Nutrition IV (week 3)
DIABETES and HYPOGLYCEMIA
incr risk of atherosclerosis, microangiopathy, nephropathy, neuropathy
advanced glycosylation endproducts-->neuropathies
chronic infx esp UTI and yeast overgrowth
7% of US pop has DM (21 million)
90% have NIDDM
6.2 million undiagnosed cases
17% of pop btw 65-74 have DM
40% of NIDDM requires exogenous insulin to maintain normal blood glucose (hmmm)
DM contributary factor in 224,000 deaths in 2002
#7 on leading causes of death list but this list hides the fact that 1-6 are incr by DM
1992 cost us $92 billion, $132 billion in 2002, dialysis
PIMA
Pimas: over 90% over 35 have DM
same tribe in Mexico has only 10% DM, weigh on average 50 lbs less, eat high carb diet but it's more beans, corn, potatoes, and plenty of fiber
PREDIABETES
41 million in 40-74 age group have "pre-diabetes"
blood sugar over 99 twice = impaired glucose tolerance = prediabetes
want average blood sugar below 100
ETIO
Western lifestyle: TV, automobile, fast food
low fiber diet (book by Margaret A Powers '96)(konjac most sol fiber)
cells that are insulin resistant are also glucagon resistant
autoimmune, low vitamin D
cortisone, OCPs, inahlers increase glucose levels
excess sucrose intake
TOXINS that may provoke or complicate diabetes
hemochromatosis-->free radicals damage beta cells or receptors, check ferritin & Sat%
(deferoxamine = iron & aluminum chelating drug) (40% sat is max normal)
insulin receptors sensitive to trans fats
streptozotocin is preferred toxin for animal experiments to destroy beta cells
N-nitroso found in smoked and cured meats also related
SYMPTOMS & SIGNS
tinea versicolor
skin tags
acanthosis nigricans
poor distal wound healing, ulcers
loss of distal sensation, peripheral neuropathies
chronic infections: BV, thrush, candida, other infx
polydipsia, polyuria
CLINICAL NUGGETS
**pts get used to having high blood sugar and then feel hypoglycemic when normoglycemic
**some diabetics have more spiking than others, with same A1C
TYPE I DM
twins more likely to share type 2 than type 1 (50%)
auto-antibodies vs Beta cells of pancreas present in 70%
normals: 1/2-2% have these abs
cow's milk protein may be the inciting antigen-->cross reactive immune response
strong link between dz occurrence and cows milk consumption world wide
viruses also may trigger production of ABs: mumps, hep, mono
more DM in colder climates, winter months (Vit D connection)
allergens may be transferred in breast milk
wheat consumption by mother or infant
wheat and milk allergies often occur together
wheat causes incr permeability of intestine
ZONULIN
gliadin activates zonulin release from ECs, zonulin opens tight jcts
Christine Daugherty studied this, book not out yet
discovered her celiac dz while she was pregnant
from wikipedia:
Zonulin is a protein that participates in tight junctions between cells of the wall of the digestive tract. Initially discovered in 2000 as the target of zonula occludens toxin, secreted by cholera pathogen Vibrio cholerae,[1] it has been implicated in the pathogenesis of coeliac disease[2] and diabetes mellitus type 1.[3] It is being studied as a target for vaccine adjuvants.[4] ALBA Therapeutics is developing a zonulin receptor antagonist, AT-1001, that is currently in phase 2 clinical trials.
AGES
formed with high temp cooking, bake, fry, grill, smoke
cooking duration not so imp
water inhibits AGE formation: boil, steam etc best, pushing pressure cooker again
microwaving not so bad for making ages but it destroys flavonoids
and makes radiolytic end products, spices are irradiated and some foods
lysine (amine containing lipid) from wheat combines with (reducing sugar) fructose-->Mayard rxn, panc enzymes can't break it down
-->allergic rxn
-->atherosclerosis, CV dz, #1 sequella of DM
accelerate aging, sclerosis
increase inflam
promote cross-linking of prot
Diabetics on comparison high and low AGE diets:
CRP up 35% with high AGE diet, decr 20% on low AGE diet
16,000kU/day is age content of typical US diet
ages and high sug-->small dense LDL-->EC damage
TYPE II DM
most pts have very high fats in serum
trans fats make phospholipid membrane less fluid, alters protein receptor site for insulin
oxidized fatty acids also poison the membrane
exercise is fastest way to reduce insulin resistance
also worked on this woman who had very low insulin levels:
Italian pasta eater woman
took her off all wheat and dairy
with blood sugar over 500 drop to 150 after 1 week riding exercise bike
back to completely normal at 2 weeks of riding bike
DIAGNOSIS
70-90 ideal fasting blood sugar
99-126 is "pre-diabetic"
fasting gluc 126 mg/dl or higher on two occasions, fasting minimum 8 hours
OGTT: sugar over 200 at 2 hours on 2 separate tests
1 HOUR postprandial over 180 is a criterion but it needs to be confirmed by other tests
LABS
lab error is common
trust your instincts
OGTT
Glucose Insulin Tolerance Test
do it in the morning when cortisol levels are high
don't do if ill
can dx low grade cases or borderline
want fasting insulin 7 or lower, above 8-9 there's insulin insensitivity
2nd and 3rd hour insulin should be under 40
sugar at 2 hours should be back to fasting level
DIAGNOSTIC: sugar over 200 at 2 hours on 2 separate tests
75 gram glucose test load administered over 5-10 minutes
30, 50, 60, 70 minutes
he frequently catches peaks at times other than 1 hour, 1 hour is mc
BP will change throughout test
check UA at peak glucose
HYPOGLYCEMIA
low blood sugar and sx from adrenal response to incr sugar:
shakes, sweats, etc
lots of people think their sugar is low when it is not: check it
a sign of hypoglycemia = a drop in glucose of 50+ points within an hour
also if blood sugar drops 20% below fasting level at any point
hypoglycemia is overdiagnosed
many diabetics think they need to eat if they feel bad when they need to eat less
DURING PREGNANCY: GESTATIONAL DIABETES
recommended for all preg women
2-4% develop it during 2nd or 3rd trimester
DM incr fetal mortality, pre-eclampsia
50gm oral glucose challenge (does not have to be fasting)
24-28 weeks gestation
gluc of 140mg/dl after 1 hour is indic for futher testing
100gm challenge for dx of dm
baby over 9 lbs then mb gestational DM
gluc under 120 after 1-2 hours is normal
over 50% of women with GD will develop DM within 5-15 years
HGB A1C
hemolytic & megaloblastic anemia-->falsely low A1C bcs RBCs have shortened life span
HGB A1C below 5.3 you're doing well
over 6 you have a problem
FRUCTOSAMINE
another test he used to use
tells about 1-3 week sugar levels
EXA-TEST
Burton silver intracellular dx
chromium
selenium
zinc
copper
magnesium
calcium
potassium
manganese
vanadium
THYROID
TSH, total T4, BBT
PROTEIN BOUND BLUC
average over prev 2-3 days
GLYCOMARK
a little pricey
he thinks it will be used more in the future
1,5 anhydroglucitol
when exceed renal threshhold for gluc then it declines
10.7-30ng/dl is normal
GLYCOMARK http://www.glycomark.com/
SONOCLOT
eval activation time, clotting time
MARZ TX for DM type I
he sorta likes Bernstein solution, low carb diet
anaerobic physical activity: sprints etc
severely limit carb intake (no onions? no fruit, etc)
aggressively take them off wheat and dairy
track children's body weight and growth curve carefully
want less insulin and more physical activity
MARZ TX TYPE II
he says use high carb (whole grain) high fiber diet
(low carb diets tend to be low fiber and he thinks this is a fatal flaw)
uncooked is lower glycemic, or less cooked
FIBER FOR BOTH TYPES
use fiber supp, he likes konjac best
http://www.konjacfoods.com/noodles/19.htm
pectin as fiber supp is OK binds endotoxin in gut, not as good as konjac
konjac reduces: LDL, chol, A1C
guar gum 5g/meal
pectin 10g/meal
oat bran 1 cup = 9g fiber
decr fat intake to 20%
decr sucrose and eliminate fructose
exercise
lose weight
use stevia rebaudiana (no glycemic response) or xylitol as sweetener
OK: chicory root, cocoa
can buy stevia plants at bi-mart here in PDX
MORE
physical activity in morning (after breakfast) reduces sugar response
increase omega 3 fatty acids to incr fluidity of membrane and fx of insulin receptors
he recommends testing by Body Bio
http://www.bodybio.com/BodyBioReport.aspx?Test=Yes ???
brewer's yeast a few TBS/day may lower insulin requirements
chromium for insulin binding 200-1500mcg/day, low toxicity, found in brewer's yeast
other Cr foods: liver, potato skin, whole grain bread, green pepper, rye
gymnema tincture or capsule
**avoid auto exhaust, it incr serum glucose
MONITOR LIPOPROTEINS
measure CV fx
cholesterol
CIMT
NUTRITION NOTES FROM WINDSTAR SHIFT ADDED 1/4/10
incr prot only if renal fx is normal bun/cr/crcl/ua/microalbumin
complex carbs: f/v/whole grain
decr glycemic load/index, www.mendosa.com
fiber (caution: gastroparesis) 30-35gm/d, flax, psyllium, konjoc, pectin
fat: no trans, decr sat, not low fat, no marg, incr avo, olive, nut, coconut? fish oil
freq meals, don't skip
exercise before meals
stress reduction
nutrients: chromium, vanadium, mg, niacin
anitox: vit c, ala, cratageus, berry extract, opuntia, vit E, D
herbs: fenugreek, gymnema, bitter melon, ginkgo, licorice, ginseng, cinnamon
incr risk of atherosclerosis, microangiopathy, nephropathy, neuropathy
advanced glycosylation endproducts-->neuropathies
chronic infx esp UTI and yeast overgrowth
7% of US pop has DM (21 million)
90% have NIDDM
6.2 million undiagnosed cases
17% of pop btw 65-74 have DM
40% of NIDDM requires exogenous insulin to maintain normal blood glucose (hmmm)
DM contributary factor in 224,000 deaths in 2002
#7 on leading causes of death list but this list hides the fact that 1-6 are incr by DM
1992 cost us $92 billion, $132 billion in 2002, dialysis
PIMA
Pimas: over 90% over 35 have DM
same tribe in Mexico has only 10% DM, weigh on average 50 lbs less, eat high carb diet but it's more beans, corn, potatoes, and plenty of fiber
PREDIABETES
41 million in 40-74 age group have "pre-diabetes"
blood sugar over 99 twice = impaired glucose tolerance = prediabetes
want average blood sugar below 100
ETIO
Western lifestyle: TV, automobile, fast food
low fiber diet (book by Margaret A Powers '96)(konjac most sol fiber)
cells that are insulin resistant are also glucagon resistant
autoimmune, low vitamin D
cortisone, OCPs, inahlers increase glucose levels
excess sucrose intake
TOXINS that may provoke or complicate diabetes
hemochromatosis-->free radicals damage beta cells or receptors, check ferritin & Sat%
(deferoxamine = iron & aluminum chelating drug) (40% sat is max normal)
insulin receptors sensitive to trans fats
streptozotocin is preferred toxin for animal experiments to destroy beta cells
N-nitroso found in smoked and cured meats also related
SYMPTOMS & SIGNS
tinea versicolor
skin tags
acanthosis nigricans
poor distal wound healing, ulcers
loss of distal sensation, peripheral neuropathies
chronic infections: BV, thrush, candida, other infx
polydipsia, polyuria
CLINICAL NUGGETS
**pts get used to having high blood sugar and then feel hypoglycemic when normoglycemic
**some diabetics have more spiking than others, with same A1C
TYPE I DM
twins more likely to share type 2 than type 1 (50%)
auto-antibodies vs Beta cells of pancreas present in 70%
normals: 1/2-2% have these abs
cow's milk protein may be the inciting antigen-->cross reactive immune response
strong link between dz occurrence and cows milk consumption world wide
viruses also may trigger production of ABs: mumps, hep, mono
more DM in colder climates, winter months (Vit D connection)
allergens may be transferred in breast milk
wheat consumption by mother or infant
wheat and milk allergies often occur together
wheat causes incr permeability of intestine
ZONULIN
gliadin activates zonulin release from ECs, zonulin opens tight jcts
Christine Daugherty studied this, book not out yet
discovered her celiac dz while she was pregnant
from wikipedia:
Zonulin is a protein that participates in tight junctions between cells of the wall of the digestive tract. Initially discovered in 2000 as the target of zonula occludens toxin, secreted by cholera pathogen Vibrio cholerae,[1] it has been implicated in the pathogenesis of coeliac disease[2] and diabetes mellitus type 1.[3] It is being studied as a target for vaccine adjuvants.[4] ALBA Therapeutics is developing a zonulin receptor antagonist, AT-1001, that is currently in phase 2 clinical trials.
AGES
formed with high temp cooking, bake, fry, grill, smoke
cooking duration not so imp
water inhibits AGE formation: boil, steam etc best, pushing pressure cooker again
microwaving not so bad for making ages but it destroys flavonoids
and makes radiolytic end products, spices are irradiated and some foods
lysine (amine containing lipid) from wheat combines with (reducing sugar) fructose-->Mayard rxn, panc enzymes can't break it down
-->allergic rxn
-->atherosclerosis, CV dz, #1 sequella of DM
accelerate aging, sclerosis
increase inflam
promote cross-linking of prot
Diabetics on comparison high and low AGE diets:
CRP up 35% with high AGE diet, decr 20% on low AGE diet
16,000kU/day is age content of typical US diet
ages and high sug-->small dense LDL-->EC damage
TYPE II DM
most pts have very high fats in serum
trans fats make phospholipid membrane less fluid, alters protein receptor site for insulin
oxidized fatty acids also poison the membrane
exercise is fastest way to reduce insulin resistance
also worked on this woman who had very low insulin levels:
Italian pasta eater woman
took her off all wheat and dairy
with blood sugar over 500 drop to 150 after 1 week riding exercise bike
back to completely normal at 2 weeks of riding bike
DIAGNOSIS
70-90 ideal fasting blood sugar
99-126 is "pre-diabetic"
fasting gluc 126 mg/dl or higher on two occasions, fasting minimum 8 hours
OGTT: sugar over 200 at 2 hours on 2 separate tests
1 HOUR postprandial over 180 is a criterion but it needs to be confirmed by other tests
LABS
lab error is common
trust your instincts
OGTT
Glucose Insulin Tolerance Test
do it in the morning when cortisol levels are high
don't do if ill
can dx low grade cases or borderline
want fasting insulin 7 or lower, above 8-9 there's insulin insensitivity
2nd and 3rd hour insulin should be under 40
sugar at 2 hours should be back to fasting level
DIAGNOSTIC: sugar over 200 at 2 hours on 2 separate tests
75 gram glucose test load administered over 5-10 minutes
30, 50, 60, 70 minutes
he frequently catches peaks at times other than 1 hour, 1 hour is mc
BP will change throughout test
check UA at peak glucose
HYPOGLYCEMIA
low blood sugar and sx from adrenal response to incr sugar:
shakes, sweats, etc
lots of people think their sugar is low when it is not: check it
a sign of hypoglycemia = a drop in glucose of 50+ points within an hour
also if blood sugar drops 20% below fasting level at any point
hypoglycemia is overdiagnosed
many diabetics think they need to eat if they feel bad when they need to eat less
DURING PREGNANCY: GESTATIONAL DIABETES
recommended for all preg women
2-4% develop it during 2nd or 3rd trimester
DM incr fetal mortality, pre-eclampsia
50gm oral glucose challenge (does not have to be fasting)
24-28 weeks gestation
gluc of 140mg/dl after 1 hour is indic for futher testing
100gm challenge for dx of dm
baby over 9 lbs then mb gestational DM
gluc under 120 after 1-2 hours is normal
over 50% of women with GD will develop DM within 5-15 years
HGB A1C
hemolytic & megaloblastic anemia-->falsely low A1C bcs RBCs have shortened life span
HGB A1C below 5.3 you're doing well
over 6 you have a problem
FRUCTOSAMINE
another test he used to use
tells about 1-3 week sugar levels
EXA-TEST
Burton silver intracellular dx
chromium
selenium
zinc
copper
magnesium
calcium
potassium
manganese
vanadium
THYROID
TSH, total T4, BBT
PROTEIN BOUND BLUC
average over prev 2-3 days
GLYCOMARK
a little pricey
he thinks it will be used more in the future
1,5 anhydroglucitol
when exceed renal threshhold for gluc then it declines
10.7-30ng/dl is normal
GLYCOMARK http://www.glycomark.com/
SONOCLOT
eval activation time, clotting time
MARZ TX for DM type I
he sorta likes Bernstein solution, low carb diet
anaerobic physical activity: sprints etc
severely limit carb intake (no onions? no fruit, etc)
aggressively take them off wheat and dairy
track children's body weight and growth curve carefully
want less insulin and more physical activity
MARZ TX TYPE II
he says use high carb (whole grain) high fiber diet
(low carb diets tend to be low fiber and he thinks this is a fatal flaw)
uncooked is lower glycemic, or less cooked
FIBER FOR BOTH TYPES
use fiber supp, he likes konjac best
http://www.konjacfoods.com/noodles/19.htm
pectin as fiber supp is OK binds endotoxin in gut, not as good as konjac
konjac reduces: LDL, chol, A1C
guar gum 5g/meal
pectin 10g/meal
oat bran 1 cup = 9g fiber
decr fat intake to 20%
decr sucrose and eliminate fructose
exercise
lose weight
use stevia rebaudiana (no glycemic response) or xylitol as sweetener
OK: chicory root, cocoa
can buy stevia plants at bi-mart here in PDX
MORE
physical activity in morning (after breakfast) reduces sugar response
increase omega 3 fatty acids to incr fluidity of membrane and fx of insulin receptors
he recommends testing by Body Bio
http://www.bodybio.com/BodyBioReport.aspx?Test=Yes ???
brewer's yeast a few TBS/day may lower insulin requirements
chromium for insulin binding 200-1500mcg/day, low toxicity, found in brewer's yeast
other Cr foods: liver, potato skin, whole grain bread, green pepper, rye
gymnema tincture or capsule
**avoid auto exhaust, it incr serum glucose
MONITOR LIPOPROTEINS
measure CV fx
cholesterol
CIMT
NUTRITION NOTES FROM WINDSTAR SHIFT ADDED 1/4/10
incr prot only if renal fx is normal bun/cr/crcl/ua/microalbumin
complex carbs: f/v/whole grain
decr glycemic load/index, www.mendosa.com
fiber (caution: gastroparesis) 30-35gm/d, flax, psyllium, konjoc, pectin
fat: no trans, decr sat, not low fat, no marg, incr avo, olive, nut, coconut? fish oil
freq meals, don't skip
exercise before meals
stress reduction
nutrients: chromium, vanadium, mg, niacin
anitox: vit c, ala, cratageus, berry extract, opuntia, vit E, D
herbs: fenugreek, gymnema, bitter melon, ginkgo, licorice, ginseng, cinnamon