Early Detection Double Standard

Every year, my doctor does a Pap smear and sends the results off to the lab.  If the results come back abnormal two years in a row, here’s what will happen:

• I will go to a specialist for a colposcopy, in which my cervix will be carefully examined under magnification and vinegar (really) to detect any abnormal cells.  Abnormal cells will be biopsied, and it is quite likely that a tissue sample will be taken from inside the cervix.
• Assuming that the results come back negative for cervical cancer, for the next several years, I will have semiannual Paps done by a specialist until no more abnormal cells are found.  Then I can go back to annual exams done by my primary doctor.

This is all done to make sure that abnormal cells, if present, are found, and to carefully monitor those abnormal cells so they can be excised if they show signs of becoming cancerous.  Early detection is widely thought to be the most important determining factor in successful cancer treatment.  And certain kinds of cancer screenings, such as Pap smears, mammograms, colonoscopies and prostate exams are routinely done on all patients over a certain age regardless of family history of cancer.

On the other hand, every year, I ask my doctor for a fasting glucose tolerance test, and she tells me that on my last routine blood workup my fasting blood glucose was normal and refuses to order the test.  (This year she offered to do another fasting BG, which I declined.  I know my FBGs are OK.)  She acts thus even though I have several risk factors for diabetes, including a family tree absolutely riddled with diabetes.

What happened to early detection?  Is my doctor guilty of malpractice?

Not really, at least not by any standard that would be acceptable in a court of law.  My doctor’s practice is part of a giant teaching hospital affiliated with one of the most prestigious medical schools in the country, and furthermore, this hospital is the home of one of the leading diabetes programs in the country.  And, according to my doctor, the hospital’s definition of diabetes is two consecutive FBGs above a certain number (which is, I think, 126 but may be higher.  I wish I’d written it down).  My FBGs are always well below 100, so no concern about diabetes is indicated.

My doctor is not being negligent; she’s following well-established diagnosis guidelines.

The thing is, I think she’s right and she’s wrong at the same time.  FBGs are a sufficient indicator of full-blown diabetes.  They are just lousy as an early detection standard.

The National Diabetes Information Clearinghouse indicates that the glucose tolerance test is more sensitive for diagnosing pre-diabetes than FBGs.  And the simple reason one would want to diagnose pre-diabetes, according to the same organization, is:

In pre-diabetes, blood glucose levels are higher than normal but not high enough to be characterized as diabetes. However, many people with pre-diabetes develop type 2 diabetes within 10 years. Pre-diabetes also increases the risk of heart disease and stroke. With modest weight loss and moderate physical activity, people with pre-diabetes can delay or prevent type 2 diabetes.  (Source:  National Diabetes Information Clearinghouse.)

It’s all about early detection, kiddos.  The Massachusetts General Hospital Diabetes Unit says, “High levels of glucose are toxic to beta cells, causing a progressive decline their function and cell death.  Consequently, many patients with type 2 diabetes eventually need insulin.”  You don’t have to be Aristotle to derive the syllogism here - those with pre-diabetes who do not receive a diagnosis can expect their beta cells to become poisoned by their high blood sugar levels, eventually leading to full-blown diabetes and possibly even dependence on insulin injections.  Why wouldn’t one of the premier diabetes centers in the country want to detect this early?

I have a lot of ideas about why, most of them sinister:

• The GTT is more expensive than the FBG, and doctors, who are paid by insurance companies, have an incentive to save money.
• Doctors don’t know that lifestyle changes can reverse pre-diabetes.
• Doctors do know that lifestyle changes can reverse pre-diabetes, but, misinformed as to what those changes are, prescribe ineffective low-fat diets.  After years of seeing patients fail to reverse diabetes on low-fat diets, doctors give up on lifestyle changes.
• Doctors not only know that lifestyle changes can reverse pre-diabetes, they even know that carbohydrate restriction is the way to go.  But doctors don’t believe that patients can make and stick to such “drastic” lifestyle changes as giving up bread.
• The research hospitals that set the guidelines for diagnosis and treatment are funded in great part by pharmaceutical companies, and therefore have an incentive to recommend a course of action that results in a medication-dependent population.

To be fair, Jenny at Blood Sugar 101 (formerly called What They Don’t Tell You About Diabetes) offers a somewhat more benign explanation:

• Decades ago, when diabetes treatment was less sophisticated, a diabetes diagnosis was not only a death sentence, it would prevent a patient from getting insurance or even a job.  Since it was thought that nothing could be done to reverse elevated blood sugars, early diagnosis was worthless and could cause financial problems for a patient.  It was deemed a kindness to delay diagnosis as long as possible.  (See Jenny’s article here for lots of fascinating information.)

The drug and insurance company problems seem tough to solve without a gigantic social upheaval.  But surely our doctors can do better!  Doctors do push back on ordering expensive tests, and patient advocacy organizations do lobby Congress to make insurers pay for certain kinds of tests.  It would be the rare insurance company that fails to pay for routine Paps, mammograms, colonoscopies, etc., even though some of these tests are rather pricey, much pricier than a GTT.  And surely doctors can shed the fatalist attitude - sure, many patients would rather jab themselves with insulin than give up their donuts, but that does not mean that every patient would.  I myself grew up watching my mother inject herself with insulin first once a day, then up to four times a day, and even though she became very callous (pun intended) about it, and even though I can submit quite stoically to needles in a doctor’s office, I am too chicken to inject myself.  Anything I can do to avoid that necessity, I will do.  I am surely not the only patient out there who would rather give up bread than poke a needle into my thighs several times a day!

Why don’t doctors give us choices?

It’s all in the presentation.  A doctor can say, “There’s nothing I can do for you but give you a drug,” because he assumes that the patient wants a quick fix.  Or a doctor can say, “I can give you a drug, or you can give up your favorite foods; your choice.”  Or a doctor can say, “I can give you a drug, but if I do that you are going to need more and more medication as time goes on; you will experience side effects that might be bothersome or even dangerous, and it will cost you a lot of money; or you can follow a diet that requires you to give up some foods you might currently enjoy a lot, but it offers you a lot of other delicious, nutritious foods; the diet will keep your condition in check for a long time without side effects, and it may cost you a bit more than what you spend on food now, but it’s cheaper than drugs.”

One more thing - when I was corresponding with my HR department about the company’s support of the American Diabetes Association, he mentioned that he’d personally talked with a number of employees who had been astounded by their diabetes diagnosis, since they’d had no indications whatsoever they were on that path.  Astounded!  Didn’t these folks have the right to know where they were heading, and the right to make a choice on how to proceed based on scientifically sound information?

And finally, if you’re not sick of this topic, please check out this post on Jenny’s Diabetes Update blog.  (Yes, this is the same Jenny who brought you Blood Sugar 101.)  Read the post comments, too.)

What Do I Eat? 8: Turkish Lamb

This marinade for lamb is adapted from Diane Kochilas’s wonderful cookbook Against the Grain:  150 Good Carb Mediterranean Recipes.  The marinade, as given in the cookbook, is enough for an 8-pound leg of lamb!  I have pared it down so that it is enough for two to four servings of lamb steaks or lamb chops; if you want to make a leg of lamb, use 1/3 cup of yogurt and multiply all other ingredients by six.  Refer to any good cookbook for times and oven temperatures to roast lamb.

I served this with roasted red peppers (highly recommended as a complement to the sweetly spicy lamb) and my usual giant green salad.

——————————–

1 teaspoon coriander seeds
1 teaspoon fennel seeds
1 teaspoon cumin seeds
1/2 teaspoon coarsely ground black pepper
1/4 teaspoon turmeric
pinch cayenne (or more to taste)
1 garlic clove, minced, pressed, or grated
2 teaspoons extra virgin olive oil
1/4 cup plain yogurt
salt
2 to 4 lamb steaks or 4 to 8 lamb chops

Grind the coriander, fennel, and cumin in a spice grinder or with a mortar and pestle.  Place in a medium bowl and add the black pepper, turmeric, cayenne, garlic, olive oil, yogurt, and salt to taste.  Mix together.

Rinse the lamb and pat dry.  Place in a container and pour the yogurt mixture over, using your hands or a basting brush to coat the lamb thoroughly.  Cover and refrigerate 3 hours to overnight.

When you are ready to cook, remove the lamb from the yogurt mixture and wipe off excess.  Cook in an oiled skillet on medium high heat until browned and done to your liking.  Figure on 1 steak or two chops per person.

Standards of Evidence for Dietary Guidelines

Last week I ran across these three articles from The American Journal of Preventive Medicine on Marion Nestle’s What to Eat blog.

The articles are an editorial calling for a higher standards of evidence for dietary guidelines, followed by a rebuttal (co-authored by Dr. Nestle), followed by a response to the rebuttal.

Editorial, A Call for Higher Standards of Evidence for Dietary Guidelines

Rebuttal, Do Dietary Guidelines Explain the Obesity Epidemic?

Response, The Authors Respond

Dr. Nestle, by the way, mischaracterizes the editorial when she asks, on her blog, Do Dietary Guidelines Do More Harm Than Good?  The editorial itself does not recommend doing away with guidelines, instead suggesting that scientists and public policy makers need to do a better job having their ducks in a row before issuing blanket statments.

I talk too much.  I want to practice my listening skills.  Readers, if you are so inclined, take a look at the editorial, the rebuttal, and the response, and let me know what you think.  The total number of pages is 11, and there isn’t much scientific jargon - a nice bit of reading for your lunch break or afternoon train ride.

Pictures!

I added a new page, which you can access here or from the upper right area of my blog, showing the usual before and after pictures.  (Well, OK, there is no “after” because I’m still slowly peeling off the extra fat.)

What Do I Eat? 7 - Smoked Salmon-Egg Salad

Although I am seldom happier than when I am in the kitchen, not everything I prepare is elaborate and time-consuming.  Take Monday morning’s breakfast - if you have hard-boiled eggs on hand (and I usually do),  it takes about 5 minutes to prepare; it contains foods that are usually available in my kitchen; and cleanup is a breeze - a knife, a cutting board, a spoon, and a bowl.  (I try to boil eggs a dozen at a time so that they are always around.)

Smoked Salmon-Egg Salad

serves 1 as a meal or two as a snack.

2 hard-boiled eggs
1 oz. smoked salmon
1 tablespoon chopped red onion
1 tablespoon capers
mayonnaise to taste

Chop the eggs and salmon.  Mix all ingredients.  Eat with a fork, or use celery sticks, bell pepper wedges, or endive leaves for scooping.

Nifty Gifty

I love little gifts, and I especially love little gifts that are consumable and won’t clutter up my house for years to come.

My husband came home with just such a gift last night - a half dozen pretty, tiny, freshly laid eggs.  They are about the size of ping pong balls and the color that my mother’s old-fashioned crocheted doily patterns used to call ecru.  Well, sort of.  The color varies slightly from egg to egg.  Having grown up in upstate New York, I’m used to pure white egg shells.  And having lived in New England for nearly 11 years, I’m also used to egg shells the color of cafe au lait.  But these super pale brown ones are just too pretty for words.

We are city people and, on principle, do not own a car, so transacting directly with farms is difficult for us.  (Thus do two of my basic principles of sustainability clash!)  We belong to a CSA where the farmer specializes in delivering produce to urban neighborhoods; this takes care of our vegetables during the short New England growing seasion, 5 to 6 months per year.  I plan to investigate a raw milk CSA that claims to have a dropoff point in our town.  But meat and eggs have eluded me, thus far, so I do the best I can in the grocery store.  I believe some of the local farmers’ markets have meat producers, and I will look into that when spring comes.  I have not yet seen eggs at the farmers’ markets that are conveniently located, though.

So where did my husband find these gems?  A colleague of his lives in a tiny town in New Hampshire, and his three kids are raising hens!  My sweetheart bought these eggs for me, for us, for 20 cents each, proceeds to go to the kids to cover chickenfeed.  This pleases me - “know your farmer” is a kind of mantra for the locally raised food movement, and I am sure these kids are treating their hens humanely.  I know what the hens eat - commercial chickenfeed in the winter, less than ideal, but they forage whenever the ground is not covered in snow.

Extra bonus - tonight I have a nice grassfed steak queued up, so I think we’re having steak and teensy tiny little eggs for dinner, with our usual two veggie side dishes (maybe a giant green salad and something cooked).

Recommended Reading 4: Letter from a Birmingham Jail

This has nothing whatsoever do with my pet topics of diet, migraine, diabetes, and bucking the conventional wisdom. (Well, it has everything to do with bucking the conventional wisdom.)

But in honor of this day, perhaps we should all take a moment to ponder something larger than our own interests, to reflect on just exactly why we don’t have to go to school or work today, or why it’s a shame if we do.

Letter from a Birmingham Jail

Shortcomings of the Glycemic Index

If you do low-carb long enough, someone will try to persuade you that you should not skip the “good carbs,” and when you press them further, they will say that they mean carbs that are low on the glycemic index.  The idea is, if low carb works by stabilizing blood sugar levels, wouldn’t it be better to follow a low-glycemic diet, which not only stablizes blood sugar, but also allows a greater range of “healthy” or “good” carbs like whole grains?  (I will comment only briefly on the circularity of that statement, assuming what you are trying to prove - that whole grains are healthy.)

I don’t want to dis the glycemic index too strongly - I myself rarely eat high-GI foods.  However, the GI is not the Holy Grail.  So today, I’d like to examine some shortcomings of the GI for managing healthy blood sugars and healthy body mass composition.  For anyone on the diabetes spectrum (reactive hypoglycemia, prediabetes, Type II, or Type I), the GI is a particularly flawed tool to be used cautiously, if at all.

Problems With How the GI Is Calculated

The GI is calculated by giving healthy volunteers carefully measured amounts of food and monitoring the rise in their blood glucose over a measured period of time.  The main problem is that this tells us nothing about how someone with disordered insulin metabolism will react.  Diabetics with no functioning pancreatic beta cells may see their blood sugar skyrocket and stay high in response to a food that causes a small to moderate rise in a healthy volunteer.  Diabetics with some functioning beta cells may see a smaller rise that also stays high.  Folks with insulin resistance but not much beta cell burnout may see initial high blood glucose readings followed by reactive hypoglycemia when the amount of insulin is finally high enough, and more than high enough, to remove the glucose from circulation.

Our second problem, according to Dr. Richard Bernstein’s excellent book Dr. Bernstein’s Diabetes Solution, is that the amount of carbohydrate in a food may vary by as much as 20% from what is shown on the label or in standard food count tables.  This is believable - we all know that summer tomatoes are sweeter than winter tomatoes, that the amount of nutrients in milk varies based on the cow’s diet, and that a ripe fruit has more sugar than an underripe one.  The GI researchers attempt to control for this by performing the test multiple times on each subject, then averaging the results.  But an average doesn’t predict how much blood sugar might rise if you eat a portion that is 20% off in either direction from the average.  For a diabetic trying to calibrate an insulin dosage, this variance could be a disaster.  According to Dr. Bernstein, minimizing this problem requires eating only very small amounts of carbohydrates, to lessen the impact of that 20% variance.

Third, the availability of carbohydrate varies with preparation method.  Cooking bursts cell walls, making starches and sugars more available.  Cooking and then cooling causes starches to become resistant to digestion, making them less available.  (Bix discusses resistant starch in great detail at Fanatic Cook.)  The GI researchers try to control for this, too, by taking separate measurements of foods prepared in multiple ways.  However, preparation methods, thoroughness of cooking, and serving temperature vary so much that the GI people can’t possibly test them all.

Junk Food In a Health Food Suit

Fourth, we have fructose.  Fructose does not cause blood sugar spikes; thus, foods containing fructose are typically low on the GI.  This does not mean that fructose may be consumed with impunity.  Fructose that is not immediately burned for energy is sent to the liver to be converted into triglycerides.  Triglycerides are then either stored in the fat tissue, leading to obesity, or float around in your blood, where they are a risk factor for heart disease.  (In fact, fructose is the single biggest reason I refer to fruit juice as junk food in a health food suit.  You get around 3 ounces of juice from a medium-sized orange.  That medium-sized orange is one serving, yet many people think nothing of polishing off a 16- or 20-oz bottle of orange juice, around 5 to 7 servings worth of fructose, just at breakfast!)

Beta Cell Burnout

Fifth, the GI does not measure how much insulin the body produces to cover a given rise in blood sugar.  This is important for those people on the diabetic spectrum who still have some beta cell function and want to avoid burning them out through overwork, thereby lessening their lifetime need for insulin injections.  As Dr. Bernstein points out, your pancreas has to make enough insulin to cover 100 grams of carbohydrate regardless of how fast or slow the carb is absorbed.  Whether it pumps it out quickly (when you’ve eaten a high GI food) or slowly (when you’ve eaten a low GI food) doesn’t matter much if you’re trying to preserve beta cells.

What Does It Mean?

As I said, I think the GI can be useful, but it is important to understand its flaws.  People with blood sugar issues may achieve better blood sugar control, need less insulin or oral medication, maintain a healthier body mass composition, avoid the risk of heart disease, and preserve their beta cells better if they limit the total amount of carbohydrate consumed than if they consume large amounts of low-glycemic foods.  Some people may need to combine the two methods, both limiting total carbohydrate and choosing low-GI carbohydrates, to achieve optimal control.  That is, choosing 10 grams worth of salad greens, broccoli, green beans, and cauliflower may be more helpful than choosing 10 grams worth of high-glycemic white rice.  (Furthermore, the flavor, nutrition, and eye-appeal of the green vegetables is greater.)

Most days the combined method is the one I choose, though I would be dishonest if I did not admit that I do, very rarely, trade part of my veggie allotment for a tablespoon of rice or a bite of bread.

Weight Loss Update

I am down to 143 pounds.

This is the lowest weight I’ve ever had, in the downward direction.  People have begun to notice, too - my husband’s oldest friend commented on it when I saw him in San Francisco right after Christmas.  And here’s something really cool - the plus-size boots I bought from Naturalizer several years ago because I wanted tall boots and couldn’t fit my calves into normal ones?  They used to be rather snug, but today I noticed they kind of flop around my calves when I walk.

Maybe next winter I’ll be wearing normal-size boots.  Heck, maybe I could wear them now.

A quick history of my weight loss:

• My highest ever weight was 167 (at 5′ 3″ - yikes), when I started Atkins for the first time in July 2002.
• Over the course of several months (I don’t remember how many, exactly) I lost 24 pounds.  My lowest weight was 143.
• I let way too many things intervene.  Too many so-called “low-carb” specialty products.  Too many “occasional” cheats.  And then at least a few periods of several months when I ate whatever I wanted.  Swore I’d never get above 150 again.
• Hit 155.
• I lost a bit of weight for my wedding in 2006 - I think I weighed in at 149.  Swore - again - I’d never get above 150 again.
• In August 2007 I weighed 161.

So I have lost 18 lbs in 22 weeks, a little less than 1 lb a week.

If anyone ever tells you low-carb is a quick fix, send them my way so I can straighten them out.

When I re-embarked on low-carb in August, I made those little graphs you see above to show how long it would take me to lose weight at 1 lb a week or 2 lbs a week.  The red line is the aggressive target, and the gold line is the moderate target.  The green line is my actual weight.

Note the stairstep pattern.  I have noticed that, immediately after my menstrual period, I shed several pounds in just a matter of days.  Then my weight holds pretty steady again until my next menstrual period is over.  For some reason my last plateau, at 147 pounds, lasted through two menstrual cycles instead of one.  Perhaps this is due to my indiscretion with the damn Hershey’s Nuggets; perhaps it has to do with my eating more fruit and vegetable carbs over the holidays that I would ordinarily consume.  Or perhaps it’s just one of those flukes that happens in complex systems like the human body.  In any case, I think the plateaus are connected to my menstrual cycle, a fact that other women who are struggling with plateaus might find reassuring.  I am certainly reassured during those three weeks every month when the scale doesn’t budge, knowing as I do that I am going to drop 2, 3, or even 5 pounds a few weeks from now.

I can’t wait for 142!  That will be my lowest ever weight.  In fact, provided I stick to my guns, every weight I record for a while will be my lowest ever.

Blog Spotlight: Weight of the Evidence

image from Texas A&M University College of Education and Human Development

I haven’t been writing much lately, for a variety of reasons - travel, contagious diseases, a small promotion at work that’s sucking up much of my time, winter blues (alleviated some by getting back to my daily multiple-mile walks, along with my usual winter cod liver oil supplement - oh, and being able to eat normally after my bout of stomach flu), a backlog of household chores due to travel, illness, winter blues, and work.  And then of course there are two other factors -  that creeping self-doubt that comes from trying to digest conflicting information about a subject that is important to oneself, and the lure of reading other people’s blogs.  I find that more of my “goofing off” is spent reading what other people write (and commenting on it), leaving less time to actually write for myself.

Oh, and one other thing - when I do sit down and write a post, I get almost done and wonder when I became so verbose!  So I set the post aside, intending to edit later, and then something intervenes.  Like, say, another idea for a blog post.  WordPress tells me I have 21 draft posts!  Clearly I have a problem with finishing things.

I don’t know if I’ll ever get back to writing daily - I doubt it - but I hope to post at least a couple of times each week.

Today I’m starting a new series on this blog - the Blog Spotlight.  I’ll shine the Blog Spotlight on blogs that I find to be interesting or informative.  Most of these blogs cover subjects that are dear to the heart of the Migraineur - migraine, low-carbohydrate eating, nutrition, and the strange state of medicine in the U.S.  Human nature being what it is, I will largely cover bloggers who say things that make sense to me, but I promise to also throw some alternative views into the mix.  And finally, as in today’s post, I may use a specific post as a jumping off point for my own views on a topic.

In today’s Blog Spotlight, we have Weight of the Evidence.  Written and researched by Regina Wilshire, Weight of the Evidence is largely devoted to examining research both in favor of and against low-carbohydrate diets.  “Examining” is the key word here.  In my opinion, too many people accept without question what the media says about scientific studies.  If a scientist makes a claim, and it appears in the news, it must be true.  Wilshire, however, is a born skeptic.  She doesn’t settle for reading the news; she obtains the research papers and applies her considerable skill to analyzing the research methods, the data presented, and the conclusions drawn.  Anyone who has done this even once knows that the stories you read in the paper are often oversimplified, uncritical parrotings of the press release from the study’s authors.  In fact, sometimes the data in a research paper support conclusions other than, or even opposite to, the claims of the investigators.  Wilshire’s great gift to the blogosphere is her willingness to find out what that study really shows.

In addition, Wilshire makes some sharp commentary on the news in nutrition and science.  Take yesterday’s post, on a new study that has uncovered one of the mechanisms by which protein consumption causes satiety.  The study shows that protein consumption increases the release of a hormone called PYY.  The conclusion the study authors draw is that we might be able to create the same sense of satiety by giving people PYY supplements.  Wilshire, quite rightly, asks why we don’t just eat protein instead.

This reminds me of the idea of gene therapy for diabetes.  Some of us (lots of us, probably) have genes that make us more susceptible to contracting diabetes in an environment full of grains, sugars, and starchy root vegetables.  Wouldn’t it be nice if there was a gene therapy that made it possible for us to eat all the pasta, bagels, Snickers bars, mashed potatoes, apple pie, ice cream, and corn chips we wanted without fear of contracting diabetes and all its ugly complications?  For a carbohydrate addict like me, with a massive family history of diabetes, this would be a dream come true!

Wait, no, it wouldn’t.  Well, it probably wouldn’t.  We just don’t know.  For one thing, we don’t fully understand all the ill effects that sugar has on our bodies.  Supposing there was a gene therapy that would make us immune to diabetes.  What then?  What other ill effects does sugar have on our bodies?  Does it displace other, more nutritious foods, leading to subclinical deficiencies?  Does it mess with other pathways other than the insulin-endocrine pathway?  We already know it’s bad for our teeth.  Plus, gene therapy is way more expensive than substituting chicken for pasta.  In effect, I’m advocating that, before we go too far down the path of fixing our genes, we try to fix the environment in which those genes are expressed.  For diabetes, that environment is the great mountain of carbs that is the Food Pyramid.

The same thing would be true with a PYY supplement.  Satiety is a complex phenomenon.  PYY surely isn’t the whole story.  There are multiple hypotheses to explain satiety; I’ll name just a few here.

• Fat consumption causes satiety.
• Protein consumption causes satiety.  (PYY)
• Fiber consumption causes satiety.
• Insulin and glucagon regulate satiety.
• The hypothalamus regulates satiety.
• Satiety is related to micronutrient consumption.  Subclinical deficiencies of micronutrients can cause hunger.

These are just the ones that popped into my head without .  How could tampering with one of these factors possibly fix the problem of overeating?  And even if it could, wouldn’t a PYY supplement be more expensive than just, say, eating a couple of eggs?  Besides, unlike PYY, the eggs would cover three of the hypotheses above (fat, protein, and insulin).