Reactive Hypoglycemia: a cautionary tale

For many people, losing a lot of weight results in blood glucose (BG) levels at or close to normal, and your doctor may tell you that you're no longer diabetic. If this happens to you, first of all you should be congratulated for the difficult job of losing weight. That's wonderful.

But you should also be vigilant to make sure you don't get reactive hypoglycemia, which means very low BG levels after you've eaten a lot of carbohydrate. This can happen even when you're not diabetic.

I had reactive hypoglycemia about 20 years before I got the diabetes diagnosis. At the time, I was a night owl and hated getting up early in the morning. But occasionally, at the daily newspaper where I worked, I had to do the "wire desk," which meant arriving at 7 am. Because I hated it so much, I'd treat myself to a chocolate doughnut. Usually I didn't eat breakfast at all.

Then at almost exactly 4 hours after the doughnut and black coffee, I'd get the shakes and feel as if I'd die if I didn't eat something. In fact, I could almost set my watch by this phenomenon. "Oh. The shakes. It must be 11 o'clock." Then I'd eat a candy bar and feel fine for the rest of the day.

Why does this happen?

Insulin secretion is biphasic. When a nondiabetic eats a carbohydrate food, the pancreas quickly spurts out a pulse of insulin. This pulse doesn't last very long but it's enough to keep the  carbohydrate that reaches the intestine from going very high. It also suppresses the production and release of glucose from the liver. This is called the phase 1 or first phase insulin response.

Then insulin is secreted continuously as long as carbohydrate comes into the system in proportion to the amount of carbohydrate reaching the intestine. This is the phase 2 or second phase insulin response, and it lasts much longer than the first one.

The food that we eat, including carbohydrate, isn't dumped into the intestine all at once. Instead, the stomach releases only a certain amount at a time, usually containing about the same number of calories, so the insulin release is pretty steady. Liquids leave the stomach faster than solids.

Unfortunately, those of us with type 2 diabetes tend to lack a first phase insulin response and may have lacked it for a long time before we were diagnosed with diabetes. This means that when we eat carbohydrate, our BGs aren't knocked down by that first insulin pulse, so they go much higher than they would in a nondiabetic who ate the same amount of carbohydrate. Then the body sees these high numbers and assumes they're that high despite a first phase insulin response. So the second phase response is extra strong, and with all that extra insulin, we may go low. Some people call this "too much too late."

Now, no one really knows at what point in our life the first phase insulin response is eliminated, although there is evidence that first-degree relatives of people with diabetes have impaired first-phase insulin responses despite having normal BG levels.  We also don't know if or when the first phase is restored when people normalize BGs enough to be considered nondiabetic again.

I was in a clinical study in which they did an intravenous glucose tolerance test that measured both BG and insulin after a huge dose of glucose. I started with almost no phase 1 response. But after I was on the study drug (salsalate) for a couple of weeks, the phase 1 response was restored to about 70% of normal, which is consistent with the idea that the situation is reversible.

Weight loss alone may or may not restore the phase 1 response, but there's some evidence that phase 1 is restored after weight-loss surgery.

So if you've reversed your diabetes so that your BG levels are in normal ranges, you may still lack that phase 1 response and be sensitive enough to large carbohydrate loads that you'll have reactive hypoglycemia.

That happened to Joseph recently. He had lost a lot of weight after gastric bypass surgery, and his BG levels were usually normal, but he still watched his diet and didn't go overboard with the starches. Then one day he was at a football game, and it was very cold and his friends had a lot of tasty crackers with them, so he ate some. No, he ate a lot. A few hours later, he felt odd and tested his BG. It was 35. Luckily, he wasn't alone, and someone gave him some juice and he recovered.

I have no idea how low I was when I worked the wire desk and got the shakes after eating a doughnut with black coffee. But I do know it was very unpleasant. So if you're a recovered diabetic, be vigilant and don't let this happen to you. Avoid carbohydrate fests, especially on an empty stomach. And if you can't avoid them, make sure you have available some glucose tablets or other food that will raise BG quickly in case you do go low.

Reactive hypoglycemia is counterintuitive ("How could I be low when I just ate all those carbs?"), but it can be serious. You can outsmart it, though, if you're prepared.

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Being Positive

Getting a diagnosis of diabetes can be pretty depressing. Then we're usually given a lot of admonitions about things we can't do. Don't eat this. Don't eat that. Don't eat too much of anything. Don't drive without testing first. Don't sit down and read a book when you could be walking on a treadmill. And the list goes on.

Thus it's a pleasant change when one comes across some diabetes information that is positive.

One such find is an article by type 1 blogger and author Riva Greenberg and Boudewijn Bertsch that describes their approach to diabetes treatment. They are currently traveling around the world teaching health care people how to implement their approach and report that they are getting a lot of interest.

"Last night in Almelo, the Netherlands, 62 doctors got it. And trust me, a Dutch crowd isn’t easy," Greenberg wrote on her Facebook page.

They call their approach the The Flourishing Treatment Approach, and it focuses on health rather than on disease, the positive rather than the negative.

The authors call traditional treatment a Coping Treatment Approach, in other words treating a disease and helping people cope with the difficulties caused by the disease.

Their Flourishing Treatment Approach, on the other hand, focuses on the causes of health instead of the pathogenesis of the disease. For example, rather than asking how the patient is coping with "dietary challenges," the health care person should focus on "dietary successes" and ask the patient to think of ways of increasing these successes.

I think many health care professionals (like many parents) want to improve their patients' (or children's) lives by pointing out their faults so they can correct them. If you have a stellar hemoglobin A1c, they won't mention that but will point out that you need to lose more weight. I've heard many patients complain about that and say it makes them depressed, because no matter how hard they work to improve their health, they get criticism rather than praise.

Focusing on the positive results should give patients an incentive to obtain more of them, and everyone should benefit.

The other source of a positive approach is Adam Brown's book Bright Spots & Landmines: The Diabetes Guide I Wish Someone Had Handed Me. Brown has type 1 diabetes. He is a senior editor at diaTribe.org and leads Diabetes Technology & Digital Health at Close Concerns. He calls things that work and should be done more often Bright Spots, and things that don't work and should be done less often Landmines.

For example, Brown finds that eating breakfast foods high in protein, fat, and fiber is a Bright Spot for him. Other than eggs, one example is his chia seed pudding, which also includes nuts, seeds, coconut oil, and berries. The recipe is in the book. Eating white foods like bread, potatoes, rice, and so forth is a Landmine. He says that the Landmines should be done less often; he doesn't say you should never do them, which is more daunting.

The good thing is that Brown has put the Bright Spots ahead of the Landmines in his title. Like the Flourishing Treatment approach, this ordering tends to make the reader focus on the positive instead of sulking about the negative.

Sure, there's definitely a downside to having diabetes. But I think focusing on that just makes things worse. Let's focus on flourishing with Bright Spots and dietary successes instead.

It's the Patient's Fault: Not

A lot of doctors don't understand how difficult it is to make major lifestyle changes of the sort that most everyone agrees will help to control type 2 diabetes. "Lose weight!" they'll say, although you may have been trying to lose weight for most of your life and not succeeding. "Get more exercise!" they'll say, even if you've been going to the gym religiously every day.

But one doctor is trying to teach medical students how difficult it is to be a type 2 diabetes patient. In  an editorial in Clinical Diabetes, Stephen Brunton describes how he tried to train medical students by asking them to give up something they loved for just one month. Just one month! Only 2 of the 40 who took part were able to comply. That means 95% failed.

Yet physicians and other medical people routinely tell diabetes patients to give up certain foods or certain behaviors not for a month, but for the rest of their lives. Is it surprising that many don't succeed?

Of course, not everyone says to newly diagnosed patients that they'll never be able to eat a doughnut again, but it's implied when they are told to eat a turkey sandwich on whole-grain bread and an apple (the favorite of nutrition writers) instead of the burgers and fries and pie that they love.

Brunton's approach isn't going to make being a type 2 diabetes patient easy. But I think patients are more apt to work with health care people who understand the problems. "Lose weight" isn't useful. Better would be to suggest keeping a food log and then looking for ways to cut back on unhealthy foods.

I once met a health care worker from Missippi who was making a booklet designed to help overweight people lose weight. She had a "before" photo of a big burger and a big order of fries, the meal taking up the whole plate. Then the booklet had a photo of what the patient should eat instead: a tiny burger and three fries, most of the plate empty. But to anyone with a huge appetite who has always eaten huge meals, a tiny burger and three fries would seem like a punishment. And they'd still be hungry. She apparently didn't understand what it was like to live with a huge appetite.

I wondered if it would work better to show a big burger without the bun and a huge mound of green beans, or some other vegetable that the patient enjoyed. That way, the meal would still take up the whole plate and would also take up room in the stomach, helping to dampen hunger.

Whatever, I think if more physicians tried to look at the problems of living with diabetes from the point of view of the patient rather than just wondering why the patients didn't improve, we'd see more progress.

"She just won't lose weight." Maybe she can't. Maybe there's something wrong with her appetite control so she's ravenously hungry all the time. It's almost impossible to not eat when you're ravenously hungry.
"He doesn't exercise." Maybe he works two jobs and commutes for two hours and just doesn't have the time or energy for formal exercise.
"I doubt that he takes his meds." Maybe he can't afford them.

Feeling that your physician understood your struggles would help a lot more than just being told to do this and give up that. No one really understands how difficult it is to live with diabetes unless it happens to them, but at least Dr Brunton is trying. Let's hope his editorial motivates some physicians to change their approach.

Whole Grain Spinning

It's interesting how news reports of nutritional studies can spin the results, probably without the authors realizing that's what they're doing.

Take a recent report titled "Several reasons why whole grains are healthy." Now, you see a headline like that and you're apt to think "Whole grains good" and you might eat more of them, increasing your carbohydrate consumption.

Yet the article might just as well have well been titled "Several reasons why processed grains are not healthy." In that case you would be apt to think, "Processed grains bad" and eat less of them. Instead,  you might eat more whole grains, or you might eat more fish or broccoli or beef or whatever. And if you have diabetes, the latter would be more beneficial for your blood glucose levels.

The study I cited took 50 adults at risk of cardiovascular disease or diabetes and had them substitute whole grains for the processed grains they usually ate. They found that doing so reduced the amount of inflammatory markers in these adults.

I have no problem with the study or the results. Just with the way it's spun.

Controlling Weight

Controlling weight is affected by so many physiological factors it's sometimes difficult to keep track. Before 1994, when leptin was discovered, people thought weight control was simply a matter of willpower. Now we know better.

Most of us know that leptin is secreted by fat cells when we have had enough to eat and the fat cells are full, and the leptin turns down our appetite. Children born without leptin have voracious appetites and become obese as toddlers; when given leptin, they slim down. People with no leptin are rare, but overweight people may have leptin resistance, just as people with type 2 diabetes have insulin resistance. In both cases, levels of the hormones can be high but the body doesn't respond to them properly.

On the other hand, the hormone ghrelin is produced by the stomach when we haven't eaten, and it makes us hungry.

Now a third hormone has been discovered that increases appetite during fasting and decreases it during feeding. It has been named neurosecretory protein GL, usually referred to simply as NPGL.
This hormone not only affects appetite, but it also increases the storage of fat, even on a low-calorie diet.

Another study found a gene with the snappy name GTRAP3-18 that helps to regulate both food intake and glucose levels. Mice without this gene were both lean and hypoglycemic, and this was due to neither less activity nor an increased metabolism, but rather to eating less. The authors suggested that the gene could be a target for drugs, saying, "Eating too much or too little could actually be a genetic problem," although we know that other factors such as emotions and the food environment can play a role as well.

A third study found yet-another protein with a snappy name, MKK6, that affects weight by stimulating the burning of fat to generate heat. Overweight people seem to have higher levels of MKK6, which hinders the conversion of white fat cells into brown fat cells. White fat cells store fat, and brown fat cells burn fat.

A fourth study described brain cells called tanycytes that detect nutrients and tell us when we've eaten enough. Foods high in certain amino acids (the building blocks of protein) activate the tanycytes and make us feel full sooner, which is consistent with the commonly stated fact that protein is satiating. Interestingly, the receptors in the tanycytes are the same as those in the tongue that detect the umami flavor of protein foods.

The two amino acids that react the most with the tanycytes are arginine and lysine. Foods rich in these amino acids include pork shoulder, beef sirloin, chicken, mackerel, plums, apricots, avocados, lentils and almonds.

Finally, a Swiss study showed that severely obese people release fewer satiety hormones than people of normal weight because they have fewer of the intestinal cells that produce the satiety hormones than normal-weight people. Weight-loss surgery seems to increase the number of these cells.

We all know that weight loss, and especially maintenance of weight loss, is difficult. One reason is that there are so many factors involved (and I'm sure even more will be found in the future), and different people may have deficits in different systems.

In fact, an Israeli study showed that the glycemic index of various foods could vary a lot between individuals. A food that was problematic for one person might be fine for another. And for some individuals, even white bread seems to be better for blood sugar levels than whole grain bread.

Even the bacteria in your gut may affect whether or not you will lose weight on a diet with a lot of fruits, vegetables, fiber, and whole grains, according to a Danish study. So if some recommended diet doesn't work for you, it may not be that you're "doing it wrong." It may be that the diet isn't the right one for you.

What this all means is that it's up to us to take charge and find out which diets are best for our personal physiology. It's a lot more work than simply following guidelines set by some "diet expert." But it's worth the effort.

And it's encouraging that so much research is going into what factors govern appetite and fat gain or loss. In the long run, this basic research should lead to real solutions. Let's hope funds for basic research aren't cut any more in a misguided effort to save money. In the long run, figuring out the best way for people to lose weight and keep it off will save even more money from health care expenses than the costs of the research.

Information overload

One of my favorite cartoons, which I have pasted on my desktop computer, shows a man with a little beach pail standing on a beach while a huge wave (which looks like the woodcut "Great Wave Of Kanagawa" by Katsushika Hokusa) is about to break over him. The man is saying, "Eureka! More information."

(I can't show the cartoon here because it's copyrighted. I was going to link to the author Ted Goff's page, but he's apparently updating his website and the links don't work for now.)

This cartoon illustrates how I feel about science news these days. I get about 150 Eurekalert science press releases every day, as well as the tables of contents from a lot of journals. And it seems as if just as some fact is generally accepted, a paper comes out refuting that fact.

Also, science research is getting much more technical these days. Unless a study is commissioned by some commercial group like the the California Walnut Commission, which funds a lot of studies showing the health benefits of walnuts when some of those benefits might be found by eating similar nuts, people no longer tend to publish simple studies saying that factor X increases or decreases diabetes symptom Y. Instead the authors (often 20 or more) drill down to the molecular level and try to show that factor X increases or decreases the level of numerous cell factors that govern gene expression or hormone activity.

Unless the reader has a background in biochemistry or molecular biology, I figure the reader probably wouldn't understand these studies (sometimes I don't either), so there's no point in discussing them.

Also,  unless I think there's a major flaw in the evidence, I see no need to link to a study that has been picked up by all the news media, something like "Eating pickles and figs will make you lose 10 pounds in a week." You'll most likely see that study on the TV news anyway.

All this is a way of explaining why I'm not blogging much at the moment. But I haven't disappeared. I continue to try to keep up with new research developments, and when something both interesting and comprehensible by the average reader comes out, I'll let you know.

Hang in there. I'm trying to.

Is Childhood Obesity Psychological?

"Is Childhood Obesity a Psychological Disorder?" says a headline in a press release from Children's Hospital Los Angeles.

Now, many people get their information from headlines and don't read the articles. Also, a headline with a question mark suggests that the answer is Yes. If it were no, it wouldn't usually be newsworthy, akin to asking if childhood obesity were related to the name of the child's kindergarten teacher.

So this headline suggests that childhood obesity is a psychological disorder, and although there are many definitions of "psychological," a common one is "it's all in your head," meaning it's not a real disorder, and suggests that these kids are emotionally unstable and could become thin if they really wanted to.

In fact, the article focussed on brain scans of overweight or obese and normal-weight adolescents. They found that after showing the adolescents words describing various kinds of food, although the brains of all the participants were stimulated in areas that support reward and emotion, the overweight/obese ones had less activity in brain areas that support attention and self-regulation. I'd call this a brain disorder, not a psychological disorder.

As you might expect, when offered a buffet after the testing, the overweight/obese adolescents ate more than the lean ones.

This study is interesting, but I think the headline reflects an unconscious bias against fat people, suggesting that fat children have psychological problems. If the brains of overweight people are indeed different, we should try to figure out why they're different and then figure out how to normalize them.

I'm sure there are some overweight people who overeat because of psychological traumas. But there are others who overeat because they have differences in their hunger sensations, for example the rare children who lack leptin. And there are others who don't actually overeat but have metabolisms that are superefficient at converting food into fat.

It would be nice if all weight problems had only one cause so it would be easy to fix, but that's not the case. Until we have the solutions, we should at least stop stigmatizing overweight people and instead help them heal.





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When to Measure Postmeal Glucose Levels

What's the best time to test your blood glucose (BG) after meals?

Of course that depends on what you want to learn from testing after meals. If you want to know the after-meal peak, then you should test about an hour after you eat. The peak will differ a bit with different foods; fats slow down gastric emptying, and liquids pass through faster than solids. It also can differ with different people.

So if you want to know where your own peaks are, you should test every 15 minutes or so starting about 45 minutes after eating and continuing until the numbers start coming down.

If you want to know if you're able to return to normal, or close to normal, BG levels within a few hours, then you should test at 2 or 3 hours.

"After eating" is also ambiguous. Should you test X minutes after you start to eat or after you stop eating? Again, it depends on your habits. If you wolf your meal down, it doesn't much matter. If you eat leisurely and take 30 minuts to finish a meal, then it does. What you really want to know is differences between different meals, so the important thing is to test about the same way every time. Don't compare one meal you ate in 4 minutes with another one that you took an hour to finish. Most people measure the time after starting to eat.

If you ask CDEs or your doctor when to test, they'll usually tell you to test at 2 hours. This is because most research papers about postprandial (after meal) BG numbers use the 2-hour reading. But this may not be the best.

One researcher, Antonio Ceriello, recently published a paper proposing that it's time to switch to a one-hour postprandial measurement. He kindly sent me a copy of the full text of the paper.

Ceriello says that there's evidence that the one-hour measurement has even stronger power than the two-hour measurement for identifying impaired glucose tolerance. He said this number is also related to the risk for cardiovascular complications. In vitro experiments have shown that just one hour of high BG levels is enough to cause endothelial dysfunction that can then lead to coronary vascular disease, as well as reactive oxygen species (strong oxidants), he said.

Endothelial function is worse at one hour than at two hours both during oral glucose tolerance tests and after meals, he said.

If all this isn't enough, Ceriello said short-term high BG levels can impair beta-cell function.

When I've measured BG levels in nondiabetic friends and relatives, I've sometimes found one-hour readings of 160 or so, but the numbers come down to baseline by two hours. Testing only at two hours wouldn't identify these people, who might be at risk of developing diabetes in the future.

Ceriello's recommendations apply to clinical studies, but there's no reason you couldn't measure at one hour if you so chose. The best, of course, would be to measure at both one hour and two hours if you could afford enough strips. Then you'd know which time made most sense for you.

Even if most clinicians accept Ceriello's recommendations, it will take time before they become standard. So for now most studies will continue to use the two-hour numbers. But when  you see a study mentioning postprandial (or postmeal) numbers in the future, you should check to see what they mean, if you can (abstracts may not specify).

If anyone wants references to the studies Ceriello was citing, let me know and I'll send them to you. If I get tons of requests, I'll just edit this post to put the links in.

Of Mice and Humans

"New Research Describes the Differences Between Mice and Humans" screams a headline of an article in Eurekalert. 

Golly. I guess I'm ahead of my time because I've known the differences between mice and humans for decades. The mice are the furry ones with long tails, and the humans are the larger ones who fight and kill each other because they don't agree on politics or religion.

But once you get past the headline on Eurekalert, you find that researchers are finally accepting that mouse research often doesn't translate into human treatments. Mice have been cured of diabetes hundreds of time, but the drugs the researchers used just don't seem to work when they try them on humans. 

The problem is that it would be unethical to try new drugs on humans without some evidence that they might do something beneficial. Mice are relatively cheap to maintain, and we already know a lot about them. If we used only larger animals like pigs or dogs or monkeys, the cost of research would be even higher than it is now, and animal rights groups would protest. Very few people object to mistreating rodents.

Now researchers are beginning to find out why mouse research doesn't always translate into human cures. These researchers looked into a class of receptors found on beta cells in both mice and humans. They are called G-protein-coupled receptors (GPCRs), but the names don't matter.

What they found was that some of these receptors are found in both mice and humans, but others are not. Some are found only in mice, and others are found only in humans. If they know which ones are found in both mice and humans, future researchers can limit their research to those receptors. There's no point in spending millions of dollars on some drug that affects a receptor found only in mice! That money could instead be used to study drugs that affect both species.

Of course not all drugs target GPCRs. But a large number do. Let's hope these findings channel research into fruitful drugs, and not duds.

Hunger

I know what ravenous hunger is.

More than 20  years before I was Dx'd with type 2 diabetes, I used to get reactive hypoglycemia, although I didn't realize that's what it was. At the time, I was working at a daily newspaper, and I occasionally did the wire desk, which mean I had to arrive at work at 7 a.m.

I normally didn't eat breakfast, and I wasn't especially hungry for lunch. But because I was a night owl and hated getting up early enough to get to work by 7, I'd reward myself with a chocolate doughnut, in addition to the strong black coffee I usually had.

Then, almost exactly 4 hours later, I'd get the shakes and a feeling that if I didn't eat something immediately, I was going to die. So I'd rush to the candy machine and get a candy bar, and that got rid of the shakes and the feelings of doom.

Now if I go low, which doesn't happen often but it does happen, I have that same feeling that if I don't eat I'm a goner. And because I want to get rid of that feeling that I'm doomed, I sometimes overtreat and then go high for hours.

Of course the official recommendation is to eat 15 grams of carbs, wait 15 minutes and retest, then eat a little more if you're still low. But one thing I really miss on my low-carb diet is fruit. When I was a kid I remember telling my mother, "What I really like is meat and fruit." So I keep canned sugarfree peaches in the cupboard to eat if I go low. They have about 6 grams of carbs in a cup, which is often just right when I'm not very low, and I wolf them down.

So I was wondering if this same 15/15 approach would work not just for lows but for weight loss.

I suspect that many people who have weight problems have something wrong with their appetite controls. When everyone else is feeling just hungry before a meal, they may feel ravenous. And when you're ravenous you tend to wolf down whatever you can reach. It takes about 20 minutes before your body lets you know you've had enough, and if you eat fast, by that time you've eaten a lot more than you need.

It's not enough to tell people to eat slowly. What exactly does that mean? Would it work better to measure out a small amount of food, eat it, and then wait 15 minutes? If you were still hungry, you could eat a second small amount of food. You'd keep doing this until you were no longer hungry.

Of course, if you have only 30 minutes for lunch, this would be difficult. Even with an hour it might be hard if it took four small portions and until you felt full. If so, you could increase the portions until you found an amount that filled you up with one or two servings.

So would this work? I really don't know. I'd try it myself but I no longer get ravenously hungry except when I'm very low, and that doesn't happen very often. I've always had a big appetite. One time a waiter at a Chinese restaurant remembered me two years later. He said they'd all been talking about me, "Because we'd never seen anyone so small eat so much." (This was in the days before they let you take extra food home and I hated to waste food, so I ate my whole meal, including the rice, and then finished what my brother couldn't eat.)

But as I get older my appetite seems to have abated, and "normal" portions now seem dauntingly large. So I no longer have that urge to stuff myself. I sometimes even stop eating when there's still food on my plate and heat it up and eat it at the next meal. So my weight has been steady for a long time.

It's nice to have a normal appetite after all these years, but I do understand what it's like to feel ravenous. I wish we could figure out how to fix that.

Is Blood Glucose Testing Worthwhile?

Here we go again: Another study  claiming that self-monitoring of blood glucose levels (SMBG) doesn't help patients with type 2 diabetes. You can see the full text here.

Some previous studies have claimed the same thing, and some even claimed harm from SMBG, namely increased rates of depression or decreased "quality of life," although others claimed benefit.  Most informed patients agree that in order to be effective, patients must be trained in how to interpret the results and take action as a result. If you eat doughnuts and see a high number on your meter after a couple of hours, don't eat doughnuts. Just measuring without using the results to take some kind of action is, most agree, pretty useless and a waste of money.

The authors of the recent study agree: ". . . for SMBG to be an effective self-management tool in non–insulin-treated T2DM, the patient and physician must actively engage in performing, interpreting, and acting on the SMBG values."

In this study, patients were randomly assigned to one of three groups: no testing, testing, or testing with feedback. In the latter group, the feedback was computer-generated, not actual conversations with a human being. Here are examples of the feedback:

Sample Messages for Blood Glucose Values at Goal

• You are right on target. Remember to check your blood sugar tomorrow morning.”
• “Keep up the good work.”
• “Outstanding!”
• “Way to go. Keep checking every morning before breakfast!”
• “Your blood glucose goal is between 70-130 in the morning before you eat. You are doing marvelously.”

Sample Messages for Blood Glucose Values that are Mildly Elevated

• “Keeping track of the foods you are eating and the physical activity you are doing may help you pinpoint reasons why your blood sugars are running high.”
• “This number is a bit off target. Remember to check again tomorrow morning before eating.”
• “Your target in the morning before eating is 70-130.”
• “Staying on track with your diabetes can be tough at times. You can do this! Aim for a target fasting blood glucose value in the morning between 70-130.”

Sample Messages for Blood Glucose Values that are Very Elevated

• “Please discuss with your health care provider to talk about ways to get your blood sugars down to a more healthy range.”
• “Please consider making an appointment with your doctor. Your blood sugars have been too high lately. Your target before breakfast is 70-130.”
• “Time to check in with your primary care provider about these blood sugar numbers. They have been running too high.”

This is certainly better than nothing, but the messages are too general to be of much use and focus on fasting levels. I don't see anything like "Oops. Your numbers were high after this meal. See if you can figure out what it was in the meal that made your numbers go too high."

In fact, I couldn't find in the paper or even supplementary material anything about when patients were told to test, so I asked the corresponding author, Katrina Donahue. It turns out it was not simple. She said,

"The testing was based on once daily testing, but would vary depending on the patient’s blood sugar levels. First, they were instructed to test a.m. fasting blood sugars. When at goal, they were instructed to test a.m. fasting 3-4 times per week and pre bed 3-4 times per week. If still at goal, they were instructed to test a.m. fasting 1-2 times per week and 2 hour post prandial 5-6 times per week."

So only those patients who reached their fasting goals (70-130 mg/dL) were told to test after meals, and it's testing after meals that really tells you how different foods affect your blood sugar numbers, although your fasting levels may give a general idea of your overall control.

One interesting thing in this paper is the graphs showing hemoglobin A1c levels with time and the proportion of patients actually testing when assigned to the testing group. The A1c levels over 12 months are very similar to the results we usually see in diet studies. Initially the intervention is successful, but then, usually after about 6 months, the results slowly revert to baseline.

A similar pattern was seen with the proportion of patients told to test who were actually testing: High compliance at first dropping to about 60% by the end of the year.

I think these graphs show something important. People who are diagnosed with diabetes are at first really upset and are willing to follow some lifestyle change, be it eating less, eating fewer carbohydrates, exercising more, taking expensive drugs, or whatever. But then, with time, the enthusiasm for major changes begins to pall. Temptations seem greater.

The same is often seen with people who diet simply for weight loss. Each new diet promises that they'll look like movie stars, so they're very compliant at first, but then the cheesecake seems more important than fitting into smaller clothing and gradually they revert to former habits and then try some other diet that has the same unrealistic promises.

So the really important question is: How can we deal with this loss of enthusiasm for a new, healthier lifestyle? I don't think getting text messages from faceless health care people will have a tremendous impact long term, although as a non-texter maybe I'm wrong.

I think we need intensive education with real human beings and contact with other people who have diabetes. We don't need individual instruction; classes should work and also let people meet fellow patients they can keep in touch with. Of course, diabetes classes already exist, but too many people have complained that they were pretty useless and focussed on cutting out fat.

We need to study what kind of diabetes education works best. We need to teach people that it's not enough to "watch your diet." As patients, we have to accept that our diet must change in major ways, and that these changes are not short term but for the rest of our lives. I think accepting that is one of the most difficult aspects of having diabetes. Years ago, when I went on a diet to lose weight, I thought that when I reached my goal weight I could then eat like everyone else. Of course if one has a tendency to gain weight, one can't.

In order for dietary changes to  have a major impact, we must accept that we can no longer revert to eating the huge amounts of food usually served at restaurants, and we can no longer eat a lot of cake and cookies. Even "healthy" fruit makes my blood glucose go too high, although I do eat limited amounts of berries. Yes, it's inconvenient, but so is losing your feet or going blind.

We need to teach people that that for most (there are always exceptions) fingerpricks really don't hurt very much. I always laugh when I read popular press articles about some new treatment that they claim will eliminate "painful insulin injections." Insulin injections are even less painful than fingersticks because you inject into areas that aren't very sensitive. The popular press probably doesn't realize that neuropathy is a lot more painful than insulin injections or fingersticks.

The key is real education. Maybe not in the first weeks or so, when most patients are still in shock, but as soon as possible. With real education, we can live a long time with this disease, maybe even longer than we would have lived had we maintained our old habits.

So the health care system should figure out how to teach patients how to test productively rather than just testing. Productive testing is a lot cheaper than treating complications.

With time, the frequency of testing can decrease as we learn what we can eat and what we should avoid. I've had type 2 for more than 20 years, and I had a continuous glucose monitor for about a year (thanks to a generous friend), so I have a pretty good idea of what works and what doesn't and now do only spot checks to make sure my control hasn't deteriorated. Without all this information I might now have serious complications that would be expensive to treat.

Testing works when done correctly. Let's find out the best way to teach it.

Can Beta Cells Be Restored to Normal Function?

Is type 2 diabetes caused, in part, by beta cells that are dedifferentiated?

I say "in part" because type 2 is a complex disease and many things may contribute a little to its cause. Today more than 80 genes or parts of genes have been associated with type 2 risk. Each one may contribute only a little to that risk, but the additive effect of all those small effects can finally add up to a large effect that precipitates full-blown diabetes.

A recent article suggests that type 2 diabetes results in dedifferentiated beta cells that are like immature cells before they differentiate into their mature insulin-producing form. (You can see the full text of the article here.) Because they are immature, they don't produce insulin, and hence the number of insulin-producing beta cells in the pancreas is reduced and you have difficulty producing enough to keep blood glucose levels from rising, especially with a large carbohydrate load.

Most interesting, however, is that the researchers at the Sahlgrenska Academy in Sweden found that the product of a gene called SOX5 controls this process. When the researchers decreased the activity of SOX5, the cells become less mature and less insulin was produced. Conversely, increasing SOX5 increased the activity of 168 genes and the production of insulin was normalized.

The researchers say that eating "unhealthy foods" and exercising too little can decrease levels of SOX5. Of course different people have different ideas about what foods are healthy, but we probably all agree that a diet of potato chips and soda is not healthy.

The researchers also found that the drug valproic acid, which is used to treat epilepsy and bipolar disease, increases levels of SOX5. It is known that people given valproic acid sometimes develop hyperinsulinemia, but the drug has not been studied as a diabetes treatment. Like all drugs, valproic acid has side effects, sometimes serious, and only more study would determine if the benefits for type 2 diabetes exceed the risks .

This new discovery is not likely to lead to a cure for type 2 diabetes in the near future, but it's encouraging that the defective (dedifferentiated) beta cells can be restored to normal function and can produce normal amounts of insulin again. Wouldn't that be nice.

Genes and Health

One thing that we see a lot on the internet is the person who lost a ton of weight with some diet and saw their blood glucose levels revert to normal. Then they write about their diet and imply that it will work for everyone.

But it won't. We need to find the diet that works for us.

I remember long ago, when I thought I was fat because I weighed 110 pounds (I'm small, and in college I weighed between 100 and 105), so I went on the Weight Watchers diet, which at that time was low-carb. A Hungarian colleague who saw that I was dieting said to me, "I hate to tell you this, but you don't have to diet to lose weight." I asked what you had to do. "Just give up sour cream," she said. I told her I didn't eat sour cream. She was aghast, as she put sour cream on almost everything she ate.

But that's typical of the "It works for me, so it must work for you" attitude. But we can have different genes that affect how we react to different diets.

Here is an article about a population in a remote part of Greece who eat a very high animal fat diet but have low levels of triglycerides and LDL. Now, low-carb diets reduce triglyceride levels, but they don't usually reduce LDL and sometimes make it go up. And as this wasn't a diet study, they didn't describe the participants' diets, but most Greeks don't follow low-carb diets.

So people from this area of Greece could tell others that their diet (whatever it is) reduced LDL so it should work for everyone. But it's apparently their genes, not their diet, that is important. Anyone who wishes to read the full text of the article can see it here.

Another recent article, this one in the New York Times, describes a similar situation, but in an American woman: very low levels of LDL and triglycerides. Both the woman and some of her siblings were found to have a rare gene that caused a lack of plaque in their arteries. One sibling with the gene had been a heavy smoker and had high blood pressure and type 2 diabetes but still lacked plaque in his arteries.

Again, it was no particular lifestyle that resulted in low levels of some lipids. It was their genes.

So if some diet or some exercise program or some drug makes your blood glucose return to normal, of course that's wonderful. But before proselytizing on the internet, remember that our genes may affect how we respond to any regimen. By all means, let people know the wonderful results that you got. But don't expect the same regimen to work for everyone.

Nutrition Label Errors

Nutrition labels are good for knowing how much carbohydrate is in the processed food you eat, if you eat any. Unfortunately whole foods don't come with nutritional labels.

But I've always considered the labels as approximations rather than exact numbers. They'll tell you, for example, that there's more protein than fat or whatever in some food, but they won't really tell you the exact amounts.

There are several reasons for this. First, they round the numbers off. So 3.49 grams would be listed as 3 grams and 3.5 grams would be listed as 4.

Second, they don't have to include anything with less than 5 calories or 0.5 grams. And this pertains to the serving size. So if you ate 4 servings, you could have a lot more of something than you thought.

Third, the manufacturers don't analyze every package they sell. One estimate was $750 per analysis in 1997, a lot for a loaf of bread, although they can also us nutritional tables to estimate the totals.

Finally, the nutritional content of the ingredients used to make the product can change from batch to batch and the manufacturer can't control that.

So overall, the labels are useful but not exact.

I recently came across a label that was just plain wrong. It was a sausage product and listed the ingredients as pork, water, wheat rusk, and salt and spices. So pork was the first ingredient (manufacturers are required to list ingredients according to amounts) but the label said it had no protein, as well as no carbohydrate. Huh? Pork is mostly protein and fat and rusk is mostly carbohydrate.

I telephoned the company and asked if maybe they just used pork fat and was told yes. Then I went back to the label and saw that it said one link had 150 calories, of which 50 calories were from fat. So what were the other 100 calories from. The water?

I called the company back, and now they admitted that the label was wrong. The sausage contained 4 g of carbohydrate and 19 g of protein. That totaled 146 calories, or 150 rounded up.

But what if someone used the carbohydrate and protein content to calculate bolus insulin. The calculated insulin would be incorrect, and they'd go higher than expected.

So that's yet-another reason it's so difficult for people who inject bolus insulin to keep their blood glucose levels level. I wonder how many other labels contain similar errors.

What this means is if you see a label that seems odd, don't assume it's correct. First check the numbers. Multiply grams of carbohydrate and protein by 4 and grams of fat by 9 to get calories. If they don't add up, call the company to find out. In someone without diabetes, thinking you were eating a little less carbohydrate and protein would not cause much harm. But when you're injecting bolus insulin, it could.

And because of rounding off, always take labels with a grain of salt.

Furthermore, remember that you can't always believe what someone who answers the telephone tells you. They could know about the issue, or they might not. In a large company, it sometimes pays to call twice to see if two different people have the same response.

Good control requires constant vigilance, but it's worth it in the long run.

Honoring David Mendosa

Diabetes writer David Mendosa died on May 8, only about a month after he was diagnosed with angiosarcoma in the liver. The diabetes community is mourning, with tributes at all the major diabetes sites in the United States and Europe as well as personal blogs.

David didn't want any kind of services. I was thinking of a fitting memorial for him, and I thought of this. He told me that he hoped his legacy would be his promotion of low-carbohydrate diets. He had been following one since 2007, with excellent results.

So one way to honor David would be to follow a low-carb diet for a month, or a couple of weeks, or just a week, if you haven't already been doing so. If you're already on a low-carb diet, you could make sure you're strict with the diet for a period of time to honor David. Let's face it, most of us do fall off the wagon from time to time.

Then, if you find the low-carb diet works for you, if you have better blood glucose levels and you discover that a low-carb diet doesn't mean deprivation, tell your diabetic friends. Ask them to tell their friends. Wouldn't it be wonderful if we could see an explosion in the number of diabetic people following low-carb diets in honor of David Mendosa?

A couple of caveats: if  you go suddenly from a high-carb to a low-carb diet, a period of adaptation is needed as your body builds up the enzymes needed to metabolize fat, and some people lack energy for a week or two. It's called the low-carb flu. If that happens to you, don't despair. It's temporary. Also, low-carb diets act like diuretics, so make sure you eat enough salt to retain some water.

Of course not everyone may be able to honor David in this way. For those who would prefer some other kind of donation, Caring Bridge, on which David, and then his friends and relatives, posted about his final journey is accepting donations in his memory, as is Tru Hospice Care Center, the hospice where he spent his final days.

David Mendosa

Many have heard already, but for those who haven't, David Mendosa, diabetes journalist, blogger, hiker, photographer, and so much more, has incurable cancer, angioscarcoma in the liver. He has recently been moved to a respite place with 24-hour care but may be able to return to his apartment if he can gain back some strength.

David wrote a chapter on Searching the Internet for my book, and it was a needed addition, as it wasn't something I had a lot of expertise with. David has been using computers since the early days and has a lot more experience with them than I do.

He was also one of the first people to have a diabetes webpage on the internet, and it has grown into a gigantic site. A friend will continue to maintain that.

He also has a blog describing various hikes, illustrated with photographs of birds and other wildlife. Many of his wildlife photos can also be found here.

David is a Buddhist and is very accepting of his situation. He has medication to control his pain. Some of his many friends in Boulder, and a niece, are supervising his care. He has become too weak to type, and telephone calls tire him out, but any who wish can follow his final journey on Caring Bridge. He has already received thousands of messages of thanks and love from all over the world.

David has said that he hopes his legacy will be his promotion of low-carb diets for people with diabetes. Even at the end, he is thinking of the well-being of fellow patients with diabetes.

Can a Drug Reverse Insulin Resistance?

A new drug seems to reverse insulin resistance in fat mice, who have normal blood glucose (BG) levels when taking the drug. Of course, we've all seen mice cured of diabetes kazillion times, but I find the approach in this case interesting.

To understand what the drug does, you have to understand a little about what causes insulin resistance, which I'll try to outline. When insulin binds to the insulin receptors on target cells, for example muscle cells, the insulin receptor phosphorylates itself. This means it adds phosphate groups. As a result, a complex chain of reactions is triggered, culminating with glucose transporters called GLUT-4 moving to the cell membrane. This allows glucose to get into the cell.

In general in the body, when something triggers a reaction, something else then slows down or stops the reaction so it won't get out of hand. For example, if you eat carbohydrate, which stimulates insulin secretion, BG falls, and that stimulates glucagon secretion, which keeps the BG from falling too low. If you get an infection, you produce chemicals that cause inflammation. But then if things are working properly, you produce chemicals that stop the inflammation when its job is done.

In the case of the insulin receptor, another enzyme called a phosphatase removes the phosphate groups that the insulin receptor added, and this slows the action down. So it made sense to look for compounds that would inhibit the phosphatase so that a little insulin would have a longer effect.

In the last half of the 20th century, scientists were investigating the effect of vanadium compounds on people with diabetes, as there were reports that it lowered BG levels. The vanadium seemed to inhibit a phosphatase. Unfortunately, because phosphatases are involved with many systems in the body and the vanadium wasn't specific to the insulin receptor, giving people enough of the vanadium compounds to be effective caused too many side effects, and interest waned.

There are many different phosphatases in the body, and what is new about this recent study is that they targeted on specific phosphatase, called LMPTP for low molecular weight protein tyrosine phosphatase. Then they looked for a small molecule that would inhibit LMPTP, and they found one. Giving this drug to the mice, they found no side effects.

One interesting thing is that blocking LMPTP only in the liver, via genetic studies, improved BG control. When one has type 2 diabetes, the liver seems to be insensitive to insulin. When BG levels are low, the liver produces glucose. When BG levels go up, insulin is supposed to stop the liver from producing glucose. But that doesn't happen in type 2. So a drug that could make the liver more sensitive to insulin sounds promising.

In fact, as I noted here, insulin resistance might be protective for the heart. So increasing insulin sensitivity in the liver while retaining it in heart muscle might be just what we need.

Science magazines have been describing this research as if the cure for type 2 diabetes has been found. Far from it.

Reversing insulin resistance might "cure" diabetes in people whose primary defect was insulin resistance, as is often the case in obese people. The studies were done in diet-induced obese mice. But it takes at least two defects to produce type 2 diabetes: insulin resistance and a defect in beta cells that makes them unable to produce the extra insulin needed to overcome that insulin resistance. In people with very little insulin production left, even reducing the insulin resistance might not be enough.

Also, as noted before, these studies are in mice, and often mouse studies don't translate into human treatments. Taking a drug from "proof of concept" to a safe drug for humans is a long process.

Nevertheless, I think this approach is interesting enough to be aware of. Perhaps it will develop into something very useful for type 2.

Do Diabetics Cause Global Warming?

People with type 2 diabetes have been accused of increasing health care costs. Now we're accused of contributing to global warming!

The first meme is that people with type 2 diabetes brought it on themselves by eating junk food and becoming overweight, with the weight triggering diabetes in those with a genetic susceptibility. What many don't understand is that junk food, high in both carbohydrate and fat, is cheaper than healthy food. When you have hungry children, you'll feed them what you can afford, and you'll eat the same thing yourself. This explains the apparent paradox that low-income people are often fatter than the rich, who can afford meat and fresh vegetables and fruit.

Now comes this:

"Meanwhile, an increased prevalence of diabetes may lead to more carbon emissions being generated by the health care systems treating those patients. 'Diabetes-related complications -- such as (cardiovascular disease), stroke and renal failure -- cost lives and money. Hospitalizations from such complications are also energy-intensive and increase (greenhouse gas) emissions,' according to the report."

This is from an article on diabetes and climate change. The main point of the article is that hotter climates result in more cases of diabetes. This makes no sense to me, as the Inuit have very high diabetes rates when they adopt a Western diet. 

Also, the story involves correlation, not causation. One can find all kinds of correlations that are meaningless. My favorite is the correlation between cheese consumption and fatal bedsheet-tangling accidents, from Tyler Vigan's book "Spurious Correlations." As time passes, temperatures increase. All sorts of other things also increase, like exotic pizza varieties and emmigration to Canada. Do these cause diabetes?

The article on climate change also contradicts another recent article that claims that lounging in 104-degree water for an hour results in better blood glucose control.

Does having patients in a hospital use significantly more energy than having the beds stay empty? True, if a room was empty, they might turn off the lights. But how about all the energy used by commuters driving an hour or so twice a day? (Not to mention all the fuel burned to get Trump to his weekend golfing expeditions to Florida.)

How about all the energy used by people watching giant-screen TVs? Working out at a gym instead of going outside to exercise in the fresh air? Using leaf blowers instead of raking their leaves?

What percentage of all these types of energy use would type 2 patients with complications add?

This kind of sweeping generalization can cause harm. And in our current political climate, in which some think it's OK to pick on the sick and poor, it could result in making diabetes care even more difficult. 

We have to stop blaming patients and focus on early detection and treatment of disease for everyone so no one gets complications.

Connected

Everything is connected.

No, this won't be an essay on meditation and the Oneness of Being. It's about the various organ systems in the body and how, the more we learn, the more we discover they're all connected and communicating with each other.

Physiology is usually taught around different systems: circulatory system, nervous system, skelatomuscular system, with individual organs within the systems. Of course you know they're interrelated, but one tends to think of them in isolation. The pancreas produces insulin, the liver produces bile, the stomach produces acid, and so forth.

However, as science progresses and we're able to detect things in tiny amounts, not just the large amounts that we could detect in the past, we're learning how complex it all is. For example, insulin is produced mostly by the beta cells in the pancreas. But smaller amounts of insulin can be produced by the thymus, liver, and fat and probably brain.

And various systems interact in ways that one might not think of until someone stumbles on them.

For example,  a recent paper shows that nerve growth factor (NGF), which is known to regulate the development of nerve cells, also helps to tell beta cells to release insulin. High blood glucose levels cause NGF to be released from pancreatic blood vessels, and the NGF then tells the beta cells to release insulin.

Another paper shows that the immune sytem uses gut bacteria to control glucose metabolism. An immune system molecule called interferon helps to fight infections. But a decrease in interferon-gamma can improve glucose metabolism. And when these interferon levels decrease, levels of a specific species of bacteria increase. The researchers think the bacteria are providing the link between the immune system and blood glucose control.

Another one  shows that gut bacteria can block the loss of appetite that often accompanies a stomach bug. They do this to promote the bacteria's transmission to other hosts.


Another paper shows that cutting the nerves to the kidneys reduces insulin resistance. It seems that the liver and the kidneys communicate to set glucose levels, and cutting the nerves to the kidneys makes the liver more insulin sensitive. One problem in type 2 diabetes is that because of liver insulin resistance the liver keeps pouring out glucose even when the level is already too high. Kidney function in the dogs used in the study remained normal.

Finally, a paper  shows that a brain hormone triggers fat burning in the gut. This hormone, called tachykinin, was identified 80 years ago as a peptide that triggered muscle contractions in pig intestines. It seems that this hormone is released in the brain in response to the serotonin level. Serotonin is related to mood, and low serotonin levels can cause depression. Also, some of the side effects of the drug metformin seem to be mediated by binding to serotonin receptors in the gut.

In this case, sensory cues such as food availability cause the brain to release serotonin. This tells certain neurons to release tachykinin. The tachykinin then activates a receptor in intestinal cells, and the intestines begin to burn fat.

These are just a few examples of how one organ affects another, and even our gut bacteria are involved in the communication.

There's more and more evidence that gut bacteria control a lot of things in the body. Wouldn't it be wonderful if some species could produce an  insulin-like molecule that was resistant to degradation in the gut? No evidence for that. I'm just dreaming.

Understanding all these interactions is not easy, but it means that everything in our bodies is important. We can't focus only on blood glucose levels and ignore our mental health or our intake of healthy foods that don't affect blood glucose directly but may nurture the good gut bacteria.

Our bodies know how to communicate in ways we don't yet understand. Our job is to be kind to our body so it can do its job as best it can. Enjoy life. Enjoy your friends. Enjoy your food. And stay healthy for a long, long time.

Good Glucose Control

We all know (I hope) that it's a good idea to keep our blood glucose (BG) levels as close to normal as possible. Deciding how close involves a lot of factors, balancing good BG control with enjoyment of life, economics, family preferences, and so on.

But it seems that more and more things are affected by our BG levels, which should give us an incentive to put a little more effort into good control.

It's been known for a long time that keeping BG levels close to normal can reduce the risk of the complications I call "the O'Pathy sisters": retinopathy, neuropathy, and nephropathy. But there's more recent evidence that high BG levels can contribute to Alzheimer's disease. It's known that people with type 2 diabetes are at increased risk of Alzheimer's.

Glycation apparently affects an enzyme involved in Alzheimer's, and "a glycation pattern similar to that observed in AD brain homogenates could be reproduced by incubating [the enzyme] MIF with glucose." You can see the full text here.

Note that this research is complex and preliminary. So it's not something you should lose sleep over. However, it's one more hint that controlling BG levels is important.

Another recent study links poor diabetes control to heart disease. Note that the headline links heart disease to diabetes. A more accurate headline would have linked it to poorly controlled diabetes, as the text says, "When diabetes is poorly managed, your blood sugar goes up and the amount of this protein goes down." Too little of the protein in question contributes to atherosclerosis.

You can see the abstract of the study here.

Finally, a third study showed that tighter glycemic control in type 2 patients with heart failure for just 4 months helped to preserve muscle strength and lean body mass. This was not what most of us would call tight control, as the final hemoglobin A1c level was 7.6, but that was lower than the 8.4 in the controls. The free full text of that paper can be found here.

These are just a few studies, but as more studies of other functions are carried out, it's likely that the effect of good control will be duplicated.

Good control isn't always easy in today's world, but it's worth the sacrifices.

Nutritional Information

I was at a local coop recently and saw a new brand of tortillas. They had only a few ingredients, mostly corn, so I looked at the nutritional information. It said they had only 1 gram of carbohydrate.

At first I was ecstatic. True, the tortillas were small, but if there was only 1 g of carbohydrate, it would be wonderful. Then I looked at the fiber content. It was 2 g. Huh? Fiber is indigestible carbohydrate, so how can you have more fiber than carbs?

If the product is made in Europe, this is possible. This is because the European system lists only digestible carbs as carbohydrate, so to get what we consider total carbs, you add the carbs to the fiber. In the American system, carbohydrate means total carbs, and to get digestible carbs you subtract the fiber.

This dual system can cause problems. The GG brand crispbread used to promote their product as having zero carbs because it was made in Europe and when you subtracted the listed fiber content from the listed carb content, you got zero. After many people complained, they fixed their label.

But these tortillas were made locally. That couldn't be the answer.

Back to the coop. I found someone in charge and asked about the label. I said regular tortillas that are about twice the size of the new ones have about 20 grams of carb, so I suspected this label was a typo and it should be 10. They went into the back room and stayed there for ages and then came out and gave some kind of an answer that made no sense, so I didn't buy the tortillas. When I got home, I emailed the company.

They replied that there was an error on the label, and the total carbs should be 11, not 1. They said they'd correct it, but the next week I found the same misinformation and no sign by the coop warning people that the label was wrong. In the meantime, were people on insulin injecting the wrong amount of insulin on the basis of incorrect information?

The tortillas I usually buy contain a mixture of grains and seeds, gluten (a protein), soy flour, and cornstarch. I get them because I think they have the best taste. The package used to claim 11 grams of carb and 6 grams of fiber, for 5 grams of digestible, or net, carbs. When I eat them (which isn't often), I eat only a half, which would be about 2.5 grams of net carbs. I can deal with that.

But when I recently bought a package, I noticed that they're now advertising 8 grams of net carbs, 12 grams of carbs and 5 grams of fiber. Of course 12 minus 5 is 7, not 8, but the difference probably has to do with rounding. So if I eat half of a tortilla, I'd be getting 4 grams of net carbs. Still not enough to send me into the stratosphere, but definitely higher.

When I scrutinize the label with a magnifying glass, I see that the order of the ingredients has been changed.  Have they changed their recipe? Or do they periodically test the product with slightly differing results each time? Or were the results falsified?

After the Dreamfields, and Julian Bakery scandals, one has to be cautious. When we find a product we like and buy it regularly, most of us don't scrutinize the label every time. But it's probably a good idea to double-check from time to time.

I've tested the tortillas I usually buy (Joseph's), and in small amounts they seem to be OK for me. That doesn't mean they'd work for you. We are fortunate in having meters to do tests of new foods. I tend to be lazy, and once I've tested something I don't keep retesting. This label snafu has reminded me that perhaps I should.