Conquering Diabetes

Celebration Time!

2011-12-27T20:30:47Z

By Michael Dansinger, MD

It’s holiday party time! Many of my patients find this time of year to be particularly challenging for maintaining glucose, waist size and body weight. So many treats, so many parties, so many mixed feelings about this time of year. For some the right balance is to remain strict, while for others the right balance is to loosen up a bit and enjoy a little more dietary freedom. In either case they’re looking to January for renewed commitment and resolve, or at least a “clean slate”.

In my view, this time of year is part of a natural order that compels us to simultaneously celebrate our present situation and to think about our future. It is in our nature to work hard and then celebrate a job well done. We need to recharge, rejuvenate, celebrate and prepare for the work to come.

It is natural to reflect at this time on the gifts life brings. Many of us are fortunate to have family members and friends who care a great deal about us. We are fortunate to have others in our lives we care about. Many of us are grateful for the opportunity to do meaningful work that provides a service or product that people need or want. I am particularly grateful for the opportunities I have had to engage in a variety of intellectually stimulating and/or challenging projects that hopefully make the world a better place, at least for some. Many of us are grateful for the health we have (even if it is not as good as it once was), recognizing it could be very much worse. I am particularly grateful to have a healthy body and the freedom and opportunity to substantially influence my state of health. Many of us are grateful to live in a place that affords the freedom to have a good amount of control over our destinies, as well as the experience, knowledge, and wisdom to take advantage of opportunities to better ourselves.

When it comes to health and wellness during this natural time of celebration, my philosophy is that what matters most is how you live MOST of the time, not SOME of the time. Are you “celebrating” 70% of the time or 10% of the time? This is the most important time of the year to think about how you want to conduct yourself during the next year. Are you living in “balance”? Are you living like its December all year long? In my view, the most important thing right now isn’t putting the cookie down but taking stock of what a great gift your life is and preparing mentally for the work required to take full advantage of life’s opportunities. In other words, let’s get ready to eat right and exercise all year long, so we can celebrate once in a while without guilt and without going overboard.

I, for one, pledge to do a better job with eating and exercise in 2012 than I did in 2011. Not that I did a bad job this year, but there’s always room for improvement no matter who you are or what your circumstances are. So join me in celebrating all we have to live for, and all the opportunities we’re going to seek to better ourselves in the year to come!

Best wishes for a healthy, happy, peaceful holiday season and New Year.

Exercise!

2011-05-20T18:48:51Z

Photo: Ryan McVay

This WebMD article highlights the latest scientific findings on the favorable effects of exercise for diabetes patients. The article reports what we would all expect: cardiovascular (aerobic) exercise and resistance training are both beneficial for diabetes and lower the hemoglobin A1c levels.

Structured exercise programs (I like to think of these as formal exercise programs with some degree of hands-on supervision) typically produce better results than “exercise advice”, simply because the structured exercise programs achieve greater intensity and duration and greater compliance, than when patients are left to their own devices to get the recommended exercise.

In fact, studies with “exercise advice” typically produced no improvement in the hemoglobin A1c (due to poor compliance) unless dietary improvements were also made. The best combination is always simultaneous dietary improvement plus exercise (cardio and/or resistance), and the more “structured” or “formalized” the better. In fact, while patients who achieve the standard recommended “2.5 hours per week” see greater improvements in hemoglobin A1c than those who do not meet this standard; those patients who exceed the standard get even greater improvements!

Easier said than done! Exercise is one of life’s biggest challenges. We all know it is good for us, but almost none of us get enough of it. Why is that? What keeps us from doing the things we want to do (and what makes us do things we don’t want to do)?

I think the main reason is because the subconscious mind fights against the rational mind that knows better. I believe the subconscious mind is genetically designed (through millions of years of evolution) to keep us alive in the wild natural world, where survival had typically depended on saving one’s strength and energy for the immense daily work required just to live. Until the past century or so, physical exertion was an automatic part of life, with few machines to do our work. In my view, one price we must pay (the “tax” we owe) in order to take full advantage of this modern world of technology and freedom, is the exercise necessary to keep our bodies healthy.

For the majority of us who do not automatically gravitate toward exercise, we must find a way to overcome the natural resistance caused by the subconscious mind. The subconscious mind will bombard the conscious rational mind with all kinds of excuses. The barriers are almost never truly physical. I work with chronically ill patients with diabetes every week so I have a very good understanding of the degree of debilitation that does and does not exist across the entire range of patients with diabetes. At least 90% can exercise regularly. Even patients who are missing their legs or have very weak heart or lung function can perform and benefit from exercise.

It is easy to say it can’t be done, and to find seemingly good reasons to justify the decision. Just be aware these are typically just the subconsious mind dominating over what objective science documents time and time again — that you’ll feel better and probably live longer with regular exercise no matter how healthy or unhealthy you are today. Put it this way — if you would literally die today if you failed to get 30 minutes of physical activity you would get it done, and if death would come the very day you failed to exercise you would do exactly what was necessary to avoid this fate. You are genetically designed to do so! We just don’t live in that kind of world anymore.

The trick, I believe, is to use your rational mind to anticipate and outsmart the subconscious mind’s resistance tactics. For example:

Put yourself in a position of being “forced” to follow through with exercise — where someone is keeping you accountable. This can be a personal trainer, an exercise class you pay for, or an exercise partner for tennis, walking, workouts, etc.

Join a fitness or weight loss contest at work or at a health club.

Link entertainment to exercise — –save your best music, movies, etc. exclusively for exercise time.

Buy yourself something if you meet an ambitious exercise goal.

I even have some patients who have chosen to “penalize” themselves for failing to meet their exercise commitments by donating money to their LEAST favorite presidential candidate or other charity.

Create regular opportunities to read and re-read all the good reasons to keep yourself in shape — write your reasons down and post them and carry them.

Hang out with others who set a good example.

There are many other tricks you can discover. Let’s figure out how to do whatever it takes to win this battle as if our lives depend on it NOW, rather than later.

- Michael Dansinger, MD

Chocolate for Diabetics?

2011-04-11T20:51:46Z

Photo: Pixland

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

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

From a medical standpoint, chocolate appears to be a “mixed bag”. A bar of dark chocolate contains a complex mixture of sugar, fat, cocoa, and other flavor enhancers. The sugar content is lower in dark chocolate than in milk chocolate, however it’s presence certainly offsets (either partially or fully) any potential health benefits of chocolate. We don’t actually know whether eating more dark chocolate is favorable for heart disease or diabetes or longevity, compared to eating less of it. The fat in chocolate is highly saturated, which is concerning as a potential accelerator of heart disease and atherosclerosis. However, much of the saturated fat is comprised of stearic acid, which does not appear to adversely affect cholesterol levels compared to other more common types of saturated fat. Still, fat is high in calories and contributes substantially to chocolate’s high caloric density. It is hard to maintain a healthy weight or battle obesity when eating enough chocolate to potentially achieve health benefits from it.

Any health benefits of chocolate certainly come from the cocoa component. Cocoa contains “polyphenolic flavanoids” which are antioxidants with the potential to improve multiple heart disease risk factors. Much work is underway to better understand how these compounds work on a cellular level. In any case, most of the studies that indicate improvements in heart disease risk factors are inconclusive because they are either short-term trials that just look at risk factors rather than actual disease rates, or because they are observational studies that cannot draw conclusions about cause and effect. The matter is further complicated by the fact that many of the studies use special chocolate products that are uncharacteristically high in cocoa content and/or low in sugar, and/or sponsored by companies that sell chocolate.

My guess is that cocoa is actually beneficial, but the sugar and fat present in dark chocolate bars entirely offsets those benefits such that dark chocolate bars are “health neutral” rather than beneficial. The logical way to leverage the potential health benefits of cocoa would be to find ways to incorporate significant amounts of unsweetened cocoa powder into foods and/or beverages that do not contain excess sugar or fat. For example, I use my blender to make home-made shakes containing frozen banana, cocoa powder, a few almonds (or almond milk) and a little stevia.

Unfortunately, much of the chocolate and cocoa available is produced by African children working under conditions that would be considered unethical and illegal in most Western countries. Some of the chocolate is likely produced by slave labor and efforts are underway to address this serious political problem. Fortunately, it is possible to buy cocoa and chocolate that is certified as conforming to our usual ethical standards. Trader Joe’s and Whole Foods would be good places to find such products.

In the final analysis, our love affair with chocolate gets mixed reviews on multiple levels. Like many of life’s potential treasures, “the devil is in the details”. If we’re smart about it, we can probably do a much better job learning (on multiple levels) how to properly harvest and harness the healthy aspects of this wonderful gift from “mother nature”.

- Michael Dansinger, MD

Prediabetes: A National Emergency!

2011-03-01T15:42:09Z

iStockphoto

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

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

I caution nondiabetics who are overweight and over age 50 to assume they have prediabetes until proven otherwise. Prediabetes involves mildly increased blood sugar levels, most commonly after meals but sometimes also in the fasting state. This occurs because the pancreas organ can no longer produce enough insulin hormone to sustain normal blood sugar levels (usually about 50% loss of function in prediabetes). Doctors usually diagnose prediabetes with a simple fasting blood sugar level (at least 110 mg/dL) or a hemoglobin A1c level (at least 5.7%). Adults who are overweight or over age 45 should typically be screened for prediabetes/diabetes.

Individuals with prediabetes typically go on to develop type 2 diabetes, especially if they do not take steps to delay or prevent this disease via lifestyle changes. Primary care providers have a great opportunity to uncover the huge number of prediabetics out there. I’ll estimate that 40%-50% of a typical primary care panel has prediabetes or type 2 diabetes, but that the minority of these patients are diagnosed. It is crucially important to find and warn these patients because lifestyle change, especially weight loss, can really make a tremendous difference in delaying or preventing progression to type 2 diabetes.

We know from clinical trials (Diabetes Prevention Program, Finnish Diabetes Prevention Trial) that long-term weight loss in the 4% range delays the progression of from prediabetes to type 2 diabetes by about 4 years longer than when no weight loss occurs. The greater the weight loss the longer one can expect to delay diabetes. In fact, my working assumption is that prediabetics who achieve long-term weight losses of 10% will delay diabetes by about 10 years, and those who maintain weight losses of 20% will delay diabetes by about 20 years, and so on. I can’t prove it, but I think this is a reasonable guess. The crucial point is that the rate of progression from prediabetes to type 2 diabetes is exquisitely sensitive to weight loss, and failure to recognize and capitalize on this fact amounts to a shamefully wasted opportunity in my view.

Now, we all recognize that sustaining weight losses on a long-term basis, even in the 4% range, is no easy feat. However, patients stand a much better chance if they participate in a formal program designed for long-term results. We now have much greater experience in designing programs that can cost-effectively achieve this degree of weight loss.

If we in the medical profession make it a priority, we can offer good weight loss support and a better chance at living a fuller life, to the enormous number of undiagnosed prediabetics out there who would like the chance to be found and helped. The medical profession has a pivotal role in addressing this national emergency. I challenge current and future leaders to recognize and act on the alarm I and others are sounding now, in the early stages of catastrophe.

- Michael Dansinger, MD

Should Artificial Trans Fats Be Banned in the US?

2011-02-01T20:47:38Z

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

Calls like mine were commonplace among nutrition experts and some politicians, and since that time there has been an increasing amount of legislation at the city, county, and state levels restricting or discouraging the use of trans fats in prepared foods. The FDA has required foods with at least 0.5 grams of trans fat per serving to report the amount in the nutrition facts label. Many (but not all) fast food chains and major food companies have been reducing or eliminating trans fats from their products, such that there has been a dramatic decrease in the amount of trans fat in the food supply. I’ll guess it is currently about 1/3 of what it was. That is so much better, but there is no safe level. Health experts would like to see it gone altogether. Doing so would result in even greater projected reductions in future heart disease and diabetes.

Walmart, the largest grocer in the U.S., recently announced that they will be eliminating trans fats from their store-brand foods by 2015 (and making other favorable changes as well), which will directly impact a large number of consumers, and can potentially cause a large ripple effect by inducing competitors to follow suit.

This move by Walmart is newsworthy and has caused me to want to revisit — with the benefit of hindsight — whether my position in 2007 calling for a national ban was a good idea then or now.

As I discussed at the time:

“Opposition has focused not on whether the fats are unhealthy, but rather on whether paternalism and government intervention are necessary, appropriate, and desirable. My short answer is “yes,” but I would like to discuss this complex issue in greater depth.

There is widespread agreement that in a free-market economy, government regulation of the availability of goods and services is generally unnecessary, inappropriate, and inefficient. The burden of proof does and should rest on those who wish to regulate or ban any specific goods or services.

There is also widespread agreement that, in general, unhealthy foods should not be banned. For example, few would argue that cookies should be banned. People should be free to decide for themselves what to eat, even if the consequences of their unhealthy eating habits result in higher societal costs due to excess health problems.

There is also widespread agreement that newly proposed food additives (such as sugar and fat substitutes) should not be introduced into the food supply if there is any suggestion that they promote cancer or other illnesses. If partially hydrogenated fat was introduced as a new food additive today, there is no way that it would make it into the food supply, given what we now know about the adverse health effects.

So once a society learns that an artificial ingredient in the food supply promotes chronic health problems, the question boils down to whether public education is sufficient, or whether the government should require the elimination of the offending agent. Such issues need to be dealt with on a case-by-case basis. Important considerations include the extent of the damage caused by the offending agent, and the extent of the damage caused by requiring (rather than promoting) elimination of the offending agent.

In the case of partially hydrogenated fats, the health damage is substantial, although it is diffuse and chronic, and easy to ignore. The forced elimination of partially hydrogenated fat would be relatively painless for the consumer because food manufacturers would be able to offer the same foods with minimal effect on taste or price. The effect on food manufacturers would be acute (during the time it takes to perfect new recipes), but short-lived.

Loss of freedom and acceptance of paternalism would be important costs of employing a ban on partially hydrogenated fat. Some individuals believe that there are no circumstances in which such sacrifices seem acceptable. For others, the fact that children eat these unhealthy fats because we have failed to ban them is compelling enough to warrant government action.

In the case of partially hydrogenated fat, I believe that a ban is necessary to overcome the inertia that has prevented the free market from acting in the best interest of society, consumers, and especially children.”

Today we are not terribly far behind where I was hoping we’d be by now. The past 4 years have seen a dramatic improvement in the amount of artificial trans fat in the food supply, and things continue to move in the right direction. There is really no question that partial trans fat bans in major cities such as New York City, Boston, and in all of California have accelerated the pace of trans fat reduction on a national level, and there is no question that the mandatory reporting on food labels has done the same. The price we paid as consumers and citizens was not significant in terms of reduced food palatability or cost, but occurred as a result of increased government intervention at the local or state level. We do not want any more government regulation or laws than we truly need, or at least significantly benefit us as a society.

Looking back, I’m glad I took the position I took 4 years ago. I believe that my family has benefited in a meaningful way from the government actions. I am skeptical that trans fat levels would be nearly as much reduced as they are now without such government intervention. I believe the free market would have produced reductions in trans fats as a result of companies responding to consumer demand, but I do not believe such dramatic and rapid improvements would have occurred during the past 4 years.

George Doyle

This is important to me in part because my children are now 9, 7 and 4, and the amount of trans fat they have consumed during the past 4 years — during a significant portion of their growth years including brain development etc. — has been directly affected by the speed and magnitude of the changes in food levels. Something that still bothers me is the high amount of trans fats in cake frosting — and my kids seem to attend birthday parties every few weeks. I’m not going to stop my kids from eating frosting at birthday parties. I’m waiting for someone or something to “force” those companies who make frosting to reformulate. All the trans fat they still eat is in situations like this, where they are eating treats or at a restaurant, and nobody is aware of the amount of trans fat in the food. I suspect the same is true for most Americans. We still eat trans fat simply because food companies and restaurants still add it to certain foods.

I am still in favor of a national full ban on artificial trans fats. You can bet that if trans fats caused cancer instead of heart disease and diabetes they would have been banned many years ago. Instead, I predict trans fats will continue to linger in many foods for many years to come, and we will simply tolerate their presence along with many of the other toxins in our environment.

The sad thing is that this particular toxin is so easy to remove from our environment by simply pulling the plug. It is not in America’s best interest to keep it around when such an easy and painless fix is available. Our children will not be impressed when they look back to see their parents and grandparents missed a relatively easy opportunity to have helped them live cleaner, healthier lives. That’s why I have raised this issue again and I hope others who agree with my position can help us finish the job a number of forward-thinking politicians, policy-makers and food company executives have started.

- Michael Dansinger, MD

How To Wean Off of Diabetes Medication

2010-12-29T20:15:46Z

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

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

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

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

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

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

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

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

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

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

- Michael Dansinger, MD

Come On Let Your Colors Burst — Like a Firework!

2010-12-14T22:22:12Z

Duncan Smith/Valueline

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

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

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

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

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

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

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

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

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

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

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

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

- Michael Dansinger, MD

Finding a Middle Ground on Artificial Sweeteners

2010-11-09T20:42:54Z

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

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

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

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

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

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

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

The argument against artificial sweeteners goes something like this:

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

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

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

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

Finding an Elusive Middle Ground:

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

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

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

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

- Michael Dansinger, MD

High-Fructose Corn Syrup

2010-09-23T18:19:07Z

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

Ryan McVay

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

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

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

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

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

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

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

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

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

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

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

- Michael Dansinger, MD

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

Type 2 Diabetes Causes Brain Damage In Teens

2010-08-12T20:20:36Z

iStockphoto

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

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

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

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

- Michael Dansinger, MD

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