Wildly Fluctuating by Gretchen Becker

19 February 2020

A diabetes blog with wildly fluctuating topics ranging from humor to serious stuff to miscellaneous musings on the diabetes news of the week by a type 2 diabetes patient/expert and author of The First Year: Type 2 Diabetes
  • Big Pharma and Research
    I'm hardly a big fan of big pharma (understatement). But I think we sometimes don't think of how difficult it is to develop an effective drug that is also safe. Derek Lowe is a chemist who used to work in drug development, and I follow him to see how such people think. I found this recent blog interesting.

    Management puts pressure on their chemists to develop profitable drugs in a minimum amount of time. But that means they sometimes don't have time for rigorous testing. He cites a trial in France in which 2 of 9 patients in a phase 1 trial (which is supposed to test safety) died.

    PK = pharmacokinetic, and PD = pharmacodynamic.
  • Is Dietary Protein Dangerous?
    A currently popular diet is a low-carbohydrate diet, often high fat with normal amounts of protein. But some people call low-carb diets high-protein diets. So recent headlines disparaging high-protein diets may cause worry to people on low-carb diets even if they're not eating an especially high amount of protein.

    Two examples of such headlines are

    High-protein diets boost artery-clogging plaque, mouse study shows.

    And Lower-protein diet may lessen risk for cardiovascular disease.

    If you just read headlines like this, you might worry that you're eating too much protein.

    But we need protein. And as we get older, we need more protein because our muscles tend to lose strength and the dietary protein helps to slow this decline.

    So how much protein do we need? A rule of thumb is 0.8 grams of protein per kilogram of body weight, or 0.36 grams per pound. An ounce of meat has about 7 grams of protein.

    If you're math-phobic, Jenny Ruhl has a calculatorthat will estimate how much protein you need on the basis of size and age, and you can find other calculators online.Some use lean body mass, rather than weight, for the calculations because it's muscle mass, not fat, that determines how much protein  you need.

    Note that all these calculations refer to a minimum amount needed for good health. Especially if you're getting older, you should eat a little more than the minimum, and recommendations increase to 1.2 to 1.5 grams per kilogram weight or lean body mass. I weigh about 50 kg, and different calculators say I need from 31 to 71 grams of protein a day, so don't take the results as totally accurate.

    When I was first diagnosed in 1996, I was told to follow the ADA low-fat diet, which prescribed an average of less than 2 ounces of meat per meal. I felt very deprived and not satisfied. I now try to eat 3 or 4 ounces of meat or other protein per meal, and that satisfies me.

    But the real question here is what the authors of the papers I've cited mean by "high protein" or "low protein." The mice in the first study were fed 46% protein. This is indeed high. Normal protein intake in humans is 12% to 20% of calories from protein. And except for people on the Carnivore Diet (nothing but meat), I doubt that many people, even those on low-carb diets, are eating 46% of calories as protein. 

    However, with protein, the amounts rather than the percentagesare the important factors, because as you reduce one nutrient, like carbohydrate, the percentages of the other nutrients go up even if the amounts stay the same.


    In addition, this study was done in mice, and mouse results often don't translate to  human results. In the wild mice eat mostly seeds, grains, and small fruit, although they'll eat almost anything they can get their paws on.

    However, people seeing "high protein" and "artery clogging" linked in the headline might cut back on their protein intake and end up protein deficient.

    The second study, citing "lower protein diet," focussed on sulfur-containing proteins, and their intake is difficult for the average person to estimate. But again, the headline is misleading. It doesn't refer to sulfur-containing proteins but proteins in general.

    And just to confuse patients even more, a 2015 study was titled "High protein foods boost cardiovascular health, as much as quitting smoking or getting exercise."


    Nutrition is a very fuzzy science. Many studies are done with food-frequency questionnaires. I sometimes can't remember what I had for lunch, much less how many chicken legs I ate last month. Sometimes people don't mention foods they think are unhealthy. Or they'll overestimate or underestimate the amounts they ate.

    So when you see headlines like the ones cited here, take them with a grain of salt (unless, of course, you're on a low-salt diet). If they worry you, try to read the papers themselves to find out what they mean by fuzzy terms like "high protein," and ask your doctor for another opinion.

    If you eat real foods, not fast foods or boxed foods, in reasonable portions, you probably have a healthy diet. If your blood glucose and hemoglobin A1c levels are good, you're following a diet that is good for your diabetes. Keep it up and don't obsess about sensational headlines.


  • Drug Costs
    We're all aware of the obscene increases in the price of insulin and the Epipen. But it's not just those drugs. All drugs are fast getting more expensive.

    I'm doing bookkeeping in preparation for taxes, and I could see how the prices are going up. I have Plan D, which means I don't pay the full costs of the drug, but in the following I'll use the full cost so the results won't be affected by the rules of the plan. Here are some examples, all in 2019. I get drugs mail-order and each order is for 3 months.

    Ezetimibe (generic Zetia) increased by 2.56 times

        April, $24.50
        July, $36.75
        October, $44.88
        December, $62.83

    Omeprazole (generic Prilosec)  increased by 4.8 times
        January, $5.89 
        April, $10.59
        July, $19.38
        October, $28.42
        December, $28.42

    Lisinopril (went up then down; maybe they negotiated a new contract)
        January, $2.20
        April, $5.54
        September, $10.48
        December, $6.05

    Pravastatin doubled
        April, $21.06
        July, $36.16
        October, $45.97
        December, $43.53   

    Some drugs did stay the same, including Levemir, $926, but I paid only $30.

    What will we do if the drug costs double, or more, every year? Will it come to choosing between food and shelter and drugs? Some people are already doing that with insulin, and some deaths have resulted from people with type 1 reducing their insulin doses to save money. That's criminal in a country whose president has spent more than $13 million on golfing trips. Where are our priorities? Does golf for some matter more than lives of others?

    We must figure out a fair way to provide life-saving drugs to those who need them.


       




  • Insulin Clearance
    I recently came across this paper on insulin clearance. It's a little technical but discusses the insulin-degrading enzye (IDE) and how it affects type 2 diabetes.

    As we all know, insulin makes blood glucose (BG) go down, and glucagon makes it go up. In most cases, the absolute amount of these hormones is not as important as their ratio. But other hormones can affect BG levels as well. For example, the hormone somatostatininhibits the secretion of both insulin and glucagon as well as other hormones.

    And IDE can also affect BG levels by degrading insulin in the liver.

    So if, for some reason, you were producing too much insulin and not enough glucagon, IDE could help to control the excessive insulin levels. This is called insulin clearance,and it seems to decline with the progression of type 2 diabetes. Lower levels of IDE are found in obesity and type 2 diabetes. Less insulin clearance would result in higher insulin levels, and these could cause insulin resistance.

    However, there's no agreement on whether lower levels of IDE are because insulin levels are declining or insulin resitance is increasing (essentially reducing the levels of effective insulin) or whether they are the result of dysfunction in the liver.

    From a practical point of view, it doesn't matter that much what causes the decline in IDE levels. What matters to us is how this decline affects our BG levels. The authors found that exercise can increase IDE levels.

    One interesting thing about all this is as an illustration of how complex the control of BG levels is. Many hormones and enzymes are involved, and we may have differences in the effectiveness of the various hormones and enzymes. Is it any wonder that we don't always see the same results from some drug or diet? Results of big clinical studies are reported as averages. But there are usually outliers.


    We have to constantly experiment, keep records, and work out what is best for us. It's a lot of work, but it's worth that effort. Good control now will mean fewer problems in the future.


  • Helping Obese Mice (humor)
    OK, I admit it. I'm a worrier. I worry about big issues, like climate change. But I also worry about smaller issues, like what I would do if we had five straight days of snow so I couldn't get out and I was almost out of toilet paper and coffee.

    [Correction: Being out of coffee is a big issue.]

    But one thing I don't worry about a lot is obese mice. As long as they don't eat all my food, I don't care how svelte my resident mice are. So when I saw an articletitled "Watermelon supplements bring health benefits to obese mice," I didn't exactly race to the supermarket to buy watermelon for my live-in mice.

    I did wonder why the researchers even thought about giving mice watermelon in the first place. Were they sitting around in the shade some hot day eating watermelon when one of them said, "Say, I wonder if watermelon would solve the urgent national problem of obese mice? Might they have a better self-image if they were healthier after eating this fruit?"

    Then I read on. "The study was funded by the National Watermelon Promotion Board."  Ah, that explains it.

    Food industry groups support research that takes some product they're pushing, extracting something from it, and giving a lot of the extract to mice or people, hoping it will show some benefit. If it doesn't, you'll never hear about it: "Kale extract doesn't help diabetics" is a headline you'll never see in your newspaper, ever. If it does help, the story will be trumpeted everywhere: "Kale extract may cure diabetes in platypuses." Even if the effect is miniscule and the test organism rare, the PR experts hope you won't remember the details, just "cure diabetes," so you'll buy a lot of it.

    Thus unless you're losing sleep over the problems of fat mice, when you see news stories lauding some common food as an obesity or diabetes treatment, see who sponsored the study. If it's a food industry group, take the findings with a grain of salt.

    Unless, of course, you're on a low-salt diet.