Welcome to this special issue dedicated to Live Well with Diabetes. Live Well with Diabetes is an educational initiative of the B.C. Endocrine Research Foundation that is intended to provide clear up-to-date information on all aspects of diabetes self-management. It is our belief that the better informed an individual with diabetes is then the more likely they are to make the right decisions and be proactive with respect to optimal management of their diabetes.

Live Well with Diabetes is a multimedia educational tool that serves as a comprehensive guide to the understanding and management of Type 2 Diabetes, a condition that affects 7-10% of the adult Canadian population, is associated with a doubling of the risk for heart disease and stroke and is the commonest cause of blindness, amputation and kidney failure in our society. Live Well with Diabetes is available on DVD, CD-ROM, videotape and online at livewellwithdiabetes.com. It is soon to be released through public libraries and drug stores.

Live Well with Diabetes covers type 2 diabetes definition and diagnosis, management guides, lifestyle change recommendations, medical therapy explanations, information on complications associated with diabetes, blood sugar testing instructions, information links and much more. This complete information source should always be at your fingertips.

	Live Well with Diabetes was developed by the B.C. Endocrine Research Foundation with the assistance of volunteers, donors and its sponsors LifeScan Canada, GSK, and Merck Frosst Canada.
Call 604-875-5934 or email dvd@livewellwithdiabetes.com to order the DVD or CD-ROM

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The Causes of Diabetes

The fundamental aspects of the cause of diabetes appear to be increasing insulin resistance combined with a pancreas that eventually fails to produce sufficient insulin. When insulin supply can no longer overcome insulin resistance then blood glucose homeostasis is compromised and diabetes results. There appears to be a number of genes involved in the tendency to acquire diabetes yet typically this represents only the potential to acquire diabetes since environmental conditions must be such that the genetic potential is expressed and diabetes results. Therefore insulin resistance and pancreatic insulin production are both areas of interest.

Insulin Resistance. Research suggests that obesity is a key element in the development of insulin resistance yet obesity is complex as well and also has a genetic component. Researchers continue to try and determine the mechanisms whereby obesity leads to insulin resistance since this may provide insight into therapeutic options and possibly the prevention of diabetes. Even the subtleties of how fat is distributed on the body appears to play a role in the progression of insulin resistance.

Beta Cell Function. The cells in the pancreas that produce insulin are called beta cells. The mechanism behind the failure of the beta cells to produce sufficient insulin is one key area of research. While the function of beta cells is reasonably well understood it is not clear why these cells eventually fail to produce sufficient insulin in some people.

Diabetes Treatment

The Canadian Diabetes Association recently announced its updated guidelines for the treatment of diabetes. This of course means the treatment of blood pressure and blood cholesterol as well. Periodically these guidelines undergo revision based on research being done all over the world. The research is geared towards answering numerous questions that still exist regarding how diabetes is best managed and as answers are found the guidelines are adjusted to reflect the new information. Often these studies will focus on blood sugar management, blood pressure management and blood cholesterol management. One very important long-term study being conducted right now is looking at all three of these risk factors and trying to determine the optimal therapeutic approach for each. This North America wide study is called ACCORD, which stands for Action to Control Cardiovascular Risk in Diabetes (www.accordtrial.org) and is in the process of recruiting 10,000 volunteers in 70 centres throughout Canada and the United States. Key aspects of the study will involve an assessment of the benefits/risks associated with aggressive lowering of blood sugars, blood pressure and blood cholesterol in people with type 2 diabetes. This study will finish in 2009 and the results will be very exciting indeed.

Another interesting study is looking at heart disease in type 2 diabetes. In people who have major progression of heart disease and who are potential candidates for heart by-pass surgery it is not clear whether early intervention is beneficial. A major North America wide study is trying to answer this question. Bari 2D (www.diabetesheartstudy.org¹) is investigating the outcomes in diabetes patients who receive by-pass surgery versus those who receive medical therapy as the first line of treatment. Patients are randomized to one group or the other and then followed for a number of years while treating their diabetes as effectively as possible.

There are many other areas of diabetes research so keep tuned into our website for more information and more updates.

¹Note — www.diabetesheartstudy.org is no longer operational

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• Your doctor. It is important to have a good trusting relationship with your doctor. Your doctor is responsible for gathering all your health information making sure your are well taken care of.
• A specialist, an endocrinologist or an internist. A diabetes specialist can make certain all aspects of your diabetes are addressed.
• A diabetes nurse educator. Nurse educators are very gifted at helping you to understand all aspects of your diabetes care and taking the time to explain things clearly.
• A dietitian. A good diet is critical to an effective diabetes management strategy. Dieticians can make the appropriate recommendations and keep you on track.

These are the most important people. There is often a need for a number of special helpers. These include:

• Your pharmacist can help clarify the pills you are taking and help you understand the roles of the different medications.
• A foot care specialist. To avoid foot and lower limb complications you should see a foot care specialist regularly as well as checking your own feet yourself everyday.
• An ophthalmologist or an eye doctor. The problems that occur with the eyes associated with diabetes don’ always appear as an immediate impairment of vision. Therefore it is important to have regular eye check-ups. If there is evidence of eye damage, laser therapy can be used to halt the progression of the damage and preserve your vision.
• A social worker to help you cope with some of the social problems and perhaps even a psychologist because it is often difficult for you and your family to cope with this disease. Sometimes it can actually become somewhat depressing. Therefore, depression sometimes needs professional help.

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What have I done to cause diabetes? You might ask yourself why do I have diabetes. Have I done something wrong? Well almost always the answer is no. We know that the vast majority of the tendency to diabetes is genetically transmitted. If you are obese, your chances of developing diabetes are much higher than if you are not obese. But by the same token we know that obesity has many genetic causes as well. So, rather than blame yourself for where you are at, I think it is better to think of what I can do about it, to control your diabetes and to make your health better.

Why do I have to test my blood sugars? Testing blood sugars provides you with valuable information that lets you know whether the diet, exercise and possibly medical therapy are working for you. Ask your diabetes doctor what your blood sugar targets are and do your best to achieve those targets. If changes in diet and physical activity for a period of 8 to 12 weeks doesn’t help then it may be time to start some form of medical therapy. Good blood sugar control is essential to good diabetes management and therefore you need to test your blood sugars and take medications as prescribed by your doctor.

I feel okay so why should I bother with medications and making changes in my diet and exercise? Diabetes is a very deceptive disease because most people diagnosed with diabetes have probably had it for a number of years but didn’t know it. The symptoms are not always obvious. The average blood sugar tends to rise gradually and as it rises there is damage occurring throughout the body; to the heart, the eyes, the kidneys, the nerves. This can occur even though you feel okay. That is why it is so important to take action as soon as you are diagnosed with diabetes. Make the changes suggested by your doctor and see a dietician immediately. Take the medications if needed and focus on taking care of yourself. Managing your diabetes is like managing a long-term investment. You must be thinking years ahead and the quality of your future life depends on decisions and actions in the present.

Once I start taking these medications will I have to take them for the rest of my life? It is very possible that you may be taking many of these medications for the rest of your life but this should not be your focus. These medications are helping you to manage your diabetes and the associated risk factors. Think of these medications as a way to help you manage your wellness and avoid the long-term complications associated with diabetes. What really matters is the quality of life and these medications are often essential to helping you manage your blood sugars, blood pressure and blood fats, the risk factors associated with diabetes.

Once I start insulin am I going to gain weight like friends say? When diabetes is poorly controlled there is a large amount of glucose being excreted in the urine. When insulin is started and blood sugar control improves much of the blood sugar (calories) that was previously being excreted in the urine is now being effectively absorbed into the body tissues and as a result some people may gain weight. This only happens when excess calories are consumed so when taking insulin you should pay very close attention to your food intake, carbohydrates in particular, as well physical activity.

I’m getting plenty of physical activity but I can’t seem lose any weight and don’t know what to do? Weight loss can be very difficult and is a complex issue. Sometimes the best efforts at balancing energy output with caloric intake result in little or no success with respect to weight loss. Please keep these two important messages in mind. First of all increased muscle tone and mass can mask a reduction in fat tissue and the focus should be on how you feel with respect to energy levels. Always remember that the physical activity is helping you to lower your insulin resistance and improve blood sugar management. Secondly, there are numerous research studies that indicate ‘fat and fit’ represents a far lower risk for heart disease and stroke than someone who is thinner but is less fit. Although some weight loss is desirable and beneficial the primary emphasis of a physical activity program should be on improved fitness and a sense of well-being.

My vision is fine so I don’t understand why I need to keep going to an eye doctor? The problems that occur with the eyes associated with diabetes don’t always appear as an immediate impairment of vision. With diabetes the small blood vessels in the back of the eye can become damaged, especially when blood sugars and blood pressure are poorly controlled. This can occur before you notice any change in vision. Therefore it is important to have regular eye check-ups. If there is evidence of eye damage, laser therapy can be used to halt the progression of the damage and preserve your vision.

My cholesterol lab results are in the normal range so I don’t understand why I should take a cholesterol lowering medication? There is strong evidence that lowering the bad cholesterol, the LDL cholesterol, to levels well below the normal range can reduce heart attacks and strokes in people who have a high risk for these events, and that includes people with diabetes. In other words the LDL target is lower for people with diabetes. The family of medications that is used to lower cholesterol most effectively is the statins, and along with a heart-healthy diet and exercise, you should take your cholesterol-lowering medication if your doctor prescribes it.

My blood pressure is the same as my wife’s but she isn’t being told to take blood pressure medication? One of the reasons for this would be that blood pressure needs to be managed more aggressively in people with diabetes. There is clear evidence that lowering blood pressure below normal targets helps to reduce damage to the eyes and the kidneys, two major long-term complications associated with diabetes. Lower blood pressure can also reduce heart attacks and strokes in people with diabetes so blood pressure lowering medications are often essential as part of the treatment of diabetes.

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The Complications

Heart Disease and Stroke. The risk of developing coronary heart disease, which is the kind of heart disease that is commonest in western society and the kind that people with diabetes are particularly prone to, is very high. The risk is roughly double in diabetics when compared to the general population without diabetes. A large proportion of diabetics will present some form of arteriosclerosis, either in their heart in the form of angina, heart attack or congestive heart failure or in the circulation to the brain leading to stroke or in the circulation to the periphery leading to abnormalities of blood flow to the legs, the development of aneurisms in the abdomen and abnormalities of the blood flow to the kidneys.

The Eyes (Retinopathy). We know that about one in twenty Canadians have diabetes and even more than twice this number have it and just don’t know it. Years ago, a lot of patients used to lose eyesight from diabetes. It still happens but it happens a great deal less than it used to. The primary reason that it does not happen as much is because we are able to save a lot of patient’s eyesight by using laser treatment. Diabetes affects the blood circulation throughout the body including the small blood vessels everywhere and the eye is no exception. The eye is very much like a camera with lenses upfront and film in the back. The film that lines the back of the eye and takes pictures of what we see is called the retina. In the retina there are tiny blood vessels, arteries and veins that bring the blood to and from the back of the eye. In diabetes, the blood circulation is not as good as it ought to be and those blood vessels can close off and what can happen is new blood vessels can grow. They can cause bleeding and scarring and blood vessels can leak fluid into the center of vision, which is called the macula. The two problems that we see in diabetic eye disease are new blood vessels growing and bleeding and the blood vessels leaking fluid into the center. Both of those problems can be treated with laser, which can often cut vision loss in half. We find that if we catch patients early, while they still have pretty good vision, the laser treatment is much more effective. Therefore we really need to screen patients in advance before they have trouble with their eyesight on a routine basis, usually once a year. If they are doing well, we will see them back the next year. If they have problems, then we can do some tests to see whether laser treatment will be helpful in keeping their vision. Some of the people who take really good care of themselves can have wonderful sight for their whole lives and other people who are not as careful often lose significant eyesight.

The Kidneys (Nephopathy). In diabetes there is a very high risk for damage to the kidneys. As a result of high blood sugars and high blood pressure the small blood vessels in the kidney can become damaged and leaky. When this happens the filtering ability of the kidney is impaired and it is no longer as good at getting rid of the bad and keeping the good. One of the best ways to avoid kidney damage is to manage your blood sugars and blood pressure as best as you can. Your kidney function should also be checked by your diabetes doctor at least once a year.

The test is one that measures very small amounts of protein in your urine, and is called microalbumin. The test can be done on a urine specimen taken at any time of the day, or on one taken in the early morning. The results should be less than 2.8 mmols/mg of Creatinine in the female, and less than 2.0 in the male. Microalbumin, if present can be successfully treated by both good blood sugar control and good blood pressure control. The goal level of your blood pressure is less than 130 and less than 80 (130/80 mm Hg).

Nerve Damage (Neuropathy). In diabetes there can be progressive damage to the peripheral nerves, especially the feet and fingertips as well as the sexual organs. This can occur gradually so that many people are often unaware of the progression. One of best ways to avoid this is with good blood sugar and blood pressure management as well as regular physical activity. Nerve damage to the feet means that lesions or sores on the feet may go unnoticed and thereby become infected. The healing process is also not as rapid as it used to be. This is why you should check your feet everyday, the soles and in between the toes. Make sure any issues are dealt with.

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Answer from Dr. Prior: The answer to the question you asked about whether or not she needed hormone therapy depends on whether she was still menstruating when she had the surgery, whether it was performed for a non-malignant reason, and whether she now has disturbing hot flushes or osteoporosis.

I’ve tried to summarize the good reasons for menopausal hormone therapy on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca . Briefly they are: menopause too early (doesn’t apply to your sister); severe hot flushes not helped by other therapies and osteoporosis with hot flushes. There is also an article called “Stopping Estrogen Therapy.”

Since the Women’s Health Initiative study (the estrogen arm was recently stopped because of increased strokes and no benefit for heart) we know that otherwise healthy menopausal women do not need hormone treatment. In fact those studies are quite clear about risks, especially that of blood clots with pill forms of estrogen. I never, any more, prescribe estrogen except as a patch, gel or cream.

Women who have their ovaries removed almost always lose bone rapidly following the surgery. That would be ok if their initial bone health was good. If your sister has no risk factors I would still urge her to look at the ABCs of Bone Health for Menopausal Women on the website. If she has risk factors she needs a bone density and if it is low the ABCs of Osteoporosis Treatment would be more appropriate.

One of the treatments that has been shown to treat hot flushes is progesterone cream in a dose of 20 mg twice a day. That would be useful if she has mild hot flushes/night sweats.

Otherwise, she may need to take no treatment at all! After all, menopause is not a disease!

Question: I am 46 years of age and I knew there would come a day when the “hot flushes” would start and I find it is now that I am in perimenopause (premenopause?). I just refuse to believe that I must suffer through my body’s inability to control its heating system.

I have been doing as much research as a layman possibly can regarding premenopause and menopause and interestingly, the name of Dr. Prior came up in my doctor’s office today. With much excitement I asked for a referral to Dr. Prior but did not know if she accepts patients. This is why I am emailing now. I am keenly interested in Progesterone treatment or any cutting edge information and tools for relief of these symptoms I am experiencing. I just don’t believe I have to wait it out. Can you please help?

Answer from Dr. Prior: Although I’m still following women I’ve ever seen, I am not taking new patients. However I would be happy to speak with your doctor about your situation.

In the meantime, I’d suggest you look at the material we have on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca. There are articles, in particular “Perimenopause–the Ovary’s Frustrating Grand Finale” and the Daily Perimenopause Diary and instructions so that you can track what you are experiencing.

We know a lot about treatment of hot flushes in menopause. Currently no randomized trial has tested perimenopausal women and identified an effective treatment of hot flushes. However, our clinical experience suggests that cyclic natural progesterone (Prometrium) is both effective and a safe therapy in women with hot flushes and periods. There is a handout about Cyclic Progesterone Therapy also on the website.

Question: I would like advice on assembling a team for diagnosing and treating my perimenopausal symptoms and other conditions, as well as providing me with support and access to services.

At the moment I am feeling pretty well. Since I have not had a period for many months I may be approaching menopause, which may partly explain the reduction of my symptoms. Certainly I have used (extreme) lifestyle modifications to assist myself in coping. I have suffered symptoms which have been debilitating to me, which have caused me to live in a condition of disordered thought for several years and significant pain for the better part of one year. This has disrupted my life and nearly bankrupted me.

I have not been diagnosed as perimenopausal. I have been variously diagnosed as having Post Traumatic Stress Disorder (which is probably also true), having anxiety starting several years ago, and as having had anemia and gastrointestinal bleeding within the last year. I also believe I had symptoms of Mild Traumatic Brain Injury (from a motor vehicle accident several years ago ), and may have had health effects from removing around 12 mercury amalgams from my mouth about five years ago.

I would like to provide some information, but hope my letter doesn’t sound bleak. I am feeling better and therefore am writing this letter. I would like to be tested, to know what is going on with my body and mind as a basis for treatment. Some questions which I have follow: What pertinent tests (including endocrinological) are available in BC, in Canada, or elsewhere, to examine me? What practitioners or clinics could help me? What insurance plans could help or could have helped me to afford alternative medical treatments, counseling, and to provide money to support me during an extended (though temporary) illness?

Answer from Dr. Prior: First of all it sounds like you are very close to ‘graduation!’ That’s what I consider menopause–you will reach that when you have been a year without flow. Menopause is a normal part of every woman’s life and doesn’t need any treatment. However, if it came before the age of 40, or if you know you have osteoporosis (especially if you also have hot flushes) or if you have persistent, disturbing hot flushes then and only then does menopause need treatment. We have learned from the Women’s Health Initiative Estrogen plus Progestin trial results that hormone therapy is not healthy for menopausal women who don’t have one of those three situations mentioned above. We now know the same about estrogen therapy.

This is the time of perimenopause when you are more likely to experience hot flushes and night sweats. But often if they only start now they are mild and go away quickly. You may also notice some vaginal dryness. That usually only needs some water soluble (over the counter) lubricant.

I trust you have looked at the BCERF website (www.bcendocrineresearch.com) which has the article ‘Perimenopause The Ovary’s Frustrating Grand Finale’. That will help you understand perimenopause which it sounds like you have almost completed. There is also information on our Centre for Menstrual Cycle and Ovulation Research website (www.cemcor.ubc.ca).

Now’s a good time to think positive and look ahead to many healthy years. You don’t need a specialist. You can deal with your family doctor for any problems. If you live in BC and have a perimenopause problem you and your family doctor can’t solve, you can ask your family doctor to phone me.

Perimenopause can be quite rough, and it sounds like you’ve had a difficult time of it. You can rejoice when it is over!

Question: I need your help. I had a total hysterectomy five weeks ago. Since then, I am literally falling apart, and cannot get the doctors here to either listen to me, or else I cannot get an appointment at all. I guess they don’t consider endocrinology an emergency. I am basically treating myself because the doctors aren’t listening to me.

I switched from Premarin to Menest because I thought the Premarin made me feel mentally foggy. I discovered that Premarin does contain androgens (they don’t tell you that) because it was making my skin break out. I am now taking a .625 Menest and a .3 Menest every day because on the .625 alone I was still having night sweats. It seems, however, that I am still not getting as much estrogen as on the Premarin because my skin is still dry, and I don’t know if Menest has as much or any androgens in it as Premarin.

Now for the worst part, the part I need immediate help with. Since the hysterectomy, I have arthritis symptoms almost overnight. I can’t get an appointment with an endocrinologist here. I’ve been trying to get an appointment with an endocrinologist who can write prescriptions for compounds because I think my DHEA, which used to be high, and other hormones are all messed up.

The doctors, my OB/GYN group, pooh-poohs me when I try to talk to them about it. They won’t order blood work yet, but I am extremely chemically sensitive, and drugs affect me immediately.

I don’t know what to do. I am at my wit’s end about all of this. I need to get the right treatment so I can go on with my life.

Thank you very much.

Answer from Dr. Prior: It sounds like life is pretty rough right now. I will do my best to provide you with some ideas and support. However, I can’t really know what is going on without having seen you and taken a history as well as done a physical exam.

It is not uncommon to feel badly after having a sudden removal of your ovaries. The natural menopause or perimenopause transition is a more gradual process with spikes and dips over about 10 years.

The first and most important thing is that you get a prescription for oral micronized progesterone (Prometrium) 100 mg and take 3 capsules at bedtime (as long as you aren’t allergic to peanuts–the medicine is in peanut oil). This will help your sleep (improves deep sleep by 15%), help the estrogen to control night sweats and may also help your joint symptoms.

I strongly suggest that you use a kind of estrogen that is a patch or a gel rather than a pill. We now know that important risks for blood clots (increased by 211% over placebo) occur in menopausal women on estrogen pills. Estrogen delivered through the skin is less likely to cause clots.

Other things that will help with the hot flushes/night sweats are some regular exercise and some relaxation (such as yoga). I’d also recommend 400 IU of vitamin E, 1200 mg of calcium/day (with 500 mg at bedtime) and at least one multiple vitamin to provide 400 IU of vitamin D. Calcium has been shown to decrease PMS-like symptoms in a randomized double blind trial.

I don’t know anything about you and what you do and what supports you have. But I would urge you to be with people you trust, to talk with close friends or family and to start thinking about what you are good at and that you want to do with the rest of your life. It is really easy, when life/hormones/health are disrupted as yours have been, to focus on illness and lose perspective.

Please also go to the Centre for Menstrual Cycle and Ovulation Research website at: www.cemcor.ubc.ca. You will also find the Daily Menopause Diary that you can use to track changes you are experiencing. Knowing changes helps you to better understand and deal with them.

I know that you will soon start to feel better.

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

The post Question and Answer – with Dr. Jerilynn Prior appeared first on BC Diabetes Foundation.

First, we need to talk concepts and language. Women are obviously different from men ? our normal life cycle of hormones includes low estrogen and progesterone levels after menopause. However, for about six decades, medicine has taught us that having low menopausal estrogen was abnormal. Why? Because men’s high testosterone levels continue into old age (with a bit of a decline). Therefore, the idea that menopausal women were deprived of estrogen or ‘estrogen deficient’ became common. And ‘HRT’ was invented to fix women’s supposed problem.

But it wasn’t enough to say women were deficient’, this deficiency must cause disease. One early, important study, The Framingham Study, a decade-spanning observational study (meaning that the scientists observed what occurred over time) showed that when women reached menopause they started to have heart attacks. The authors noted that menopausal women have low estrogen levels. Therefore estrogen ‘deficiency’ must be the cause for heart disease! Of course, on average menopausal women were older, less active and heavier, too, but those facts were ignored.

The Framingham Study was followed by the huge Nurses’ Health Study that was another observational one. It showed that the women who took estrogen compared with the women who didn’t, had fewer heart attacks. However, women who took estrogen were slimmer, more active, less likely to smoke, less likely to have high blood pressure, abnormal blood cholesterol levels or diabetes. These characteristics, in addition to a family history, represent a woman’s main risks factors for heart attack. All of the observational studies, we now know, were biased’the women who took estrogen were healthier to start out with. Other similarly biased studies multiplied showing that women on estrogen had better sex, were less likely to get Alzheimer’s, grow wrinkles or fracture hips. ‘HRT’ became the wonder drug for women.

I don’t know quite why but I have never believed the estrogen deficiency idea of menopause. And I knew of the blood clots, strokes, high blood pressure and weight gain (for some) that estrogen therapy could cause. I also remembered a study of men who took estrogen or a placebo (sugar pill). The men taking estrogen had increased clots and heart attacks and the study was stopped early because of harm. This was in 1972. (Somehow the heart disease experts had forgotten that study). However, enough experts questioned the validity of the observational studies, that a very large multi-part, randomized, controlled trial called the Women’s Health Initiative was conducted. Results of the Women’s Health Initiative combined with several other controlled studies showed that one of every 250 women ages 50-59, and one of every 150 women over 60 taking estrogen treatment for five years will develop blood clots, stroke, heart attack or breast cancer.

But knowing this, what do we do now? First of all, accepting that low levels of estrogen after menopause are normal, means we don’t have to fear we’re missing out on some magic preventive. Instead we can concentrate on exercising, stopping smoking, getting to and keeping a normal weight, and (if needed) getting effective treatment for high blood sugar, blood pressure or cholesterol. There are now fracture-preventing non-hormonal treatments for osteoporosis such as etidronate (Didrocal), alendronate (Fosamax) and risedronate (Actonel). We can use very low dose vaginal estrogen or a compounded, safer kind of estrogen called estriol for vaginal dryness if over-the-counter lubricants don’t help.

And what about hot flushes? Relaxation, yoga, deep breathing and meditation decrease them significantly. Some of the newer anti-depressants and soy foods may also be effective. For severe hot flushes, relaxation combined with a synthetic progestin medroxyprogesterone (Provera) mean most women become virtually free of hot flushes. However, the pill form of natural progesterone that is the same as your ovaries made (bio-identical), Prometrium, is an effective option if you are worried that medroxyprogesterone might cause harm (because a low dose was used with full dose estrogen in one arm of the Women’s Health Initiative). The Centre for Menstrual Cycle and Ovulation Research (CeMCOR) at UBC and Vancouver Hospital is doing the first trial of Prometrium as treatment for hot flushes in a four-month placebo-controlled study in menopausal women. Because we are also studying blood vessel effects we are looking for women a year past their final period who have moderate or severe hot flushes and no risks for heart disease (for further information call 604 875-5917, email chris.hitchcock@ubc.ca or go to the website www.cemcor.ubc.ca).

What if you’ve re-started estrogen despite the bad news from the Women’s Health Initiative because you just couldn’t stand the hot flushes? As explained in ‘Stopping Estrogen Therapy’ on the CeMCOR website, the key is to take full dose progesterone to treat the symptoms while you very gradually taper and eventually stop your estrogen. Hot flushes are caused by the reaction of a brain that has become used to high estrogen levels. Therefore the process of effective withdrawal must be a slow one. Prometrium helps in the estrogen withdrawal process because it improves deep sleep (although this has only been proven in men!) and also treats hot flushes.

However, there are specific instances where menopausal women will need to take estrogen with progesterone therapy. These include women with early menopause (before age 40 for sure and probably before 45), women with both osteoporosis and hot flushes, and those with severe hot flushes not effectively treated by non-hormonal therapies. There are bio-identical choices for getting estrogen through the skin as a patch or gel (Estragel, Estradot and Climera, to name a few). These are less likely to cause clots than pill estrogen. Bio-identical progesterone is available as oral Prometrium (in peanut oil) or it can be compounded in oil by local pharmacies. Women with early menopause can safely continue estrogen and progesterone until they are 52 years old (the average age at menopause). Women with osteoporosis and hot flushes can count on combined hormones to treat hot flushes and prevent fractures. After five years estrogen should be replaced with a non-hormonal bone medicine (as described earlier). Women with severe hot flushes can use progesterone alone and (I believe) safely continue for as long as needed. Family doctors and women with questions will find more information on the CeMCOR website.

We are in a new and healthier world for women in 2004. We no longer need to rely on an old and wrong idea that menopausal women are estrogen deficient and need treatment. I think it is a good news story!

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

The post Menopausal Women’s Hard Decisions appeared first on BC Diabetes Foundation.

I have received several requests for information regarding genetically modified organisms (GMOs). Given the previous issue’s Evolution of Diet article it seemed appropriate to follow with a brief comment on GMOs since these impact our food choices, food quality and the health and future of our children and the planet.

For this discussion a genetically modified organism (GMO) is a plant food that has been artificially created by splicing genes from one species into the DNA of another. I say artificial to distinguish from the natural process of pollination. What GMO’s typically represent is a combination of genetic material that would never ever have come together under any natural pollination process. In other words fish genes would never ever have combined with corn genes.

While this makes them a bit strange perhaps is it really cause for alarm? The answer to that is a resounding YES. The European Union ban on GMOs is certainly an indicator that someone is concerned about the impact of these plants on our health and on the environment. There is not room for a complete discussion here but a recently published book called ‘Seeds of Deception’ written by Jeffery M. Smith provides an excellent starting point and some valuable insight. The book has numerous references, websites and even suggestions for action if this is an issue that you find you would like to pursue.

One of the major problems with the theory behind the GMO concept is that it is based on an outdated concept of one gene regulating the production of one protein. This is now known to be false as demonstrated in the human genome project where the expected 100,000 genes for an equivalent number of proteins turned out to be only 30,000 genes. We now know that genes can code for numerous proteins, the record being held by a fruit fly gene which has been shown to generate 38,016 different proteins. Based on this new information it is clear that attempts to insert a gene with a single desired trait is going to also include numerous additional proteins with completely unknown effects. And they really are unknown because at this point in time there is no adequate safety testing of these foods. That is only the tip of the iceberg lettuce, as you’ll find out if you read Jeffrey Smith’s book. Numerous other genetic problems arise which further compromise the safety of the resulting food product. And this only refers to the human safety issues.

Another major issue is the environment and the fact that pollen travels in the wind and this cannot be controlled. This means that there is documented extensive contamination of adjacent crops and the potential for genes to move across plant species. This is not finely controlled laboratory science. This is happening right now in fields throughout North America and now that these genes are in the gene pool they can never be recalled. This is happening without our consent and our governments are not looking out for our best interests but rather the interests of the biotech industry.

The testing is in fact being done on us, the general population who consume these products without knowing it. There is no way of knowing since there is no labeling required to inform us which products contain genetically modified plant material. As mentioned by Arran Stephans in the Preface to Jeffrey Smith’s book, ‘we are now in the middle of the largest feeding experiment in history and we human beings are the guinea pigs’.

On May 1, 2003, a new organization, the Independent Science Panel was formed with a commitment to the Promotion of Science for the Public Good. The founding members consist of 24 scientists in a variety of disciplines from all over the world. They released a 136 page document on the GMO issue and at the end they recount the major problems with GMO’s. The excerpt below summarizes many of the concerns we should all share. For their comments they use GM when referring to the GMO issue.

Eric Norman is a research scientist investigating heart disease in post-menopausal women and in individuals with type II diabetes.

Reading

• Seeds of Deception, Jeffrey M Smith., 2003. Publisher YES1 Books, Fairfield, Iowa, US.
• The Case for A GM-Free Sustainable World, Independent Science Panel, May 10th, 2003.
• www.indsp.org

The post Genetically Modified Foods appeared first on BC Diabetes Foundation.

Founder of the Atkins Center for Complementary Medicine

What we learn from our early ancestors’ eating habits are the myriad ways that one can eat and be healthy. Unlike the conventional nutrition community attempting to force everyone into a one-diet-fits-all mindset, our Paleolithic ancestors discovered that they needed to be flexible to survive. Modern individuals need to find the type of eating pattern that provides good nutrition yet meets their unique needs. We must begin to provide individualized regimens that allow for dietary diversity as well as health benefits.

Whole foods of animal origin, vegetables, fruits, unrefined grains, seeds and nuts are the best choices for promoting good health. Processed foods, added sweeteners, refined carbohydrates, such as white-flour products, pasta and snack foods, contribute to the over consumption of calories, elevated blood-sugar levels, high insulin production and our current obesity and diabetes epidemics.

Walter Willet MD PhD

Professor of Epidemiology and Nutrition at Harvard School of Public Health

The major threats to survival in Paleolithic times were not coronary heart disease and cancer, but more likely, infectious diseases, starvation and violence. Thus, populations consuming diets that promoted a robust immune system, a reliable source of calories and physical prowess would have been most advantageous. The same diet would not necessarily be optimal for 21st century North Americans.

Today individuals who are sedentary and overweight, when fed a high-carbohydrate diet, experience elevated risks of heart disease and diabetes. Not until high consumption of grains collided with modern refining processes, added sugar and extreme inactivity did we experience an explosion of obesity and diabetes. Unfortunately, the full price in terms of heart disease and kidney failure is yet to be paid. Learning more about Paleolithic diets is fascinating and can be useful, but further research is desirable before ordering from the Paleolithic menu.

Barbara Rolls PhD

Professor of Nutrition at Penn State University

For most, ancient diets do not apply well to modern lifestyles. We learn to like particular food as kids, and they become a part of who we are. These foods are very different from those eaten by our early ancestors.

While reading about ancient diets is fascinating, we don’t need to go back in time to determine today’s optimal diets. Instead we should focus on what is currently available and practical. Numerous nutritional investigations show that eating more high-fiber foods, such as fruits, vegetables and whole grains, along with lean protein sources, can have health benefits, including weight control.

Unfortunately, messages that reach the public about dietary choices are those that are either controversial or extreme. Nutrition professionals must emphasize areas of agreement about what constitutes an optimal diet if they are to convince the public to change their eating habits. It is unlikely that such changes will get us close to a Paleolithic diet, but we could all benefit by going out and hunting and gathering more high-fiber foods such as fruits and vegetables.

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Who do you believe? In answer to that I would say believe yourself. Read everything with an open mind. Consider the source, the evidence, seek out the references if possible and ask yourself, “Does this make sense?” The latter question is one I try to ask myself all the time with respect to the deluge of nutritional advice we see or hear almost every day.

Diet Evolution

When we use the term diet in this article we are referring to general food intake and not reduced or restricted food intake as in dieting. There have been many articles recently that make reference to anthropological diets with the assumption that since our ancient ancestors never experienced disease they must have had a far healthier diet than the one we now consume. This could be true and we’ll discuss this later but certainly they had a more active lifestyle and probably had a better balanced caloric budget than we do. Their level of activity in obtaining food was balanced by the food calories obtained and as such they stayed fit and healthy. At times when excess calories were available they most likely gained some weight but that would be in anticipation of hard times when food was scarce and they would have to rely on their body’s reserves. For most people in developed countries the annual cycles of food scarcity never happen. There are endless calories, which when combined with poor judgement or weak wills lead to rates of obesity unheard of in human history.

There is an interesting aside here in terms of the prevalence of type 2 diabetes. It is hypothesized that in the past individuals with a genetic predisposition to rapid fat storage would have had an evolutionary advantage when confronted with a period of food shortage. This makes sense given that many of our ancestors certainly would have had to confront periods of near starvation and rapidly storing fat calories when food was abundant would be a survival advantage during difficult times. That genetic advantage turns out to be a disadvantage in our society since food is rarely scarce. In those individuals with a predisposition to rapid fat storage and available endless calories there is excess and un-required fat storage, progression to increased insulin resistance and eventually type 2 diabetes. It is important to note here that this genetic predisposition represents a potential for fat storage but typically type 2 diabetes will only present itself when there is excessive caloric intake in the absence of balanced energy-burning activities.

Efforts to generalize a single anthropological diet really make no sense since the geographical location often dictated the diet. ‘Eat locally, think globally’ was probably their slogan out of necessity rather than environmental concerns. In fact there would have been Paleolithic diets composed entirely of plants, others entirely of animals and a range of combinations, largely dictated by what was available. This simple fact emphasizes one thing: Humans are phenomenally adaptable in their ability to meet caloric and nutritional needs with any variety of foods.

Some of you who have read this newsletter for a while may recall the article I wrote regarding the findings of the heart protection study where cholesterol lowering medications were used in a large study population and demonstrated a significant reduction in heart attacks and strokes (Vol.3 No.4). One of the key messages behind this study was that lowering the LDL (the low density lipoprotein, ‘bad cholesterol’) with the medication Zocor (a statin) could help to reduce hospitalization and surgeries and ultimately save the health care system significant amounts of money. Keep in mind that this pharmaceutical intervention (Zocor 40 mg once per day) would come with it’s own hefty price tag if applied to the 10-15% of the population at risk. In addition, the Zocor intervention did nothing for nutritional wellness.

There was an interesting study that appeared not long after that which was done in a smaller group of people and showed that an ‘ape diet’ was just as effective as a statin (in this case Lovastatin) at lowering the bad cholesterol. This was a Canadian study headed by Dr. David Jenkins at the University of Toronto and published in the prestigious Journal of the American Medical Association. This study randomized 46 men and women to one of three groups: a. A low-fat diet, b. A low-fat diet plus 20 mg lovastatin (Mevacor) and c. An ape diet. The latter consisted of an easy to prepare menu including such foods as oat bran bread and cereal, soy drinks, fruit and soy deli slices. They list a typical dinner as consisting of tofu bake with eggplant, onions and sweet peppers, pearl barley and vegetables. This really is a diet rich in nuts, fibrous grains and vegetable proteins. This was intended to be like an anthropological diet. It was unfortunate that this work didn’t get as much exposure as the results of the heart protection study since the message is quite powerful. Diet can make a difference. Many advocates of statin therapy have argued that diet could not achieve the significant reductions in LDL observed with statin use. In this study however, the ape diet reduced the LDL by almost 29% compared to the 30.9% reduction observed in the statin treatment arm. It’s all a matter of compliance, whether you’re popping a pill or consistently embracing healthy food choices. The diet also lowered the C-reactive protein, a blood protein used as a risk marker for heart disease. An interesting comment from the author with respect to dieting and being hungry. Dr. Jenkins stated “the trouble was that the dieters were too full. We had to force feed people to get them not to lose weight. So that is a problem. The diets are very filling. So for those people who don’t want to lose any weight, this diet is very filling and they may have trouble maintaining weight “. My response to this comment is that the majority of individuals with elevated cholesterol requiring some intervention are overweight and some weight loss may actually be beneficial as long it is done slowly and with adequate nutrition.

So where does this leave us? Once again it all comes back to balance, moderation and listening to the body. Which leads us to the ‘Low Carb’ craze that is everywhere you look now. The hype seems to be based largely on anecdotal evidence rather than science. Those studies that have been done suggest some short-term weight loss but after 12 months there seems to be little benefit with respect to weight loss.

I asked a dietician who specializes in diabetes her opinion on the low carb diets that so many people are embracing. Her response was:

Most dieticians will tell you that you should get 55% of your daily caloric intake from carbohydrate and the rest from fat and protein in approximate proportions of 20 to 25% making up the remainder. This is a guide and a good starting point but we are all different. Most of the low carb diets that are getting bashed tend to be extreme and the term LOW is both vague and relative. My personal feeling is that the majority of individuals could benefit from a lower relative carbohydrate intake. All I mean by this is that most people probably consume way too many carbs without realizing it since carbs can be hidden in many foods, especially the low fat foods that are so heavily marketed.

It should be mentioned that the obesity epidemic began around the early 1980’s and shows little sign of abating, based on current statistics. That rise in obesity coincided with the intense advertising campaigns by the food industry touting low fat foods which are loaded with sugar to achieve the desirable mouth texture. People consumed low fat foods with reckless abandon and here we are today in the midst of an obesity and diabetes epidemic of unprecedented magnitude. Who or what’s to blame?

There is no simple answer to that. Two things are certain though. If total caloric intake remains the same then a lower amount of one component means a higher amount of the remainder and this is true whether we’re talking low fat or low carb or low protein. The second point is that no two people are the same and a diet that works well for one may not work well for another. Although the fundamentals of human nutrition are generally universal we all have slight differences in metabolism and more importantly in our activity levels. Therefore, energy and nutritional needs will differ and how we respond to certain foods will vary. So what is the bottom line. It’s different for everyone. I would take a good look at your own diet and try to estimate the proportion of carbs, fat and protein. Try to identify the nutritious and less so elements. Be particularly careful with the hidden carbs so you get an accurate estimate. If the carb content is in the 55% range than you might think your diet is spot on. But is it? What if the majority of your carbs are nutritionally empty…or worse yet are found in processed junk food loaded with nasty preservatives, damaged fats and artificial sweeteners. And what if none of your fats are from whole foods or are all deep-fried in origin. Not so pretty. If this was the case you might fare better with a diet of 40-45% carbs but with whole grains, fruits and vegetables as the core of your carb sources. The putative risk of a lower percentage of carbs would certaiinly be outweighed by the benefits of better quality carbs. Carbs full of nutrients and fiber. Quality over quantity.

The human diet has evolved over millions of years but much of what we find on our plate has only appeared in the last 60 years or less. A mere blip in time but even in that short time we have seen many changes in our foods and our health. Yet over the millions of years humans have been shown to be adaptable to all types of foods ranging from mostly meat diets to vegetarian diets and all things in between. Perhaps we are not evolving quickly enough to keep up with our strange changing diet. If the current state of human health is any indicator of the quality of our diet I would certainly suggest that we are losing ground when it comes to nutrition and wellness despite the wealth of research and information available. Not to mention a wonderful selection of foods.

Eric Norman is a research scientist investigating blood vessel function in postmenopausal women and also works on a type 2 diabetes clinical trial.

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