* At least two members of this group have married each other.
* Although most medical journals and textbooks throughout the world measure blood glucose in mmol/l (millimoles per liter), most physicians, laboratories, and blood glucose meters in the United States measure blood glucose in mg/dl (milligrams per deciliter). Blood glucose values in this book are as a rule given in mg/dl. If you should need to translate from one to the other, 1 mmol/l = 18 mg/dl.
* Very high blood sugars cause frequent urination.
* For a period of time, many people considered the designations type 1 and type 2 out-of-date, replacing them with the terms IDDM and NIDDM, which are slightly misleading and are losing credence. While it is true that most of those with type 2 can stay alive without injecting insulin, many patients who suffer from type 2, or so-called NIDDM, do inject insulin to preserve their health. The terms “autoimmune diabetes” for type 1 and “insulin-resistant diabetes” for type 2 are more precise, but are unlikely to take over for the much-easier-to-say type 1 and type 2. The situation is further complicated by the recent discovery that most type 2 diabetes also has an autoimmune component.
* Anabolic and catabolic hormones normally work in harmony, building up and breaking down tissues, respectively.
* Recent studies show that even type 2 diabetics experience some degree of immune attack on their beta cells.
† New evidence demonstrates a role for fat contained in muscle cells (intramyocyte fat) as another important factor in causing insulin resistance.
* A common early sign of mild chronic blood sugar elevation in women is recurrent vaginal yeast infections that cause itching or burning.
* A deciliter is one-tenth of a liter, or a little over 3 ounces. A milligram is one one-thousandth of a gram, or about one three-thousandth of the weight of sugar in a level teaspoon.
* Waking, or fasting, blood sugars are frequently normal in mild type 2 diabetics. After they eat carbohydrate, however, their postprandial blood sugars are usually elevated.
† Beta cell burnout can be caused both by overactivity of the cells and by the toxicity of high glucose levels.
* It’s worth noting that one of the hallmarks of high blood sugars is fatigue. However, diminished thyroid function can cause profound fatigue, coldness, or muscle cramps. If you’re still “always tired” or “always cold” after normalizing blood sugars, talk to your physician about a thyroid profile. This test can be costly.
* For information on the proper treatment of these conditions, visit www.diabetes-book.com; select “Articles,” then “Research,” and then the article title that begins “Some Long-Term Sequelae of Poorly Controlled Diabetes.”
* The most accurate personal meter as of this writing is the HemoCue. It is much larger and more difficult to use than other meters and requires much more blood. It is great for calibrating more portable meters.
* The size of SweeTARTS varies with the packaging, so 10 mg/dl can likewise vary.
† MedicAlert also offers sterling silver and gold-plated bracelets and ID wristwatches at an additional cost.
* My patients, myself, and many diabetic violinists are much indebted to Ron Raab, president of Insulin for Life, of Ballarat, Victoria, Australia (www.insulinforlife.org), for this not-so-obvious technique. Mr. Raab’s attempts to publish this important finding were repeatedly scorned by medical journals and finally came to my attention via personal correspondence. He has had type 1 diabetes since 1956 and favors a low-carbohydrate diet. I use Mr. Raab’s technique myself and find it far superior to the palmar technique, which I used for years. By the way, this technique was in common use by physicians eighty years ago. Like so many things in medicine, it had to be rediscovered.
* Most manufacturers provide strips that have an invisible hole at the tip. Blood is sucked into the strip by capillary action. The puncture site should point upward and the tip of the strip must be inserted into the drop of blood. With such strips, the blood should not be put on top of the strip as erroneously practiced by some users.
* GLUCOGRAF is a registered trademark owned by Richard K. Bernstein, MD. The data sheet form is protected by U.S. copyright, and may not be reproduced for sale without permission of the author. Readers of this book who wish to have some practice copies for immediate use may make photocopies of the form, which is reproduced at a reduced size here in order to make it fit into this book. Most photocopiers can enlarge the image in order to provide you with standard 8½ × 11 sheets. Pads containing enough pages to cover one year can be ordered by phone from Rosedale Pharmacy, (888) 796-3348, or from www.rx4betterhealth.com.
* Insulin-sensitizing and insulin-mimetic agents are blood sugar–lowering pills that you may be using. They are discussed in detail in Chapter 15, “Oral Insulin-Sensitizing Agents, Insulin-Mimetic Agents, and Other Options.
* Consuming alcohol at bedtime can inhibit gluconeogenesis overnight, but not in a predictable fashion.
* Except for noncaloric fluids that flow through the intestines without causing distention.
† Several readers from China have e-mailed me that their restaurants don’t use sweet sauces, so this effect shouldn’t apply to them. This is a misunderstanding of the effect—the Chinese restaurant effect is caused by any solid foods. It is also caused by nutrient-loaded foods containing carbohydrate, protein, or fat.
* Or oral agents for controlling blood sugar.
* Since 80 percent or more of type 2 diabetics are overweight, weight loss should be an important part of treatment for the majority.
* Nevertheless, I record my 4–6 hour training sessions for my patients and give them the tapes. Readers of this book can purchase CD recordings of actual training sessions at www.rx4betterhealth.com.
* Your physician, if interested, may order a copy of my eight-page examination for diabetic complications by contacting me as instructed here.
† My training program consists essentially of the material covered in this book. It’s my hope that physicians who have little time to educate patients will use this book to assist in that task.
* I used to have some fun with nondiabetic sales reps when they came into the office selling blood sugar meters. They’d be demonstrating a meter, which I would compare to my own meter. I always used their blood because I’ve had enough finger sticks. I’d “guess” their blood sugar. I’d make a show of examining their skin, then give them a number. It was always the same, but they didn’t know that. The number was 83 mg/dl. Inevitably I’d be within ±3 mg/dl. You know, of course, that I didn’t have any special powers—it was just that I’d seen so many random finger-stick readings from nondiabetics that I knew what number the nondiabetic was likely to show.
* A study published in the New England Journal of Medicine found that nondiabetic men with fasting blood sugars of 87 mg/dl or more had greater risk of developing diabetes than those with values less than 81 mg/dl. Another study of about two thousand healthy men, published in Diabetes Care in January 1999, showed that over a period of twenty-two years the risk of cardiac death was 40 percent greater for those with fasting blood sugars greater than 85 mg/dl. To my amazement, a medical director of a major insulin manufacturer recently told me that it found most nondiabetic men to have blood sugars in the 70s. Dr. Stan De Loach, a diabetes specialist in Mexico, tested three hundred nondiabetic children and found them all to have blood sugars in the 70s.
* Phosphate, a by-product of protein digestion, requires calcium in order to be eliminated from the body—about 1 gram of calcium for every 10 ounces of protein foods. If you don’t eat much cheese, cream, milk (too high in carbohydrate), yogurt, or bones, all good sources of calcium, it would be wise to take a calcium supplement. This will prevent the slow loss of calcium from your bones. I recommend calcium citrate in formulations supplemented with magnesium and vitamin D.
† And other so-called counterregulatory hormones, such as cortisol and growth hormone.
‡ This amounts to about 7.5 percent of the total weight of a protein food. Say you eat a 3-ounce (85-gram) hamburger, no bun, for lunch—the protein in it can slowly be transformed by the liver into no more than 6½ grams of glucose.
* This is discussed further in Appendix A.
* Contrary to traditional thinking, a study published in the Journal of the American College of Nutrition demonstrated that the metabolizable calories in fats are about the same as in carbohydrates.
* Except for the Chinese restaurant effect (see here).
† A lipid profile is the measurement of cholesterol, HDL (good cholesterol), LDL (bad cholesterol), and triglyceride levels in the blood. Some physicians now consider lipoprotein(a) to be an essential component of the lipid profile. (See Chapter 2, “Tests: Baseline Measures of Your Disease and Risk Profile.”)
* You can read about this study, described in the journal Circulation in 2009, at http://circ.ahajournals.org/cgi/content/full/120/11/1011.
* You’d also be missing the vitamins and other nutrients contained in low-carbohydrate vegetables, so a zero-carbohydrate diet is not in my game plan.
* I use this test on television to show that even “whole grain” breads, contrary to claims of the ADA, become instant glucose when exposed to saliva.
* Many websites falsely perpetuate the myth that aspartame is toxic because its metabolism produces the poison methanol. In reality, one 12-ounce can of an aspartame-sweetened soft drink generates only 1/25 as much methanol as does a glass of milk.
* You can find the liquid at www.leansupplements.com.
* Looking for 0 under carbohydrate may not tell you everything you want to know. Also look in the list of ingredients to see if the product contains any of the sugars listed. If it does, check your blood sugars after drinking, if you choose to drink them, and see what effect they have on you.
† Unfortunately, the manufacturers of sugar-free Jell-O brand gelatin add maltodextrin to the powdered version. I expect that they will soon add it also to the ready-to-eat version. A suitable substitute would be Knox unflavored gelatin with added liquid stevia and your choice of DaVinci sugar-free syrup or Crystal Light powder for flavoring.
* You can find Splenda liquid online at www.leansupplements.com.
* In the United States, Walmart sells a flavored sugar-free product without maltodextrin.
* It’s not at all necessary to consume carbohydrate of any type for breakfast. If you do, the only kind I recommend is in the form of acceptable vegetables (which can work well in, for example, an omelet) or the bran crackers mentioned in the previous chapter.
* These foods are listed because they contain small amounts of slow-acting carbohydrate. They do not have any special nutritional or health benefits.
* This would amount to 11.7–14 ounces of protein daily for a nonathletic individual whose ideal body weight is 155 pounds.
* Remember that the carbohydrate in 10 cups of coffee, each with 2 tablespoons cream, can raise the blood sugar of a 140-pound type 1 diabetic by 50 mg/dl.
* For more information on the Pimas, visit http://diabetes.niddk.nih.gov/dm/pubs/pima/index.htm.
* At www.amazon.com, www.amazon.co.uk, and www.diabetes-book.com.
* This is especially true for many menstruating women, who retain more water during the week before their periods.
† This may not work for girls or women with polycystic ovarian syndrome (PCOS). They may fail to lose weight even on a near-starvation diet (see Appendix E). The same problem may occur if you are taking fat-building medications such as lithium or antipsychotic drugs.
* A fourth exception relates to the rare use of intravenous gamma globulin for treatment of an immune deficiency disorder, which causes random intermittent recovery of beta cells. (See here.)
* Dr. Spiegel passed away in 2009, but his widow, Marcia Greenleaf, PhD, was a student of his and still teaches autohypnosis to curb overeating. She practices in New York City. You can contact her at (212) 534-8877.
* Reproduced (with minor modifications by me) from Trance and Treatment: Clinical Uses of Hypnosis, by Herbert Spiegel, MD, and David Spiegel, MD, American Psychiatric Press, 1987.
† I have some patients who must do this 15 times daily, including once before each meal.
‡ Requiring only about 20 seconds each time.
* An excellent source for such products is e-Pill, LLC, 70 Walnut Street, Wellesley, MA 02481, (800) 549-0095, www.medicalwatches.com. I recommend their 12 Alarm Vibrating Pager ($75.95). It will give as many alarms as you desire if used in the “repeat countdown” mode. The website displays a number of other alarms that you may prefer.
* In medical terms, “tolerance” refers to declining efficacy over time, so that higher and higher doses are required to produce the same results.
* The compounding chemist that most of my patients use is Rockwell Compounding Associates, (800) 829-1493. (Compounding chemists are pharmacists with special training in the precise mixing of pharmaceuticals and over-the-counter medications. They can prepare capsules, powders, liquids, and even ointments, just as all pharmacists did when I was a child. There are many compounding chemists in the United States and elsewhere. Most require a physician’s prescription.)
* Plasma endorphin levels can be measured by most commercial laboratories. If you are curious about your level, just ask your physician to order plasma beta endorphin prior to starting an exercise program or a regimen of naltrexone and again a few weeks or months later.
* As I will explain in Chapter 15, I recommend not using sulfonylureas and similar medications.
* Alternatively, you may prefer Dex4 bits, which contain only 1 gram of glucose per bit.
* This type of cardiac exercise is not nearly as effective in raising heart rate as those described under “Cardiovascular Exercise,” here.
† A number of years ago, a report from the human physiology lab at Tufts University reported that only twelve weeks of weight training tripled the strength of male subjects ages 60–96. This was believed to improve their quality of life significantly. Subsequent studies showed similar effects in women.
* A number of inexpensive multiexercise machines on the market utilize thick rubber bands instead of weights. Beware of these: since you have to stop and change the bands to change the resistance, they do not permit true anaerobic training. Hydraulic and pneumatic machines that utilize rotary knobs to adjust settings are usually excellent but often quite costly.
* Some gyms have a machine that strengthens the adductor muscles of the legs by having you squeeze them together against resistance. I got a double hernia when I used this machine improperly, so I recommend that you avoid it.
* In addition to eventually impairing beta cell insulin production, sulfonylureas also impair circulation in the heart and elsewhere by closing ATP-sensitive potassium channels that relax blood vessels. They have been shown to increase all causes of mortality, including deaths from heart disease and cancer.
* Note that ALA has two molecular forms—a right (R) enantiomer and a left (L) enantiomer. For many years, commercial ALA was a mixture of the two called alpha lipoic acid (ALA). Then it was discovered that the active form is the R enantiomer. R-ALA is twice as potent as the R-L mixture (ALA), and this is the form usually marketed today. Although conventional ALA is widely available, R-ALA is more effective. As of this writing, the principal manufacturer in the United States is Glucorell, Inc., of Orlando, Florida, phone (866) 467-8569, www.insulow.com. Their product, Insulow, contains 100 mg of R-ALA per capsule, plus 750 mcg (0.75 mg) biotin. Insulow is available from Rosedale Pharmacy, (888) 796-3348, and www.Rx4betterhealth.com.
* Available from Med Specialties Compounding Pharmacy, Yorba Linda, California, (877) 373-2272.
† A deficit of vitamin B-12 can increase serum levels of the renal disease risk factor homocysteine. It would therefore be wise for your physician to check your serum homocysteine every six months while you are using metformin.
* Even though reports of liver toxicity are far fewer than with some commonly used medications such as niacin and the so-called statins, it’s a good idea for users of Actos to have their blood tested for liver enzymes annually.
† The FDA may restrict the use of Actos because of a weak association with bladder cancer.
* Vitamin E should only be used in the forms called gamma tocopherol or mixed tocopherols. Remember, however, that high doses of the common alpha tocopherol form, which can inhibit the absorption of essential gamma tocopherol from foods, has been shown to increase the risk of cardiac death.
* Except by commercial pilots, who must avoid insulin (see here).
† The enzymes are alpha-glucosidase and pancreatic amylase.
* Investigators in Buffalo, New York, have demonstrated that injected insulin appears to lower the production of inflammatory substances and increase levels of anti-inflammatory agents in obese individuals. Since inflammation increases the likelihood of atherosclerosis, chronic use of insulin injections can lower the risk of cardiac disease, peripheral vascular disease, and stroke, independent of its effects upon blood sugar. Injected insulin also facilitates the dilation (opening) of coronary and other arteries that may be constricted in many diabetics and even in nondiabetics. It also has been found to improve the absorption of oxygen by blood flowing through the lungs. On the other hand, the industrial doses of insulin used to cover high carbohydrate diets have pretty much the opposite of these effects.
* For obvious reasons, many of my patients, including myself, must use diluted insulin for precise measurement (see here).
* A polymer is a large molecule made up of identical smaller molecules bound together.
† The reason for this is that the minute amount of insulin remaining in a used needle will become polymerized (inactivated) within a few hours. If it is injected back into the vial, it will eventually act as a seed for the polymerization of much of the insulin in the vial.
* I do not recommend Lantus for most patients.
* Some communities forbid the disposal of such containers in local garbage. It is wise to contact your garbage collection department for advice. You can also visit www.safeneedledisposal.org to access a national database of local regulations in the United States.
† I save plastic grocery bags for this purpose and always pack a few empty ones when I travel.
* My favorite long- and intermediate-acting insulins, ultralente and lente, were taken off the market in 2006 because they were less profitable to the manufacturers. Diluting fluids were available for these insulins. Although the American Diabetes Association made no protest when these discontinuations were announced, there has been an uproar over this intrusion upon patient care in the U.K.
* For this reason and because studies have found it to be associated with increased cancer incidence, I do not recommend Lantus.
* They should be supplied with relatively wide-bore (21–23 gauge) needles.
† Eli Lilly and Company provides diluting fluid for Humalog, regular, and NPH insulins, but Novo Nordisk supplies diluents only for Novolog insulin.
* Note that we use the symbols + and − to indicate that a dose is just above or just below the nearest whole unit on a syringe scale. So 1− means ¾ unit and 3+ means 3¼ units.
* Novolog and Apidra are about 1½ times as potent as the other insulins. Humalog is about 2½ times as potent. For the three other insulins I recommend (regular, Levemir, and NPH), as noted in the previous chapter, except for the speed with which each insulin acts, 1 unit of one insulin is equivalent to 1 unit of any of the others.
* I have some patients whose blood sugars are so easy to control that we shoot for zero blood sugar change throughout the day.
* See here for our introduction to the concepts of basal and bolus insulin dosing.
* See here if you’ve forgotten how we arrive at a blood sugar target.
† Insulin users must always check blood sugar before they drive and hourly while driving. Ditto for operating potentially dangerous machines. Scuba divers should probably check blood sugars after every 20 minutes of diving.
* Some diabetics who also have the disease lupus erythematosus may experience just the opposite—lower insulin requirements in cold weather and higher requirements in warm weather.
* Only two of the insulins we discuss (regular and NPH) have the same molecular structure as human insulin. All the others have slightly different structures and are therefore called “analog” insulins, not “human” insulins.
* Remember from Chapter 17 that 1⁕ means ¾ unit and 1+ means 1¼ units.
* For those who are not insulin-resistant, I avoid Humalog for this purpose because it is so powerful (½ unit will lower my blood sugar by 50 mg/dl). But many obese patients are so insulin-resistant that ½ unit may lower them by only 10 mg/dl. In such cases, Humalog is the ideal insulin because it works more rapidly than the others.
* Note that this experiment requires that you refrain from eating for 5 hours after your last shot of regular and then another 6 hours after the Novolog, for a total of 11 hours. With luck, you’ll have to do this only once in your life.
* Insulin in large doses causes fluid retention. Avandia and Actos can also cause fluid retention. It is likely that the people reported to have developed heart failure while taking both Avandia or Actos and insulin were taking large doses of insulin to cover the usual high-carbohydrate diabetes diet currently advocated by the ADA.
* It has been claimed that the insulin-sensitizing agents (ISAs) cannot cause abnormally low blood sugars. This is not so. As we discussed in Chapter 15, I’ve seen it happen—in a very mild diabetic who was using it to facilitate weight loss. Nevertheless, this is a rare occurrence.
* One study has shown these symptoms to occur when blood sugar drops to 45—65 mg/dl. Furthermore, symptoms were found to continue for 45 minutes after blood sugars were normalized.
* If your physician still believes what he learned in medical school about this fictional phenomenon, ask him to read “The Somogyi Phenomenon—Sacred Cow or Bull?,” Archives of Internal Medicine 1984; 144:781—787.
* Both are available at kosher stores. Winkies are available at Rosedale Pharmacy, (888) 796-3348; Smarties are available at www.smartiesstore.com.
* This time frame can be greatly reduced by drinking a glucose solution (see here).
* Many insulin users will awaken automatically when blood sugar gets too low during sleep, so these people have built-in protection.
† Search the Web for “continuous glucose monitor” to compare different models.
* It is absolutely important when experiencing dehydrating illness not to do anything that would hasten dehydration—and that includes the use of certain medications, such as ACE inhibitors and diuretics. Never discontinue a medication without discussing it with your doctor, so ask your physician as soon as you experience such an illness about ceasing use of these and similar medications. If you’re unsure, most pharmacists can tell you if a particular drug can facilitate dehydration.
* Including tremors, lip-smacking, and neck-jerking.
* Figure on 0.022 quarts per pound of body weight (0.048 liters per kilogram). Thus, about 3 quarts (or 3 liters) for a person weighing 150 pounds (68 kilos).
* Beware of D5 or D10 saline solutions. These contain dextrose (glucose) and will certainly raise your blood sugar and thereby cause further dehydration. For uncontrollable diarrhea, half normal saline should be used; otherwise, normal saline.
* My current favorite probiotic is saccharomyces boulardii (brand name Florastor). It is available at most pharmacies.
* If, during an R-R study, your heart rate varies only 28 percent between inhaling and exhaling, then you will likely have mild gastroparesis. If the variation is about 20 percent, gastroparesis will probably be what I call moderate, and if less than 15 percent, I would call it severe.
* For a list of medications that should not be used with cisapride, go to www.propulsid-lap.com.
* A number of Canadian pharmacies for an additional charge of $5 can secure prescriptions for distant foreign patients from Canadian physicians.
* Such as Rockwell Compounding Associates, (800) 829-1493.
* I recite six digits (Sam Spade’s license number) and ask the patient to repeat them in reverse order.
* If your physician finds all of this hard to believe, he or she might benefit from reading the seventy articles and abstracts on this subject contained in “Proceedings of the Fifteenth International Diabetes Foundation Satellite Symposium on Diabetes and Macrovascular Complications,” Diabetes 45, supplement 3, July 1996. Also worth reading is “Effects of Varying Carbohydrate Content of Diet in Patients with Non-Insulin Dependent Diabetes Mellitus,” by Garg et al., Journal of the American Medical Association, 1994; 271:1421–1428. Many studies comparing low-carbohydrate and low-fat diets are collected each year in the archives of the Nutrition and Metabolism Society, http://locarbvslofat.org. The low-carbohydrate diets invariably have shown reduced cardiac risk.
* A 1995 article in the journal Nutritional Biochemistry, 6:411–437, demonstrated that a higher-protein diet enables the kidneys to increase their capacity for net acid secretion as ammonium. In other words, it improved kidney function.
* Your physician might find informative the following articles on this subject: “Molecular and Physiological Aspects of Nephropathy in Type 1 Diabetes Mellitus,” by Raskin and Tamborlane, Journal of Diabetes and Its Complications, 1996, 10:31–37; “The Effects of Dietary Protein Restriction and Blood Pressure Control on the Progression of Chronic Renal Disease,” by S. Klahr et al., New England Journal of Medicine, 1994, 330:877–884; also, in the same issue of the New England Journal of Medicine, the editorial “The Role of Dietary Protein Restriction in Progressive Azotemia” (pp. 929–930). Another study, in the journal Diabetes Care, 25:425–430, in the year 2000, showed that obese people on a high-protein diet lost more fat and less muscle mass than those on a low-fat diet. They also showed more than double the reduction in LDL (the “bad” cholesterol).
* A study of older individuals who were rotated between low-, moderate-, and high-salt diets demonstrated that those on low-salt diets experienced significantly more sleep disturbances, and had more rapid heart rates and higher serum epinephrine (adrenaline) levels. An international study called Intersalt, covering 10,079 people in 32 countries, reported in 1988 that “salt has only small importance in hypertension.” More recently, another study showed that salt restriction increases insulin resistance and thus can indirectly increase blood sugar. Large amounts of dietary salt can facilitate loss of calcium from the bones of postmenopausal women, who are already at high risk for osteoporosis (bone weakening).
* To complicate things somewhat, a 1998 report in the Journal of Clinical Endocrinology and Metabolism demonstrated that salt restriction in nonhypertensive type 2 diabetics reduced insulin sensitivity by 15 percent. A prior article in the American Journal of Hypertension found a similar effect in hypertensive individuals. Another study of rats, published in the journal Diabetes in 2001, found that this insulin resistance cannot be reversed by the insulin-sensitizing agent Actos.
* As the first edition of this book was going to press, a report appeared entitled “Dietary Fiber, Glycemic Load, and Risk of Non-Insulin-Dependent Diabetes in Women” (Journal of the American Medical Association, 1997; 277:472–477). This study of 65,173 nurses and former nurses found a strong association between diets high in starch, flour, and sweet foods and the development of type 2 diabetes. Furthermore, consumption of minimally refined grain (such as bran without flour) lowered this risk. The combination of high glycemic foods and low intake of unrefined insoluble fiber was associated with a 2.5-fold higher incidence of diabetes. If you remember our discussion of beta cell burnout (here), this should come as no surprise.
* By the way, natural peanut butter has a glycemic index much higher than that of the peanuts from which it was created because it is digested more rapidly.
* Many hospital pharmacies do not stock the products that we commonly utilize in this book, such as 25–30 unit insulin syringes with ½-unit markings; detemir (Levemir) insulin; or regular, glulisine (Apidra), lispro (Humalog), or aspart (Novolog) insulins.
* There are many other OTC and prescription medications that contain phenylephrine.
† There are many other OTC and prescription medications that contain pseudoephedrine.
* Recent research suggests that this may not occur.