Bicycle adventures

5 years ago I was 25# heavier and gasping for air on a 2 mile bike ride. Last weekend I rode a metric century supported ride at the Fallon No-Hills Hundred. Including the ride to and from the start line I logged 75 miles in 5 hours. Yes, I hurt the day after. Yes, I will do it again, only faster. You, too, are not too old to get thinner and faster.

Do kidneys get better with age?

The most common way to assess kidney health is with a blood test called creatinine. This test is used in a calculation for glomerular filtration rate (GFR), the amount of fluid filtered by the kidney in one minute. In addition to the creatinine blood test the person's age, gender and race have big impact on the overall calculation. As you might expect, as you get older the kidney function slows down even if the blood test is stable.
When I was 20 years old my GFR was 74 ml/min. This is fairly low for that age. My doctor said it was due to my diabetes and high blood pressure. At age 45 my GFR was down to 54 ml/min. My blood test was unchanged over the years. I had been on a wide variety of blood pressure pills and very diligent controlling my diabetes yet the kidney funtion did not improve.
After carefully analysing all my food, beverages, medicines and exercise I concluded that I might be eating too much protein. A high protein diet has been the cornerstone of diabetes nutritional therapy for decades and I had been carefully following it. So I cut my animal protein in half- less milk, less cheese, less beef, pork and poultry, less fish. I ate more carbohydrates and I did not gain any weight. I ate more carbohydrates yet I did not need more insulin and my average blood sugar did not go up. I ate less protein and my GFR improved by 40%. I 'found' a treatment for my kidney disease that cost no money and had no side effects. It will not be recalled by the FDA, will not react with any other medications and I will never develop an allergy to it. I hope you can find better health through better nutrition as I did.

Preventing diabetes: can it be done?

The challenge in preventing type 1 diabetes is figuring out who will get it before most of the damage is done. The immune system may be attacking the insulin-producing cells (beta cells) up to 5 years before the blood sugar goes up. By then only about 10% of the beta cells are left. Scientists are also discovering how challenging it is to stop the immune sytem from completing the attack. The research goes on...

Prevention of type 2 diabetes is easier to study because it's easier to predict who will likely get it. Studies compare treatment groups to a group of people who are not given any specific treatment to lower their chance of getting diabetes and are given vague directions to exercise and eat healthy. The research results are as follows:
metformin 2000 mg daily reduces frequency of diabetes by 30-40%
specific diet + exercise program reduces diabetes 50-70%
strictly following diet + exercise goals reduces diabetes by 90%
Actos 45 mg daily reduces diabetes ~70%
Avandia 8 mg daily reduces diabetes ~70%

So it's important to know what type of diabetes you might get in order to know how you might prevent it. It's also important to know that even with the most effectve prevention, it doesn't work all the time.

Byetta for weight loss or people on insulin

I recently received questions about using Byetta combined with insulin, and using Byetta for weight control when a person ahs well-controlled diabetes. Here is my response.

I'll start with the Amylin company position that Byetta is not FDA approved for use with insulin.

I have dozens of patients on insulin and Byetta, most commonly for weight loss and improved control. People well-controlled on small doses of insulin sometimes get off the insulin. A patient with an A1c of 7 but gaining weight would benefit from Byetta; I would be inclined to cut the insulin in half, and if on 20 units/d or less stop it when starting Byetta. They need to know that they may need to go back up on the insulin dose or restart it if the Byetta doesn't quiet control things.

I've also added Byetta or switched people to Byetta who are well controlled on oral agents but struggling with weight. As long as the A1c is >6.5 it should be covered by insurance. If they're on a weight-gaining medication such as sulfonylurea, Actos or Avandia I would reduce or stop them while adding Byetta.

Don't change or stop any of your medications based on the above information. Only make medication changes by working with your treating physician.

Dietary definition: MEAT

Many times a day when asking patients about food intake I am told 'I don't eat meat'. When I ask how the person gets protein in their diet, they tell me they eat chicken, fish, turkey, dairy products. Somehow the term 'meat' has come to mean specifically 'beef' or 'red meat'. Well, you can take the following as good news or bad news: beef as a general source of animal protein is no more or less healthy than chicken, turkey, pork or fish. a lean cut of any animal flesh will have about the same fat content and overall nutritional value. You will be no healthier eating a pound of chicken or bluefin tuna than a pound of sirloin steak or pork loin. There are a number of on-line nutritional content tables that can verify this. If you know of any dietary research that shows a health benefit from specifically consuming only one source of animal protein or specifically excluding one source of animal protein I will happily share it on my blog.

ADA news: Byetta gets better

Byetta will soon be available as a once-weekly injection. The study presented revealed more weight loss and better improvement in hgb A1c compared to twice daily Byetta. The people who inititally took twice daily Byetta were switched over to the weekly dose and they also experienced further weight loss and further improvement with hemoglobin A1c. The weekly dose initially caused some itching and irritation at the injection site but this side effect goes away over time. There's no projected date for weekly yetta to be available.

Lessons from the American Diabetes Association

Three big studies announced results this year. Each was designed to determine if aggressive blood sugar control would reduce the risk of having a heart attack in people with type 2 diabetes. This is an important question since most people with T2DM will die of a heart attack or stroke at a younger age than people without diabetes. Aggressive control meant blood sugars under 100 mg/dl and hemoglobin A1c under 6.5%

The tightly controlled groups fared no better than the groups whose A1c was 7.5-8% for the frequency of heart attack, stroke or death from any cause. There was some indication that people who had diabetes for less than 7 years or who had healthy hearts to begin with were less likely to have a heart event if their A1c was under 7%

It was fairly evident that lower blood pressures and lower cholesterol definitely reduced risk of heart disease regardless of level of diabetes control. The results were so hot off the press the researchers did not have time to analyse if lower A1c helped to prevent or stop progression of eye, kidney and nerve damage.

More in the next few days.

headlines: Cinical Endocrinology News

I finally got a chance to look at the May 2008 issue of
Clinical Endocrinology News
Here are some interesting headlines:
Weight Loss After Bariatric Surgery Lowers Bone Density page 14
Yoga Not Found to Improve Bone Mineral Density page 17
Teens With Bedroom TV's Haver Poorer Diets, Are Less Active page 22
Please comment if you want more discussion on any of these articles.

American Diabetes Association Scientific Meeting

June 6-10 2008 in San Francisco, CA. I'll be there to learn the latest in diabetes care and related topics including prevention and management of complications. Eye disease, kidney disease, nerve damage and heart disease can run rampant in people with diabetes and I will do what I can to prevent, arrest and if possible reverse these complications. I will be posting my findings here soon.

diabetic neuropathy and benfotiamine

Your feet burn, tingle, itch and there's nothing you can see on your feet or shoes causing it. Sometimes it's a stbbing or shooting pain. This is the start of diabetic neuropathy , damage to nerves. The link leads you to the National Institutes of Health/National Medical Library and offers a more complete description of various forms of diabetic neuropathy .

There are many treatments for neuropathy; cheap generic medications, expensive brand medications, IV insulin and Anodyne therapy to name most of them. Most prescription medications have impressive side effect profiles although many patients will have no side effects and many others find the pain relief to be worth putting up with side effects. One treatment that gets little recognition is Benfotiamine, a nonprescription thiamine derivative effective in treating diabetic neuropathy. I can summarize all the research as follows: it's about as effective as any prescription medication with far fewer side effects and no interactions with other medications. It treats the actual cause of the neuropathy rather than simply treating symptoms. Benfotiamine 150 mg, 2 capsules twice daily can frequently reduce symptoms of neuropathy. The link will connect you to a retailer that also has all the research posted at his web site. I have no business relationship with this company.

Keep in mind that any treatment for neuropathy is only a treatment and not a cure.

Metabolic Activation Therapy

This treatment was first developed by Dr. Tom Aoki and has been available at his center in Sacramento CA since 1986. A number of people in Reno NV seemed to be appropriate candidates for this treatment but Sacramento was too far away for the weekly treatments. Endocrine Associates began offering this treatment in Reno March 2002. The results confirm the findings published on this therapy.

The most notable benefit is how kidney failure slows down. Some patients note that they can feel hypoglycemia more easily. Some note an improvement in neuropathy. Some have reported that their retinopathy (eye disease) has stabilized.

The treatment is a once-weekly, 6-hour process. An IV is started and a specially-programmed pump delivers pulses of insulin. The patients eat carbohydrates to prevent hypoglycemia. Finger stick blood sugars are tested every 30 minutes. Every hour a 2-3 minute breathing test is performed to see how well the person is using the carbohydrates (respiratory quotient).

This treatment does not replace insulin therapy but is in addition to multiple daily injections or insulin pump therapy.

For more details and a list of publications on metabolic activation therapy see the Aoki Diabetes Research Institute website. Information is also available at Metabolic Industries and Advanced Diabetes Treatment Centers. If you think you would benefit from MAT ask your physician for a referral to Endocrine Associates.

Basics of diabetes care and other endocrine conditions

Rather than repeating what has been published in print and on the internet I will provide links to web sites that I have found to be useful and reliable. I am starting off with a very short list and will be adding more as I can.

American Diabetes Association:
http://www.diabetes.org/

American Association of Clinical Endocrinologists:
http://www.aace.com/

What is an endocrinologist?

I treat patients with hormone abnormalities. Diabetes mellitus is the most common endocrine condition. Insulin is a hormone that allows the body to use sugar as fuel or for storage. I see more and more people with diabetes because more people are getting diabetes and treatments for diabetes are getting more complicated. There are new insulins, new pills, new pumps and continuous glucose sensors That can make a person's life better with diabetes but also can be more confusing with medication interactions, different ways the medications work and how to best use the technology and information available.

The thyroid is another source of hormones, and both too much and too little thyroid hormone can be a problem. Because the thyroid is considered an endocrine organ I also evaluate and treat people with enlarged thyroid (goiter), absent thyroid, thyroid nodules and thyroid cancer. I do not perform thyroid surgery.

Osteoporosis falls within my area of specialty. It is considered a metabolic disorder and has traditionally been studied by endocrinologists. A variety of treatments have been developed in the last 20 years to effectively treat this condition.

Other endocrine conditions are related to the pituitary gland, adrenal glands and reproductive glands.