Monday, October 24, 2011

Secretes to success in your dietitians office

I have had the pleasure of working with many dietitians and I believe that their expertise, work and compassion provide the basic components needed for successful diabetes management. Without their help , your success with food management and diabetes control is almost impossible. They are basically just full of useful difficult to accomplish information that you and I need to know as patients.

After one little quote from the American Diabetes Association treatment guidelines , I will start revealing the secretes of how to get the most out of your visit with a dietitian.

"Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein,and fat appears to vary depending on individual circumstances. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal. Further,individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile, renal function) and/or food preferences. Plant-based diets (vegan or vegetarian) that are well planned and nutritionally adequate have also been shown to improve metabolic control

Basically the above quote points out that no one knows the exact proportions of different foods we should eat. Our specific food habits have to be evaluated and then adjusted to the requirements imposed on us by diabetes .We will focus on carbohydrates for this discussion because they have the most impact on our efforts to control blood glucose levels. Proteins and fats in our diet are also important but have less direct effect on our daily glucose levels.

The requirements imposed on us by diabetes is primarily the result of our pancreas failure to produce enough insulin to effectively use the glucose derived from the carbohydrates in our diet.

Basic ideas

#1 recognize foods that contain carbohydrates- fruit , vegetables , grains and milk

#2 control portion size-- understanding that 15 gms is one serving

#3 become more consistent with carbohydrate intake from day to day

# 4 start reading food labels

It is also a good idea to hear a lecture on diabetes diet in class and read about the diabetes diet on google , however that will not move the needed information into the getting it done portion of your brain.

Practice and multiple repetitions help turn ideas into usable tools.
practice and repetition converts
Remember your diet has to be adapted to you as an individual.

Now how to talk to your dietitian, right after you do a little home work.
Home work

Review - look under Diabetes resources , down loadable materials
My Carbohydrate guide. I like page 13 The" Handy" guide to portion sizes

Review - Mediterranean diet ideas from my blog a few days ago and try to find ways for
including These ideas into your life style.

Start - reading carbohydrate amounts on food labels for the commonly used foods in your current diet

Start - using measuring cups and comparing your fist size to 1 cup. Your hand could become a
useful always with you measuring tool to help with portion size .

Start - thinking about how many grams of carbohydrate do I need to eat each day. How much at
each meal

Start - keeping and easy to read food diary with portion sizes for at least 1 week before seeing you dietitian


The American Diabetes Association recommends a minimum of 120 to 130 grams o
I will share my simple tool for estimating the carbohydrates needed for a 40%
carbohydrate diet.

Goal weight = grams of carbohydrate per day

Example. 178 pounds = 178 grams of carbohydrate
( I will provide the complete formula if requested)

The American Diabetes Association recommends at least 120 to 130 grams of carbohydrate each day

the how to talk to a dietitian secretes exposed

Hand the dietitian your food diary records , tell her about you home work above and then say!

Can you help me adjust my eating habits and life style to meet the requirements imposed on me by having diabetes.

Consider adding some of the Mediterranean diet ideas to your plan.

Have fun ,read food labels

Wednesday, October 19, 2011

Diabetes diet , a low tech idea for a low tech problem

This discussion is about an idea that may help with some of the problems of food management and glucose control

Controlling portion size and maintaining consistent daily carbohydrate intake is a major obstacle for many of us and is a big contributor to blood glucose control problems. Todays discussion is about combining two well know ideas ( Lilly's handy guide to portion size and the Mediterranean diet )into one useful tool . This discussion is not about weight loss however weight loss may be a desirable side effect.

I have spent over 30 years looking for a high tech solution to a low tech multiple variable problem ( our food intake). The low tech problem is maintaining consistent carbohydrate intake and controlling portion size . I teased our dietitians by telling them that I was going to find a high tech inexpensive handheld gadget to replace them. I have bought a lot of gadgets over the years and I am happy to report that all of my dietitian friends are still working. I do use one iPhone app , "Carb Master" , occasionally .

I have finally given up on my pursuit of the easy perfect gadget and realize that a low tech solution for a low tech problem may be in the palm of my hand.

The "Handy " guide to portion size found in the Lilly Diabetes -My Carbohydrate guide. combined with some of the ideas found in the Mediterranean diet may help overcome some the problems of controlling portion size and consistent carbohydrate intake.

You could point out that using our hands as a measuring tool is not accurate because we all have different size hands . I think this is actually a plus because smaller people have smaller hands and need smaller a portion sizes than bigger people. Remember we are looking for "Handy " available tool to help us control portion size and maintain a more consistent carbohydrate intake.

I have looked at Lilly's "Handy" guide many times in the past and never really use it until I read an article about applying the Mediterranean to our daily lives. Unfortunately I copied this article and missed the name of the author and the source. I believe it was in webMD . I apologize for my mistake and beg for your permission to use your article.

Two things in this article caught my eye ; nuts: a handful each day and vegetables 2 cups /day reminded me of the Lilly Handy guide to portion size .

The idea that my fist is about the size of a cup ,and my thumb is about the size of a table spoon is fairly easy to remember.

Finding a way to work vegetables into my diet has been difficult for me. Remembering to eat a , 1 fist size serving of legumes , 2 fist size serving of other vegetable a day may just work. I have found that eating a handful of mixed nuts each day may be the easiest part of the Mediterranean diet. It is also easier to measure and spread a thumb size portion of peanut butter on a knife than it is to actually use a tablespoon.You can point out that a serving size is 15 Grams of carbohydrate and the portion size will be different for different vegetables and grains. I cup ( 1 fist size ) is about 30 grams of carbohydrate . Remember we are talking about a guide for help in maintaing a more consistent intake of carbohydrates and and a way of adding some of Mediterranean diet ideas to our diet.

Read the article below and focus on " What you can Eat Section " . Simplifying our approach to food intake may just be the low tech idea that works.

I have attached the Mediterranean diet article and Lilly's Handy guide to portion size below.----------------------------------------------------------------------------------------------------

Try your hand at these guidelines for estimating portion sizes*:

page2image22192.pngA fist is about 1 cup or about 30 grams of carb for foods such as 1 cup ice cream or

1 cup cooked cereal.

page2image20624.pngYour thumb is about
1 tablespoon or 1 serving of regular salad dressing, reduced-fat mayonnaise or reduced-fat margarine.

page2image21216.pngYour thumb tip is about 1 teaspoon or 1 serving of margarine, mayonnaise or other fats such as oils.

These portion estimates are based on a woman’s hand size. Hand sizes vary. Measuring or weighing foods is the most accurate way to figure out a portion size.

page2image19760.pngYour palm, not including fingers and thumb, is about 3 ounces of cooked and boneless meat.

*Adapted from: Warshaw, H.S., Kulkarni, K. Complete Guide to Carb Counting 2nd Edition. Alexandria, VA: American Diabetes Association, 2004; and Wondering How Much to Eat? Do the Hand Jive! Diabetes Spectrum 1999; 12:177-178.


he Mediterranean Diet: What It Is

Some experts consider the "Mediterranean diet" -- rich in plant foods and monounsaturated fats -- to be one of the healthiest in the world. The Mediterranean diet has long been associated with heart health and longevity. Beyond that, it can also be an excellent weight loss plan, as long as you eat in moderation.

The Mediterranean coastal region stretches across Europe from Spain to the Middle East. Fifty years ago, scientists noticed that people living in this region tended to be healthy and live long lives, primarily because of their diet and lifestyle. Mediterranean cuisine varies by region, but is largely based on vegetables, fruits, olives, beans, whole grains, olive oil, and fish, along with a little dairy and wine. Additionally, the Mediterranean lifestyle includes leisurely dining and regular physical activity.

Studies show that calorie-controlled diets rich in plant foods, healthy fats, and lean protein -- like the Mediterranean diet -- are a nutritious formula for weight loss. A study in the New England Journal of Medicine found that a Mediterranean diet was as effective as a low-fat diet for losing weight and also offered some metabolic benefits.

"Research continues to demonstrate that being physically active and eating a nutritious diet of primarily whole foods that are filling and satisfying can enable people to control weight," says cardiologist Arthur Agatston, MD, creator of the South Beach Diet, which is based on the Mediterranean diet model.

Some other perks of living the Mediterranean lifestyle include a reduced risk of chronic diseases such as diabetes, cancer, Alzheimer's and heart disease, says cardiologist Robert Eckel, MD, past president of the American Heart Association.

Mediterranean Diet: What You Can Eat

There is not a single "Mediterranean diet." Instead, it's a dietary pattern of plant foods, monounsaturated fats (mainly olive oil), fish, and limited amounts of animal products.

The basic Mediterranean diet pattern is as follows:

  • Legumes: Eat daily.
  • Fruit: 2.5 cups daily.
  • Vegetables: 2 cups daily.
  • Fish: More than twice weekly.
  • Nuts: A handful daily.
  • Meat/poultry: Less than 4 ounces daily.
  • Dairy products: 2 cups of a low-fat variety daily.
  • Wine: 1 daily serving for women, two for men.
  • Fats: Use primarily monounsaturated fats.
  • Eggs: Less than 4 per week.

Some tips for embracing the Mediterranean style of eating:

  • Select whole grains for your breads, cereals, and other starches.
  • Choose nuts, seeds, legumes, fish, low-fat dairy, and poultry to satisfy your protein needs (you can include lean meat on occasion as well).
  • Most importantly, reduce the amount of saturated and trans fats in your diet. Use olive or canola oil instead of butter or margarine.
  • If you choose to drink alcohol, enjoy it as a glass of wine with lunch and/or dinner.

"It's almost too good to be true -- a steaming pasta dish with tomato sauce and herbs, or a grilled piece of snapper drizzled with olive oil and fresh cracked pepper, or a great salad of greens, tomatoes, a crumble of Parmesan, and a drizzle of olive oil and lemon," says K. Dun Gifford, Oldways Preservation Trust president. "Scientists report these dishes are as healthy as it gets."


What do you think about the above idea. ? Do you think it will work ?

Next discussions . How to talk to a dietitian. Have fun , Read food labels . Dr. Calder

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Almost daily blog is behind

I apologize for my delay in getting my almost daily blog done. I have been busy working and also having a few technical problems . My computer is misinterpreting my intentions .
Dr. Calder

Sunday, October 16, 2011

The ultimate brain food and the hand ,fist and thumb idea

The ultimate brain food is glucose. Maintaining a consistent supply of glucose to the brain is regulated by by food intake, insulin, glucagon, liver and other processes. Maintaining the consistent glucose supply is an automatic process for a person without diabetes.. This automatic process is disrupted in someone with diabetes who has to deal with a dysfunctional insulin and glucagon system. One major stumbling block for controlling blood glucose levels in someone with diabetes is how to adjust food intake , primarily carbohydrates , to match their limited or non- existent insulin supply.

The foundation for controlling glucose levels is supported by three pillars , recognition of foods that contain carbohydrate , controlling portion size and maintaining consistent day to day carbohydrate intake.

Many of us get lost with trying to remember serving size , grams per serving , scales , labels , measuring cups and etc. . It is just very difficult to move all of the information from the intellectual part of our brain to the actually doing it section in our brain. I am convinced that the daily practice of an action is necessary for attaining excellence in preforming any task.

Repetition , Repetition , Repetition, Repetition

In my diabetes practice I understood the general principles of diet management but relied on dietitians to hammer the details into the daily habits of my patients. This became a little more personal after I developed pre-diabetes and discovered that diabetes is much easier to talk about than it to deal with on a day to day basis.

I would like to give you a little home work assignment before we proceed.
Use breakfast as your test meal . Decide how many servings of carbohydrate your dietitian ask you eat for that meal . It is probable between 3 and 5 servings. Write down your favorite breakfast foods and the amount you usually eat . Go to our cabinet and read the food labels and focus on the carbohydrate content and try to determine the amount needed for each serving.
You may have noticed . Having diabetes interferes with you daily life. So what, get over it and just do the job.

Over the years I have relied on the Lilly diet sheets for help. Please go to their web site and review their "Food list for meal planning" and "My carbohydrate guide ". The" Meal planning options " below was copied from the lilly website. The hand , fist , and thumb idea may help simplify your food management. Think about it , your hands are usually with you .
Click on" Diabetes Resources " then click " downloadable materials" and download and read, daily meal planning guide My carbohydrate guide.

Tomorrow more discussion of the hand, fist and thumb idea and the Mediterranean diet.

have fun read food labels when you are bored. Dr. Calder

Friday, October 14, 2011

Brain foods and Diabetes

Answers to yesterdays questions.

Name the 4 food groups that contain carbohydrate.--- Fruits , vegetables , grains and milk

New medications that could be taken with glucophage to help improve glucose control with minimal risk of hypoglycemia.

Injectables--------- Byetta( exenatide) or Victroza ( liraglutide )

oral medications----Januvia ( sitagliptin ) or Onglyza ( saxagliptin )

How much carbohydrate should I eat each day?

The information below was taken from the American Diabetes association Standards of care 2011
The optimal macronutrient distribution of weight loss diets has not been established. Although low-fat diets have traditionally been promoted for weight loss, several randomized controlled trials found that subjects on low-carbohydrate diets (<130 g/day of carbohydrate) lost more weight at 6 months than subjects on low-fat diets (136,137); however, at 1 year, the difference in weight loss between the low-carbohydrate and low-fat diets was not significant, and weight loss was modest with both diets. A study comparing low-fat to low-carbohydrate diets, both combined with a comprehensive lifestyle program, showed the same amount of weight loss (7%) at 2 years in both groups (138). Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months with the Atkins low-carbohydrate diet than with higher-carbohydrate diets (139). Changes in serum triglyceride and HDL cholesterol were more favorable with the low-carbohydrate diets. In one study, those subjects with type 2 diabetes demonstrated a greater decrease in A1C with a low-carbohydrate diet than with a low-fat diet (137). A recent meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets (140). In a 2-year dietary intervention study, Mediterranean and low-carbohydrate diets were found to be effective and safe alternatives to a low-fat diet for weight reduction in moderately obese participants (141).

The RDA for digestible carbohydrate is 130 g/day and is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested protein or fat. Although brain fuel needs can be met on lower-carbohydrate diets, long term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability


The take home message is .

Glucose is the primary fuel for our brain and carbohydrate in our diet supplies that fuel .

Your job is to eat foods that supply a consistent amount of glucose for normal function of your brain and nervous system

Eating at least 120 to 130 gms. of carbohydrate a day is a good idea .

I believe that the biggest mistakes many people with diabetes make is is ;
# 1 failing to recognize foods that contain carbohydrate . ( makes glucose control impossible )
# 2 failing to pay attention to portion size ( can increase blood glucose )
# 3 failing to be consistent in their day to day carbohydrate intake ( can cause low blood sugars )
Remember , you are trying to manage food to help deal with your limited supply of insulin.

Tomorrow - counting carbs. is not an exact science . a few tips that may help .
Have fun Dr. Calder

Thursday, October 13, 2011

"Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile, renal function) and/or food preferences. Plant-based diets (vegan or vegetarian) that are well planned and nutritionally adequate have also been shown to improve metabolic control "

Todays focus is on carbohydrates and people with type 2 diabetes

The above quotation was taken from the American Diabetes Association Standards of Care. I believe this is one of the most important statements to to consider when you are considering the latest diet fad or when you are handed a printed diabetes diet sheet and told to follow it. I do not believe that the perfect diet that we should all follow exist . Our eating habits and foods are very specific for each of us. This brings us to dietitians and the value they bring to your overall diabetes care. I have had the pleasure of working a number of great dietitians and I appreciate their knowledge and skills. I also learned the dietitian and diabetes educators can make a doctor look very good .

basic idea- dietitians can help you adjust your existing diet habits to meet the the requirements imposed on you by Type 2 diabetes. Accurate food diaries and analysis by a skilled dietitian is essential to your success.Before you had diabetes your beta cells made just the right amount of insulin to match carbohydrate intake . That is reversed now that you have Type 2 diabetes and you now have to adjust your carbohydrate intake to match your limited ability to make insulin

one big poorly understood reality -- You have insulin deficiency.

If you have Type 2 diabetes then you no longer make enough insulin to eat whatever you want, as much as you want ,whenever you want. This is a concept that is easy to say but difficult to do.
Controlling portion size and being consistent with carbohydrate intake is a difficult requirement for controlling blood glucose levels. We will discuss ideas for being a little more consistent later.

Example case
A 78 y/o man comes in for an office visit with his wife and request a specific diet to to help him avoid reoccurring problems with low and high glucose test and symptoms.He takes glucophage and glyburide. His A1c is 7.8 He has worked with a dietitian and says that he is following the recommended diet. His wife adds one important point. Honey , sometimes you don't feel like eating and skip a meal and eat a snack later and other times you eat 2 or 3 servings of something you really like.
He has forgotten one basic problem of people with type 2 diabetes.He does not make enough insulin. What does this mean in practical terms ? He may make enough insulin to eat 1 piece of bread but not enough insulin to have 2 pieces. Basically any time his carbohydrate intake exceeds his ability to produce insulin his sugar will go up. It is worth talking to a dietitian and trying to adjust his meal carbohydrate intake to match his ability to produce insulin.

What about the low sugars.
He is taking glucophage( metformin) that generally does not cause low blood sugars and if it does it very mild and in the late afternoon. The culprit is his diet and not understanding glyburide. Glyburide is a sulfonylurea drug that stimulates the Beta cells in the pancreas to release insulin with no concern about you insulin needs or your about your carbohydrate intake. If you are taking this medication and for some reason chose not to eat ,your sugar will get to low.
Consistant carbohydate intake is essential if you take insulin or sulonylurea drugs( gyyburide , glipizide and glimepiride are common drugs in this class)

Remember that controlling portion size and being consistent with daily carbohydrate intake is important.

Can you name the 4 food groups that contain carbohydrate?
Can you think of other medications that could be used to reduce our patients risk of hypoglycemia?
How much carbohydrate should we eat each day ?
Answers tomorrow. Dr. Calder

Wednesday, October 12, 2011

Stopping the Heart Disease Pandemic

This coverage is not sanctioned by, nor a part of, the United Nations General Assembly.

From Medscape Cardiology

Stopping the Heart Disease Pandemic

John (Jack) C. Lewin, MD; William Zoghbi, MD

I am generally not a fan of the United Nations however I believe this a noble cause to support, for those of us with Pre-diabetes and diabetes. Heart disease is the major cause of death and disability especially for those people with type 2 Diabetes.
I have attached one part of the discussion that I think is of particular importance to each of us

"Dr. Zoghbi: Believe it or not, I think, it is simple. If we address the very basic principles of the [known] risk factors in these noncommunicable diseases, and they share the whole spectrum of cardiovascular disease, diabetes, and cancer, [then it is] very simple. People were having a problem adopting them, and they're not high tech.
We're not talking about imaging. We're talking about healthy lifestyles -- exercise, not smoking, and knowing what your blood pressure is and making sure that your blood pressure is controlled, which also means a healthy diet, lower salt intake, and an overall healthy lifestyle. ."

I believe the solution for solving this problem lives in each of us and not in the high tech devices and procedures that get much of our attention. I also believe that we are very fortunate in the United States and many other countries to have access to the very skilled cardiologist and cardiovascular surgeons when needed .

I would like to spend the next week discussing each of the recommendations above and search for simple things that we can do each day to help us develop a permanent life style change that will help each of us avoid seeing a cardiologist or heart surgeon. I will start with an easy one first.
Stop smoking
smoking is not smart . It accelerates aging , causes wrinkles, heart disease , cancer and chronic lung disease.
My first patient( the cadaver )mentioned a few days back had scared lungs and a soft ball size hard mass in his chest that could have been prevented by just not smoking.
He could probable been out enjoying life with his family if he had chosen not to smoke . His decision to smoke allowed him instead, to provide valuable anatomy lessons for 4 medical students.
As interns and residents I picked up have some of the unglamorous nick names such as the Pink Puffers and the Blue Blotters . I learned a lot about shortness of breath, ventilators and the need for oxygen from the smokers in our clinics.

As a practicing physician I saw the deadly impact this habit has on patients and there families. I saw people decide to quit on day and just do it and never smoke again. I saw people quit to late and still suffer the damage done by smoking. I also came to understand that;

The same person who decided to smoke is the same person who has to decide to quit .

To smoke or not to smoke is your choice. Make the right choice and enjoy the gift of life.
-------------------------- Dr. Calder

Next . What is a healthy diet and why can't we stay on it ? We will start with the American Diabetes Association ideas and expand from there.

Here is a little sample " Although numerous studies have attempted to identify the optimal mix of macronutrient( carbohydrates, proteins and fats) for meal plans of people with diabetes, it is unlikely that such a combination of macronutrients exist." Stay tuned and let's try to make this dry subject interesting.
Have fun Dr . Calder

Monday, October 10, 2011

little changes in BP and A1c can have big a impact on our lives

Yesterday we discussed cardiovascular risk factor reduction associated small decreases in our weight. Today I would like to review a study done by Dr. Heintjes and presented at the European Society for the Study of Diabetes and reviewed in ,Internal Medicine news by Michele G. Sullivan

LISBON – Even small changes in hemoglobin A1c and blood pressure could significantly reduce the risk of heart attack, stroke, and other cardiovascular complications in people with type 2 diabetes, according to the findings of a population-based observational study.

A 0.5% decrease in HbA1c and a 10 Hg/mm decrease in systolic blood pressure could avert 10% of such events over 5 years,

Those patients with the greatest risk factors – elevated HbA1c, high blood pressure, and higher body mass index – stand to gain the most when they improve those factors, she said.

Dr. Heintjes’ analysis included 5,841 Dutch patients with a diagnosis of type 2 diabetes for at least 2 years. The patients were all taking some form of treatment – oral medications, insulin, or both – for at least 6 months to be included in the study. After examining both baseline data and 5-year outcomes, she was able to extrapolate how improvements in the three risk factors might impact the expected number of cardiovascular events.A multivariable analysis allowed her to extrapolate that 796 cardiovascular events (heart attack, ischemic heart disease, stroke, and chronic heart failure) would occur if all of the patients were followed for 5 years


My interest in this study faded quickly after I realized that she did not actually follow the patients for 5 years . It appears to me the results are the result of a mathematical calculation. This is interesting data but I prefer studies done by researchers following patients in clinics and analyzing actual collected data.

Wait a minute . don't give up on the idea.

I recall one classic study completed in 1998, THe UKPDS study( the United Kingdom Prospective Study. This was a study done on patients with Type 2 diabetes. They found that a small reduction in BP 154/87 to 144/82 resulted in a 34 % reduction in death related to diabetes , a 34% reduction in small vessel disease (eye and kidney damage) , a 44% reduction in strokes and a 56% reduction in heart failure.

This same study also revealed that a 1 point drop in A1c from 8 to 7 reduced the development of eye damage 17 to 21 % ,kidney damage 24 to 33 % and cardiovascular disease 16%. If you were taking metformin the result were even better with a 29% reduction in eye and kidney damage , 39% reduction in heart attacks and a 36% reduction in all cause mortality

Little changes do have a big impact. You can beat this disease with little steps. Celebrate a victory with ever little improvement in this game of numbers.

Play hard , have fun. Dr Calder


Sunday, October 9, 2011

Weight loss,benefits and the obesity paradox

This first light reading article offers a little bit of hope for all of us struggling to lose a few pounds.
Incremental weight loss improves cardiometabolic risk in extremely obese adults. The American Journal of Medicine (2011) 124,931-938

This study involved 208 obese ( BMI 40 to 60 ) people with and without type 2 diabetes. The study demonstrated that cardiovascular risk factors begin to improve with almost any weight loss and continued to improve with each incremental decrease in weight.

Weight loss -------- ----------- 2 to 4.9%---------5 to 9.9 %---------10 to 19 % ------>20 %

blood pressure reduced ---- - 4.9 % ------------ 8.3 % ------------- 4.7 % ----------- 10 mmhg

Fasting glucose reduced ----- none -------------10.5 % ------------18.2 %----------- 25%

Triglycerides reduced -------- 2.4%-------------- 22 %----------------19%--------------37.7%

LDL Cholesterol increased ---2.6% -------------------------------------------------------------
LDL cholesterol reduced --------------------------3.6 %---------------.7%---------------.6 %

HDL increased ------------------------------------------------------------6.9 %------------20%

This article basically demonstrate that improved risk factors for cardiovascular disease occur with almost any weight loss and then gets better for each additional few pounds lost. I think we can celebrate each pound lost as one victory in our battle with diabetes.

I weigh 187 pounds on a good day. Trying to lose 10 % of my body weight (18.7 pounds ) is a big challenge that I have not mentally decided to do . Losing 5% of my body weight( 9.3 pounds) looks possible and I will still gain some benefit according to this article. That is good news even with the fact that this study was done in very obese individuals.

Another article in the same journal, The obesity Paradox and weight loss , is interesting.

Being overweight ( BMI > 25 to 29.5) or obese ( BMI > 30) is associated with numerous risk including hypertension, diabetes, lipid disorders and increased cardiovascular disease. Despite the association between obesity and these conditions, a number of studies have shown that overweight and obese individuals have a better prognosis than the normal weight individuals.

This is the "obesity Paradox"

This study followed 3834 men with established cardiovascular disease for 7 years and found that death rates were higher in the men who lost weight compared to the men who gained weight . A closer look at the causes for death in each group revealed that the men in the weight loss group had other diseases such as cancer, heart failure and others that could explain the difference.. This "unintentional" weight loss resulting from occult disease may be the answer to this paradox.

I think that we can still believe that " intentional " weight loss is associated with a marked reduction in the metabolic syndrome, inflammatory markers, lipids, Blood Pressure , glucose levels and a lower risk of developing cardiovascular disease . Dr Calder

Saturday, October 8, 2011

Lessons from my first patient

I was doing a little light reading this morning in The American Journal of Medicine ,
Vol 24 ,October 2011 and 4 articles got my attention.

The first article, Lessons from my first patient, was written by Lt. Brent W. Casey, MD. He was freshman in medical school at the time and was just starting his anatomy lab. He was looking at the body of a red haired women whose brain had been ravaged by cancer. His professor told the group of students that this lady had written them a letter. She explained in the letter that she was a physician trained in neurology who 1 year ago felt that she had all of the time in the world and was beginning to think of retirement. She discussed her cancer and apologized for leaving her brain in such a mess. Then she left the students with a bit of wisdom." Remember that your first responsibility always is to care for your patients,and don't forget that you may learn more from them if you allow it than any professor can teach you. Always remember , above all else, to give them hope.
All the best, Dr. Ruth Ashland "

Friday, October 7, 2011

This is a good combination pill -sitagliptin and simvastin

From Heartwire > Alerts, Approvals and Safety Changes > Approvals

FDA Approves Diabetes and Cholesterol-Lowering Drug Combo

Michael O'Riordan
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October 7, 2011 (Bethesda, Massachusetts) — The US Food and Drug Administration has approved the first drug combination to be used in the treatment of diabetes and elevated LDL-cholesterol levels [1]. Known as Juvisync (Merck), the new medication combines sitagliptin (Januvia, Merck), a dipeptidyl peptidase-4 (DPP-4) inhibitor used for glycemia control, with the cholesterol-lowering simvastatin.