Wednesday, February 29, 2012

My favorite diet ideas including the DASH diet

My comments about the DASH diet

I have seen many diets come and go. Most of them confirmed my opinion that no one knows exactly 
what some one  else should or should not eat. Many of them left general concepts and principles that
have been useful . For example  I think we all agree that that eating a low salt, low saturated fat diet  
helps control  BP and lowers the risk for cardiovascular disease. Some of my favorite diet ideas are
 listed below.

Mediterranean Diet

I became a fan of the Mediterranean Diet
because of its simplicity and the evidence that it did reduce the risk for cardiovascular disease. It also
seemed like something I could actually do myself

Basic idea

The basic idea of  using  olive oil, eating beans daily, 3 fruits , 3 vegetables, a hand full of nuts , 2 cups 
of low fat dairy , 2 to 3 eggs a week and a glass of wine appealed to me. However I soon found that 
I was real good at eating the handful of nuts and fruit each day However I had problems eating the veggies 
 and I really don't care for wine .

"Most of the time"

 Despite my problems I did work on and have been able to follow the ideas most of the time
 "The most of the time "is another one of those concepts that has been useful. I like the 
90/10 rule high lighted in blue green below.

Lilly Diet sheets

Another idea that I have found useful is the Lilly diet sheet which put serving size into our own hands.
A fist is about 1 cup serving ( 30 gms.of carbs), the thumb is about a tablespoon , palm is a serving size 
of meat and the tip of a thumb is about 1 teaspoon. I also like the idea that this is a calorie self adjusting
 process. Big people have bigger hands and get a larger serving , Little people with smaller hands get 
smaller servings. A overweight person with small hands will get smaller servings and lose weight. The lilly 
hand idea promotes the basic concepts of controlling portion size and  consistent carbohydrate intake.

DASH diet

The Dash ( Dietary Approach to Stopping Hypertension )  Diet is relatively new . I generally thought is was 
just a low salt version of the Mediterranean diet. 
 My interest in this diet peaked after reading an article in
 Internal Medicine news Feb.1, 2012              Diet Reverses " 30 Years of Blood Pressure Aging" 

I have read numerous articles and attached some abstracts , head lines and ADA recommendations
below. I also went to the Dash Diet website and bought 3 months of their diet support. 

Tomorrow the reality of the Dash Diet and my first impressions of their program.

Have fun , Be Smart and Defeat Diabetes
David Calder, MD

Head Lines 
Diet Reverses " 30 Years of Blood Pressure Aging"
Internal Medicine News Feb. 1 , 2012

Dietary Approaches to Stop Hypertension  ( DASH ) Diet applicability and accetability to a UK population
   J.Human Nutr. Diet Feb 2010

Adherence to a DASH-Style Diet and risk of coronary heart disease and stroke in women
 Arch. Internal medicine 2008;168:(7):713-20

Copied from " Standards of Medical Care Diabetes- 2012 "  ADA position statement

Treatment strategies. Although there are no well-controlled studies of diet and exercise in the treatment of hypertension in individuals with diabetes, the Dietary Approaches to Stop Hypertension (DASH) study in nondiabetic individuals has shown antihypertensive effects similar to pharmacologic monotherapy. Lifestyle therapy consists of reducing sodium intake (to ,1,500 mg per day) and excess body weight; increasing consumption of fruits, vegetables (8–10 servings per day), and low-fat dairy products (2–3 servings per day); avoiding excessive alcohol consump- tion (no more than two servings per day in men and no more than one serving per day in women) (230); and increasing ac- tivity levels (219). These nonpharmaco- logical strategies may also positively affect glycemia and lipid control. Their effects on cardiovascular events have not been estab- lished. An initial trial of nonpharmacologic therapy may be reasonable in diabetic indi- viduals with mild hypertension (SBP 130– 139 mmHg or DBP 80–89 mmHg). If the blood pressure is 140 mmHg systolic and/or $90 mmHg diastolic at the time of diagnosis, pharmacologic therapy should be initiated along with nonpharma- cologic therapy (219). 

Maintaining a heart-healthy diet most of the time.

J Cardiovasc Nurs.  2010; 25(3):233-7 (ISSN: 1550-5049)

Christie C
Department of Nutrition & Dietetics, University of North Florida, Jacksonville, FL 32224, USA.
Changing dietary behavior is inherently difficult and even more so given the current obesity-promoting environment. Health professionals may facilitate this process for patients by assessing readiness to change, identifying personal priorities and barriers, and providing personalized knowledge, while increasing healthy-eating skills, motivation, and self-efficacy. It is also important to address the obesity-promoting environment through pubic policy as well as individual dietary change. Implementation of the American Heart Association diet and lifestyle recommendations is discussed along with barriers and recent assessment data. Patients may require assistance with interpretation of recommendations to their specific situations and practical application strategies considering their barriers and needs. One concept that may be helpful is a discussion that dietary change is not an end point but a process. Introducing patients to the 90-10 rule applied to food choices may help them conceptualize this process more easily. This idea revolves around the principle that what an individual does 90% of the time is most critical, and allowing some flexibility can make changing any lifestyle behavior more palatable and achievable.

Saturday, February 25, 2012

Are you losing the Afternoon Snack Battle by not using the right weapons

I was reading a fellow blogger  thoughts on her struggles with controlling her afternoon desire for a snack or two. She basically feels that she does not have enough will power to control this urge.

I Think there is more to this problem than weak will power. 
She may be fighting a  battle, not of her choosing , with the wrong weapons .

Her will power is hobbled  by dysfunction of her Alpha cells  ( produces Glucagon ) and Beta cells (produces insulin and amylin) in her pancreas further complicated by a deficiency go GLP-1 from the intestine.

My question . Is she giving her will power the support it needs to do a better job ?

Lunch with:

A Person Without Diabetes

Her friend without diabetes can eat anything she wants for lunch and the food will very quickly leave the stomach  and trigger the release of GLP-1 from her intestine. Her blood glucose will will increase and trigger an immediate quick release of insulin  and suppression of glucagon  that allows the glucose level to peak in about 1 hour and return back to new normal baseline within 2 hours and stay there until she decides to eat again which can be 2 hours or 8 hours and it really doesn't matter because her liver is gas tank filled with glucose and its output is carefully regulated by glucagon.

A Person With Type 2 Diabetes

Our friend with Type 2 Diabetes can eat the same meal at lunch and may have a different outcome. Eating the meal is no problems but dysfunction exist from there on . Her stomach may or may not empty correctly , her alpha cells  are dysfunctional and inappropriately releasing glucagon  causing her liver to release glucose resulting a higher glucose  at the start of her meal, her beta cell have sluggish and  inadequate insulin release contributing to the problem . This is further complicated by inadequate  GLP-1 from the intestine.

 The outcome of all of this is that she starts her meal with a higher glucose, her insulin arrives to little to late , glucose spills into the urine and then the late arriving insulin arrives and causes a low glucose reading and an intense desire to eat  in the afternoon.

Choose A better weapon and win the battle 

Please read my  Feb. 13 2012 blog  ,New medication, High Cost : Hypoglycemia to the Rescue  , for more detail on the medications discussed below.

 Food choices  ( the amount and type of carbohydrate )and portion size play a role along with with her choices of medications.

 Incorrect insulin use and sulfonylureas make the problem worse .

 Glycophage( metformin ) helps improve insulin function with low risk of hypoglycemia

GLP-1 agonist such as Byetta(exenatide ) Victroza ( liraglutide )  slow stomach emptying , improve insulin and glucagon release , help with weight loss without the risk of hypoglycemia and protect your beta cells.

 DPP-4 inhibitors have similar effects of the GLP-1 agonist without helping with weight loss.

 The right medicine may give your will power  a little R&R

Have fun , Be Smart and Defeat Diabetes
David Calder, MD

Thursday, February 23, 2012

Should I take an aspirin to reduce my risk of having a heart attack ?

Most of use will take an aspirin for pain without any thought of risk.
There is good data to support recommending a daily aspirin for people with" known cardiovascular disease "

There is  a large group of people " without known cardiovascular disease" asking a question.

           " should I be taking an aspirin to lower my risk of a heart attack or stroke ? "

This seems like a simple question that I have mumbled my  answers through  for years. The first problem I have is with the term "known cardiovascular Disease " Most of us have some silent fat build up in our arteries . I also know that we have no safe way of detecting who does and who does not have silent cardiovascular disease. We do know that correcting know risk factors for heart disease lowers our risk of having a heart attack or stroke.  I also know that the risk factors do not tell me the status of a persons arteries at the moment the question is ask. This combinations of uncertainty  turns  a simple question into a complex issue for most doctors.

Dr Ebbert , A professor of medicine at the Mayo Clinic in Rochester, Minn., wrote a short article in the Feb. 1, 2012 Internal Medicine News. He reviewed a large meta- analysis published in the Archives of Internal medicine 2012 Jan. 9  . The data suggest aspirin will prevent one non-fatal heart attack for each 162 patients  and one nontrivial bleed for each 73 patients  treated without known cardiovascular disease.
Basically ,by treating patients with aspirin who are at low risk for cardiovascular disease  may make them bleed.

 I have attached the ADA recommendations and one of my blogs from Dec 1, 2011 for more information on this topic. The decision to take or not take aspirin becomes a personal decision made with advise from your physician.  

Have fun Be Smart and Defeat Diabetes
David Calder,MD

American Diabetes Association Recommendations

Consider aspirin therapy (75-162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-yr risk > 10%). This includes most men > 50 years of age or women > 60 years of age who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (C

• Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men <50 years and women <60 years with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits. (C) 

In patients in these age groups with multiple other risk factors (e.g. 10-yr risk 5-10%), clinical judgment is required (E).

Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD. (A) 

For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. (B)

Combination therapy with ASA (75-162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year after an acute coronary syndrome. (B)

Dec. I, 2011
The question of when and if we should take an aspirin a day has not been completely answered. The article below may help with your understanding of the problem. I suggest that you read the highlighted areas first and then read the whole article if you want more detail. 
Dr. Calder

From Therapeutic Advances in Chronic Disease
Recommending Aspirin for Primary Prevention in Diabetic Patients
What May We Conclude From the Data?
Antonio Nicolucci, MD
Authors and Disclosures
Posted: 05/10/2011; Ther Adv Chronic Dis. 2011;2(3):157-160. © 2011 Sage Publications, Inc.
Physician Rating

Cardiovascular (CV) disease is the leading cause of morbidity and is responsible for premature mortality in patients with diabetes [King et al. 1998]. In addition to its association with multiple classical CV risk factors, diabetes is associated with accelerated atherosclerosis and inflammation that contribute to the pathogenesis and progression of vascular complications [Evangelista et al. 2005]. For this reason, antiplatelet therapy is considered an essential component of diabetes care to reduce ischemic risk [Angiolillo, 2009].
Aspirin has been on the market since 1899, and is still one of the most widely used medications for the treatment and prevention of CV disease. Despite such a long history of use, the role of aspirin for the primary prevention of CV events in individuals with diabetes is still a matter of debate. The new evidence made available in the last few years seems to have increased, rather than resolved, all the doubts regarding the risk–benefit profile of antiplatelet therapy. The uncertainty surrounding this topic is clearly demonstrated by the extreme heterogeneity in the recommendations issued by different scientific societies. As an example, until 2008, the American Diabetes Association recommended the use of aspirin for primary prevention of CV events in all individuals aged over 40 years or with additional risk factors [American Diabetes Association, 2008]. This recommendation was graded as A, that is, supported by evidence of the highest quality. In 2009, while maintaining the same recommendation, grading was changed to C (evidence from poorly controlled studies) [American Diabetes Association, 2009]. In 2010, the recommendation to use aspirin in the primary setting was changed to include individuals with a 10-year risk of CV events >10% (i.e. most men over 50 years of age and most women over 60 years with at least one additional risk factor). The recommendation was attributed a C grading [American Diabetes Association, 2010]. A completely different conclusion was reached by the Canadian Diabetes Association in its 2008 recommendations, where it was concluded that there is no clear evidence to support the prescription of aspirin to the vast majority of patients with diabetes, leaving aspirin use to individual clinical judgment [Bhattacharyya et al. 2008]. Guidelines issued by the Scottish Intercollegiate Guidelines Network (SIGN) in 2010 go even further, by considering the evidence on the lack of efficacy of aspirin strong enough not to recommend its use for primary prevention of CV events (A grading) [SIGN, 2010].
Then the question is: ‘what is the body of evidence leading to such divergent conclusions regarding the efficacy of aspirin in individuals with diabetes?’
In 2002, a meta-analysis (287 trials, 135,000 participants) on the efficacy of antiplatelet therapy in the prevention of major CVevents found a clear benefit of aspirin overall (22% risk reduction), but no statistically significant benefit in the subgroup of 5126 participants with diabetes (7% risk reduction) [Antithrombotic Trialists' Collaboration, 2002]. Consistent with the findings of the meta-analysis, a subgroup analysis of the Primary Prevention Project in 1031 diabetic patients showed that low-dose aspirin only marginally reduced the risk of major CV events after 3 years of follow up (relative risk [RR]=0.90; 95% confidence interval [CI] 0.50–1.62) [Sacco et al. 2003]. On the same line, results of the Women’s Health Study documented in 1027 women with diabetes that treatment with low-dose aspirin was associated with a nonsignificant 10% reduction in the risk of major CV events when compared with placebo (RR=0.90; 95% CI 0.63–1.29) [Ridker et al. 2005]. This overall effect was the net result of a reduction in the risk of stroke (RR=0.46; CI 0.25–0.85), associated with an increased risk of myocardial infarction (MI) (RR=1.48; CI 0.88–2.49).
Controversies about the role of aspirin have been refueled by the results of two recent trials. The Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial was specifically designed to address the issue of aspirin therapy for the primary prevention of CV events in diabetes [Ogawa et al. 2008]. The trial, including 2539 patients with type 2 diabetes, showed that after a median follow up of 4.37 years, aspirin therapy was associated with a nonsignificant 20% reduction (hazard rating [HR]=0.80; CI 0.58–1.10) in the risk of the primary composite endpoint, including fatal or nonfatal ischemic heart disease, fatal or nonfatal stroke, transient ischemic attack, and peripheral arterial disease. In a subgroup analysis restricted to individuals aged 65 years or older, a marginally significant reduction in the incidence of the primary endpoint was documented in patients treated with aspirin compared with controls (HR 0.68; CI 0.46–0.99). A major limitation of the study was represented by the inadequate statistical power, determined by a rate of events much lower than expected.
The Prevention of Progression of Arterial Disease and Diabetes (POPADAD) study involved 1276 patients with asymptomatic peripheral arterial disease, followed up for a median of 6.7 years [Belch et al. 2008]. The study found no evidence of benefit of aspirin on CV events and mortality, despite a baseline CV disease risk in the study population close to 3% a year. Nevertheless, the POPADAD trial was largely underpowered, due to an observed event rate less than half that hypothesized and the recruitment of 1276 patients instead of 1600 as planned. Further to this, only 50% of the patients were still taking aspirin after 5 years.
The persistence of a substantial uncertainty was further confirmed by the publication of two meta-analyses summarizing the results of trials testing aspirin in individuals with diabetes [Zhang et al. 2010; De Berardis et al. 2009]. Overall, aspirin use in primary prevention was associated with a 10% relative reduction in the risk of major CV events (CV death, nonfatal MI, nonfatal stroke). Such an effect was mainly attributable to a significant reduction in the risk of nonfatal MI in men, and to a reduction in nonfatal stroke in women. No clear effect on CV and overall mortality was documented. These findings were further confirmed by the recent Antithrombotic Trialists’ Collaboration (ATT) meta-analysis [Antithrombotic Trialists' Collaboration, 2009], based on individual patient data deriving from six large primary prevention trials. The meta-analysis showed that both in patients with and without diabetes aspirin decreased the risk of major CV events by about 10%.
Overall, these findings suggest that the benefits of aspirin in the primary prevention setting could be lower than expected on the basis of the results obtained in secondary prevention. It is therefore important to weigh the documented benefits against the risks of intracranial and gastrointestinal bleeding. It is estimated that low doses of aspirin cause one or two cases of major bleedings for 1000 individuals treated for one year [McQuaid and Laine, 2006]. Such a risk is probably higher in the real-world setting [Hernandez-Diaz and Garcia Rodriguez, 2006], and exponentially increases with age, being particularly elevated in the elderly. Further to this, the recent ATT meta-analysis suggests that diabetes per se may be associated with a 55% higher risk of gastrointestinal bleeding and a 70% higher risk of intracranial bleeding compared with individuals without diabetes [Antithrombotic Trialists' Collaboration, 2009]. Therefore, given the lack of specific safety data in individuals with diabetes, the assumption that major side effects of aspirin are rare should be taken with caution.

How should we use this information in clinical practice?
Taken together, existing evidence does not support strong recommendations to use aspirin in the primary prevention of CV events in all people with diabetes. From recent studies it can be estimated that the incidence of major CV events in people with diabetes and without prior CVevents is between 10 and 20 per 1000 person years. Assuming a RR reduction associated with aspirin treatment of about 10%, as suggested by the different meta-analyses, 1000 people need to be treated for one year to prevent one or two major CV events. Therefore, the expected benefits might not exceed the risk of major bleedings, particularly among people at low-intermediate CV risk (i.e.>15% over 10 years), or among older patients (>70 years) at high risk of bleeding. Although preventing one episode of MI or ischemic stroke can be considered far more important than provoking a transient episode of gastrointestinal bleeding, the lack of evidence of benefit of aspirin use on CV mortality might also suggest that antiplatelet therapy only prevents the less severe forms of MI or stroke.
Further to this, we completely lack information regarding the possible differential role of aspirin in individuals with type 1 and type 2 diabetes. Epidemiological data suggest a harmful effect of hyperglycemia on CV risk, not only for type 2, but also for type 1 diabetes [Turnbull et al. 2009; Juutilainen et al. 2008]. Nevertheless, given the profound differences in the pathophysiology of type 2 diabetes compared with type 1 diabetes, particularly as far as insulin resistance is concerned, the extrapolation of trials results, including mainly or exclusively individuals with type 2 diabetes, to type 1 diabetes is not warranted.

As for the dose of aspirin, evidence from the ATT collaboration meta-analysis suggests that the benefits obtained with low doses (75–162 mg/day) are similar to those obtained with higher doses (500–1500 mg/day) [Antithrombotic Trialists' Collaboration, 2002]. Although platelets from patients with diabetes have altered function, it is unclear if higher doses of aspirin are required in the patient with diabetes [Pignone et al. 2010]. In fact, many alternative pathways exist for platelet activation and aggregation that are independent of thromboxane A2 and thus not sensitive to the effects of aspirin [Evangelista et al. 2005]. Therefore, while platelet activation appears higher in patients with diabetes when measured by a variety of ex vivo and in vitro methods, these observations alone are insufficient to recommend empirically higher doses of aspirin [Pignone et al. 2010]. Furthermore, it remains to be established whether diabetes represents a specific case of ‘aspirin resistance’, related to accelerated platelet turnover making the 24-hour dosing interval inadequate to suppress completely platelet cyclo-oxygenase [Davi and Santilli, 2010].

The role of aspirin in the primary prevention of CV disease in people with diabetes will probably be clarified by ongoing trials. Two trials, A Study of Cardiovascular Events in Diabetes (ASCEND, International Standard Randomized Controlled Trial Number ISRCTN60635500) and the Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes (ACCEPT-D) [De Berardis et al. 2007], will enroll more than 15,000 participants. In addition, the Japanese primary prevention project [Teramoto et al. 2010], involves 14,466 elderly patients, one third of which have diabetes. While awaiting new, firm data, it seems prudent to consider aspirin not indicated for individuals with a 10-year risk below 10%, while the decision to prescribe it in individuals with a moderate risk (i.e. 10–15%), must be taken on an individual patient basis, after a careful evaluation of the balance between the expected benefits and the significant risk of major bleeding. Finally, given the currently available limited evidence, it seems reasonable to suggest that patients at high intermediate risk (i.e. >15%) and higher, and without contraindications for aspirin, probably warrant treatment.

Wednesday, February 22, 2012

Fixing The 9 ,prevents heart disease and amputation

I was reading Internal Medicine News this morning and one article got my attention.

 Amputations decline 65% in Diabetic patients
      by Diana Mahoney
    The major finding was , the rate of hospitalizations for non traumatic amputations has decreased from 11.2/1000 persons in 1996 to 3.9/1000 persons in 2008. This informations was collected and reported by the Centers  For Disease Control (CDC )

This is good news and probable means that we are all doing a better job with preventive  health care.

The bad news was reported in Diabetes Care 2012;35: 273-7. They reported that even with the significant decline in amputations , the amputation rate is still eight times higher than in the non-Diabetic population.
(3.9 vs 0.5 persons per 1000)

comment ;
      When was your last Diabetes Foot Exam ?

      Do you know what a Diabetes Foot Exam is ?  It is more then a quick look at your foot

 This  subject brings up something that has bothered me for years about our approach to diabetes care. 

Diabetes  risk management by default is primarily physician and institution based .
I helped develop a  computer assisted Diabetes Wellness Assessment Program  (DWAP) for my medical group with a goal of reducing the risk of heart disease and other diabetes complications. This was very successful in improving diabetes risk factor management . However, even with the  great effort and expense by the doctors , nurses , diabetes educators and administration , we were not 100% successful .
We had the most success in test and exams that were set up to be done automatically such as lab. test and we had the least success with test and exams requiring input and recall by patients, physicians and staff with things like foot exams and achieving some of the goals.

I have felt for a long time that one essential ingredient in our plan was overlooked. 

We neglected to adequately empower each patient with the responsibility for their own care and
we also made risk management to complicated.

 Finding a way to Simplify diabetes care and Empower Patients to be more involved in their own care was the reason for me writing  , Diabetes Office visit .

The basic principle of the book and iPhone , iPad app is to empower patients to set target goals for their test and exams, then reach those goals with the help of their doctor and prevent the complications of diabetes.

 I manage to hide these basic concepts with to much verbiage, discussing back ground and studies supporting the reasons for the test. 

 My son in law, Vince,  and Herman Cain  helped me simplify and make my idea more useful. 

Herman Cain promoted the idea of his 9-9-9 plan for simplifying our tax code.

My son in law helped me realize that reaching diabetes treatment goals is simply a game of numbers and that understanding the numbers is not necessary for fixing them.

 The understanding and meaning of those numbers will come with time and repetition .

So I have now shortened my book  concept to Fixing the 9 for people with Diabetes and Fixing the 6 for non -diabetics with a primary goal of reducing the number one killer for all of us , Heart Disease

Fixing those 9 risk factor will have a little side benefit of reducing the risk of eye and foot problems

please go to the Diabetes office Visit Training Video  tab above for more information on goals setting and risk management ideas . I developed the video for Iphone and iPad users but it help you understand the ideas behind goal setting and risk management .

Have fun , Be Smart  and Defeat Diabetes,
David Calder,MD

Monday, February 20, 2012

Should Sulonylureas be retired ?

Should sulfonylureas be retired  ?

 My answer is a strong YES .
      The short answer is that we have better safer medications that actually preserve Beta cell function. The sulfonylureas  are just as effective at lowering abnormal glucose  levels but at the cost of increased risk of hypoglycemia , they seem to burn out any  remaining Beta cells , cause weight gain and are suspect for increase risk of cardiovascular disease . 

These medicines served us very well and helped a lot of people when the only choices of medications for type 2 diabetes was animal based insulins and sulfonylureas . Technology and better understanding of type 2 diabetes has made dramatic improvements in diabetes care  and these drugs should join urine glucose test and move into the history of diabetes care.

Names on my list for receiving a gold watch and a slap on the back for a job well done during their day
                              chlopromamide ( Diabinase )
                              tolazamide ( Tolinase)
                              Glipazide (Glucatrol )
                              gliclazide (Damicron )
                              Glyburide ( Diabetea, Glynase )

                              Glimapiride ( Amaryl ) Amaryl could remain on the on call list for the occasional
                              patient who could benefit .
 Will they be retired is probable no ?
          These meds will not go away because they are inexpensive and they are effective for lowering
          glucose levels.

Have Fun , Be Smart and Defeat Diabetes
David Calder,MD

Saturday, February 18, 2012

Diabetes Office Visit App. updates are almost complete

New updates are almost complete on the iPhone,iPad App. The update will include the ability to view your lab. results in mg/dl or mm/l .  Data entry for goal setting and cardiovascular risk risk management is improved. The next update will make Diabetes Office Visit App available for mac computers and Pc computers.

Diabetes Office visit App iTunes add update

I have revised my iTunes  explanation of  the Diabetes Office  Visit App.  Comments ,corrections and discussion is welcome .

The only comprehensive diabetes management App - see more 
**CREATED BY David Calder MD to provide an always at your finger tips comprehensive diabetes management tool , that will simplify your diabetes care and help you preserve your good health. 
                                         "  Diabetes Office Visit app.  " is designed to help you , 
                                             Set goals> reach goals> and prevent complication 
                                          :" Diabetes office visit app " is designed specifically to deal with all risk 
                                             associated with having Diabetes. 
                                            Diabetes control is more than just controlling blood glucose levels. 
                                            Cardiovascular disease is the major risk for people with Diabetes and 
                                            pre -diabetes.
     " RISK MANAGEMENT SECTION "     provides the tools for tracking and managing the risk factors ( Blood 
                                                            Pressure , LDL cholesterol , HDL cholesterol , Triglycerides , Apo b 
                                                            levels and albumin/ creatinine ratio ) associated with Diabetes and 
                                                            heart disease.

      "GOAL SETTING SECTION "             provides you with the recommend target goals and the ability to 
                                                             adjust those goals to meet your specific situation.
                                                             Having target goals makes diabetes care much simpler. If you know
                                                             the target goals- then any thing that is not meeting that goal is a
                                                             reason for discussion with your physician
                                      ” YOU FAIL TO ACHIEVE 100% OF THE GOALS YOU DON'T SET”. 
     " GLUCOSE MANAGEMENT SECTION " is designed by me to present the the information needed by you
                                                                and your physician to make management decisions . Collecting 
                                                                and presenting the right  data to your health care provider is 
                                                                crucial to making the correct glucose management decisions. 
                                                               You can follow just your glucose results or add carbohydrate 
                                                               intake, exercise or medications if needed.
                                                               The ebook discusses when to test and how to  present your data to
                                                                your health care provider. 
     " e BOOK SECTION "                          Provides all of the above tools , plus a better understanding of 
                                                               treatment goals and a light hearted look at our diet problems and 
                                                               geezerhood treatment decisions and diabetes .
                                                              Diabetes office visit deals one of the biggest diabetes associated
                                                              risk , COMPLACENCY .
                                                                       (the feeling of quite security often while unaware of a 
                                                                        potential danger )
    " DIABETES OFFICE VISIT WEB SITE "   This web site and "The Doctor is in"  section is designed to answer 
                                                               any diabetes related questions and includes a almost daily blog 
                                                               focused on improving your understanding of basic management 
                                                               concepts.  The 10 minute App training video will help you find and
                                                               use all of this app's features.
      You and I , as patients ,are ultimately responsible for managing all of the aspects of diabetes care. 
       Imagine what could happen if, each of us accepted the privilege and responsibility for   
       maintaining our own good health. Diabetes Office Visit App. provides you with the tools to make this 
       this happen 

       You can also reach me  email           
                                            Regular mail —- Diabetes office Visit PO BOX 1170 Creswell, Oregon 97426 
I will do my best to make this app work for you.
One of the technical issues we had in development was the inability of me to make test and corrections prior to its release. This resulted in 8 updates over 3 to 4 months as I found and corrected Items that did not meet my goals. I apologize for that problem 
If you are unhappy with the app for any reason i will refund your money . 
                 Thank you , have fun  and be smart . You can defeat diabetes
                                                                                                                  David Calder, MD 
This eBook and App is written by David Calder,MD  , a diabetes specialist with over 35 years of experience , who worked hands on to design this app to help patients better manage all aspects of 
their diabetes care. This app taps the knowledge and experience of Dr. Calder to  help you get more out of each doctor's visit .

Cancer survival, another reason to take glucophage( metformin )

 Reducing the risk of and the damage done by cancer is another benefit of taking Glucophage 
( metformin ) . The abstract below supports the use of metformin as the first  choice of medications for people with Type 2 Diabetes. It also provides another reason to retire all of the sulfonylureas from the list of medication used to treat Type 2 Diabetes . 

Tomorrow, more reasons to retire sulfonylureas . 

Have Fun be Smart and Defeat Diabetes
David Calder,MD

Diabetes Care. 2012 Feb;35(2):299-304. Epub 2012 Jan 20.

Mortality After Incident Cancer in People With and Without Type 2 Diabetes: Impact of metformin on survival.


Corresponding author: Craig J. Currie,


OBJECTIVE Type 2 diabetes is associated with an increased risk of several types of cancer and with reduced survival after cancer diagnosis. We examined the hypotheses that survival after a diagnosis of solid-tumor cancer is reduced in those with diabetes when compared with those without diabetes, and that treatment with metformin influences survival after cancer diagnosis. RESEARCH DESIGN AND METHODS Data were obtained from >350 U.K. primary care practices in a retrospective cohort study. All individuals with or without diabetes who developed a first tumor after January 1990 were identified and records were followed to December 2009. Diabetes was further stratified by treatment regimen. Cox proportional hazards models were used to compare all-cause mortality from all cancers and from specific cancers. RESULTS Of 112,408 eligible individuals, 8,392 (7.5%) had type 2 diabetes. Cancer mortality was increased in those with diabetes, compared with those without (hazard ratio 1.09 [95% CI 1.06-1.13]). Mortality was increased in those with breast (1.32 [1.17-1.49]) and prostate cancer (1.19 [1.08-1.31]) but decreased in lung cancer (0.84 [0.77-0.92]). 
When analyzed by diabetes therapy, mortality was increased relative to nondiabetes in those on monotherapy with sulfonylureas (1.13 [1.05-1.21]) or insulin (1.13 [1.01-1.27]) but reduced in those on metformin monotherapy (0.85 [0.78-0.93]). 
CONCLUSIONS This study confirmed that type 2 diabetes was associated with poorer prognosis after incident cancer, but that the association varied according to diabetes therapy and cancer site. Metformin was associated with survival benefit both in comparison with other treatments for diabetes and in comparison with a nondiabetic population.