Thursday, 28 January 2016

Dangerous advice from dietitians



Many Westerners consume as much as 2g/kg of protein daily. More than enough. The potential dangers of excessive protein consumption as well known. That is why many people who low carb replace the lost carb calories with calories from fat rather than protein.

From one of their websites, it appears that Australian dietitians think it is OK to consume 1.25g/kg of BCAAs. On top of the usual protein intake.
Are they completely ignorant of how the nitrogen in BCAAs is eliminated from the body?
Do they really think that the reference quoted had sufficient sample size or follow-up time to exclude an increased incidence of renal failure in users of that dose? 
Their reference to a dose of 1.25g/kg also ignores the fact that many of the gym crowd who may consider taking this have a weight which exceeds ideal body weight, but no, they they didn't give a recommendation in grams per kilo of ideal body weight.





Addit: People who take BCAAs may also be taking creatine. Add this to your nitrogen load.

Endocrinologist calls Diabetes Australia "irresponsible"

Endocrinologist calls Diabetes Australia "irresponsible"
Also note the 70 likes within hours of this post compared to 2 likes for an alternative point of view.
Dr Lee was referring to a chocolate cake recipe promoted by Diabetes Australia which specified the use of high glycaemic load ingredients from Arnott's, Nestle and SPC, as well as lots of sugar and way too much omega 6.
Yes, diabetics need desserts, but this is a shocker.






Tuesday, 26 January 2016

Health bureaucrats pervert science.

You can read online about the case of Jennifer Elliott who was sacked from her Government employment for recommending a moderately low carb diet to a diabetic patient with poor blood sugar control. It is reported that the patient did well following her advice.

It appears that Health bureaucrats in Australia will go to any length to avoid discussion of the issue in the appropriate scientific forums. Jennifer's advice to the patient was entirely consistent with the evidence based recommendations of the American Diabetes Association and the National Diabetes Education Initiative, who list list low carb eating as a valid  therapeutic option for diabetics and reject placing limits on the percentages of carb and fat a diabetic's diet should contain.

What do these same bureaucrats think of radiologist Troy Stapleton. With Tye 1 diabetes, he travelled to a place remote from medical care, injected insulin, did strenuous exercise, and ate very low carb?

Its not what I would do, but I do commend Troy for moving at least part of the way towards the way I manage my diabetes.


If you believe what dietitians say, don't blame me for your poor health outcomes.

Let's look at some of the claims on the Dietitians Association of Australia website.

Firstly " ..no one who lived in the Paleolithic era actually consumed coconut oil..."

Obviously false. Early humans didn't separate the coconut into component parts before cooking. They just ate the whole insides, including the oil, as do these people from a remote village in PNG I visited some years ago, with no road access, electricity or running water.


The bananas cooking here in coconut are not the soft sweet Cavendish variety, but are fibrous, savoury and require extended cooking.

Secondly "The Paleo diet may be too low in carbohydrate for some people ... who regularly participate in exercise and sport."

Have dietitians actually read a #paleo cookbook? The tapioca flour used in pastries is full of carbs. Lots of recipes use honey and dates. Cavendish bananas are in, as are many other fruits.
Count the calories and carbs in the paleo dessert section. They are NOT low carb.

Have dietitians ever gone online to see how many athletes are performing amazing feats on low carb diets?

Thirdly " Carbohydrate foods are used in therapeutic diets for diabetes to help maintain blood sugar within a tight range."

Do dietitians know anything about "tight" sugar control? The average low carber has much better control than the average patient following dietitians' advice, and then there's the really good low carbers like
diabeticalien.blogspot.com.au
Wow.

NB. I do not eat Paleo. I just hate bad science.

Friday, 22 January 2016

It's Good To Miss Breakfast (sometimes) - Runnersworld rules for eating right

Hundreds of diabetics have complained online that their dietitian has demanded they eat at least 50 grams of carbs for breakfast every day. They are right to complain.

If you are going to spend all morning sitting in front of a computer, you don't need a big breakfast. You don't need Atkins style bacon eggs and spinach. And you certainly don't need a big bowl of chaff covered in bran and wheatgerm, as was recommended by Australian dietitians not so long ago. Talk about a hair shirt for your insides.

Runnersworld.com goes further and says you should even skip breakfast on mornings when you are exercising. Tens of thousands of people do this successfully, but they do it in the right circumstances.
It is not going to work unless certain aspects of your health are up to scratch. If you are considering it, learn the details.

Health Department recommendations are designed to be simple, able to be understand by the average 15 year old, and fairly easy to comply with. They are not designed to be the best approach to health.
If you are willing to work for the best results, study the details, and don't accept simple cliches like "never skip breakfast" from your health professionals.

Wednesday, 20 January 2016

Just how bad are statins?

The question "What dose of statins are you on?" was recently asked on a large diabetes patient forum. Here is a summary of the responses.
2 said they no longer took statins, but did not specify why
1 had recently started, without side effects
1 said statins were only OK if you also took CoQ10
10 said statins had such bad side effects they would never take them again or start them.

The internet is no longer just a soapbox. People of all opinions and experiences are posting. Patient support and discussion forums like this one for diabetics are full of genuine and helpful people giving well meaning advice based on real experience. Of course people with bad experiences are more likely to post, but in this case there is none of the usual warm fuzzy support.

The question posed was not even about side effects. Yet it elicited many reports of them, principally muscle aches, often exercise related. If medical researchers survey a group of largely sedentary patients, many of them on analgesics, the prevalence of muscle pain on exercise is going to look small regardless. Add to that the several reasons why muscle aches are more likely in diabetics compared to non-diabetics

I was not one of the respondents, but I too no longer take statins due to muscle aches while running. Nor do I take ezetrol.

How often do statins cause side effects in physically active diabetics? Ask your doctor why they can't give you a good answer to this question.

More on serious inconsistencies in statin research later.

Sunday, 17 January 2016

Potatoes and Diabetes - The pendulum swings again



I first heard of the problems high potato consumption caused for diabetics 35 years ago, although it is more than 200 years since the first recorded medical advice for diabetics to avoid potatoes.

In my blog post of 9 Nov 2015, "Diabetes doctors are the worst food nazis" I noted that many decades ago, diabetics were advised to seriously restrict their intake that particular "vegetable"

Then along came the Glycaemic Index scientists who provided more insight into one of the reasons why potato consumption causes problems.

Without any evidence, their advice was overturned by the puritanical zealots of the low-fat fad diet, who said potatoes were OK as long as you didn't smother them in sour cream or butter.

The Moderationists said potatoes were OK in moderation, whatever that means. It didn't change anything because every patient can rationalize in some way why their current consumption is "moderate". Nearly everyone knows people who eat more than them.

The Australian Government promoted Plate Model says a quarter of your dinner plate should be carbohydrate. Not even Mr Creosote would complain that a quarter of a large plate of mashed potato was too small a serving.

How much mashed potato do successful older Type 1 diabetics eat on sedentary days? Ask your doctor why the medical profession can't give you an answer to this question.





BMJ 2016;352:h6898


Saturday, 16 January 2016

Anaesthesia News - At Least Six Patient Deaths from central lines - all avoidable



From the latest College of Anaesthetists bulletin

"Last year Incident Information Management System NSW were notified of six patient deaths from central line related air embolus. However, the actual number of deaths is likely to be greater than this due to under reporting from lack of awareness. All cases were avoidable." 

Outrageous. And it's not like it is a difficult problem to avoid.

What has this got to do with Addison's disease, apart from the fact that Addison's patients would like to think that their doctors are at least a little bit competent?  Everything!

Look at the video I shot while lying flat in bed. It shows a pulsating vein in my forearm, just below the elbow which is also resting on the bed. I am breathing quietly. My BP is normal.

Why was I concerned?

What did I do about it?

If you had Addison's and went to your doctor complaining of feeling tired, are you confident that they would diagnose and treat the problem correctly?

Answers to the first 2 of these 3 questions at the end of next month.


VVS again

Friday, 15 January 2016

Avoiding vascular dementia


Diabetes increases the risk of vascular dementia. I fight this with the occasional puzzle.  Ok, I admit it, I do the diabolical from sudokuoftheday.com every day. The puzzle from last Tuesday (12 January 2016) is rated diabolical with a difficulty of 17,500. The published solution uses the forcing chain technique on two occasions. 

Can you spot the simple shortcut that solves this puzzle in a few minutes, without the use of forcing chains, guesswork, multiple path analysis, swordfish or any other convoluted technique?

Answer in a few weeks.

ps Howard from sudokuoftheday.com has confirmed the validity of my method.


Added note The diabolical sudokus of 17.1.16 (rating11700) and 21.1.16 (rating 24100) can also be solved by the application of simple logic, without the use of forcing chains.

Thursday, 14 January 2016

When you allow science to be run by lawyers, you get the results you deserve.

Who knows what went on in this research?
What did the original data show?
How can anyone have confidence in any Australian research if the issues are not open to debate. The public are just "told" by lawyers what to believe.

Banned! - They must be worth looking at.

My views that is.

Why do I blog? There are all the usual reasons. Plus I have a special one. For a long time now I have not been allowed to present at any CME/CPD meeting within ACT Health. Ever since I discovered a mathematical error in a paper which was authored by the friend of a professor.

Doctors seem to think they are smart when they say "no comment" All they are doing is guaranteeing that the problem will move to a different forum. It's not like I haven't discovered any issues worth discussing.

When I offered to present one of these issues at a meeting, I was told "No one is interested"

10,000 views of my combined social media contributions in the last 6 months says ACT Health was wrong.

Optimising steroid dose and type


Here are my mountain running results over a 4 year period.

Hydrocortisone was my only glucocorticoid at the start of this period. My results were occasionally quite good ( I obviously wasn't unfit then), but despite trying all different doses and timings I could not get consistent results. Many have attributed this to the rapid swings in plasma levels from standard treatment. If I got it right, I was ok, but mostly I didn't .

Not only was my performance variable, it was declining over time. Note the paucity of results from 2013.

Substituting some of my HC for prednisolone appears not only to have reversed the decline, but also led to gradual improvement. Starting Pred did NOT cause a sudden improvement, nor did I expect it to. Muscles weak and flabby from a sub-optimal steroid regimen do not recover instantly. It takes many months.

Training is what makes people faster. All good steroid replacment does is allow me  to train with greater frequency and intensity. If I had just sat back and waited for pred to work, it wouldn't have. What do I mean by training? I don't have a coach or a rigid scheme. I ski, skate, climb, run, juggle and so on. I just get out there and have fun. The right steroids allow me to have more intense fun more often.

Veterans Athletics tables show that the average 55 year old Masters competitor gets about 15 seconds slower per year in races that take about 20 minutes. In the absence of any special intervention, I expect that my times would have declined by 5% over the 4 years due to ageing. Instead they are still improving.

I can also use these tables to look at whether I am taking too much steroid. Excess glucocorticoid causes myopathy. Glucocorticoids are not banned from sport because they are performance enhancing per se. They can produce a very short term effect by masking the pain of inflammation and allowing athletes with injuries to compete. This is going to have a deleterious effect in the long term.

Finally, to reiterate a previous point. In optimising my steroid dose, I am meticulous in doing all the physical activity,  lower AND upper body, to mitigate the risk of osteoporosis. I have also learned of the association between cycling and spinal osteoporosis, and factored that into my lifestyle.

Added note : It is not my speed that is important here. It matters not whether I run 5k in 21 or 51 minutes, the important thing is the trend. Ask your local statistician about the power of trend tests. If my times are worsening faster than age-related decline says they should, I want to know why. Improving times suggest I am doing the right thing. Even just maintaining your times as you age is an achievement.
To paraphrase Drucker, if you don't measure it, you can't manage it. Merely feeling that you are doing OK is not a sufficient condition to meet the WHO definition of Health.



Credits : A big thank you to John Harding,  the driving force behind mountain running in Canberra.

Wednesday, 13 January 2016

Recent Addison's disease research from Europe

Recent #Addisons disease #research from Europe finds that a glucocorticoid regimen commonly used by Australian endocrinologists is INFERIOR to an alternative treatment in many respects, particularly for those with diabetes. It also confirms poor quality of life in many patients using conventional therapy.

You can readily find this information online, and that way you will be sure that I am not selectively quoting references. If looking online at recent research is too hard, at least ask your doctor whether you are on treatment similar to the one that was found to be inferior.




Advice from the Canadian Addison Society on glucocorticoid combinations

In response to a question on a mixed glucocorticoid regimen :

"If you have been taking the combination of prednisone and cortisol...and have found it satisfactory, there is no reason to change."

Presumably they think the same about prednisolone and hydrocortisone.

Don't believe something just because the person who told you was a medical specialist.

The #evidencebasedmedicine movement has been around for decades, but the old guard of medicine still cling to the alternative - Eminence Based Medicine. You have to believe something just because a "medical expert" got up and said "the evidence shows...", when it does no such thing. If you want the best answer, look at the evidence yourself. Sackett said look at the best evidence. Don't reject something because it doesn't fit a particular professor's definition of "good" evidence. Did the research study people like you in most respects? Did it measure outcomes that are important to you? eg quality of life, absence of fatigue, ability to play sport at your desired level? Did it measure marginal or conditional probabilities?

My definition of good evidence is quite different from most doctors. Perhaps that is why I am successful. Heckman's Nobel Prize winning work on this subject will be the subject of a future post.
Unfortunately, many doctors only quote Heckman when his methods support their theories. Doctors are terrible at looking for evidence that might contradict their current beliefs.

I am not an endocrinologist, but I do have far more formal education in the mathematical analysis of scientific research than any endocrinologist I know.

Of course you should not believe me just because I do maths. I would be a complete hypocrite if I suggested that. If you want the best answer, learn enough about diabetes, addison's and maths that you can work it out yourself. If you want a simple answer of average quality, do something different.

Tuesday, 12 January 2016

NATIONAL TOP TEN PLACING !

Orienteering Australia has now announced rankings  for 2015 for competitors who race in age classes other than the opens or junior elite (17-20)

I placed 10th in M55s !

A substantial improvement on my previous performance. Read the forums - many Addisonians have trouble just getting out of bed. Score another point for my method of disease management.

As far as I can tell, only one Addison's patient in the world has done as well in their age category in a national event, and he didn't have diabetes.
If you, or someone you know has done better, drop me a line via google plus and I will be sure to include the details here.


(Addison's is more of a lifestyle impediment than type 1 diabetes - subject of a future post)

Why do endocrinologists prescribe treatment that NEVER works (part 2)

I read a story this morning about a 90 kg triathlete whose endocrinologist advised him never to take more than 25 mg of hydrocortisone on an event day and recorded evidence that he had given this advice to the patient for medicolegal purposes.

Lets assess whether 25 mg HC is a good maximum dose for athletic endeavours of this sort by two different methods.

Firstly medical : The vast majority of Australian endocrinologists have never seen a patient with Addison's disease who does triathlons or similar competitively. They might consult Pubmed or similar, but will find very little. Their advice is mostly derived from extrapolation.

Secondly, internet evidence : There are a lot of Addisonians out there. More than 8000 in the UK alone, mostly adults and most with internet access. While not all of them wish to run marathons / ski race / bike race etc, many will. There would be something seriously wrong if very few of them wanted to.

If 25 mg HC was a good dose, at least some people taking that dose would have posted their success online. I can't find ANY. I do, however, find many Addisonians racing successfully on much higher doses.  Like 15-20 mg Prednisone (approx eq 60-80 mg HC)

You can also look online to see what Addison's athletes take on rest days. It is not what your endocrinologist may have led you to believe.

So many people are now online, that internet evidence gives a much better picture of what is happening in some areas than medical research.

Take home message for the day : Look at what is NOT on the internet. If you can't find any first hand accounts of success with the treatment you are using, start asking questions.


Monday, 11 January 2016

Why do doctors prescribe a treatment that NEVER works well?

I have spent hundreds of hours scouring the internet. I have requested information from many different diabetes discussion forums in many countries around the world.

There is a lot of data there. There are tens of thousands of diabetics on diet forums, many posting about what they eat and what they do.

Yet I have been unable to find even a single person who meets the following criteria
1. Age and disease duration equal to or greater than me.
2. Complication free
3. Physical capabilities sufficient to enjoy a range of outdoor sports
4. Eats a low fat diet, uses low fat cheese etc on days when they are sedentary.

I am unable to find any evidence that low fat diets work really well in the long term for people with Type 1.
I do, however, find many very successful diabetics whose dietary fat to carb ratio far exceeds that recommended by Australian Government health authorities.

Doctors are no help. They consistently refuse to collect any formal data on the long term effects of various diets which might cast doubt on their pet theories. That leaves the internet as the current best source of information, even if it is far from perfect. Ignore it as your peril.




Additional notes

1. What athletes eat on training or competition days is irrelevant. 300 grams of carbs a day with little fat does NOT stop you achieving goals of normal blood sugar and low insulin levels if it is consumed during a long day in the mountains, on foot, skis or bike. This practice shouldn't be used as evidence to support a low fat / high carb diet generally.

2. Many people with diabetes claim to have an "individual" diet that works for them. How do they know it will work in the long term? Most of us will die from cardiovascular disease or cancer, not an abnormal HbA1c. How do they know that their current levels of consumption of sugar, fat and insulin are not increasing their individual cancer risk, or the amount of atheroma in their own cerebral arteries? Evidence of long term effect can only come from population studies.





Sunday, 10 January 2016

Identifying Dodgy Research - part 1

Lets attack this problem in pieces. Firstly, are there particular specialties that are more likely to be involved? Yes. I am not the first to notice that anaesthesia is grossly over-represented in the list of culprits.

The Scientific American in 2009 referred to anesthesiologist Scott Reuben as "A Medical Madoff", who faked data in 21 studies.
As noted by Retraction Watch, this number of withdrawn studies was eclipsed by Joachm Boldt. The current record holder is Yoshitaka Fujii, who is reported by Retraction Watch to have fabricated his results in at least 172 published studies.

Anesthesiologists "have an absolutely horrifying track record in terms of retractions," according to a researcher who studies ethics quoted by Retraction Watch. You would think that the profession would get its house in order after the first scandal, but no, that didn't happen.
Also of note is the extreme persistence of the complainants in these cases, in the face of a serious reluctance by anaesthetists to criticise their colleagues. It is likely that many complainants have not been so doggedly persistent and have let dodgy research remain on the books for the sake of their careers.
Anaesthetists comprise only a small percentage of medical specialists, yet the retractions from just these three are far more than proportional.

Is the problem now under control? I think drugs in sport would be an appropriate metaphor here. The bureaucrats say they have testing and policies against it, yet the truth is quite different.

Noted anaesthesia academic Dan Sessler, with whom I have discussed research, is more concerned with widespread minor misconduct, rather than outright fraud. Some of his particular concerns include unreported data selection, and outcomes and hypotheses which are not specified in advance.
He believes that the likelihood that these are more common than fabrication means they probably contribute more to scientific error.

There is indisputable evidence that the problems noted by Sessler are still occurring here, and that Australian research regulators are doing little to stamp out the practice. The RACP has declined to comment on the evidence. (Yes, RACP. It is not just an anaesthesia problem.)

Next time you read a scientific paper, check whether there is a statement that all data has been reported on, or an explanation given for why it was not.