Saturday, July 21, 2012

Transcend Diabetes

Most of our lives we are caught up in the moment.  Let’s now take a moment to look at diabetes from 10,000 feet up, where we can see clear patterns and insight emerge from the fog of hypoglycemia, and its opposite, hyperglycemia.  If we plot carbohydrate consumption from low to high on the y-axis, and injected, fast acting (bolus) insulin from low to high on the x-axis, we can see all possible combinations of expected results on the following matrix:

When injected bolus insulin is low or zero, and carbohydrate consumption is high, we are presented with the classical triad of diabetes symptoms: polyuria, polydipsia, and polyphagia: respectively, frequent urination, increased thirst and consequent increased fluid intake, and increased appetite.  Other manifestations will include weight loss (despite normal or increased eating), irreducible fatigue, and changes in the shape of the lenses of the eyes, resulting in vision changes.
When the glucose concentration in the blood is raised beyond the renal threshold, reabsorption of glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine, which is called glycosuria.
Patients may also present with diabetic ketoacidosis (DKA), an extreme state of metabolic dysregulation characterized by the smell of acetone on the patient's breath; a rapid, deep breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and any of many altered states of consciousness or arousal (such as hostility and mania or, equally, confusion and lethargy).  In severe DKA, coma may follow, progressing to death.
Surrounding this cell on the matrix is hyperglycemia, both to the right, when carbohydrates consumed are high and injected insulin is moderate, but not enough to cover the load, and below, when a decrease in carbohydrates is consumed, but still not offset enough by injected insulin.
In the middle of the chart, where one eats a moderate amount of carbohydrates and injects a moderate amount of bolus insulin, lies the typical diabetes treatment.  “Eat a balanced diet and learn to adjust your insulin accordingly” is the principal treatment that is followed here.  It is possible to attain near-normal A1c levels with this approach, however, normal levels of cholesterol, weight, and blood pressure may prove unreachable.
Furthermore, this area of the table is fraught with negative consequences at nearly all adjacent and opposite borders.  Not enough insulin puts one in hyperglycemia territory both to the left and above.  Not enough carbohydrates, and one finds themselves hypoglycemic to the right and below.
At the other extreme, when injected insulin is high, and carbohydrates consumed are too low, severe hypoglycemia could result, necessitating a visit from the local paramedics when subsequent low blood glucose causes unconsciousness.  If not attended to quickly, coma and death could occur within minutes.
Too, if carbohydrates and insulin injected are high, the result is a hyper-hypo-glycemic swing—a rollercoaster ride if you will—of great magnitude, where the patient is constantly adjusting carbohydrate and insulin loads to offset their blood sugar.
But look what happens when both carbohydrates consumed and insulin injected are as low as possible.  At the far lower-left cell of the matrix, one doesn’t eat a great many carbohydrates, and, subsequently, does not need to inject much insulin as a result.  In this case, one can achieve a stable and normal blood sugar concentration, and enjoy the benefits of a normal life: lower VLDLs, higher HDLs, stable or decreasing weight, and less anxiety not having to think about whether one has injected the right amount of insulin.  And testing can be reduced to once a day, in the morning, to validate your successful Insulin Glargine dosing, i.e., whether or not your morning BG is in the 70-110 mg/dL range.  This home base is where thriving begins.
At the zero bolus-insulin and near-zero carbohydrate home, you may thrive for a long, long time.  There are three major centenarian studies going on around the world, the New England Centenarian Study, the Georgia Centenarian Study and the Okinawa Centenarian Study.  According to Dr. Ron Rosedale:

They are trying to find the variable that would confer longevity among this group of people who live to be 100 years old.  Why do centenarians become centenarians?  Why are they so lucky?  Is it because they have low cholesterol, exercise a lot and live a healthy, clean life?
What researchers are finding from these major centenarian studies is that there is hardly anything in common among these people.  They have high cholesterol and low cholesterol, some exercise and some don't, some smoke, some don't.  Some are nasty as can be, some nice and calm and some are ornery.  But, they all have relatively low sugar for their age, and they all have low triglycerides for their age.  And, they all have relatively low insulin…The way to treat virtually all of the so-called chronic diseases of aging is to treat insulin itself” (“Insulin and its Metabolic Effects,” Ron Rosedale, Signs for Health Institute’s BoulderFest, August, 1999).

Although the use of exogenous bolus insulin as a treatment to mitigate the effects of carbohydrate consumption was innovative, exciting, and promising nearly a century ago, its use has become—save on the acutely serious hyperglycemic—obsolete with the introduction of Insulin Glargine, and the knowledge that carbohydrates are non-essential.
A remarkable picture develops when you take those three highlighted cells from the previous figure and place them on two different axes, one a continuum of complexity from low to high, and the other, a continuum of knowledge, skill, efficiency, and effectiveness, again, from low to high.

The y-axis, complexity, relates to the treatment—medication & nutrition—and lifestyle a person implements or recommends.  Regarding the x-axis, knowledge, skill, efficiency, and effectiveness, it could be looked at from two perspectives; one, from a diabetic’s perspective, where the focus is on their knowledge & skill as it relates to implementing advice from a third-party or self-directed behavior, and another, from the perspective of a third-party’s knowledge & skill, be it friend, relative, caregiver, nutritionist, nurse, or doctor.  Treatment efficiency and effectiveness in either case is also measured.
The lowest complexity matched with the lowest skill & knowledge, will result in a diabetic on the brink.  It is quite easy for them to eat carbohydrates at will and develop the hyperglycemic symptoms of full-blown diabetes: polyuria, glycosuria, polydipsia, polyphagia, ketoacidosis, weight loss, etc., culminating in shortened life span.  Knowledge for the patient about diabetes may be non-existent, and they will likely seek out medical attention for help, though, unfortunately, some don’t or for many reasons even if they do, helpful advice is not available.  Acquaintances will also most likely notice the change in persona or appearance, and they too will make it a point to tell the person that something is wrong.
“Diabetes Managed” represents a diabetic trying to follow the instructions and advice of his or her general practitioner, though both are influenced by a wide variety of stakeholders with oftentimes divergent self-interests.  A majority of the influencers in the medical advice providing supply chain include:

·        Pharmaceutical companies
·        Researchers
·        Doctors
·        Endocrinologists
·        Nutritionists
·        Educators
·        American Diabetes Association
·        World Health Organization
·        Medical schools
·        Nurses
·        Reference media such as the Physician’s Desk Reference
·        Food manufacturers
·        Food marketers
·        Popular internet sites, print media & the news
·        Friends, family, co-workers & acquaintances

By default, advocates of each group act in their own perceived best interest, based upon their knowledge and skill, which may in turn be based upon the state of information available at their time of training or education.  Many of the above stakeholders, with the exception of the end users themselves—the people with diabetes—have significant power.  In fact, some have a near-absolute advantage in the marketplace—the ability to influence behavior without question or pause—leaving the buyer of an optimal diabetes treatment treating their diabetes sub-optimally, i.e., carbohydrate & bolus-insulin intensive.
And the results?  Perhaps an HbA1c at or below 7%, weight gain, increasing VLDL levels, increasing blood pressure, too much time spent counting carbohydrates and measuring insulin doses, anxiety caused by constantly wondering whether or not too much or too little carbohydrates were eaten or insulin dosed, the ever present chance of hypo- or hyper-glycemia, constant blood sugar testing, and the list goes on.  “Diabetes Managed” may not achieve optimal results for the end user, but, for the other stakeholders, it brings and keeps customers longer.
Although the science behind the drugs that either limit the amount of glycogen released from the liver or that bind and carry glucose from the blood to the receptors that transport it across cell membranes is remarkable, it is based upon two assumptions: (I) that carbohydrates are an essential majority part of the diet, and/or (II) that through education, a patient cannot, will not, or should not keep from consuming them.  Remove those key assumptions, and the house of cards from which that remarkable science is based comes toppling down.
Caveat emptor.  “Diabetes Managed” may be the first natural step for diabetics to enter—a complex medical-advice-providing system—in progression of their self-treatment, but it doesn’t have to be.
As knowledge about diabetes increases, trusted advisers and patients alike will choose a less-complex method, one that transcends diabetes by avoiding the root cause of symptoms and complications—carbohydrates—and replacing those carbohydrates in the diet with fat, resulting in benefits such as healthy weight loss, lowered VLDL levels, increasing HDL levels, reduced mTOR activity, normal blood pressure, etc.; in short, leading to a longer, happier, healthier life.
To transcend diabetes requires reduced carbohydrate consumption to near zero, with emphasis on a combination of fats and protein.  It is orders of magnitude less complex, less worrisome, and less risky than counting carbohydrates and matching it with doses of insulin.  It is simple.

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