All Posts tagged diabetes

Maintain Your Brain

            Seventy year old Mrs. Lansing drew a complete blank as I asked her if she could recall any of the five words I’d given her to remember some 4-5 minutes ago as part of her mental status exam.  Inwardly I always wince at those moments.  It feels like I’m unintentionally bullying a harassed person into looking the fearful specter of their approaching dementia directly in the eye.  Her husband quickly came to her rescue with a small white lie, “That’s alright darlin’, I don’t remember any of them either,” and we all smiled with relief.

Dementia is the common term for a set of symptoms including memory loss, mood changes, and difficulty with communication and reasoning.  Modern medicine is trying to replace the term with “major and minor neurocognitive disorder”.  Yah, for now let’s stick with the term everyone knows, dementia.  There are several types of dementia, with the most common two being Alzheimer’s disease (AD) and vascular dementia (due to atherosclerosis [plaque] on the blood vessels supplying the brain) coming in a close second.

AD currently affects about 5 million Americans.  There are a handful of approved prescription medications to treat AD.  They delay (but do not stop) the progression of the disease by about 6 to 12 months.  This is useful, but far from a cure.  Likewise various supplements and vitamin treatments have come and gone over the years.  When subjected to careful scrutiny the results have generally been disappointing.  The likelihood of AD dramatically increases with age, roughly doubling in likelihood every 5 years after age 65.  If one lives to 85 years old the likelihood of having AD is almost 50%.

So can anything be done to prevent it?  Of course certain risk factors cannot be altered, such as age, family history and genetics.  But at the same time, there is a growing body of research showing that certain lifestyle choices have a substantial impact on whether AD or vascular dementia will indeed show up in your life.  Certain treatable maladies contribute to a significant increase in dementia.  For example, dementia is:

  • 41% higher in smokers
  • 39 % higher in people with high blood pressure
  • 22% higher among whites who are obese
  • 77% higher in diabetics

So obviously there is room for better lifestyle and aggressive treatment of these

conditions to help delay or prevent the onset of dementia.  A recent article predicted that substantial improvement in lifestyle factors could reduce the risk for AD (and perhaps even more so vascular dementia) by 50%.

What lifestyle factors can substantially impact the likelihood and/or timing of you or me getting dementia?

  • Being a regular exerciser could reduce AD by 21%. A recent study showed 5% greater brain mass retention in active folks vs. inactive.  Five percent may not sound like a lot, but when it comes to the brain, it is substantial.  A reasonable goal in terms of time and activity would be a 30 minute brisk (3-4 miles per hour) walk or the equivalent 5 days per week.
  • Quit smoking
  • Avoid excess alcohol. Anything beyond one drink a day in females or two daily in males is associated with increased risk of dementia.
  • Stay socially connected and mentally active.
  • A heart-healthy diet rich in nuts, seeds, whole fruits and vegetables, olive oil, fish and other low fat meats, and low in sugars and simple carbohydrates is beneficial in reducing vascular dementia.
  • Finally, if you have diabetes, cholesterol issues, obesity, or high blood pressure, treating these well can impact the incidence of dementia.

In the end, there is no way to guarantee that you will avoid the scourge of dementia.  At the same time, we want to avoid the fatalism that assumes that nothing we do will impact its likelihood or timing.  Dementia is a grim enemy.  While more weapons against it are sought, it’s worth using every one that is available to delay or prevent it.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835

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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.

-mbm

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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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Cholesterol Meds – Awesome or Awful?

Statins – those frequently-prescribed cholesterol-lowering medicines that include Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Livalo (pitavastatin), Mevacor (lovastatin), Lescol (fluvastatin), and Pravachol (pravastatin) – are they awful toxins or awesome remedies?  You can certainly read both opinions if you follow the news or scan the web.  The New York Times once touted them as “the underused wonder drugs” while other articles and blogs claim they are dangerous and no one should use them.  Meanwhile they are the most prescribed drugs in the world and over 20 million Americans take them.

So where is the truth when it comes to statins?  No one can credibly claim that they don’t effectively lower cholesterol.  We routinely see up to and beyond 100 point drops three weeks into treatment with a statin.  What’s more, they act as anti-inflammatants inside the blood vessels and inflammation promotes plaque formation (the stuff that damages and blocks arteries leading to heart attacks and strokes).  But does lowering cholesterol and inflammation translate into reduced heart attacks, strokes, and overall mortality?  For high-risk individuals who have already had a coronary event (a heart attack or stent or bypass surgery) the answer is clearly, yes.  Statins reduce the chance of a second heart attack by about a third.

However, in what’s called primary prevention – preventing bad outcomes in individuals who are at lower risk and have never had a coronary event – the numbers are still there, but not quite as compelling.  An analysis of 14 randomized trials involving almost 35 thousand patients showed the following:

  • 17% reduction in all-cause mortality
  • 28% reduction in heart attacks
  • 22% reduction in strokes
  • No significant additional adverse events in those treated vs. placebo groups nor negative effect on quality of life

That sounds fairly impressive, but put another way, when the numbers are worked out, 1000 people would have to be treated for one year to prevent one death.  So there is a real, but modest benefit in treating lower risk individuals with statins.

On the side-effect side of the equation, we already noted that substantial side effects seem to be statistically insignificant in the studies.  But that’s not the whole story.  Liver effects are actually rather uncommon, with a significant rise in liver enzymes occurring in roughly 1 in 100 patients.  If they occur, the statin is simply stopped and the enzymes return to normal.  Actual liver failure rates in those on statins are almost the same as those in the untreated population.

Muscle pains occur in some 10% (estimates vary) of those on statins and, again, generally resolve promptly when the statin is stopped.  More serious muscle damage can occur, though rarely (in over 25 years of prescribing I’ve not had my first yet).  Other recent findings note a slight rise in blood sugar with statins and a fairly uncommon incidence of mental fuzziness and memory issues. If the latter occurs, the statin can be stopped and the problem clears.  All in all, my experience has been that some 8 out of 10 persons put on statins have no problem.

So, in the real world, if you have high cholesterol, how do you decide whether to be on a statin?  Sit down with your physician and go over your cholesterol numbers in detail.  Then look at all your other risk factors for heart disease and stroke (smoking, hypertension, diabetes, family history, sedentary life style, etc.).  For many I also recommend a coronary calcium score (a rapid, non-invasive CT of the coronary arteries looking for calcified plaque), a cardiovascular inflammation panel (I use Cleveland Heart Lab), and sometimes a CIMT (carotid intima media thickness, an evaluation of the state of plaque formation and inflammation in the blood vessels).  These tools give us a much better handle on who really is showing blood vessel damage and risk and who isn’t.  This allows us to target our preventive efforts, including statin use, on those who will most benefit from it.  Of course in all of this, don’t forget lifestyle changes such as the one highlighted in another New York Times article: “Underused Therapy for the Heart: the Gym.”

So statins are neither simply awesome nor awful; they’re one treatment that may or may not be right for you, when added to your steady efforts to minimize all those other risk factors.

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