It may be wishful thinking to say that we can solve this problem by promoting a healthy lifestyle. Most people would like to stay on a healthy diet for life, and do at least 30 minutes of physical activity daily, but all too often we do not persist with such changes, and we revert at least in part to our former ways.

So we must face the problem by trying to identify solutions in the form of therapy. Are there medicines that will reduce appetite successfully? Are there medicines that, if given very early at the onset of elevated blood sugar, can prevent the development of the disease? Are there treatments that, when given to patients avoid or delay the need for insulin? Are there new types of insulin that can reduce the basic cause of adult onset, type II diabetes, namely a resistance to insulin action? Are there new medicines that can be taken by mouth that will lower blood sugar levels and control blood sugars more effectively? The answer to all of these questions is “yes”.

At the present time, there are two classes of pills for reducing blood sugar levels that are approved in British Columbia for reimbursement under the Medicare system without recourse to “special authority”(meaning the physician has to justify the use of the medicine). These two classes are the Sulfonylureas (glyburide) and the biguanide class, represented by metformin. Yet others in North America can use gliclazide, glimiperide, repaglinide, rosiglitazone, pioglitazone, and miglitol, as well as the newer insulins Humalog and Glargine. These are not available in British Columbian. Should they all be made available? The answer is not simple. Some of these drugs are extremely expensive, and the health care system is trying to guard their finances to allow treatment of multiple diseases. There is no question that, if these medicines represented an essential advance, they might be approved. But who is to make the decision that a new drug is an essential advance rather than a marginal improvement on an existing drug? Rather than giving physicians information on the efficacy and cost of these drugs and allowing them to make these decisions, the government has decided to appoint an advisory body of experts to advise them, none of whom are endocrinologists or who treat people with diabetes. Even after receiving the decision of these non-experts, the government reserves the right to deny the medication if its financial review indicates it will cost too much. Is it correct to do this? Does the epidemic of diabetes cry for a more humane approach? This question has been posed in a poll of British Columbians.

In April 2000, a professional team assessed the public’s reaction to this problem by polling 503 randomly selected adults throughout British Columbia. The results of this poll would be accurate 19 times out of 20 and would differ by no more than 4.4 percentage points. What were the questions asked, and what were the responses? Perhaps you might read each question and answer for yourselves before seeing the responses given.

The questions were:

1. As far as you know, is the incidence of diabetes in BC increasing, staying about the same, or decreasing? If increasing, would you say is rapidly increasing or increasing at a moderate rate?

2. In your view, should health care spending on diabetes be increased, decreased, or kept at about the same level?

3. Over the next fifteen years, the incidence of diabetes is expected to nearly double to the point where one person in twelve will have or develop diabetes in their lifetime. This rate of increase qualifies diabetes as an epidemic. Given this, please tell me whether you think spending should increase, decrease or be kept the same for each of the following:

The diabetes epidemic is becoming one of the most costly to the health care system. One fact recently noted was that the cost of all medicines, physician’s costs, and other treatments for people with diabetes are much smaller than just the costs of the treatment of the heart disease that ensues as a result of diabetes. If we had the tools to fight the disease in its early stages, we would reduce these costs very effectively. The current policy of the Ministry of Health appears to be shortsighted. Perhaps you could write to your MLA on this matter?

Dr. Dawson is a director of the BC Endocrine Research Foundation and has been involved with the Canadian Diabetes Association for many years. He is a leader in educating general physicians about diabetes and last year received two of Canada’s most prestigious medical citations. The first was the Gerald S. Wong Award earned for his exceptional efforts in assisting individuals with diabetes. The second was the Distinguished Service Award. He was chosen by his peers to receive this award for his contributions to the field of endocrinology.

The post The Diabetes Epedemic – B.C.’s Public Perception appeared first on BC Diabetes Foundation.

One of the most important concepts to understand when you are a diabetic is the concept of glycemic index (GI), the measure of how quickly carbohydrate foods affect blood glucose levels. Since the condition of diabetes impairs the body’s ability to effectively maintain proper levels of glucose in the blood it is important to make informed food choices that can reduce the speed at which carbohydrates from a meal reach the bloodstream as glucose and the total amount of glucose reaching the bloodstream. In this article we will briefly review the fundamentals of carbohydrate structure and the glycemic index of different foods. You may be in for some surprises.

As you are probably aware the three major food groups (macronutrients) include proteins, fats and carbohydrates. While fats and proteins are essential for growth and repair of tissue and membranes and their general maintenance it is the carbohydrates that provide us with most of the fuel that we burn for energy. Carbohydrates are made up of carbon, hydrogen and oxygen. These molecules are arranged in ring structures that can be linked together to form larger molecules. Carbohydrates can be as simple as single-ringed monosaccharides such as glucose, fructose (fruit sugars) and galactose (a milk sugar). They may also appear as two-ringed molecules, called disaccharides, including maltose (glucose plus glucose), sucrose (glucose plus fructose) and lactose (glucose plus galactose). Neither plants nor animals store energy in the form of these sugars as this would lead to an osmotic imbalance (the cells would take up water and burst). Therefore, sugars are converted to larger molecules for storage. In plants these are called starches, the two most common being amylopectin and amylose. Amylose is made up of glucose rings strung together in a long strand. Amylopectin is similar except it has many side branches. This difference is important because it affects their rate of enzymatic breakdown during digestion. Because of the many side chains amylopectin offers more sites for enzymes to work and is broken down more rapidly.

The Glycemic Index

How is the glycemic index (GI) actually determined? Typically the reference point against which all other foods are measured is pure glucose since that is the final product of carbohydrate digestion that enters the blood. The rate at which pure glucose enters the blood is designated a GI value of 100, all other foods being relative to this glucose standard. An important thing to keep in mind is that the GI reflects the rate or speed that different foods appear as glucose in the blood. We also need to consider the total glucose load which that food will deliver to the blood stream which is a function of the food amount and the percent carbohydrate content of the food. It is the large carbohydrate loads with high GI values that will deliver large amounts of glucose into the blood in a very short time. By regularly consuming foods geared towards a low average GI and low total carbohydrate, it should be possible to improve glycemic management in diabetes.

The GI is determined for a single type of food but in the real world the typical meal is a combination of foods composed of not just carbohydrates but also fat and protein along with fiber and micronutrients. The interaction of these foods in the digestive tract can alter the rate of digestion and absorption. The GI is still a valuable guide, however, when trying to estimate and reduce the GI of a whole meal, which should be the goal of all diabetics.

Sample calculation: For the sake of simplicity let’s say that a breakfast meal contained 100 grams of carbohydrate. This included white toast (2 slices at 13 grams each = 26 grams), hash brown potatoes (54 grams), and half a grapefruit (20 grams). First calculate the percentage each contributes to the total carbohydrate. Then multiply that by the glycemic index of each type. Then add these three numbers together. You should try doing a few of these calculations since many food combinations appear in your diet repeatedly meaning you don’t have to do calculations at every meal. You will learn to identify various food combinations and amounts as you would a spicy dish (ie. mild, medium, hot and very hot) in terms of the GI.

Points of Interest

Many people intuitively appreciate the concept of GI as it relates to various foods. What I would like to draw to your attention are some interesting specifics that could lower the GI of a meal by 50% or more.

Breads

When it comes to GI not all breads are created equal. The breads that have highly processed refined flour (white or whole wheat) are going to have a much higher GI (70) than breads made with stoneground flour (coarse) containing whole grains (GI=53). These coarse, heavy, chewy breads are digested more slowly. The problem with highly processed flours is that the high speed milling process pulverizes the starch into tiny particles increasing the surface area and accelerating the rate of digestion resulting in a higher GI, as high in fact as a Mars Almond Bar! (GI=68)

Rice

Nor is all rice created equal. Our discussion above regarding amylose and amylopectin applies especially to rice. White rice has a high GI (72) and the main starch is amylopectin. By contrast, basmati rice is mostly amylose and has a much lower GI (58). You should also try the long grain brown rice with the germ and husk as this has a favorable GI (55) and better nutritional value.

Pasta

Although pasta in general already has a moderate (GI~55-65) it can be reduced by preparing it al dente (still very firm) which slows down its rate of digestion.

Sugars

The GI values determined for various sugars are interesting. Table sugar, raw cane sugar and honey are all essentially sucrose (a glucose and fructose molecule linked together) and while they may vary slightly in their micronutrients they all have similar GI values (65). They are not as high as white bread either because the body is very slow to process fructose (GI=23). That also explains why many fruits have low GI values as many contain mostly fructose as a simple sugar, making them an excellent snack.

Legumes

Legumes such as lentils, kidney beans, chick peas and navy beans all have GIs in the 27-38 range. Need I say more? When included in a meal they can help reduce the GI of the whole meal. In addition they are low in fat and contain high amounts of fibre that can improve your cholesterol profile.

Summary

If you are a diabetic this information may provide an additional tool to help manage blood sugars more effectively. We are all different so test your blood sugars regularly and learn which foods and combinations work for you. This doesn’t mean that you should sit down before each meal with a calculator trying to determine the GI of your meal to the nearest decimal point. The GI is simply a guide to help you understand and more accurately estimate the impact of a meal on your blood sugars. You can then make appropriate food selections.

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

References

1. Wolever, T. et al.. The Glucose Revoluation: The Authoritative Guide to the Glycemic Index. Marlowe and Company. 1999.
2. Weil, A. Eating Well For Optimal Health. Alfred A. Knopf. New York. 2000.
3. (You can find an extensive list of GI values for a variety of foods in The Glucose Revolution listed in the references.)

The post Food For Thought – Glycemic Index appeared first on BC Diabetes Foundation.

In Part II of this series we discussed improving your diet and exercise regimen and giving up smoking as ways to improve your plasma lipid profile (cholesterol). Unfortunately, not everyone responds to, or is capable of, these lifestyle modifications and as a result lipid lowering medications are often recommended by physicians. Here in Part III of this series we will consider a number of the cholesterol lowering medications currently available. These include HMG-CoA reductase inhibitors (statins), bile acid sequestrants (resins), nicotinic acid (niacin), fibric acid derivatives (fibrates) and Probucol (anti-oxidants). You can think of each one of these as a family, each family working in its own particular way to alter the plasma lipid profile, and each family having several members who vary in their relative tolerance and efficacy.

HMG-CoA Reductase Inhibitors (statins)

The enzyme HMG-CoA reductase is a key enzyme in the synthesis of cholesterol. There are a number of compounds that have been developed to block this point in the pathway thereby reducing plasma cholesterol. These include lovastatin, simvastatin, fluvastatin (Lescol), cerivastatin (Baycol), atorvastatin (Lipitor). Collectively these are referred to as “statins” (a term used in the media) and they are capable of reducing total cholesterol by as much as 30% and low-density lipoprotein (LDL) cholesterol levels by as much as 40%. They often reduce triglycerides (TG) by as much as 20% and increase high density lipoproteins (HDL) by 5-10%. These medications are most effective when taken at night as this is when maximal cholesterol biosynthesis occurs. These medications are well tolerated and the main significant side effect is myopathy (muscle aches). This risk is increased when these medications are taken in combination with niacin, gemfibrozil, erythromycin or cyclosporine. Liver enzyme function should be monitored if taking combinations of medications. Long term side effects of these inhibitors are not known although lovastatin, which has been in use for over ten years has no observed long term toxicities.

Bile Acid Sequestrants (resins)

These are anion-exchange resins that exchange chloride for negatively charged bile acids. The bile acids, bound to the resin, are then excreted with the feces. This results in stimulated oxidation of cholesterol to replace the bile acids, an increase in LDL receptors in the liver and eventually a lowering of plasma LDL concentrations. This is very similar to the principal of dietary fibre and its mode of action in reducing cholesterol discussed in Part II of this series. Most of the side effects of resins are localized in the gastrointestinal tract and include bloating, gas and constipation. They can potentially lower plasma cholesterol by 15-25%. Two main points of caution. They are not recommended for people with high triglycerides since they have been known to increase plasma triglyceride levels. Secondly, these resins can also bind certain medications such as levothyroxin, digoxin, warfarin, and thiazide diuretics. For this reason the resins should be taken 4 hours before or 1 hour after other medications.

Nicotinic Acid (niacin)

Niacin is a B vitamin and one of the cheapest drugs used to treat hyperlipidemia. Taken at therapeutic doses (2.0-4.5 grams per day) niacin can lower total and LDL cholesterol by 15-30%, lower triglycerides by 30-40%, and raise HDL by 15-25%. Two points worth clarifying here. We are referring to niacin, not niacinamide, which has no efficacy. Secondly the doses of niacin used are very high, 20-50 times higher than the usual nutritional supplement amounts. As a therapy niacin is well tolerated. The main side effect is a flushing of the skin (redness) that occurs shortly after taking the niacin. This can be reduced by starting therapy at a low dose (eg. 100 mg) and gradually increasing the daily dose over a period of weeks to months, as a tolerance is built up. Taking an aspirin I hour before the niacin can also reduce the flushing. A more serious side effect of niacin therapy can be liver toxicity and therapy should be accompanied by liver function tests. A slow-release form of niacin is available that reduces the flushing side-effect but unfortunately liver toxicity is more common with this form and therefore the immediate-releaseform is preferred.

Niacin can worsen glucose intolerance and therefore its use by diabetics is questionable. In addition it is not recommended for people with a history of gout or an active peptic ulcer.

Fibric Acid Derivatives (fibrates)

This class of medications which includes clofibrate, fenofibrate and gemfibrozil have been shown to lower plasma triglycerides by as much as 40% and to increase HDL levels by about 10%. Typically they are well tolerated. Minor side-effects include gastrointestinal discomfort and a possible increase in the incidence of gallstones. One note of caution is the use of fibrates in the case of renal insufficiency due to increased myopathy in this setting.

Antioxidants

Commonly used antioxidant food supplements such as vitamin E and C are believed to have benefits with regards to prevention of heart disease but there is a lack of scientific evidence to back this up. Most of the large well-designed trials have shown in fact that these supplements have no effect on plasma lipids and the progression of heart disease or rates of death. It doesn’t mean that they don’t benefit some other aspect of your health, simply that the available evidence suggests that lower plasma lipids and heart disease prevention is not one of their benefits.

Fish Oil Supplementation

Fish are an excellent source of the omega-3 polyunsaturated fatty acids and high dosages of fish oil (4 or more grams per day) can dramatically reduce plasma triglycerides. This benefit appears to be sustainable as long as the dosages are continued. Keep in mind this is very different from simply eating fish. Comparable to what we discussed about niacin therapy vs niacin in our regular diet, in terms of doses fish oil supplementation should be considered a medical therapy and should only be done under physician guidance. It is typically used only for patients with very high triglycerides and is not generally recommended. When it is used it has been shown to reduce triglycerides by 39% and increase HDL by 6% although benefits with regards to coronary heart disease have not been established.

Summary

The use of any of these medications is not a trivial matter. They should only be used under a physician’s supervision and absolutely should not be used to compensate for an unhealthy lifestyle. Even when using these medications you should always be optimizing your diet and exercise habits.

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

References

1. Manual of Lipid Disorders. Reducing the risk for coronary heart disease. Antonio M. Gotta Jr.; Henry J. Pownall. Second Edition. Publisher: Williams and Wilkins. 1999.
2. Disorders of Lipid Metabolism. Chapter 23. Mahley, R.W.; Weisgraber, K.H.; Farese, R.V. in Williams Textbook of Endocrinology, Ninth Edition. Editors: Wilson,J.D.; Foster, D.W.; Kronenberg,H.M.; Larsen,P.R.. Publisher: W.B. Saunders Company. 1998.
3. Advanced Nutritional Therapy. Cooper, K.H.(M.D., M.P.H.). Thomas Nelson Publishers. 1996.
4. 8 Steps To A Healthy Heart. Kowalski, R.E. Warner Books Inc. 1992.

The post Cholesterol PART III appeared first on BC Diabetes Foundation.

Dr. Keith Dawson starts with a discussion of the reality of diabetes in our society and the politics of medication availability. He also presents the findings of a recent diabetes survey conducted in BC.

Dr. David Thompson presents some interesting facts regarding the high incidence of heart disease in diabetics and how blood sugars play a role in the process.

The BC Endocrine Research Foundation has organized a special Diabetes Symposium which is free and open to the public. Please come.

I have chosen to discuss the concept of glycemic index in this issue’s Food For Thought column, providing a tool to help manage blood sugars.

The final installment in the Cholesterol series deals with lipid lowering medications. These medications are often needed in cases where plasma lipid levels do not respond to lifestyle modifications or lipid lowering must be more aggressive, as is the case with many diabetics.

I hope you enjoy this issue of the Quarterly Newsletter as you go about the fall rituals preparing yourself and home for the upcoming season.

The post From the Editor appeared first on BC Diabetes Foundation.