March 5, 2015

Nephropathy – Part 1

The definition of kidney disease varies some depending on the type and cause. Diabetic nephropathy is this topic, but I would be remiss if I do not include more. According to several sources, several causes must be considered in any definition.

IgA nephropathy - is the most common glomerulonephritis throughout the world.
Acute glomerulonephritis is an inflammatory disease of both kidneys predominantly affecting children from ages two to 12. Chronic glomerulonephritis can develop over a period of 10-20 years and is most often associated with other systemic disease, including diabetes, malaria, hepatitis, or systemic lupus erythematosus.

Acute glomerulonephritis is an inflammation of the glomeruli, bundles of tiny vessels inside the kidneys. The damaged glomeruli cannot effectively filter waste products and excess water from the bloodstream to make urine. The kidneys appear enlarged, fatty, and congested. Diabetic nephropathy will be the discussion in the next blog, based on this definition.

For more information, please enter the word 'glomerulonephritis' into the Search box of this medical dictionary. You may wish to use the medical dictionary for other terms below, as some are dependent on a correct meaning. You may wish to bookmark the dictionary as in future blogs, you may wish to use it again.

Analgesics - One cause of nephropathy is the long-term usage of analgesics. The pain medicines which can cause kidney problems include aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs, or NSAIDs. This form of nephropathy is "chronic analgesic nephritis," a chronic inflammatory change characterized by loss and atrophy of tubules and interstitial fibrosis and inflammation. Specifically, long-term use of the analgesic phenacetin has been linked to renal papillary necrosis (necrotizing papillitis).

Iodinated contrast media - Kidney disease induced by iodinated contrast media (ICM) is called CIN (= contrast induced nephropathy) or contrast-indueced AKI (= acute kidney injury). Currently, the underlying mechanisms are unclear. But there is a body of evidence that several factors including apoptosis-induction seem to play a role.

Xanthine oxidase deficiency - Another possible cause of Kidney disease is due to decreased function of xanthine oxidase in the purine degradation pathway. Xanthine oxidase will degrade hypoxanthine to xanthine and then to uric acid. Xanthine is not very soluble in water; therefore, an increase in xanthine forms crystals (which can lead to kidney stones) and result in damage of the kidney. Xanthine oxidase inhibitors, like allopurinol, can cause nephropathy.

Polycystic Disease of the Kidneys - Additional possible cause of nephropathy is due to the formation of cysts or pockets containing fluid within the kidneys. These cysts get enlarged with the progression of aging causing renal failure. Cysts may also form in other organs including the liver, brain, and ovaries. Polycystic Kidney Disease is a genetic disease caused by mutations in the PKD1, PKD2, and PKHD1 genes. This disease affects about half a million people in the US. Polycystic kidneys are susceptible to infections and cancer.

Toxicity of Chemotherapy Agents - Nephropathy can be associated with some therapies used to treat cancer. The most common form of kidney disease in cancer patients is Acute Kidney Injury (AKI) which can usually be due to volume depletion from vomiting and diarrhea that occur following chemotherapy or occasionally due to kidney toxicities of chemotherapeutic agents. Kidney failure from break down of cancer cells, usually after chemotherapy, is unique to onconephrology. Several chemotherapeutic agents, for example Cisplatin, are associated with acute and chronic kidney injuries.[3] Newer agents such as anti Vascular Endothelial Growth Factor (anti VEGF) are also associated with similar injuries, as well as proteinuria, hypertension and thrombotic microangiopathy.

March 4, 2015

Complications from Diabetes

In the last month, I have been writing about some of the complications of diabetes or related problems of diabetes. I will list several of the blogs about complications of diabetes, retinopathy and related, neuropathy which affects me and then I will write about those I have not written about in detail. This will be about nephropathy or kidney damage, atherosclerosis, and deafness are the most common, and many don't include deafness. The first three and deafness are grouped together under the term microvascular complications because they result from damage to the small blood vessels. The macrovascular complication is atherosclerosis, which is caused by damage to the large blood vessels.

There are several others that affect type 1 diabetes and seldom affect those with type 2 diabetes. Then there are those that affect both types, depression, hypoglycemia, hyperglycemia, and a few others. Over the next few months, I hope to write about all the complications.

Retinopathy – eye damage & diseases Your eyesight is too important to ignore and keeping your blood glucose levels near normal is the best treatment for your eyes.

The above three blogs are about eye diseases affected by high blood glucose levels.

Neuropathy – nerve damage About two-thirds of the people with diabetes do develop neuropathy. Some are more affected by this while others are able to continue doing what they have been doing and are able to exercise. Others are prevented from exercising because of the pain level. I urge everyone to read the nine blogs as they contain a lot of information.

In the next blogs, I will write about nephropathy. In my research, I apparently have not really done much reading about nephropathy, as I made some surprising discoveries. Hope that you will learn from the information as well.

March 3, 2015

New Non-ADA Diabetes Treatment Guidelines

When I first saw this, I had to wonder why other medical organizations would do this. “The Guiding Principles for the Care of People With or at Risk for Diabetes was produced by the National Diabetes Education Program (NDEP), a federally funded program sponsored by the U.S. Department of Health and Human Services’ National Institutes of Health and Centers for Disease Control and Prevention. NDEP’s partnership network includes over 200 partners working together to improve the treatment and outcomes for people with diabetes, promote early diagnosis, and prevent or delay the onset of type 2 diabetes.”

The information article appeared in Diabetes-in-Control and the guidelines are in a PDF file that can be downloaded here. It was a real surprise in the number of medical and other care providers organizations included. I was not disappointment to find the American Diabetes Association and the Academy of Certified Diabetes Educators missing from the list of partners. Admittedly, I was not disappointed in finding a few other medical organizations on the list.

Judith Fradkin, M.D., director of the Division of Diabetes, Endocrinology and Metabolic Diseases in the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health says, "With these Guiding Principles, we aren’t creating new guidelines, but clarifying where there is general agreement across myriad diabetes guidelines. Guiding Principles represents a set of sound practices. Our goal in developing this resource is to help clinicians help their patients with diabetes."

Two of the medical societies endorsing the principles include the American Diabetes Association, the American Association of Clinical Endocrinologists, but they are not partners in the guidelines. From my further reading, yes, this is a government move maybe to force the ADA and AACE into making some changes. Once the government becomes involved in guidelines, we all know that the patients suffer when the government becomes involved.

Medical societies endorsing the principles include the American Diabetes Association, the American Association of Clinical Endocrinologists, the Endocrine Society, the American Geriatrics Society, the American Association of Diabetes Educators, the American College of Obstetricians and Gynecologists, the American Association of Nurse Practitioners, and the American Heart Association. In addition, representatives of the American College of Physicians and the American Academy of Family 
Physicians participated on the writing committee. While these organizations have policies on endorsing guidelines that this document has not fulfilled, they nonetheless have said they plan to promote it.

The 10 principles are:
  1. Identify people with undiagnosed diabetes and prediabetes.
  2. Manage prediabetes to prevent or delay the onset of type 2 diabetes.
  3. Provide ongoing self-management education and support for people with or at risk for diabetes and its complications.
  4. Provide individualized nutrition therapy for people with or at risk for diabetes.
  5. Encourage regular physical activity for people with or at risk for diabetes.
  6. Control blood glucose to prevent or delay the onset of diabetes complications and avert symptoms of hyperglycemia and hypoglycemia.
  7. Provide blood-pressure and cholesterol screening and control, and smoking-cessation and other therapies to reduce cardiovascular disease risk
  8. Provide regular assessments to detect and monitor diabetes microvascular complications and treatments to slow their progression.
  9. Consider the needs of special populations -- children, women of childbearing age, older adults, and high-risk racial and ethnic groups.
  10. Provide patient-centered diabetes care.”

It will be interesting to see how this affects the actions of doctors that are not members of the ADA and other doctors that do not follow the ADA Guidelines.

March 2, 2015

Is the High Carbohydrates Era Finally Ending?

Yes, the high carbohydrate advice is slowing, but it is still not ending. With the Academy of Nutrition and Dietetics being a puppet of Big Food, it will take more than a few people advocating for the healthiness of low carbohydrates for people with type 2 diabetes to move the dial.

Dr. Osama Hamdy, Medical Director, Obesity Clinical Program, Director of Inpatient Diabetes Management at Joslin Diabetes Center, Assistant Professor of Medicine at Harvard Medical School does say that a low carbohydrate diet is beneficial for people with diabetes. We need more medical professionals saying this and pointing out that the Dietary Guidelines produced every five years for the USDA and HHS are based on weak scientific evidence.

The guidelines were started in 1977, when the Select Committee On Nutrition and Human Needs of the US Senate chaired by Senator George McGovern recommended that people increase their carbohydrate intake to 55 to 60 percent of the total caloric intake, while reducing fat consumption from approximately 40 percent to 30 percent of the total daily calories. The aims of these recommendations were to reduce health care costs and maximize the quality of life of Americans.

The proposed cost saving was predicted to result from the possible reduction in the incidence of heart disease, cancer, as well as other killer diseases. Despite controversy, the United States Department of Agriculture (USDA) created in 1980 a food pyramid representing the optimal number of servings to be eaten each day from each of the basic food groups. Carbohydrates were placed at the base of the pyramid (making up the largest portion of caloric intake, 6 to 11 servings per day), and fats were placed at the tip of the pyramid to show that they should be “used sparingly.”

As we all know now, these recommendations turned out to be the opposite of what the USDA expected. What has been aptly described as a “national nutritional experiment” contributed to the increased prevalence of obesity. And, contrary to the main aims of the recommendations, the prevalence of type 2 diabetes and cardiovascular disease went up significantly.

What happened should have been expected. An increase in carbohydrate intake results in an increased insulin response to carbohydrates, which through its fat-storage promoting action increases obesity. And, it has been shown, that accumulation of fat inside the belly (visceral fat) is associated with chronic inflammation that is directly related to type 2 diabetes and heart attacks.

The problem is especially severe for people who already have type 2 diabetes. We know today that increasing the carbohydrate load in the diabetes diet increases what is called glucose toxicity and consequently increases insulin resistance, triglycerides level and reduces beneficial HDL-cholesterol.

Now that we are past the history, Dr. Hamdy isn't really for low carbohydrate food plans. He only advocates a small reduction from 55 to 60% to 40 to 45% which is only a quarter reduction instead of much lower that was advocated by Drs. Elliot P. Joslin and Fredrick Allen, the fathers of diabetes science, successfully treated their patients diagnosed with fatty diabetes (later known as type 2 diabetes) with a diet very low in carbohydrates. Bold is my emphasis.

How Dr. Hamdy considers this much of a reduction leaves me wondering why he even makes that statement. I also have to wonder where he found the information that most medical societies have departed from the recommendation of high carbohydrates intake. A few, yes, and they still believe in low fat which is also harmful and makes for slow weight loss.

Dr. Hamdy is more right when he writes - “Unfortunately, many healthcare providers and dietitians across the nation still recommend high carbohydrate intake for patients with diabetes, a recommendation that may harm their patients and contribute to increasing obesity and worsen diabetes control and consequently increase the chance of developing diabetes complications.” He may as well be writing about his position of high carbohydrates

March 1, 2015

Understanding the “Experts”

I will say this now – I never want to be classified as an “expert.” I see “experts” making irrational statements, promoting statements either based on lack of evidence, or constantly denying studies that refute their beliefs or would jeopardize their status and from whom they receive monetary incentives (conflicts of interest). I would much prefer being an ordinary citizen that can see the lies and conflicts of interest and be able to write about these harms that the “experts” advocate.

An example of this happening is this British study. The study has found a correlation between the amount of fluoride in public drinking water and a rise in incidence of hypothyroidism. The findings were published in the Journal of Epidemiology & Community Health. The researchers found that in locales where tap water fluoride levels exceeded 0.3 mg/L, the risk for having an under active thyroid rose by 30%. The research team also found that hypothyroidism rates were nearly double in urbanized regions that had fluoridated tap water, compared with regions that did not. The key here is a correlation and this does not mean a cause.

However, a representative of the American Dental Association (ADA) took issue with the British report. "Public health policy is built on a strong base of scientific evidence, not a single study," Edmond Hewlett, DDS, ADA representative and a professor at the UCLA School of Dentistry, told HealthDay. "Currently, the best available scientific evidence indicates that optimally fluoridated water does not have an adverse effect on the thyroid gland or its function."

Yes, I agree that the ADA has strong evidence because Big Chemical paid for most dental studies about fluoride and when I have asked dentists about the health side effects of using fluoride in the past, I was always told that there are many studies showing the healthful benefits of using fluoride and having fluoride in the city water supply. When I have asked for copies of these studies, I was just told that the studies were not for the public, but they did exist. In the recent past, several cities have debated eliminating fluoride from the water supply. This brought out the dental profession in full force to argue against this happening.

Conflict of interest keeps rearing its ugly head without me having to look for it lately. I guess having been a bean counter and technical writer makes me more aware of information that appears on the surface as being correct, but on further investigation, the conflict of interest is exposed. This is often not the most comforting and too often, I choose not to write about a topic as a result.

The above statement by Edmond Hewlett, DDS, ADA representative when he said, "Public health policy is built on a strong base of scientific evidence, not a single study," really bothers me and points out how poor scientific evidence can be. If the USDA and its Dietary Guidelines Advisory Committee (DGAC) used strong scientific evidence for the food guidelines, maybe we would not have the obesity epidemic we have today. This is the reason for the Healthy Nation Coalition which is calling on the DGAC to pay attention to scientific evidence which at present still is very conflicting because Big Food still calls the tune.

What this means is that research needs to be done without the influence of Big Food and their minions. Pure independent research is the answer.

February 28, 2015

Is Precision Medicine for the Masses?

Since the President's “State of the Union” address, the medical community, including the drug industry has been licking their chops in anticipation of the money to be gleaned in the process. Even patients are wondering how quickly this will be available.

I admit it sounds exciting until more information comes to light and there are many variables that may not have been considered. With each individual being so different, how will doctors be able to know which medication is applicable. Precision medicine is still a buzzword at present and it will be at least a decade, if not longer, before there will be a practical application. Medications will need to be developed to cover the different types of individuals and since there will be less needed; the costs will be significantly higher.

Doctors writing about precision medicine at this time, like Dr. Pelzman, are creating pie-in-the-sky scenarios that may never happen. For this to be successful, new specialists will be needed that understand the relationships involved in the individual genomes. Add to this, ethnical variances and other factors, and who will be able to determine what will be best for the individual patient. Doctors presently have problems with people with different ethnicities.

This will tend to exclude the elderly as few clinical trials are done to determine the effectiveness of medicines for the elderly.

Precision medicine cannot be precise if the implications/malfunctions of specific DNAs/RNAs/Proteins identified in an individual patient are unknown. With more than 20.000 genes, many of them with allelomorphs (alleles) in every human being, the number or permutations are astronomical and do not with our current limited molecular biology/physiology/pathology understanding allow doctors to select the information most relevant to a particular patient. An overload with chaotic information will make the doctor just as ill as the patient he/she is trying to help.

Then when the doctor prescribes one medication and sees no improvement, will they continue as they do today, of prescribing another medication in addition to (stacking) the current medication in hopes that the combination will solve the problem. With the cost of the two medications, or even more, the patient will not be able to afford the treatment.

There may be a place for precision medicine, but too little is known at this time about the under pinnings of how some medicines react positively for some individuals and negatively for others. Add to this allergies and the world of medicine may not be as precise as some are hoping.

February 27, 2015

Hypoglycemia and You

With hypoglycemia, remember testing is the most reliable and not your feelings. However, if you do not trust one meter reading, it is often wise to rewash your hands, paying attention to the finger you will be using for the test and then retest. Keep in mind that insufficient blood on the test strip can give a false reading on your blood glucose meter. The correct technique of testing is especially during hypoglycemia is important.

If you find that you develop hypoglycemia during or after exercise, contact your doctor to decide if a lower medication dose may be necessary. Remember, low blood glucose is any reading below 70 mg/dl (3.9 mmol/L). Treat it and do not suffer the complications of not treating low blood glucose.

Remember, very low blood glucose levels may require more than 15 grams of carbohydrates to correct back to safe levels of blood glucose. To do this, consider your blood glucose reading, the amount of medication in your system, the amount and timing of your last meal, and the effects of any recent exercise. All of these can affect the amount of carbohydrates needed to correct low blood glucose readings.

Appropriate carbohydrate choices to treat hypoglycemia include:
3 or more glucose tablets
½ cup orange, apple, or pineapple juice
1/3 cup prune, grape, or cranberry juice
½ cup of regular soda (not diet)
1 small apple, orange, pear, peach, or banana
2 tablespoons of raisins
1 cup of nonfat milk
1 tablespoon of sugar, honey, or syrup (can mix in water if desired)

Don't consider donuts, ice cream, candy bars, pie, cookies. These all contain fat in quantities that will slow digestion and availability of the carbohydrates. With hypoglycemia, fast digestion and absorption into the blood stream is required. If you take any medication that can cause hypoglycemia, you should always carry an appropriate source of carbohydrates with you in case you need it.

Keep glucose tablets in the car's glove box, your purse, your desk at work, or your pocket. It is also wise to wear form of identification that states that you have type 2 diabetes. This is where medical alert jewelry comes in handy.

It is important to follow up or talk with your doctor regularly. You may be needing a different medication or your dose of your current medication may need to be adjusted. Medication doses often need to be reduced when you start an exercise program, improve your food choices, or lose some weight. Continue to do your blood glucose testing and write down the results. The doctor may only use your A1c results, but you may need to show your testing results to prove you need a change in dose.

Be prepared to show the doctor blood glucose readings below 70 mg/dl if they happen. If they don't happen, you are fortunate and probably not on a medication that will cause hypoglycemia. The best idea is to research or look up your medication and I suggest on WebMD, or on this website, or this discussion of oral diabetes medications that may cause hypoglycemia.

Part 4 of 4

February 26, 2015

More Information on Hypoglycemia

If you haven't figured it out yet, your body does not like low blood glucose and does its best to correct the condition. The body does store some glucose in the muscles and the liver in the form of glycogen. When the body needs glucose, the liver breaks down glycogen stores and releases glucose into the blood. When the liver or you body is short of glycogen, gluconeogenesis can occur. Gluconeogenesis is the term for making new sugar in the body.

The liver and even the kidneys, to some extent, can take the building blocks from proteins (amino acids) and convert them into glucose. This is why drinking alcohol is discouraged for people with diabetes. The liver is prevented from making new glucose when it is processing alcohol. This is the reason alcohol can cause hypoglycemia. Insulin is the hormone that lowers blood glucose. Just about all of the other hormones (adrenaline, glucagon, cortisol, and growth hormone) can raise blood glucose levels.

When prescribed correctly and taken correctly, both insulin and oral diabetes pills can work well at controlling blood glucose levels without causing hypoglycemia. It is when you take too much medication or eat less food that you can cause hypoglycemia. If the body's defenses are down or not a match for the amount of medication taken, then hypoglycemia will result.

The following are the symptoms of mild hypoglycemia and include, hunger, trembling, rapid heartbeat, increased pulse, sweating, heavy breathing, tingling, nausea, weakness, and nightmares., If you think these are bad, here are the symptoms of moderate to severe hypoglycemia. They include, headache, slow thinking, lack of coordination, trouble concentrating, blurred vision, anger, dizziness, slurred speech, seizure, coma, and potential death.

With the above symptoms, don't count on being able to predict your blood glucose levels by the way your feel. The only sure way of knowing is by testing. Newly diagnosed patients often have some of the symptoms when they are still above 100 mg/dl. This is because their body has adapted to a higher blood glucose level and when the medication acts, some medications do bring the blood glucose level down rapidly. This can cause false hypoglycemia. This is the reason for testing to prevent over reacting and eating carbs because you body is giving you a false alarm. As your body adapts to the lower blood glucose levels, the false alarms will stop.

The official level for hypoglycemia is 70 mg/dl. Readings above this and below 100 mg/dl are considered normal. This is a reason to keep blood glucose tablets and if your blood glucose test is less than 70 mg/dl then you need to follow the rule of 15.

The rule of 15:
Treat low blood glucose with 15 grams of carbohydrates/
Wait 15 minutes, then test again.
If your blood glucose had not risen 15 to 20 points, repeat the procedure.
Remember that if your blood glucose is below 50 mg/dl, then it is better to take 30 grams of carbohydrates and then test in 15 minutes. Low blood glucose can happen if you eat too few carbohydrates, and especially if you skip a meal. Learn that once you start feeling of any of the symptoms, your body can continue the symptoms for 15 to 25 minutes after eating glucose tablets. This is because of the hormones released by your body to combat hypoglycemia and it takes time for these hormones to settle down.

If you continue to eat until your felt better, you will likely eat too much. This would then result in raising your blood glucose level to a higher level than needed. Then you would need to possibly take more medication and the roller coaster ride begins.

Part 3 of 4