, would result in only 4 grams of carbs in well-fermented yogurt and kefir. (The counts can vary a bit depending on when you stop the fermentation. Sour is best as it has the least amount of carbohydrate.)

Unfortunately, the book was published just as a low-carb trend had peaked and was coming down, so the book did not do well. However, that's a benefit for you, as you can now get a used copy for a penny plus shipping.

I still think the diet is the healthiest out there. And all the suggested menus include nutritional analysis of carbs, fiber, net carbs, and percentage mono fat. The suggested 7-day starting menus work up slowly to a lot of fiber, but by day 7 you'd be getting 28 grams of fiber, close to the recommended minimum unless you're a man under 50 years, in which case the minimum is 38 grams.

So if you want both low-carb and sufficient fiber, it would be worthwhile to look into this book.

Saturday, October 3, 2015

Is Insulin a Red Herring?

Yes, I know: Insulin is essential for life. People who don't produce enough insulin have to take insulin shots to stay alive. And by carefully matching their food with their insulin, they can live long and happy lives, albeit lives that are more difficult than those of people who don't need extra insulin.

However, controlling diabetes through diet and insulin -- even with the "artifical pancreas" that does some of the calculations for the patient --  is not enough for most people. We want a cure. Both type 1 and type 2: We want a cure.

What is a cure? Different people define cure differently. Some sellers of the "miracle cures" that you can find on the Internet seem to define cure as having lower blood glucose levels than you had when you started. Some people define cure as not taking any drugs, even though you might have to go on a strict low-carb diet in order to do so. Dr Richard Bernstein defines cure as having a normal glucose tolerance test. I agree with him.

There's certainly no lack of studies of insulin. I just searched PubMed, which showed almost 13,000 articles with insulin in the title published so far in 2015, and more than 30,000 papers about diabetes.

But we still don't have a cure.

Is it possible that because insulin is so important for diabetes, and essential for controlling it, it's drawing attention and research funding away from other compounds that might be less important for control but more important for prevention or cure?

Don't ask me what these compounds would be. If I knew I'd be famous. But some people feel that hormones like glucagon play a big role, and more and more are studying this hormone (about 1300 papers in 2015). How about somatostatin (621 articles), which inhibits the release of both insulin and glucagon, as well as having effects on other hormone systems?

It wasn't that long ago that we didn't know about leptin (identified in 1990s), which plays a large role in obesity. Could there be other yet-undiscovered hormones out there that would be the key to preventing diabetes and maybe even reversing it once it's manifest? Could the focus on the essential-for-life hormone insulin be blinding us to the effects if other, more obscure hormones?

I'm probably wrong, but it never hurts to wonder.

I'm Back

As of October 1, I am no longer blogging for Health Central, and I hope to use the increased time to revive this blog. I doubt that anyone is still reading it, but writing my thoughts down helps me to organize them, so I will try to do so.

I'm interested in new ideas, new ways of looking at type 2 diabetes, and new research, rather than flogging old ideas or getting involved in what I call Diet Wars. I think too many diet blogs tend to preach to the converted rather than trying to come up with new ideas that might help us all in the obesogenic diabetogenic environment in which most of us live.

Re diets: I believe strongly in low-carb diets for people with type 2 diabetes, but I also recognize that we all have different genes, different food preferences, different financial situations, and different family situations, and there are some patients for whom another diet might work as well. Nevertheless, I think the LC diet should be what Richard Feinman calls "the default diet." Unless there are strong reasons to start with something else, you start with a LC diet, and if that doesn't work for you, you can try something else.

Some people say no one can stick to such a diet for very long. I've been on one for almost 20 years, and Richard Bernstein for even longer than that. As I stack wood I'm listening to an audiobook about medical myths. He repeats this argument and suggests that to lose weight you should just "eat healthy." I don't know any overweight person who has managed to lose and keep the weight off by using such an approach. The people who use that approach are usually thin people who don't have diabetes.

In the next post I will discuss the idea that insulin resistance, as well as body fat, may be protective for our health.