Sunday, December 20, 2015

Type 2 Diabetes, a Dietary Disease #308: Introduction to What Causes Type 2 Diabetes

Google “type 2 diabetes” and, in one third of a second, you get 118,000,000 “hits.” On my search the very first, after a brief description of the biological condition, asks, “What Causes Diabetes?” Their answer: “Usually a combination of things cause [emphasis added by me] type 2 diabetes,” What follows is a list of 6 symptoms, effects and parallel conditions associated with type 2 diabetes, none of which is a cause of type 2 diabetes. Only the first “cause” listed, “genes,” is relevant in that it is a precondition, but not a cause of this disease.
I am not a microbiologist or geneticist, but geneticists will tell you the genetic aspect of the science of Type 2 Diabetes is in its infancy. Although some genes associated with Type 2 Diabetes have been identified, no one has yet deciphered the complex combination of genes that have been modified by our Western diet to express themselves in a way that compromises the ability of our cells to accept glucose. This modification is called “insulin resistance.” Insulin carries glucose through the bloodstream, delivering it to cells throughout the body. If glucose can’t enter the cells, it continues to circulate. The pancreas releases still more insulin to solve the problem and eventually (after years) it wears out.
Elevated blood sugar, again over time, causes the complications of diabetes. And elevated insulin in the blood signals that there is glucose (energy primarily from carbs) circulating in the blood so there is no need to burn fat reserves for energy. So the body keeps our fat in storage, and the liver converts excess dietary carbohydrates (and fats) to triglycerides (fat) and adds them to our stores. Insulin resistance, resulting in high levels of circulating insulin in the blood, is thus the cause of diabetes and obesity, not the other way around. IR causes diabetes, IR causes obesity.  And obesity is usually a signal that your blood glucose is not under control.
What then is the “treatment” for type 2 diabetes caused by insulin resistance? The website cited lists 18 generalized “risk factors:” 3 are “things you can’t control,” and 11 others are “related to your health and medical history,” things that are epidemiologically associated with those who develop Type 2 Diabetes. That may be helpful to your doctor if he or she is otherwise clueless about whether to diagnose you as “pre-diabetic” or a frank Type 2. But let’s face it: they are history. There’s not much you can do to change the past.
Then the website lists 4 “Other risk factors (that) have to do with your daily habits and lifestyle.” It suggests, “These are the ones you can really do something about.” The site’s advice (amid pop-ups for anti-diabetic drugs): “Take medications and follow your doctor's suggestions to be healthy.” The site’s suggestions: “Lose weight, Get active, Eat right, Quit smoking.” Not bad advice, but not an effective treatment plan for IR.
The best way to think of Insulin Resistance is that you have become intolerant of dietary carbohydrates, i.e., you are Carbohydrate Intolerant. So, an “eating pattern” that reduces dietary carbohydrates to a minimum, or as few as you are willing to eat, will reduce the levels of both glucose and insulin circulating in your blood. This will, by lowering your blood glucose, 1) minimize your risk of pre-diabetes, frank type 2 diabetes and later complications, and, by lowering your blood insulin, 2) enable your body to access fat stores. You’ll lose weight and, in the bargain, avoid diabetes. Why doesn’t your doctor tell you this, instead of writing a prescription?
* If you’ve been wondering if you are one of those who is genetically predisposed, there is no genetic test as yet, but if you are overweight there is a very strong likelihood (true, just an association) that you have developed a degree of Insulin Resistance sufficient to cause that buildup of adipose tissue (body fat). This is particularly true for those with a waist/hip ratio greater than 1.0.

Sunday, December 13, 2015

Type 2 Diabetes, a Dietary Disease #307: A Personal Story (N = 1)

I was diagnosed with type 2 diabetes in 1986. The standard at the time was 2 consecutive fasting blood sugars ≥ 140mg/dl. The standard today is ≥126mg/dl, so I had probably been diabetic for many years. I weighed 300 pounds at that point, up from 250 in 1974. So my doctor told me to lose weight. He also began to treat me with a sulfonylurea, an oral antidiabetic medication that called upon my pancreas to produce more insulin whenever it was presented with simple sugars and other carbohydrates that I had eaten.
I tried many times to lose weight on the “balanced, calorie restricted” diet recommended by my doctor and his staff nutritionist, a registered dietitian (RD). I was always hungry. And from time to time when I did lose weight, I always gained it back. Over the years I continued to gain weight, and my diabetes worsened. In the mid 1990s, after I was “maxed out” on the sulfonylurea (glyburide), my doctor prescribed metformin, a new medication (in the U.S.). In a few more years I was maxed out on that drug too, and my doctor started me on a third class of oral diabetes medication. Soon, I feared, I was going to be injecting insulin directly into my veins.
By August 2002, I was the heaviest I had ever been. In fact, for several previous appointments I had been too heavy to be weighed on my doctor’s office scale. So before my next appointment, I weighed myself (with permission) at the Fulton Fish Market. The commercial scale told me the truth: 375 pounds. That was really scary. When I walked into the doctor’s office later that day, I was motivated to lose weight.
“Have I got a diet for you!” my doctor said as he greeted me from the nurse’s station in the lobby of his office. Serendipity had created a moment where my doctor had a specific recommendation for me, and I was totally receptive to his suggestion. He told me that he had personally tried a diet that he had read about in The New York Times! It was the July 7th Sunday magazine cover story, “What If It's All Been a Big Fat Lie?” by Gary Taubes, an award-winning science writer. This was a ground breaking story that was to change countless lives.
Both my doctor and I were interested in this diet because we both wanted me to lose weight – a lot of weight. But as my doctor walked me down the hall to schedule my next appointment, he put his hand on my shoulder and said, “Dan, this may help your diabetes too.” Boy was that an understatement!
The first day on this new diet, in the late afternoon, I experienced a “hypo” or hypoglycemic episode – a low blood sugar with “sweats.” I knew something was wrong so I tested my blood and then went to the news stand in the lobby and bought a candy bar. I then called my doctor, and he told me to stop taking the 3rd oral medication. But the next afternoon I had another hypo. I ate another candy bar and called the doctor again. This time he said to cut the other 2 oral meds in half, and the next day, when the scene repeated itself, to cut them in half again. In only a few days of strictly following this diet I was taking just 1/9th the meds as before.
On this diet, as is manifest, I didn’t need to take all these antidiabetic medications. And in time I was able – correction, I had to eliminate the sulfonylurea completely to avoid hypos. And all this happened before I lost weight. Of course, I did lose a lot of weight on this diet (170 pounds at my lowest), but more importantly my type 2 diabetes went into remissionso long as I continued to stay on this diet. I’m not “cured.” I never will be, but neither is my Type 2 Diabetes still “a progressive disease.” It is, quite simply, A DIETARY DISEASE.
* My lipid profile also improved dramatically: My HDL more than doubled and my triglycerides dropped by 2/3rds. My ratios (TC/HDL and TG/HDL) are now stellar, and my inflammation markers have plummeted. My blood pressure, of course, also improved (on the same meds). And my type 2 diabetes is in total remission!

Sunday, December 6, 2015

The Nutrition Debate #306: My New Manifesto: “Type 2 Diabetes, a Dietary Disease”

You may have noticed I took some time off for R & R.  The 305 archived columns, however, saw frequent visits.
The hiatus gave me an opportunity for introspection. It enabled me to re-examine my purposes and the best methods of achieving them. As my visitors know, I d­­o this for eleemosynary purposes. I have no pecuniary interest: no advertising, no dietary supplements to sell, no book to promote; there’s nothing in it for me. I do this, with the help of a great volunteer editor, for purely educational purposes.
As I said in The Nutrition Debate #114, “My Insulin Dependent Type 2 Pharmacist,” I started writing this column because a friend in my community – who was a registered pharmacist – died, unnecessarily and tragically. He was a Type 2 Diabetic. In 1986 when I was first diagnosed a Type 2, he helped me pick out my first blood glucose meter, and he filled my first prescription for an oral anti-diabetic medication.
That’s when my pharmacist told me that he was an insulin-dependent Type 2. He followed his doctor’s orders – and the advice our government has dispensed for half a century – and his disease progressed to its inevitable conclusion. His death was a waste. It didn’t need to happen that way. And that’s my motivation and my message.
With that in mind I have decided to focus my efforts on a large underserved segment of the diabetic population.  I want to explore an aspect of Type 2 Diabetes care that is little understood and generally ignored by the medical and pharmaceutical communities: the self-management of Type 2 Diabetes by the patient and how best to do it.
I am especially interested in reaching what the medical community calls the “treatment-naive” patient, that is, someone who is newly diagnosed (as Pre-Diabetic or Type 2 Diabetic) and has never been subject to any “treatment.” Such patients are at a critical juncture, and denial is an extremely tempting option. Typically, the patient just defaults into a dependent state and accepts their doctor’s ministrations (as we usually do in healthcare matters). However, a diagnosis of Pre-Diabetes or Type 2 Diabetes is actually a great time to look into what this disease is really all about and learn what you, the patient, can do about it. As a well informed patient, you can self-manage your diabetes care under your doctor’s watchful eye and “supervision”? 
Self-management of Type 2 Diabetes is a mutually beneficial arrangement. Doctor’s know that Type 2 Diabetes is largely a patient managed disease. They call it “patient-oriented” care, but that still leaves the impression that patient care is a collaboration that the doctor manages. I’m sorry, but as far as dispensing dietary advice is concerned, most doctors and conventionally educated and certified Registered Dieticians aren’t qualified to manage the care of Type 2 diabetics. So, in the days, weeks and months between doctor’s appointments, you will manage your diabetes care, and at the office visit your doctor will order tests and monitor (not manage) your improvement. Alternatively, if you default to medical management, after initially getting your blood sugar under control with drugs, your doctor will simply manage, and record, the progressive worsening of your condition.
You, the patient, know full well that “doctor’s orders” to “try hard to diet, exercise and lose weight,” aren’t easy to follow and aren’t enough. You’ve seen friends and relatives struggle. Something must be wrong with the “prescription,” you’re thinking. The doctor knows it too, but the only arrow in the quiver of the otherwise uninformed or, sadly, misinformed clinician is, “More medications could be used.” That’s the road my poor pharmacist took, and look what it got him – progressively worsening disease… and then a slow, premature death.
Therefore, the new focus of “The Nutrition Debate” will be “Type 2 Diabetes: A Dietary Disease.” It will begin with this post (#306) by the eponymous title. Then, the next posts will be #307, “Preface, A Personal Story (n = 1),” and then #308, “An Introduction to What Causes Type 2 Diabetes.” The first is my bona fides – my “credentials,” as it were. The second post is an overview of the science, as I see it. These will be followed by #309, “Type 2 Diabetes Q & A: 20 Brief Vignettes,” each fewer than 150 words (4-pages total) in Q & A format.
Further posts will return to the manifesto that drives this new focus: that Type 2 Diabetes is a Dietary Disease. I welcome comments and “debate.” After all, I have taken a very strong position which, as I see it, is irrefutable. Of course, although I consider myself “informed,” mine is just “A Personal Story: n = 1,” and “Your Mileage May Vary (YMMV).”  But, if you read “An Introduction to What Causes Type 2 Diabetes,” it’s difficult for me to see how anyone could look at Type 2 Diabetes in any way other than that Type 2 Diabetes is a Dietary Disease.”