Question for The Expert:

What really is the best diet for diabetics to follow for weight loss? Everything is so confusing.

I have been following Dr.Richard Bernstein, the diabetes diet, but it is very tough and I am

sick of meat already.

Thanks.

Answer:

Dear "Meatless in Seattle"

I am not one for "fad" diets that people cannot sustain for a lifetime as
diabetes will not go away. Instead I recommend a visit to your "friendly
neighborhood" dietitian certified diabetes educator (CDE) to establish an
individualized meal plan. The key to weight loss is fairly simple -
getting yourself into a negative calorie balance. Meaning taking in less
calories in a day than you burn. How to do this is also fairly easy to
accomplish. Eat a well balanced diet, don't skip meals, and exercise. What
you eat is not as important as portion control!!! A well balance diet of
health foods is the best diet. There is really not much you cannot eat -
the key is moderation and portion control. Also be sure to eat breakfast
as missing breakfast puts people at risk for weight gain and obesity.
Lastly, exercise is key!! Moderate intensity aerobic exercise (a brisk
walk) for 30-45 minutes 5 days a week is ideal. Exercise not only burns
calories but also increases the body's metabolism. If you want to follow a
diet then I would recommend Weight Watchers as their program emphasizes
all the things I outlined above and is a diet people can follow for a
lifetime.
Good luck,
Andrew S. Rhinehart, MD, FACP, CDE

Question:

I wasn't sure what information you needed so I copied and pasted the questions you asked someone else so that you can have a better idea of my father's case. He is 61 years old, he is overweight and does have high cholesterol which is being controlled by a medication(atorlip) prescribed by his doctor. But he is otherwise healthy and has had no major health issues in the past.
What type of diabetes does he have?
A. Once the blood sugar was high (PP 200mg) and was diagnosed to have diabetes Type II NIDDM.
June 2009, HbA1C=7.10 (Normal Range=4.40-6.4)
November 2009, HbA1C=6.40
February 2010, HbA1C-6.90
What diabetes medication does he take?
A. Metformin 500mg in June 2009 for 5months. Had hypoglycemic attacks and discontinued. Still gets hypoglycemic attacks around noon time but takes breakfast of only one glass vegetable juice and one cup of coffee.
Does the hypoglycemia only occur after eating?
A. Not usually. But it has happened twice or more even after breakfast.
How low will his glucose get?
A. 45 mg/dl
Is there a reason for my father's recurrent hypoglycemia? Can you recommend any tests he has to undergo? Are there anything underlying health problems that's causing this?

Thank you!

Answer:

I am definitely concerned that with his hypoglycemia and having elevated C-peptide & Insulin level at that time would be inappropriate. With hypoglycemia the body should be suppressing the insulin production. 

The next test would be for him to fast and check glucoses hourly until his glucoses are <45 mg/dl and at that point check an insulin level, sulfonylurea levels, & c-peptide as the diagnosis of an insulinoma (an insulin-producing tumor) would necessitate his glucose to drop below 45 mg/dl. If this is abnormal (meaning an elevated c-peptide & insulin level) that would prompt radiologic imaging of the pancreas to look for a tumor -- these can be very small and hard to find at times.

Good luck,

Andy

Question:

I wasn't sure what information you needed so I copied and pasted the questions you asked someone else so that you can have a better idea of my father's case. He is 61 years old, he is overweight and does have high cholesterol which is being controlled by a medication(atorlip) prescribed by his doctor. But he is otherwise healthy and has had no major health issues in the past.
What type of diabetes does he have?
A. Once the blood sugar was high (PP 200mg) and was diagnosed to have diabetes Type II NIDDM.
June 2009, HbA1C=7.10 (Normal Range=4.40-6.4)
November 2009, HbA1C=6.40
February 2010, HbA1C-6.90
What diabetes medication does he take?
A. Metformin 500mg in June 2009 for 5months. Had hypoglycemic attacks and discontinued. Still gets hypoglycemic attacks around noon time but takes breakfast of only one glass vegetable juice and one cup of coffee.
Does the hypoglycemia only occur after eating?
A. Not usually. But it has happened twice or more even after breakfast.
How low will his glucose get?
A. 45 mg/dl
Is there a reason for my father's recurrent hypoglycemia? Can you recommend any tests he has to undergo? Are there anything underlying health problems that's causing this?

Thank you!

Answer: 

The first thing I would do is double check his medication list for 2 reasons: 1) Metformin is unlikely to cause hypoglycemia, especially at the very small (subtherapeutic) dose he was taking & 2) It would be very unusual to have hypoglycemia on diet alone especially into the 40-50 mg/dl range. Be sure he is not taking another oral antidiabetic medication such as Glipizide, Glyburide, Gliclizide, or Glimepiride as these are common causes of hypoglycemia.

If this is not the case I would ask if he has had gastric bypass surgery as this is a common cause of reactive hypoglycemia (hypoglycemia after eating). The best diagnostic test of hypoglycemia is for him to fast (at his doctors office or a lab) and see if his glucose drops and if so he should have blood drawn to check an insulin level and a glucose when his fingerstick glucose is below 50 mg/dl. (this test looks for very rare insulin producing tumors) He could also perform an oral glucose tolerance test to help diagnose reactive hypoglycemia. Reactive hypoglycemia is treated with dietary measures such as small frequent meals, avoiding concentrated sweets, and a lower carbohydrate & higher protein type diet.

Let me know what happens,

Andrew S. Rhinehart, MD, FACP

Q: Hi Dr. Rhinehart,

Thanks so much for your help. My father and I have an appointment on the 12-9-09. He thinks reducing the mg from 10 to 2.5 may help. I have made a list of the medications. I'll see what he thinks then.

Thanks, Lisa

A: I  did miss the most obvious of recommendations (decrease the dose of the Glipizide). Whoops!! LOL!! But any dose can still cause hypoglycemia so be prepared by keeping glucose tablets or other rapidly acting carbohydrates available (regular soda or juice). To treat hypoglycemia I would recommend 15 grams of carbohydrates (3-4 glucose tablets or 4 ounces of soda or juice) for a glucose of 50-70 mg/dl or 30 grams of carbohydrates for a glucose less than 50 mg/dl then recheck a glucose in 15 minutes and if still less than 70 retreat and if above 70 then eat a meal if it is mealtime or a snack if between meals. For severe hypoglycemia in which the patient cannot eat or drink a Glucagon injection would be advises -- you may ask his doctor if keeping a Glucagon Pen available would be advised.

Keep me up to date.

Andy

Q: Hi Dr. Rhinehart,

My father is a type 2 diabetic. He has been on dialysis for 6yrs and receives treatment three days a week. He is 65 years old, 6'6'', and weights 220. The lowest reading for his glucose was 42. Yes, his blood sugar level drops every two hours by 33 to 36 points if he doesn't eat anything sweet. He was on Glipzida but the doctors have put him on a need to use basis until we find out what's wrong. The doctor told me to not let it get over 200. This means I'd have to test my dad every hour because once he eats something sweet it spikes by 80-100 points

He's never had hypoglycemia problems before. He hasn't changed his diet or medications in the last three years. Please let me know if you need anymore info. He does use the patch for high blood pressure.

Thanks again,
Lisa

A:The cause of his hypoglycemia is two fold:

1) Glipizide is a long-acting sulfonylurea that causes the pancreas to release insulin and since Glipizide is long-acting it continues to cause this insulin release even between meals therefore --> hypoglycemia.
2) Kidney failure cause the action of insulin to be "exaggerated" since the kidney is the organ that clears insulin from the body.

That being said I believe there are a number of treatment options:
Stop the Glipizide and try one of the below options:
1) Start another medication or a combination of medications that do NOT have hypoglycemia as a side effect such as Actos® and/or Januvia®
2) Change the Glipizide to another shorter-acting sulfonylurea that is therefore much less likely to induce hypoglycemia such as Prandin® or Starlix®. These are typically taken immediately before a meal and they only cause insulin release for a short period of time to control the after eating glucoses.
3) The last option would be rapid-acting insulin at a very low dose before meals for after eating glucose control.
Good luck.
Keep me up to date.

Andy

Q:Hi Dr Rhinehart,

My dad has started to have hypoglycemia problems. His sugar drops by 33-36 points every two hours after eating. I have to give him his medication to lower his blood sugar after he raise it when he eats sweets.

The doctors he has now is a renal specialist and doesn't have a clue as to what's wrong. Can you help us?

Thanks
Lisa

A: I would love to help but would need more information. 
What type of diabetes does he have?
What diabetes medication does he take?
Does the hypoglycemia only occur after eating?
How low will his glucose get?
Does he have kidney problems?

Andrew S. Rhinehart, MD, FACP

Q:  Hi Dr. Andrew, I am Egyptian medical student and I am very intersted in diabetes as my dad is a diabetic person and he refuses in some way to see a doctor to arrange his diet or anything he take insulin as a treatment but many times he became hypoglycemic and he makes strange movemnts and reactions and his reactions get so confused some time he shout at me some time laugh very loudly without showing any reason for this and I feel scared of this .... 

my question is how to discover hypoglycemia and treat it? also does hypoglycemia lead to mental problems?? 
thank you

A: This is a very common problem for people taking insulin. The first question I would have would be what type of insulin is he taking? The newer analogue insulins are much less likely to cause hypoglycemia and he may need a change in ther type of insulin he is taking. He needs to look for patterns to the hypoglycemia and discuss them with his provider as discussed in my article on Factoidz.com -- http://factoidz.com/treating-diabetes-getting-the-most-from-your-healthc...
Also read my article on factiodz.com regarding hypoglycemia -- http://factoidz.com/hypoglycemia-in-diabetes-knowing-the-symptoms-and-un...
If the first symptom your father develops is a personality change he then as a degree of hypoglycemia unawareness in which he is possible not experiencing the early symptoms such as weakness and feeling shaky. In people with hypoglycemia unawareness it is best to relax the treatment goal in order to prevent hypoglycemia that can be not only scary but also dangerous. He may also need a prescription for glucagon that a family member, friend, or caregiver could give if he is unable to take oral carbohydrates.
There is some data to suggest that recurrent episodes of severe hypoglycemia may cause some loss of brian function and possible early dementia; therefore, prevention of these episodes with a change in his insulin regimen is the best option.
I hope this and the articles are helpful. Both of my books discuss this issue indepth and may also be of help

Q:  Thank you Dr.Andrew,,, really I appreciate all your great effort :) 
my father is taking (mixtard 30) insulin,, and actually I don't know is this type is good for him or not?? also he takes it twice a day the first one before breakfast and the other one before lunch then he goes to bed so he may have hypoglycemia while sleeping and I don't know if he feels the first symptoms of hypoglycemia or not? please Dr.Andrew can you tell me what is better in case of hypoglycemic coma injecting glucagon or injecting glucose?? also I want to ask about the loss of the brain function and dementia after hypoglycemia can be permanent or temporarily and it is rarely or commonly recorded?? 
sorry for asking too many questions but I consider my father as a good one and I love him so much ..... 
thank you Dr.Andrew for those amazing useful links ..... 
Sarah Kamal

A:  I am not exactly sure of the insulin either as insulins have different names in different countries but it sounds like a mixed insulin -- these have a higher incidence of hypoglycemia than some other insulins. He needs to discuss this with his healthcare provider and consider a change in his therapy or at least a dose reduction.
Glucagon is best for severe hypoglycemia as it can be given as an intramuscular injection while glucose must be given intraveneously which is obviously not always practical unless hospitalized with IV access.
Since hypoglycemia can lead to loss of brain cells I would believe some of the effects could overtime be permanent if this is happening frequently and is severe in nature.
Andrew S. Rhinehart, MD