Archive for the 'What’s New in Diabetes' Category

Diabetes Care in the Philippines

April 22, 2016

Screen Shot 2016-04-22 at 1.14.02 PMMy article on Diabetes Care in the Philippines is now published in the Annals of Global Health Volume 81, issue 6 November-December 2015. This is a thorough review of the kind of Diabetes Care the Philippines available to our countrymen.

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Diabetes Care in the Philippines

Gerry H. Tan, MD

Abstract
Background

Diabetes is increasing at an alarming rate in Asian countries including the Philippines. Both the prevalence and incidence of type 2 diabetes (T2D) continue to increase with a commensurate upward trend in the prevalence of prediabetes.

Objectives

The aim of this study was to review the prevalence of diabetes in the Philippines and to describe extensively the characteristics of diabetes care in the Philippines from availability of diagnostics tests to the procurement of medications.

Methods

A literature search was performed using the search words diabetes care and Philippines. Articles that were retrieved were reviewed for relevance and then synthesized to highlight key features.

Findings

The prevalence of diabetes in the Philippines is increasing. Rapid urbanization with increasing dependence on electronic gadgets and sedentary lifestyle contribute significantly to this epidemic. Diabetes care in the Philippines is disadvantaged and challenged with respect to resources, government support, and economics. The national insurance system does not cover comprehensive diabetes care in a preventive model and private insurance companies only offer limited diabetes coverage. Thus, most patients rely on “out-of-pocket” expenses, namely, laboratory procedures and daily medications. Consequently, poor pharmacotherapy adherence impairs prevention of complications. Moreover, behavioral modifications are difficult due to cultural preferences for a traditional diet of refined sugar, including white rice and bread.

Conclusions

Translating clinical data into practice in the Philippines will require fundamental and transformative changes that increase diabetes awareness, emphasize lifestyle change while respecting cultural preferences, and promote public policy especially regarding the health insurance system to improve overall diabetes care and outcomes.

Key Words
diabetes; diabetes care; Philippines; Southeast Asia; type 2 diabetes

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Rosiglitazone (Avandia) Does not cause Heart Attack

November 26, 2013

Rosiglitazone (Avandia) Does not cause Heart Attack

Been a user of this drug prior to its removal.  I strongly believe in its usefulness as a drug.  Now I can safely tell my patients that I was indeed right all along.  Sometimes its how the news is perceived by the public that forces others to listen and then strongly believes.  It is best to instead let the Facts do the talking.

 

Sleep and Diabetes: Quality Matters NOT Quantity!!!!

May 30, 2011

Go to fullsize imageLack of sleep causes stress. Stress increases stress hormones that can increase glucose. Understandably,lack of sleep equals risk for diabetes.  I used to believe from previous studies that a duration of sleep less than 7 hours increases ones risk to develop diabetes. 

 Now comes a new study published in Diabetes Care March 2011, that tell us Quality is important than Quantity…

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OBJECTIVE To examine whether sleep duration and quality are associated with fasting glucose, fasting insulin, or estimated insulin resistance in a community-based sample of early middle-aged adults.

RESEARCH DESIGN AND METHODS This was an ancillary study to the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Habitual sleep duration and fragmentation were estimated from 6 days of wrist actigraphy collected in 2003–2005. Insomnia was defined as self-reported difficulty falling asleep or waking up in the night three or more times per week plus average sleep efficiency of <80% based on actigraphy. Fasting blood samples to measure glucose and insulin were collected after the sleep measures during the CARDIA clinical examination in 2005–2006. Insulin resistance was estimated using the homeostatic model assessment (HOMA) method. Analyses were cross-sectional and stratified by the presence of diabetes.

RESULTS There was no association between sleep measures and fasting glucose, insulin, or HOMA in the 115 subjects without diabetes. Among the 40 subjects with diabetes, after adjustment for covariates, 10% higher sleep fragmentation was associated with a 9% higher fasting glucose level, a 30% higher fasting insulin level, and a 43% higher HOMA level. Insomnia was associated with a 23% higher fasting glucose level, a 48% higher fasting insulin level, and an 82% higher HOMA level.

CONCLUSIONS The observed association between poor sleep quality and higher glucose, insulin, and estimated insulin resistance among subjects with diabetes warrants further examination of the effect of sleep disturbances on glucose control in type 2 diabetes.

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In the study, sleep duration was assessed as the amount of sleep obtained per night while sleep fragmentation was based on the periods of restlessness and movements that the pateints had during the night.

What is interesting in the study was that there was no association between sleep duration and glucose metabolism in groups with or without diabetes.  This is in contrast to earlier studies which showed otherwise. 

However sleep fragmentation was signicantly associated with increasing blood sugar so that for every 10% higher sleep fragmentation,  there was an associated 9% higher fasting glucose and higher insulin level suggesting insulin resistance.  What is important is that sleep fragmentation WAS not associated with higher glucose if one is NOT a diabetic.  Meaning, sleep disturbance is a risk factor  for poor blood sugar control among diabetics!

In conclusion, the authors assessed that POOR sleep and NOT Short Duration is associated with poor glucose control!!!  That intervention to warrant investigations of causes for poor sleep can help make diabetics have better control.

So do you snore? and probably stop breathing often?

Ask your partner… and better have your sleeping pattern assessed as this may lead to better control of your blood sugar if corrected!

The Dangers of Sugary Drinks

November 16, 2010

Consumption of sugary drinks not only make you gain weight BUT now has been proven to strongly increase your risk to develop Diabetes and other obesity related diseases. 

A new study has shown us there is a  link regarding the risk of developing diabetes to intake of sugary drinks and this link is high enough to approximate the risk that one gets from smoking!!!!

This new study is published in the recent publication of Diabetes Care in 2010:

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OBJECTIVE: Consumption of sugar-sweetened beverages (SSBs), which include soft drinks, fruit drinks, iced tea, and energy and vitamin water drinks has risen across the globe. Regular consumption of SSBs has been associated with weight gain and risk of overweight and obesity, but the role of SSBs in the development of related chronic metabolic diseases, such as metabolic syndrome and type 2 diabetes, has not been quantitatively reviewed.

RESEARCH DESIGN AND METHODS: We searched the MEDLINE database up to May 2010 for prospective cohort studies of SSB intake and risk of metabolic syndrome and type 2 diabetes. We identified 11 studies (three for metabolic syndrome and eight for type 2 diabetes) for inclusion in a random-effects meta-analysis comparing SSB intake in the highest to lowest quantiles in relation to risk of metabolic syndrome and type 2 diabetes.

RESULTS: Based on data from these studies, including 310,819 participants and 15,043 cases of type 2 diabetes, individuals in the highest quantile of SSB intake (most often 1-2 servings/day) had a 26% greater risk of developing type 2 diabetes than those in the lowest quantile (none or <1 serving/month) (relative risk [RR] 1.26 [95% CI 1.12-1.41]). Among studies evaluating metabolic syndrome, including 19,431 participants and 5,803 cases, the pooled RR was 1.20 [1.02-1.42].

CONCLUSIONS: In addition to weight gain, higher consumption of SSBs is associated with development of metabolic syndrome and type 2 diabetes. These data provide empirical evidence that intake of SSBs should be limited to reduce obesity-related risk of chronic metabolic diseases.

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In practical terms, the association between intake of sugary drinks and Diabetes can be translated to something like this:

For every  12 oz sugar laden drink that you order in a restaurant today like the ever famous and popular sugary and tasty Ice Tea or canned OJ… a roughly 25% increase in risk  for you to develop Diabetes on top of your risk to gain more weight!

So if one actually drinks 2-3 bottles of Soda per day then the risk is further increased to 30% roughly similar to the risk one gets due to smoking!

Would it be better to take Diet Drinks then? It maybe safer BUT the associated increase in food intake is the culprit.  Likewise there are some concerns now that link Diet Sodas also to increased risk of Metabolic syndrome suggesting that artificial sweeteners may have a role in itself. 

So my recommendation to my patients is to limit one’s consumption to only 1 diet soda per day and if possible enjoy Water instead!

Coffee or Tea Keeps Diabetes Away….

May 11, 2010

Anothe rgood news for coffee lovers like me… Now comes a new study agina showing the reduction in ones risk to develop diabetes.  The study was recently published in the Archives of Internal Medicine December issue

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Background  Coffee consumption has been reported to be inversely associated with risk of type 2 diabetes mellitus. Similar associations have also been reported for decaffeinated coffee and tea. We report herein the findings of meta-analyses for the association between coffee, decaffeinated coffee, and tea consumption with risk of diabetes. Methods  Relevant studies were identified through search engines using a combined text word and MeSH (Medical Subject Headings) search strategy. Prospective studies that reported an estimate of the association between coffee, decaffeinated coffee, or tea with incident diabetes between 1966 and July 2009.

Results  Data from 18 studies with information on 457 922 participants reported on the association between coffee consumption and diabetes. Six (N = 225 516) and 7 studies (N = 286 701) also reported estimates of the association between decaffeinated coffee and tea with diabetes, respectively. We found an inverse log-linear relationship between coffee consumption and subsequent risk of diabetes such that every additional cup of coffee consumed in a day was associated with a 7% reduction in the excess risk of diabetes relative risk, 0.93 [95% confidence interval, 0.91-0.95]) after adjustment for potential confounders.

Conclusions  Owing to the presence of small-study bias, our results may represent an overestimate of the true magnitude of the association. Similar significant and inverse associations were observed with decaffeinated coffee and tea and risk of incident diabetes. High intakes of coffee, decaffeinated coffee, and tea are associated with reduced risk of diabetes. The putative protective effects of these beverages warrant further investigation in randomized trials.

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This study again shows same conclusion as in the past that a mere 4 cups of coffee per day whether regular or decaf has been shown to reduce ones risk to develop diabetes by 27%.  And what is interesting is that for every extra cup of coffee, an additional 7 % further reduction is risk to develop diabetes was noted.

The study therefore points out to one thing…that caffeine may not be the factor as decaf can result in similar reduction in risk.  Other chemicals present in coffee therefore need to be explored…. 

However…one should not resort to just relying on coffee to reduce our risk to develop diabetes.  We have to remember that lifestyle and proper food intake has been shown to reduce the risk of developing diabetes by a whoooping 50%….

There you go guys…enjoy our coffee!!!!

Weight Loss and Health….

November 6, 2009

Now the good news….

The main reason for my weight loss through lifestyle change is my aim to reduce my risk to develop diabetes in the future.  After a scary 96 mg/dl fasting blood sugar during my annual executive checkup, I pushed myself to achieve my ideal BMI becuase apparently I was overweight.

Now as published in Lancet this October 29, 2009, the long term Diabetes Prevention Program extended study showed long term benefits of modest weight loss through lifestyle as better in preventing the progression of the disease compared to intake of medication called Metformin. 

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Background

In the 2·8 years of the Diabetes Prevention Program (DPP) randomised clinical trial, diabetes incidence in high-risk adults was reduced by 58% with intensive lifestyle intervention and by 31% with metformin, compared with placebo. We investigated the persistence of these effects in the long term.

Methods

All active DPP participants were eligible for continued follow-up. 2766 of 3150 (88%) enrolled for a median additional follow-up of 5·7 years (IQR 5·5—5·8). 910 participants were from the lifestyle, 924 from the metformin, and 932 were from the original placebo groups. On the basis of the benefits from the intensive lifestyle intervention in the DPP, all three groups were offered group-implemented lifestyle intervention. Metformin treatment was continued in the original metformin group (850 mg twice daily as tolerated), with participants unmasked to assignment, and the original lifestyle intervention group was offered additional lifestyle support. The primary outcome was development of diabetes according to American Diabetes Association criteria. Analysis was by intention-to-treat. This study is registered with ClinicalTrials.gov, number NCT00038727.

Findings

During the 10·0-year (IQR 9·0—10·5) follow-up since randomisation to DPP, the original lifestyle group lost, then partly regained weight. The modest weight loss with metformin was maintained. Diabetes incidence rates during the DPP were 4·8 cases per 100 person-years (95% CI 4·1—5·7) in the intensive lifestyle intervention group, 7·8 (6·8—8·8) in the metformin group, and 11·0 (9·8—12·3) in the placebo group. Diabetes incidence rates in this follow-up study were similar between treatment groups: 5·9 per 100 person-years (5·1—6·8) for lifestyle, 4·9 (4·2—5·7) for metformin, and 5·6 (4·8—6·5) for placebo. Diabetes incidence in the 10 years since DPP randomisation was reduced by 34% (24—42) in the lifestyle group and 18% (7—28) in the metformin group compared with placebo.

Interpretation

During follow-up after DPP, incidences in the former placebo and metformin groups fell to equal those in the former lifestyle group, but the cumulative incidence of diabetes remained lowest in the lifestyle group. Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years.

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The study clearly shows that weight loss through lifestyle changes can significantly reduce ones risk to develop diabetes by as much as 34%. 

The Intensive lifestyle changes in the study consisted of lowering fat and calories in the diet and increasing regular physical activity to 150 minutes per week.  Most exercise was in a form of walking.  Modest weight loss was around 15 lbs in the first year but overtime regained them all but 5 lbs over the next 10 years.  I guess this shows that lifestyle really is difficult for some to maintain.

What matters most for this study is that lifestyle change through fitness and nutrition really works.  The only problem is how one can maintain to be active throughout ones life and how one can withstand the sight of FOOOOD!!!! 

For me….Its a matter of discipline and focus… The two main ingredients to achieving success through behavioral modification.  Clinically, the measure of success is when one is able to maintain the weight loss beyond 1 year of intervention.  Losing weight in 6 months is good…but gaining them back in the next 6 months is bad…..

The Facts are here… the Benefits are known… The rest now depends on YOU!

The 20-40 RULE in Fitness and Disease

July 13, 2009

My 20-40 rule:

A low fitness level in your teens translate to a high level of risk for developing diabetes by age 40! 

That’s the message I got from this study published in Diabetes Care called the CARDIA Fitness Study.

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Objective: Test the association of fitness changes over 7- and 20-years on the development of diabetes in middle-age.

Research Design and Methods: Fitness was determined based on the duration of a maximal graded exercise treadmill test (Balke protocol) at up to three examinations over 20-years from 3989 black and white men and women from the Coronary Artery Risk Development in Young Adults study. Relative fitness change (%) was calculated as the difference between baseline and follow-up treadmill duration/baseline treadmill duration. Diabetes was identified as fasting glucose ≥126 mg/dL, post-load glucose ≥200 mg/dL, or use of diabetes medications.

Results:

  • Diabetes developed at a rate of 4 per 1000 person-years in women (n=149) and men (n=122) and lower baseline fitness was associated with a higher incidence of diabetes in all race-sex groups (hazard ratios from 1.8 to 2.3).
  •  On average, fitness declined 7.6% in women and 9.2% in men over 7 years.
  • The likelihood of developing diabetes increased per standard deviation decrease (19%) from the 7-year population mean change (−8.3%) was in women (hazard ratio [HR]=1.22, 95% CI: 1.09, 1.39) and men (HR=1.45, 95% CI: 1.20, 1.75) following adjustment for age, race, smoking, family history of diabetes, baseline fitness, body mass index (BMI), and fasting glucose.
  • Participants who developed diabetes over 20 years experienced significantly larger declines in relative fitness over 20 years vs those who did not..

Conclusions: Low fitness is significantly associated with diabetes incidence and explained in large part by the relationship between fitness and BMI.

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This study shows that inidviduals risk to develop lifestyle related diseases especially diabetes are at increasing overtime depending on the level of fitness:

  • Women were at 22% increased risk of developing diabetes
  • men were at a 45% increased risk…

 for every standard deviation decrease from the mean fitness change.  This relationship continued to exists even after adjusting for age, smoking, family history of diabetes, and baseline fasting glucose.  In fact the researchers noted that the baseline BMI was a better predictor for developing diabetes than the baseline fasting glucose as well as baseline fitness.

What Do These Data MEAN?

  • If two individuals have similar fitness level; the bigger person with a higher BMI is more likely to develop diabetes than the smaller frame guy overtime in the next 10-20 years.
  •  The possible mechanism by which fitness decreases risk for diabetes is most likely related to the regulation of body mass.  A lower BMI means better insulin sensitivity and less production of toxic substances by increased adiposity that can lead to further cardiovascular complications associated with obesity and diabetes. 

The authors conlcuded:

That regular physical activity to “improve and maintain cardiorespiratory fitness is an important component of a healthy lifestyle.” 

 AMEN!

Reduce Your Risk for Diabetes Through Weight Loss: The Impact of Weight Loss Surgery

March 9, 2009

Go to fullsize imageWeight gain and Obesity play very important roles in the development of chronic diseases like Diabetes, High blood pressure and complications like Stroke and Heart Attack.  One therefore has to incorporate proper lifestyle and good behavior through daily physical acitvity to help avoid developing these conditions.  However there are certain inidividuas where weight loss through these behvioral methods no longer are enough to provide the weight loss one desires and therefore for ” medical” reasons, one resorts to drastic measures like Bariatric surgery.

But do they work in decreasing the risk? or do they help patients improve disease outcomes?

Now comes s study published in the American Journal of Medicine, March 2009  to show that weight loss indeed can work wonders to diabetes and that bariatric surgery can help:

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  • 621 studies from 1990 to April of 2006 were analyzed:  78.1% of diabetic patients had complete resolution and diabetes was improved or resolved in 86.6% of patients as the result of bariatric surgery.
  •  Gastric banding yielded 56.7% resolution, gastroplasty 79.7%, gastric bypass 80.3% and BPD/DS 95.1%.
  •  After more than 2 year post-operative, the corresponding resolutions were 58.3%, 77.5%, 70.9%, and 95.9%.
  • The Percent excess weight loss was 46.2%, 55.5%, 59.7% and 63.6%, for the type of surgery performed suggesting that BPD yielded the best result.

Concluding that:

  • 82% of patients had resolution of the clinical and laboratory manifestations of diabetes in the first 2 years after surgery, and
  • 62% remained free of diabetes more than 2 years after surgery (80% and 75% for the total group).

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The study for me tells us one thing: that weight loss indeed can work wonders.  However lets not all resort to surgery to achieve improvement in our risk for diseases as surgery also entails risks! 

While proper diet and physical activity are completely free and easy to do…all they need are the Two D’s to succeed: DETERMINATION and DISCIPLINE!

High Blood Sugar Predicts Death in Heart Attack Patients

February 26, 2009

Just a note for all of the readers with family members who are diabetics.  This is just to make you aware that control of sugar is of paramount importance even at the time of hospitalization especially due to heart attack.

This new study published in Archives of Internal Medicine, Feb 2009 shows that the relationship between fasting blood sugar on admission and its ability to predict outcome of death within 6 months of the acute attack.

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Background  Elevated blood glucose level at admission is associated with worse outcome after a myocardial infarction. The impact of elevated glucose level, particularly fasting glucose, is less certain in non–ST-segment elevation acute coronary syndromes. We studied the relationship between elevated fasting blood glucose levels and outcome across the spectrum of ST-segment elevation and non–ST-segment elevation acute coronary syndromes in a large multicenter population broadly representative of clinical practice.

Methods  Fasting glucose levels were available for 13 526 patients in the Global Registry of Acute Coronary Events. A multivariate logistic regression analysis was used for assessing the association between admission or fasting glucose level and in-hospital or 6-month outcome, adjusted for the variables from the registry risk scores.

Results 

  • Higher fasting glucose levels were associated with a graded increase in the risk of in-hospital death (odds ratios [95% confidence intervals] vs <100 mg/dL: 1.51 [1.12-2.04] for 100-125 mg/dL, 2.20 [1.64-2.60] for 126-199 mg/dL, 5.11 [3.52-7.43] for 200-299 mg/dL, and 8.00 [4.76-13.5] for 300 mg/dL).
  • When taken as a continuous variable, higher fasting glucose level was related to a higher probability of in-hospital death, without detectable threshold and irrespective of whether patients had a history of diabetes mellitus.
  • Higher fasting glucose levels were found to be associated with a higher risk of postdischarge death up to 6 months.
  • The risk of postdischarge death at 6 months was significantly higher with fasting glucose levels between 126 and 199 mg/dL (1.71 [1.25-2.34]) and 300 mg/dL or greater (2.93 [1.33-6.43]), but not within the 200- to 299-mg/dL range (1.08 [0.60-1.95]).

Conclusions  Short-term and 6-month mortality was increased significantly with higher fasting glucose levels in patients across the spectrum of acute coronary syndromes, thus extending this relation to patients with non–ST-segment elevation myocardial infarction. The relation between fasting glucose level and risk of adverse short-term outcomes is graded across different glucose levels with no detectable threshold for diabetic or nondiabetic patients.

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Better still…. across the spectrum of diabetes management that good control should always be practiced.  

No ifs or buts…its the RULE!

Reduction in short term complications, the sense of well being…plus reduction of long term complications like stroke and heart attack…are more than enough for any diabetic in the family to make sure that good control should always be practiced.  

Ths study tells us that up to the time of the acute event, high sugar continues to present itself as a menace.  And that high sugar should not be relegated as a mere stress effect but for me should be aggressively treateed as metabolic effects can have lasting impact on ones health and are irreversible!

Be aggressive as high sugar may not manifest any symptoms until its late!

Can Daily Intake of Eggs Be Healthy?

February 23, 2009

Go to fullsize imageControversies continue to surround whether eggs can cause harm if taken daily or not. Debate among the experts continue with assumptions that cholesterol in the diet actually has little effect on blood cholesterol.  No doubt that intake of saturated fat can increase the level of blood cholesterol and risk a patient to develop heart attack and stroke.  The relationship of Egg intake to disease continues to be debatable.

Now comes a new study publsished in the Diabetes Care , this February 2009  that for sure will add fuel to the ongoing controversy:

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OBJECTIVE—Whereas limited and inconsistent findings have been reported on the relation between dietary cholesterol or egg consumption and fasting glucose, no previous study has examined the association between egg consumption and type 2 diabetes. This project sought to examine the relation between egg intake and the risk of type 2 diabetes in two large prospective cohorts.

RESEARCH DESIGN AND METHODS—In this prospective study, we used data from two completed randomized trials: 20,703 men from the Physicians’ Health Study I (1982–2007) and 36,295 women from the Women’s Health Study (1992–2007). Egg consumption was ascertained using questionnaires, and we used the Cox proportional hazard model to estimate relative risks of type 2 diabetes.

RESULTS—During mean follow-up of 20.0 years in men and 11.7 years in women, 1,921 men and 2,112 women developed type 2 diabetes. Compared with no egg consumption, multivariable adjusted hazard ratios for type 2 diabetes were 1.09 (95% CI 0.87–1.37), 1.09 (0.88–1.34), 1.18 (0.95–1.45), 1.46 (1.14–1.86), and 1.58 (1.25–2.01) for consumption of <1, 1, 2–4, 5–6, and 7 eggs/week, respectively, in men (P for trend <0.0001). Corresponding multivariable hazard ratios for women were 1.06 (0.92–1.22), 0.97 (0.83–1.12), 1.19 (1.03–1.38), 1.18 (0.88–1.58), and 1.77 (1.28–2.43), respectively (P for trend <0.0001).

CONCLUSIONS—These data suggest that high levels of egg consumption (daily) are associated with an increased risk of type 2 diabetes in men and women. Confirmation of these findings in other populations is warranted.

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The question arises: whether it is the intake of egg that increased the risk to develop diabetes.  Or is it the relationship of the high fat diet associated with the egg intake that increased the risk.  It is known that high cholesterol and saturated fat intake can increase a patients risk to develop diabetes.

So when the study participants’ daily cholesterol intake was assessed, it showed a relationship related to diabetes risk!!!  When the researchers factored this relationship in, the association between egg intake and diabetes weakened suggesting that a cholesterol-rich diet might promote diabetes.  This also suggest that a person who may like eggs may also eat other fatty foods that will result in increasing the risk to deveolp the disease.

So a not so good news for egg lovers who have family history of diabetes.  This is one food that one may have to limit for now until more studies will show the relationship to be otherwise.

But for the others who have no risk of developing diabetes…I suggest that eggs should remain to be enjoyed as long as one should not exceed 3-5 eggs per week.  This recommnedation will stay for now. 

But do … Watch out in this site if new developments come in about eggs because for sure I will be the first to know and you will be the first to be informed !!!!

Another Reason to Follow the Low Carb Diet… Your Blood Sugar!

January 19, 2009

Go to fullsize imageFinally a study that looked at the practice of using low carbohydarte diet for our diabetics in helping control their blood glucoses was recently published in Nutrition and Metabolism journal.  Everytime I give a lecture on Nutritional therapy the question of my practice in lowering the total carbohydrate content of the calorie intake is the central issue.  This study is one proof that the concept of limiting the carbs can do wonders to ones blood sugar!

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Objective

Dietary carbohydrate is the major determinant of postprandial glucose levels, and several clinical studies have shown that low-carbohydrate diets improve glycemic control. In this study, we tested the hypothesis that a diet lower in carbohydrate would lead to greater improvement in glycemic control over a 24-week period in patients with obesity and type 2 diabetes mellitus. Research design and methods: Eighty-four community volunteers with obesity and type 2 diabetes were randomized to either a low-carbohydrate, ketogenic diet (<20 g of carbohydrate daily; LCKD) or a low-glycemic, reduced-calorie diet (500 kcal/day deficit from weight maintenance diet; LGID). Both groups received group meetings, nutritional supplementation, and an exercise recommendation. The main outcome was glycemic control, measured by hemoglobin A1c.

Results

Forty-nine (58.3%) participants completed the study. Both interventions led to improvements in hemoglobin A1c, fasting glucose, fasting insulin, and weight loss. The LCKD group had greater improvements in hemoglobin A1c (-1.5% vs. -0.5%, p=0.03), body weight (-11.1 kg vs. -6.9 kg, p=0.008), and high density lipoprotein cholesterol (+5.6 mg/dL vs. 0 mg/dL, p<0.001) compared to the LGID group. Diabetes medications were reduced or eliminated in 95.2% of LCKD vs. 62% of LGID participants (p<0.01).

Conclusions

Dietary modification led to improvements in glycemic control and medication reduction/elimination in motivated volunteers with type 2 diabetes. The diet lower in carbohydrate led to greater improvements in glycemic control, and more frequent medication reduction/elimination than the low glycemic index diet. Lifestyle modification using low carbohydrate interventions is effective for improving and reversing type 2 diabetes.

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What is amazing of the results is that by following a low carb diet, diabetes medications were reduced or eliminated in 95 percent and likewise resulted in a greater weight loss.  We also know that by losing weight, patient becomes more insulin sensitive and therefore contributes further to improvements in metabolic profile. These are the two effects that we like whether we employ diet or medication to any patient we assessed to have a disease of the lifestyle. 

Is this nutritional therapy easy to do? 

Definitely not BUT its the determination to succeed and be treated without medication that can drive our patients to follow the regimen.  Just like any regimen involving FOOD… our vigilance to do what is healthy is more important than following our DESIRE to love food and EAT more!

Lower Your Risk To Develop Diabetes By Eating Veggies….

March 24, 2008

www.calpoly.edu/~lcimarel/vegetables.jpgWe all know veggies are good.  But this recent finding that veggies can prevent diabetes is a welcome news to us trying to curb the epidemic of this disease due to unhealthly lifestyle and poor dietary habits.

I have trained my kids to eat veggies.  I found it amusing that one day my son said to me:  “Dad my classmates are teasing me that I am a Vegetarian!”  Suggesting that of all his classmates, he was the only one who had veggies on his lunch box.  Lucky me… my kids love veggies….and for a good reason!

This good news about veggies and diabetes was published in the March 2008 issue of the Journal of Nutrition:

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A population-based prospective study of 64,191 women with no history of T2D or other chronic diseases at study recruitment and with valid dietary information.

The relative risk for T2D for the upper quintile relative to the lower quintile of vegetable intake was 0.72 (95%CI: 0.61–0.85; P < 0.01) in multivariate analysis. Individual vegetable groups were all inversely and significantly associated with the risk of T2D.

Fruit intake was not associated with the incidence of diabetes in this population.

Our data suggest that vegetable consumption may protect against the development of T2D.

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This data is great suggesting that those who consumed the highest amount of vegiies in 4-5 years reduced the likelihood of developing diabetes by 28%.  That is… taking 428 grams of veggies per day reduced ones chances to develop this chronic disabling disease compared to if you only take 121 grams of veggies per day!

The advantages of veggies is that it contains high fiber as well as other substances like phytates and isoflavones that may help in reducing the risk for developing diabetes.

Although fruits did not show benefit…it likewise did not show harm.  Just the same fruits have been shown to reduce the risk of developing other diseases like cancer or heart disease.  Such that… its intake remains to be a cornerstone in promoting health!

Train Yourself and Your Kids To Eat Veggies for Health!

Nutrition in Health and Disease….

March 17, 2008

This is called the Paradox of Food:  you need food to live and survive but the very reason for disease and illnesses stem from the abundance of food and poor nutrition!

I practice a field dealing with the metabolic diseases where poor nutrition plays a key role in its onset and progression to develop complications.  Control of blood glucose requires the right balance of nutrition, exercise and medications. The same formula apllies when treating obesity, hypertension and high cholesterol.

The problem with handling these diseases stem from the medical field lack of understanding of nutrition and the lack of importance given to medical nutrition therapy!   If you make rounds in the hospital … you see the diet prepared for a diabetic hypertensive is almost similar if not similar to the other patient in the other room who is not a  diabetic…  It may not be the dietician’s fault but the doctor prescribing the diet!  This is where I am very particular with my patients because I believe the long term success of successfully controlling their blood sugar or blood pressure or cholesterol stem from not what I give them as medications but what they take in as food!

The recent 2008 ADA recommendation for Nutrition  reasons out why Nutrition is important:

Clinical trials/outcome studies of Medical Nutrition Therapy have reported decreases in HbA1c (A1C) of 1% in type 1 diabetes and 1–2% in type 2 diabetes, depending on the duration of diabetes . Meta-analysis of studies in nondiabetic, free-living subjects and expert committees report that MNT reduces LDL cholesterol by 15–25 mg/dl . After initiation of MNT, improvements were apparent in 3–6 months. Meta-analysis and expert committees also support a role for lifestyle modification in treating hypertension .

The proportion of calories in the specific nutrition Rx will now be individualized and should be prescribed by your doctor.  I have my own personal dietician in my clinic now that I offer free couseling to my patients where personal preferences of food is taken into consideration.  I believe in individualized counseling so as to offer a  more successful diet regimen.  No prepared diets printed on a piece of paper!

I have been a proponent of using a 40% of total calories from carbohydrates for my diabetic patients as more and more data are coming out regarding the benefits of limited carbohydrate not only for losing weight but for better glycemic control.  It is but proper that for the first time the American Diabetes Association came up with their position paper recommending the same.

For me…it is plain and simple challenging one’s self discipline in not giving in to the “want” but following to the details of what is nutritious and healthy!!!

Live Life To The Fullest…By Eating Right!

Low Carb Diet and Diabetes: A Better Partner?

February 29, 2008

Go to fullsize imageDieatry intervention remains the cornerstone of therapy for Diabetes.  It requires education and self discipline for it to work!  It may be frustrating for doctors but if only we find time to explain the benefits and allow this intervention to work…it is really worth the effort.  My center now not only caters to diabetes education but has already 2 dieticians on board to see the dietary needs of my patients with diabetes, high blood pressure and high cholesterol.

I have been a proponent of the 40% carb and 40% fat diet for my diabetic patients. The fat however should be mainly monounstaurated which will give us the source of the good fat with less than 7% to 10% of the Saturated fat or the Bad fat!  I always emphasize the low fat sources or the vegetable sources of protein! 

This February 2008 comes a new study from the Harvard Medical Group of the longstanding Nurses Health Study that came up with the finding that indeed a Low Carb Diet may be the way to go for Diabetic patients.

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Design:  prospectively examined the association between low-carbohydrate-diet score (based on percentage of energy as carbohydrate, fat, and protein) and risk of diabetes among 85 059 women in the Nurses’ Health Study.

Results: During 20 y of follow-up, we documented 4670 cases of type 2 diabetes. 

  •  A higher dietary glycemic load was strongly associated with an increased risk of diabetes in a comparison of extreme deciles (RR: 2.47; 95% CI: 1.75, 3.47; P for trend < 0.0001)).
  • A higher carbohydrate consumption was also associated with an increased risk of diabetes in a comparison of extreme deciles (RR: 1.26; 95% CI: 1.07, 1.49; P for trend = 0.003).

Conclusion: These data suggest that diets lower in carbohydrate and higher in fat and protein do not increase the risk of type 2 diabetes in women. In fact, diets rich in vegetable sources of fat and protein may modestly reduce the risk of diabetes.

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The term glycemic load refers to the capacity of a food to increase ones blood sugar upon ingestion.  As a result, I always emphasize to my patients to avoid some of the fruits with the highest glycemic index like pineapple, mangos, watermelon and banana and instead enjoy apple and pear.  The study proves that indeed the higher the glycemic load, the higher the risk to develop diabetes or for those with diabetes…the more difficult blood sugar control will be!

One more reason to go low Carb!  This recommendation looks similar to the Atkins Diet but with a better and healthier protein source with less saturated fat!

Finding a partner in life requires committment… similar to finding a partner in our quest for controlling blood sugar through proper lifestyle and the right diet AND should be made…. a way of life!

Indeed Low Carb Is The BETTER Partner for Health!

MODY : Another Form of Diabetes That You May Have!

February 6, 2008

Go to fullsize imageI was just scanning through some articles and this interesting review on MODY caught my attention because definitely some of our patients that are labelled Type 2 as insulin resistant diabetes may actually have MODY where the tissues are actually insulin sensitive.  As a result the way we treat these patients will actually change. 

Below is a summary of the salient features of MODY from Janet Ruhl published in Diabetes In Control online website:

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1. People with MODY are extremely sensitive to insulin.  A dose of as little as two units may have a strong effect on their blood sugar.

2. People with MODY, no matter how high their blood sugars might be after meals, may have near normal fasting C-peptide levels. This is because the defects characteristic of MODY does not affect basal insulin secretion but only the ability to secrete insulin as blood sugars rise after eating.

3. People with MODY do not have GAD or islet antibodies. Though people with severe expressions of MODY genes may be misdiagnosed in their teens with Type 1 diabetes, they can be distinguished from true Type 1s by the very low doses of insulin they need and the lack of the autoimmune antibodies.

4. People with MODY may respond extremely strongly to sulfonylurea drugs. These drugs are often prescribed as the appropriate treatment for MODY. However, these drugs  are most effective for people whose severe expression of these genes causes blood sugars high enough to be mistaken for Type 1 diabetes. For those whose MODY is milder, even 1/4 of a 1 mg tablet of Amaryl ( Glimipride) may cause a dramatic hypo. For these people the use of very small doses of insulin–no more than 2 to 4 units per meal–is more effective and more easily tailored to varying food intake.

5. MODY should always be suspected in a woman of normal weight who develops gestational diabetes early in a pregnancy and who tests negative for autoimmune antibodies. This is often how MODY first reveals itself.

6. The different forms of genetic diabetes that are lumped together under the heading of MODY have different complication profiles. The two most common forms are MODY-3 caused by a defect in HNF1-a and MODY-2 caused by a defect in the glucokinase gene GCK.

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The point of this post is for us doctors to be aware that this form of diabetes exists and that the way these patients respond to our medications differ from the typical insulin resistant Type 2 Diabetic.

Likewise patients should be aware that this kind of Diabetes exist and may need to inform their doctors if the features of the above fit their kind of diabetes.

I see a lot of diabetic patients and the need to be informed and updated all the time regarding new research on the pathophysiology, diagnosis and treatment of this epidemic is the main reason why I continue to study and learn in whatever mode or material either through books, journals, websites or conventions. 

I guess the same is true to everyone everyday…

We Should Never Stop LEARNING!

Intensive Blood Sugar Control Can Reduce Risk of DEATH

December 20, 2007

Go to fullsize imageFor my diabetic patients, it is very important that they understand that the reason for controlling their blood sugar is… to reduce the risk for complications like heart disease and stroke.

Now comes a new study that proves…tight control of blood sugar can indeed lower the risk of a patient to die from the disease…. published in Diabetes Research and Clinical Practice 2007

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The study concluded:

Normal mortality was attained in the elderly under intensive mutifactorial diabetes control ( Including control for BP and cholesterol)

Renal dysfunction, prior stroke, high LDL-cholesterol, and prior obesity were prominent risks for mortality, macroangiopathy and/or ESRD.

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For me the bottom line in addressing any disease is based on two key  things:

  1. Discipline to live a healthy lifestyle! Remember…to live longer does not mean controlling blood sugar alone because if you continue to gain weight with high blood pressure and high BAD cholesterol due to poor choices of food then the end result is still early mortality due to complications!
  2. Follow Your doctor’s advise!.But choose the right doctor for your specific disease to get the best solution to your problem because just like any job we want done… you find for the best person to do the job RIGHT! and not just to finish the job!…

In the end of the day… everything boils down to one conlcusion….

To Live LOnger Requires Discipline!

Vitamin E and Heart Disease Among Diabetics…

November 27, 2007

Vitamin E has received a lot of good news and bad news. Now you read it being the antioxidant of choice in one study…then the next…it shows the opposite result.  Majority of these studies however are epidimeological and observational in nature and not well controlled prospective studies.  The HOPE and NIH studies were prospective studies that did not show positive effect of Vitamin E on heart disease.

Recently a new data on the possible important role of Vitamin E came about in a new prospective study which is worth looking published in the Journal Atherocsclerosis, Thrombosis and Vascular Biology….

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Methods- 1434 DM individuals  55 years of age with the Hp 2-2 genotype were randomized to vitamin E (400 U/d) or placebo. The primary composite outcome was myocardial infarction, stroke, and cardiovascular death. At the first evaluation of events, 18 months after initiating the study, the primary outcome was significantly reduced in individuals receiving vitamin E (2.2%) compared with placebo (4.7%; P=0.01) and led to early termination of the study.

Conclusions—Vitamin E supplementation appears to reduce cardiovascular events in individuals with DM and the Hp 2-2 genotype.

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Since 40% of our diabetic population has the Hp 2-2 gene…It’s probably about time for us to rethink whether all diabetics should take Vitamin E or not…

However the bottom line is:  more studies need to be done and outcome studies to support this new finding!

Vitamin E Is Worth a Second Look!

What is An A1c?…. A New Guideline For The Diabetics….

November 23, 2007

http://martonhouse.wordpress.com/category/work-life-balance/I have to write about this new guideline in interpreting A1c for my Diabetic Patients who have been loyal followers of this website.  Or to those who are not used to doing home glucose monitoring and rely solely on A1c results in their blood test to check if their control is good or not.  Although I am not advocating to do away with monitoring…in fact I strongly advise all diabetics to do so!

Recently a new calculation was made to correlate A1c to average blood glucose levels.  Now there is a computation one can do and based on data from continuous home glucose monitoring, the correlation is now better than what it used to be.

This is a new information I gathered from the American Association of Diabetes Glucose Control Trials from the ADA News as reported in Diabetes in Control:

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Prior to this new information, the A1c was tied to the results of the DCCT, where a 6% was equal to 135mg/dL.  This came about when they checked the A1c and then looked at a couple of thousand finger sticks and averaged them out.  Now with the use of hundreds of thousands of readings, not just with the finger sticks but also with the use of continuous blood glucose monitors, we have more accurate results.  The equation yields a linear correlation over a wide range of A1c. This means that a 6% is no longer an average of 135mg/dL:  The new numbers:

o 6% = 126 mg/dl
o 7% = 155 mg/dl
o 8% = 182 mg/dl
o 9% = 211 mg/dl
o 10% = 239 mg/dl

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So for all patients who wonder what this A1c means…now this new information will help you decide what to do to your lifestyle especially if you go beyond the A1c of 6.5% that we recommend to help prevent the onset of complications. 

Remember a single blood sugar alone does not give you the whole picture…so if your physician keeps on checking just a Fasting blood sugar and tells you you’re doing fine…demand for an A1c level!

Does Avandia Cause Heart Attack? : The Ongoing Controversy

November 16, 2007

Recently, The US FDA made a new ruling regarding the controversy on whether the popular antidiabetic agent Avandia can really cause heart attack.  Below are important excerpts of the FDA ruling released as of November 14, 2007:

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People with type 2 diabetes who have underlying heart disease or who are at high risk of heart attack should talk with their health care provider about the revised warning as they evaluate treatment options. FDA advises health care providers to closely monitor patients who take Avandia for cardiovascular risks.

Avandia is approved to be used as a single therapy or used in combination with metformin and sulfonylureas, other oral anti-diabetes treatments.

During the past year, FDA has carefully weighed several complex sources of data, some which show conflicting results, related to the risk of chest pain, heart attacks and heart-related deaths, and deaths from any cause in patients treated with Avandia.

At this time, FDA has concluded that there isn’t enough evidence to indicate that the risks of heart attacks or death are different between Avandia and some other oral type 2 diabetes treatments. Therefore, FDA has requested that GSK conduct a new long-term study to evaluate the potential cardiovascular risk of Avandia, compared to an active control agent. GSK has agreed to conduct the study and FDA will ensure it is initiated promptly.

The revision of Avandia’s existing boxed warning – FDA’s strongest form of warning – includes the following statement:

A meta-analysis of 42 clinical studies (mean duration 6 months; 14,237 total patients), most of which compared Avandia to placebo, showed Avandia to be associated with an increased risk of myocardial ischemic events such as angina or myocardial infarction. Three other studies (mean duration 41 months; 14,067 patients), comparing Avandia to some other approved oral antidiabetic agents or placebo, have not confirmed or excluded this risk. In their entirety, the available data on the risk of myocardial ischemia are INCONCLUSIVE!

The previous upgraded warning, added to certain diabetes drugs (in class of drugs related to Avandia) on Aug. 14, 2007, emphasized that these types of drugs may worsen heart failure, a condition in which the heart does not adequately pump blood, in some patients. GSK is also developing a Medication Guide for patients to provide additional information about the benefits and risks and safe use of Avandia.

To date, no oral anti-diabetes drug has been conclusively shown to reduce cardiovascular risk. Consequently, the agency also will be requesting that labeling of all approved oral anti-diabetes drugs contain language describing the lack of data showing this benefit.

Today’s action follows recommendations made at the July 2007 joint meeting of FDA’s Endocrine and Metabolic Drugs and Drug Safety and Risk Management Advisory Committees. At the meeting, members voted 22-1 to recommend that Avandia stay on the market, pending a review of additional data. The committee also advised that information warning of the potential for increased risk of heart attacks should be added to the drug labeling. _______________________________________________

Ever since the data on avandia came into light after the Niessen article, further analysis of that article showed flaws in the statistical analysis.  It is therefore not surprising to me why this drug will not be pulled out in the market solely because of that article.  The medical community looks at actual facts rather than what is reported in newspapers or the media.

Based on my experience, the benefits of this drug continue to outweigh the potential risks…and just like any other drugs… all one needs to do is use the right drug for the right patient profile!

Meaning..never use this drug if the patient has heart failure or heart disease.  And this is true to all antidiabetic agents as reported by the US FDA as the risk of heart attack has not been shown to be different among the different oral agents. 

Plus…all patient with Diabetes…by the time of diagnosis… more than 5o% or probably ALL already have ongoing heart disease because by the time ones fasting blood sugar is abnormal…the disease process has been ongoing for 7 to 10 years already!

Therefore and Again… I always emphasize to all patients at risk: Lifestyle Change.  If one has the risk to develop Diabetes … do something NOW!  

Remember… All medications have risks!  But the benefits should always outweigh the risks before any drug is started on any patient!

Snoring and The Risk of Diabetes

November 13, 2007

Just came back from a successful preceptorship at the UCSF- Stanford University- Whittier Institute for Diabetes in San Francisco and San Diego.  There were only 10 MDs from the Asia Pacific region being taught by more that 12 professors.  It’s actually more than a 1:1 learning from the 4th Best institution in Endocrinology from the survey in The US News and World Report 2007.

One very interesting topic we discussed was snoring and the risk of developing diabetes.  Needless to say…snroing can be very common and yet often negelcted symptom.  We alwaus associatet snoring as… the person is either being too tried from work or just in a deep good night sleep.  But now studies have shown that snoring is indeed an unhealthy sign of future disease risk.

In a study published in the Journal of Epidimeology… it was noted that snoring actually increases a persons risk to develop Diabetes….

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Purpose: To examine the association between snoring and risk of developing type II diabetes mellitus, the authors analyzed data from the Nurses’ Health Study cohort.

Methods: This analysis included 69,852 US female nurses aged 40–65 years without diagnosed diabetes, cardiovascular disease, or cancer at baseline in 1986. Snoring patterns were ascertained by questionnaire.

Results: During 10 years of follow-up, 1,957 women were diagnosed with type II diabetes. In analyses adjusted for age and body mass index, snoring was associated with risk of diabetes

  1. for occasional snoring vs. nonsnoring, relative risk (RR) = 1.48 (95% confidence interval (CI): 1.29, 1.70);
  2. for regular snoring vs. nonsnoring, RR = 2.25 (95% CI: 1.91, 2.66); p for trend < 0.0001).
  3. Analyses stratified by body mass index, smoking history, or parental history of diabetes showed a consistent association between snoring and diabetes within the categories of these variables.

Conclusion: These results suggest that snoring is independently associated with elevated risk of type II diabetes.

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Snoring can be benign but can also be due to a more difficult disease called Obstructive Sleep Apnea where patients intermittently stop breathing with episodes of snoring suggesting obstruction.  Inability to breath causes them to cough and then resume sleeping.  Unfortunately these patients dont get into deep sleep and therefore feels tired when they wake up and tend to sleep or nap while awake in the chair or anywhere they feel sleepy.

We now know lack of sleep can be a stress factor that can contribute to increasing ones risk to develop diabetes.  It is therefore not surprising that snoring as a sign of sleep apnea is one way of being sleep debt!

Treating sleep apnea therefore in a person who is diabetic or at risk to develop diabetes can definitely have an impact on ones health…by improving his risk profile and improving blood sugar control.

My recommendation therefore for all  my diabetics who snore is to get a sleep study.  The sleep lab can determine what kind of sleep disorder one has and then implement measures to help one sleep including the administration of a CPAP machine.

Ask your partner if you snore… discuss it with your specialist and demand for a sleep study.  Treating sleep apnea can have a tremendous impact in controlling your blood sugar including ones risk to be overweight!  Plus.. you feel better when you wake up and a better sense of well being.

Snoring Can Be Bad For Your Health!