Sunday, December 30, 2018

Type 2 Nutrition #465, Diabetic neuropathic complications

If the subject matter of this post turns you off, good! I’m going to get personal, and I’m not especially fond of the idea of your reading about my bladder dysfunction. But the truth is, my urologist thinks, and my internist agrees, that as a 32-year type 2 diabetic, I may have begun to show a sign of diabetic neuropathy. His Dx: that I have a neurogenic bladder that appears to be responsible for a worsening eGFR. What’s that, you ask?
An eGFR, “estimated glomerular flow rate,” is a lab test of kidney function. It is a common marker for Chronic Kidney Disease (CKD) and is evaluated on a scale of declining kidney function (5 stages ending with end-stage kidney disease, and renal dialysis. That “complication” is called nephropathy, the second of three possible microvascular complications  of long-term type 2 diabetes. The third is retinopathy (leading to blindness).
So, what is a normal eGFR? According to Wikipedia, the National Kidney Foundation defines, “a normal GFR for adults as greater than 90 mL/min/1.73m2.” “Because the calculation works best for estimating reduced kidney function, actual numbers are only reported once values are less than 60. Normal GFR values are largely over 60 in healthy subjects, at least before the age of 70 years. However, we know that GFR physiologically decreases with age, and in adults older than 70 years, values below 60 could be considered normal.”
My doctor began to request eGFR tests for me in 2011, one month before I turned 70. For three years, the next nine tests were all ≥60. Then, starting in 2015, 5 of the next 7 were below 60 (mostly low 50s); then, last summer I had a 43, which repeated at 47 and 45 (average of 3 = 45). I also wanted to know why I peed a lot and so little, so my urologist undertook a series of tests and examinations. We think we now know the answer.
I have a very large bladder – over a one-liter capacity – and it doesn’t completely empty despite the urethra having a clear passage through the prostate. The reason, apparently, is neuropathy: the muscle that normally contracts the bladder to make me “void” isn’t getting a signal to contract from my nervous system. Hence, the enlarged bladder and the frequent urge to urinate small amounts that I’ve observed since the beginning of the year. The urologist ordered a prescription to relax the muscle in the neck of the bladder, but it didn’t help.
As a result, his thinking goes, when my enlarged bladder is really full, and not emptying much, urine backs up the ureters to the kidneys; and this back pressure on the kidneys is beginning to cause the reduced kidney function (lower eGFRs). My internist concurred and added that back pressure affects both kidneys, and I only have two! He also stressed that I must drink plenty of fluids because dehydration also causes kidney damage.
My urologist has now twice suggested that the best option for me at this point is self-catheterization. I have reluctantly come to the same conclusion. Ugh! My plan is to live to be 100, and to do that I’ll need my kidneys, such as they are. When I was in my 40s, the idea of taking a pill every day for the rest of my life was anathema. Now, I take a handful twice a day. So be it. At least I can say I am “otherwise healthy,” knock on wood.
The “plan” (the urologist’s ploy to get me to start) was to have me catheterize myself three times a day for a few weeks and then do another eGFR. If my kidney function improves, that is, if my eGFR increases, as he thinks it may, then I will have to continue with catheterization from that point forward (until I get to 100 or otherwise expire), to preserve the benefits. Apparently, no other remedy is available for a neurogenic bladder.
Two subsequent eGFRs, performed at two-week intervals after catheterization began, were improved (53 and 55). A third, 2 months later, was, alas, back down to a disappointing 47. So, now we’ll just have to “wait and see.”
In the meantime, the message here is to take notice of changes in your daily habits (like frequency of urination) and discuss it with your doctor(s) before you too have no choice but to “siphon the python.” Happy New Year!

Sunday, December 23, 2018

Type 2 Nutrition #464: “She was only 75.”

Penny Marshall died at age 75…of “complications from diabetes.” A commentator lamented, “She was only 75.” Nobody explained, which was correct, I suppose. An obituary is about a person’s life and accomplishments. Penny Marshall was brilliant in “Laverne and Shirley” and as a director. “A League of Their Own” is one of my favorite movies, but when I saw a recent picture of her, I knew she was probably diabetic. She was fat.
I don’t want to blame her for that, although I regularly hector and cajole my readers for the very same thing. I do that because, like the rest of us, she probably followed “doctor’s orders,” especially when she knew she was sick and presented with unmistakable markers. But when we simply gain a little weight over the years, and have no symptoms, we (including the doctor!) mark it up to eating too much and moving too little. We are told “diet and exercise” is the way to drop the weight. We try it again and again, and we fail, again and again.
So, it’s our fault. We heeded the doctor’s advice and we tried. We went to the gym (maybe) and tried to eat less of the foods the doctors and the medical associations and government told us not to eat, and we lost some weight. We were always hungry, and eventually we lost resolve and gained it back. We failed. We did as we were told to do, and we failed. Over and over again. Is anyone thinking of the famous Einstein aphorism?
Einstein said, apocryphally, “Insanity is doing the same thing over and over and expecting different results.”
That’s why, I suppose, there are so many different diets out there. It’s so we don’t see ourselves as doing the same thing over and over again. But, don’t you see, we are, really. We are getting the same result! It’s insane.
All these diets have different names and other things that make them seem different, but they are really much more similar than we think. They are mostly “balanced.” What does that mean? They include the ratios of fat, protein and carbs (the “macronutrients”) that government and the medical establishment have recommended, without solid scientific evidence, for over half a century.
These ratios are on the Nutrition Facts panel on every box and bag that we buy at the supermarket. The daily amount recommended for every adult woman is 300g of carbohydrates, 50g of protein, and +/-65g of fat, mostly polyunsaturated fat (PUFA), from “vegetable” (seed and grain) oils. That translates to 1,200kcal of carbs (@4kcal/g), 200kcal of protein (@4kcal/g) and 600kcal of fat (@9kcal/g).
Here’s the truly shocking Percent Daily Value (%DV) of that 2,000kcal diet that “women of a certain age” are counseled to eat: 60% carbohydrate, 10% protein and 30% fat. Did you know that? That’s 60% percent carbs! And for men the percentages are the same; it’s just that we’re allowed 2,500kal a day, as follows: 375g carbs, 62.5g protein and 83g fat. That’s still 60% percent carbs, men! Is that insane, or what?  Bonus trivia: this is an excellent recipe for fattening livestock. No, I’m not joking.
That’s why Penny Marshall was fat. Not because she ate too much and didn’t exercise enough. Her obituary didn’t say that. It didn’t have to. The simple statement “complications from diabetes” said it all. Let that sink in. Then, ask yourself, was it a Microvascular complication? Neuropathy (with amputations), retinopathy (with blindness), or more likely nephropathy: end-stage kidney disease, with dialysis. Or perhaps a Macrovascular complication (stroke, heart failure, or old-fashioned MI (heart attack), increasingly common with diabetics.
In any case, Penny had, and you still have, a choice. Type 2 diabetes is a dietary disease. It is the result of eating a “balanced” diet of way too many processed carbs and foods with added sugar and processed vegetable oils. What does that have to do with being fat? When you greatly reduce the amount of carbs in a meal, starting with “breakfast,” you allow your body to burn its own fat for energy…so you won’t be hungry all the time. You won’t eat as much and put on the extra pounds. In fact, you will start to lose them, quickly. Just have coffee with heavy cream for breakfast, or bacon and eggs. No cereal, no toast, no fruit, no yogurt!

Saturday, December 15, 2018

Type 2 Nutrition #463: “You eat healthy, take statins…”

The TV commercial begins, “You eat healthy, take statins…” and then goes on to describe a new class of drug designed, “to lower LDL-C when added to a high-dose statin” (my emphasis). That’s what gets me riled. Folks, if you’re “eating healthy,” unless you have a very rare condition called “familial hypercholesterolemia,” you shouldn’t need to take a statin, much less another drug in addition to a high-dose statin. Geez…
Of course, this claim all revolves around what you (or they, the drug maker) call “eating healthy.” The drug maker will claim, rightly, that their “eating healthy” is what you have been told to eat by All the Powers that Be in our culture: The USDA/HHS Dietary Guidelines for Americans, from 1980 through 2015, with only minor modifications,, and the entire medical establishment – the AMA, the AHA, the ADA, etc.
So, if you “eat healthy” in the way they prescribe, you very well may need to take a statin. And if it doesn’t lower your LDL-C sufficiently to satisfy the Total Cholesterol and LDL-C Standards of Medical Practice for a lipid profile, established by the corrupt practices of those government/medical entities, you’re going to be cajoled relentlessly to start taking a statin, and if a high-dose statin doesn’t “do the job,” to start taking this new drug.
In 2002, I had been a diagnosed a T2D for 16 years and was still eating the Standard American Diet. I was on 3 classes of oral antidiabetic drugs (maxed out on 2), and still “out of control.” To help me to lose weight, my doctor suggested I start eating Very Low Carb (VLC), i.e. 20g of carbs a day. The first day I had a hypo, and 2 more that week. He took me off 1 drug and cut the other 2 in half TWICE. And in 9 months I lost 60 pounds.
Then in 2003, following the prescribed standard, my doctor started me on a high-dose statin and in no time got my LDL-C down to “target” (<70mg/dl). In 2006 I rededicated myself to VLC and lost another 100 pounds in a year. By 2008 I had lost 170 pounds total and lowered my blood pressure to 110/70 (on the same BP meds).
But I also transformed my lipid panel. While my Total Cholesterol (TC) and LDL-C remained about the same, I doubled my HDL-C and lowered my triglycerides (TGs) by two-thirds. When my doctor saw these outcomes, he used his clinical judgment and took me off statins completely. That was 2008, 10 years ago. I still basically eat VLC most of the time, and my latest lipids were TC 189; LDL-C* 83; HDL-C 92; non-HDL 97 and TG 56mg/dl.
* Calculated by Quest using Martin/Hopkins; previously Quest calculated LDL-C by the Friedewald method.
A chart below illustrates my TC and LDL-C while off, then on, then off again a statin, from 1980 to the present.

So, I think it’s reasonable to ask, “Is your ‘eating healthy,’ (the way the USDA/HHS and the AMA, AHA and ADA have been telling you to do all your life), the reason your doctor has you on a high-dose statin and is now twisting your arm unremittingly to take yet another drug to lower your LDL-C?” I think so. And my doctor apparently agreed. Do you suppose if you changed the way you eat, you wouldn’t “need” to take a statin?

Tuesday, December 11, 2018

Type 2 Nutrition #462: The TG/HDL-C ratio and Insulin Resistance

Dr. Jay is Jay Wortman, MD, a Canadian clinician, Very Low Carb and political activist who I first found in 2012 at Franziska Spritzler’s Low Carb Dietitian. Both he and I are among a very good list of links and resources there. That was only two years after I had started blogging, so when I visited Dr. Jay's Blog, I left a comment on his “The Story So Far….” And, as shameless self-promotion, I also left a link to my blog’s website. It has since garnered several hundred hits. I also get lots of page views originating from Franziska’s blog list.
Jay Wortman has become very active on Facebook. A while ago when I offered wishy-washy advice to a newly diagnosed type 2 looking for help on a popular Facebook group, Dr. Jay intervened with a reply comment to mine. He blasted my lame advice, telling the hapless newbie to face facts. The newbie had Insulin Resistance and was therefore Carbohydrate Intolerant. I was embarrassed by my half-baked input, but very grateful he is lurking, or more likely, following the group. Dr. Jay is both passionate and selfless, and dedicated to helping. 
Dr. Wortman also keeps up with the most relevant medical research. He recently posted on Facebook this PubMed Central (PMC) mouse study, “The Failing Heart Relies on Ketone Bodies as Fuel,” which concluded, “These results indicate that the hypertrophied and failing heart shifts to ketone bodies as a significant fuel source for oxidative ATP production.” Translation: the ketogenic diet is good for the failing heart, in mice.
Another Facebook post by Dr. Jay is this study from Malaysia appearing in PMC. Looking for “an easy to use, precise and low-cost diagnostic test to predict Insulin Resistance,” 271 overweight and obese children were “stratified by tertiles using the homeostasis model assessment (HOMA), a good surrogate for the gold standard for measuring IR, the hyperinsulinemic euglycemic clamp.” “The children were analyzed for fasting glucose, lipids, insulin and waist circumference. The children were then stratified by tertile of TG:HDL-C ratio.”
The study’s conclusion: “the odds of having IR was about 2.5 times higher (OR=2.47, 95%CI, p=0.01) for those in the highest tertile of TG:HDL-C ratio. Hence, TG:HDL-C may be a useful tool to identify high risk individuals.” Dr. Jay’s endorsement/imprimatur of this conclusion was, “I calculate this for all my patients.”
Below is a chart of my 82 TG/HDL-C ratios since 1980. The first 17 ratios were while I was eating a Standard American Diet (SAD) and, since dx in 1986, treated for type 2 diabetes with antihyperglycemic drugs. The last 65 ratios are since I began to eat VLC in 2002. A TG/HDL ≤ 1.0 is ideal, a ratio of ≤2.0 is good, anything over 3 is “indicates significant risk of heart attack and stroke.  Note almost all of mine since #17 are ≤1.0.

This metric has been in use by non-cholesterol-phobic physicians for years. I wrote about in 2011 in my #27 “...the strongest predictor of a heart attack.” I hope more physicians, like Dr. Jay, start to routinely use it.

Sunday, December 2, 2018

Type 2 Nutrition #461: Very Low Carb is the Basic Precept

The best diet for a type 2 or pre-diabetic to control blood glucose is Very Low Carb (VLC). How many grams of carbs you eat will depend on your degree of Insulin Resistance (IR). Your meter will tell you. Then, the number of carbs you eat will be up to you. How much do you want to mediate your condition? Do you want to put your diabetes in remission, or do you want to let your doctor manage it as you go on with your old diet?
In the last 16 years I have tweaked how I eat a lot. My doctor started me on Atkins Induction (20 carb grams a day). I few years later I switched to Richard K. Bernstein’s 30 grams a day (6-12-12). I transitioned to LC-HF (low-carb, high-fat), then Very Low Carb (VLC) or VLCKD (“keto”), and finally VLC with lower protein and moderate fat, to allow my body to burn fat, while I fasted or had one-meal-a-day (OMAD) and was “fat-adapted.” This Way of Eating has been called many things, but the basic precept is Very Low Carb.
Besides always being fundamentally Very Low Carb, it has also always been Moderate Protein. It is not high protein as some would have you think. People who say “high protein,” are thinking negatively in two respects: 1) They think “high protein” is harmful to the kidneys and 2) they are afraid to call it or think of it as “high fat,” which it is, because they think high fat, especially saturated, is harmful to the heart, which it is not.
With respect to PROTEIN, a moderate level means from 15% to 30% protein, depending on the carb and fat calories. Mine has been 20% for many years. Second, only a diet that is higher than 30% protein, of total calories (including body fat burned), might be harmful to the kidneys and then only if you already have kidney disease. Third, fear of fat is not supported by sound science, as the world is just now coming to realize. We have all been unwitting subjects in a 60-year, world-wide, low-fat, public health experiment.
As for  FAT, I hope you’ve noticed that the 2015 Dietary Guidelines have quietly dropped the “30% and lower” target in their recommendations. You probably didn’t notice that the Dietary Guidelines Advisory Committee told the full committee that “cholesterol is…no longer a nutrient of concern for overconsumption.” You no longer are being guided to limit your CHOLESTEROL to 300 mg a day! Eat eggs! Eat shrimp! Enjoy!
Unfortunately, the Guidelines still focus – in fact they have doubled down – on the dietary recommendation against SATURATED FAT, found mostly in animal products but also in coconut oil. They – ahem, the United States Department of Agriculture, the co-authors of the Dietary Guidelines with another government agency, HHS – want you to “shift from eating solid fats to oils,” specifically the highly processed grain and seed oils grown, manufactured and “baked into” foods, literally and figuratively, by AgriBusiness. Anyone see a conflict?
Basically, a diet that is very low carb, moderate protein and high fat – or moderate fat if you are fat-adapted and need to lose more weight with fasting or just calorie restriction – is going to work for you to manage your blood sugar and to lose weight without hunger. When my doctor started me on Atkins Induction 16 years ago, for weight loss, it worked. But we were both surprised that I had hypos every afternoon for a week until I stopped all the anti-diabetic meds he had me on. And eventually I lost over 180 pounds!
My blood lipids also improved dramatically, doubling my HDL-C and cutting my triglycerides by 2/3rds. And, with weight loss, my blood pressure went down, as did my inflammation levels. I am so much healthier today than before, and I feel so much better. It all began with VERY LOW CARB. It is the basic precept for type 2s.
My apologies to my regular readers of this blog. I’ve told this story many times; however, since my columns cover a wide range of subjects and aren’t indexed, the majority of my readers find me through a “Google” search.  If that includes you, I hope you will return often and make this one of your favorite sites, or even become a “follower” and send a hyperlink to a friend. I accept no ads because I have no products to promote or sell – only nutritional advice and encouragement for type 2s and pre-diabetics.