Achieving an A1c of 7.5 may be a better target for many of us

Question - 

Is hypoglycemia associated with increased mortality ?         Yes    or   no

Recent studies

Two recent studies , * Accord and Advance studies , reported a higher mortality rate in both the intensive treatment (A1c goal < 6 ) and standard treatment ( A1c goal 7  to 7.9 ) groups in patients with hypoglycemia.

 The mortality rate , in the Accord Study , was highest in the group of patient with A1c > 8.5 struggling to achieve and A1c of 6 .

Bonds et al                            BMJ 2010; 340 :b4909

Zoungas et al                        N . England J. med 2010;363:14108

Calles- Escandon et al         Diabetes Care 2010 Apr; 33(4): 721-7 

Take home message
   Achieving an A1c of 7.5 may be a better target for many of us

Many  people with  diabetes can achieve A1c of 6  or less without  hypoglycemia . 
This group benefits with reduced risk of eye , nerve and kidney damage . The  cardiovascular benefits of achieving an A1c < 6 is still not definite.

The person with longer duration of diabetes , higher unstable glucose levels

( A1c 8.5 + )   with hypoglycemia and a history of heart disease may put themselves at increased risk struggling to achieve an A1c of 6. 

Setting and trying to achieve blood glucose and A1c goals  is a very individual process and determined by the problems mentioned in the above paragraphs.
A recent study *  provides more support for the idea glucose and A1c individuality. 
 Data discussed in this study demonstrates the lowest mortality in people achieving A1c 's in the 7. to 7.5 range with mortality rates going up as the A1c dips below 7  toward 6 and increase as the A1c progresses above 7.5 to 8.

Currie et al. Lancet , 2010; 375 (9713): 481-9

Have Fun Be Smart chose your targets carefully
David Calder,MD

Recognized hypoglycemia is probable just the visible tip of a very large dangerous iceberg

 The discussions over the last few days have focused on  the importance of testing the fasting blood glucose to help regulate  Basal insulin production and/or injections.

What is the second most helpful glucose test of the day  ?

# 1      1 hour after a meal
# 2      before lunch or dinner 
# 3      before bedtime
# 4      at 2 to 3 am

The answer is  #4  because we are the most sensitive to the effects of insulin in the early morning hours. 

Some studies suggest that early AM unrecognized hypoglycemia is very common and that recognized hypoglycemia is less common .

  Recognized hypoglycemia is probable just the tip of a very large dangerous iceberg

Have fun , Be Smart and check a 3 am glucose
David Calder,MD

Question - Is hypoglycemia associated with increased mortality ? 
     Yes    or   no

Tips for testing before meal and bedtime glucose levels

                                        Question answers from yesterday
 Common ways of increasing Basal insulin and correcting the fasting glucose include.

  #1  adjusting the basal rate on a persons insulin pump      yes      
  #2  adjusting the dose of Lantus insulin                                yes     
  #3  adjusting the dose of bedtime NPH insulin                     yes      
  #4  adjusting the dose of oral diabetes medication              yes      
  #5  adding a medication  to more effectively  control 
        glucagon levels                                                                    yes     
  #6  checking a 3 am glucose                                                     no
  # 7 not eating a bedtime snack                                                 no


We have spent a lot of time discussing the importance of checking the fasting blood glucose and looking for patterns. 

Review and suggestions
Persistent  elevation of the fasting blood glucose suggest that you are not producing or taking enough insulin to maintain normal glucose and fat metabolism and it is time to talk to your health care provider about medication adjustments.

Occasional elevation is often unexplained but can be caused by an unrecognized low blood sugar at 2 to 3 am. It is time to  start checking  bedtime and 3 am glucose levels.

Occasional low fasting glucose can be a warning of a severe hypoglycemia in the future.  It is definitely time to start checking bedtime and 3 am glucose levels and talk to your health care provider about medication adjustments.

Testing before meal and bedtime glucose levels

Starting the previous meal with a elevated glucose almost guarantees an elevated glucose before the next meal

People taking
 Oral diabetes medications or injectables , such as Byetta or Victoza
     (assuming you started the previous meal with with your glucose on target)
These test are useful for helping you determine if you are producing or taking enough insulin to allow you to use or store the glucose from the carbohydrate eaten with the previous meal. 

People taking 
a rapid acting insulin before each meal or snack  have a little advantage. They have probable been trained to use *formulas that will allow them to take extra insulin to correct the elevated glucose and then also adjust the insulin dose to take enough insulin to efficiently use the glucose from meal.

* correction factors for Aperson
    1 unit of insulin will reduce the glucose x amount 
     For example .  Aperson has worked with their health care provider( usually a dietition / diabetes
                             educator) and  determined that 1 unit of rapid acting insulin will lower an elevated
                             glucose level by 20 mg/d
                             glucose goal before lunch is 90 to 120 mg/dl
                             test result 160 mg/dl
                             Take 1 unit of insulin for each 20 mg /dl above goal = 2 units

        #2Insulin / carbohydrate ratio
     For example. Aperson has worked  with their health care provider and determined that  1 unit of
                           rapid acting insulin will allow them to efficiently metabolize 30 grams of carbohydrate.
                           Carbohydrates eaten 90 gms
                           90 divided by 30 = 3 units of insulin
                          Aperson's total insulin dose   5 units 

        Track 3 is a good iphone app to help with these calculation

Have Fun , Be Smart and check your blood glucose levels wisely
David Calder,MD

Repetition of basic concepts moves them toward effective action

Questions from yesterday

 #1 Can you name one cause of elevated Fasting Glucose Tests not related to insulin 
      deficiency ?
      Answer- unrecognized low blood glucose between 2 and 3 am

#2  Can you name 2 groups of diabetes medications , other than insulin , that helps control 
      the dysfunctional  glucagon  problems ?
      Answer -  GLP-1 agonist - exenitide ( Byetta and Bydureon ) and liraglutide ( Victoza )
                        DPP-4 inhibitors - liragliptin ( Tradjenta ) , saxagliptin ( Onglyza ) , and 
                                                        sitagliptin ( Januvia )

     

The take home message from a few days ago is worth repeating

       ( remember : Repetition of basic concepts moves them toward effective action )

Take home message- 

                                         Look for patterns
  Do not focus on the occasional unexplainable glucose elevation look for patterns. Significant medical problems such as insulin deficiency and illness cause persistent glucose elevations. 

We have spent the last few days discussing the importance of testing the fasting glucose and and adjusting your medications to correct this test into your selected target range. I will  now add another term  , basal insulin.
                                         Basal Insulin.
Basal insulin is the steady insulin released from Beta cells maintaining normal fat and glucose metabolism when we are not eating. Basal insulin production is decreased in people with diabetes . 
                                                     Best tool
Your best tool for evaluating your basal insulin production is the fasting blood glucose test. This is the one test of the day that has not been effected by food intake.

             Persistant daily elevation of the Fasting glucose indicates ;
that you are not producing or taking enough insulin to suppress the inappropriate release of glucose from the liver.
Insulin deficiency is the most common cause for this problem . Illness ,especially unrecognized bladder infections , and medications such as steroids also have to be considered.

                                                    Question.
 Common ways of increasing Basal insulin and correcting the fasting glucose include.

  #1  adjusting the basal rate on a persons insulin pump      yes      no
  #2  adjusting the dose of Lantus insulin                                yes      no
  #3  adjusting the dose of bedtime NPH insulin                     yes      no
  #4  adjusting the dose of oral diabetes medication              yes      no
  #5  adding a medication  to more effectively  control 
        glucagon levels                                                                    yes      no
  #6  checking a 3 am glucose                                                     yes      no
  # 7 not eating a bedtime snack                                                 yes      no

Have fun , Be Smart and  set target goals and correct your fasting blood glucose
David Calder, MD

   

Diabetes Office Visit e-book is $ 2.99

Diabetes Office Visit  e- book  is now available for your computer .  $  2.99
Order today

Diabetes Office Visit helps put you in the drivers seat for your diabetes care with my common sense approach for improving communication between you and your health care provider.

Have fun , Be Smart  and read this ebook
David Calder, MD

Fasting Glucose Test . The best test of the day ?

Continued from yesterday.

What is the best home test to help you keep track of who is winning the day? 

1)     A1c test 
2)     after meal glucose test
3)     Fructosamine  test
4)     Fasting blood glucose
5)     3 AM glucose test


The correct answer is # 4 , Fasting glucose

Discussion points

  *The primary fuel for our body is glucose.       ( especially optimal brain function )
                                                                                  ( insulin is not required for glucose use in the brain)   
                                                                                      
 * Our liver acts as a storage depot for glucose       ( we have about an 8 hour gas tank)
 * that is supplied from carbohydrates in our diet    ( at least 130 gms/day is recommended )
                                                                                         Diabetes care vol 35, supplement1 jan. 2012
 * Insulin allows glucose to be stored in our liver        (and used in our muscles and other tissues)
 *Glucagon regulates glucose release from the liver    ( to maintain stable glucose levels)

Discussion
Beta cells and Alpha cells in the pancreas are involved

People with type 1 and type 2 diabetes have a deficiency in insulin( beta cells), effecting glucose metabolism in the liver and other tissues.

They also have a dysfunctional release of glucagon from alpha cells in the pancreas causing unpredictable release of glucose from the liver resulting in high blood glucose  levels. Having adequate circulating insulin helps  control the dysfunctional alpha cells and lower glucagon levels.

The fasting glucose is not usually effected by food intake

The fasting glucose test is the best home indicator of a persons ability to produce enough insulin to lower glucagon levels and control the release of glucose from the liver.

Take home message

*The fasting blood glucose test is the best home indicator of your basal insulin production. *  

*Persistant elevation of the fasting blood glucose test  above your target range is a reason to talk with your physician  and discuss medication options.*

The other choices ------my opinion

1)     A1c test  - a good way to look at your 3 month average glucose results and also provides an
                          indicator for long term complication risk.

2)     after meal glucose test - Provides a method of determining if you have enough insulin to control
                                                the glucose contained in the carbohydrates in the meal you just 
                                                enjoyed. This assumes you started the meal with a normal blood 
                                                glucose level.
        
3)     Fructosamine  test -   This test evaluates you average glucose for the last month. (More on this 
                                             later)

4)     Fasting blood glucose - correct answer

5)     3 AM glucose test- one cause for elevated fasting  glucose results and  a good way to detect
                                        unrecognized hypoglycemia ( more on this later )

More questions

 #1 Can you name one cause of elevated Fasting Glucose Tests not related to insulin deficiency ?

#2  Can you name 2 groups of diabetes medications , other than insulin , that helps control the 
      dysfunctional  glucagon  problems ?

Have fun , be smart and check and understand your Fasting Blood Glucose test
David Calder, MD
We will get to the rest of the discussion on recording and presenting glucose test to your physician or diabetes educator
                                                                                                                    

Under stand glucose testing and " Win the Day"

Office Ready , Glucose checking and management tip

Testing frequency
    People with type 2 diabetes make up about 95% of people with diabetes with the largest variation in available approaches to management. This group is also less likely to use insulin pumps, continuous glucose monitoring and artificial pancreas as part of their management program. Many people with type 2 diabetes rely on home testing one to two times per day, A1c test  and  their physician  to make management decisions.

Diabetes management is a game of numbers
 I have previously discussed the idea that diabetes management is a game of numbers and that your good health depends on how well you play the game.  "Win the Day ", is a slogan used by some football coaches to motivate their players. It could also apply to you and I as we deal with the daily ups and downs of diabetes management.
 For more on the numbers game,read the link below
 Diabetes Office Visit Simplifies Diabetes Care


Win the Day

Why are you testing your blood glucose every day. ?
    To help you and your physician make management decisions . Sometimes the YOU part of the team is not fully participating in the game.

My purpose today is to help make you a better player

I will focus on the morning fasting glucose with a little football added.
Your goal is to score between 80 and 130 mg/dl ( this can be adjusted by your physician coach )
Your best player is insulin backed up by a strong growing team of medications .

Your opponents, are the dysfunctional Beta cells not providing adequate insulin  and out of control Alpha cells releasing unneeded glucagon ( glucagon stimulates the liver to release glucose ). Resistance to your own insulin has  also signed on with your opponents.
Their goal is to keep your glucose above your goal.
For more information about glucagon,read the link below
Glucagon effects your life every day


What is the best home test to help you keep track of who is winning the day ?

1)     A1c test
2)     after meal glucose test
3)     Fructosamine  test
4)     Fasting blood glucose
5)     3 AM glucose test

Make your choice and we will discuss the possible answers tomorrow.

Have Fun , Be Smart and "Win The Day"
David Calder,MD

Unexplainable glucose elevations? Look for Patterns !

Diabetes Office Visit - The Goal
The goal of my book , iphone /pad App. , and Diabetes office visit  web site , is to improve  communication between people with diabetes and their physician and or diabetes educator.

 This is a new year  and after a recent conversation with a friend with diabetes  ,who claims to have read my book. I again realized that , despite the amazing new advances in diabetes care , the basic make up of a diabetes office visits has not changed that much for many people with diabetes.

Diabetes management in most medical offices is still doctors and diabetes educators setting down with patients and looking at home glucose values recorded on paper. How this data is recorded and presented to the physician has a major impact on the benefit achieved from the visit. Patients and their physicians are often frustrated trying to understand and explain the often unexplainable variations in glucose values.  The process of just living our daily lives , and the inability of our most sophisticated management tools to match the speed and agility of beta and alpha cells in a healthy pancreas , will continue to effect glucose test results.

I have found one exception , other than of an islet cell transplant for controlling glucose results.
Patients in the intensive care unit , heavily sedated and I controlled their intake with IV fluids , IV insulin and hourly glucose test. The controlling glucose levels problems returned as the patient started eating and taking subcutaneous insulin and oral medications again.

Take home message- look for patterns
  Do not focus on the occasional unexplainable glucose elevation look for patterns. Significant medical problems such as insulin deficiency and illness cause persistent glucose elevations. 

A common example is elevations of the fasting glucose:
 #1  First test and rule out unrecognized low sugars at 2 to 3 am. causing a rebound increase
      glucose
 #2  In my experience insulin deficiency is the most common cause of persistant elevation of fasting
      glucose.
Tomorrow , more on  office ready usable glucose testing 

Have Fun ,Be smart  and if you have my book , Diabetes Office visit , please read chapters 3 and 4.
David Calder, MD

Steroids increase glucose levels , GLP-1 agonist may help

Steroids *
Steroids , oral or injectable , are useful tools in medical practice and provides welcome relief for a multitude of medical problems. The short term use of steroids , one injection or a 4 to 5 day course of oral steroids, causes a temporary increase in glucose levels and is not a significant problem. The long term use is a little more complicated.

Down side
 For people with prediabetes and type 1 and type 2 diabetes the benefits of steroids comes with a down side , elevated blood sugars . Steroids increase glucose levels by making tissues resistent to the glucose lowering effects of insulin , increases glucagon levels and decreases insulin secretion.

side effects are dose related
  The effects of steroids is dose related, higher doses cause high blood sugars.


Dosing methods and different doctors complicates glucose management
  Steroid dosing methods another level of difficulty for some one with diabetes. It is not uncommon to start with high doses and then tapering the dose as need decreases or to use every other day doses.There are also frequent communication breakdowns between the doctor ordering the steroids and the diabetes doctor.

Multiple Insulin injections are usually necessary
Insulin with changing insulin doses based based on blood glucose levels and steroid doses can be complex and far from perfect . Patient education , frequent glucose testing and insulin self management protocols are usually necessary.

GLP-1 Agonist ** may improve and simplify this diabetes management problem
A recent article published ;
 Internal medicine vol.52 (2013) no.1 p.89-95
 Evaluation of the effects of Exenatide administration in patients with type 2 diabetes withworsened glycemic control caused by glucocorticoid therapy.
Dept. of Diabetes Mellitus and Endocrinology , Osaka Red Cross Hospital ,Japan

I have not yet seen the entire article. I have read the abstract and obtained the first 2 pages of the article and review the first case.  She is 63 years old with type 2 diabetes who developed Rheumatoid Arthritis and was started on steroids. Insulin was required and she gained 16 kilograms  over the next year. She was switched to exenatide (Byetta ) 5 ug twice daily . Four months after starting exenatide her glucose control , weight , Bp and LDL cholesterol and triglycerides showed significant improvement.
The story was similar in al 4 patients.

I believe this is a significant report that will lead to more study and improved management of a difficult problem.

Have fun, Be smart and be thankful for the wonderful medications that will improve the lives of everyone with diabetes
David Calder,MD

*commonly used steroids
 prednisone ( deltasone), dexamethasone ( decadron ,Dexpak , dexazone), betamethasone ( celestone), cortizone, methylprednosolone( solu-medrol) , triamcinolone (kenalog) ,fludrocortsone (florinef)

** GLP- 1 Agonist 
     Exenatide (Byetta ,Bydureon )
     liraglutide ( Victoza)
Please review the older post for more information GLP-1 Agonist

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Dash Diet , Simple ideas that may work

Dash Diet, Simple Ideas That Work

This a repeat post that is worth reviewing as we think about our New Years resolutions. Dr. Calder

My first impression of the DASH diet is very good. Their ideas are simple , much like the Mediterranean Diet , with a focus of gradual lifestyle change.  I purchased a 3 month trial of the diet and then had to talk my wife into trying to follow it with me. She was reluctant to join in the venture because she knows it means more work for her. She has been down this road before with more than a few diet ideas. We both agree that the ADKINS Diet was the most challenging .


My wife likes the structured organized approach

  The one part of the diet that she likes is the structured , 1 week  of meal plans with recipes and a shopping list.   This diet will not be a big change for us because we have followed the basic ideas of a  Mediterranean diet for years but it will require more work for my wife

Things I like about the diet


Less salt but not low salt
 My impression of the DASH Diet from reading the literature  was wrong. I thought it was just  a low salt version of the Mediterranean diet and a useful  tool for blood pressure management.


Immediate response to questions
I reviewed  the excellent web page and the diet and was surprised to find very little to no mention of salt.
I immediately emailed their contact person and received a response within 24 hours. She explaimed the idea of eating more fruits, vegetables and grains but couldn't tell exactly how many grams of sodium the diet contained.  She referred my request to a physician who explained that most of the salt is hidden in the foods and he could not give me an exact number . He estimated that a typical  1600 to 2200 calorie  diet recommendation would have between  2300 mg  to   2875 mg  of sodium/day.
This is close to the goals recommended by the American Heart Association of 2400 mg/day.
These recommendations help us avoid excessive salt intake rather than trying to impose a rigid salt 
 restriction.                           Another good idea

According to the National Health and Nutrition Survey from the  Centers for Disease Control (CDC ) the typical american eats between 2500 mg to over 4000 mg of sodium /day
http://www.cdc.gov/nchs/nhanes

Daily Serving Goals
I think this is the best part of the diet. 
This is the take home message that I can remember and apply most of the time . I chose an 1800 calorie diet because my initial goal is to weigh 180 pounds.


                                                  My serving goals:


fruit    vegetables    dairy    grains    meat/ fish/poultry     nuts/beans      fats      sweets
  4            4                 3             7                  1.5                         0. 5              2            0.5    


I have tweaked my goals because  I am an almost vegetarian and will most of the time eat no meat and increase my bean and nut serving to 2. They have a nice serving size sheet and a discussion of ideas for vegetarians.




 I think this diet is a big step forward in  simple diet management ideas that we can all use.


Be happy , Be Smart and Defeat Diabetes
David Calder,MD

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

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*: A fist is about 1 cup or about 30 grams of carb for foods such as 1 cup ice cream or 1 cup cooked cereal. Your thumb is about 1 tablespoon or 1 serving of regular salad dressing, reduced-fat mayonnaise or reduced-fat margarine. Your 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. Your 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 theSouth 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."

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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