Saturday, March 31, 2012

Depression, Exercise and Medications

People with diabetes and other chronic diseases have more depression.
And people with depression don’t take care of themselves as well and that means poor blood glucose control.
As discussed in a recent post, exercise helps blood sugar control for people with diabetes.
And now an analysis of 90 studies showed that exercise appears to improve depression.

In this analysis, exercise was shown to help depression in those with a variety of chronic illnesses like diabetes.
Although the beneficial effect of exercise is modest, exercise might be considered in those with mild depression especially for those who decline psychotherapy or taking a medication.

For those people willing to take a medication for depression,
medications that do not cause weight gain are almost always preferred.

Bupropion is one of those that does not cause weight gain
Bupropion has the added benefit of not causing sweating or sexual dysfunction.
Keep in mind that none of the medications for depression is addictive.

There are many other anti-depressant medications each with its pros and cons.
Paroxetine (Paxil) is one of the worst of these, for many reasons.

And who should be checked for depression?

We should think of depression in those people with several of the following symptoms:
·      Low energy
·      Problems getting to sleep or staying asleep
·      Frequently feeling sad or hopeless
·      Loss of interest, motivation or pleasure in things
·      Overeating or poor appetite
·      Problems with mental concentration or memory
·      Feeling that you are no good for yourself or others
·      Frequent thoughts about death

Too often doctors may not take the time or have the knowledge to find out if someone has depression.
Some doctors might just say: “Do you think you’re depressed”?

Doctors don’t ask the patient to diagnose their diabetes or thyroid problem.
Doctors make those diagnoses by appropriate exams and blood tests.

There are no blood tests for depression.

For depression, the diagnosis is made by talking with the patient and asking key questions in a sensitive manner.
Sometimes questionnaires are used to help diagnose depression.

There are many online resources for people who want to learn more.
Here’s one from  the National Alliance on Mental Illness 

Hearing the patient’s story is always important.
The electronic medical record is not optimal for listening or what is called narrative medicine.
Grief, loss and traumas are often but not always contributing factors in depression.

And once the diagnosis of depression is made treatment should be discussed.

Now it looks like exercise can be part of the treatment plan.
The challenge often is getting people motivated to start exercise.
Perhaps the hardest part is getting started.

Taking a walk might work for starters. 
Then talking to your doctor at the next visit.
I hope he or she is good listener.

Saturday, March 24, 2012

Appetite Control Insights

You say your “metabolism” is slow and that's why you can’t lose weight.
Maybe, but that's not likely. But let's just say you’re right.

At this time there are no proven safe weight loss options that speed up your metabolism. 
By that I mean, nothing safe has been found to increase your burning of calories while you are at rest. That includes such recent rubbish as "raspberry ketones". 

We call the amount of calories you burn up while resting your resting metabolic rate or RMR. The RMR equals the amount of energy or number of calories used to keep all your vital organs working.

Large doses of thyroid hormone or amphetamines will increase your RMR.
And both of these types of drugs in high dose will increase your heart rate at rest. 
That increased heart rate alone would increase your RMR.
But neither of those drugs is safe in those high doses for weight loss. 
Obesity experts do not prescribe or recommend thyroid hormone or amphetamines for weight loss.

All safe weight loss requires consuming fewer calories from food than the calories we burn up throughout the day and night.
And since we cannot increase our RMR we must take in fewer calories or burn up more with activity or exercise.

For most of us, if we keep eating as we having been used to, we simply will not burn up enough calories with exercise alone to lose weight.
We must reduce calorie intake for weight loss.
And even if you believe you eat almost nothing, you need to eat even less if you want to lose weight. 
Sorry, that may sound cruel but sadly it's true.
But how to do this? How to eat less?

Controlling food intake is really hard.
There are many reasons we all eat.
We may eat to celebrate, or because we’re nervous or sad or angry or bored or maybe because we really enjoy the taste of a particular food.

In these posts called appetite control insights I will focus on, appetite or eating in response to hunger. I will share an important insight on appetite control. The appetite control insight might be on how exercise or sleep affects appetite or how a drug might help control appetite or how what you eat might regulate appetite.

So here’s the first insight. 

A recent study of obese male police officers studied the effects of two low calorie diets over 6 months. One diet had most of the carbohydrates eaten at dinner. The other diet included carbohydrates evenly spread throughout the day. Both groups ate morning and afternoon snacks and so they ate 6 times a day. There were 63 men studied who were randomly assigned to one group or the other.

The researchers found that there was less hunger and more satiety in the group of men who ate carbohydrates mostly at dinner. There was also a little more weight loss in that group. Leptin a key hormone associated with satiety tended to be higher in this group also. The higher leptin might have contributed to the reduced hunger in that group.

These preliminary findings are very interesting and encouraging. This small study warrants further investigation.

In the meantime, I do think that these results can provide insights for those struggling to lose weight and control their appetite. Protein does provide more satiety than carbohydrates or fat. 
For those who find they lose weight by reducing carbohydrate intake, perhaps they would do just as well by reducing carbohydrates mostly at breakfast and lunch. 

By the way, it is clear that there appears to be no benefit by routinely eating 6 times a day as discussed in a previous post. But that was done in this study.

So along with cutting portions and calories, try eating a lower carbohydrate breakfast and lunch. Nuts or seeds are an option but keep in mind that about a fourth of a cup is ~200 calories. Try low fat, high protein yogurt (Icelandic or Greek style). Or meat, fish (maybe smoked, pickled or canned), salad, or cheese. And don't drink your calories.

More insights to follow. 

Saturday, March 17, 2012

Why does my sugar go up overnight?

One question I am often asked: I don’t eat at bedtime so why does my blood sugar go up overnight?  Many patients with Type 2 Diabetes notice that their sugar goes up overnight. 
There is one main reason for this overnight rise in glucose.

Before answering I first  must stress that I am speaking about a rise in blood sugar level from bedtime to the next morning in people with Type 2 Diabetes.
You would have to test your sugar at bedtime, at least 4 hours after the evening meal to check this out.

Some people just check before meals and not at bedtime.
A high bedtime reading could be caused by a large supper and could carry over to the morning.

So let’s say you check your sugar at bedtime, around 4 hours after supper, and you get a reading of 130 mg/dl. And you find the next morning  your sugar is 170.
And you might find this 40 point rise much of the time.
Why does the sugar go up overnight?

Well we need to understand what brings the blood sugar up in general.
I discussed this in a post last year on how insulin should be used.

Blood sugar increases come in two ways:
from the food you eat and from what the liver makes.

Let’s focus on the liver.

If you don’t eat for a day or two or more, your sugar does not go to zero. Right?

Correct! That is correct even if you have not fasted this long. Why is it true?

Because your liver makes sugar. And in people with Type 2 Diabetes, the liver makes too much sugar. This excessive liver production of sugar causes the glucose to rise even without eating.

Extra insulin would take care of this overproduction of glucose by the liver. But people who have Type 2 Diabetes have inadequate action of insulin on the liver.

Another hormone from the pancreas called glucagon causes the liver to make excessive glucose. And in the morning, other hormones may contribute to a rise in glucose in the morning. Those hormones are growth hormone and cortisol.

People without diabetes simply make more insulin to prevent a glucose rise in the morning. That extra insulin counteracts the other hormones that would tend to increase the glucose. But people with Type 2 Diabetes may not be able to make extra insulin and their liver does not respond to insulin normally.

In treating people with Type 2 Diabetes, it may difficult to prevent the glucose from going up overnight.
Regular exercise, weight loss, metformin and other agents including insulin may be necessary to control this glucose rise overnight.

Now here’s a final strange observation. Occasionally I see people who think that by eating carbs at bedtime, their morning sugar is actually better in the morning than if they do not eat! And they often have evidence to support that.
Now these are patients who are not getting hypoglycemic overnight and rebounding up.

Although I do not understand the mechanism for this apparent benefit on morning sugars in these people, I do know that eating more makes you gain more weight and that’s not good for people with Type 2 Diabetes. So eating at night is not the best answer for them, even if they note that it might help the morning glucose readings.

For the vast majority of people with Type 2 Diabetes, there is no mystery as to why the sugar goes up overnight. The answer is in the liver. And we can take care of it!

Saturday, March 10, 2012

What is fish oil good for?

What is fish oil good for? 

It seems that most of the patients I see in the office each day are taking a fish oil supplement. Despite that, most can't say why they are taking it!

Should you take a fish oil supplement? If so, why? What is fish oil good for?
Did you know that a recent study suggested a new reason to consider taking a fish oil supplement?

Over the years, fish oil has been studied for a multitude of conditions.
But very few of those studies demonstrated conclusive benefit.

The key active components of fish oil are the omega-3 fatty acids known as docosahexaenoic acid and eicosapentaenoic acid or DHA and EPA. 
Omega-3 fatty acids cannot be made very well by your body. 
So that means they are important to have in your diet.

Omega-3 fatty acids are important for brain and retina development in infants. 
And omega-3 fatty acids may be important for many functions in the body and in modulating inflammation. 

So what if you don't eat fish. Should you take a fish oil supplement?

 What can you expect from taking a fish oil supplement?
The results of randomized trials can provide the most reliable scientific evidence to answer this question.

And this is what those trials have shown, thus far:

That trial used 1 gram of omega-3 fatty acids daily and was completed over 10 years ago. It was  large trial but was not placebo-controlled. Most of the benefit appeared to be due to a 43 percent reduction in the risk of sudden cardiac death.

A more recent trial in adults with a recent heart attack was placebo controlled, randomized and double blind. That study showed no benefit of 1 gram of omega-3 fatty acids.
It had one third the number of patients and newer therapies for myocardial infarction were available not used in the older trial.

Another randomized controlled trial in those with stable cardiovascular disease showed no benefit but a very low dose of 600 milligrams of omega-3 fatty acids was used.

Fish oil reduces death by 9% in those who have congestive heart failure. That trial used 1 gram of omega-3 fatty acids and was placebo-controlled and double blind.

Fish oil supplements providing 1.8 grams of EPA daily reduced cardiovascular events by 19% in adults with coronary artery disease. Those events were mostly nonfatal heart attacks . That trial was very large but was not placebo-controlled. These were impressive results even though that study was done in Japan where most people eat lots of fish.

 Fish oil providing 2 grams of omega-3 fatty acids daily, in certain circumstances, probably reduces the likelihood of getting the common heart arrhythmia called atrial fibrillation. 

One study showed reduction in atrial fibrillation after coronary artery bypass surgery.
Another placebo controlled double blind study of atrial fibrillation not related to cardiac surgery showed no benefit of 4 grams of omega-3 fatty acids.

Fish oil  providing about 4 grams of omega-3 fatty acids daily  reduces elevated fats in the blood called triglyceridesA prescription fish oil is available to treat high triglycerides. 
Early data suggest that the DHA and EPA components appear to act slightly differently on the blood fats called lipids. A new prescription fish oil preparation may be available soon.

Other isolated smaller studies suggest benefit from fish oil supplements in reducing anxiety in adults, in reducing liver fat in children with fatty liver disease, and symptoms in children with attention deficit hyperactivity disorder.

Now a recent study showed muscle benefit from fish oil providing around 700 milligrams of combined DHA and EPA daily. That's less than one gram of marine omega-3 fatty acids a day. These women, average age of 64 years, all underwent leg strength training three times a week for 12 weeks. At the end of that period, those who took fish oil had significantly better muscle strength than those not taking the fish oil.

 You can see that most of the benefit of fish oil has been shown in those with a history of heart disease or with elevated triglycerides.

But there appears to be no harm in taking fish oil even if you don't have those conditions.

And despite common belief, in the usual doses, recent findings show that fish oil does not affect how well your blood clots.
 A previous analysis concluded the same.

More studies are coming but that’s all the evidence for now.

If you choose to take fish oil you ought to read a previous post to be sure you are getting close to the amount you expect.
Keep in mind that the  content of combined EPA and DHA in non-prescription fish oil supplements is very variable.

And now you the know the answer to the question, "what is fish oil good for?"

Your Diabetes Endocrine Nutrition Group

Saturday, March 3, 2012

Do Statins Hurt The Liver? An Update

Are you still one of the many doctors or patients who worry that statins hurt the liver? As posted here 9 months ago, this concern is nonsense.

And now the Food and Drug Administration (FDA) finally had the courage to state so.

The FDA stated in a recent safety announcement: “the available scientific evidence does not support the routine monitoring of liver biochemistries in asymptomatic patients receiving statins … because (1) irreversible liver damage resulting from statins is exceptionally rare and is likely idiosyncratic in nature, and (2) no data exist to show that routine periodic monitoring of liver biochemistries is effective in identifying the very rare individual who may develop significant liver injury from ongoing statin therapy.”

In other words, there is no need to be worried that statins hurt the liver and there is no need to do routine blood tests to check for liver damage from statins.
There is actually no good evidence that statins cause liver damage.

And for years, there was no good evidence that any of the statins hurt the liver.

How much harm and untold anxiety were caused by the previous FDA requirement to monitor  liver tests in people on statins?

How many people had their statin stopped inappropriately and suffered a cardiovascular event because blood tests worried the doctor that the statin hurt the liver?

How much time and money were wasted on making patients go for unnecessary blood tests to monitor their liver?

Look, I admit knowledge is not fixed. We learn over time. 
New evidence becomes available.

But our regulatory authorities seem very predisposed to send out scary warnings and alerts about dubious harms.  Of course, in so doing, they cannot be blamed because of failure to warn. They “cover” themselves.

But there is real harm caused when these authorities scare people unnecessarily or when they fail to withdraw warnings, cautions or alerts that are no longer supported by the evidence.

Similar considerations and politics affect FDA drug approvals.

For now, as pointed out here last year, if you have been prescribed a statin there is no worry it may hurt your liver.

Check back soon for more evidence based updates, not influenced by politics.