Diabetes Blogs

This is the first in a series of blog posts about the most common diabetes myths.

This is something you see all the time in the media, in general news reports, newspaper articles and the implication is everywhere, even if the words aren't.  Type 2s are made to feel like its their own fault they got diabetes because if you get fat, you get diabetes, right?

Wrong.

The phrases used are very subversive along the lines of "There is a link between obesity and diabetes".  Well yes there is, but the implication we seem to be bombarded with is that obesity causes diabetes.

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The T2 "You don't need to test" Myth.

There were 2 studies published in 2007 and 2008 which appear to be used as the main justification for the claim "you don't need to test" in relation to Type 2 diabetics.  These studies were both flawed in this reasoning and their conclusions incorrect.

The DIGEM study published in 2007 by Farmer et al started out with the objective of using Self Monitoring of Blood Glucose (SMBG) to reinforce the prescribed dietary advice, using 3 BG readings each on 2 days per week.  However the patients were told not to change their diet because of the results they obtained and were encouraged to stick more rigidly to the prescribed diet.  
"They were also given training and support in timing, interpreting, and using the results of their blood glucose test to enhance motivation and to maintain adherence to diet, physical activity, and drug regimens" [1]

However, because the HbA1c of the patients did not improve as a result of testing, their conclusion was that SMBG does not help to lower HbA1c.

This is a flawed conclusion.

It merely demonstrates that getting patients to test while instructing them to do nothing about the major cause of high BG (meal choices) does not help reduce HbA1c.  The patients were told not to change anything, but to stick more rigidly to what they were already doing.  It appears to be rather obvious to most laymen that simply recording data while preventing any change to the underlying causes does not help to reduce problems.

Since no change was observed in relation to the HbA1c of the patients in the study, it would appear to demonstrate that the prescribed diet does not help reduce HbA1c.  This is not surprising.  The dietary advice from the British Dietetic Association, echoed by Diabetes UK and other organisations is to base meals on starchy carbohydrates.  Since carbohydrates raise blood glucose levels and as a result, contribute to the HbA1c this dietary advice is clearly not designed to reduce HbA1c.

The ESMON study published in 2008 came to the same flawed conclusion as the DIGEM study, but for different reasons.  It also concluded that SMBG increased rates of depression in patients.

Their method can be seen from this quote:
"They were asked to monitor four fasting and four postprandial capillary blood glucose measurements each week. They were advised on appropriate responses to high or low readings. Such advice included the need for dietary review or the suggestion of exercise (such as walking) in response to high readings." [2]

Notice that there were 4 fasting and 4 post-meal readings.  Unless the post-meal readings were all at breakfast, there is no relationship between the before and after BG of a meal.  The post prandial readings were then likely to be unrelated to anything else and if the BG was high before the meal, this would tell the patient nothing about the cause of the high BG.  As any scientist or statistician knows full well, a single spot check proves nothing.

Also, because of the unpredictable nature of Dawn Phenomenon, a fasting reading on its own demonstrates very little.

Also due to the reliance on dietitians in other areas of the study's methodology, it would appear that "dietary review" involved discussion along the lines of reinforcing the prescribed dietary advice.

How the patient is supposed to gauge the effects of exercise based on a post prandial BG, unrelated to the exercise session without any readings before or after the exercise itself is not explained.  Presumably this was to reinforce the slight difference to BG made by exercise for the following 48 hours, although this can be wiped out by unwise dietary choices.

So again, this study was attempting to reinforce the standard dietary advice, which is not aimed at reducing HbA1c.

The reason for the increased levels of depression then is easily explained.  When these patients obtained out of range BG readings, they undertook dietary review, reinforcing a diet which is not aimed at reducing BG levels which then did not help to reduce BG.  So the patients were sticking more rigidly to their dietary plan, more rigidly to their medical advice and failed to see any improvement.  Then they got depressed.

One respondent to the BMJ site on this topic recommended the study for a "no s**t sherlock" award.


The method of SMBG recommended by diabetics across the world via the web is usually summarised by Jennifer's Advice:
http://www.diabetes-support.org.uk/joomla/jennifers-advice
Increasingly, it appears, people are also recommending pre-meal BG readings to compare with the post-meal readings in order to see the change in BG rather than absolute numbers.  This gives a better indication of the effect of the meal.

The important thing about this approach is the emphasis on learning from those BG readings to govern future food choices.  As time progresses the patient learns more about the effects of food.  But the more intensive the testing, the more effective the process.  Using SMBG a couple of days per week is not effective since the patient does not learn anything the rest of the time and may be elevating their BGs as a result of  unwise dietary choices.

Key to the control of BG, as shown by all those who have used Jennifer's Advice is the control of carbohydrate intake.  This does not specifically mean carbohydrate avoidance, but a tailoring of the diet to the quantities and types of carbohydrates which can be tolerated by the individual.

Over 6 years I have seen a great many Type 2 diabetics try Jennifer's Advice and achieve massively improved HbA1c results.  I have not seen any patient who has given it a serious try, who did not have an improved HbA1c.

Perhaps someday, a researcher will bother to ask a well controlled Type 2 how to study the effects of SMBG.  The study would then involve more intensive testing with a premeal test and both 1-hour and 2-hour postprandials.  There would be groups which performed this level of testing for 1,2 or 3 meals per day and a group which also did additional tests at other times.  The study would obviously show an improvement in HbA1c over a 3 month period - better still 6 months to allow the patients to learn and improve from that learning.  From the results of such a study it would be possible to work out the most cost-effective way of helping patients to self-educate over a period of months

So in summary, these two studies do NOT prove that SMBG does not work.  It proves instead:
1)  The specific methods and purposes of SMBG used in the DIGEM and ESMON studies do not help to lower HbA1c
2)  The prescribed diet based on starchy carbohydrates does not help to reduce HbA1c.

 

 

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What is Second Life?

This question comes up time to time since we have a few people on Second Life in recent months and it get a mention in the forums occasionally. So I thought I should put up a blog post to explain.

Second Life (SL) is an online 3D virtual world. For most of the time DSF members use it as more of a 3D chatroom than anything else, although we have not quite got around to using microphones yet. However there's more to it than that.

To get started in Second Life you need to visit http://www.secondlife.com , create an account and download the software. The account name you create cannot be your real name and will be the name you appear as in-world. Its also your login. So when you start Second Life on your computer, you will log in with that name.

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Since I am flying today, I've been checking up on the current restrictions for airport security and checking through my hand luggage for any stray items from previous trips.

All very logical, but I am certain that at least 2 people in the queue for security ahead of me will not have done.

I went to the Liverpool passport office yesterday.  You now have to go through a metal detector on the way in.  There's a long queue before the metal detector so you know whats coming well in advance.  To pass the time you can read the notices advising you that if you joke about having a bomb you will get arrested.

So after 5 minutes of shuffling along to get to the metal detector, the prat in front of me gets to the front and suddenly realises that he might have to empty all 27 of his pockets and take the bag off his shoulder.  Then he goes through the metal detector and sets it off anyway.

I set it off as well which is odd because I had gone through without setting it off the day before.  But at least I had not wasted everyone else's time simply by doing 5 seconds of preparation while I was waiting.

You get the same in supermarkets as well of course.  Its always been women as well in my experience.  The blokes always have a wallet in hand before the start.  But after shoving through 400 items (and packing 50 of them), there is a moment of stunned realisation that she might actually have to pay for this stuff.  This means unearthing the handbag from underneath that two bags that she has actually got around to packing, then rummaging around in the 4 tons of assorted hankies and other crap to find the purse.  Then there's the inevitable hunt for the last penny.

I go through, have my card in the PIN machine before the till jockey has finished announcing the total, telling them that I don't want cashback thanks, well before being asked and constantly packing while the machine farts around.  By the time the receipt comes out, I have hold of everything and am itching to leave.

So here's some tips for airport security.
1)  Empty your pockets into your bag or jacket BEFORE you go to the security point if you don't want to hear obscenities muttered behind you.
2)  Take your bloody jacket off BEFORE you go to the security point.  Its not rocket science.
3)  Your passport and boarding pass should be in your hand, not at the bottom of your cavernous handbag.  Yes those notices telling you to have those items to hand DO apply to YOU as well.
4)  If your watch, belt, glasses or jewelry have ever set off a metal detector in the past, hows about taking them off this time?

If you are unwilling or unable to follow these simple instructions, kindly tell the security people that you are carrying a bomb.  Then some helpful security types in rubber gloves will take you to a small room for a chat and get you the hell out of my way.

Airport security - doesn't affect my BG but it plays hell with my BP.

Mention going somewhere on business and people immediately think in terms of the exotic and start comparing it in their heads to some form of holiday or short break.

Nah.

These things are never fun, as anyone who has done a few will tell you. Off to Milan this week for an overnight stay and meeting. What this means in effect is the following...

You go to the airport and have to hang around bored for an hour after check in, get on a plane which may sound exciting for anyone who doesn't fly much but its as exciting as getting on a bus after a while. You arrive eventually at a hotel and have enough time for a coffee or one beer. Spend an hour looking for the one TV channel in English, shaking your head at some of the more bizarre TV shows they have in that country (The german TV gameshow "Strip" being a classic). Then maybe get prepared by reading some dull papers and get some sleep. Up and breakfast then off to a meeting.

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I've recently started making clothes again in Second Life. Part of the reason for this is that we have extended DSF island to the extent that it costs $8 USD per month. Half of the island is free, but we are having to pay for the other half.

However with a little effort and a bit of startup cash, its possible to make money from Second Life. In fact there are now millionaires who have made their fortune from SL and other virtual worlds. One of the first who was publically known is Ansche Chung who I heard about 3 years ago. She made a million dollars (US), moved to china and set up a business employing at least 9 people purely making money out of virtual worlds, with SL being the main one.

So if other people can do it then it should be possible for me to make enough money from SL to be able to pay for the island.

In the next week I intend to set myself up in a shop, selling clothes. So how did I get to this point?

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Why Counting Calories Makes You Fat

For years, medical advice and diets have been thrown at us in relation to "calorie control" and for years, people have had great difficulty losing weight with these kinds of diet. A great deal of hardship has been gone through to lose relatively small amounts of weight. Considering it recently I've come to the conclusion that calories are a bit of a con and that's why calorie control does not work.

Q: How do they measure calories in food?

A: They set fire to it.

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Are Petitions a Waste of Time?

...and should we just give up?

This is a question which rears its head from time to time in relation to dietary advice and test strips in particular. My answer to that would be "No, but we should be prepared for disappointment".

Lets take test strips as an example. NICE has set out its guidelines regarding the use of test strips and also given its reaction to studies which claim that SMBG (Self Monitoring of Blood Glucose) does no good. PCTs have interpreted this as an excuse to cut test strips from all T2 patients and have put pressure on doctors to do this. Doctors however can always override any recommendation in the interests of the patient, although if they are given medical advice that a process such as SMBG is of no benefit to the patient, then they will take some convincing.

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When talking to T2s, I generally try to get across the importance of testing and in some cases its an uphill battle.  We not only fight the medics and dieticians advice, but habits and cultural conditioning.

 Because dieticians advice (and so medics advice) changes very little simply because we are diabetic, there is a cultural conditioning element to food in the UK and probably most of the rest of the world.  Since the "Fat is evil" message started getting out in the 50s, we have become accustomed to eating a lot of carbs.

So we have become culturally conditioned to think of high carb as being a "normal" diet.  Managing carbs then appears to be abnormal and the last thing anyone wants is to be abnormal.  

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One of the projects I really need to get my finger out with is recording BG numbers on my phone.  Although all meters will store your BG results, they mostly do not have any way of recording the additional information that makes the data useful.

 I have been using PDA phones for years.  These are basically a phone and computer combined and the ones I have been using have a version of Windows on them.  Frankly I spend more time reading books and news on it than anything else but it has other uses.

One of these uses is recording BG data.  Along with the actual numbers, I need to record time since last meal, type of test (pre, post, fasting) and some notes on what was eaten, any exercise taken etc.  I'm just bunging it in excel for the moment and shoving it all in a database at a later date.

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