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Wednesday, June 18, 2008

Eating Out

In this fast, convenience society of ours we eat out so much more than our parents did. One of the most frequently asked questions by newly diagnosed type 2 diabetics is "what can I eat when I eat out?".

I just went around the world for seven weeks via nine cuisines. Every meal was eating out; but I didn’t put on weight and my blood glucose levels were good as I travelled. Here are some of the tips that I’ve learned, to make sure I don’t undo the good work I’ve done at home when I’m eating out.

1. Be strong. We were brought up to clean our plate, not to waste food. But now that "waste not, want not" attitude to food on our plate that can kill us. Be strong enough to leave food on your plate even though you paid for it.

2. Order appetisers or soups. One is often enough for a meal, but if it isn't have a second appetiser. Or a soup. In the USA, UK and Australia I very rarely order a main course. In other countries the serve sizes tend to be smaller but I still often left food on the plate.

3. Make it clear to the waiter or server that you absolutely do NOT want chips/fries even though they are included with the meal. Often they will substitute vegetables or salad if you ask. If unwanted foods do appear, it can sometimes help if you transfer them to a side plate and then ignore them.

4. Avoid fast-food franchises where possible; although in some countries they can be useful for other things such as clean conveniences. In that case I order the least dangerous food item I can to "pay" for using them; whether or not I eat it depends on the situation. Actually, I quite liked McAloo Tikki in India the one time I tried it. Then I read the nutrition detail when I got home. I won't be trying it again.

5. Don't ask for low-carb or diabetic meals. Both will only confuse your waiter. Just pick the best you can from the menu and do what you can to modify it easily, such as substituting vegetables for fries or potatoes and similar.

6. When fast food is the only choice, be strong again. Eat the burger, toss the bun. Don't order up. Don't drink post-mix sodas - you have no control over which button the waiter presses or even which line is connected to the diet soda when they run out of diet syrup. If you can't buy a bottle or can - drink water or coffee or tea, with sweetener if necessary, not sugar.

7. If you eat at a restaurant you are likely to return to, test one hour afterwards to see what happened. That may affect your decision on returning or your menu selection when you do. Test, don't guess.

8. If possible, share meals with a partner. Order one meal, extra cutlery and an empty plate, then split it. Where it isn’t possible because of language barriers or embarrassment of others order a main course and a side salad or starter – just to get the plate – then mix between the two.

9. For low-carb breakfasts, many European hotels include buffets where you can choose appropriately. In the USA and UK, if an appropriate breakfast is not available or prohibitively expensive, I check out the local area on an evening walk after arrival and note where any diners or breakfast cafes are. Bacon and eggs at the diner or a "Full English Breakfast" minus it's carbs at a cafe not only may be cheaper but the walk there and back can be part of the day's exercise.

10. If in Asia - leave almost all of the rice on the plate.

Use your imagination, but always remember that the portion sizes on your plate are chosen by the chef to entice you to return, not by your doctor to improve your health.


Cheers, Alan

Tuesday, June 10, 2008

Money, Medications and Motives



From the New York Times, June 8, 2008


"A world-renowned Harvard child psychiatrist whose work has helped fuel an explosion in the use of powerful antipsychotic medicines in children earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but for years did not report much of this income to university officials, according to information given Congressional investigators."

"In the last 25 years, drug and device makers have displaced the federal government as the primary source of research financing, and industry support is vital to many university research programs. But as corporate research executives recruit the brightest scientists, their brethren in marketing departments have discovered that some of these same scientists can be terrific pitchmen."

Corruption always smells putrid.

We are in a catch-22 that is difficult to resolve. Research is expensive, very expensive. Medicine has changed to the point where big pharma has become the most significant non-government funder of research; and in many fields it is more significant than government.

There is a very, very old cliche that is still unfortunately true. He who pays the piper calls the tune.

And make no mistake about it - big pharma is BIG.

Ten seconds on google found this: "Pfizer’s U.S. operations decreased last year as competition in the cholesterol market contributed to an 8 percent decline in revenues for the firm’s flagship product Lipitor. The company’s $48.6 billion 2007 total revenue was 1 percent better than its 2006 revenue of $48.4 billion."

That's just Pfizer. You can fund a lot of research with a tiny percentage of nearly 50 billion dollars. Of course, the company would never attach strings to that funding...yeah, right.

Now consider some of their competitors. I came across this list, it's not exhaustive:

* Baxter
* Bayer HealthCare, Diagnostics Division
* BD Medical Diabetes Care
* Eli Lilly and Company
* GlaxoSmithKline
* Lifescan, Inc., a Johnson & Johnson Company
* Merck & Co., Inc.
* Novo Nordisk Inc.
* Pfizer Inc.
* sanofi-aventis
* Takeda Pharmaceuticals North America, Inc.


Do your own googling to find out the revenues for those; this may help: Fortune 500 Industry: Pharmaceuticals. Add it up and you probably exceed the combined gross domestic product of half the countries in the United Nations.

So, is it any wonder that the funding for long-term studies into non-pharmaceutical aspects of diabetes or heart treatment, such as diet, BG testing and exercise, is minuscule compared to that for medication interventions such as ACCORD and ADVANCE?

Incidentally, I didn't need to google for that list. I found it here, at the top of the page: ADA FY06 Corporate Recognition Program.

I don't wish to imply that sponsorship or research funding necessarily means that influence is exerted. Without sponsorship many of the most worthy and useful support groups in the world would disappear and without research funding many of the miracles of modern medicine would never have been discovered. However, even when a funding source has impeccable integrity there is still an inherent problem that those receiving the funds will tend to investigate or promote in particular directions, mindful of the next project and the funding needed for that. There is nothing corrupt about that - it is simply reality.

Consequently, when organisations issue guidelines, or scientists publish the results of research, one of the first sections we should read is the "Funding Acknowledgements" section to include that information in our assessment of the merits of those guidelines or the validity of that research.
Cheers, Alan

Saturday, June 07, 2008

ADVANCE and ACCORD

Today both the ACCORD and ADVANCE trials, and some editorials related to them, were published in the new England Journal of Medicine. They were massive studies covering thousands of subjects over long periods. The newspapers today are already trumpeting the news. News like this in the New York Times:
Tight Rein on Blood Sugar Has No Heart Benefits

I'm very disappointed by these studies. Not so much for the conclusions they drew, but for the ones that I believe they missed.

You can read them in full on the links. I've only had time for a very quick glance. I hope someone can show me where I'm wrong and point out where the valid conclusions are from these massive studies.

ACCORD
Effects of Intensive Glucose Lowering in Type 2 Diabetes The Action to Control Cardiovascular Risk in Diabetes Study Group

ADVANCE
Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes The ADVANCE Collaborative Group

New England Journal of Medicine Editorial
Intensive Glycemic Control in the ACCORD and ADVANCE Trials

New England Journal of Medicine Editorial
Glycemic Targets and Cardiovascular Disease

That second editorial is the better of the two in my opinion, and makes this point:
"In the ACCORD trial, patients in the intensive-therapy group who did not have a history of a cardiovascular event or whose baseline glycated hemoglobin level was below 8% had significantly fewer fatal and nonfatal cardiovascular events than did patients at higher risk. These findings suggest that intensive therapy was beneficial at least in this subgroup. Whether achieving glycemic targets below 7% will be beneficial to the vast majority of patients with type 2 diabetes and a low risk of cardiovascular disease remains another unanswered question."

This is a section from the first NEJM editorial, which didn't actually compare the two trials so much as attempt to make a conglomerate sense out of them. Judging by the snippet I include at the foot of one of their conclusions, I believe they failed.

"Two studies in this issue of the Journal — the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial7 (ClinicalTrials.gov number, NCT00000620) and the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation) trial8 — sought to determine the effect of the lowering of glucose to near-normal levels on cardiovascular risk. Although the ACCORD and ADVANCE trials both compared intensive and standard glucose-lowering targets in type 2 diabetes, the trials differed substantially (Table 1). Most patients in both studies received drugs from a variety of classes, with or without insulin. However, in the ACCORD study, there were no restrictions on glucose-lowering treatments to reach glycemic targets, whereas in the ADVANCE study, all patients in the intensive-control group were required to receive the sulfonylurea gliclazide (modified release) at initiation. Thiazolidinedione treatment was infrequent during the ADVANCE ."
And they note:
"Neither study appears to have emphasized lifestyle or dietary modification."

In other words, both studies ignored that as a means of lowering A1c to their respective targets or even of assisting the meds. I know from past discussions that ACCORD educated subjects in "adhering to" the standard low-fat high-carb dogma. My brief skim of both papers indicates that there were two major differences; ADVANCE covered a wider range of nationalities, and thus lifestyles, and both studies intensively used drugs, but different drugs. However, that was a very quick skim so I would be very interested in hearing opinions from others more analytical or more qualified than I.

And the NEJM analysis conclusions? In part:
"The most appropriate target for glycated hemoglobin should remain 7%, though lower individualized targets may be appropriate when the focus is primary prevention of macrovascular disease. When glycated hemoglobin values under 7% are the goal, clinicians will need to balance the incremental benefit of a reduction in microvascular events with the increased rates of adverse events; these patients may benefit from consultation with a specialist.

*sigh*

These studies could have achieved so much and they actually achieved so little. Worse than that, the scientists are missing a point that to me is blindingly obvious, and using that misunderstanding to reinforce an incorrect conclusion.The conclusion that jumps out at me from just this cursory analysis of both papers is that attempting to use medications to drive down type 2 diabetes glycemic levels without individually reviewing the appropriateness of the present dietary guidelines for each patient has inherent dangers clearly shown in ACCORD and shown to a lesser degree in ADVANCE.




Cheers, Alan

Friday, June 06, 2008

Grazing

"Ozgirl", a good friend on the alt.support.diabetes newsgroup, introduced me to "grazing" as a blood glucose management tool some years ago. She developed her own method to combat her pronounced reactive hypoglycemia and I found that the method was very effective.

As a diabetic one of my management goals is to try to keep my BG's as stable and as close to normal as I can. I found that eating the traditional "three square meals" daily caused problems and it became much easier when I broke those meals up into a series of smaller meals and snacks. Dinner is still my biggest meal, but the others are all small. And I rarely feel hungry.

My day goes something like this:

Breakfast, as soon as possible after waking, usually 5-6:30am.
Mid-morning, 10am, a small snack.
Lunch, around noon.
Mid-afternoon, a small snack.
Dinner, about 6pm.
An hour or two after dinner, a small snack
Bedtime supper.

Effectively I rarely go more than three hours without eating something, but the portion I eat is very small. When I say a small snack, that is the equivalent of half an apple, or a cracker with cheese, or a half-cup of yoghurt with berries; that's the sort of portion sizes I mean. Breakfast is equivalent to an egg or two and a slice of ham; lunch an open sandwich, or a soup, or a stir-fry or similar.

The total calories in the day are the same; they are just spread across the time more evenly. By testing after each of these snacks or small meals I've also found that I need to start with a very low carb breakfast but as I approach the evening I can eat higher carbohydrate snacks without spiking. That's why I can have my Psyllium, Fibre, Muesli and Nuts as a bedtime snack.

It works for me. Maybe it could work for you.

Cheers, Alan