Toussaint

Happy Halloween!
A poster with a grinning pumpkin welcomed us to the supermarket for the weekly shop. Unlike in the UK, it's rather incongruous,the US traditions for Halloween haven't yet become commonplace here. Inside the supermarket there is one stand with an assortment of witches hats, skeletons and plastic spiders,but one feels that they aren't big sellers. There are pumpkins on sale but most will get used for soup. The parents of children with diabetes here are lucky.They don't yet have to cope with the problems of what to do about the tacky sweets associated with trick or treating

But this time of year is very important here. November 1st is Toussaint, All Saints day.In English , All Hallows,(the origin of Halloween). The following day is All souls. Half a century ago it was celebrated as a solemn festival in Anglican churches, the service finishing with a rousing chorus of 'For All the Saints'. Today its less evident , times have changed. My grandchildren will attend a church party set up to counter the attractions of more secular Halloween activities with their emphasis on witches, ghosts and evil.

It is the church festivals which dominate here.
Outside the supermarket, in a large area of the market and outside every florist are pots and pots of Chrysanthemums. The beautiful displays look lovely in the autumn sunshine.
(If you visit at this time, please don't buy a pot for a French friend). These flowers have one destination;the cemetery. The chrysanthemum is a symbol of immortality. It flowers in the last quarter of the year and resists frosts. Toussaint also marks the turn of the year towards winter,
'A la Toussaint le froid revient,
et met l'hiver en train'
The chrysanthemum's bright petals will be sign of hope in the autumnal fogs to come.

In the week leading up to Toussaint families visit the family graves, and sepulchres, weeding the surrounds, cleaning the stonework, making everything spick and span . The new pots of flowers are placed around the tomb.Those who are too far away from home do not forget, often organising a florist to do the job for them. The cemeteries gradually become a blaze of colour.

As November 1st is a bank holiday, family gatherings take place with those that can, returning to their home towns and villages for the day.
Traditionally, on the day itself masses take place in the churches followed by prayers for the dead in the cemeteries, though in villages like ours, the priest has to spread his services thinly so some services now take place later in the week.

This is a lovely festival, bringing together the generations. It's not sad, not so much a day of mourning. There is no sense of evil or fear connected with the cemeteries. It's a time of remembrance, a time to honour one's dead ancestors and celebrate the family.
Will it survive the pressure of consumerism with it's plastic spiders,dangling skeletons, swag bags and tacky sweets?
I hope so.

Osteoporosis ,No Joking matter

Sadly on some diabetes forums , some posters, mainly men, think that as they have no signs of osteoporosis now, they’re not at risk. The very idea has become a joke Some of them may not be at high risk but unfortunately their comments may well be read by those most definitely at risk.

Osteroporosis means porous bones. Your bones lose internal strength through demineralisation. Inside they become like a honeycomb with gradually less and less strength. Even slight falls or bangs can result in a fracture, Spinal bones become squashed or compressed because of their reduced strength.resulting in curvature of the spine and loss of height.

I don’t find it funny when I see my mother . She suffers from a combination of osteoporosis and osteoarthritis. She’s tiny, fragile, she no longer looks like my mother. She has lost about 10 inches in height through the disintegration of her spine. In daily life it is the arthritis that causes the pain but it is the osteoporosis that has sapped her confidence and destroys her quality of life. She lives in fear, she’s scared to move, afraid of a hip fracture. She’s right to be, her mother died following a hip fracture as do the incredible number of 1150 people a month in the UK.

Many people are at risk even without considering their diabetes. Conditions such as celiac disease , hyperthyroid or a mismatched dose of thyroxine for hypothoid, a genetic history, an early menopause are just some of the risk factors. All women have a 50% chance of some degree of it in old age; the risk for men is less at about 10%. Most won’t know they’ve got it until they start to lose height, or suffer their first break. Saying,’ well I’ve been on this diet for 6 months and don’t see any sighs of osteoporosis is meaningless.’

What’s this got to do with diabetes?
Diabetes however may be an additional risk factor In the case of diabetic women a study found women with Type 1 were 12 times more likely to have had a fracture compared to women without diabetes. Studies have found long term bone loss in type 1 so it does seem that people with Type 1 are at risk of osteoporosis

The studies are less clear for type 2 If you are male and have been overweight, you may have some protection as the extra weight may have strengthened your bones in the same way as weight bearing exercise . Men as a whole are less likely to develop it as they tend to have bigger frames

However, the Iowa study found that women with type 2 on oral medications, or insulin had an increased risk of fractures. A meta analysis in the BMJ covering both diabetic men and women , type 1 and 2 also showed an increased risk of fracture for both genders, but why is unclear. It could be because of diabetic retinopathy, peripheral neuropathy, and cerebral stroke or hypoglycemia, increasing the risk of falling.
http://care.diabetesjournals.org/content/24/7/1192.full
http://aje.oxfordjournals.org/cgi/content/full/166/5/495#BIB42

If you are at risk you can do something about it?

1) The best thing is to work on prevention whilst young by building up strong healthy bones. It is in childhood that most bone development takes place but peak bone density may not be reached until 30. So what you do in your teens and early twenties is important. If you build stronger bones in the first place they are less likely to become osteoporotic.
2) Even if you’re older you can do something. Bone loss is gradual, the same factors that build healthy bones also protect against loss.

Factors that may help increase bone strength

Exercise:
weight bearing exercise like walking, running , dancing, even walking from the shops carrying the shopping . This seems to be really important. Good for bones, for heart and for blood glucose contro.For bones exercise such as cycling and swimming are less good as they are non weightbearing.

Calcium
Women between the ages of twenty to forty typically require a recommended daily allowance (RDA) of 1000 mg/day in the UK, as age increases so does the recommended dose of calcium required. For women over 40 years of age, who are not taking hormone replacement therapy the recommended calcium dose is 1200 mg/day in the UK . For Women 40 and above who take hormone replacement therapy the recommended daily allowance of calcium is slightly lower at 1000 mg/day. The recommended calcium daily allowance for women over sixty is 1200 mg/day. 20% of women don’t have nearly enough in their diet.
Good sources of calcium are dairy products such as milk, cheese and yoghurt. Calcium is also found in canned fish with bones, such as sardines. Other sources of calcium include green leafy vegetables (such as broccoli and cabbage, but not spinach), soya beans and tofu
So eat your dairy and your greens!

Vitamin D get outside in the sun during the summer months (but sensibly. The Cancer research organisation says that the amount needed to synthesize vit D is less than the amount needed to cause sunburn. A British study by the Health research forum recommends that people in the UK should put on sun-cream only after they have been in the sun for five to ten minutes, in order to allow vitamin D to be made in the skin)
Good food sources are oily fish and eggs.
Protein :
People need sufficient protein to establish strong bones and studies have shown that low protein diets in older people are associated with fractures.

Factors that may cause increased bone demineralisation (bone loss)
(the controversial bit)

Smoking (thats not controversial)

High protein diets
Some high protein diets have been shown to cause people to excrete more calcium than normal through their urine. Over a prolonged period of time, this may increase a person's risk of osteoporosis. However, it might depend upon the actual diet. (how much protein, what type and what other things are eaten)
There was a recent study where subjects ate a reduced- calorie, high protein diet which included 3 dairy servings. The results showed increased urinary calcium excretion but at same time provided improved calcium intake and attenuated bone loss. This continued both during the 4 month weight loss phase and the following 8 months of 'weight maintenance' The principle researcher said 'The combination and/or interaction of dietary protein, calcium from dairy, and the additional vitamin D that fortifies dairy products appears to protect bone health during weight loss. NB Fresh milk is not fortified with vit d in the UK
(Thorpe)
People at risk who adopt this diet need to investigate very carefully there is a plethora of contrary information. Some high protein diets have very little calcium intake. (but I think it's the same message as above..... Eat your dairy and greens!

Ketogenic diets
These are also very controversial and may be high protein as above or normal protein and high fat.
Children on ketogenic diets for epilepsy (high fat, adequate protein and low carb) even though carefully supervised have had problems with bone demineralisation. A six year study at John Hopkins university showed of 28 patients, 6 experienced fractures( Groesbeck) .Morbidly Obese children on a similar diet wee also found to have experienced bone loss.( Willi)

Personally I'm not a dietitian or a doctor but I'd be very wary of putting a child with diabetes on this type of diet without expert advice . I'd also be very careful if I were a young person in my teens or twenties and still to reach peak bone mass.

In older adults there very little evidence available , certainly no long term evidence. and whats available is equivocal. A 3 month study of the effect on bone turnover and a low carb diet found no difference (Carter). However a 6 month one led by Westman found there wa an increase in urinary excretion of calcium and uric acid, possibly resulting from ketosis, proteinuria, or weight loss. (Yancy et al)
A paper by SA Bilsborough and TC Crowe discusses the possible problems (p401). It’s worth reading if you’re considering this type of diet.
Low-carbohydrate diets: what are the potential short and long-term health implications?
Shane A Bilsborough and Timothy C Crowe

(available in full but PDF doesn't seem to link why??)
References:
Matthew P. Thorpe et al, A Diet High in Protein, Dairy, and Calcium Attenuates Bone Loss over Twelve Months of Weight Loss and Maintenance Relative to a Conventional High-Carbohydrate Diet in Adults1–3, Nutr. 138:1096-1100, June 2008
DK Groesbeck, RM Bluml, EH Kossoff Long-term use of the ketogenic diet in the treatment of epilepsy. Developmental Medicine and Child Neurology, 2006 - Cambridge Univ Press
Steven M. Willi*, et al The Effects of a High-protein, Low-fat, Ketogenic Diet on Adolescents With Morbid Obesity: Body Composition, Blood Chemistries, and Sleep abnrmalities Pediatrics: 1998, pp. 61-67
Eric C. Westman et al: Effect of 6-Month Adherence to a Very Low
Carbohydrate Diet Program The American journal of medicine, 2002
J. D. Carter The effect of a low-carbohydrate diet on bone turnover
Osteoporosis International. Sept 2006

I was very lucky!

If you have frequent urination,
If you drink a lot, have a dry mouth
If you have recurrent thrush
If you are losing weight

EVEN IF YOU ARE THIN,TAKE EXERCISE,AND THINK YOU EAT A HEALTHY DIET
GO TO YOUR DOCTOR. DON'T PUT IT OFF .

if you have previously been diagnosed with type 2 (particularly if you were not overweight at diagnosis) and find it difficult to control your diabetes with oral medications and diet, ie you have very high glucose readings, and are rapidly losing weight without really trying.
Insist that you see a specialist and are checked properly.

I know of several people who like me ignored diabetes symptoms, finding reasons to explain them away because they didn't fit the right categories.. Recently I came across Lees story as
told here in Mens Health 'Undiagnosed diabetes nearly killed me' 'http://www.malehealth.co.uk/userpage1.cfm?item_id=2891 I read it and realised how similar his story was to mine. Sadly his diagnosis came perhaps at a slightly later stage.
He hadn't heard of LADA, nor had I.
Why should we ? Unless you actually search for ityou're unlikely to find it on the general information sites . I did check my symptoms of various websites and realised they were those of diabetes but even then I was confused. I read statements like this
The ADA says:
'Type 1 diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes.'
I was in my 50s
The site also has a risk test for type 2, I did it
I was low risk.

Diabetes UK says:
'Type 1 diabetes develops if the body is unable to produce any insulin. This type of diabetes usually appears before the age of 40. '
I was well over 40.
Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). In most cases this is linked with being overweight. This type of diabetes usually appears in people over the age of 40.
I was over 40 but was not overweight, I was thin and getting thinner.
Other sites stress the rapid onset:
About .com
'The symptoms of type 1 diabetes usually develop quickly and over a brief period of time. '
The longer I left it, the easier it was to rationalise, it did not cause a rapid crisis

I've explained my rationalisations in an earlier post , but basically they were that I was too old, too thin , too physically active. I hadn't ended in hospital, I couldn't have type 1. If I had by any chance got type 2, the treatment was to lose weight(I'd done that) and eat a healthy diet and exercise (I did that ) so why bother the doctor. Besides the symptoms came and went.... this latter seems to happen frequently from anectotal reports but I have only seen it once mentioned in the scientific literature.

None of the statements from the Diabetes organisations and information sites are completely true. By trying to give simple information, they omit the common exceptions.

• ‘The incidence rate of insulin-dependent (Type I) diabetes mellitus is bimodal: one peak occurs close to puberty, and the other in the fifth decade.’ (Karjalainen et al New England Journal of Medicine 1983.. pre definition of LADA !)
• There is a percentage of people (can't find the figure at the moment) diagnosed with type 2 who are not overweight. (A proportion of these may have LADA)
• The classic rapid onset is often seen in childhood type 1, but even then not always. In older people the onset is very ofen (but again not always) a slower onset . LADA is defined by slow onset.

Perhaps LADA affects such a small number it would only confuse

Well if this were the case, one could understand not mentioning the possibility, but according to Swansea university 10-13% of those people diagnosed with type 2 in the UK have the antibodies connected with LADA. Action LADA says 'This form of latent autoimmune diabetes of adults (LADA) is found in about 10% of initially non-insulin requiring diabetes patients and is therefore probably far more prevalent than classic type 1 diabetes. Joslin puts the figure at between 5% and 30% depending on the population. Its not rare.

OK but if you had gone to the doctor then you would have found out sooner

Possibly, and some people are very lucky and find a doctor who investigates. As my French doctor immediately diagnosed LADA this might well have been true....but I was in DKA by the time he saw me and he was a specialist.
Sweet Magazine this month tells of a young woman diagnosed at 28 . She was a yoga teacher and was losing weight, felt hungry and dizzy. She visited her GP several times but he thought that she was too old to develop type 1. Eventually she looked so ill her mother(a nurse) went with her to the GP and her glucose level was tested. She had a level of 30mmol but amazingly the GP didn't believe the result and sent her away again. Her sensible mother took her to A&E where she was immediately put on an insulin drip.(Sweet, Oct/Nov 2009)
Hopefully cases like this are rare, but this young woman wasn't even 30 yet deemed by her doctor to be too old for type 1. Unfortunately,I've read of many people who have had problems in getting a diagnosis. There are several similar stories told on the various diabete's forums to the one above. Quite frequently people are at first diagnosed with type 2 and then find that oral medications don't work for long. Sometimes they are considered to be uncompliant. On more than one occasion I have read that a person has ended up in hospital with DKA before they were diagnosed correctly.

GPs are not specialists, information on LADA is available but you need an interest and time to investigate. I feel strongly that the diabetes organisations should do more to make both the public and GPs aware of the possibility of LADA (and other possibilities such as MODY).

Why Wholegrains?

On a forum a poster wrote the following question.

Can someone please tell me the secret ingredient that's found in in wheat that I can't get from far healthier sources elsewhere? It must be a secret, no one has been able to answer that question up till now. Are we really advocating that refined carbs are better than fibrous, organic vegetables?


Of course it was a loaded question, I don't think anyone advocates refined carbs not yet wheat as the sole grain. What is frequently suggested is to eat whole grains. My answer was quite long, probably too long and took a long time to write (twice because Windows decided to switch off to install upgrades in the middle of it) so as I had intended to blog today I'm using my answer with a bit added as a blog .

I don't think I've ever read it suggested to substitute refined grains for vegetables. What is suggested is that there are health benefits from minimally processed whole grains*(see Slavin below for definition, history of processing , summary of possible benefits and mechanisms) This is far too difficult to summarise so you'll have to read the paper.

Wheat is of course only one type of grain, there are many others. Some I've never heard of , let alone used. I've included the latin names to help me, because the French names are bound to be different!
Amaranth* (Amaranthus spp.),Barley (Hordum vulgare) ,Buckwheat *(Fagopyrum esculentum) Bulgur (Triticum ssp.)(derived from wheat), Corn* (Zea mays mays), Farro / Emmer (Triticum turgidum dicoccum); Grano (Triticum turgidum durum) (Durum wheat 'berries') ;Kamut® Grain (triticum turgidum turanicum) an 'ancient' variety of wheat ;Montina* (Indian rice grass) ;Millet* (Panicum miliaceum) ;Oats (Avena sativa) ;Quinoa* (Chenopodium quinoa)not botanically a true grain but normally counted as one. ;Rice* (Oryza sativa) ;Rye (Secale cereale) ;Sorghum / Milo *(Sorghum spp.) ;Spelt (Triticum aestivum spelta) ;Teff* (Eragrostis tef)(principle source of nutrition for 2/3 of Ethipians!) ;Triticale (x triticosecale rimpaui) modern hybrid of durum wheat and rye ;Wheat (Triticum aestivum; Triticum turgidum) ;Wild Rice *(Zizania spp.)
With all those to choose from, wheat is definitely not the only source of wholegrain. Anyone with coeliac or a gluten intolerance might like to know that according to the wholegrain council those marked with an asterick are gluten free.

It is possible that the suggested health benefits are entirely due to their fibre content. If so then it is of course possible to eat enough vegetables to do this.
I decided to work out just how much:First problem, how much fibre is recommended? The UK suggestion is 18g; however the BNF feels that this is too low suggesting 30g. The WHO recommends an RDA of between 20g and 40g. I have rather arbitrarily used 25g; this is higher than the UK suggestion but the median rec. for women from WHO, though still lower than that suggested for men .
Using a British online source (and different sources will produce different figures) I chose a selection of common vegetables, mostly green but added red peppers and aubergine to widen the variety. After selecting 800gm worth I had reached the British target amount but widened my source to include nuts as these are another nongrain source of fibre. Fifty grams of nuts and still there was still less than 25g of fibre, so I turned to fruit choosing avocado , low in carb but high in fibre. I also counted the carbs; this selection has a carb content of 33 so just over Bernstein’s limit.
Spinach 100 g fibre 2.4g carb 3.75
Broccoli 100g fibre 2.6 g carb 2.1
Cauliflower 100g fibre 1.6 carb 2.7g
Aubergine 100g fibre 2.3 carb 2.8g
Red pepper 100g fibre1.6 carb 6.4g
Savoy cabbage 100g fibre 2.8 carb 3.5g
Courgette 100g fibre 1.2 carb 2.2g
Mixed salad 100g fibre 3g carb 3.4g
Almonds 50g fibre 4.2 carb 4.25g
Avocado 100g fibre 3.4 carb 1.9g

But how many people eat this amount ? The five fruit and veg a day, advice assumes a total of 400grams a day but is set alongside advice to eat starchy carbs, preferably whole grains. You have to eat an awful lot of 'fibrous organic vegetables'.
Even with a mixed diet including grains, legumes , fruit and vegetables many of us probably fall short but it is certainly much easier.
I realised I was a bit low and have tried to include more high fibre legumes recently.

It maybe that not all fibre is beneficial for all purposes. Possibly different types of fibre are useful in specific areas. Beta glucans seem to be beneficial in cardiovascular health, major sources are barley and oatmeal. Residual starch may be beneficial for lipid control and glucose stability, and probably is important for colonic health, this is chiefly found in whole or partly-milled grains and seeds, pulses, and cooked and cooled (retrograded) potatoes. (and some processed breakfast cereals)This becomes difficult to test and to separate out and often results in fairly artificial types of experiments but there have been many. of varying quality. (and the literature search would take a long time!) some of these are summarised by Oldways and the Wholegrain council in the link below.
One recent study did attempt to separate the effects of fibre from wholegrain to that of fibre from other sources in the incidence of colonic cancer. (Schatzkin et al)In this prospective cohort study, total dietary fiber intake was not associated with colorectal cancer risk, whereas whole grain consumption was associated with a modest reduced risk.According to the researchers ”These findings suggest that whole-grain components other than fiber — e.g. vitamins, minerals, phenols, and phytoestrogens affect colorectal carcinogenesis.”

As suggested above .There may be health benefits in whole grains caused by something other than the fibre. It maybe a combination of phytonutrients or vitamins, or minerals etc acting synergistically , ie the whole package (and of course different whole grains will vary, it’s not just wheat!) The Slavin paper discusses this.

Slavin J Nutrition Research Reviews,Vol17:99-110, May 2007Whole Grains and HealthReprinted @http://www.wholegrainscouncil.org/files/SlavinArticle0504.pdfSchatzkin et al., Am J Clin Nutr., 85: 1353-1360, 2007Dietary fiber and whole grain consumption in relation to colorectal cancer in the NIH-AARP Diet and Health Study[urlhttp://www.wholegrainscouncil.org/files/WGResearchSummary_WGCJan09.pdf]Recent research into wholegrains and health from Oldways and the Wholegrain Council (up to you to decide on validity,and check out its origins and funding)http://www.ajcn.org/cgi/content/abstract/85/5/1353[/url]

Windsor Half Marathon

Exercise alone might not make you lose weight but it certainly helps.
I was a proud Mum when I got to the finish sometime after my daughter and OH. She completed the Windsor half marathon in 2hr 26min. Since February she has lost 60lbs in weight by eating a healthy diet (Weightwatchers) coupled with regular training for this event. Like many women she had put on weight during her first pregnancy and didn’t lose it before the second. After three pregnancies she had become very overweight. She started training with 2 min walk, 30 seconds run. Gradually, as the weight came off and she got fitter the running times increased. On event day she ran the whole 13 miles with no walking breaks,. She crossed the finish line side by side with her father.
As for me, well I finished but was very,very slow(though there were still quite a few finishing after me). I hadn’t really trained properly and I was hampered by poor glucose control. The event started at the difficult time for me of 1pm ie lunchtime. I had breakfast at about 9.30am and had planned to eat a cereal bar before the start. With 20 minutes to go, I tested my levels...3.9mmol, far too low but on top of this no cereal bar: OH had checked my bag into the baggage store and I'd forgotten to take it out. I set a low temp basal and took some dextrose but it wasn’t a good way to start. Psychological or not I felt low and very heavy legged. For the first five miles I did a lot of walking. When I spotted my family at the side of the course I stopped and almost gave up then and there butafter dithering for a few minutes decided to carry on for a bit. Round the corner, out of sight, I checked my glucose level, too low and I would have given up. It was 5.6mmol, so why did I feel so b......y awful? New tactics were called for.. I used my emergency hypo gel (15g carbs) and then upped my basal rate back to almost normal.(85%) I had some strange idea in my head that I might not have enough circulating insulin but in retrospect I don’t think that was logical.

Strangely, it worked and the last part of the run, seemed much easier and I felt much happier. I was still slow but I stopped going backwards and caught and overtook several people before the finish.
I’m now determined not to let my training slide again, and I’d hoped that I would be able to work towards the London marathon in April. Sadly that’s not to be as I’ve just received my 5th rejection in a row. That means I’ll get a place for the 2011 event (you get an automatic entry after 5 ballot rejections) so I’ve got 18months to train for it.