Monday, June 27, 2011

How Should Insulin Be Used? Take it the way you would make it!

A study presented at the American Diabetes Association (ADA) meeting in the last few days confirmed what I have been arguing and teaching for years about how insulin is best taken.

But first a warning: this post is not simple but it  is really important. 

Sadly, most people with diabetes do not understand how best to use insulin. And, what’s worse, very few doctors, who prescribe insulin prescribe the best insulin in the best way for people with diabetes. This includes endocrinologists who are doctors who specialize in diabetes!

Two concerns with insulin treatment include: problems with low blood sugar (glucose) and difficulty with weight control. By the way, hypoglycemia is the medical term for low blood glucose, usually considered to be below 70.

Have hypoglycemia and weight control been issues for you on insulin therapy?

The key point of this post is that these issues, risk of hypoglycemia and weight control can be kept to a minimum when you take insulin like the way a person without diabetes would make insulin. Take it the way you would make it!

First is a fact you need to know. Glucose comes from two places: the food you eat (and liquids you drink if they have calories) and from what your liver makes.

A person without diabetes makes a little bit of insulin around the clock even when they don’t eat. That’s called “basal” insulin. It’s like a slow-release insulin. This basal insulin tells the liver to not make too much glucose.

Normal people, without diabetes, also make a bunch or “bolus” of insulin that prevents the glucose level from zooming up after food. That’s like quick-release insulin. Let’s call it mealtime insulin since it’s for food.

This mealtime insulin is meant to match the meal. It’s gone when the effect of the meal on the sugar level is gone, at around 4-5 hours.

Of course, not all meals or drinks will tend to increase the blood glucose. Meals and drinks that contain carbohydrates do that. But that’s another subject.  Don’t get distracted now.

So in order to mimic, reproduce or simulate how insulin is made normally, we need basal insulin and mealtime insulin; that’s both slow- release and quick-release insulins.

Lantus  also called insulin glargine is the long acting basal insulin for which we have the most experience. Levemir (insulin detemir) is another good basal insulin.

Lantus takes 2-3 hours to start working and lasts 24 hours. It’s like a slow-release type of insulin; it releases a little around the clock.

The amount (the dose) of Lantus the person should take is the same everyday but that dose (measured in units) needs to be figured out so that a meal can be skipped and no low blood glucoses (hypoglycemia) will occur. The person taking Lantus should not have to eat to prevent a low blood sugar.

In fact, in general, a person with diabetes who is on the right dose of Lantus should have a stable blood sugar overnight and during the day without food.

Lots of people who see us as new patients are taking way too much Lantus insulin. Most of them need far less Lantus and more mealtime insulin. Lantus is not for the meals; it is the between-meals-around-the clock- even-when-not-eating insulin.

Then there is the mealtime insulin. Mealtime insulin is also called rapid acting insulin. Rapid acting insulins work quickly and are gone after roughly 4-5 hours. They are quick-release and short-acting.

Rapid acting insulins include Humalog

and Apidra

So how can you get the best sugar control using insulin therapy?

Take a rapid acting insulin before 1 or more meals and 1 injection of Lantus (long acting, basal) insulin. In general, patients take the rapid acting insulin only when they eat.

And with this basal bolus approach, you can eat when you want to as long as you take the rapid acting insulin at the time you eat. 

Of course, getting the doses right for each patient is really important and takes expertise.

Now, unlike the basal bolus type approach, there are insulins that make you eat at the same time even when you can’t or might not want to eat. These are the pre-mixed insulins like: Novolog Mix, Humalog Mix, the 70/30, 75/25, 50/50 insulins and N or NPH insulin.

These insulins all look cloudy, not clear like those insulins for basal bolus therapy. And all these cloudy insulins do not allow flexibility with meals. With those cloudy insulins, you better eat or else, you’ll get hypoglycemic. 

So, as you can imagine, an important benefit of basal bolus insulin treatment is that weight control is easier. Many people who switch from other insulins to the basal bolus approach lose weight. And, after the switch, they almost always have fewer problems with hypoglycemia.

There are other advantages of the basal bolus insulin treatment. For example, good blood sugar control is easier to achieve.

I teach doctors in the use of basal bolus insulin treatment. And most of our patients prefer it. The recent study presented at the ADA confirmed all of these reasons to use basal bolus therapy and not to use the cloudy insulins mentioned above.

In fact, less than 5% of the patients in our practice are on  cloudy insulins like 70/30. If you are on one of those insulins, you might consider a change.

Remember, regarding insulin: take it the way you would make it.

In many ways, you will see your way clear to better glucose control and easier weight control. 

Friday, June 24, 2011

Waste, Fraud and Abuse

Did you know that now doctors have to go through “waste, fraud and abuse”  (WFA for short) training?

And we have to document that the training was completed. It appears that the government sees us doctors as potential criminals eager to steal and cheat.

So the training instructs us as to what constitutes WFA and the consequences of  committing WFA?

I completed the training, as did our entire staff. And, of course, we all found it stupid and maddening.  Another one of those government mandates taking us away from patient care!

But I was not as nearly mad or rather livid as when I read the article written by James Bovard in this week’s Wall Street Journal.

Speaking of waste, fraud and abuse! Bovard describes how the federal administration encourages fraud, cheating and waste in the food stamp program. I urge you to read it!

The feds would rather prosecute doctors as criminals for using the wrong Medicare billing codes. They don’t really care about WFA.

You see the WFA in the food stamp program serves their purposes: to increase government dependency.  And this maintains the status quo of those in power.

Is Mr. Bovard wrong?  Am I? Let me know what you think.

Wednesday, June 22, 2011

Statins and Red Yeast Rice Dangers

Are you taking a statin? I have had patients claim to have a variety of side effects of statin drugs.  Statins are  those drugs that lower cholesterol and  very rarely cause serious side effects.

These drugs have been proven to reduce heart attacks, strokes and death from heart disease. The FDA approved the first statin in the United States in 1987.

There are now 7 statins on the market in the United States: lovastatin, pravastatin, simvastatin, fluvastatin, pitavastatin (Livalo) atorvastatin (Lipitor) and rosuvastatin (Crestor). The first 3 listed are lower in cost because they are available as a generic instead of the higher cost brand name. These first 3 are also found in nature; you might say they are naturally occurring or “natural”. Lovastatin, for example, is found in certain yeasts or fungi. The other statins are synthesized; they are not naturally occurring.

Some people get achiness in their muscles with statins. This is not joint achiness and it does not happen on one side of the body. Those symptoms would be from something else.

Most of the time the muscle achiness from statins is nothing serious. The cause of the achiness is not clear. And often if people get that symptom with one statin they will get it with the other statins.

 It’s too bad if they can’t tolerate statins. These drugs are very safe overall and quite effective in saving lives especially in persons at high risk for heart disease, like persons with diabetes. In the United Kingdom, you can get simvastatin without a prescription. That’s how safe statins are.

But safety is a relative thing. There is an increased, but still low, risk of serious muscle damage when certain drugs are taken by people on high doses of statins, especially 80 milligrams of simvastatin or lovastatin. In fact, the FDA recently advised caution on using the 80 milligram dose of simvastatin. Doctors need to know about interactions between drugs so that risk to the patient is as low as possible.

Sometimes people take red yeast rice because they’ve heard it can safely and “naturally” lower their cholesterol. Red yeast rice, is a so-called dietary supplement, so the FDA does not strictly regulate it. Some red yeast rice preparations may actually work to lower cholesterol.

Why is that? Well, it turns out that red yeast rice contains a chemical called monacolin K. Monacolin K is chemically identical to lovastatin.

Remember some yeasts make lovastatin and the yeast used in making red yeast rice makes monacolin K, otherwise known as lovastatin. But these red yeast rice supplements are not standardized; that means that the amount of monacolin, if any, in the red yeast rice preparation you buy may vary considerably each time you buy it and may vary when you change the brand you buy.

Also keep in mind that there have been reports of muscle symptoms, rarely serious, from red yeast rice just like you might expect for people taking lovastatin.

In the past, I told my patients who did okay with red yeast rice and got their cholesterol to goal, that they should also do fine with the prescription pill lovastatin.
And, after all, lovastatin by prescription is usually cheaper.

And they’ll know what they’re getting in each pill of prescription lovastatin. You can never be sure with the red yeast rice pills.

But now, speaking of not knowing, there is another reason to stay away from red yeast rice. A recent study showed that one third of the red yeast rice products on the market contain an increased amount of citrinin, a chemical substance which has been shown to cause mutations and kidney damage.

So now, I advise my patients, if you want to significantly and most safely lower your cholesterol, stick with statins by prescription. And get regular monitoring by your medical doctor.

Monday, June 20, 2011

Drawbacks of the Electronic Medical Record

For those who did not have the opportunity to read the News-Herald article I wrote on the electronic medical record, I am posting it here.

            As a diabetes specialist and endocrinologist, I ask what is the evidence to support this treatment compared to other therapies? When I supervise clinical research studies, I do so with strict attention to protocols designed to answer the question: how safe and effective is the drug being tested compared to other treatments? 
            Sadly, policy makers in Washington never demand answers to similar questions when they pass laws that affect millions of lives and cost billions of dollars. The best recent research shows no convincing evidence that use of an electronic medical record (abbreviated EMR) improves care or saves money. And implementing EMRs will introduce hidden and unknown human costs.

            More and more physicians use EMRs because large networks like the Cleveland Clinic or University Hospitals require them. If you went for a check-up recently you may have had to compete with the computer for your doctor’s attention. Most EMRs have templates that require physicians to tick off boxes or fill in blanks. But people do not speak in templates. The flow of the patient’s story can become lost as the doctor stares at each EMR screen, typing to complete each section.

            Physicians who focus on procedures, like surgeons and surgical subspecialists may be less troubled by EMRs. But many physicians find that the EMR detracts from active listening. A patient’s story and life situations are always important in evaluation and treatment. Good listening is at the core of therapy for family practitioners, cognitive specialists like endocrinologists, psychiatrists, and others. Many physicians with whom I have spoken wish they could return to paper charts. They describe their EMR as cumbersome, user-hostile, time-consuming and dehumanizing. They say they wouldn’t use an EMR if they had a choice.

            Despite these concerns, the federal government has set aside over $19 billion of taxpayer money to help implement EMRs. Big businesses like General Electric are expecting to profit as they sell their versions of EMR to doctors across the country.  Most EMR reports from an office visit are 10 pages or more of unreadable gobbledygook with no paragraphs or complete sentences.
            And a recent survey showed a majority of physicians were concerned that an EMR would require they see fewer patients and would be costly to implement and maintain.  These views explain why adoption of EMRs has been slow.
            In response, the feds now offer a modest annual bonus to those physicians demonstrating “meaningful use” of an EMR for their Medicare and Medicaid patients. The Center for Medicare and Medicaid Services (CMS) has defined “meaningful use” in a recent 276-page document; CMS can change this definition whenever they like. By 2015, those practices failing to comply with EMR requirements will be penalized a percentage of their Medicare charges.

            I question why such bonuses and penalties are necessary if EMRs really improve practice. No one needed government incentives to start using computers or smartphones. Along with many others, I share the concern that an EMR is open to breaches in privacy and exposure of confidential data by hackers. And with EMRs, patient care comes to a halt in the event of a power outage.           
            I am also concerned that the implementation of EMRs has been haphazard. There is a lack of standardization. No two EMRs are the same and they cannot interface with each other.
             In my practice, I dictate each office visit after the patient is seen. The transcribed note is promptly printed out and sent to the patient’s primary doctor. Each note tells a confidential, readable, human story.

            As technology improves, future EMRs may be more humane. At present, I will not implement an EMR until its benefits are clearly shown. In the meantime, I am prepared to pay government penalties for the privilege of listening to and caring for my patients.

Saturday, June 18, 2011

Fish Oil and How the Labels Mislead

Are you taking a fish oil supplement? If so, you are probably not taking prescription fish oil. Did you even know there is prescription fish oil, called  Lovaza ?

In large well-designed clinical trials, Lovaza has been shown to reduce death after previous heart attack and death in persons who have congestive heart failure. In another large study, done in Japan, high doses of a different fish oil supplement reduced vascular events in people with known coronary artery disease.

At this time, Lovaza is only approved by the FDA to treat high levels of triglycerides in the blood.  Triglycerides are a type of fat related to cholesterol. One third of Americans have borderline or high triglycerides in their blood.

High triglycerides are associated with an increased risk of heart disease. And when triglycerides are especially high, above 750-1000 milligrams per deciliter, there is a higher risk of pancreatitis. Pancreatitis is a life threatening condition with inflammation in the pancreas.

4 Lovaza pills daily is the dose to lower triglycerides.

There are two active ingredients in fish oil; these are abbreviated EPA and DHA. Lovaza is a very concentrated preparation of fish oil that contains 900 mg. of these omega-3 fatty acids in each pill.

But what if you don't take prescription fish oil? Most people who take a fish oil pill are taking dietary supplement, non-prescription, fish oil.

Well, if you choose to take fish oil you would want at least 1000 milligrams (1 gram) of combined EPA and DHA daily. And if you are trying to get down your high triglycerides you need 4 grams daily of combined EPA and DHA.

Now take a look at this label, typical for non-prescription fish oil pills:

This label tells us that each pill with 1000 mg. of fish oil only contains only 300 milligrams of the active ingredients (EPA plus DHA is 180 + 120). That means you would need more than 3 pills to get 1000 milligrams (1 gram) of the stuff that works. And you would need more than 13 pills daily to get 4 grams.

The point is: you must look at these labels because almost all the fish oil pills you will find for sale have on the front of the container “Fish Oil 1000mg” or “Omega-3 1000 milligrams”. But the label on the back tells you about the stuff that matters, the active ingredients, EPA and DHA. Tricky, isn’t it?

Keep in mind that there are other possible benefits of fish oil other than those I mentioned above. But these have far weaker evidence. 

Now I’m not telling you to take a fish oil supplement. But if you do, you should know what you’re taking and why, whether it’s by prescription or not.

 Your Diabetes Endocrine Nutrition Group

Tuesday, June 14, 2011

Good Sources of Protein for Weight Control

There is good evidence that high protein diets are effective for promoting satiety and reducing appetite. So it’s always good to find tasty convenient options to get your protein.

What foods provide high quality protein besides eggs, lean meat and fish?
Well of course, there’s tofu and related soy products.

But I bet that not too many of you have had tofu. It has very little taste, and it takes on the taste of what it’s cooked in. In that sense tofu is kind of like plain cooked pasta.
I like to do a stir fry using extra firm tofu. Find recipes at  Cooking Light

And if you like yogurt you may be familiar with so called Greek yogurt.  

But how about Skyr, pronounced skeer?

Skyr is a special yogurt originally from Iceland. Skyr has much more protein than Greek yogurt and I think it tastes better.

I discovered Skyr when my wife and I went hiking in Iceland a couple of years ago. There are some imitations of real Skyr, like Siggis brand, but I much prefer real Icelandic Skyr

Luckily, you can get Skyr in our area at Whole Foods.

Take a look at the label on a container of Skyr : the plain variety is 6 ounces and offers up 22 grams of protein. Wow!

There are only 6 grams of carbohydrate and zero fat in this serving of Skyr.
And it only has 110 calories. I like to put in a few berries with some Splenda or Nutrasweet . Sometimes I just add a spoonful of my favorite jam.

Skyr makes a great high protein breakfast or snack. Have you tried it yet? 

Sunday, June 12, 2011

Infant Formula and Type 1 Diabetes

What wouldn't you do to keep your child healthy?
            Any Mom would want to do anything she could to reduce the chances her baby would get a chronic disease like Type 1 Diabetes. People with Type 1 Diabetes know what it’s like to deal with Type 1 Diabetes every single day.
            Just the other week, I saw a Mom with Type 1 Diabetes who had done all she could before and during pregnancy. She worked really hard with our team to control her blood glucose using all the tools and tricks we had. Although her baby arrived a few weeks early, she delivered a healthy baby boy. Our whole staff celebrated with her.
            But like many mothers, she could not quite meet her baby’s nutritional needs by breastfeeding. So she supplemented with formula. She was using Enfamil.
            Her doctors apparently had not yet informed her of the results of an important recent study.
            To understand this study it is important to know that Type 1 Diabetes is an autoimmune disease. That means a condition in which the body’s immune system attacks itself. There are many autoimmune conditions.
            In Type 1 Diabetes, the insulin producing (beta cells) cells are attacked. Blood tests for autoantibodies can show up evidence of this attack on the beta cells.
            This major study was conducted in Finland where there’s lots of Type 1 Diabetes. Babies who had a mother or father or sibling with Type 1 Diabetes were studied. That means these newborns were at especially high risk of getting diabetes. All these babies were not able be breastfed so they needed formula during their first 6 months of life. Half of the babies were given mostly Enfamil, a cows milk formula and the other half were given Nutramigen which contains cow's milk protein that has been broken down or hydrolyzed into its building blocks called amino acids. The babies were randomly assigned, like the flip of a coin into one group or the other. The babies were then followed for up to 10 years for signs in the blood of those auto-antibodies relating to Type 1 Diabetes.
            So what did they find?  The likelihood of having auto-antibodies was about 50% less with the Nutramigen!
            I gave a copy of this study to my happy mom with Type 1 Diabetes for to her to share with the pediatrician.
            Although further studies need to be done, these results may translate into a much lower risk for Type 1 Diabetes by avoiding cow’s milk or cow’s milk formulas like Enfamil in the first 6 months of life.
            Lets’ hope so.
            Have you heard about this important study?

Tuesday, June 7, 2011

Do Statins Hurt Your Liver?

Whenever we see a commercial for a statin like Crestor or Lipitor we hear warnings about risk of liver damage. And my patients often worry about liver damage from statins and ask to have blood tests done to check for this.

But do statins really cause liver damage? The simple answer is no! It just doesn't happen. I’ve never seen a case of liver damage from a statin in all my years of practice. Neither have other doctors I’ve polled.

Recent reports confirm my experience. Large studies have shown that if a blood test related to the liver (called ALT or AST, known as serum transaminases) goes up, it comes down over time while the statin is continued. And the chance of increased transaminases in most studies with statins is similar to placebo, an inactive pill.

Even without medication lots of people have increased transaminases. Why’s that? Because as many as 40% of the U.S. adult population have a condition called non-alcoholic fatty liver disease (NAFLD). This condition causes inflammation in the liver, often with increased ALT levels. NAFLD is more common in overweight persons.

A recent study done in Greece asked: what happens if you give statins to people with coronary artery disease (blockages in the heart arteries)  who also have increased transaminases?

The answer: They get better!

Not only were the liver tests more likely to improve but also the risk of a vascular event
( including death, heart attacks or stroke)  was 68% lower, compared to people who did not take statins.

Statins also improve transaminases in people with chronic Hepatitis C.
Hepatitis C is a viral infection that causes liver damage and affects about 4 million people in the U.S..  These people often are at higher risk of heart disease. So they too would benefit from statins.

So if statins don’t damage the liver why the warnings on commercials and in the drug package inserts? Well,  back in the 1980’s the FDA required these warnings. Now, despite the facts, unless a drug company wants to spend the time and money to get the warnings removed,  those warnings stay in the label. And they scare patients.

So don't worry about statins hurting your liver. Save your time, money and blood for other testing.

Don't feel bad if you didn't know all this, alot of doctors don't either.

Did you learn something?


Bader, T. Liver tests are irrelevant when prescribing statins. The Lancet, Volume 376, Issue 9756, Pages 1882 - 1883, 4 December 2010
doi: 10.1016/S0140-6736(10)62142-3