Back Again

I recently returned from a short trip to southern France, which was great. But unfortunately I and my traveling companion both returned with some kind of virus, which we probably got on the crowded plane, and I've been under the weather since then, not trusting my brain to write anything very worthwhile.

However, I'm finally seeing the light at the end of the tunnel and I've started tackling the stacking of 3 cords of wood. Maybe that's helping to cure me.

France was great for someone on a low-carb diet, as the French aren't as fat-phobic as most Americans. My first meal, in a small town along the coast, was the only thing they were serving at that hour (restaurants serve only from noon to 2 p.m., which we didn't know): a large assortment of delicious cold cuts, pates, and a green salad. I was in heaven.

Also, meals didn't come with huge mounds of mashed potatoes or rice, and corn. Of course all the meals come with bread, but I only tasted that. Some was delicious and some was mediocre, not as good as the stuff I used to make using Julia Child's bread recipe and King Arthur flour. A popular "dessert" in France is cheese, and I was able to substitute that for the sweet dessert that came along with full-course meals. Breakfast at the B&B included yogurt and "fruits rouges" (berries), cheese, and sausage along with bread and homemade jam, which I tasted.

But the woman couldn't grasp the concept of a LC diet and assumed I was gluten intolerant. When she finally grasped that I was diabetic, she then assumed I could eat other starches, just not sugar. Oh well. I survived.

I was stuffing myself with fatty cheeses along with other LC food, and when I got home I discovered I'd lost 2 pounds.

I think I need to get a grant to return to France to study this phenomenon.

Inflammation and Heart Disease

We all know that chronic inflammation is a bad thing, and many of us try to eat antinflammatory foods or we take supplements that are supposed to reduce inflammation.

But like everything in human biology, inflammation may not be as simple as some people think.

In the short term, inflammation is usually a good thing. It's what protects us from infection. When you cut your skin, it usually hurts and becomes hot and red. Sometimes it swells. This is a sign of inflammation. (Doctors sometimes refer to rubor, calor, dolor, and tumor, referring to red, heat, pain, and swelling.)

What happens is that the wound releases signals that tell the body to send white blood cells to the area to repair the damage, removing dead tissue and replacing it with new tissue. Local blood vessels dilate and become leaky, allowing fluids and white blood cells to exit and get to the wound. This results in swelling, heat, and redness.

Again, short-term inflammation is a good thing. It's chronic inflammation that is supposed to contribute to chronic diseases such as diabetes and heart disease.

But a paper published last month showed that among an obscure tribe in the Amazon, chronic inflammation is the norm, but heart disease is rare.

According to the scientists, the Tsimane tribe still live a traditional lifestyle, fishing, hunting and gathering, growing crops, and also growing and using tobacco, although they smoke much less than Americans who smoke. Most of them die from infections or parasitic diseases. About three-quarters harbor intestinal worms or protozoa. Their life expectancy at birth is only 43 years.

Chronic inflammation is prevalent, and they have high levels of C-reactive protein (CRP), which is often used as a marker of inflammation in the Western world. The Tsimane also have low HDL levels, which is supposed to mean high risk of heart disease.

But the Tsimane had almost none. Not a single adult, even the elderly ones, showed signs of peripheral artery disease, a sign of atherosclerosis. Peripheral artery disease increases with age in every other population studied.

The scientists reported that no one died of a heart attack during the 7 years that they were studying the population, which consisted of about 9000 people.

What this suggests is that chronic inflammation alone is not enough to trigger heart disease in a population living a traditional lifestyle. That means they're pretty lean and get plenty of exercise every day just obtaining their food. Their food is fresh.

Of course, many of them died from infectious diseases before they were old enough to be at higher risk of heart attacks and type 2 diabetes.

And one of the flaws of this study is that the authors do not indicate how many people were in each age group for which they reported data. There were only several hundred people in the whole samples (they did more of the simple tests like blood pressure than the more complicated ones), sometimes even less, and they report the results as percentages, so you have no idea how many people were in each age group.

Nevertheless, I think it illustrates one of the flaws to the American approach to health. Too many people focus on one or two factors, try to control those with drugs, and then expect chronic diseases to go away.

It doesn't happen like this.

Our entire lifestyle makes a difference. We can't pop antioxidant and anti-inflammatory pills and think the risk of cardiovascular disease will evaporate. We need to try to live more like the Tsimane, getting exercise as we go about our daily lives and eating real foods that are as fresh as possible.

One would hope that it's not the parasites that are protecting the Tsimane from heart disease. But that's also possible. Some people theorize that allergies in the developed world have risen because our parasite loads are so low. Maybe parasites also help our arteries. One never knows. As I said, human biology is never simple.

Another possibility discussed by the authors is that the Tsimane are somehow protected by genetic differences. In my opinion, that's always a way to explain the results when they don't come out as you expected they would.

This article also illustrates another issue: the effect of preconceptions by the scientists doing the study. Most people today think thin is good. They think eating a low-fat diet is good, especially if it's vegetarian.

And the title of this article is "Inflammation and Infection Do Not Promote Arterial Aging and Cardiovascular Disease Risk Factors Among Lean Horticulturalists." In other words, they're saying, "Well, these risk factors might not work if the rest of your lifestyle is healthy, like being thin and eating a plant-based diet."

They could just as easily have said, ". . . Among Tobacco-Using Hunters With High Parasite Loads," or "Well, these risk factors might not work if you smoke, eat meat, and have a lot of worms."

Many people read only the titles of articles, and perhaps the abstracts. So any biased generalizations made there can mislead a lot of people. It takes much longer to plow through the full text of an article. But sometimes it's necessary to learn what it really shows.

Some Progress

Many of us whine about doctors' lack of understanding of the diabetes research that we read. One reason for this knowledge gap is that current standards for medical education don't require that medical students be give significant instruction in some areas -- for example, statistics, nutrition, and disease prevention rather than disease treatment.

A fairly recent (well, OK, it was June 5; I get behind in my reading) editorial in the journal Science suggests that medical education in some of these areas may improve if the recomendations of the Association of American Medical Colleges and the Howard Hughes Medical Institute are followed. (The full text is free if you register.)

The report, titled Scientific Foundations for Future Physicians, says that "physicians must have a firm grounding in the biomedical sciences and understand their relation to the physical sciences and mathematics. For physicians to be prepared for inquisitive, critical thinking and lifelong learning, they should also be able to incorporate the methods of science into their practice, including skeptical and critical analysis."

Wow! Skeptical and critical analysis instead of listening to drug reps and reading medical magazine summaries. Wouldn't that be wonderful!

To achieve these goals, the groups recommend changing medical education starting in the undergraduate years: "Students should arrive at medical school prepared in the sciences, including some areas not currently required, such as statistics and biochemistry."

The idea is that if first-year studenst already have a grounding in the basics, then medical school can focus on more advanced concepts, for example, "the synergistic relationships among biomedical science, research, and clinical medicine."

They also recommend more emphasis in medical school on "the physical sciences and mathematics in biomedical research and clinical practice."

They also recommend assessing incoming students by their competency, rather than according to what courses they've taken. This should allow creative students to design their own ways of learning rather than forcing them into taking certain undergraduate courses.

Whether or not these recommendations will be followed of course no one knows. And even if they are, it will take a long time before physicians trained with the new guidelines -- better equipped to do critical statistical analyses of the latest blockbuster study of a new kind of cholesterol drug, for example -- constitute a significant percentage of the practicing physician population.

Even when they do, the problem that even a physician with a firm grasp of physical sciences, statistics, mathematics, and biochemistry as well as medicine and with a burning desire to do critical analyses still needs to have the time to do it. Not all physicans spend their afternoons on the golf course. Many of them are overworked.

Still, just the idea that people in the field are recognizing the deficiencies in the training of physicians is a good thing. Let's hope something comes of it.

Summary

For anyone not subscribed to Health Central, here are links to my most recent posts there.

Thinking Outside the Box is about how success in diabetes control often stems from being able to think outside the box, applying what you learn to your own individual physiology rather than following the cookie cutter advice you may get from your health care team.

Is Type 2 Diabetes Your Fault? discusses the myth that "you brought it on yourself." Needless to say, it stimulated a lot of discussion.

Finally, Avoiding Diabetes, is an allegedly humorous post about how to avoid getting diabetes. When I read the Comments, I wondered if some people had taken it seriously!

Absent

I'm afraid I've been absent lately, working through a Blogger Identity Crisis.

I've been thinking about how to deal with two blogs, this one and the one at Health Central. Initially, I was using this site for longer posts and writing shorter versions of the same thing for Health Central. But that came to be too much of a chore, figuring out how to say the same thing in a briefer way, and I found I was sometimes putting off writing something for just that reason.

So I've decided to abandon that approach and write brief, more general posts for Health Central, discussing the things people always want to seem to talk about, like diet, feeling overwhelmed, exercise, trying to lose weight, whether or not to take meds, etc. I also promised to write diabetes humor posts for them.

At this site I'll focus more on new research, both in-depth discussions and brief notes about research or other items that catch my eye.

I'll be assuming that anyone reading this blog is intelligent, already knows at least a little about diabetes, and wants to understand things in greater depth. I hope this works and I won't need to undergo another Blogger Identity Crisis!

Are Grains Healthy?

Several studies have shown that the so-called Mediterranean Diet is healthy.

This is not surprising, because as interpreted by various groups, it consists mostly of whole foods instead of a lot of processed junk, and you can show that almost any reasonable diet is healthy if you compare it to the "standard American diet" that is high in trans fat and processed carbohydrates.

Definitions of the diet do differ.

As interpreted by the American Heart Association, the key features of the diet include "high consumption of fruits, vegetables, bread and other cereals, potatoes, beans, nuts and seeds"; emphasis on olive oil in place of other fats; low to moderate consumption of dairy products, fish and poultry, with little red meat, and eggs only zero to four times a week; and low to moderate amounts of wine. They suggest that the diet may have too much fat.

A WebMD article says the Mediterranean Diet features "fresh fruits and vegetables, whole grains, nuts and seeds, legumes, seafood, yogurt, olive oil, and small amounts of wine for heart health."

A New England Journal of Medicine article described the diet as being "rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb," with olive oil and "a handful" of nuts as the main source of fat.

It's clear that different people interpret the "Mediterranean Diet" differently, although they all seem to agree that it is high in vegetables and low in beef. But there are many components to the diet, and it hasn't been clear if the healthy aspects of the diet (for people in general, not necessarily people with diabetes) are because of all the components, some of them, or maybe just one or two.

So when a statistical study of the components of the diet was recently published, showing that some of the Mediterranean Diet components didn't seem to have any effect on mortality at all, I was expecting an avalanche of blog posts commenting on this.

I'm still waiting.

Most of the blog posts and articles I found simply restated what the researchers had reported in their publicity releases, without comment.

The study showed that consumption of cereals, dairy products, and fish had very little effect on the mortality of the participants in the 8-year study in Greece. In fact, in this study, increased fish and seafood consumption slightly increased mortality, although this increase was not statistically significant. But we've been bombarded with messages telling us to eat more "healthy whole grains," fish, and low-fat dairy if we want to be healthy.

Of course, the authors of the study couldn't believe that whole grains aren't healthy, so they suggested that the lack of effect of cereals might be because they didn't separate out processed cereals and whole grains.

It's possible that's true.

It's also possible that when the results of a study don't fit the preconceptions, the authors find some reason to explain it. When the results are what they expect, they accept the study as proof of their pre-existing theories.

The study did show that both low alcohol consumption and high alcohol consumption were associated with a statistically significant increase in mortality compared with moderate alcohol consumption.

They said high consumption of vegetables, legumes, fruits and nuts (which for some odd reasons they lumped together), and olive oil and low consumption of meat and "meat products" (which would included luncheon meats) were associated with reduced mortality.

Then they said that none of these results were statistically significant. This lack of statistical significance is not mentioned in the press releases.

Because the researchers were expecting the results they found for vegetables, legumes, fruits and nuts, olive oil, and meat (although they were not statistically significant), they didn't try to interpret them. For example, "meat" is a broad category. It's possible that some meats such as luncheon meats are unhealthy and other meats such as lean beef are not. Maybe nuts are beneficial but fruits are not, but because they grouped them together, there's no way to know.

Although they called the diet Mediterranean, you notice that all these foods that showed benefit are real, whole foods that hunters and gatherers could eat, rather than processed garbage. You could just as well eat these foods and call it a Whole Foods Diet or a Traditional Diet or a Neolithic Diet. Hunters and gatherers probably eat all the meat they can get, but their hunts are not always successful. Olive oil is processed but in a minimal way. You could get the same monounsaturated fat by eating the olives themselves.

I'm not a big fan of any nutritional studies because most of them are based on food recall forms. I often can't remember what I had for lunch. There's no way I can remember what I ate for the past few days or the past month or so. Nutritional researchers claim they've tested the recall and it's reasonably accurate, but I'm not convinced.

Furthermore, we're all individuals. High fruit consumption might be beneficial for people without diabetes (certainly better than high banana split consumption), but a lot of fruit will raises the blood sugar of people with diabetes.

I suppose this study is a first step. Perhaps future studies will be able to refine these results.

In the meantime, follow the advice we patients so often give. Don't accept any diet as the "best diet" until you see how it affects you individually. If your nutritionist tells you to eat a lot of "healthy whole grains," try a few whole grains and see what it does to your blood glucose levels 1 and 2 hours after you've eaten them.

Then make up your own mind.

Propaganda

The readers of this blog are intelligent, so I don't think I need to comment a lot on this.

What's sad is that the people who write the headlines are so gullible. When I worked for a small daily newspaper and we got press releases, we always edited the BS out. Today, people seem to reproduce online what everyone sends them.

Science Daily does a lot of that. Sometimes you have to look hard to find out what's new in one of their articles, which focus on the names of all the scientists involved, the institution where they worked, the fact that the results were published in "prestigious" journals, and suggestions that this research opens the way for new drugs to treat diabetes.

It's nice that the pork researchers are supporting low-carb diets, but the constant barrage of specific food "cures" or "preventatives" for diabetes is making patients confused and cynical and harming them in the long run.

I've posted a satirical take on the same article here.