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Diabetes Update: e-Patients

Number 52; January 2, 2003

By David Mendosa

Our Garden Our Garden

This newsletter keeps you up-to-date with new articles, columns, and Web pages that I have written. I list and link most of these on my Diabetes Directory at www.mendosa.com/diabetes.htm

From time to time Diabetes Update may also include links to other Web pages of special interest.

My most recent contributions are:

  • e-Patients
    Like it or not, we are all rapidly becoming e-Patients. That’s shorthand for patients who use the Internet to gather information about the condition that they hire doctors to treat.

    And the doctors often like it not. Patients with opinions sometimes get in their way. These doctors have to “suck it up and deal with it,” in the expressive phrase of today’s youth. The URL for my column on e-Patients is http://www.diabetes.org/main/community/info_news/web/default.jsp

Updates include:

  • Trans Fats
    I take it back. In an earlier issue of this newsletter I had the audacity to criticize our government. I wrote that the Food and Drug Administration’s proposed change to Nutrition Facts panel “will not go far enough.” It won’t list a Daily Value because the Institute of Medicine’s report on which the FDA based its actions says on one hand that “trans fatty acids are unavoidable in ordinary diets” and on the other that the facts suggest “a Tolerable Upper Intake Level (UL) of zero,” because the more trans fat in the diet the greater the risk of coronary heart disease, which is of course a particular concern for people with diabetes.

    The FDA is still refraining from proposing an UL of zero. But it plans to do the next best thing. A footnote on nutrition labels that would read: “Intake of trans fats should be as low as possible.”

    While I appreciate the FDA’s proposal, it’s now getting even more flack from the other side. The Grocery Manufacturers of America, the world’s largest association of food, beverage, and consumer product companies, and the National Food Processors Association, which represents companies such as Unilever, and Nabisco, are so unhappy that they may sue, according to The Wall Street Journal. While the WSJ has an online site, it isn’t free. It does make available some of its articles to other publications, and this article is free online at the San Francisco Chronicle’s at Food industry gags at proposed trans fats label rule .

    The controversy could add yet another delay. My earlier Diabetes Update reported the FDA’s statement that it “hopes to publish the final rule early in 2003.” Now, however, the WSJ says that the new rule is unlikely before summer.

  • Diabetes and Diet
    Derek Paice, an engineer who has type 2 diabetes, developed the concept of the substance glycemic index based on a fixed weight of foods. Formerly, he printed and sold his book. Now, he has authorized me to make available online at no cost. The URL is Diabetes and Diet: A Type 2 Patient's Successful Efforts at Control. Since this is a PDF file, you need the free Acrobat Reader on your computer. If you don't have it already, you can download it at http://www.adobe.com/products/acrobat/readstep.html.

Research Notes:

  • Acrylamide
    There is bad news for people who follow a high-carbohydrate diet, particularly if they eat fried or baked foods that have starch in them. You know, like french fries, potato chips, bread, crackers, and breakfast cereals. Last April Swedish scientists discovered high levels of a potentially cancer-causing chemical called acrylamide in these foods. You can read their report online at Acrylamide in Heat-Processed Foods.

    In spite of worldwide publicity it was hard to believe. There wasn’t anyone who knew where the acrylamide came from or if there was in fact a link between it in food and cancer.

    Since then, scientists around the world have been busy. First, the British Food Standards Agency confirmed the Swedish findings. Then researchers at institutions in England, Switzerland, and the United States showed that acrylamide is produced when asparagine, an amino acid abundant in cereals and grains, is heated above 212 degrees Fahrenheit with either of two sugars, glucose or 2-deoxyglucose.

    Now Bruce Ganem, a professor in Cornell University’s Department of Chemistry and Chemical Biology, has offered a more-detailed explanation in a letter, “Explaining acrylamides in food,” in the December 2 issue of Chemical and Engineering News. The letter is not online but you can read Cornell's press release. While British and Swiss scientists thought that the Maillard reaction explained the formation of acrylamide, they could not explain how it happened. The Maillard reaction, also known as non-enzymatic browning, involves the reactions between proteins and carbohydrates that cause food to turn brown when cooked.

    Professor Ganem didn’t think that the combination of asparagine and 2-deoxyglucose could form acrylamide, because 2-deoxyglucose lacks a key molecular feature needed for the Maillard reaction. He focused on another possible pathway, the release of carbon dioxide through a natural metabolic process known as enzymatic decarboxylation and traced the step-by-step chemical mechanism.

    “The pathway I presented probably would not occur under normal biological conditions,” Professor Ganem says, “but it’s important to recognize that we’re talking about temperatures well above 100 degrees Centigrade while the food is being cooked.”

    So watch that high heat. While you are at it, why not switch to a totally raw foods diet? Maybe those nuts were right all along.

  • Less Fish
    More is not always better. Yes, it is better to be a billionaire than a millionaire, I guess. But eating more food isn’t better. Not even, it seems, more fish, one of the best things to eat.

    That’s the surprising result of a new study, “Fish Consumption and Risk of Stroke in Men,” by the Harvard School of Public Health in the December 25 issue of JAMA, the journal of the American Medical Association. Men who eat seafood as seldom as once a month may cut their risk of the most common kind of stroke by more than 40 percent. However, a higher frequency of fish intake was not associated with further risk reduction.

    “Previous studies found that you had to eat fish once or twice a week," Dr. Ka He, the Harvard nutritionist who led the study, told The New York Times. “And they found a linear association—the more fish you ate, the more benefit you got. But in our study, we found a threshold. Further fish did not provide further benefit.”

    This research is a part of the Health Professional Follow-up Study, a U.S. prospective cohort study with 12 years of follow-up. The participants were 43,671 men aged 40 to 75 years who completed a detailed and validated semiquantitative food frequency questionnaire and who were free of cardiovascular disease at baseline in 1986.

    Since the risk of strokes is greater among those of us who have diabetes, that’s really good news for those of us who don’t eat as much fish as they told us we should.

  • Don’t Drink Just on New Year’s Eve
    The news about alcohol is so strange that for years the government tried its best to keep it from us. While heavy drinking causes all sorts of terrible problems, it has become quite clear that moderate drinking can prevent heart attacks, strokes, and amputated limbs—all of which are complications of diabetes. It can even help prevent dementia, one of the few conditions that diabetes hasn’t been blamed for, as far as I can remember.

    Now, in a sober assessment of the benefits of a glass or two of wine, beer, or hard liquor—any one of which seems to do the trick—Abigail Zuger in The New York Times reviews the evidence. You can read the article online at http://www.nytimes.com/2002/12/31/health/31ALCO.html?pagewanted=print&position=top.

    The biggest surprise for me was this quote:

    “Moderate drinking was about as good for the heart as an hour of exercise a day,” in one study of more than 80,000 Americans.

    Nevertheless, the recommendation to drink even in moderation must still remain an individual one. And that is not just because so many of us are unable to control our drinking. Pregnant women and people with liver disease should not drink. It offers no benefit to teenagers. Women who regularly have as little as one drink a day have a 10 percent higher risk of breast cancer than nondrinkers. Men under 40 and women under 50, except for those known to be at risk of heart disease (like people with diabetes), do not benefit from moderate drinking.

Book Reviews:

    Insulin Pump Therapy book
  • Insulin Pump Therapy Demystified
    The pump remains the instrument of choice for insulin users who want the tightest possible control. This is control not just in terms of A1c levels but also in terms of reducing the numbers of highs and lows.

    For years MiniMed (now Medtronic Diabetes) has dominated this market. It seems to be such an attractive market, however, that this industry pioneer must be giving up share not only to arch-rival Disetronic but also to new and forthcoming entrants into the market—Animas, Debiotech, Deltec, Diabetex, SOOIL, and Therafuse. Yet the biggest challenge to Medtronic Diabetes has to be not from a rival pump manufacturer but to a relatively new insulin from Aventis—Lantus. With a flat profile of at least 24 hours in most users, Lantus is the ideal basal insulin. When supplemented by bolus shots before meals, many people are getting the kind of control that they only dreamed of earlier.

    Yet people continue to turn to the pump. Some of them are those who have tried Lantus without success, according to Gabrielle Kaplan-Mayer, the author of Insulin Pump Therapy Demystified: an Essential Guide for Everyone Pumping Insulin (New York: Marlowe & Company, 2003, 192 pp., paperback, $15.95).

    Gabrielle was diagnosed with diabetes exactly 21 years ago, when she was 10. She has been on the pump since 1999. I don’t know which pump, because she doesn’t say. Part of me wishes she told us what her preferred pump is, while another part understands that she might not have the experience to single out the one she uses at the expense of those she hadn’t had the opportunity to try.

    A comparison of the features of the pumps of four of the manufacturers is a useful part of this book. In another 25 or so short chapters Gabrielle covers all the important considerations for those who are thinking about going on one.

    Pumps do remain a mystery for many of us with diabetes, making the “demystified” label of this book quite appropriate. As Gabrielle points out, 88 to 90 percent of those of us on insulin are not using a pump. She wonders why and answers her own question. Many of us are satisfied with “good enough.” Some certainly are concerned with the cost, particularly if the lack health insurance. But most probably just need more information.

    That information is here. Gabrielle’s book is a major contribution to the growing literature of diabetes by people who know the disease first hand. In fact, I can think of only one other book about insulin pumps by someone who uses one. That is Pumping Insulin: Everything You Need for Success With an Insulin Pump by John Walsh and his wife Ruth Roberts (San Diego, Torrey Pines Press, third edition, 2000, 288 pp, paperback, $23.95). John has been on the pump for 19 years and also writes from his intimate knowledge of the device. Both books deserve close attention from anyone considering the pump.

    The URL for the book is http://www.insulinpumpbook.com.

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  • I send out Diabetes Update e-mail in HTML format, which all Web browsers and most modern e-mail programs can display. HTML has live links to all the sites named in the text so that with a simple click of a mouse you can connect to the site you have just been reading about.

  • This newsletter is free and will never include advertising. Nor will I ever sell, rent, or trade your e-mail address to anyone.

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