Improving Sight in People With Diabetes & Diabetic Retinopathy

Clinical trial tests effects of supplements for vision

By A. Paul Chous, MA, OD, FAAO 
Tacoma, WA

I have written previously that the main reason people with diabetes have trouble seeing on an eye chart is the same reason other people without diabetes have trouble – because we need a recent eyeglass or contact lens prescription to correct for nearsightedness, farsightedness, astigmatism, and presbyopia (see my previous dLife column, "Nearsightedness, Farsightedness and Astigmatism – What's the Difference," February 2008). Beyond this, a good deal of research shows that people with diabetes have problems with seeing in the ‘real world,' where what we need to see is not typically black letters on a white background, but objects with low contrast (a grey car on a cloudy day) and in low light (driving at night). Moreover, people with diabetes are more likely to have problems with color vision and efficient processing of visual stimuli received by the eye and interpreted by the brain (see my previous dLife column, "Macular Pigment and Diabetes," October 2012). The question is – can anything other than eyeglasses, contact lenses, or LASIK treatment help with these kinds of visual function issues? Consider supplements for vision.

We now have evidence that a novel, multi-component nutritional supplement may protect and improve visual function in people with both diabetes and diabetic retinopathy, and that the same formula preserves normal retinal structure and metabolism in an animal model of diabetic retinopathy. The formula consists of a number of molecules previously shown to positively impact eye health of animals with diabetes, and some studies of humans with diabetes: lutein, zeaxanthin, benfotiamine, Pycnogenol , alpha-lipoic acid, resveratrol, curcuminoids, vitamin D, n-acetyl cysteine, omega-3 fatty acids, and several others (for more information, see my previous dLife column, "Doctor – Can't I Just Take a Pill? (Part 2), December 2007). All of these components are currently available over-the-counter as nutritional supplements; the novelty of this formula is that they have been put together in a single capsule for ease of use and synergism.

In rats with diabetes, this formula was shown to minimize damage to the energy-producing mitochondria within retinal cells, to normalize electrical activity within the retina (assessed by electro-retinogram), to lower levels of pivotal proteins that lead to severe diabetic retinopathy (nuclear-factor Kappa Beta – nfKB. and Vascular Endothelial Growth Factor – VEGF), and to prevent early damage to capillaries delivering blood to the retina1(a crucial event in the development of diabetic retinopathy.)

To assess the effects of this formula in human beings, I am running a clinical trial in my Tacoma, WA practice called the Diabetes Visual Function Supplement Study (DiVFuSS)2, a six-month, placebo-controlled study investigating contrast sensitivity, color vision, visual field sensitivity (detecting dim flashes of light on a light background), retinal integrity (using optical coherence tomography – OCT – a sort of optical ultrasound) and a survey of symptoms associated with diabetic neuropathy, as well as blood tests to detect proteins associated with diabetic retinopathy, in people with pre-existing diabetes and either no or mild diabetic retinopathy.

Although the study is not yet completed, peer-reviewed, or published, data from the first 46 people to complete the trial show statistically significant improvements in contrast sensitivity, visual field sensitivity and color vision, reduced symptoms in patients with diabetic neuropathy, and reductions of C-reactive protein (CRP), a chemical implicated in diabetic macular edema. Subjects on placebo showed no such improvements. No side effects have been reported thus far, and a number of study participants have commented that their vision ‘in the real world' is dramatically better. Two patients on the test formula have also shown a marked lessening of their diabetic retinopathy (see images below). Additional studies of the formula, including its use in patients with more severe retinopathy, and as an add-on therapy in patients with sight-threatening retinopathy requiring laser or injection therapy, are being planned. The formula is now available as EyePromise DVS through eye doctors' offices or on-line. Stay tuned.

Image of patient's left retina at beginning of our study. Note the white spots (hard exudates) signifying leakage of protein/fat from the retinal blood vessels.	Image of the same eye at study completion. Note resolution of hard exudate.

Prenatal Nutrition for Mother's Day!

The following guidelines were developed to help you get the best possible nutrition for you and your baby. These guidelines are only recommendations and may need to be adjusted if you are under or overweight, unable to eat, have special dietary needs or food allergies; or if you are carrying more than one baby. If you are concerned about weight gain or need help using a food guide, talk to your health care provider about a referral to a prenatal nutritionist.

Food guidelines

The USDA food guide for pregnant and/or breastfeeding women (My Pyramid Plan) which you can use to get your own individualized nutrition plan is located atwww.choosemyplate.gov/. Go to the site and click on "Pregnancy and Breastfeeding".

Key nutritients

• Protein
• Folic acid and other vitamins
• Calcium
• Micronutrients, including iron

Food servings recommended per day:

• 6-11 breads and cereals
• 3-5 vegetables
• 2-4 fruits
• 2-3 protein/protein alternates (6-9 oz per day)
• 2-3 dairy
• Drink 8 or more large glasses of water

Recommended weight gain during pregnancy

Weight gain usually occurs at a smooth, gradual rate during pregnancy. For the first three months, expect to gain a total of 2 to 5 pounds. During the remaining six months, the normal rate of weight gain is about 2 to 6 pounds per month or one pound per week. The average expected weight gain is 25 to 35 pounds if you begin a pregnancy at a desirable weight and are carrying only one baby. A variety of weight gain levels can result in healthy babies. What is important is to gain enough weight to keep you and your baby healthy. The amount of weight gain needed depends on your height and weight before becoming pregnant.

Range of weight gain*

• If you start pregnancy underweight, the recommended total weight gain is 28 to 40 pounds.
• If you start pregnancy at desirable weight, the recommended total weight gain is 25 to 35 pounds.
• If you start pregnancy overweight, the recommended total weight gain is 15 to 25 pounds.
• If you start pregnancy very overweight, the recommended total weight gain is 15 pounds.
• If you are pregnant with twins, the recommended total weight gain is 35 to 45 pounds.

* Women who are shorter than 5'2" should gain weight within the lower ranges. Teenagers and women who smoke should gain weight within the upper ranges. You never want to lose weight while pregnant. 

A note on the psychological aspects of pregnancy weight changes

The topic of weight and weight gain can be a source of concern and anxiety for some women. However, pregnancy is the ideal time to embrace your body as it gradually changes in shape and size. Remember, pregnancy is a temporary state. With good nutrition and exercise, there is every reason to expect that you will return to your pre-pregnancy weight after your baby is born and your body has recovered from the birth. 

May 9, 2014 Diabetes Rates Skyrocket in American Youth Diane Fennell

The prevalence of Type 1 diabetesand Type 2 diabetes jumped by 21% and 30%, respectively, in US youth over an eight-year period, according to new data from the SEARCH for Diabetes in Youth Study. An estimated 215,000 Americans under the age of 20 have been diagnosed with diabetes,according to the National Diabetes Education Program.

Type 1 diabetes is an autoimmune disorder in which the immune system attacks the insulin-producing cells in the pancreas, causing it to secrete little or no insulin. Type 2 diabetes is defined by insulin resistance, a condition in which the body does not use insulin efficiently, and insufficient insulin secretion by the pancreas.

To estimate changes in the prevalence of Type 1 and Type 2 diabetes in youth in the United States, researchers collected data from more than three million children and adolescents seen at centers in California, Colorado, Ohio, South Carolina, and Washington state, as well as on American Indian reservations in Arizona and New Mexico. The data was collected between 2001 and 2009 and included cases of doctor-diagnosed Type 1 diabetes in children ages 0–19 and Type 2 diabetes in children ages 10–19.

In 2001, the prevalence of Type 1 among the study subjects was 1.48 per 1,000, which had increased to 1.93 per 1,000 by 2009. After adjustment, this represented a 21% increase in the condition over the eight-year study period. The greatest increase was seen in adolescents 15–19 years old. The rise was not confined only to the traditional at-risk group of white adolescents, but rather was seen in children and adolescents of white, black, Hispanic, and Asian Pacific Islander descent.

"I don’t understand the basis for an increase," said Robin S. Goland, MD, of the Naomi Berrie Diabetes Center, who was not involved in the research. "There are a few possibilities, but we need to figure it out if it’s something in the environment or something in our genes."

The prevalence of Type 2 diabetes in the study population was 0.34 per 1,000 in 2001, increasing to 0.46 per 1,000 in 2009, representing an increase of roughly 30.5% in eight years. A significant increase was seen across all age groups and in white, black, and Hispanic youth. This rise was likely attributable to the obesity epidemic and the long-term impact of higher rates of gestational diabetes, according to the researchers.

"Our study is really the first in the US to quantify the burden of Type 2 diabetes at the population level — and not just in a clinic or group of clinics, [but] in all major racial/ethnic groups in the US — and documents increasing trends in several racial-ethnic groups," said lead study author Dana Dabelea, MD, PhD.

The rise in diabetes cases in youth is important, the researchers observed, because these children will enter adulthood with several years of diabetes duration and an increased risk of early complications. The youth will also have diabetes during their childbearing years, which could increase the diabetes rate in the next generation.

Further study is needed to address the cause of the increases in Type 1 and Type 2, the study authors note.

Because the study ended in 2009, it cannot provide information about diabetes trends in youth over the past five years. Also, because it included only children and adolescents who had been diagnosed with diabetes by a physician, it may have missed those who would have met the criteria for the condition had they been screened.

For more information, read the article "Large increase in type 1, 2 diabetes among US youth, study shows" or see the study in Journal of the American Medical Association.And for more about diabetes in children, click here.

What do you believe accounts for the increasing rates of Type 1 and Type 2 diabetes in American youth? Let us know with a comment.

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Insulin Myths and Misconceptions from DLife!

How much information out there about insulin is actually true? Can insulin cure diabetes? Do insulin injections hurt? Can I get addicted to insulin? If you're looking for the facts, read on to discover the truth behind the top ten most common insulin myths.

1. MYTH: Insulin cures diabetes.

Currently there is no cure for diabetes. Instead, insulin is a method of controlling diabetes. Insulin supplements what the beta cells of the pancreas cannot make. Insulin converts glucose into energy and is used to manage diabetes and control blood glucose levels.

2. MYTH: Insulin injections will disrupt my life.

If your doctor prescribes insulin, don't panic. You will not be confined to home, destined to never travel again. Instead you will find in time that insulin injections will simply become a part of your daily routine. Your doctor can design a dosing schedule that will fit your lifestyle and various types of insulin are available for different needs. Convenience devices like insulin pens and pumps may provide even more flexibility in your daily life.

3. MYTH: Taking insulin means I have failed at managing my diabetes.

Using insulin is not a sign of failure to control your diabetes. Nor is it an indication of severe health problems or proof that your risk ofdiabetes complications has increased. Try as you might, the beta cells in your pancreas are not under your control. All people with type 1 diabetes must take insulin. And after years of successful management, it is not uncommon for people with type 2 diabetes to reach a point where improved glucose control can only be obtained by using insulin. This is not your fault. It is a natural progression of type 2 diabetes.

4. MYTH: Insulin injections hurt.

A fear of needles is a common complaint for many people taking injections. However, today's insulin syringes and pens are virtually painless. The best way to overcome this fear is to tryinsulin injections yourself. Your primary care physician can show you how to administer the injection. If you try it yourself and still feel pain, discuss this with your doctor. Your injection method and even the temperature of the insulin could be a factor.

5. MYTH: If I take insulin, I will have more hypoglycemic events.

Using insulin can increase your risk of hypoglycemia but there are insulins available that make hypoglycemia less likely to occur. Among people with type 2 diabetes, hypoglycemic events are rare.1 Learning how to properly determine how much insulin you need is the first step to preventing hypoglycemic events. But it is important to also learn how to treat low blood sugar in case of an emergency. Talk to your doctor about ways to prevent hypoglycemia.

Insulin Effects

 

6. MYTH: Insulin will make me gain weight so I shouldn't use insulin.

Insulin can in fact stimulate the appetite but its benefits outweigh its risk of weight gain. In fact, it is excessive eating that causes weight gain. Ahealthy diet that includes portion control, fruits and vegetables, as well as regular exercise remains the most effective way to control weight gain.

7. MYTH: Insulin is addictive.

You cannot become addicted to insulin. It is a natural substance that the body requires. It is understandable that using a needle to inject insulin might provoke thoughts of drug use and addiction, so if using syringe needles in public causes you concern, try going into a bathroom or talk to your doctor about other methods you can use to administer your insulin, such as pumps.

8. MYTH: It does not matter where insulin is injected.

Where you inject your insulin determines rate of absorption. Injection around the abdomen has the fastest rate of absorption, while the thighs and buttocks are the slowest. Injecting in the arm falls somewhere in between. Wherever you inject your insulin, be sure to inject into a fatty subcutaneous area of your body. Also, it is a good idea to rotate injection sites. Multiple injections in the same place can cause fat deposits to build up under the skin, which can delay insulin absorption.

9. MYTH: Once you start insulin you cannot stop.

Type 1 diabetes is defined as such because insulin-producing beta cells within the pancreas are gradually destroyed and eventually fail to produce insulin. Therefore people with type 1 diabetes require insulin. The treatment for type 1 diabetes also includes a proper diet and exercise. People with type 2, however, are still able to produce insulin at diagnosis but over time, the overworked beta cells of the pancreas can wear out completely and lose the ability to secrete sufficient insulin. People with type 2 may be treated with insulin at one time and then switched to oral medications or other injectable diabetes medications. Some people may even be able to decrease their medications as their blood glucose improves and others still may find they are able to stop taking medications altogether once they lose weight and improve their lifestyle.

10. MYTH: Using insulin means I can eat the way I want.

Great theory, but actually a poor diet means you need more insulin to lower your blood glucose levels. Insulin, like oral medications, are only a part of the diabetes treatment plan. The most effective way to use insulin is in combination with a healthy diet and exercise. However, insulin or any other diabetes medication cannot take the place of you taking care of yourself.

Are You Protein Deficient? By Lara Rondinelli, RD, LDN, CDE

Lots of people trying to eat healthy don't get enough of this crucial nutrient

The daily menus below are actual food records from patients of mine who thought they were eating very healthy diets. See if you can spot the problem. One eats a vegetarian diet and the other does not.

Vegetarian ("Lacto-ovo," i.e. eats eggs and dairy products)

Breakfast — 1 cup Raisin Bran and 1 cup skim milk
Lunch — 1 cup rice, 1/2 cup lentils, and 30 grapes
Dinner — 1 cup spinach and eggplant, 2 slices whole-wheat pita bread, 1/2 cup white rice
Snack — 1 apple, 1 oatmeal cookie

Non-Vegetarian

Breakfast — 1 banana, 1 whole-wheat bagel with light cream cheese
Lunch — green salad with 2 ounces chicken breast and light balsamic dressing, 1 can "healthy" cream of broccoli soup, high-fiber granola type bar (30g carbs and 2g protein)
Dinner — 2 cups whole-wheat pasta with marinara sauce (with green peppers and zucchini), 1 whole-wheat roll
Snacks — 1 cup sugar-free pudding, 30 baked tortilla chips with salsa

In the vegetarian record above, the protein sources are skim milk and legumes. Most of the other foods, such as the cereal, rice, bread, and the cookie, provide large amounts ofcarbohydrate and little protein. In the non-vegetarian example, the main protein source is chicken. Although both patients were trying to eat lowfat, high-fiber foods, their diets were inadequate in protein and excessive in carbohydrate, which is very common. When people don't eat enough protein, it's easy to overeat carbs in an effort to feel satisfied.

Why is Protein Important?

Proteins function as building blocks for bones, muscles, cartilage, skin, and blood, as well as for hormones and vitamins. Protein is the structural component of all cells in the body. During digestion, proteins in food are broken down into amino acids, which the body uses in all those ways. Nine of the amino acids must be supplied by our diet (they're not made in the body); these are called essential amino acids. All nine essential amino acids are found together in animal products. Protein is important for people with diabetes for another reason: They don't raise blood glucose levels like carbohydrates do.

What Foods Contain Protein?

Meat, eggs, and milk are all considered excellent sources of high-quality (or complete) protein. Some plant-based foods contain good amounts of protein, but in general they don't contain all the essential amino acids and so are not "complete" protein.

When you combine certain incomplete protein foods you can form a complete protein. For example, you get a complete protein when you combine grains (such as barley) with legumes (such as lentils), or legumes with nuts. In the past, it was thought that complementary proteins needed to be eaten at the same meal for your body to use them. But studies have since shown that your body can combine proteins as long as they're eaten within the same day.

Protein sources for vegetarians include eggs (for ovo-vegetarians), beans, lentils, peas, nuts, nut butters, and soy products (tofu, tempeh, veggie burgers). It should be noted that many vegetarian protein sources, such as beans, lentils, and some soy products also contain large amounts of carbohydrate and should be counted carefully.

How Much Protein Do I Need?

The protein recommendations for adults are 0.8 grams protein per kilogram of body weight. For a 150-pound woman, this equals 55 grams protein per day. For a 220-pounds man, this equals 80 grams protein per day.

A 3-ounce portion of meat (roughly the size of a deck of cards) contains about 21g of protein. A 4-ounce chicken breast or pork chop contains about 28 grams protein.

* 1 ounce equivalent of protein includes:

• 1 ounce of meat, poultry, or fish
• 1/4 cup cooked beans
• 1 egg
• 1 tablespoon of peanut or almond butter
• 2 ounces tofu
• 1/2 ounce of nuts or seeds (12 almonds, 24 pistachios, 7 walnut halves) 

• To make things very simple, I tell people to try to include a protein source with every meal. It can sometimes be difficult to get protein atbreakfast every day (so do your best), but definitely eat the protein with lunch and dinnerdaily.

  Here are some ways the vegetarian and non-vegetarian (from the example at the beginning) can work in proper amounts of protein in their diet.

  Vegetarian ("Lacto-ovo," i.e. eats eggs and dairy products)

  Breakfast — 1 egg, 1 whole-wheat pita bread, 1/2 cup strawberries
  Lunch — 1/2 cup barley, 1/2 cup lentils, and large green salad with tomatoes, cucumber, sunflower seeds, and olive oil and vinegar dressing
  Dinner — 1 cup spinach and eggplant, 1/2 cup quinoa with 1/2 cup kidney beans and almonds, 1 small pear
  Snacks — Morning: small apple with 1 ounce cheese
                   Afternoon: 4 ounces Greek plain yogurt

  Non-Vegetarian

  Breakfast — 1 smoothie made with 1 cup plain yogurt, 1/2 cup blueberries, 1/2 cup strawberries, 1 slice whole-wheat toast
  Lunch — green salad with 3 ounces chicken breast and balsamic dressing, 1 cup black bean soup, 1 small pear
  Dinner — 3 ounces pork tenderloin, 1/2 cup sweet potatoes, 1 cup zucchini, 1 cup milk
  Snacks — Morning: 1/2 cup sugar-free pudding
                   Afternoon: 3 cups popcorn

The Life of a Needle

There's a lot of diabetes happening in my house. I'm a type 1 and my wife is a type 2. One Saturday morning recently she drifted into the kitchen and said, "Hey, babe, I'm starting a new Byettapen. Should I move the old needle over to it, or put a new one on?"

"Well, that depends on how long you've been using the needle," I said.

There was a long hesitation. A hint of a shadow flitted across her dark eyes.

"Ah…. How long have you been using it?" I finally asked.

She shrugged one shoulder. "It's the same one you put on when you showed me how to use the pen."

My head crunched the math. "You used the same needle all month?"

"Uh-huh."

"Sixty shots?" I asked, shocked. I run the diabetes education and treatment program for a rural nonprofit health center. I've seen needle use stretched out quite a bit, but right here under my own roof was a new record.

"Yeah..."

"Well, OK then, I think you can change it now, Hon," I told her, recovering my wits. "We got our money's worth out of that needle."  (Note: the retail cost of a pen needle is 22¢)

So, OK, I confess that was an extreme case of needle use. And my lovely bride tells me that she never noticed any pain using an arguably over-used needle. But how many times could you use a needle? How many times should you use a needle? And what about those little lancets that you use to poke your finger? Can they be stretched too?

In short, how long can you, or should you, stretch the life of all the pokey things we use to break our skin with? When do you risk losing their effectiveness? At what point does stretching the life of your sharps put you in danger? What kind of danger does that put you in?

But before we dig into the nitty-gritty details, we should back up for one quick second and ask the bedrock question: Why would you want to use a needle over and over and over? And there are only two answers I can think of: money and, frankly… laziness.

But we all do it. Some of us stretch how long we use our sharps because we can't afford not to stretch. Either our insurance is poor or the part of the burden we carry is too high for the family budget. And some of us stretch how long we use our sharps because swapping out those little things as often as we should takes time. And time is in short supply too. And you know, come to think of it, there is a third reason for stretching the length of use of our sharps.

Gimmie a minute here.

I'm trying to come up with a polite word for "paranoid."

Well… Darn. No luck. OK, so bluntly put, while most of us with diabetes are grateful to the various companies that supply us, I think that there's also a degree of suspicion that they might just be more concerned about their bottom line than they are concerned about our health.