My Favorite Vermeer

This newsletter keeps you up-to-date with new articles, Web pages, and books that I have written about diabetes.

• I list and link most of these on my at Diabetes Directory and in the site’s menu.

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

My recent contribution is:

• Coding
  Nowadays codes can be awfully difficult or even impossible to crack. Fortunately, the codes that you have to enter on most blood glucose monitors are much easier. Still, we often miss the mark. What happens when you miscode your meter? And what meters don’t need to be coded? To find out the answers to these questions please read the article that I wrote for the October 2004 issue of Diabetes Health. It is now also on my site at http://www.mendosa.com/coding.htm.

Updates:

• Niacin
  The American medical establishment continues to push the statin drugs as if it were the only game in town. It isn’t.

  The statins are indeed big business. Sales of these six drugs exceeded $15 billion last year, according to SmartMoney.com. Two of the statins, Lipitor and Zocor, ranked No. 1 and No. 2 respectively among all drugs sold in the United States last year, according to RxList.com.

  Many people would agree with SmartMoney.com that “Statin drugs should probably be in the water, like fluoride.” The only little problem is that “Statins break down muscle fiber in some patients, and in exceedingly rare cases, that causes kidney failure.”

  Not everyone suffers these unfortunate side effects, but I have read enough and talked to enough people to be sure that the excruciating pains I suffered when these drugs attacked my leg muscles were not all that rare.

  From talking with your doctor you might never know that there are many cholesterol-lowering alternatives to the statins. My article on Cholesterol originally reported on several of them. Later, I added an update on policosanol.

  Now, I have updated the article once again to consider niacin. This vitamin, when consumed in large doses, is perhaps even more of a miracle drug than the statins. The only problem is that the pharmaceutical companies can’t make any money on it.…Please see http://www.mendosa.com/cholesterol.htm.

• Atkins Hates Me
  It’s about time that the Atkins people realized that in my article Net Carbs I had made a strong attack on their veracity. Seven months after I posted the article on my site, they got around to challenging one of my basic claims — that some of the sugar alcohols they say have a minimal blood glucose impact in fact have a considerable impact.

  The article now has an “Update” section giving the Atkins reply and my rebuttal. Perhaps more than most disagreements I think that you will find this argument worth reading.

Research Notes:

• How Low Can You Go?
  There’s more good news about keeping your blood glucose levels low. The bad news is that even glucose levels previously considered to be normal as measured by your A1C increase your risk of cardiovascular disease like heart attacks, strokes, and artery disease.

  Two new studies published a few days ago in the Annals of Internal Medicine link blood glucose with the risk of heart disease. One of these studies found that whenever A1C levels went up one percent — like from 5.0 to 6.0, from 6.0 to 7.0 and so on — the risk of heart disease rose about 20 percent and the risk of death increased likewise.

  One of these articles reports on a study of more than 10,000 people in Norfolk, United Kingdom. The other was a meta-analysis of more than 9,000 people with diabetes.

  The results of these studies should sound a wake-up call for everyone, whether or not they have diabetes. The normal range for people who don’t have diabetes is 4.5 to 6.2, according to the UK Prospective Diabetes Study.

  The UKPDS results confirmed that high blood glucose is a major cause of the microvascular complications of diabetes like retinopathy and kidney disease. This study showed that better blood glucose control reduces the risk of major diabetic eye disease by 25 percent and early kidney damage by about 33 percent.

  But neither the UKPDS or the earlier Diabetes Control and Complications Trial (DCCT), which studied people with type 1 diabetes, gave a definitive answer to the question of whether glucose control reduces the risk of heart disease.

  Now we know that it does. It was only when our levels go above 6.2 that we start getting complications, the UKPDS said. Now it looks like we need to shoot for even lower A1C levels.

  The ADA’s top medical expert once told me that the average American with diabetes probably has an A1c between 8.5 and 9. He went on to explain to me that the ADA did not push for levels below 7.0 because below that level you get more hypoglycemia, need to change medication, or have to make other changes in their lives.

  It is certainly true that such tight control does lead to more hypoglycemia. However, it is rare unless you are using insulin and one of the older sulfonylureas. And it now appears that making lifestyle changes and changing the drugs you use are more important than ever.

  My recently A1C of 6.2 indicates that at least in this one respect I am normal rather than a typical person with diabetes. But we know now that even normal isn’t good enough, so like almost everyone else I will have to redouble my efforts to reduce my blood glucose.

  You can read the abstracts of the two new studies online at http://www.annals.org/cgi/content/abstract/141/6/413 and http://www.annals.org/cgi/content/abstract/141/6/421.

• ADA Statement on Diabetes
  The good new is that the American Diabetes Association has finally recognized the glycemic index and the glycemic load. The bad news is that this esteemed organization still recommends that our diets should be 45 to 65 percent carbohydrate.

  Without a subscription to Diabetes Care (or without paying $12 for the privilege of reading this one article) you can only read the abstract online for “Dietary Carbohydrate (Amount and Type) in the Prevention and Management of Diabetes: A statement by the American Diabetes Association.” Fortunately, Dr. Arturo Rolla posted the entire article from the September 2004 issue on his mailing list.

  The ADA statement even recognizes the crucial finding that implementing a low-glycemic index diet lowered A1C values by 0.43 percent when compared with a high-glycemic index diet (citing Professor Jennie Brand-Miller's meta-analysis, “Low-glycemic index diets in the management of diabetes,” in the August 2003 issue of Diabetes Care).

  Yet the ADA still dismisses the value of the glycemic index: “The type or source of carbohydrate has on postprandial glucose level has continued to be an area of debate,” the organization continues. That it is an area of debate is an understatement.

  Failing to distinguish between a low-glycemic and a low-carbohydrate diet, the ADA goes on to summarize its conclusions as follows:

  “Low-carbohydrate diets are not recommended in the management of diabetes. Although dietary carbohydrate is the major contributor to postprandial glucose concentration, it is an important source of energy, water-soluble vitamins and minerals, and fiber. Thus, in agreement with the National Academy of Sciences-Food and Nutrition Board, a recommended range of carbohydrate intake is 45 to 65 percent of total calories. In addition, because the brain and central nervous system have an absolute requirement for glucose as an energy source, restricting total carbohydrate to less than 130 g/day is not recommended.”

  A low-GI diet is certainly not necessarily a low-carbohydrate diet. Many high-carbohydrate foods are low glycemic.

  Take your pick. Personally, my head is persuaded that a low-GI diet makes a lot of sense. Yet my mouth does not always agree. I expect that this dichotomy represents is the very heart of the diet controversy now raging among those of us with diabetes.

• Inhaled Insulin
  Insulin has saved millions of lives since Dr. Frederick Banting and Charles Best made the first a pancreatic extract in 1921. It is not only the most effective drug for diabetes but is also the least expensive.

  The problem with insulin is the “ouch factor.” Annual injections for flu shots are one thing. But insulin shots once or even more daily are another. People with type 1 diabetes don’t have a choice. But all too often those shots scare away those of us with type 2.

  Soon, however, taking your insulin may well be as unremarkable as taking a deep breath. Clinical trials are showing that a brand of inhaled insulin known as Exubera works as well as injected insulin for people with both type 1 and type 2 diabetes.

  There have long been concerns that Exubera could cause lung problems. But it looks like new studies confirm its safety. The companies involved, Aventis, Pfizer, and Nektar Therapeutics, plan to file a new drug application with the FDA sometime next year. And Lilly and Alkermes are also working on their own brands of inhaled insulin.

  For more, you can read the Pfizer press release summarizing results presented last month at the Annual Meeting of the European Association for the Study of Diabetes in Munich, Germany. For me the most impressive finding was that study results showed that A1C levels decreased from 9.6 percent to 7.7 percent after two years for patients receiving Exubera, compared with 8.1 percent for patients in the control group.

Book Review:

Many Reflections

• Reflections On A Life With Diabetes
  The time seems to be ripe for books about the emotional aspects of diabetes. Last month I reviewed one of the first of this genre. It reflects the love of a mother for her daughter who has type 1 diabetes. This month the scene broadens.

  The title of the book, Reflections On A Life With Diabetes, is a misnomer, albeit clarified by the subtitle, a memoir in many voices. This book, compiled and edited by Diane Parker and Ruth Mark, includes contributions chronicling the lives of 47 contributors.

  The breadth of these contributions written in both prose and poetry is the book’s strength. At the same time the many voices dilute the intensity of the reading experience compared, for example, with the book reviewed here last month.

  This is still a powerful book. The contributors are either excellent writers or they have been extremely well edited or both. Read this and know that you are not alone.

  By a strange coincidence the title of this book, Reflections On A Life With Diabetes, is exactly the same as the subtitle of one of my least favorite books about diabetes, Sweet Invisible Body: Reflections on a Life With Diabetes. That book, by Lisa Roney, came out four years ago. The overwhelming impression that I retain about the earlier book is one of negativity. By contrast, I am left with a hopeful feeling after reading the current book.

  This new book, published this year by Virtualbookworm.com Publishing, is softbound with 285 pages. It lists for $14.95. You can buy it through Amazon.com, B&N.com, virtualbookworm.com, or by calling (877) 376-4955.

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