American Diabetes Association (ADA)

American Diabetes Association trying to normalize fatness with new recommendation that obese diabetics eat more PROCESSED SUGAR

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One of the latest pieces of bizarre “fat acceptance” propaganda to come from the establishment is a “sweet and sour cucumbers” recipe from the American Diabetes Association (ADA) that encourages diabetics to add a whopping 60 grams of processed sugar to their pre-fermented cukes.

Calling those who run the ADA “sadistic biomedical profiteers,” Armageddon Prose‘s Ben Bartee says the recipe is “damn near criminal” in that it advises diabetics to consume the opposite of what they should be eating for their condition.

“Diabetics should all, without exception, in perpetuity until their metabolic dysfunction is resolved and insulin sensitivity restored, be on either ketogenic or extremely low-carb diets,” Bartee writes.

“To the metabolically compromised, sugar is poison, and all the more so when it’s processed and unfiltered through fiber.”

If the ADA were in the business of actually curing diabetes, it would provide helpful information about how to reverse it through diet and self-discipline. Instead, the organization is pushing sugar on diabetics, which is a death sentence.

“But then, if diabetics suddenly discovered their own power to heal themselves, the executives over at the ADA who make a killing off of the proliferation of disease might be forced to do an honest day’s work,” Bartee says. “And that they would never abide.”

(Related: Did you know that optimizing vitamin D levels can reduce the risk of diabetes by 43 percent?)

“Fat acceptance” driving pro-sugar insanity at ADA

To advise against sugar intake on the basis of the metabolic damage it causes, as well as weight gain, would be “fatphobic,” which is probably why the ADA is pushing loads of sugar on diabetics.

Consider a recent “FatCon” event where large people gathered to emotionally support one another in some kind of quest for self-acceptance. The types of people who attend FatCon want to be told that being fat is beautiful and normal, and that their bodies are still healthy.

The ADA seems to have embraced that same sentiment, or at least the organization does not believe that diabetics need to change their diet in any way to see their disease subside.

Another thing to consider is the fact that the new ADA recommendation that diabetics consume more sugar was paid for by a company that profits from treating kidney patients at its vast network of kidney centers.

“This dubious recommendation for diabetics to eat sugar was paid for by DaVita Corp which runs kidney centers,” tweeted Dr. Robert Lufkin, M.D. “The leading cause of renal failure is … diabetes.”

In the comments, someone wrote that he stopped eating processed sugar years ago, and has not consumed even a speck of fast food since 1994.

“Nothing from a ‘factory’ based box or bag,” this person added. “No weight or health problems at all.”

Another wrote that the ADA’s sweet-and-sour cucumbers recipe is no surprise because the Alzheimer’s Association does the very same type of thing by recommending that dementia patients consume seeds oils, which are highly inflammatory and toxic by nature.

“It’s not about health and never has been,” this person added. “It’s about keeping folks on the Big Pharma and Big Medicine train until the state gets its windfall from burial and estate taxes. We are but commodities to our government overlords.”

Someone else stressed that a big part of the globalist agenda right now is to divide everyone up into little “special communities” with the hope that doing this will herd everyone into supporting one of the two main political parties, which are technically a uni-party in disguise.

Why Diabetes Experts Just Started Taking Sleep Health Very Seriously

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Karolina Grabowska/Pexels

By Ross Wollen

December 23rd, 2022

The experts have selected a brand-new focus for doctors and caregivers who treat diabetes: sleep health.

The directive comes from the American Diabetes Association (ADA), which issues a new version of its Standards of Medical Care in Diabetes annually. This is the single most influential document in diabetes treatment, at least for Americans. The recommendations in this guidance govern the way that diabetes is treated in the country.

The 2023 edition, which was released on December 12, has an entirely new section on sleep health and explains in detail why diabetes experts now believe that sleep health can be such an important part of diabetes health.

Here’s the most important takeaway: Diabetes healthcare providers are now recommended to “consider screening for sleep health in people with diabetes” and to “refer to sleep medicine and/or a qualified behavioral health professional as indicated.”

In other words, if you’re having any problems getting healthy sleep, your sleep problems are now officially diabetes problems, and your doctor, nurse, or diabetes educator should help advocate for you to get the sleep help that you need.

Making the Case

We’ve discussed the many connections between sleep and diabetes in detail: The Importance of Sleep Health for Diabetes. Here, we’ll go over the evidence that led the ADA to make the change.

  • Sleep disorders are a risk factor for developing type 2 diabetes.

Many elements of suboptimal sleep — including short sleep duration, obstructive sleep apnea, shift work, and insomnia — have been found to correlate with type 2 diabetes development and progression, enough for poor sleep to be named a significant risk factor for the disease.

  • Sleep disorders may be a risk factor for developing gestational diabetes.

One large review, which evaluated 16 studies with data on millions of pregnant women, showed that women who got either too little sleep or too much sleep were more likely to develop gestational diabetes. Poor sleep quality, snoring, and obstructive sleep apnea only increased the risk.

  • Sleep disturbances make diabetes self-management much more difficult.

If you live with diabetes, you know how true this is. When we’re exhausted, we are not in the right frame of mind to make the kind of methodical decisions that optimal diabetes care so often demands of us.

  • Sleep disorders are extremely common in diabetes.

The ADA reports that more than half of people with type 1 diabetes have obstructive sleep apnea. In type 2, it could be as much as 86 percent! Insomnia, sleep disturbances, and restless leg syndrome are all common as well.

That so many people with diabetes deal with sleep disorders is further proof that there’s a significant link between sleep health and metabolic health — and all the more reason for diabetes doctors to make sleep health a priority.

  • Diabetes can interfere with sleep (especially type 1).

Intensive insulin management leads to all sorts of sleep disturbances. Insulin pumps and continuous glucose monitors sound alarms in the middle of the night (sometimes these alarms are important, and sometimes they’re erroneous). Extreme blood sugars cause us to wake up drenched in sweat, disoriented, famished, or all of the above.

And then there’s the way that diabetes distress can impact sleep: It’s not easy to sleep well if your head isn’t in the right place, and diabetes is unfortunately associated with very high rates of stress, anxiety, and similar mental health challenges. The ADA cites a qualitative study that identified diabetes-related “emotional distress” as a major cause of sleep difficulties. Putting it all together, some people with diabetes almost never enjoy an uninterrupted good night’s sleep, which puts them at risk of the many health problems associated with poor sleep.

  • Sleep therapy can reduce A1C and insulin resistance.

We know from a 2022 study that cognitive behavioral therapy can help patients improve both their metabolism (A1C, fasting blood sugar, and blood pressure) and their sleep quality. Pharmacological intervention may help too; a 2021 study found that both behavioral medication and sleeping pills can improve insulin resistance and may also improve A1C.

Additional Factors

We actually think that the ADA is only scratching the surface here in connecting sleep health to diabetes health:

  • Sleep quality is intertwined with diet quality. A poor night’s sleep makes you more likely to binge on unhealthy foods, and unhealthy foods probably lower sleep quality, a vicious cycle.
  • Good sleep is essential for a properly functioning immune system — a special concern for people with diabetes, who are generally more susceptible to infections and illnesses.
  • Good sleep is also essential for good mental health, another huge issue for many people with diabetes.
  • Sleep quality and quantity can moderate your risk for cardiovascular disease.

We’ve got links and details on all of the above in our article on the importance of sleep health for diabetes.

For ideas on how to create healthier sleep habits, check out this link from our partners at Everyday Health: Sleep 101: The Ultimate Guide to a Better Night’s Sleep.

The Bottom Line

Sleep is a surprisingly important factor in diabetes management, in so many ways. Getting the right amount of sleep isn’t a cure-all, but it can help get your health back on the right track, putting you in the best possible position to manage your diabetes optimally.

If you have sleep issues, it may be time to take them seriously as a health problem that you need to solve. Consider this news an encouragement to discuss any sleep issues with the healthcare provider you see for your diabetes. There’s a growing recognition that sleep health and metabolic health are intimately related, and it may soon become easier for you to get the help you need.

Dining Out Tips for the Low-Carb Lifestyle

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Photo credit: minree (Pixabay)

By Maria Muccioli Ph.D.

August 29th, 2022

If you are carefully watching your carbohydrate intake, or sticking to a strict low-carbohydrate diet, dining out can present a unique set of challenges.

I have been eating low-carb to optimize my type 1 diabetes management for almost four years now and have learned a lot about my best practices, as well as pitfalls, when it comes to eating out.

The good news? Over these last few years, I have noticed more and more restaurants offering up low-carb-friendly choices and being happy to make accommodations.

Here are my top tips for dining out successfully while sticking to the low-carb plan:

Breakfast Choices

Eggs are the low-carb superfood of breakfast and brunch! Omelets or poached or fried eggs with a side of bacon or sausage always hits the spot for me. Also, I often substitute avocado and berries for the more carb-heavy sides.

At Starbucks, I often purchase string cheese and avocado dip. Also, I recently discovered Moon Cheese there, which is delicious (and addictive)! They also sell sous-vide egg bites, some of which are relatively low on the carb count, but they do contain potato starch, so may not be everyone’s cup of tea.

Also, some on-the-go breakfast places have wonderful “bowl” options. For instance, I had a great breakfast experience at Currito, a burrito joint, at Boston Logan airport!

Photo by Maria Muccioli; Scrambled eggs, chorizo, bacon, guacamole, salsa and cheese.

Don’t forget the coffee!

Fast Food Picks

Whether at McDonald’s or Burger King (or a similar on-the-go place), I tend to opt for a burger and skip the bun. The salads aren’t usually very tasty in my opinion, although I sometimes also get a garden salad to go with my burger. I feel pretty satisfied with ample protein from the burger and eat some veggies on the side. Hold the ketchup! Consider mayo, hot sauce, or mustard on the burger to keep the carbohydrate count down.

Photo by Maria Muccioli

Some places, like Red Robin and Five Guys, actually offer the choice of a lettuce wrap. No matter where you are, it doesn’t hurt to ask if they will do that — after all, you don’t really feel like you’re eating a burger unless you’re using your hands!

When at Subway, I always opt for a salad with protein on top. My go-to order: salad with all the veggies (except hots) topped off with guacamole and a choice of tuna, chicken and bacon, or steak and cheese. The cold cuts on top are a fun option, too. Yum!

We have an entire article on the subject: The Healthiest Choices at the 10 Biggest Fast Food Chains.

Dining Out

When choosing an appetizer, you can look for protein or veggie options. My favorites include charcuterie boards (skip any bread or honey), roasted or fried Brussels sprouts or cauliflower, oysters, bacon-wrapped scallops, and mussels (don’t overdo it on tasting the broth and skip the bread)!

Photo by Maria Muccioli; Buffalo-style cauliflower with blue cheese dressing

Photo by Maria Muccioli

At one restaurant in my college town several years ago, a favorite of mine was “tofu fries”. They were not breaded, surprisingly crispy, and served with a spicy garlic mayo — absolutely delicious with a round or two of drinks!

When it comes to the entrée, I tend to choose my protein (be it steak, salmon, shrimp, or scallops) and then pair it with low-carb sides, such as cauliflower mash, broccoli, spinach, Brussels sprouts, seasonal veggies mix, asparagus, etc. Check the menu or ask the server about what is available, and don’t be afraid to ask about the ingredients if you are unsure of the carb count (creamed spinach or cauliflower casserole can sound promising unless you learn that there is flour and breadcrumbs involved).

Photo by Maria Muccioli; Salmon with mixed greens and sprouts.

Also, it’s a good idea to ask for the sauce on the side or consult your server about how it’s made. That way, you can limit how much you have or choose to skip it entirely if it does not align with your carb intake goals.

Also, I love buffets! You can see exactly what you’re getting and that’s just awesome! Check out these options I found at the press office at the American Diabetes Association (ADA) Scientific Sessions conference!

Photo by Maria Muccioli

Photo by Maria Muccioli

Excitingly, more and more restaurants are offering low-carb options, so you don’t even need to make changes to your order! Just the other day, I was at restaurant that offered a “paleo” section that had several attractive options. Another place nearby is serving up cauli-rice with coconut aminos and zoodles — impressive!

Common Pitfalls

Look out for these common offenders that can throw a wrench in your low-carb diet:

  • Breading: Whether around your chicken tenders or hidden in your burger meat, ask the server ahead of time if you’re unsure whether breadcrumbs or flour is involved.
  • Stuffing: Something like cheese-stuffed mushrooms may sound appetizing and low-carb-friendly, but more often than not, stuffing of any kind contains flour and/or breadcrumbs. Always double-check!
  • Pancake batter (in your eggs!): In theory, nothing is safer than eggs when it comes to following a low-carb eating plan. But, did you know that some hotels and restaurants actually add pancake batter to make the eggs “fluffier” (and perhaps to save money)? When in doubt, check with your server and ask for “freshly cracked eggs”.
  • Salad dressings: Some house-prepared or commercial salad dressings are actually low-carb, while others have a ton of sugar. Ranch and Thousand Island, in particular, are commonly higher on the carb count. You can always ask for oil and vinegar to be extra safe!

Bottom Line

You’re paying money for your food and dining experience. There is no need to be shy about asking questions or for substitutions to suit your lifestyle. Find the places and choices that work well for you and enjoy delicious food while not worrying about a blood sugar roller-coaster!

What Are My Choices for Metformin Alternatives?

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Metformin alternatives

While you are likely familiar with metformin and insulin as the two well-known medications for treating type 2 diabetes, many other options are available to help you manage your glucose levels. Here is a rundown of some of the other options that may improve your health and diabetes management.

When you are diagnosed with type 2 diabetes, you will likely hear from your healthcare team that the most common initial treatment regimen consists of some combination of metformin and lifestyle changes to your diet and exercise.

For most people, type 2 diabetes is a progressive disease (this means that without proper treatment it can continue to worsen over time). In addition, some people may have more severe and chronic hyperglycemia for a long time prior to being diagnosed with type 2 diabetes. As a result, you might need additional medications the longer you have diabetes to keep your glucose levels in a healthy range.

Insulin remains the most effective therapy to lower glucose, particularly in comparison to most oral medicines for type 2 (including metformin). Therefore, at the time of diagnosis, if there is evidence of long-standing and persistent hyperglycemia, you may be advised to start insulin, since it is most effective and rapid in its action to lower glucose levels. Once diagnosed, if you are unable to meet your glucose targets (whether that be because your condition has progressed over time, your current medications are not doing enough to lower your glucose, or because you were experiencing significant symptoms), your healthcare team may suggest using insulin.

While these treatments are some of the most well-known, there are many other medications available today for people with type 2. These additional drugs have dramatic effects; many of them can lower your risk for various diabetes-related complications, while still maintaining similar glucose-lowering properties.

“People with diabetes should be aware of their need for different medications based on their risk profiles,” said Dr. Robert Gabbay, chief scientific and medical officer for the American Diabetes Association. “All people with diabetes should also be referred for and receive DSMES, or diabetes self-management education and support, at diagnosis. This gives people the opportunity to engage with a skilled diabetes care and education specialist, ask questions about therapies, and increase awareness.”

As new diabetes drugs continue to receive FDA approval at an unprecedented rate, here is a look at the different types of medications that can improve your health and help you better manage your diabetes. If you are at an increased risk for developing complications, or your glucose levels have not responded well with metformin, talk with your healthcare provider about whether these medications may be a better option.

SGLT-2 inhibitors

SGLT-2 inhibitors are oral medications that can help lower your glucose levels by helping your body remove excess glucose by excreting it in your urine. These drugs can lower A1C levels, and research has shown that they can also slow the progression of kidney disease and protect against heart disease (heart attack, stroke, hospitalization for heart disease and death) and heart failure. However, SGLT-2 inhibitors should not be prescribed to those who have already progressed to stage 4 or end stage kidney disease.

Additionally, unlike other glucose-lowering drugs, SGLT-2s come with a relatively low risk of hypoglycemia. The currently available SGLT-2 inhibitors include Farxiga, Invokana, Jardiance, and Steglatro.

Side effects of taking an SGLT-2 inhibitor may include:

  • More frequent urination
  • Increased risk for urinary tract infections and genital yeast infections
  • Increased risk for kidney damage for those already at advanced stages of kidney disease
  • Increased risk for diabetic ketoacidosis (DKA)
  • Low blood pressure, syncope (loss of consciousness caused by low blood pressure), and dehydration due to volume depletion
  • Invokana, specifically, may increase your risk for amputations, ketoacidosis, and kidney damage beyond that associated with other SGLT-2 drugs.

GLP-1 receptor agonists

GLP-1 receptor agonists are another type of glucose-lowering medication, which can either be taken orally or, more commonly, through a once-daily or once-weekly injection. GLP-1 receptor agonists can lower your A1C levels, and some have been shown to lower your risk for heart and kidney disease as well.

Perhaps most remarkable, however, is that taking a GLP-1 receptor agonist can lead to significant weight loss. If you have struggled with weight management through diet and exercise changes alone, talk with your healthcare provider about starting a GLP-1 receptor agonist. The currently available medications in this class are Adlyxin, Bydureon, Byetta, Ozempic, Rybelsus, Trulicity, and Victoza.

Side effects of taking a GLP-1 receptor agonist may include:

  • Nausea
  • Vomiting and diarrhea (usually decreases over time)
  • Risk for hypoglycemia, if taken in combination with insulin or a sulfonylurea (read below)

DPP-4 inhibitors

DPP-4 inhibitors are a class of drugs that can lower your glucose by inhibiting glucagon release in your body, a hormone that causes your blood sugar to rise. This helps stimulate insulin production and decreases the emptying of your stomach, making you feel more full. Both of these effects help lower glucose levels.  These drugs are taken orally and are often combined with metformin to bolster the glucose-lowering action. When taken with metformin, there is a low risk for low blood sugar with a DPP-4 inhibitor, but taking them with insulin or sulfonylureas can place you at a higher risk.

While they can lower your glucose, DPP-4 inhibitors have not been shown to have the same effects on weight loss and complications as the SGLT-2 and GLP-1 drug classes. Available DPP-4 inhibitors include Januvia, Nesina, Onglyza, and Tradjenta.

Side effects include:

  • Gastrointestinal problems
  • Flu-like symptoms
  • Increased risk for pancreatitis

Sulfonylureas (SFUs)

SFUs are a type of glucose-lowering medications that have been around for many years as a treatment for type 2 diabetes. While SFUs are effective at lowering glucose and are available as less expensive generic brands, they significantly increase your risk for low blood sugar and can cause weight gain. Given that other drug classes can lower your glucose and reduce complications without the added risk for hypoglycemia, you may want to discuss these other options with your healthcare provider.

Side effects include:

  • Higher risk for experiencing hypoglycemia
  • Weight gain
  • Hunger
  • Upset stomach

Thiazolidinediones (TZDs)

TZDs are another glucose lowering medication that work by reducing insulin resistance. Similar to SFUs, TZDs are cheaper and come in generic brands but can place users at a higher risk for negative side effects such as weight gain and an increased risk for heart failure. Discuss these risks with your healthcare provider to find the best option for you.

Side effects include:

  • Weight gain
  • Edema, or fluid buildup, usually in your feet, legs, hands, or arms
  • Increased risk for heart failure or experiencing a bone fracture

Combination Drugs

Combination drugs, as the name suggests, combine two or more drugs, usually from different classes, into a single medication. Combination drugs can increase the effectiveness of each individual medication, reduce overall side effects, or decrease the total number of injections or pills in your daily treatment routine. Some currently available combination drugs include Janumet (Januvia + metformin), Kombiglyze XR (Onglyza + metformin extended release), and Synjardy (Jardiance + metformin).

Of course, these different drugs can also be taken as separate doses at the same time, or in combination with your insulin regimen. Layering multiple therapies can alleviate some negative side effects, help lower your glucose more effectively, and help prevent complications at the same time. Combination therapies allow your healthcare provider to develop a much more personal treatment for you.

Cost and access

Depending on your insurance coverage, drug costs are often a factor in determining which treatment you receive. Given how they minimize side effects and protect against complications, GLP-1 receptor agonists, SGLT-2 inhibitors, and DPP-4 inhibitors are all ideal options, but they tend to be more expensive and aren’t yet available in generic forms in the US.

SFUs, TZDs, and metformin are available in generic brands and are typically much cheaper – but obviously, as is the case with SFUs and the risk of severe hypoglycemia, there may be reasons why these drugs are not preferred. Regardless, all of these medications can help you lower your glucose, so talk with your provider about which treatment fits your budget and insurance coverage.

The bottom line

While metformin and lifestyle modification remain the first-line therapies for type 2 diabetes, as you can see, there are several other medications that you may be able to try before needing to go on insulin. Depending on your risk for developing complications like heart or kidney disease, it’s often more effective to start using a GLP-1 receptor agonist or an SGLT-2 inhibitor before progressing to insulin injections.

This flowchart from the American Diabetes Association details the process for how your healthcare provider makes decisions on which medications may best for each individual. While the chart may seem complex, it illustrates the many different options that might be available to you depending on cost, risk factors, and overall health goals.

“Ask questions,” said Dr. Gabbay. “Have a frank discussion with your diabetes care provider to understand the available options, why a treatment may or may not be for you, and ask questions to understand the treatments you do receive.”

Talk with your healthcare provider about whether you might benefit from one of these drugs. The path from metformin to insulin is by no means direct, and there may be other options that can help you improve your diabetes management.

Type 2 Diabetes: Medical Groups Disagree on What Your A1c Goals Should Be

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A1c goals for type 2 diabetes

The American College of Physicians (ACP) has written a guidance statement for providers to use when selecting targets for pharmacologic treatment of type 2 diabetes.

In other words, they share how aggressive clinicians should be when it comes to using medications to treat type 2 diabetes.

The American College of Physicians Guidance Statement

1: Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.

2: Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

3: Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

4: Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

Diabetes Medical Associations Disagree

Medical associations whose focus is diabetes do not agree with the ACP’s guidance statement.

The president of the ACP, Dr. Jack Ende explained in a statement that “ACP’s analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms,”

“The evidence shows that for most people with type 2 diabetes, achieving an A1C between 7 percent and 8 percent will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs,” he added.

Do These Recommendations Prioritize Individualized Care?

It’s reasonable to wonder that if taking medications is not a burden and costs are not an issue and low blood sugar risk is appropriately managed, is an A1c between 7 and 8 percent less desirable than one closer to non-diabetic levels? Type 2 diabetes is a serious disease and a 7% A1c would lead to its diagnosis, meaning that an A1c between 7 and 8 is not ideal for good health.

Yet, the reality is that these burdens do exist for a great many patients. The ACP seems to make the case that when burdens increase and patients do not reap additional health benefits in return, the extra medication intervention is not worthwhile but actually detrimental.

It makes sense to seek guidance from statistics. The problem is when these recommendations trump individualized care. It may make sense for one type 2 patient to keep a higher A1c level based on their unique circumstances but it would be an irresponsible measure for a provider not to share the risks of the higher A1c with any patient and leave them inadequately treated.

The ACP is not against a more ideal end result, however.

“Although ACP’s guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss,” said Dr. Ende. Perhaps this signals a change in focus from aggressive drug therapy to lifestyle interventions or perhaps more of an an emphasis on a healthier balance between the two.

The American Diabetes Association’s chief medical officer Dr. William Cefalu told NPR News that they disagree with the ACP’s guidelines and stand by their own. He said that new drugs are effective in managing blood sugar and carry less risk for low blood sugar and some of them help lower body weight and improve cardiovascular risk factors–a win/win for patients who need to address all three common issues.

Former president of the American Association of Endocrinologists, Dr. George Grunberger told NPR that “The moment your glucose goes above normal, it’s incurring damage to the back of the eye, to kidneys and to nerves, especially in your feet,” and that he worries these guidelines will effectively tell physicians not to worry too much about their patients elevated A1c levels.

The Endocrine Society released a statement as well, sharing their strong disagreement with the ACP’s statement. They pointed out in a press release that the ACP’s “recommendations do not consider the positive legacy effects of intensive blood glucose control confirmed in multiple clinical trials, particularly for those newly diagnosed with type 2 diabetes, and, therefore, are not reflective of the long-term benefits of lower A1C targets.”

The recommendations might prove costly if physicians do not treat each individual on a case-by-case basis. Physicians and patients need to have very candid talks about what is desired because not all patients want or are capable of the same things.

So Who is Right?

The ACP has a point about how few benefits are often seen at various points of treatment which barely outweigh burdens incurred by type 2 diabetes patients who are treated aggressively with medications.

However, other medical associations who recommend getting A1c levels lower are also accurate in recommending for lower targets. Blood sugar levels above normal do indeed cause damage, even if only slightly elevated. Patients have a right to be aware of that fact and to get help from their provider in achieving normal blood sugar levels, if possible.

Should providers encourage normal blood sugars or should they follow their patient’s lead? The ACP’s stance suggests the patient needs to advocate for the best blood sugar outcomes they can get. Will this guidance statement lead patients to leave providers who want them to settle at higher A1c targets? Finding new providers is often more than an inconvenience. Will this stance ultimately help or hurt patients?

As studies indicate, the future points to more emphasis on lifestyle habits as well as better medications. It’s also likely that continuous glucose monitoring devices, known as CGM are going to be used more in type 2 diabetes and become powerful aids. An individual with type 2 diabetes using a CGM will be able to find out exactly what certain foods, stress, and exercise does to their blood sugar levels and be motivated to act accordingly.

Perhaps a good question to ask is what motivations do people with type 2 diabetes have to rely more on lifestyle interventions versus aggressive medication protocols?

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Does Having Diabetes Mean You Have a Disability?

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 diabetes as a disability

oes having diabetes mean that you have a disability or are disabled?

It depends.

Some people with diabetes do not think they are disabled. I don’t presently think of myself as disabled, but I do see diabetes as potentially and temporarily disabling. Sometimes my blood sugar is low, and for a few minutes, I have to stop what I’m doing and treat it no matter what is going on. If my blood sugar is high, I don’t feel my best, and my productivity may be temporarily diminished by some degree until my blood sugar comes back down.

To me, it’s not too different from the way the average individual will sometimes get sick or injured and require assistance, time off work, or the need to follow some treatment plan.

Maria Muccioli, Ph.D., writes for Diabetes Daily and also lives with type 1 diabetes. She gives the example that if someone has a stomach virus, “it would be difficult to carry on with work tasks; this difficulty is for sure more pronounced than for someone who does not have diabetes” she shares.

Circumstances Matter

Maria also doesn’t consider it a disability for herself, personally, but she notes that she does work a desk job that doesn’t involve physical labor or other aspects that can challenge managing blood sugar as needed. “I can see how someone (even if they would normally have excellent control) may be in a profession that makes it more difficult to manage blood glucose and would thus be more likely to claim a disability,” she says.

Some people with diabetes do consider themselves as having a disability. They may have other medical conditions, complications, or hypoglycemia unawareness. The circumstances of people with diabetes vary like the weather, and that’s why you’ll get different opinions on the matter.

Maria also mentions pregnancy as “another example that may make one more likely to view having diabetes as a disability – between the need for very stringent blood glucose management, frequent adjustments, and increased number of appointments, the condition makes it more challenging to continue working as usual.”

“Personally, I worked until 39 weeks with my daughter, but I was lucky to have my doctor only a five-minute walk from where I worked and an accommodating boss who allowed me to work 7-3 so I could go to all my appointments after those hours,” she says.

What Does the Law Say?

The American Diabetes Association says that “under most laws, diabetes is protected as a disability.”

In 2008, the Americans with Disabilities Act Amendments Act (ADAAA) was signed, and it meant that you could no longer be denied a job just for having diabetes. It also meant that you could go to court for that discrimination and the defense wouldn’t be able to say you take good care of your diabetes and aren’t disabled. In other words, whether we take great care of ourselves or not, we are given disability status and protection by law.

What people with diabetes can and can’t do is highly individualized, but it may be useful to know these protections exist.

What about you? Does having diabetes mean you have a disability?

 

Why Don’t People Take Diabetes Seriously?

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When we hear that a loved one or friend has a serious illness it can evoke in us strong emotions of fear, worry, sadness and compassion. “I’m so sorry” and “How can I help?” are commonly offered sentiments in these difficult situations. Hearing the news that someone has diabetes does not often herald the same degree of concern.

Why is this? I believe that the reasons are multifactorial.

Broad Terms Contribute to Confusion

If we consider the word “cancer” people typically have an immediate reaction of alarm. However, cancer is a large umbrella representing over 100 distinct diseases depending on the organ or system affected. Prognoses for cancer are widely variable and many cancers are curable with early diagnosis and treatment.

These important distinctions reflective of cancer’s diverse landscape are often lost on the public’s perception. Thus, people may endure unnecessary anxiety, dread and anguish. Society’s increased understanding of the medical and scientific advances in cancer treatments would alleviate a lot of suffering and fear and replace it with hope and optimism. Even those who can’t be cured are often able to have significantly lengthened periods of disease-free survival and enhanced quality of life due to new treatments.

While the term diabetes is not as deceptively broad as cancer it does represent over seven distinct conditions each with its own pathophysiology. If you consider that diabetes may occur as a result of another disease or condition like cystic fibrosis, hemochromatosis or chronic pancreatitis, just to name a few, there are even more types of diabetes.

Unless you’ve personally known someone with diabetes and seen firsthand either a complication of the disease or its daily, labor-intensive management you may not grasp the seriousness of the diagnosis. Perhaps we’ve heard the word so much that we are desensitized to it. This is unfortunate since diabetes has become one of the fastest growing risks to human health throughout the world.

Since my own child was diagnosed with type one diabetes in 2013 I’ve become very attuned to how diabetes is perceived both in personal encounters and in the media. In our circle of family, friends and teachers, the reactions to my son’s diagnosis were a mix of bewilderment, sadness and nonchalance. Most people simply didn’t know what it was.

The knowledge gap with T1D may partially be attributed to its name. For clarity, I tell people that it was previously called Juvenile Diabetes. That charged term usually captures attention. Putting “juvenile” in front of any word will often do that (e.g., juvenile delinquency, juvenile detention center, etc.)

In my experience people generally assumed that my son would now need some sort of low-level lifestyle tweaks. The word sugar was always coming up. Should we get some sugar-free foods for him? Can he have cake? Wouldn’t some exercise, a “balanced diet” and a Crystal Light or two keep this thing in “control?”

Someone once told me to ditch my son’s insulin and go macrobiotic. Although disturbing, at least one of my son’s classmates understood that diabetes was serious. Lacking a filter he felt compelled to share that he had a relative who had his leg amputated. My husband who is an ICU physician had to reassure my son that these complications are very rare.

Pre-Diabetes

With so many different types of diabetes it’s no wonder that such a knowledge deficit exists. Take prediabetes as a perfect example.

According to the American Diabetes Association, in 2015 an astonishing 84.1 million Americans or more than 1 out of 3 adults had pre-diabetes. A person may leave an annual doctor’s visit with this news and a general recommendation to lose weight and exercise more. He may compare notes with his friends and discover that some of his buddies are in the same boat. With the tendency to feel like there is safety in numbers one might be inclined to either ignore the diagnosis or just try a few lifestyle tweaks like joining a gym or eating brown rice instead or white.

Unlike those with type 1, those with pre-diabetes don’t leave the doctor’s office with an abrupt and permanent new way of life requiring 24/7 insulin. Perhaps this is another factor that contributes to a lack of urgency to reverse pre-diabetes. Some will gamble that they can coast along with no lifestyle changes without converting to type 2 diabetes. They might be right but they need to know the real risks of this strategy.

Pre-diabetes means that something is wrong with a fundamentally important body function: glucose metabolism. Even if an individual does not ultimately receive a type 2 diagnosis he is still at risk for serious complications like retinopathy and neuropathy. So, feeling “fine” with this relatively silent condition is, indeed, a false sense of security.

Inspiration from a Type 2

Before my own child was diagnosed with type one I had a grim, skewed perception that diabetes was either coping with spirit crushing food restrictions or trying to persevere through difficult complications. Two relatives with type 2 succumbed to those complications. I just didn’t understand the other perfectly viable scenario of a healthy life filled with abundance.

One type 2 thriver who has intruigued me so much is the acclaimed English actor, Robin Ellis. In the 1970s he was the heartthrob leading man, Captain Ross Poldark, of the beloved BBC and Masterpiece Theatre series, Poldark.

A remake of it is currently thrilling millions on Masterpiece Theatre.

A huge fan of the original, I was fascinated to discover that Mr. Ellis is an inspiring type 2 diabetic. He has contributed to the diabetes community by being very transparent about his condition and his successful journey adapting to it.

An accomplished chef, Mr. Ellis’s lushly photographed and delectable diabetic-friendly cookbooks are a wonderful resource. Anyone with diabetes perusing these books may begin to feel that there is, indeed, another way to not just live with diabetes, but flourish as a result of it.

His latest, Mediterranean Cooking for Diabetics: Delicious Dishes to Control or Avoid Diabetes, is a go-to book in my cookbook collection. My type one son is a big fan of Mr. Ellis’s lower carb recipes and it makes me feel good to cook his healthy and flavorful dishes for my entire family.

So why do some people with diabetes like Robin Ellis become converts to a new way of living with diabetes? Growing up with a mother with type 1 diabetes who passed away from a heart attack due to her condition, Robin was cognizant of the dangers of diabetes as a result of this terrible loss.

However, I believe his motivation for a lifestyle change was not simply motivated by fear. Living in the French countryside with his supportive wife, Meredith, Mr. Ellis embraced the healthy culinary treasures of this region. He used his diagnosis as a springboard to explore new possibilities in food, exercise and wellbeing.

As the mighty Theodore Roosevelt used to say, “get action.” Take diabetes seriously no matter what type you have. Don’t let denial put your health at risk. You can shift from a place of worrisome vulnerability to one of hopeful optimism and fortitude if you are open to change.

There is a full life of abundance waiting for you.

ADA’s 2018 Standards of Medical Care Released

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Standards of Medical Care in Diabetes 2018

Every year the American Diabetes Association (ADA) puts out an updated Standards of Medical Care approved by their board of directors which is their official position and provides all of their current clinical practice recommendations.

In this year’s Standards they state that “To update the Standards of Care, the ADA’s Professional Practice Committee (PPC) performs an extensive clinical diabetes literature search, supplemented with input from ADA staff and the medical community at large.” they update it each year or as needed online based on incoming evidence or regulatory changes.

It should be noted that most current Standards supersedes all previous ADA position statements.

Citing the way the field of diabetes moves quickly, the 2018 Standards of Care reveals the following major revisions:

Limits of A1c and Diagnostic Recommendations

Since recent evidence shows limits to A1c measurements because of hemoglobin variants among individuals, conditions that affect red blood cell turnover, and assay interference, recommendations have been “added to clarify the appropriate use of the A1C test generally and in the diagnosis of diabetes in these special cases,” states the ADA.

The ADA now recommends pre-diabetes and type 2 diabetes screening in children and teens who are overweight or obese and have one or more additional risk factors.

Comprehensive Medical Evaluation and Comorbidities

Components of a comprehensive medical evaluation now includes “information about the recommended frequency of the components of care at both initial and follow-up visits.”

The ADA added information about “the importance of language choice in patient-centered communication.”

They also now recommend healthcare providers consider checking serum testosterone levels in men with diabetes who have signs/symptoms of hypogonadism.

Dietary Clarification

The ADA stresses a clarification regarding nutrition: the ADA states that “there is no universal ideal macronutrient distribution and that eating plans should be individualized.” They have also included text to “address the role of low-carbohydrate diets in people with diabetes.”

low-carb diet for people with diabetes

On this point the Standards state, “The role of low-carbohydrate diets in patients with diabetes remains unclear,” They write that some of this confusion is due to different definitions of low-carb diets. “While benefits to low-carbohydrate diets have been described, improvements tend to be in the short term and, over time, these effects are not maintained,”

They concede that some studies show “modest benefits of low-carbohydrate or ketogenic diets” which entail under 50 grams of carbohydrate per day and say that ” this approach may only be appropriate for short-term implementation (up to 3–4 months) if desired by the patient, as there is little long-term research citing benefits or harm.”

The ADA does recommend children and adults with diabetes to reduce their intake of refined carbohydrates and added sugars and to get carbohydrates from vegetables, legumes, fruits, dairy, and whole gains. They write that the “consumption of sugar-sweetened beverages and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged,”

CGM Recommendation

Considering the latest data, the ADA now recommends the use of CGM (continuous glucose monitoring) in adults with type 1 diabetes to all adults ages 18 and up who are not meeting their glycemic targets (recommendation was previously for age 25 and up).

Drug Recommendations for Blood Sugar Treatment

Recommendations have been added due to data from the recent cardiovascular outcomes trial (CVOT) which shows that people with atherosclerotic cardiovascular disease should start with lifestyle management treatments plus metformin and “subsequently incorporate an agent proven to reduce major adverse cardiovascular events and/or cardiovascular mortality after considering drug-specific and patient factors.”

Managing Blood Pressure from Home

All patients with high blood pressure are now recommended to monitor their blood pressure at home to find out if they have “masked or white coat hypertension” and to help motivate patients to take their hypertension medication via awareness of elevated blood pressure.

Caution in Older Adults

New recommendations have been added to indicate how important individualized drug therapy is in older adults in order to lower the risk of low blood sugar episodes and to avoid over-treatment, as well as simplifying complicated regimens if at all possible while keeping the A1c target.

Pregnancy and Diabetes

A new recommendation emphasizes that insulin is “the preferred agent for the management of type 1 and type 2 diabetes in pregnancy.”

Citing new evidence, the ADA now recommends that pregnant women with type 1 and type 2 diabetes take a low-dose aspirin beginning at the end of the first trimester for the purpose of lowering the risk of developing preeclampsia.

Diabetes Care in Hospital

Insulin degludec (Tresiba) has been added to the insulin dosing for enteral/parenteral feedings.

For all the revisions visit the Summary of Revisions. For the pdf of the 2018 Standards of Care go here.

The Two Levels of Hyperglycemia and a Separate Definition for People With Diabetes

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two stages of hyperglycemia

A Steering Committee made up of representatives from the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange formed a decision-making group for the Type 1 DiabetesOutcomes Program.

Their goal was to develop a consensus on definitions for hypoglycemia, hyperglycemia, time in range, DKA, and patient reported outcomes and while their decisions were informed via input from researchers, industry, and people with diabetes they relied on published evidence, their own clinical expertise, and Advisory Committee feedback.

We recently wrote about their definitions for hypoglycemia, here.

Level 1 Hyperglycemia

Level 1 hyperglycemia is defined by this group as a blood glucose concentration of >180 mg/dL (10.0 mmol/L) but ≤250 mg/dL (13.9 mmol/L).

The committee wrote that “In clinical practice, measures of hyperglycemia differ based on time of day (e.g., pre- vs. postmeal). This program, however, focused on defining outcomes for use in product development that are universally applicable.”

They believe that based on glucose profiles and post meal blood glucose data in those with no diabetes tell us that at or  over 140 mg/dL (7.8 mmol/L) is high blood sugar. However, since most people spend most of their day over that blood sugar level, they believe the guideline for measuring hyperglycemia should be different in those with diabetes.

Since the current guidelines for those with diabetes indicate that after meal blood sugar shouldn’t ever go over 180 mg/dL (10.0 mmol/L), the committee states that they would define high blood sugar starting at that point.

Changing Definitions to Keep Up With Patients?

It’s appropriate to clarify that this definition seems to be largely informed by the majority of patients with diabetes and not by what is deemed healthy in persons with no diabetes.

In other words, no matter what we call a blood sugar level of just under 180 mg/dL (10.0 mmol/L), the body will not discern between how hard it is to achieve a lower blood sugar and the damage that is known to be incurred through an elevated blood sugar.

The chronic and serious condition of type 2 diabetes is diagnosed with a fasting blood sugar of only 126 mg/dL (7 mmol/L) or higher on two separate tests, according to the Mayo Clinic. Some diabetes complications have been shown to occur with only slightly elevated blood sugar levels.

Is it a good idea to define high blood sugar differently for those with diabetes? Could this information be used by people with diabetes as a guide for their blood sugar goals? Would this be like the hypothetical example of telling an overweight person they’re not overweight if the definition of “overweight” has been changed due to a majority obese population?

Level 2 Hyperglycemia

Level 2 hyperglycemia is considered as “very elevated glucose as defined by a glucose concentration of >250 mg/dL (13.9 mmol/L).”

The committee states that over these levels, a patient’s risk for DKA is increased and the A1c levels associated with that glucose level are linked to a “high likelihood of complications”.

They write in their report that this definition “allows for the assessment of the ability of therapies and technologies to provide better glucose outcomes and to limit exposure to level 1 and level 2 hyperglycemic blood glucose values,” and that the definition is basically intended to apply to those with type 1 diabetes at any point of the day.

BG Levels

More Research Needed

The committee explains that we need more research in order to improve our understanding of how an individual high blood sugar vs sustained high blood sugar affects a person with diabetes over time.

They write that we could also use more research to improve our knowledge regarding to ties between high blood sugar and microvascular disease and other complications as well as ” the role of genetic factors and a patient’s ability to recognize when hyperglycemia is occurring”.

How Does a Cup of Beer or Glass of Wine Affect Blood Sugar?

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drinking with diabetes

 

As a diabetes educator, I frequently get asked by patients, “Can I drink alcohol and, if so, how much?” A lot of people don’t know that alcohol can actually lower your blood glucose level. If you use insulin or certain diabetes medications you are at greater risk of having a low blood glucose reaction if you drink alcohol. It’s important to have this conversation with your doctor to see if it’s safe.

Keep in mind that alcohol should always be consumed in moderation; however, if you choose to have an alcoholic drink, here are some tips to help keep you safe:

  1. Don’t drink on an empty stomach or when your blood glucose is low. Drink alcohol with a meal or carbohydrate snack like pretzels or crackers.
  2. Don’t carb count your alcohol. If you count carbohydrates don’t add alcohol to the equation. Replacing alcohol with carbohydrate foods can be risky and lead to low blood glucose or hyperglycemia. Alcohol is considered empty calories. It provides no nutritional value, so drinking too much will add no benefit to you.
  3. Drink in moderation. The American Diabetes Association recommends drinking in moderation and people with diabetes should follow the same guidelines as those without diabetes. Women should have no more than 1 drink a day, and men, no more than 2 drinks a day. You might be wondering, “What is one drink?” To give you an idea, one drink is equal to 12 ounces of beer, 5 ounces of wine or 1 ½ ounces of distilled spirits (American Diabetes Association).
  4. Sip on your drink and make it last. By drinking in small sips, you can savor the flavor and make that one drink feel like much more.
  5. Hydrate yourself by keeping water close by. It’s easy to forget to drink water especially when you’re in the midst of a conversation. Grab a glass of water when you grab your alcoholic beverage and keep it close by, so that you remember to stay hydrated.
  6. Wear a medical ID bracelet. Wearing an ID bracelet is a great way to let others know you have diabetes in case of an emergency.
  7. Beware of cocktails. Cocktails can use some very sugary mixers with high calories. This doesn’t mean you can never have a cocktail again, but find out the ingredients and make substitutions if necessary. Some examples of zero calorie mixers are diet soda, club soda, diet tonic water, or water.
  8. Be safe and smart when drinking alcohol. Always check your blood glucose levels and drink with someone who supports you and knows how to react when you have a low blood glucose level.

Cheers!

Source: 

  1. American Diabetes Association. (2017). Making Healthy Food Choices: Alcohol. http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/making-healthy-food-choices/alcohol.html?loc=rfhl.