New Drug Treatment

 I haven't seen a lot of new treatments for type 2 diabetes lately. Most research seems to concern refining current approaches, but here is a study about a drug, phenylbutyrate, commonly prescribed for urea cycle problems, that seems to help in type 2 diabetes.

I confess I'd never heard of phenylbutyrate, as I haven't had urea cycle problems, but the drug helps to remove urea from the blood. It also seems to improve insulin sensitivity and the oxidation of glucose. No adverse effects were found in the cited study, but the study was short term.

The idea that phenylbutyrate affects glucose metabolism is not new. For example, this 2011 study suggests that it helps reduce lipid-induced insulin resistance and improves beta cell function.

Phenylbutyrate works by breaking down branched-chain amino acids, which are amino acids that instead of having straight chains, have branched chains. They are leucine, isoleucine, and valine. How this affects glucose metabolism is not clear.

In other words, phenylbutyrate may help with glucose metabolism in type 2 diabetes, but it's not a miracle cure. Nevertheless, if you know it might be helpful, you can be alert to other news about this prescription drug.

Type 2 diabetes is such a complex disease, with genetics, lifestyle, and current food growing and processing all having effects. We will eventually figure it all out if we don't destroy the planet first. But it's going to take a long time.

YMMV Again

 Another article highlighting the fact that we're not simple machines, that what works for one person may not work for another, has hit the popular press.

 This time it's not diet but exercise they're speaking of. Some people, despite sticking closely to an exercise program, see no improvement in their fitness. They're called nonresponders.

 Unfortunately, most health care providers don't have the time to investigate your lifestyle closely, so if you are supposed to go on an exercise program but fail to improve your fitness, they probably think you're "cheating," and not exercising as much as you're supposed to. In some cases, that's probably true, but in others not. I wish I'd be prescribed a napping program, which I'm sure I'd follow religiously, but that has yet to happen.

 The results described in the cited article at first sound depressing. Who wants to lift weights for an hour if it doesn't do anything beneficial. But then, if you read the whole thing, you see that when one type of exercise doesn't work for a person, another type will. "No one had failed to respond at all. Every man and woman had measurably improved his or her fitness in some way after one of the sessions, if not the other."

So the secret is to try different types of exercise to see which seems to work best for you, and also to see which types you enjoy enough to keep doing. I hate running, because I have the wrong build for that, but I enjoy walking, and I don't mind lifting weights. So I never plan to run.

One problem with various studies is that their conclusions are usually based on the average results. A group does X and 90% of them improve factor Y. The headlines will all say something like "X improves Y," but you might be in the 10% who don't improve. Keep that in mind if you try it.

The chances are good that you will improve factor Y, so it's certainly worth trying. But if it doesn't improve, don't despair. Try something else.

 

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Obesity as a Disease

 Many people think of obesity as a moral failing. They think that obese people simply have no self-control, and if they did they would be slim.

But that doesn't explain why you can have two people who eat exactly the same things and one is skinny and one is fat. I once read of a mother who had two daughters, one fat and one thin. She told her doctor that one daughter loved vegetables and the other one loved doughnuts and pizza. The veggie lover was the one with the weight problem.

Many of us already know that obesity isn't a moral failing, but sadly some health care practioners do not, and blaming their patients for their weight problems can cause even more harm. Luckily, they do not all think this way. Here is a practitioner, Dr. Lee M Kaplan, who told healthcare professionals at a recent virtual meeting that obesity isn't a moral failing but a disease caused by dysfunction of the metabolic system that regulates body fat, in the same way that immune dysregulation can lead to asthma.

Now, if you're thinking of mildly overweight, for example the "freshman 10" or "freshman 15," the amount of weight that some college freshmen are said put on in their first year, that's not apt to be a disease but stress or a more fattening diet than they had at home. If it were a disease, they would have arrived fat.

We're talking about real obesity, a BMI (body mass index) of 30 or more, the kind that really doesn't want to leave no matter how much the person diets. Or if they starve themselves into losing, the weight just returns with time.

No one really understands what causes this metabolic dysfunction. When the hormone leptin was discovered in 1994, some people thought the problem was solved. But it wasn't. Obesity, like type 2 diabetes, is undoubtedly multifactorial, and because of this, different people have different reasons for the problem and different responses to treatment.

A few people who lack leptin can transform from obese ravenously hungry constant eaters to slim normal eaters when given leptin. But those cases aren't common. Most of us will have to find a way of eating that lets us slowly lose the excess weight or resort to weight-loss surgery.

There is no one perfect weight-loss diet. If you're diabetic, I think the best place to start is with a low-carb diet, as this controls blood sugar levels as well as weight. Then you can tinker with the diet to get something you enjoy and you can follow for years. 

On your journey it's important to realize that your obesity is not your fault. You have a disease. Try to find a health care team that understands this and is willing to work with you to find the best treatment for your particular physiology.

It is good that Dr. Kaplan is trying to educate health care professionals. Let's hope that in the future we will all be educated about the complex factors controlling weight.

Too Many Carbohydrates

 Most of us with type 2 diabetes don't stuff ourselves with huge plates of spaghetti, but some nondiabetics and even some people with diabetes do, sometimes because they're still brainwashed by the low-fat diet fad of the 1990s. And when you limit fat, you eat more of other things, especially carbohydrates, which are both cheap and filling, at least for a short time.

 When I was diagnosed with type 2 in 1996, I started off following the ADA-recommended low-fat diet. I did lose weight on this diet, which limited calories as well as fat, but I was ravenously hungry 24 hours a day. I finally decided I didn't want to live if I was hungry all the time, so I switched to a low-carb diet, even though the traditional dieticians said the diet would kill me. My hunger immediately went away. The weight loss also slowed down.

The dieticians also said no one could stick with this diet long term. I don't know if 25 years qualifies as long term, but so far the diet hasn't killed me.

Some people continue to criticize low-carb diets, but a recent study showed the dangers of high consumption of carbohydrates. They found that high consumption of carbohydrates reduces the level of antioxidants in the body, especially in those who are overweight. The study was done in nondiabetics.

Here is the journal article. You can download a 52-page full text if you like.

Now, there are populations that have always had high-carb diets, like the Kitavans, who eat lots of yams, not lots of croissants, and they're pretty healthy. Have their bodies adapted to their diet to produce more antioxidants? No one has studied this, but the body is often able to adapt to dietary changes.

Also notice that the article refers to overconsuming carbohydrates, not just having the occasional piece of bread. So the research probably doesn't have much practical application for now. But it's interesting. And it's another small piece of evidence showing the advantages of low-carb diets, which are demonized by some.

 

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Life Is Unfair

This certainly does seem unfair. You do the right thing and exercise, and your body figures you're going to do it on a regular basis and so reduces the number of calories you burn at rest to make sure you don't get too thin. This means that if you don't exercise on a regular basis but eat the same as before, you're at risk of gaining weight. Bummer! 

But in the environment in which we evolved, very few people were overweight. Getting enough food was the problem, not getting too much of it. So we evolved to not waste energy when possible. Every calorie was precious in those times, and even today in areas of famine.

So, because it's unfair, does it mean we should just give up and stop exercising? Of course not. Most of us are so much better off than people in the rest of the world that a few metabolic injustices aren't that important.

When I was first diagnosed with type 2 a friend who was diagnosed at about the same time asked me, "Do you ever wonder 'Why me?' "

I said no, just as when a close friend died from a brain tumor I didn't say, "Why her, not me?"

Life is unfair, and we can only try to make the best of whatever life we've been given. I try to learn as much as I can about type 2 and then share information with others, although that's getting harder and harder as research seems to be increasing exponentially and the complexity is also increasing so that if you don't have a degree in biochemistry it's difficult to understand.

Some research I don't even try to blog about because it's so complex, sometimes over my own head.

But I keep reading, in the hopes that some of it will be useful to others.

Diets

 If you're overweight and feeling that it's all your fault, the headline of this article, Scientists Claim that Overeating is not the Primary Cause of Obesity, should remove some of the guilt. The full text is here.

Of course, most people reading this blog already know that overeating is not the main cause of all cases of obesity, but it's nice to have attention called to that fact.

Weight control is complex and depends on numerous factors including genetics, income, access to physical activity, social class, what our friends are eating and a need to fit in (especially among adolescents), what kinds of foods are available in our neighborhood, and many more-subtle factors.

Even without rigorous studies, we all know families in which everyone is skinny, despite having voracious appetites and other families in which everyone is fat despite eating sensibly. Genetics clearly plays a role. However, that doesn't mean weight loss is impossible. It's just harder than it is for people born into thin families.

Income has a big effect on weight control. Rich people can afford to buy meat and fresh vegetables, with fresh fruit for dessert, whereas poor people may be forced to eat mostly cheap starches swimming in oil. I once spent the summer in Paris with a rich classmate who was overweight. They had a chef who prepared delicious low-calorie foods for her, and she also had a masseuse who massaged her every day. I'm not sure how much the massages helped her lose weight, but she was so terrified of the woman that she starved herself and did lose some weight.

Sadly, she kept losing and regaining weight and eventually died from a heart attack at a relatively young age.

People who live in dangerous neighborhoods aren't likely to do a lot of recreational walking or running even if they want to.

Social class dictates what weights are acceptable. You don't see a lot of obese people in the society pages.

So the causes of overweight are myriad, and so are the best ways to avoid or reverse obesity. There is no best diet for everyone, just as there is no best exercise. Losing weight is difficult, very difficult, and we all have to find our own path. What works for someone else (not counting starvation, which works for everyone) may not be the best for you.

Lately, I've started losing weight without trying. I think it's because I'm bored with the foods I've been eating for the last 20 years, so I only eat enough to dull my hunger and then I put the rest in the fridge to eat at the next meal. I hope the lack of appetite isn't a sign of some disease. There are worse things than being overweight.

 I'm also shrinking, and I just hope I don't just shrink into nothingness. I see a 2-inch tall me, but very thin. Is that what I really want?

 

 

Einstein

Einstein has little to say about diabetes. Or maybe he does, in addressing questions like how we come to solutions.

Deric Bownds, an emeritus biology professor at the University of Wisconsin, has reposted some quotes from Einstein, and those concerning how we solve problems could apply to anyone trying to decipher the very complex disease we call diabetes. For instance,

"I think 99 times and find nothing. I stop thinking, swim in silence, and the truth comes to me."

Our brains keep working on problems even when we're not consciously thinking about them, one reason for the old adage "sleep on it." The problem that seemed unsolvable when you went to bed is clearer when you wake up.

Deric and I were teaching fellows in an introductory biology lab many eons ago. 

Anyone with diabetes has to solve many problems every day. "Should I eat that?" "How much should I eat?" "Can I skip my daily walk if I'm going to be roaming the aisles of the gigantic supermarket?" "Are there many carbs in that dish a friend is serving me, and is it impolite to ask?"

Maybe we need to spend more time swimming in silence.

Insulin Resistance: Mechanism

 We all know that insulin resistance (IR) is one of the main causes of type 2 diabetes. Many people with type 2 can produce some insulin, but it's just not enough to overcome the IR.

What causes this sluggishness? No one knows for sure.

A recent paper suggests that the key is ATP, the energy-containing molecule that is produced when you eat and can then be used to drive other reactions in the cell.

I always thought ATP was good to have, and the more ATP the more energy. But this author (Jianping Ye) suggests that too much ATP can cause what he calls overheating. In the winter, it's nice to get heat from your furnace; the heat is nice, but you don't want it to get up to 100 degrees. He suggests the same is true of ATP.

Ye says that when you have too much ATP, the cells become insulin resistant to prevent overburdening the cells with too much energy. Hence, cells are insulin sensitive under conditions of energy deficiency and insulin resistant when there's an energy surplus.

So insulin sensitivity/resistance is an index of energy demand.

Interestingly the drug metformin inhibits ATP production.

He notes that as we age, energy demand decreases. If you're 95, you're not apt to go out and play three sets of tennis, so you need less food.

We all know that, but many of us eat portions determined by habit rather than by need. Restaurants don't serve meals adjusted for need. Everyone gets the same thing, although of course someone who just spent the day mountain climbing can order more than someone who spent the day reading. But how many of us act on that? In our "clean plates club" society, we often eat more than we really need. This is especially true in people who eat all their meals out.

In support of Ye's hypothesis, it has been known for about 60 years that elevated ATP is a risk factor for insulin resistance. But he says its importance hasn't been appreciated because of technical difficulties in measuring ATP in various tissues.

Interestingly the drug metformin inhibits ATP production

So is one solution to the diabetes epidemic simply to eat less? Sadly, that's often difficult to do. If  you eat out a lot, one solution is to get a tightly sealed container, carry it in a nice handbag, and use it to take at least half of the meal home without carrying around those awful plastic things restaurants usually put leftovers into.

We need food. We need energy. We need ATP. But as with many things in our lives, we just don't need too much.

ACCORD Revisited

 In 2008, the results of the ACCORD "landmark" trial were published and were interpreted by some to mean that people with diabetes shouldn't get their blood glucose (BG) levels down to normal or below. This is because those whose diabetes was treated aggressively in this trial had greater mortality than those with less aggressive treatment.

Sadly, some physicians used these results to urge their patients to have higher hemoglobin A1c levels. Patients were reporting on diabetes lists that their doctors told them that their normal A1c levels were too low and they should get them up.

Careful analysis showed that in fact, the patients with increased mortality were those who used very aggressive treatment but despite this did not lower their A1c. So they had harm from the treatment without compensating benefit from lower BG levels. Those who got aggressive treatment and did lower their A1c got benefit.

"It has been recognized that patients treated intensively in ACCORD who attained a lower HbA1c had reduced risk of death compared to those treated intensively with little HbA1c reduction."

Unfortunately, these analyses did not get the wide publicity that the initial results did, so many busy physicians may not have read about them.

Now a new analysis of ACCORD  says that there is a subtype of type 2 that shows real benefit from intensive glycemic treatment.

Now, most patients will not be given genetic tests to determine if they are in this subgroup. And there might be other subgroups that these researchers did not study. However the analysis suggests that you should not accept without question the results of big studies of diabetes patients as applying to you. They probably will, but they might not.

If you're a physician, you need to work on the assumption that big trial results will apply to most of your patients, so you start by following their recommendations. But most of us aren't treating others, so what we really care about his how some approach will affect us.

This means we should test as much as we can, not just BG levels but other factors that affect our health, to see what works for us. We're fortunate these days because if we can afford it, we have access to a  lot of tests.

Stay informed. Read about the latest big studies. But read them critically and try to figure out if they make sense for you. Try what they suggest is beneficial, but don't apply the suggestions blindly.

In the long run, we have to be in charge of our health.

Self-control

Some time ago, in an online suport group I started, one woman said her biggest problem was that she couldn't stop eating potato chips after she'd had one.

I knew she lived alone, so I asked why she bought potato chips, and she said, "Because I like them."

I think this is a common problem. 

The most important thing you can do when you're diagnosed with type 2 diabetes is to accept that your life is going to have to change if you want to control it. Of course, that's not easy. If you live with others who aren't diabetic, you're probably going to keep buying food you shouldn't eat. That's difficult.

It should be easier if you live alone. If something makes your blood glucose spike, keep it out of the house. I suppose there are people with iron self-control who can eat just one bite of a cookie and no more. I'm not one of them.

Once before I got diabetes, I was on a diet to lose weight. I was avoiding sweets and they no longer had any appeal for me. Out of curiosity, I went into a bakery, and nothing looked good, but I bought a bag of cookies anyway to see if they'd taste good. I planned to eat just one, but as soon as I did I craved more and ate the whole bag.

So much for that approach. After that I just kept the cookies and pies out of the house. If I learn that a comet is headed for the earth and will destroy all life, I'm not going to call my nearest and dearest to say good-bye. I'm going to the bakery to buy a blueberry pie, and then I'm going to eat the whole thing.

Just my luck the comet will change course and we'll all be saved and my blood glucose will go over 500. Oh well. It would be fun while the pie lasted.

But until then I won't make pies, and I won't buy them. It's easier than trying to have self-control.

Obesity Benefit

 Most of the news about people who are overweight or obese is bad. We see a constant stream of articles saying obese people are at higher risk of this and they're at higher risk of that.

But here is an article saying that obesity protects you from dying from severe bacterial infections. In this study, 26 percent in the normal weight group were dead within a year. The corresponding figures in the groups with higher BMI were 9-17 percent. Full text is here. The authors note that although obesity is associated with higher survival in bacterial infections, it's associated with lower survival in viral infections. The authors have no explanation for this.

Other studies have shown similar effects, and this is called the obesity survival paradox.

 So does this mean we should all stuff ourselves with pies and cakes, hoping we'd become obese and thus have a better chance of surviving a bacterial infection? No. For one thing, we don't know we're going to get a severe bacterial infections, and for another, too many negative side effects are associated with overweight.

So as so many authors conclude, "more studies are needed."

 

CGMs in Nondiabetics

 As continuous glucose monitors (CGMs) become a little less expensive, they're starting to be used by nondiabetics as a way to understand their responses to different foods. You need a prescription, but they're not difficult to get.

On one hand, it annoys me that well-heeled nondiabetics are able to use CGMs when many people with diabetes cannot. On the other hand, the more we understand how foods affect our blood glucose (BG), and the more the general public understands this, the more pressure there will be on the food industry to produce healthy foods that don't raise BG.

Some physicians are even using CGMs themselves so they have better understanding of how foods affect their diabetic patients. This is good.

 If you're interested in this, search on "CGM nondiabetic" and you'll get a lot of hits. Following are a few samples.

Here is a formal study from 2007. Glucose was measured by means of a catheter inserted at the study site. Note that they found BG levels went highest after breakfast, but many people continue to eat carby breakfasts.

 This one is a blog by a "nutritional therapy practitioner" with PCOS (polycystic ovary syndrome). PCOS does increas the risk of developing type 2 diabetes, but it hadn't yet developed in the blogger, Emily Blasik. It was interesting in part because of some of the confusion about carbs. For instance, she mentions eating a "zucchini crust pizza," after which her BG spiked. But if you read the text, you see that the pizza crust included tapioca starch, which has a very high GI. In fact, if you look at the incredients of "cauliflour pie crust" in your supermarket, you'll find that they add flour, most likely to get the crust to stick together.

Here's a blog by a nondiabetic CDE, LilyNichols. It's long, with references and 149 comments currently, but if you have the time you might enjoy it, as she's very thorough, so there's something for everyone.

This blog is by a dietition, Kara Collier. The high-stress day is especially interesting.

And for athletes, especially men, this one in Men's Health, focuses on the effect exercise has on BG. Interestingly, some of the nondiabetic participants found what people with diabetes have found for years: you can eat exactly the same thing at the same time of day and get different results.

Finally (in this blog; there are zillions more blogs about CGMs in nondiabetics), here is a CGM site by a physician.

 What most of the bloggers learned was something people with diabetes have known for a long time: it's carbohydrate that makes BG go up, and "healthy" foods like oatmeal with milk are among the worst offenders, whereas "unhealthy" foods like bacon and eggs keep BG more level. Several also found that strenuous exercise made BG go up (I've always found that). It makes sense, because if your body senses that you're needing more energy, it's going to try to produce extra energy as glucose even if you're fat adapted.

Perhaps when people realize that old-fashioned foods like meat and cheese are kinder to BG levels than pasta and rice, we'll see new food trends. One problem is that in some parts of the world, people can't afford a lot of meat, and they may not be able to eat dairy because as adults they don't have the enzymes that break down lactose. Perhaps one reason they were able to tolerate high-grain diets in the past was because they didn't have enough food to overeat. Or perhaps the high-grain diets did make their BG levels go up but they got a lot of exercise and didn't live long enough to see the long-term effects of the grains.

 Whatever, the study of BG levels in nondiabetics may give us new ways of thinking about BG levels in people with diabetes.

Fructose and Triglycerides

 When I was diagnosed with type 2 diabetes in 1996, it was thought that although fructose, which is half of sucrose (table sugar; the other half is glucose), didn't raise blood glucose (BG) as much as glucose, it could have an effect on triglycerides (fats).

One source said that although fructose didn't affect blood triglycerides in people with unimpaired glucose tolerance, it could raise them in people with defects in carbohydrate metabolism (e.g., people with diabetes) even at relatively low levels of fructose intake.

Yet despite this, products sweetened with fructose were sold as diabetes friendly. We have to remember that factors other than BG levels are important for health, so higher triglycerides are not benign.

A recent study shows that consumption of fructose or sucrose, but not glucose, doubles the synthesis of triglycerides in the liver. The full text can be found here. Note that this study was done on "healthy lean men." Results might be even more pronounced in those with diabetes.

Increased fat production in the liver is a significant first step in the development of common diseases such as fatty liver and type-2 diabetes, so this is important.

Some people say that diabetes isn't caused by eating sugar. Are they wrong?

Asian Glycemic Index

Many people no longer use the glycemic index or the related glycemic load, which rate carbohydrate foods by how quickly they raise blood glucose levels, because they focus on reducing the consumption of carbohydrate foods regardless of their glycemic index. But some people still do use this index.

And now there's a list of Asian foods with glycemic indexes. There's still no African index. But the Asian index should be useful for people who eat a lot of such foods and wonder about their effect on blood glucose levels without testing for themselves.

Long ago, when I gave up regular noodles and didn't yet know about shirataki noodles, I discovered I could eat small amounts of cellophane noodles, also known as glass noodles or bean thread or mung bean noodles (the ones not containing other starches), without a big effect on my blood glucose levels. They're included in this Asian list and have a glycemic index of 28, which is relatively low.

So my self-testing was correct.

Metformin and Supplements

 A recent study suggested that the supplement goldenseal interferes with the ability of metformin to control blood glucose levels.

I doubt that a lot of people are using goldenseal, but this study illustrates a general problem: Everything can interact with something else. That means not just drugs and supplements or drugs and other drugs, but drugs and foods or drugs and exercise and probably even drugs and your mental state.

For this reason, whenever you try something new, you should add only one new thing at a time, so if there is an effect, you know it's due to that new thing. If there's no apparent change in anything you can then try something else.

Vermont participates in the HomeMeds program for older adults, and although I hate to admit I'm an older adult, I took part. A nurse came to my house (this was before covid-19) and took a list of all my drugs and supplements. She then took the list to a pharmacist, who made sure there were no bad interactions. The pharmacist didn't see any.

I'm sure you can do the same yourself by making a list and taking it to a pharmacist, or running it through an online site like this. Of course if you're taking a bunch of obscure herbs, the online site might not include them. A pharmacist might be able to research them if willing to take the time.

The important thing is to be alert for any changes in your health when you try something new, even a new vegetable you just found at the grocery store.

Everything can interact with everything else. Sometimes the result is good and sometimes it's not so good. Most interactions are trivial. We just need to notice the major ones.

CGMs for Nondiabetics

 The New York Times today had an article describing the experience of a nondiabetic who tried a continuous glucose monitor. (CGM).

 It's interesting, but it bothers me that affluent nondiabetics can get CGMs when many people who have diabetes cannot because their insurance won't cover them and they can't afford to pay out of pocket. Many people with diabetes probably don't even realize that CGMs exist, not to mention their benefit.

I once met a woman on an elevator in a medical building, and she said she had type 1 diabetes. I asked if she used a CGM and she didn't know what that was.

Today, many people with type 1 get insulin pumps along with CGMs. Type 2s less so. But I've always felt that people with type 2 should use a CGM shortly after diagnosis so they can learn what foods make their blood glucose go up. Different people have different reactions to carbohydrates. Some can eat rice with no problem but potatoes make their blood glucose levels soar. Others the exact opposite.

I'm sure that in the future CGMs will become common for type 2s, and insurers will learn that controlling blood glucose levels means fewer expensive complications, so they'll be willing to pay for CGMs, maybe not all the time but periodically to check and recheck.

I hope that future isn't too far off.

Scientists to study YMMV

As diabetes patients, most of us understand the concept of YMMV, or "your mileage may vary." A diet that works great for someone else may not work well for you.

 An Israeli study a few years ago showed this to be true. A food that raised blood glucose in one person might have no effect on another.

Now NIH researchers have planned a study to test this concept in 10,000 Americans. The study will start recruiting participants by January 2023, so don't expect results in the near future.

In the meantime, keep testing before and after meals as much as you can to find out which foods are best for you. If you can afford it, a continuous glucose monitor is a good way to document this. Most insurance won't pay for the CGMs for type 2 patients, but I think the information you can get is worth the cost. I occasionally wear one, and it costs me $63 for two weeks (Freestyle Libre).

 After you learn what diet works best for you, you can cut back on the testing somewhat, although it's good to do spot checks to make sure your blood glucose isn't trending up.

New Theory about Saturated Fat

We all know that dietary saturated fat is bad because it raises blood cholesterol levels, right?

Well, maybe. 

When we get lipid tests like LDL, HDL, and so forth, they draw blood and then measure these things in the blood. They don't measure them inside the cells, or in the cell membranes. And a new study suggests that high blood cholesterol might simply reflect the membrane's need for cholesterol.

Unsaturated fats make membranes more fluid; saturated fats and cholesterol stiffen membranes. What we need is a balance between the two states, and the body is usually pretty good at knowing what we need.

The new theory suggests that when we eat saturated fats instead of unsaturated fats, the membranes don't need a lot of cholesterol to prevent the membranes from being too fluid, so they don't take the cholesterol out of the blood, and hence blood cholesterol levels are higher.

In other words, blood cholesterol levels can fluctuate according to how much cholesterol is needed in membranes. "The effect of dietary fats on blood cholesterol is not a pathogenic response, but rather a completely normal and even healthy adaptation to changes in diet" says the lead author of the study.

The authors call this the homeoviscous adaptation to dietary lipids model. They note that as of now, this is only a theory that needs to be verified. And they distingish between elevated cholesterol levels from dietary changes and elevated cholesterol levels from metabolic disturbances such as inflammation and insulin resistance.

You can read the abstract of the article here. Unfortunately, the full text is behind a paywall. 

Subtypes of Type 2 and Prediabetes

 A recent study has suggested that there are six subtypes of prediabetes, with each subtype having different risks of progressing to type 2 diabetes and different risks of various side effects. The study, which was begun 25 years ago, grouped people into clusters depending on factors like blood glucose levels, liver fat, body fat distribution, blood lipid levels, and genetic risks.

They found that people in different clusters differed in insulin secretion and insulin action in addition to the factors listed above.

People in three of the clusters have a low risk of diabetes. People in another cluster produce too little insulin. Those in another cluster have kidney damage even before overt diabetes is diagnosed.

It would be nice to know what cluster a newly diagnosed patent was in, but many patients today have difficulty getting even basic tests, and its unlikely they could get all the tests required to classify them. Even the authors concede that "our clustering aproach is not designed to provide definitive subphenotypes for individual patients in a clinical seting." However it would be useful for researchers.

I suspect that in the future they'll find even more subtypes, but for now this is a start.

Patients can differ a lot in both physical characteristics and economic and emotional ones. One patient might be willing to go on a strict low-carb diet, and another couldn't tolerate that, or couldn't afford it. Treatment may depend on a particular patient's situation, and good doctors take that into account agaialready, rather than relying on a cookie cutter approach.

The full text of this study, in preprint form, can be found here. 

This is not the first time researchers have tried grouping patients into clusters. Other researchers have grouped people with type 2 diabetes into five subgroups, using GAD autoantibodies, age at diabetes onset, HbA_1c, BMI, and measures of insulin resistance and insulin secretion.

They found that the group with severe insulin-deficient diabetes had increased risk of retinopathy and neuropathy, whereas the severe insulin-resistant diabetes group had the highest risk for diabetic kidney disease and fatty liver

Again, most physicians will probably not have the resources to measure all these parameters for every patient, but again, it's a start.