I am diabetic

More protein in our diet is good for us, says one of the country’s top diabetes researchers, Osama Hamdy, MD and PhD. He is the medical director of the obesity clinical program at Joslin Diabetes Center in Boston.

But whether you are a vegetarian or not protein still presents problems.

He spoke about “Higher Levels of Protein Intake are Good” at the American Diabetes Association’s June annual meeting in San Francisco, as I previously reported here. Since then, he has posted his slides for that presentation online.

We got to know each other in San Francisco and have been in touch by email.  And we just got another chance to talk about his protein concerns.

On one hand, vegetable protein is better for us than animal protein, Dr. Hamdy told me when I called him yesterday. Amino acids are the key.

The building blocks of protein are amino acids. Our cells use 20 standard amino acids.

Scientists call some of these amino acids the essential ones. They aren’t essential because they are more important than the others. They are essential because our bodies don’t synthesize them, so we have to include them in our diet.

All of us require eight of them: phenylalanine, valine, threonine, tryptophan, isoleucine, methionine, leucine, and lysine.  In addition, four more are essential in the diet of infants and growing children.

But most animal protein has a lot of two of these amino acids, lycine and valine, Dr. Hamdy says. Too much of these amino acids are hard on our kidneys. They can cause cause too much pressure inside the kidneys and the blood vessels in the kidneys to expand.

So maybe all should become vegetarians? I asked Dr. Hamdy that.

Actually, vegetarians have protein problems of their own, he says. But different problems than those facing meat-eaters.

The problem with vegetable protein is the opposite of that meat-eaters have. Rather than too much of two amino acids, vegetable protein has too little of several of them.

Which amino acids? When I pressed Dr. Hamdy to specify them, he demurred. He didn’t want to get technical. “Several of them,” he replied.

Then, what should vegetarians do? If they are committed to remaining completely vegetarian for religious, ethical, or other reasons, they need to take “ketoanalog amino acid supplements.”

Better, he implied would be to supplement their diet with that animal protein that doesn’t cause kidney problems. This is the protein that we get from dairy, egg whites, or fish.

For me this was good news. I get most of my protein from my usual breakfast of two poached egg whites and my lunch or dinner of strained yogurt and fish, particularly salmon and sardines, which are among the best sources of omega 3 fatty acids.

But Dr. Hamdy’s advice also encourages me to get more of the protein I need from vegetarian sources. Many soy-based foods are among the best sources of protein. Spinach surprised me by being one of the foods with the most grams of protein per 100 calories. If you have no gluten intolerance, seitan is a protein-rich and tasty food.

Since Dr. Hamdy is a leading advocate of a higher protein diet, I had to ask him about the Why WAIT program of which he is the principle investigator. This Weight Achievement and Intensive Treatment Program is the world’s first clinical practice program designed to help patients with diabetes lose weight through a novel multidisciplinary approach.

He is the lead author of “The Why WAIT Program: Improving Clinical Outcomes Through Weight Management in Type 2 Diabetes,” which  Current Diabetes Reports will publish in its October 2008 issue. The abstract is online.

He is also the lead author of “Why WAIT Program: A Novel Model for Diabetes Weight Management in Routine Clinical Practice,” which the journal Obesity Management just published in its August 2008 issue. The citation is online. The study shows that people with type 2 diabetes enrolled in the program lost on average 23.5 pounds — or 9.8 percent of their initial body weight — during the 12-week program.

Why, I asked, did participants in that program get 40 percent of their daily caloric intake from carbohydrates? They developed those meal plans according to the Joslin Nutrition Guidelines for obese patients with diabetes, he told me.

At the same time he indicated his preference for a lower carbohydrate diet. “The American medical establishment is awfully conservative.”

If you read my articles about diabetes here regularly, you might have noticed that I rarely cover four topics in the news:

1. Knowing the causes of diabetes. This doesn’t help us control it.

2. Learning how to avoid diabetes. This comes too late for most of us.

3. Reading about great new drugs or treatments, This might have in a decade or so might help us some day — but not now.

4. Worrying about the possible complications of our diabetes. This would just add more negativity to our lives.

Of the 313 articles that I have written here about diabetes in the past three years, I did write 19 of them about complications. But each of them emphasized how to prevent or control one of these complications. That’s how I stay positive about the elephant in the room.

Today I am writing for the second time about one of these complications, fatty liver, and how to prevent it. I know how serious that liver disease can be. My wife, Catherine, who had type 2 diabetes, died one and one-half years ago of liver failure.

About 20 percent of the general U.S. population has nonalcoholic fatty liver disease. From 50 to 70 percent of people with type 2 diabetes have fatty liver. The difference in those proportions is enough to convince me that having a fatty liver is a complication of diabetes.

A couple of years ago my doctor thought that I might have fatty liver after I got some routine blood tests. Then, ultrasound confirmed it (since then, I have reversed this condition). That’s the way we usually learn that we have this complication.

Initially, we may not have any symptoms either from diabetes or fatty liver. That’s why both conditions are so insidious. No big deal, we may think.

But uncontrolled, fatty liver can lead to nonalcoholic steatohepatitis (NASH), which doctors sometimes call nonalcoholic fatty liver disease (NAFLD). That in turn can lead to cirrhosis of the liver.

Unless you can get a liver transplant, cirrhosis is fatal. Liver transplants may be available for people under 70 and my wife was only 69 when she died. But her doctor told her that her weight make a successful transplant unlikely, so she died.

Cirrhosis a well-known consequence of alcoholism. But more people die of nonalcoholic liver disease than from drinking too much. I know that my wife didn’t drink any alcohol.

Yet it turns out that fatty liver is among the complications of diabetes that submit to many different treatments. In my first article about fatty liver here almost two years ago I reviewed several of them.

Now, it appears that a little exercise can reverse the levels of fat in our liver by up to 40 percent. A moderate amount of exercise is all that it takes, according to a study by physical fitness experts at the Johns Hopkins University School of Medicine.

On Friday the researchers presented their findings at the annual meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation. A Johns Hopkins spokesperson sent me the abstract of the study, “Exercise Training Reduces Hepatic Fat in Type 2 Diabetes: A Randomized, Controlled Trial” in Microsoft Word format. Since I couldn’t find it online anyplace else, I posted it on my site.

The researchers divided 77 men and women with diabetes into two groups and measured the liver fat of 44 of the participants.

Why only 44 of the 77 participants? I called Dr. Stewart at the annual meeting to find out.

“When we started the study, we didn’t plan to study hepatic fat,” he replied. “But after we started, some of my colleagues persuaded me to include it.”

Dr. Stewart says the team’s study is the first to specifically demonstrate the beneficial role that exercise plays in controlling hepatic fat levels in people with diabetes.

The researchers put half of the study participants through a moderate program of sustained aerobic exercise consisting of three weekly 45-minute sessions. The participants could bicycle, run on a treadmill, or take brisk walks. In addition, they lifted stacked weights for about 20 minutes, also three times a week — and not at a heavy-duty pace. They asked the other half of the participants to avoid any formal aerobic fitness or gym classes.

Special magnetic resonance imaging scans showed much lower levels of liver fat in the active group, which remained the same in the non-exercising group. The exercising group had 5.6 percent liver fat after six months. The non-exercising group had 8.5 percent.

Until Dr. Stewart and his team does more studies, we can’t tell how significant this is. He says his team’s next steps will be to analyze the long-term effect of moderate exercise on diabetes.

We already knew that exercise makes you feel and look better. It takes glucose out of your blood to use for energy. It helps prevent heart disease, depression, and even some forms of cancer. If you do enough, it will help you to lose weight.

But sadly, the link between exercise and fatty liver came too late for Catherine. It is timely for everyone else who has type 2 diabetes.

Yogurt is one of the few probiotic foods that Americans regularly eat. When we get enough probiotics — friendly bacteria that help to drive out their bad counterparts and some yeasts — we get a health benefit, according to a definition of the World Health Organization and the Food and Agriculture Organization of the United Nations cited by the U.S. Government’s National Center for Complementary and Alternative Medicine.

But we get little probiotic benefit from some of the yogurt we eat. Probiotic foods are fermented, and fermented foods don’t survive pasteurization. To get the probiotic benefit from yogurt we have to avoid any that say on the label that they were heat treated after culturing. This means that they were pasteurized, killing the active cultures.

Good yogurts have only active cultures and milk. But unless it’s plain yogurt, it probably has a lot of sugar.

The best yogurts also remove most, if not all, of the whey. Why?

Two reasons:

1. When they strain out the whey, the yogurt has less lactose, which is the sugar in milk products. Except for the water in whey, almost all of it is sugar, according to the USDA National Nutrient Database.

2. Whey spikes insulin levels in people with type 2 diabetes and in healthy people, according to a research report last year in The American Journal of Clinical Nutrition. Insulin spikes make us hungry, which may make us gain weight.

If that were not enough for me, I have been checking out a cholesterol-reducing program here in Boulder, Colorado. This program, BalancePoint Health, limits diary products to strained yogurt.

What we call “Greek-style yogurt” is the most commonly available strained yogurt in America. Four brands of Greek-style yogurt are on the market where I live. They have lower levels of carbohydrates — which raise our blood glucose levels and make us gain weight — than other types of yogurt.

The very best Greek-style yogurt is organic. But I’ve found only one brand of Greek-style yogurt that comes from organic farmers who don’t use antibiotics or artificial growth hormones. Stonyfield Farms products this Oikos organic yogurt. It’s readily available at both natural food stores and supermarkets.

Ever since I read The Four Corners Diet, four years ago, I have been eating more and more probiotic food (and less and less other food). Gretchen Becker, my friend and colleague, wrote that book with Dr. Jack Goldberg and Dr. Karen O’Mara.

In addition to yogurt, they emphasis the probiotic benefits of a drinkable yogurt called kefir, which may be even healthier, because it also contains friendly yeast. Buttermilk can also be probiotic, but only if it’s unpasteurized.

Aside from these dairy products, The Four Corners Diet, also mentions sauerkraut. This is the fermented vegetable that Americans are most likely to know, but unless the sauerkraut is raw (unheated) it won’t be probiotic.

But several recent food imports from Asia are also potent probiotics. These include miso, kimchi, and tempeh. All of these foods also have a prized place in my probiotic diet. But Greek-style yogurt remains my favorite.

Article by: David Mendosa.

Starting to exercise isn’t easy for anyone. It sure wasn’t for me, even though I knew all too well how important exercise is for controlling my diabetes.

It’s a particularly personal example of the universal problem called inertia, which Sir Isaac Newton told us about 321 years ago in the greatest single scientific work ever. Inertia means that a body at rest tends to remain at rest.

But that’s only part of it, the down side. Inertia’s up side is that a body in motion tends to remain in motion.

Once we get going it’s easier to keep going than to stop. I know that Sir Isaac was right. Now, for me it’s harder on my psyche — to say nothing of my body — not to exercise every day than to exercise.

“I used to exercise and really liked to do that,” a correspondent named Jan wrote me this week. But she stopped working out after going through several surgeries. Subsequently, she totally lost her desire to exercise.

“I know you used to hate to exercise and now you like to,” she continued. “What happened to get you started, and how do you make yourself continue?”

Jan’s message got me to reflect on how much my attitude about exercising has changed. I wrote her back that it was indeed awfully hard for me to get started.

But once I got a my exercise pattern established, I felt so much better that there’s no way now that I could stop — unless I had to because of some injury. I dread arecurrence of the arthritis in my left knee that kept me off the trails a few years ago.

Now that Jan stopped exercising because of her surgeries, inertia means that it will be as hard for her to get going again as it was at first. But, as I wrote her, exercise is a virtuous cycle — the absolute opposite of thevicious cycle of most things in life. The longer she does it the easier it will be because she will feel so much better.

I guess the trick to getting started is for Jan (or anyone else) to do the exercise that she likes the most (or perhaps dislikes the least). For me it has always been walking or hiking. Maybe listening to music or a book on an iPod would help her (or you) as much as it has me.

Another trick is to reward yourself. I often promise to reward myself for exercising by stopping at my favorite coffee shop for an espresso or just a cup of coffee. And I think that it is as important to keep the promises that we make to ourselves as those that we make to other people. Plus, espresso and coffee makes me happy.

We can also build on our personal differences. All my life I have been hard of hearing. I compensate for my poor hearing by being more visual than most folks. I appreciate beauty wherever I find it. That’s the main reason why I’m an avid photographer. Wanting to take beautiful pictures of where I hike is often enough incentive to get me out on the trail.

Here’s another way I think about exercise. Like most people, I spend most of my life doing what other people want me to do and helping them. We all need balance in this and is other ways. I maintain my balance in this way when I realize that by exercising, I am finally doing something for myself.

I hope that I have encouraged Jan — and you — to go down that exercise path. She replied that she she is going to get started. And as soon as she can afford an iPod she plans to buy one.

Since I know how important it is to have someone paying attention to what we are doing — it’s called the Hawthorne effect — I asked Jan to keep me informed. This should give her just a bit more incentive to do what she knows that she needs to do.

Article by: David Mendosa.