All posts in Medical Diseases

Is surgery really the best option to treat obese diabetics?

In 1993, MTV’s new hit reality show The Real World: Los Angeles was in its second season.  During that season Tami Akbar Roman famously had her jaw wired shut in an attempt to lose weight.  From her perspective it was a simple enough idea, if she can’t eat food, then she should lose weight, right?  It was one of the first of a long line of reality show TV stunts that are all too familiar today.  Twenty three years later, I’m sad to say that a panel of international experts on diabetes has recommended something very similar as their preferred treatment for obesity in diabetics.  They go on to extend these surgical recommendations all the way down the line to diabetics with class I obesity (BMI of >30kg/m2) who have poor glycemic control.  That means a 222lb man standing 6 ft tall with poor blood sugar control on medications should consider bariatric surgery as his next best option.

Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations

Even in 1993, long before I started my medical training, I understood that physically preventing food from entering the body was a poor way to lose weight and become healthier.  It must start with a change of heart and an improvement in understanding.  A point that Tami was happy to prove for me as she attempted to take all her normal foods and puree them through a blender.  I seem to remember a cheeseburger slurry showing up during one of the episodes.

That’s the story with so many patients who undergo surgical weight loss.  Without the change of heart and change of understanding, the recidivism rate is quite high.  Lest you think I’m pointing a finger, let me explain that I understand their dilemma all too well.  I teach nutrition.  I treat diabetes.  I see the heartache and pain associated with blindness, kidney failure, amputation, and neuropathic foot pain and yet I still really like Double Stuf Oreos. “Like” is too soft a word.  I long for Double Stuf Oreos.  Every summer I’m tempted mightily by these wonderful little chocolate promises of happiness.

Don’t give up what you want most for what you want now

What are we to do?  How do we change?  How can we go from surgically altering our bodies in an attempt to irrevocably force limited food consumption to choosing life-giving options that promote our wholeness physically, emotionally, and spiritually?

For me, I believe it starts with a change of my heart and a change of my understanding.  I’ve learned more about nutrition in the last 15 years then any other medical topic.  My understanding has been refined through trial and error in my own life as well as when I work with patients through their struggle.  This self-education was fostered by friends as early on as medical school and continues to this day as my fellow Trinity physicians and clinicians challenge me with new research.  I love being part of a practice culture that works so hard with individual patients in their understanding of how nutrition shapes health.  The continual education and re-education of nutrition has been the easy part for me.

Love… faithfulness, and self-control

As Paul fought against Jesus’ calling in his life so too does my heart still kick against the goads of my soul.  I am coming to believe more that for us to truly change our behavior in nutrition, among many other areas of lives, we must first change our heart’s desire.  I recently heard it said that you “Don’t give up what you want most for what you want now”.  Similarly, in Galatians 5:22-23 Paul pens the fruit of the Spirit as love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control.  I believe that if my love is rightly fix on something worthy of that love, if what I want most in my life is the growth of that love relationship, then the natural outcome will be the fruit of the Spirit including faithfulness and self-control.  Faithfulness in choosing well when someone else’s interests are at stake (ie, how I parent, how I practice medicine, how I treat my neighbor, etc…) and self-control in choosing well when only my own interest’s are at stake (ie, what I eat, how I exercise, my personal time, etc…).  (Notice that fruit is singular not plural.  That’s important because the fruit comes as a single unit not multiple fruits from which we get to pick and choose those that taste good while avoiding those that are unpleasant to us.  We produce these traits as a collective whole.)

So that begs the question, “What should I love?”  If the direction of my heart’s affection changes the choices I make and how I live my life, then what should be my heart’s desire?  There is only one thing worthy of your love and worship.  It isn’t health, or your family, or your self-image, or even the promise of less pain in your life.  It isn’t the hope of a cured cancer or the re-opening of clogged arteries that is worthy of our utmost desire.  Only God is able to receive worship properly.  Paul writes to the Corinthian church, “whether you eat or drink, or whatever you do,  do all for the glory of God.”  When our first thought at every intersection of our lives is “how do I glorify God in this situation?”, then we fundamentally start changing the things we do.  Our choices are now informed by a true and perfect set of guidelines that lead to our ultimate good.  They very often lead to our physical good, a healthier or more functional body, but that isn’t their goal.  The goal of our actions is to glorify God.  In that power, we can choose well the foods we eat or avoid.

Biblical counseling is nutritional counseling is Biblical counseling.

However, the fruit of the Spirit isn’t the fruit of my spirit but the fruit of THE Spirit.  It is God’s Spirit dwelling in me to grow in faith and love of God Himself.  It is much deeper than following a 12 step program of reform.  It is much more fundamental than even just adhering to the 10 commandments of scripture as though they are highway guard rails that keep us pointed in the right direction hopeful that we might finish the race before we screw up too badly.  Instead, we are to be driven by the hope within us in Christ’s finished accomplishment.  As God works in our lives, His fruit is produced.

Trinity’s Biblical counseling program was built on this foundation so that we can help our patients understand what their heart’s desire should be.  We saw the need to help our patients understand the hard moments of their lives in the light of God’s worthiness to receive worship.  It was only natural for us with this counseling mindset to extend our help for patients into the area of nutrition and exercise with our VitalSigns program.

I urge you as we all walk together through your life to reach out to us and begin to understand the choices that will truly fulfill you.  Please call us at 539-0270 to set up an appointment with your physician or clinician to begin this discussion.  Call and set up an appointment our Biblical Counselors or our Medical Nutrition Management clinicians to start addressing the fundamental issues that shape our lives.  Don’t let another set of superficial, hollow medical guidelines lead you further away from the truth.

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Why sugar makes you go blind. 

Here’s an interesting study looking at the prevalence of diabetic retinopathy in patients across the spectrum of blood sugar control.  It showed that individuals with a Hgb A1c greater than 5.5% have the biggest increase in retina damage due to sugar exposure.  A Hgb A1c of 5.5% is equivalent to an average blood sugar of 111 mg/dL.  For reference, diabetes is diagnosed when a fasting blood sugar is 126 mg/dL on two occasions.  That means that individuals who have not been diagnosed with diabetes may already have retina damage from high blood sugars.

Now is the time to change.  Call our office at 539-0270 to schedule an appointment with our Nutrition Counselors and take control of your blood sugar.  Save your vision!

Association of A1C and Fasting Plasma Glucose Levels With Diabetic Retinopathy Prevalence in the U.S. Population

Implications for diabetes diagnostic thresholds

OBJECTIVE To examine the association of A1C levels and fasting plasma glucose (FPG) with diabetic retinopathy in the U.S. population and to compare the ability of the two glycemic measures to discriminate between people with and without retinopathy.
RESEARCH DESIGN AND METHODS This study included 1,066 individuals aged ≥40 years from the 2005–2006 National Health and Nutrition Examination Survey. A1C, FPG, and 45° color digital retinal images were assessed. Retinopathy was defined as a level ≥14 on the Early Treatment Diabetic Retinopathy Study severity scale. We used join point regression to identify linear inflections of prevalence of retinopathy in the association between A1C and FPG.

RESULTS The overall prevalence of retinopathy was 11%, which is appreciably lower than the prevalence in people with diagnosed diabetes (36%). There was a sharp increase in retinopathy prevalence in those with A1C ≥5.5% or FPG ≥5.8 mmol/l. After excluding 144 people using hypoglycemic medication, the change points for the greatest increase in retinopathy prevalence were A1C 5.5% and FPG 7.0 mmol/l. The coefficients of variation were 15.6 for A1C and 28.8 for FPG. Based on the areas under the receiver operating characteristic curves, A1C was a stronger discriminator of retinopathy (0.71 [95% CI 0.66–0.76]) than FPG (0.65 [0.60 – 0.70], P for difference = 0.009).

CONCLUSIONS The steepest increase in retinopathy prevalence occurs among individuals with A1C ≥5.5% and FPG ≥5.8 mmol/l. A1C discriminates prevalence of retinopathy better than FPG.

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Do know you know your blood sugar past, present, and future?

“Those who cannot remember the past are doomed to repeat it.”
-George Santayana, Life of Reason, Vol 1, Reason in Common Sense

Understanding where we are and where we’ve been helps us understand where we are going.  We use three blood tests to help people understand their past, present, and future as it relates to blood sugar disorders like diabetes.

The three tests are Hgb A1c, glucose, and insulin.

Hgb A1c: This is a test that measures the average blood sugar over the last three months.  It takes into account everything you’ve eaten, done, or experienced during that time that might alter your blood glucose.  It often runs higher than people expect but it helps take into account the effect of food on the body.  Diabetes can be diagnosed when this number gets to 6.5%.  Healthy values would be less than 5.5% or even lower.

Glucose: This is a measure of the amount of glucose floating around in the blood stream at any point in time.  It is simply a snap shot of what is going on.  Typically this is done fasting so as to assess the ability of your body to get back to normal when we stop letting our food choices get in the way.  Generally a level above 100 mg/dL is too high.  When it gets above 125 mg/dL we call that diabetes.  A non-fasting glucose show you how your body may be reacting to a high sugar meal too.  A non fasting glucose above 150ish ought to give you pause and make you rethink what you had to eat.

Insulin: This a measure of the work the pancreas is doing to get your blood glucose to its current level.  It helps us understand whether that job is easy or hard.  For instance if you have a normal blood glucose but a very high insulin level that means your pancreas is working extremely hard to maintain that normal glucose.  Your pancreas can’t do that forever and will wear out sooner than you might want.  When the pancreas fails the blood sugar starts to rise.  It is estimated that by the time your blood glucose rises above 100 mg/dL one half of your pancreas has already died off.  A high insulin level is a strong indicator that change needs to happen to prevent the damage of diabetes.

So if you want to know the past, present, and future of your body’s blood sugar come in and talk to us about these three tests.

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Hide and seek is easy when you know where to look

The same is true with cardiovascular disease. It may seem obvious but one of the best ways to find a problem with your blood vessels that could lead to a heart attack or stroke is to actually look at the blood vessels themselves.

Historically, the only way to measure what was going on inside a blood vessel was to inject some dye into the blood vessel and look at it with a special type of X-ray. This is still a good way to see what’s going on inside specific arteries such as the coronary arteries or the arteries for the kidneys.

However good that type of test is it still is relatively expensive and involves irradiation and an injectable dye. There some people who can’t undergo that test due to other health problems and allergies to the dye.

Trinity Medical Associates is pleased to announce that we now have another low cost test to help us see what’s going on inside the arteries of your body by using the large arteries of the neck (the carotid arteries) as a representative. This test actually measures the thickness of the artery wall, in tenth of a millimeter increments, as well as any cholesterol that has already accumulated. This is called the Carotid Intima-Media Thickness test or CIMT for short.

If you are interested in finding out about your arteries give our office a call to set up an appointment. The next day of testing will be December 8th at both the Knoxville and Maryville offices.

This test is offered on a fee for service basis and is not billable to insurance plans. The cost is $150.

Call 865-539-0270 to set up your appointment for your CIMT.

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