Unlikely fixable connections , Snoring and Type 2 Diabetes

 A mix of seemingly unrelated symptoms ! one Diagnosis
                                   Obstructive Sleep Apnea a Case study

72 y/o male with a recent problem of syncope and near syncope.
The symptoms started about 1 year ago  with the occasional sudden onset of nausea and a feeling that he needed to sit down. The sensations lasted about 2 minutes and would pass without any residual symptoms. There was no pain or shortness of breath.The symptoms became more frequent occurring about once a month in groups of about 3 to 4 within a 24 hours time span. The symptoms occurred when sitting , walking , eating dinner and doing hard work. One episode occurred while using a weed eater and he fell down.

 His physician ordered a  24 hour  heart monitor test  revealing an electrical conduction problem , junctional rhythm. He was referred to a cardiologist and a diagnosis of vasovagal  attacks ( fainting ) was made. He was given some exercises to do and told to discontinue his blood pressure medications amlodipine and HCTZ .


The symptoms continued . 

His wife observed one episode while they were on a daily walk. He complained of the unusual nausea sensation and the urge to sit down. She observed that he was pale, sweating and unsteady on his feet . The symptoms lasted less than a minute  and they continued their walk.

The next episode occurred while driving causing him to hit a small road sign . He did have the nausea but nothing else with this episode. He felt that he just dropped of to sleep.
They discussed his long history of sleepiness when driving , some times having to stop and take a nap in less than 100 miles into a trip. The desire to sleep when driving has been very intense for many years.  Driving became a hard unpleasant chore  for years because of his struggle with drowsiness.  He always just attributed this symptoms to fatigue and long hours working. He recalled similar sleepiness dating back to his first year in college.

He saw his physician again to discuss the more severe symptoms and to discuss the question of driving safety.His physician listened to the history again , examined his neck , mouth ,weight , and suggested the idea of sleep apnea. 


    He was referred to a sleep specialist who agreed with the diagnosis and ordered a home overnight sleep test. The test was positive and confirmed the diagnosis of Obstructive Sleep Apnea. A more comprehensive in hospital overnight test was done again confirming the diagnosis.

CPAP treatment was ordered and started . The patient was amazed at how easy and comfortable  the CPAP machine was to use. He now looks forward to going to bed and sleeping soundly all night.

This was a big previously unrecognized change for him and his wife .
 He no longer keeps her awake with his snoring  . The sweating , restlessness and having to get up at 3 or 4 in the morning is also gone. He now sleeps 6 to 7 hours each night.

 His other medical problems , include mild high blood pressure and Pre-Diabetes, which started about 10 to 15 years ago.


Results of  8 months of CPAP treatment
  
     * No further vasovagal  symptoms 
     *No syncopal episodes
     * No sleepiness when driving. He and his wife have taken two road trips , totaling over 5000
        miles.  He actually enjoyed driving again.
     * His blood pressure has averaged below 140 systolic without medication. He recently restarted 
       a mild diuretic to help keep his BP below his target  goal of 130. He will  recheck his A1c test
       with his wellness exam in June.


Comment:
This case demonstrates the long unintentional delay in diagnosing sleep apnea starting with the early onset of a common everyday things such as snoring . This can be followed by a mix and gradual  addition of seeming  more unrelated things such as sleepiness while driving , mild hypertension , vasovagal symptoms , heart rhythm disturbances and Pre-Diabetes. 


Family history also needs to be considered. The above patient recalls, as a child , listening to his dads loud snoring and pauses in breathing  that seem to echo through the house. I know of another family with the father and 2 sons with obstructive sleep apnea.


I suspect that the above patients symptoms started over 20 years ago. 


Earlier Diagnosis
I believe that earlier diagnosis is possible if we pay closer attention;
         #1 to the first clue , Snoring


         #2 Make better more frequent use of the overnight home test for sleep apnea 
              and sleep specialists. 


         #3 consider family history of sleep apnea as another clue


Have fun , Be Smart-   stop snoring , live longer
David Calder, MD


                                                  
      

Sleep apnea explained in one good sentence

I looked up Obstructive sleep apnea in PUBMED and found a list of 24,784 articles . I reviewed the first 100 looking for more information on the metabolic effects of Obstructive Sleep Apnea. One well constructed sentence high lighted in the article below does a good job explaining the underlying correctable problems of sleep apnea.


"Some of the mechanisms by which sleep apnea contributes to the development of hypertension are intermittent hypoxia and/or increased upper airway resistance associated with sleep apnea that induces a sustained increase in sympathetic nervous system activity."


In fact almost every sentence is worth reading . 
 "The prevalence of sleep apnea syndrome is relatively high in population (5%)."


"There is an increased rate of car accidents in the subjects with OSA compared to those who don't have this syndrome (31% versus 6%)." 


"The association between OSA and hypertension has been much debated. The prevalence of hypertension among patients with OSA varies between 50-58%, while the prevalence of OSA in hypertensive patients is 30%. 
A particular association is OSA and resistant hypertension, i.e. blood pressure that remains above goal in spite of the concurrent use of three antihypertensive agents of different classes, one to be a diuretic and all pharmacological agents being prescribed at recommended doses."

"The impact of OSA on mortality is also given by its association with a significant number of cardiovascular diseases".

*

Pneumologia. 2011 Oct-Dec; vol. 60(4) pp. 202-7

[Sleep apnea syndrome -- cause of resistance to treatment of arterial hypertension].

Frenţ S, Tudorache V, Ardelean C, Dimitriu D, Lighezan D, Gaiţă D, Mihăicuţă S

The prevalence of sleep apnea syndrome is relatively high in population (5%). The mortality is significantly higher in those with apnea-hypopnea index >20. There is an increased rate of car accidents in the subjects with OSA compared to those who don't have this syndrome (31% versus 6%). The impact of OSA on mortality is also given by its association with a significant number of cardiovascular diseases. The association between OSA and hypertension has been much debated. The prevalence of hypertension among patients with OSA varies between 50-58%, while the prevalence of OSA in hypertensive patients is 30%. A particular association is OSA and resistant hypertension, i.e. blood pressure that remains above goal in spite of the concurrent use of three antihypertensive agents of different classes, one to be a diuretic and all pharmacological agents being prescribed at recommended doses. Secondary causes of hypertension are common in patients with resistant hypertension. Among these causes, one of the most frequent is sleep apnea syndrome. Some of the mechanisms by which sleep apnea contributes to the development of hypertension are intermittent hypoxia and/or increased upper airway resistance associated with sleep apnea that induces a sustained increase in sympathetic nervous system activity. Treatment of sleep apnea with continuous positive airway pressure devices (CPAP) improves blood pressure control, although the benefit of CPAP evaluated in clinical trials is variable.

Comment. 

I was impressed by the number of articles discussing the various effect of Obstructive Sleep Apnea on the heart. It is listed as an independent risk factor for cardiovascular impairment .It is associated with structural and functional changes in the heart. Electrical conduction problems  with Rhythm disturbances such as Atrial fibrillation and heart block.  

Pre-diabetes, Type 2 Diabetes and elements of the Metabolic Syndrome are associated with this disorder.

I personally believe that the diagnosis of obstructive Sleep Apnea is delayed for years because almost everyone snores and the other vague symptoms of tiredness , daytime sleepiness especially when driving a car are just overlooked by patients and doctors . The association with multiple  other serious disease states are often just not linked to this disorder. 

I will present a case tomorrow that exhibits bits and pieces of all of the above.

Have fun , Be Smart and Think of Sleep Apnea

David Calder,MD

Is sleep apnea a correctable cause of Pre-diabetes and hypertension ?

The common symptoms of  obstructive sleep apnea ( collapse of the upper airway during sleep resulting in decrease airflow and drops in blood oxygen levels (hypoxia) include ) ;

Snoring, daytime sleepiness , sleepiness driving a car , fatigue and is often associated with obesity and a narrowed upper airway. Your doctor may become suspicious of obstructive sleep apnea after listening to your symptoms and examining your neck and throat. Referral to a sleep specialist and/or having a home sleep apnea screening test done will help confirm the diagnosis. Consultation with a sleep specialist is recommended to help rule out the less common form of this disease , Central Sleep Apnea.

What about those subtle metabolic effects  associated hypoxia and intermittent  upper airy obstruction .

#1. increased insulin resistance
                (May correct within 2 days to 3 months depending on a persons weight with CPAP)
#2. prediabetes
#3. mild high blood pressure
#4. Vasovagal syncope ( occurrence  of "fainting "peaks at age 20  and 70 )
#5. probable link to cardiovascular disease and obesity


The diagnosis and treatment of obstructive sleep apnea is often delayed for years due to the vague non specific symptoms.  
Check in tomorrow for more details on the metabolic effects of sleep apnea and a review of a typical case.


Have fun Be Smart and diagnose a treatable  potential reversible  cause for Pre-Diabetes , mild high blood pressure and vasovagal syncope.


David Calder,MD

Home sleep apnea test. The method of choice?

I have sleep apnea and used the home sleep apnea test as a screening test to make the diagnosis of obstructive sleep apnea. The home test was very easy.

 I went to the sleep lab. and was quickly trained how to use the equipment . Basically , a technician placed a small device on my wrist with a smaller cap covering the tip of my index finger. I went home and had what I thought was a good nights sleep (about 7 hours.)

 My "good nights sleep" was a bad night metabolically.
My oxygen levels dropped into the 70 's   (98 to 100 is normal )ninety nine timeswithout my awareness.  I was diagnosed with obstructive sleep apnea and was asked to return for a more comprehensive test in the overnight hospital sleep laboratory. The diagnosis was confirmed and CPAP (Continuous Positive Airway Pressure ) was recommended.

The CPAP equipment is very sophisticated and tracks and monitors  a lot of data, including the pressure required to overcome the airway obstruction. The pressure required to overcome the airway obstruction was one of the important bits of information obtained with the overnight test done in the hospital sleep lab.

In retrospect I believe that I could have avoided the overnight hospital stay and used the home test to make the diagnosis and the CPAP equipment to adjust the air pressure required for treatment.

A recent article published in Am.J.Respir.Care Med. 2011;183: 1238-44 found no  significant difference  in the 3 month out come between patients diagnosed with the Home Sleep Apnea test and the more comprehensive overnight hospital test.

I personally believe the home test will become the method of choice for uncomplicated cases. .  The simplicity  and lower cost of the home test will make it available to more people.

It is a good idea to discuss the home test with your physician if you have  any of the subtle symptoms of sleep apnea.
 What are the subtle symptoms of sleep apnea?

Have fun , be Smart and Google sleep apnea symptoms ,
David Calder, MD

Gut surgery cures for Type 2 Diabetes ? Be careful!!!!!

I was recently ask for my opinion regarding a surgical procedure that may cure Type 2 Diabetes.
I have attached the discription of the planned surgery below.

I have noticed that some surgeons tell patient that various gastrointestinal surgeries will cure Type 2 Diabetes. I think what they really mean is that gastrointestinal surgery will help patients manage their diabetes. 


 Surgery may help manage the Type 2 Diabetes,
 but it will not cure diabetes because of one problem :

 Insulin deficiency. 

Insulin deficiency is a basic component of Type 2 diabetes.
Type 2 diabetes is associated with a progressive process of beta cell damage and failure over years with worsening insulin deficiency. The slide below was produced by the International Diabetes center illustrates  the process.



Don't be discouraged by the above slide.
Some of the newer diabetes medications are able to slow the damage and help preserve Beta cell function
see my discussion Feb. 9 ,2012    Glucophage failed , Now what should I do ?

Surgery is not risk free
Surgically altering the gut ,especially the ilium , is not without risk,and will not change a genetically driven process in the Beta cells of the pancreas

 If you are thinking about this type of surgery be sure to ask about the significant serious side effects. I have taken care of some very sick people who have had older similar procedures. Talk to your primary care doctor for advice and ask for another surgical opinion.

Have fun ,be smart , be careful and defeat diabetes
David Calder,MD
----------------------------------------------------------------------------------------------------------------------




 The purpose of the study is to determine if by performing surgery we can cure Type II Diabetes. The surgical procedures: a sleeve gastrectomy, cutting out a portion of the stomach, which provides restriction of caloric intake and rapid gastric emptying. ileal transposition which involves repositioning a 150cm segment of the ileum into the jejunum causing improved glucose homeostasis. Condition Intervention Type 2 Diabetes Mellitus Procedure: Sleeve Gastrectomy and Ileal transposition Dietary Supplement: dietary and medical management

Diabetes- knowing the risk is our advantage

  I just read an article abstract , Duration of Diabetes and risk of ischemic stroke: Manhattan Study. They concluded that people with diabetes were at increased risk compared to those without diabetes.
This is not an unexpected finding and I did not put this in todays blog to increase any ones anxiety about their health.

                                     we know 


Those of us with pre diabetes and diabetes already know that we are at increased risk of vascular  disease. We have heard about this from our doctors, diabetes educators, friends and relatives.

                  We know the enemy


The fact of knowing about the risk is our advantage. We know the enemy.
We know the names and faces of the risk factors .


          We know we can defeat the enemy


Blood pressure control
* for every 10mmhg decrease in systolic BP reduces the risk of any diabetes complication by 12%


* BP control reduces the risk of heart disease and stroke 33 to 55%


* UKPDS study demonstrate in people with Type 2 Diabetes that reducing BP from 154/87 to144/82
    produced a- 24% reduction in any adverse  diabetes outcome
                      - 34% reduction in death related to diabetes
                      - 37% reduction in eye, nerve and kidney damage
                      - 44% reduction in stroke
                      - 56 % reduction in heart failure

LDL Cholesterol control
*  CARDS study  - taking lipitor  ( Atorvastatin10 mg /day)  resulted in:
                        - a 36% reduction in acute coronary events
                        - a 31% reduction in coronary bypass surgary
                        - a 48% reduction in strokes
                        - a 27% reduction in death



Blood Glucose Control
   A1c reduced from 8 to 7 (UKPDS study  in people with type 2 diabetes) resulted  in:
                         - a 16 % reduction in heart disease in people 
                         - a 24 to 33 % reduction in kidney damage
                         - a 17 to 21 % reduction in eye damage


  A1c reduced from 9 to 7 ( DCCT study in people with Type 1 Diabetes) resulted in:
                         - a  63% reduction in eye damage
                         - a 54%  reduction in kidney damage
                         - a 60%  reduction in nerve damage


                         - a 17 year follow up of patients with treatment A1c's  of 7 found that there was a
                           57 %relative risk reduction of heart attacks , strokes , and cardiovascular death
                          


 UKPDS patients treated with Metformin ( glucophage) resulted in:
                         - 29% reduction eye and kidney damage
                         - 39% reduction in heart attacks
                         -36% reduction in all cause deaths

Don't smoke and don't hang out with people who smoke

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

Stroke. 2012 Mar 1. [Epub ahead of print]

Duration of Diabetes and Risk of Ischemic Stroke: The Northern Manhattan Study.

Banerjee C, Moon YP, Paik MC, Rundek T, Mora-McLaughlin C, Vieira JR, Sacco RL, Elkind MS.

Source

From the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY; Departments of Public Health and Epidemiology and Human Genetics, Miller School of Medicine, University of Miami, Miami, FL.

Abstract

BACKGROUND AND PURPOSE:

Diabetes increases stroke risk, but whether diabetes status immediately before stroke improves prediction and whether duration is important are less clear. We hypothesized that diabetes duration independently predicts ischemic stroke.

METHODS:

Among 3298 stroke-free participants in the Northern Manhattan Study, baseline diabetes and age at diagnosis were determined. Incident diabetes was assessed annually (median, 9 years). Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% CI for incident ischemic stroke using baseline diabetes, diabetes as a time-dependent covariate, and duration of diabetes as a time-varying covariate; models were adjusted for demographic and cardiovascular risk factors.

RESULTS:

Mean age was 69±10 years (52% Hispanic, 21% white, and 24% black); 22% had diabetes at baseline and 10% had development of diabetes. There were 244 ischemic strokes, and both baseline diabetes (HR, 2.5; 95% CI, 1.9-3.3) and diabetes considered as a time-dependent covariate (HR, 2.4; 95% CI, 1.8-3.2) were similarly associated with stroke risk. Duration of diabetes was associated with ischemic stroke (adjusted HR, 1.03 per year with diabetes; 95% CI, 1.02-1.04). Compared to nondiabetic participants, those with diabetes for 0 to 5 years (adjusted HR, 1.7; 95% CI, 1.1-2.7), 5 to 10 years (adjusted HR, 1.8; 95% CI, 1.1-3.0), and ≥10 years (adjusted HR, 3.2; 95% CI, 2.4-4.5) were at increased risk.

CONCLUSIONS:

Duration of diabetes is independently associated with ischemic stroke risk adjusting for risk factors. The risk increases 3% each year, and triples with diabetes ≥10 years.

PMID:

 

22382158

 

[PubMed - as supplied by publisher]

simple home test may predict risk for vascular disease

This article abstract below reviews the benefits of checking Blood Pressure in your Right and Left arm and using the information to evaluate risk for vascular disease.

This is an easy inexpensive test that can be done at home or in your doctors office.

Their analysis 
 a difference of systolic Blood pressure  between the Right and left arm of;

 * 10 was associated with increased risk of peripheral vascular disease ( arteries in the legs and feet)

 *15 or more is associated with increased risk of peripheral vascular disease, preexisting  
   cerebral vascular  and cardiovascular disease


Their Interpretation

"A difference in SBP of 10 mm Hg or more, or of 15 mm Hg or more, between arms might help to identify patients who need further vascular assessment. A difference of 15 mm Hg or more could be a useful indicator of risk of vascular disease and death."

Comment
This easy test is another tool that can help us be more comfortable with our current treatment program or may encourage us to have further vascular assessment and to become more aggressive with our lipid and blood pressure management.

The Lancet Volume 379, issue9819,  page 905-910 , 10 March 2012

Association of a difference in systolic blood pressure between arms with vascular disease and mortality: Review and meta- analysis

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

The Lancet, Volume 379, Issue 9819, Pages 905 - 914, 10 March 2012

<Previous Article|Next Article>

doi:10.1016/S0140-6736(11)61710-8Cite or Link Using DOI

Published Online: 30 January 2012

Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis

Dr Christopher E Clark FRCP a , PhD Rod S Taylor Prof a, Prof Angela C Shore PhD b, Obioha C Ukoumunne PhD c, Prof John L Campbell MD a

Summary

Background

Differences in systolic blood pressure (SBP) of 10 mm Hg or more or 15 mm Hg or more between arms have been associated with peripheral vascular disease and attributed to subclavian stenosis. We investigated whether an association exists between this difference and central or peripheral vascular disease, and mortality.

Methods

We searched Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, and Medline In Process databases for studies published before July, 2011, showing differences in SBP between arms, with data for subclavian stenosis, peripheral vascular disease, cerebrovascular disease, cardiovascular disease, or survival. We used random effects meta-analysis to combine estimates of the association between differences in SBP between arms and each outcome.

Findings

We identified 28 eligible studies for review, 20 of which were included in our meta-analyses. In five invasive studies using angiography, mean difference in SBP between arms was 36·9 mm Hg (95% CI 35·4—38·4) for proven subclavian stenosis (>50% occlusion), and a difference of 10 mm Hg or more was strongly associated with subclavian stenosis (risk ratio [RR] 8·8, 95% CI 3·6—21·2). In non-invasive studies, pooled findings showed that a difference of 15 mm Hg or more was associated with peripheral vascular disease (nine cohorts; RR 2·5, 95% CI 1·6—3·8; sensitivity 15%, 9—23; specificity 96%, 94—98); pre-existing cerebrovascular disease (five cohorts; RR 1·6, 1·1—2·4; sensitivity 8%, 2—26; specificity 93%, 86—97); and increased cardiovascular mortality (four cohorts; hazard ratio [HR] 1·7, 95% CI 1·1—2·5) and all-cause mortality (HR 1·6, 1·1—2·3). A difference of 10 mm Hg or higher was associated with peripheral vascular disease (five studies; RR 2·4, 1·5—3·9; sensitivity 32%, 23—41; specificity 91%, 86—94).

Interpretation

A difference in SBP of 10 mm Hg or more, or of 15 mm Hg or more, between arms might help to identify patients who need further vascular assessment. A difference of 15 mm Hg or more could be a useful indicator of risk of vascular disease and death.

Funding

Royal College of General Practitioners, South West GP Trust, and Peninsula Collaboration for Leadership in Applied Health Research and Care.

C-peptide , a clue for the " Doctor / Detective ".

Self inflicted and parent inflicted severe hypoglycemia in someone without diabetes is a challenge to diagnose and even more difficult to manage.

For reasons that have never been clear to me , one parent usually the mother , will induce severe hypoglycemia in one of their children.
 Hospitalization is required with close continuous observations of the patient and parents. C-peptide levels and other test such as islet cell antibodies, anti- Gad antibodies and insulin antibodies  are measured as a baseline and the C-peptide is repeated during any episode of hypoglycemia. Usually the hypoglycemia stops under close observation and reoccurs when the child is left alone with the offending person.

 Remember , C-peptide is a waste product of insulin production in our body. 

If someone is producing enough insulin to cause hypoglycemia then their should also be C-peptide present and measurable in their blood.

Commercially produced insulin does not contain C- peptide. Injected insulin has no C- peptide.

The official name for this problem is Munchausen syndrone by Proxy

Have fun , be Smart and Defeat Diabetes

David Calder,MD

C-peptide a useful waste product of insulin production

Making sense out of Facebook conversations is still a mystery to me, they seem like disjointed comments about various unrelated subjects. 

I was struggling through my FaceBook discussions yesterday and saw a reference for the use of urine C peptide test in people over the age of 30 to help distinguish between people with type 1 and type 2 diabetes.  They discussed a lady who was able to discontinue her insulin as a result of this " simple urine test that can be done at home ". I was unable to find the article today but I will keep looking.

A word of caution

This caught my attention and my recall of an obese patient over the age of 30 lady who  discontinued her insulin and went into ketoacidosis after getting a positive test for C-peptide.

What is c-peptide

C-peptide is basically a waste product of insulin production.   

There is one molecule of C-peptide produced for each molecule of insulin. C-peptide can be measured in the blood and urine and can be used to determine if someone  is making insulin. The problem is that people with Type 1 and Type 2 Diabetes can continue making small amounts of insulin and C-peptide for a long time. Remember , people with Type 1 Diabetes are not the only ones with insulin deficiency. Insulin deficiency is also the primary problem for people with type 2 diabetes.


 I have attached an article abstract from Diabetes Care on this subject.


Tomorrow- C-peptide , a clue for the " Doctor / Detective ".


Have Fun , Be Smart and buy my book, ebook ,1phone or iPad App Diabetes Office Visit
David Calder, MD

1. 
   

Diabetes Care

1. Limei Wang, PHD, 
2. Nicholas Fraser Lovejoy, BS and 
3. Denise L. Faustman, MD, PHD⇓

+

Author Affiliations

1. Immunobiology Laboratories, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

1. Corresponding author: Denise L. Faustman, faustman@helix.mgh.harvard.edu.

Abstract

OBJECTIVE To examine persistence of C-peptide production by ultrasensitive assay years after onset of type 1 diabetes and factors associated with preserving β-cell function.

RESEARCH DESIGN AND METHODS Serum C-peptide levels, a marker of insulin production and surviving β-cells, were measured in human subjects (n = 182) by ultrasensitive assay, as was β-cell functioning. Twenty-two times more sensitive than standard assays, this assay’s lower detection limit is 1.5 pmol/L. Disease duration, age at onset, age, sex, and autoantibody titers were analyzed by regression analysis to determine their relationship to C-peptide production. Another group of four patients was serially studied for up to 20 weeks to examine C-peptide levels and functioning.

RESULTS The ultrasensitive assay detected C-peptide in 10% of individuals 31–40 years after disease onset and with percentages higher at shorter duration. Levels as low as 2.8 ± 1.1 pmol/L responded to hyperglycemia with increased C-peptide production, indicating residual β-cell functioning. Several other analyses showed that β-cells, whose C-peptide production was formerly undetectable, were capable of functioning. Multivariate analysis found disease duration (β = −2.721; P = 0.005) and level of zinc transporter 8 autoantibodies (β = 0.127; P = 0.015) significantly associated with C-peptide production. Unexpectedly, onset at >40 years of age was associated with low C-peptide production, despite short disease duration.

CONCLUSIONS The ultrasensitive assay revealed that C-peptide production persists for decades after disease onset and remains functionally responsive. These findings suggest that patients with advanced disease, whose β-cell function was thought to have long ceased, may benefit from interventions to preserve β-cell function or to prevent complications.

My first road trip with the Dash diet as my passenger

My wife and I have a simple life style and eat 90 % of our meals at home. We use the microwave  oven and blender more than the stove or oven.

The DASH diet is like all diets . 
It is easier to talk about than it is to follow. 
One  of the main things I like about this diet is the simple idea of just eating a certain number of servings of each food group each day. 
This diet , like most things in life , has easier and more difficult parts to deal with each day.

The easy part for me was eating 4 servings of fruit , 2 servings of nuts and legumes  and .5 + serving of sweets each day. The legumes was a little more of a problem until I discovered that I love 4 bean salad( this 4 bean approach to legumes does add a little more sugar and salt to my diet )

 Eating 4 vegetables and 7 grains daily has been a challenge for me. Drinking a can of V8 juice helped with the vegetables. The 7 servings of grains is still  difficult for me.

Another hidden benefit of the dash diet
Fewer calories with less effort, Maybe.

Eating 4 fruits , 4 vegetables and a handful of nuts is very filling and does not leave a lot of room for other foods.  Could this be another hidden benefit of this diet?


Our first road trip and the DASH diet. 
My wife and I just returned from a 7 day road trip sleeping in motels and eating in restaurants . I did better the first few days and then failed worse each day after meeting up with our children and grandchildren in Palm Springs. 
We had a wonderful ,fun filled time with more than our fair share of laughs.
My wife and I are truly blessed.


The food issues were still present even using the simple approach that should work any where any time.
 I think my wife and me did a little better than we normally would have done in this situation . 
One positive step  happened, We silently thought about our meals and I believe the idea , of just trying to eat 4 fruits ,4 vegetables and etc  each day , helped. 


 Rick's in Palm Springs  has a great vegge burger.


I also discovered that regardless of what we ordered it was always 20 plus dollars.


 My last attempt at beating the  "got your money game" occurred on our way home at a wonderful place called Harris Ranch. My wife and I ordered oatmeal for breakfast  , 3.50/ bowl (as I recalled from the menu), 2 cups of coffee and 2 pieces of whole wheat toast. I left a  tip and handed the cashier a 20$ bill . I stood there waiting for change and she stood their waiting for the rest of the money that I owed her and the state of Calif.. 


Have fun enjoy life and every precious moment with your family,
David Calder,MD