Conquering Diabetes

Photo: Pixland

Chocolate is one of the world’s most prized flavor sensations, and most people who are interested in healthy eating have a vague notion that chocolate might have health benefits. For example, this WebMD article published a few weeks ago reports on the combined results of 21 studies with 2,575 participants showing that cocoa consumption is associated with decreased blood pressure, improved blood vessel health, improvement in cholesterol levels, and improvements in diabetes risk factors such as insulin resistance.

Unfortunately, the role of chocolate in disease prevention has proven to be complicated and controversial from both medical and ethical standpoints. (more…)

One in three American adults has prediabetes, and to make matters worse, only a small fraction of these people know it!

I consider this to be a national emergency. If we fail to detect and reverse prediabetes, then how are we going to stand any chance at reducing the growing epidemic of type 2 diabetes? (more…)

Four years ago, in a WebMD/Medscape video editorial, I called for a national ban on partially hydrogenated trans fat, an artificially manufactured, harmful fat that promotes heart disease and diabetes.  At that time it was commonly added to commercially prepared fried and baked foods, and average intake was estimated to be 5 to 6 grams per day with an associated 25% increase in heart disease risk in the US. (more…)

One of my greatest pleasures in life is to help patients achieve remission of their type 2 diabetes. This means their blood sugar levels have become normal in the absence of any diabetes medication.

Many clinicians and patients are interested in learning my views about how to go about decreasing and discontinuing diabetes medications. The main role for medications is to help reduce or delay the risk of nasty complications of diabetes, particularly the damage to the retina, kidney, nerves, and circulation. The higher the average blood sugar level, as indicated by the hemoglobin A1c level, the greater the complication risk (which increases exponentially with increasing A1c). We know from clinical trials that using medication to keep the A1c at or below 7% can help reduce the risk of these complications. There is broad agreement that clinicians should recommend starting or increasing diabetes medications to patients who cannot get their A1c level to 7% or less via lifestyle change.

Many patients come to me because the A1c is already over 7% and their primary care provider proposes increasing their diabetes medication, unless the patient can get to 7% or less with improved eating and/or exercise habits. Some of these patients are already on many pills, and insulin shots are the frequently the next appropriate treatment. Many patients would rather make the lifestyle changes than take more medication, so when the doctor frames the issue in this way, then a patient might become inspired to renew or increase the lifestyle efforts. The clinician might say “lets recheck the A1c in 3 months, and start the new medication if it is still above 7.0%”.

My goal with patients is to use the lifestyle strategies I’ve discussed previously in this blog to drive the A1c as low as possible. I want to push the A1c very far below 7.0%. If possible I would prefer to push the A1c into the normal range of 5.7% or less, and I’ve helped many patients push it close to 5.0%. There can be little doubt that using lifestyle changes to normalize the glucose levels and A1c is a good thing. In contrast, the strategy of driving the A1c well below 7.0% with multiple medications has little to offer most patients in terms of quality of life or reduced risk of complications.

Most patients I see are already taking metformin, which is the preferred second line treatment after lifestyle change. Opinions differ about when to start this drug. Some experts advocate starting it in patients who have pre-diabetes because clinical trial evidence demonstrates that it can delay the progression to type 2 diabetes, while other experts could argue that there is little evidence that it reduces diabetes complications when the A1c is below 7.0%, so no point in starting it until 7.0% It is important to discuss these issues with patients.

I typically recommend initiating it in patients with A1c’s of 6.5% who cannot push it any lower via lifestyle change. For patients who are already on metformin, I do not decrease the dose unless the A1c is 6.0% or less. I might reduce the dose by half every 3 months, as long as the A1c stays at 6.0% or less. I stop the final 500 mg of metformin when the A1c is 6.0% or less for at least 3 months. Once a patient has discontinued it, I would then recommend restarting it if the A1c reaches 6.5%. Other alternative approaches would also be reasonable, and patient and physician preferences should be taken into account when making such decisions about starting and stopping metformin.

Some drugs can lower the blood sugar levels below the normal range, causing symptoms of hypoglycemia. These drugs, which include insulin and those in the sulfonylurea family (which are common in patients on more than one kind of diabetes pill) need to be reduced or discontinued by the clinician as required to avoid hypoglycemia, so these are typically the first drugs to be discontinued. It is important that patients who take these medications check their blood sugar levels regularly, particularly while making lifestyle changes. Doing so lets us know the risk of future hypoglycemia and guides the decision about when to decrease or discontinue such medications.

For patients on insulin, this type of monitoring is mandatory. Initially, insulin dose reduction typically mirrors dietary carbohydrate reduction, and many patients are quickly using half as much insulin, particularly the short-acting insulin boluses used to prevent hyperglycemia during and after meals. Weight loss often brings additional reductions and sometimes discontinuations of insulin, however the glucose and A1c levels are the key to managing insulin dosing over time. The majority of my patients have not been able to discontinue insulin altogether, although nearly all of them have been able to significantly reduce their dose as well as their A1c levels. The chances of discontinuing insulin are best when the lifestyle adherence levels are high, the weight loss is large, the initial insulin requirement is relatively low, and the duration of diabetes is short, almost always less than 10 years.

In the absence of insulin or sulfonylureas, then other drugs (such as pioglitizone) come off next. I typically wait until the A1c is 6.5% or less to propose stopping such drugs, and would not initiate or re-initiate any diabetes drugs (other than metformin as noted above) unless the A1c is above 7.0%.

So, in summary, ambitious eating and exercise goals are important in all stages of diabetes, and drugs are crucially important in patients who cannot otherwise keep the A1c below 7.0%. Metformin is the first drug of choice whenever possible, and the last drug to be discontinued in patient who normalize glucose levels via lifestyle changes. The A1c levels to start and stop metformin are up for debate, and may be individualized according to patient and clinician preferences. It is clear that medications can be avoided, delayed, or discontinued when lifestyle efforts are intensified and sustained. For many (if not most) patients, lifestyle coaching by a clinician, dietitian, personal trainer, peer group, etc. can dramatically increase the odds of success.

- Michael Dansinger, MD

Duncan Smith/Valueline

For those who often feel crushed by the weight of life’s challenges; for those who feel beaten down by the fight; for those who feel trapped inside themselves; I recommend checking out the hit song at the top of this week’s popular music charts: Firework by 26 year-old pop star Katy Perry.

Firework is an inspiring and upbeat song aiming to remind us that we all have untapped strength within us. No matter how dark thing seem we must always remember that there’s a metaphorical spark in each of us waiting to be ignited. If we believe that spark is there deep within us, and if we persist in our efforts to find it and light it up, we will be ready to take the leap at the right moment. That is how we transform ourselves from what we are now to what we can be–if only we can find a way break out of our usual patterns and create the opportunities and take the risks that will allow our talents and unique gifts to shine or even “explode”.

“Do you know that there’s still a chance for you, Cause there’s a spark in you

You just gotta ignite the light, And let it shine, Just own the night, Like the Fourth of July

Cause baby you’re a firework, Come on show ‘em what your worth,

Make ‘em go “Oh, oh, oh!”, As you shoot across the sky-y-y

Baby you’re a firework, Come on let your colors burst, Make ‘em go “Oh, oh, oh!”

Music and songs have the power to inspire. However such songs are not commonplace — they are rare. This is exactly the type of song that belongs at the top of the charts. It comes from a woman who has worked hard and overcome multiple challenges to reach the top. I find it inspiring to see a young person who has worked hard to ignite her own spark and explode like a firework. Through her song she is teaching us how to follow her lead to set our sites high and to believe great things can happen even if the obstacles are significant.

Sadly, in most of the patients who come to me because of type 2 diabetes, the “spark” is buried very deep within. These patients have typically lost that part of themselves. They feel frustrated and discouraged and although they can imagine a state of being that is dramatically better, they do not believe their destiny is to reach that state. It does not occur to them that it is theirs for the taking if they can just find a way to get there. They have typically been carrying many pounds of excess body fat for decades, have tried to lose it and failed to keep it off, and have resigned themselves to living with it along with the diabetes, high blood pressure, high cholesterol, and other related problems. They have accepted that their healthiest years are far behind them and that they will live out their remaining decades in a state of substantial compromise.

I have coached many patients into long-standing remission of their type 2 diabetes. They have been able to lose enough weight through sustained improvements in their eating and exercise strategy to maintain normal or near-normal blood sugar levels for years. Each of these patients has been able to avoid or discontinue diabetes medication that would otherwise be required. None of them expected to achieve this and most did not know it was a realistic goal until I showed them the way. They have transformed themselves and the way they see themselves. They rose to the occasion by taking advantage of an opportunity to break out of old patterns. They dared to embrace the chance for a new future and they made it happen. Together we found that spark, lit it up, and watched the fireworks. They started to believe it was possible because they could tell that I sincerely believed it. They knew I saw something in them that they were hoping to find.

When I see a new patient with type 2 diabetes or prediabetes I approach that person as if he or she has the capacity for a great transformation. Everyone still has a spark. It is typically buried deep, and we cannot always find it, but I believe it is there. Most patients still have the biological capacity (remaining pancreatic insulin production) to achieve remission if they lose much of their excess body fat, and the difference between those who transform and those who don’t can be thought of as whether we were able to find and ignite that inner spark. In practical terms it corresponds to overcoming the enormous logistical and psychological barriers that interfere with 90% adherence to an ambitious eating strategy plus 7 hours per week of progressively increasing exercise. But when someone is persistent and wants it badly enough, and if they make the most of their opportunities, they can usually find a way.

Doctors and patients routinely underestimate the power of lifestyle change to transform sorrow into victory. Let’s break free from that common misconception. Let’s make sure we don’t short-change ourselves. Let’s never forget that we’re all capable of bettering ourselves if we believe it is our destiny and if we work hard to let our true colors shine.

- Michael Dansinger, MD

One of the hottest topics I’ve ever seen in the WebMD Diabetes Community is the highly polarized debate over artificial sweeteners. Below I share my views on this controversial, interesting, and scientifically challenging topic.

I believe the debate is entirely legitimate. There are strong arguments to be made both in favor and against using artificial sweeteners in my opinion. One thing that is easy to agree upon is that there we could benefit from stronger scientific data on the long-term effects of artificial sweeteners on the body. The lack of strong data helps fuel the debate in my view.

The argument in favor of artificial sweeteners goes something like this:

Excess sugar is unhealthy. When added to foods and beverages it encourages overeating and has negative health effects that help fuel diabetes, heart disease, and associated risk factors, even in the absence of obesity. For example, drinking 1 can per day of regular soda is associated with nearly a doubling of the risk of type 2 diabetes. In principle it would be great to simply avoid foods and beverages with added sugar, but in practice we recognize that living life to the fullest generally includes eating sweetened foods, including desserts. Furthermore we are genetically designed to love sweet foods because this was a survival advantage during the vast majority of human history, therefore it is very hard to overcome cravings for sweet foods.

Since we are going to be eating sweet foods, it makes sense to find healthier ways to sweeten food, if possible. Saccharin (Sweet-n-Low, Sugar Twin), aspartame (Nutrasweet, Equal), acesulfame K (Sweet One, Sunett, Swiss Sweet), neotame, and sucralose (Splenda) are currently approved by the FDA for this use. Extensive testing has demonstrated no evidence of toxicity or negative short-term health effects. Years of experience with these products has not demonstrated any clear signs of trouble.

Moreover, the availability of the “diet” version of sodas and other artificially sweetened foods helps people avoid the higher sugar alternatives, and to maintain caloric reductions and weight loss. In patients with diabetes, the availability of artificial sweeteners can help control blood sugar when used to reduce sugar intake. For example, a person switching from two regular sodas to two diet sodas per day could reasonably expect to lose about 25 pounds over time, and maintain that weight loss on a long-term basis. If this occurred in someone with type 2 diabetes, this change alone could potentially result in less medication or even a remission. Major medical organizations such as the American Diabetes Association and American Heart Association endorse the use of artificial sweeteners for the various reasons cited above, and these organizations review the evidence and make a determination on a yearly basis.

Artificial sweeteners have been blamed by various individuals for many types of medical symptoms (such as headaches) but scientific studies attempting to find an association with any symptom typically fail to confirm any relationship with artificial sweeteners. Even if a small minority of individuals are truly sensitive to certain artificial sweeteners, that would not necessarily be a good reason to discourage others from using them. Furthermore, some would argue that even if artificial sweeteners have minor health risks, that would not necessarily offset their potential benefits.

The argument against artificial sweeteners goes something like this:

As a general principle, humans and other animal species are genetically designed to eat foods that occur in nature, and artificial sweeteners do not fit this criterion. Obviously not everything that is natural is healthy, but one should assume that chemicals that do not occur naturally are not fit for human consumption. Anyone who argues otherwise should be required to prove that a specific artificial chemical is safe for long-term consumption, and the scientific methods available at this time are not sufficient to be confident that such artificial substances are truly safe.

If a compound such as aspartame, which has a relatively simple chemical structure, was fit for consumption it would be found in nature. Its absence in nature is suspicious, as it would certainly occur in nature unless there was some important reason (evolutionary disadvantage) for its absence. Along the same vein, the chemical structure of sucralose, with its atypical presence of a chlorine atom (as opposed to chloride ion), seems suspicious as well, and nobody would be terribly shocked to learn 20 years from now that such a compound caused subtle, yet significant increases in risk of serious health problems (such as diabetes, metabolic syndrome, cancer, etc.) that became clear only in retrospect. Such diseases are clearly linked to changes in the human diet, particularly as a result of food industry processes, and artificial ingredients are a clear marker of this trend.

A small but growing body of scientific evidence supports the hypothesis that non-caloric sweeteners stimulate food intake, obesity, diabetes, and related diseases. As summarized on the Harvard School of Public Health website, the concern is that sweetness in the absence of calories is unnatural and may stimulate hormonal changes that encourage overeating. Non-conclusive studies suggest that people who drink diet soft drinks are at increased future risk of obesity, and are more likely to have type 2 diabetes, than people who avoid diet (and sugar-sweetened) beverages.

For these reasons, and others, some specialty grocery chains, such as Whole Foods, do not carry any foods with artificial sweeteners or other artificial ingredients. Their position may reflect a popular philosophy that that sugar derived from natural sources is the lesser evil compared to artificial sweeteners. Natural sweeteners such as stevia and erythritol and other sugar alcohols, are typically welcomed by those who are concerned about both sugar and artificial sweeteners. However they do not provide a perfect solution either due to taste limitations, and they may raise the same concerns about sweetness in the absence of calories discussed above.

Finding an Elusive Middle Ground:

So what is the most prudent approach to sweeten foods and beverages? It is impossible to build a consensus around this topic. All approaches have limitations and concerns. Sugar tastes the best, but is clearly unhealthy when used to excess. Stevia and sugar alcohols seem the least risky, but have taste limitations. Artificial sweeteners may represent a middle ground, depending on the degree to which one believes they are safe versus risky, and data are inconclusive and sparse.

I have had the opportunity to work with food industry experts on new food development. Although water can be flavored sufficiently with stevia extract and erythritol (eg. Vitamin Water), in my experience, a complex beverage like a protein shake cannot be “sugar-free” unless artificial sweeteners are used. There is no way to make it taste good enough with just stevia and erythritol unless some form of sugar is present. The amount of sugar necessary to provide the minimum acceptable taste appears to be about 1.2 grams of sugar (5 calories) per ounce of beverage. This is about 30% to 50% of the amount of sugar typically found in other complex beverages.

So the question becomes “how much sugar should one be willing to accept in order to avoid artificial sweeteners?” I wish I could answer this question more definitively, but it is open for debate. I think it is hard not to have mixed feelings based on the current evidence.

I look forward to hearing thoughts from readers on this complex and provocative topic. Come to the Diabetes Community to share your thoughts.

- Michael Dansinger, MD

The human race is genetically designed to love sweet foods. For 99 percent of human existence, this love of sweetness was crucially important for survival, because it drove us to seek and eat fruit. Now, in modern times, our love for sweetness has backfired and has helped accelerate the epidemics of obesity, type 2 diabetes, and heart disease.

Ryan McVay

Many or even most foods in the supermarket have some sugar added, including breads, cereals, yogurts, processed meats, soups and condiments. Added sugar comes in many possible forms, including granulated white sugar (from sugar cane or beets), brown sugar, honey, molasses, maple syrup, brown rice syrup, corn syrup and high-fructose corn syrup. Adding sweetness to processed foods and beverages makes them taste better and more profitable, especially when high-fructose corn syrup is used.

High-fructose corn syrup has become especially popular in the US during the past 50 years, now accounting for nearly half of the total sugar intake. Reasons include subsidies on corn, tariffs on imported sugar, and cost-effective methods for manufacturing this sweetener. Corn is milled into cornstarch, which is then converted by enzymes to corn syrup consisting primarily of glucose, followed by further enzymatic conversion and additional steps resulting in a syrup that typically contains 55 percent fructose and about 45 percent glucose.

The nutritional biological effects of high-fructose corn syrup would not be expected to significantly differ from other common forms of sugar, such as granulated sugar or honey, because they each result in approximately equal amounts of fructose and glucose in the gastrointestinal tract and bloodstream. Once digested, the body can’t tell the difference. The glucose portion raises the blood glucose levels directly, and the fructose portion goes to the liver where it is converted to glucose. An important component of the negative health effects of excess sugar results from the necessary conversion of fructose to glucose by the liver, which can damage the liver cells (similar to alcoholic liver damage). Too much sugar is unhealthy, regardless of the form it takes prior to consumption.

High-fructose corn syrup has become increasingly frowned upon by those fighting obesity, diabetes and heart disease because it is such a common source of sugar. It has become a symbol, or “marker” of unhealthy processed foods. As a general concept, anyone who can stop eating foods with high-fructose corn syrup will probably improve one’s health. Not just by reducing sugar intake, but because foods that contain high-fructose corn syrup tend to have other unhealthy ingredients and lots of excess calories.

Similarly, simply replacing high-fructose corn syrup with alternative forms of sugar, such as honey, granulated sugar, brown rice syrup, etc. would not necessarily make those foods significantly healthier, but it would raise the cost somewhat. A number of large grocery store chains that specialize in healthier foods have excluded foods with high-fructose corn syrup, but do offer similar foods with equal amounts of sugar derived from beets, sugar cane, rice, etc.

The Corn Refiners Association, a trade association comprised of major players in the high-fructose corn syrup industry, has been fighting back against the gathering public rejection of high-fructose corn syrup. In 2008, they launched a public relations campaign called “Changing the Conversation about High Fructose Corn Syrup” with television commercials emphasizing that the sweetener is made from corn, has the same calories as sugar, is okay to eat in moderation, and has no artificial ingredients.

The Corn Refiners Association has also been in the news lately because they petitioned the FDA to allow them to use the term “Corn Sugar” instead. The reasons are obvious. The results are pending.

All this reminds me of the way tobacco companies hired public relations firms in the 1960’s to fight back against growing public rejection of cigarette smoking. The major players in the tobacco industry banded together and developed strategies to sway public opinion toward a more favorable view on cigarettes. The strategies included raising controversy about the scientific evidence documenting adverse health effects of their product, making the product seem “natural,” and stating it was fine in moderation.

In the case of cigarettes, such strategies provided the rationale or justification that helped smokers avoid trying to quit. In the case of high-fructose corn syrup, such strategies will help those who love the sweetness it adds to food to avoid trying to cut back. “Corn sugar is just like other kind of sugar” is just the justification people need to keep on eating just as much sugar/corn sugar/high fructose-corn syrup as ever.

This is a sorry state, because it is a reminder that public relations campaigns and food advertising have so much influence on the amount of unhealthy food and beverages consumed by the public. As we look back with regret, we know that adding ineffective “filters” to cigarettes revived the tobacco industry by fooling smokers into thinking the filters made the cigarettes safer. It would be sad to learn someday that changing the name to “corn sugar” effectively fooled the general public into thinking this unhealthy industrial sweetener is benign.

I’d like to see the general public continue to rise up against not just high-fructose corn syrup, but against the types of foods that have significant amounts of added sugar in general. We know added sugar is unhealthy. Let’s not let public relations campaigns distract us from solving the public health crises the next generations are counting on us to address in our time.

- Michael Dansinger, MD

Have you reduced the amount of foods with added sugar you consume? Tell us how you did on the Diabetes Community.

iStockphoto

I’m saddened to report recent findings that obese teens with type 2 diabetes have increased risk of cognitive impairment and abnormalities in the white matter of the brain, compared to other teens who are at the same weight but do not have diabetes.

This is another example of the seriousness of the obesity epidemic, which has led to an alarming increase in type 2 diabetes in adolescents. Such children will almost certainly have to make a choice as adults whether to spend the rest of their lives taking increasing doses of diabetes medications, or whether to get gastric bypass surgery or something similar. A small minority will escape having to make this choice by overcoming great odds and taking control of their eating and exercise.

Many say the key to saving these kids is to change the environment in which they live, starting with the foods the parent or parents keep in the house. Improving food choices in school cafeterias and placing greater emphasis on exercise at school are other important steps. However, I believe the prognosis is very poor for any child with obesity until that individual makes a decision that he or she is the only one who can solve the problem. Until the teen decides he or she must learn to prepare food and find the time to exercise, then there is no reasonable chance of success.

In my view, we need more teachers, coaches, parents, nurses, doctors, dietitians and others who work with children and adolescents to recognize that this is the key to helping individual kids. We need to create scenarios that help these children come to this realization, and we need to provide opportunities that allow them to learn the skills that will allow them to succeed once they decide to take control.

- Michael Dansinger, MD

What can be done to combat the obesity epidemic in teens and prevent type 2 diabetes? Post your comments on the Diabetes Community.

Christer Barregren / CC BY 2.0

Stevia is a natural sugar substitute that belongs in your “diabetes reversal” bag of tricks. I recently highlighted the medical problems fueled by excess sugar, including obesity, type 2 diabetes, heart disease, metabolic syndrome and many other weight-related medical problems. I believe stevia can be a significant part of the solution for many individuals.

The key advantage of stevia (over artificial sweeteners) is that it is all natural – it comes from the “Sweetleaf” plant that grows primarily in tropical and subtropical regions of Western North America to South America. The leaves contain the sweet glycosides stevioside and rebaudioside (discovered in 1931 by French chemists), which are 300 times sweeter than sucrose (table sugar). The leaves themselves taste sweet and can be used whole or in ground form in food and beverages. More typically, the sweet glycosides are extracted from the plant material and sold as a processed powder. Some companies sell stevia liquid resulting from dissolving the powder into a liquid, which might also contain additional flavor enhancements.

Stevia’s taste is on par with other sugar substitutes – sweetness with a mild after-taste. The key to leveraging stevia’s sweetening power is by masking the after-taste, which is easy to do. Stevia shines when used to enhance the sweetness of foods or beverages that already have some flavor as well as another source of mild sweetness. Its use in the popular beverages Vitamin Water Zero and Sobe Life Water demonstrate that it is gaining traction in the United States. It is usually available as powder, packets or concentrated liquid, in supermarkets, natural foods markets, vitamin shops and health food stores.

Its availability and popularity vary from country to country. It is especially popular in Japan, where it has been in commercial use for nearly 40 years. It is becoming increasingly popular in other parts of Asia and in Australia, and I believe it will become increasingly popular in the United States and Europe as well.

In our home, we use liquid stevia drops regularly. My favorite is the SweetLeaf English Toffee flavor. We also have Vanilla Creme and Lemon Drop flavors. I use it instead of honey, sugar, date or splenda in fruit smoothies. Without the stevia, it tastes bland and cries out for some sweetness. It tastes great with the stevia, and there is no after-taste since the fruit masks it. Here are two favorite recipes:

Banana Strawberry Smoothies

• 1/2 banana (frozen)
• 4 strawberries (frozen)
• 1 cup water
• 5 drops liquid stevia

Chocolate Peanut Butter Banana Shake

• 1 banana (frozen chunks)
• 2 teaspoons natural peanut butter
• 2 tablespoons unsweetened cocoa powder
• 12 ounces water
• 10 drops stevia

My kids and I love these! There is nothing in there I’d hesitate to call healthy. Another example: My 4-year old is much happier to drink milk when it has 3 drops of stevia added. If you have kids that will only drink milk if it is sweetened (eg. with chocolate syrup) but you don’t want them consuming so much sugar, then stevia drops are your answer. Online you can order flavors like Chocolate Raspberry, Cinnamon, Apricot Nectar, English Toffee, Peppermint, Grape, Lemon Drop, etc. A 2-ounce bottle of liquid stevia for about $12 provides about 250 servings (equivalent to about 500 teaspoons of sugar or over 50 twelve-ounce cans of soda). This saves over 8000 calories, with no effect on blood sugar!

I encourage all readers to learn more about stevia and how to use it.

- Michael Dansinger, MD

Tried stevia? How did the sugar alternative taste? Share your opinions on the Diabetes Exchange.