DrRichard K Bernstein 37 Tips Tricks and Secrets to Defy Diabetes

8/11/2019 DrRichard K Bernstein 37 Tips Tricks and Secrets to Defy Diabetes

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Dr. Richard K. Bernstein's

37 TIPS, TRICKS AND SECRETS TO DEFY DIABETES

1. A Sad Consequence of Autonomic Neuropathy

2. According to the Accord Study, Tight Control May Increase Your Risk for DeathDr.Bernstein Explains Why Tight Blood Glucose Control Will Not Kill You

3. ADA and AHA Believes Artificial Sweeteners Encourages Overeating of Fats

4. Are Ketogenic Diets Safe for People with Diabetes?

5. Beware of Powdered Artificial Sweeteners: Read Labels to See if They Contain Sugar Fillers

6.

Cancer, CVID and Diabetes

7. Carb CountingWhat Does 6-12-12 Really Mean?

8. Continued Fatigue after Thyroid Treatment, Add L-Carnitine

9. Diabetes Associations Release Joint Statement on Diabetes Recommendations

10. Diabetic Foot Ulcers and Calluses

11. Diabetic Foot Ulcers: Preventing Amputations, Venous Stasis Leg Ulcers

12.

Discussion on the Use of Aspirin for People with Diabetes

13. Do You Think You Are Too Thin? How to Gain Weight without Disrupting Your BloodSugars

14. Foot Care

15. How Elevated Blood Sugars Cause Diabetes Complications

16. How Much Do I Pay Per Year to Treat My Diabetes?

17. How to Extend the Basal Insulin for Overnight

18.

How to Prevent Hospitals from Giving Glucose Solution While You are in the Hospital

19. Hypothyroidism

20. Intermittent Claudication

21. Is Glucose a Continuous Risk Factor for Cardiovascular Mortality?


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22. Joint Diabetes Associations' A1c Recommendations

23. Legal Medical Issues for Kids with Type 1 Diabetes

24. Metabolic Ketones

25. Other Causes of Gastroparesis

26. Pancreatitis and Pancreatic Cancer Are More Common in People with Diabetes

27.

Rebuttal to the Article, Hypoglycemia: From the Laboratory to the Clinic, Published in theClinical Journal of the American Diabetes Association

28. Recommendations for the General Flu and H1N1 Vaccines for Adults and Children withType 1 or Type 2 Diabetes, and Supplements That Might Help

29. Statins Increase Artery Calcium Score

30. Statin Pros and Cons (communicated before the new data on arterial calcium came out)

31. Studies Define Normal A1c as 6.5 to 7%

32.

Telephone Consultations Cost Effective for Diabetes Management

33. Update about Statins and Incretin Mimetics

34. Updated Info on Pancreatitis and the Truth about the Drug, Cycloset

35. What Happened When I Fed Patients 900 Extra Calories Daily of Pure Fat?

36. What to Do if Blood Sugar Increases after Exercise or before Speaking Engagements

37. Why You Should Try to Avoid Unnecessary Steroid Treatments


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1. A Sad Consequence of Autonomic Neuropathy

Dr. Bernstein:You may recall from other talks, and from my book, DIABETES SOLUTION, that autonomicnerves control functions of the body that are not within our conscious control, things like heart rate, digestionof food, penile erections, amongst other things, such as the closing down of blood vessels in the legs uponstanding. Ordinarily, when a non-diabetic, or a person without neuropathy stands, there are muscles in thewalls of the large arteries in the legs that automatically constrict, instantly, like a reflex, so that blood will notpool in the legs. This happens so that when you stand, your brain gets enough oxygen, and you don't passout. I test every new patient for autonomic neuropathy. I test them in two ways:

1. The R-R Interval study I've described before, which is a very repeatable and precise way of determining ifyou have autonomic neuropathy.

2. I test blood pressure when a person is lying down, or supine, and then standing. The person lies down forhowever long it takes (five minutes, thirty minutes, or whatever) for the blood pressure to stabilize.

A nice lady in my office performs the blood pressure tests to prevent the "white coat" effect on the bloodpressure that may occur. Then she asks the patient to stand, and the blood pressure is checked directly uponstanding, and then one minute thereafter.

I would say about half of the diabetes patients whom I test have what's called postural hypotension, that is,

when they stand up, their blood pressure does not increase as it would in a normal person. The blood pressuremay even decrease, and in some, it decreases by a lot. In patients where it decreases a lot, my assistant asksthem if they feel funny, as if they are going to pass out. These patients say they do feel like they are going topass out, and in fact, they feel like they need to lie down. This is commonplace amongst people who have hadelevated blood sugars for a number of years.

About fifteen years ago I was visited by a new patient, a formerly obese type 2 diabetes patient who had beenput on the ADA diet. He was referred to me by his son, who is a physician. This patient's blood sugars werevery high, and he had lost a lot of weight by peeing away calories, and wasting away. He came to me withvery high blood sugars. He looked extremely sick. We were able to rapidly get him back to normal bloodsugars with the help of a low carbohydrate diet and insulin injections. He did very well; played golf and drovehis car, and so on. He was seventy years old.

When I first examined him, he had severe postural hypotension, like many long-term diabetes patients. Iwarned him, just the same as I warn all the others, that when you get up at night for any reason, you sit atthe edge of the bed and dangle your feet for a minute before standing up. If you don't, sooner or later, you'regoing to pass out, fall, bang your head on the floor and hurt yourself.

He dangled his feet every night until one night he forgot. He got up, toppled over, banged his nose and got abloody nose. His wife was terrified, but she had enough alacrity to check his blood sugar, which was normal.They called me the next day to tell me about it. I asked if he dangled his feet, and the patient said that hehadn't because he forgot. So, we knew what happened, and had expected it to happen.

But, the wife, unbeknownst to me took her husband to a neurologist. I got a call from the son that the

neurologist wanted his father to see a neurosurgeon, that tests of the carotid arteries showed 70% blockagein both. I pleaded with the son to not let him go to the neurosurgeon, because they usually want to operate.The guidelines then were the same as they are today for carotid endarterectomy, which is removing materialon the inside of the artery; or carotid stenting, which is inserting a device that holds the artery open. If thestenosis is as much as 70%, or perhaps even higher, but there are no neurologic symptoms, you don'toperate. I reminded the son of this, and he said he'd do his best, but his other brother, also a physician, wasin the driver's seat.


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I got word back to the neurologist to check him for postural hypotension, because that's what the patient had,and he did not have a neurologic disease. The neurologist did not find any evidence of neurological problems,but did not check him for postural hypotension. The neurologist passed the word on to the neurosurgeon, butthe neurosurgeon decided to operate, anyway, in spite of my pleas. I warned them there was good likelihoodthe patient would have a stroke, even while on the operating table.

The patient was operated on, and he had a mild stroke while on the operating table. He eventually got back tosee me, and he had a droopy lip and slightly slurred speech, so it wasn't a severe stroke, but it was a goodwarning. I warned everyone, including the wife, to not let this happen again, that if you do this again, you willkill him, because I knew there was still the other carotid that was 70% blocked.

Another year goes by, and the same thing happens. Everyone got hysterical again, they didn't listen to me.Incidentally, the first time around, I actually got a call from a neurology resident who wanted to know why thispatient's blood sugar went up to 500 mg/dl when they hooked him up to IV glucose! In any event, the patienthad the second surgery, and this time he had a stroke on the operating table and was in a coma for sixmonths, which cost the family, the hospital, and insurance companies a fortune, and lots of agony for a lot ofpeople, and this very nice gentleman eventually died. This sort of thing is going on every day with diabetespatients.

2. According to the ACCORD Study, Tight Control May Increase Your Risk for DeathDr.Bernstein Offers a Rebuttal to Explain Why Tight Blood Glucose Control Will Not Kill You

Dr. Bernstein:One of the physicians who organized the ACCORD Study summarized the results very nicely ina press release: The American Diabetes Association spokesperson, Dr. Richard Bergenstahl stated that, "When

ACCORD was reported everybody said they were sure it was the rapid drop in the A1c [ that killed people]; orthey were sure it was the lower A1c; or people were sure it was the hypoglycemia, and none of these havebeen proven to be true. It was important to see these data to see that it was really not the people with thelower A1c who had the problems; it was actually those who had the higher A1c, who despite intense effortswe could not get under control."

The most important outcome of the ACCORD trial was initially kept secret. Eventually one of the investigators

disclosed that the excess risk of all-cause mortality "was associated with persistently high HbA1c rather than

low HbA1c, regardless of the treatment group assigned." In other words, only those who could not attain the

low blood sugar targets had excess mortality. In spite of this reality many physicians who oppose blood sugar

control still cite the ACCORD trial as supporting evidence, even though it actually contradicts their claims.

Now, as you probably know, the ADA method for treating diabetes patients is to put them on very highcarbohydrate diets and then give them large doses of potent medications, such as insulin and sulfonylureaagents, which can cause problems if you do not use them properly. In large doses we cannot get predictableresults. So, for many of these people in the study, they tried the high carbohydrate/high medication approach,and instead their blood sugars got worse rather than better. Apparently those people were the people whodied in the study. The initial reports looked at the overall numbers and did not look at the breakdown that

showed if the blood sugar numbers were higher or lower. This is really the summary; it boils down to whatI've been saying all along, that it's high blood sugars and high doses of medications that kill diabetes patients.It's interesting, however, that in spite of the fact that the report I just mentioned was published in the journal,Diabetes Care, in May of this year, I still run into diabetologists who are proud of the fact that they are notseeking anywhere near normal blood sugars, and they are boasting it is because normal blood sugars killpeople. It's really an excuse to not put in time with the patients, not to pay attention to diet, and so on.


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3. ADA and AHA Believes Artificial Sweeteners Encourages Overeating of Fats

Dr. Bernstein:The American Diabetes Association and the American Heart Association issued a jointannouncement urging that diabetes patients not be encouraged to use artificial sweeteners, because theymight then reward themselves by eating a lot of fat. Those of you who have read my book know howridiculous that sounds. It assumes the diabetes patient is immature, and can't control themselves, and it is anabsurd statement. There is nothing wrong with eating fat. I eat a lot of fat, and I'm in pretty good shape.

In the same week I received a letter from the ADA. The letter ends with a statement which I quote: "TheAmerican Diabetes Association is fighting for those affected by diabetes." Sometimes it seems like they arefighting against those affected by diabetes, as is indicated by their recent announcement.

Another note of interest: I just stumbled on an old article I had in my files that points out that non-steroidalanti-inflammatory drugs (NSAIDs) can inhibit the absorption of thyroid medications; and they can inhibit evenif taken a half day, or one or two days away from the medication. Apparently, drugs like Motrin, Advil, aspirinsalsalate, and others in this class of drugs, should not be used by people who are taking thyroid replacement,because it won't be absorbed well. On the other hand, if you have to take NSAIDs, you'll have to adjust yourthyroid medication accordingly, you may have to raise the dose to get the proper blood level.

There is one more thing I want to talk about. Someone asked at the last teleconference about the use ofbenfotiamine for the treatment of diabetic neuropathy. I came upon an article entitled, "Prevention of InsipientDiabetic Neuropathy by High Dose Thiamine and Benfotiamine." Benfotiamine is a derivative of thiamine, soit's related to thiamine. Apparently both high doses of thiamine and/or benfotiamine can reduce symptoms ofpainful neuropathy. It's not just hiding the symptoms. It apparently does ameliorate the ailment to somedegree.

4. Are Ketogenic Diets Safe for Diabetes Patients?

Dr. Bernstein:Are ketones harmful to my internal organs? I'll repeat what I've said before. Our ancestors

survived eons of famines only because they were able to metabolize fat, make ketones, and use those ketonesto keep the brain alive. The brain can live off of ketones. This is an essential element of the survival of thehuman race. In addition to low carbohydrate diets being essential for the treatment of diabetes, there was anarticle in one of the journals that I picked up off the American Diabetes Association web site. It didn't tellwhich journal. It gave the name of the authors, but not the journal. However, the title is "A Low Carb Diet isBad for the Brain." They are really talking about ketogenic diets. They point out how ketogenic diets are widelybeing used to treat childhood epilepsy, and also epilepsy in adults. The ketogenic diet is being used to treatdiseases due to free radical damage, such as Parkinson's disease, and a number of neurologic diseases. If youread this article, you'd think that ketones, per se, were the fountain of youth. I imagine they are beneficial formany situations, and of course, low carbohydrate diets are beneficial for not just people with diabetes, but toanyone who doesn't want to develop heart disease, or get obese, etc.

Next subject: The American Academy of Neurology has released guidelines for the treatment of diabeticneuropathy. What was astounding about this, and very upsetting, was that all they did was try to put thevarious drugs on the market for treating diabetic neuropathy in a sequence of what you start with first. Theytotally ignore the control of blood sugar. Diabetic neuropathy is caused by high blood sugar. It doesn't happen

just because you are diabetic. The reason I don't have it right now is because I've had normal blood sugars,more or less, for the past forty years. Prior to that, I had severe neuropathies. They don't point out that: 1) itcan be prevented just by having normal blood sugars; and 2) that you can treat the underlying cause. You can


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make the neuropathy go away with normal blood sugars. As I've explained before, the neuropathy goes awayin two steps. There is what is called metabolic neuropathy, where the nerves are swollen with fluid andsorbitol that can go away in a matter of weeks; and there is what I call anatomic neuropathy where nerveshave actually died, and you have to wait until they regenerate, which depending upon the length of the nerve,can take years. But, the treatments suggested by this American Academy of Neurology did not point out thatyou can actually treat the neuropathy, rather than mask it by giving drugs that relieve the pain. As you arerelieving the pain using their method, the neuropathy will get worse and worse, so that eventually, your limbswill become totally numb, and you won't be able to feel anything with your feet. You might have a nail in your

shoe and not feel it. Or, you might step on something, and not feel it, not know you have a wound on thebottom of your foot, which eventually gets infected, and you end up with an amputation.

Another new article that sort of astounded me was from the British Columbia Cancer Agency. The article waspublished in Vancouver, BC. This was a study on laboratory animals, a particular breed of mice which have ahigh likelihood of developing cancer. These mice were fed either the typical western diet, or a lowcarbohydrate diet. The mice on the western diet had tumors by middle age. But, none of those on a lowcarbohydrate diet had tumors by middle age. So, here is another benefit of a low carbohydrate diet, which ofcourse, the ADA calls a ketogenic diet. So, a ketogenic diet not only can prevent diabetes and treat those withdiabetes, it can also prevent cancer. This is news to me.

"Short Term Intensive Therapy in Newly Diagnosed Type 2 Diabetes Partially Restores both Insulin Sensitivity

and Beta Cell Function in Subjects with Long Term Remission." This article appeared on the ADA web site,which did not cite the journal it came from, so it may have been in one of the ADA journals. The names of theauthors were all Asian: Hu, Lee, Zu, Yu, etc. What they did was put people under very tight blood sugarcontrol with essentially normal blood sugars for two weeks. They apparently were attempting to duplicatewhat Gerald Reaven did about thirty years ago, which I talk about in my book, DIABETES SOLUTION, wherehe took thirty-two diabetes patients, put them on the artificial pancreas (called the Biostatter) for two weeks.He found it took three years for the A1cs to come back up to where they were before the treatment. Thisrecent study just looked after one year, and found that their patients had much less severe diabetes than theydid at the beginning. In fact, they claim that some of their patients had complete remission. That, to me,doesn't mean that this is going to cure diabetes. What it does mean is that beta cell burnout is partiallyreversible. I'm willing to bet that every one of the people in the study, if they go back to their old habits andhave high blood sugars, are going to eventually burn out some of the beta cells that recovered by this

treatment. But, it just reiterates what I have been saying over and over, and what I've seen in my patients,that if you have really normal blood sugars, around 83 mg/dl, 24 hours a day, you can partially reverse type 2diabetes, and early type 1 diabetes, before you burn out all your beta cells.

5. Beware of Powdered Artificial Sweeteners: Read Labels to See If They Contain Sugar Fillers

Dr. Bernstein:I received an advertisement a day or two ago with a sample from McNeil Nutraceuticalspromoting their new Sun Crystals which they claim to be stevia. If you read the package and the letter ofintroduction carefully you'll see this stuff is mostly what they call cane sugar, which I expect would be tablesugar, with a little bit of stevia, which puts it in the same boat as most of the other powdered artificial

sweeteners. Those of you who've heard me talk about artificial sweeteners have heard my warning that tabletsweeteners are virtually free of sugar, whereas with the exception of stevia, powdered sweeteners inevitablyare mostly sugar, usually 96% sugar. The sugar could be glucose, lactose, or sucrose (table sugar). Up to thispoint, any stevia that you purchased was likely pure stevia, which has essentially no carbohydrate in it. Butnow, McNeil, which is a division of Johnson & Johnson, has come up with a stevia that is mostly sugar. So,stevia is now being contaminated with sugar. Why they did not make it all stevia, I don't know. It probably has


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to do with patents or something like that, but this is a mixture of table sugar and stevia. I would advise you tostay away from it.

6. Cancer, CVID and Diabetes

Dr. Bernstein:The special topic today is a little difficult for me because it involves my own personal historyleading to a discovery that applies to many diabetic patients. When I was a child I had sinusitis all winter,

every year. It would get better in the spring, and I would be fine all summer. But over the years, it got worseand worse. When I was a business executive I used to have a vaporizer on my desk, and would put my noseright up to the vaporizer to inhale the steam. I would do this for most of the winter. I went through medicalschool, became a doctor, and started practicing medicine. As I got older, the sinusitis became so bad that itbecame disabling. I knew how to treat it with antibiotics. I became an expert at treating sinusitis withantibiotics. I frequently had green, infected material coming out of my nose. Eventually it got to the pointwhere the antibiotics no longer worked. I was virtually disabled by severe sinusitis. I finally wised up andthought to myself that I must have some kind of immune deficiency. So, I tested myself by having blooddrawn for immunoglobulins. These are the basic antibodies: IgA, IgG, and IgM. I discovered I was very low inIgA and IgG. IgA is the immunoglobulin of mucus membranes, so that would affect the respiratory system,and also the digestive system. And indeed, over the prior three years, or maybe longer, I had developedsevere diarrhea. I was living on Lomotil until I discovered that codeine was cheaper, and I started usingcodeine in order to not have diarrhea. I also did a complete blood count (CBC) because I knew that immunedeficiency can predispose you to cancers, especially blood cancers like leukemia and lymphoma. Sure enough,I had lymphoma. I went to who I believe is the best immunologist in the country who has consulted for me forother patients who had immune problems. I was put on an antibody called Rituxan to kill the lymphoma cells.It worked, usually, the lymphoma recurs after three to five years, and people need to be treated again.Because my immune deficiency was so severe, and was not only causing lymphoma but was also causingdisabling sinusitis and disabling diarrhea, I was put on gamma globulin. In other words, my missingimmunoglobulins were being replaced every two weeks by intravenous infusion. When I started on the gammaglobulin, the sinusitis went away immediately. The diarrhea went away. I'm sure as a result of these frequentinfusions, my lymphoma thus far has not returned after ten years. In order to stay alive, I have to get gammaglobulin every few weeks. Once I woke up to this problem, I started looking for it in my patients, not in an

aggressive form, but if a new patient comes in and on his history form he said that he had frequent sinusitis, Iwould test him for immunoglobulins. Or, if on the routine blood chemistry his total globulins were low, or lownormal, I would test his immunoglobulins. The normal range for globulin in the blood is about 1.9 to 3.9. Ifsomeone is 2 or 2.1, or 2.2, I will get a breakdown of the immunoglobulins. Another factor that can beabnormal when you have an immunoglobulin deficiency, not always, but frequently, is serum beta 2microglobulin which I test anyway on all new patients because it can be an indicator of renal tubular damage(damage to the kidneys that frequently occurs in diabetes). If someone has an elevated serum beta 2microglobulin, I'll look at his serum creatinine, BUN, cystatin C, and other kidney tests. If they are notabnormal, I'll test his immunoglobulins. I've been doing this now for about eight years. I've tested about fiftypatients. Of those fifty patients, forty-eight had immune deficiency syndrome. I got hold of my immunologist,and got him to send an immunology fellow to look over my lab sheets on my patients, and they looked at twohundred forty-seven patients, between the first one I'd detected with immune deficiency, and the last one atthe time that they came to look at the records. However, I had only tested about fifty out of the two hundredforty-seven patients. But, nevertheless, we found forty-eight who were immune deficient, and the kind ofimmune deficiency they had is called common variable immune deficiency (CVID.) Forty-eight people out oftwo hundred forty-seven is 19%, let's say about 20%. If we were to project onto the entire diabeticpopulation, which maybe we can do and maybe we can't do, because I don't have a cross section of allnationalities, and so on, but nevertheless, I would suspect from this data that at least 19% of diabetespatients have CVID. Of my forty-eight patients with CVID, most of them have had no adverse consequences.


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It's just something that we take a look at every year by re-checking their immunoglobulins. I get a bloodcount, and I look for abnormalities. A few of them have had very significant problems. For example, one ladywas having a growth removed from her back as an outpatient in a hospital, and she got MRSA (methicillinresistant staphylococcus aureus.) Those of you who do not know about this organism, it's highly resistant toantibiotics. It spreads around the body, almost like a malignancy. You'll get one sore at the site of the initialinfection, and you'll get more sores all over your body. That was happening to this lady. Fortunately, when herblood sugars went up because of the infection, she called me to ask what to do about the blood sugars. I hadreminded her I mentioned to her two years ago when we discovered she had an immune deficiency to let me

know immediately if she got any serious infection. In any event, we immediately had her put on gammaglobulin; within a few days the infection disappeared. A similar thing happened to another patient, a man whodeveloped pneumonia. He had it for three months. When he finally called me to deal with his elevated bloodsugars, we put him on gamma globulin. Within a couple of days, it was cured. There are other stories withother patients. For example, there's one who developed chronic lymphocytic leukemia. She elected watchfulwaiting rather than treatment with gamma globulin. On top of that, my sister with CVID developed a skincancer that's treatable only with gamma globulin. It's the only thing that worked. So, she is a first degreerelative of mine. My mother had lymphoma, and also CVID. My sister has CVID; I have CVID; my mother hadCVID, so this thing is inherited. It's not caused by diabetes, but I'm willing to bet that an awful lot of diabetespatients have CVID. It is my guess that this is the major reason why the incidence of so many malignancies orcancers in diabetes patients is much greater than in the general population. There are many articles that havebeen written on this. Depending upon the cancer, it goes anywhere from twice the general population to six

times the general population. I'm pretty sure that this is the reason for it. In any event, if any of you havechronic sinusitis, chronic diarrhea, a new malignancy, I urge you to get your IgA, IgG, and IgM checked. If anyof them is abnormal, you should see an immunologist right away, who should put you on gamma globulin. Welearned from my out of town patients who needed gamma globulin that the local immunologists did not knowhow to administer it, or how to dose it, or what brand to get, etc. What they learned was that they should gothrough the following protocol that I actually suggested to them. They should call the cancer infusion center ata large local hospital. You ask them the name of the doctor that gives the most business with gamma globulin,in other words, the name of the doctor that prescribes the most gamma globulin. The doctor in your localitywho is prescribing the most gamma globulin at the local cancer infusion center is the doctor you would needto see if you have an immune deficiency. Interestingly, it's usually an allergist.

7. Carb Counting What Does 6-12-12 Really Mean?

Dr. Bernstein:The next subject has to do with a lot of confusion that I've probably caused with regard toestimating carbohydrate at a meal. What does the 6-12-12 you read about in my book really mean? It all boilsdown to a very wise question someone asked for this teleconference. The listener asked: "When I have nocarbohydrate, at all, I do best. Why should I have any carbohydrate? Why shouldn't it be 0-0-0?"

I discovered the same thing forty-five years ago when I first started measuring my blood sugars. But, as Imention in DIABETES SOLUTION, I noticed that every fifteen years or so during the 20th century, a newvitamin was discovered. I assumed that perhaps vegetables had nutrients in them that you could not get insupplement form, and that more nutrients would be discovered over time. This was a hypothesis I had forty-

five years ago. It's turned out to be true. We now hear of phytochemicals, chemicals that you find invegetables. There are probably very many that we can't get in supplements. I recommend that we eatvegetables in order to get whatever nutrients that are in them that we know about and that we don't knowabout yet. That's how I came up the 6-12-12. Because I believed we needed to eat a little bit of vegetables atmost meals, I had to determine what is the most that could be eaten without grossly upsetting blood sugars.That is where I figured that two cups of tossed green salad would be 12 grams of carbohydrate. That really is


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not so, because if you look this up in a nutrition table, you'll see that two cups of salad probably is more like 6grams of carbohydrate, but I had noticed that my blood sugars went up as if they were 12 grams.

Initially, I hadn't worked out the reasons for the Chinese restaurant effect, which is caused by eating bulkyfoods that distend the gut, and raises blood sugar. Years later after I discovered this effect, other peoplenoticed this, too, and called it the "incretin effect." It is a real effect. I mention in my book that if I were to eata handful of sawdust, or pebbles, my blood sugar would go up. So, I fudged the numbers. I said that two cupsof salad would "act like" 12 grams of carbohydrate, and this is the term I use in my book. It's not that they aretwelve grams of carbohydrate, but rather the effect upon blood sugar is like twelve grams of carbohydrate.Here is an actual excerpt from the 2011 DIABETES SOLUTION, page 180: "These lists slightly exaggerate thecarbohydrate content of salad and cooked vegetables, but because of their bulk and the Chinese restauranteffect, the net effect upon blood sugar is approximately equivalent to the amounts of carbohydrate shown."

I hypothesized based upon archaeological evidence, perhaps erroneously, that pre-historic humans did nothave access to bowls of salad, that they ate mostly flesh, with occasional leaves or roots that were nutritious.Most leaves and roots are not edible. So, they could scrounge for some vegetation that was edible. What Iwould suggest is that if an average person with an average build had two cups of salad for lunch and eitherone cup of salad or 2/3 cup of cooked vegetables for dinner, this would probably give them enough in the wayof vegetation to get adequate nutrients. That's about what I eat. For those who can tolerate nuts, these canbe eaten sometimes instead of salad for lunch. But, in my experience, far less than a third of my patients can

tolerate nuts, that is can stop eating them once they start, so if you can't stop eating nuts, it's better to noteat them. Sometimes for lunch I'll eat pistachio nuts instead of salad, which are measured out in a little bowlwith a piece of tape on it that correlates to twenty nuts, and I don't go back for more. Acceptable nuts arepistachio, macadamia, pecans, walnuts, and almonds, but only a small amount. Cashews are too high incarbohydrate to be acceptable.

This is really all I have to say about the carbohydrates in vegetables, that you keep the vegetables tominimum, and the only purpose for eating vegetables is to get the nutrition, and not the carbohydrate. Thislistener who said he did better with zero carbs was probably right. However, I think that you need thenutrients in the vegetables I list in my book. Really, it's a matter of guessing for yourself how much in the wayof vegetables you eat to give you adequate nutrition. The carbohydrate load is an unfortunate side effect thatwe are stuck with.

8. Continued Fatigue after Thyroid Treatment, Add L-Carnitine

Now I will discuss the new information concerning hypothyroidism. This is something I learned from myimmunologist. He is a co-author of a paper about Common Variable Immunodeficiency, CVID, which I'vediscussed in the recent past.

I've had a number of patients complaining that even when their thyroid levels, especially the FT3 is right onthe nose of mid-normal range, they were still tired. I asked the immunologist if he'd ever encountered this. Iwas asking on a guess because thyroid issues are not his specialty. Lo and behold, he's done some studies onthis, and he's observed the same thing. What he found was that people who had normal thyroid levels aftertreatment, but were still tired, responded to L-carnitine supplementation. They took 500 mg tablets, about sixtimes a day, and then weren't tired anymore. He said these were people who had high levels of antibodies tothe thyroid gland. I am now checking antibodies on all my hypothyroid patients, and all of my new patients.I've found that most of my hypothyroid patients, who are still tired, even though their T3 levels are midnormal range, did not have high anti-TPO levels. One of them did, most of them didn't. So, even if your anti-TPO is not elevated, it seems that L-carnitine works. If you are hypothyroid, it's being treated, you've gotten


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your FT3 mid-normal, and you are still tired, try L-carnitine, which is an amino acid. It's unbelievable. I can'tget over what I'm seeing with my patients.

9. Diabetes Associations Release Joint Statement on Diabetes Recommendations

Dr. Bernstein:The American Diabetes Association, jointly with the European Association for the Study ofDiabetes, came out with new treatment guidelines for type 2 diabetes. Unfortunately, these guidelines still

advocate very high blood sugars, even higher than before, and a lot of carbohydrates in the diet. It'sinteresting that they sort of got out of the problem that was facing them in the past when they put a lowerlimit on the amount of dietary carbohydrate. They said no less than 137 grams of carbohydrate per day, oryour brain will die. That is an absolute lie, and they got caught in it. It was so embarrassing that they don'tsay that anymore. But, they now say to eat a lot of fruit and whole grain breads. These foods are sure to raiseyour blood sugar sky high.

With regard to blood sugar guidelines, they say that hemoglobin A1c should be around 7%, and you shouldnot change the mode of treatment of your patient until the hemoglobin A1c exceeds 9%. So they want A1cs tobe between 7 and 9. Blood sugar-wise, this means an average blood sugar of anywhere from 180 to 260mg/dl, and you don't do anything to improve your treatment until the average blood sugar exceeds 260 mg/dl.This is the latest ADA guidelines.

By sheer coincidence, someone was telling me the story of a drug called Provenge, which is used to treatbreast cancer. It's a last resort for people who are dying of breast cancer. It was shown to give women maybeanother four months of life, and it was very expensive, about $8000 a dose. So, the FDA allowed it to be onthe market briefly, and then took it off the market. But, the protest from women with cancer and their familieswas so great that the FDA caved in, and allowed it to come back on the market.

Here we have between twenty and thirty million diabetes patients in the USA alone, and we have the ADArecommending the kind of blood sugars that I just stated. The ADA is telling doctors all over the world thatthese are the blood sugars that patients should have. Do we hear any protests? I haven't heard anything onthe news or television. There are a few voices on the internet, people who have blogs that are protesting this.The Nutrition and Metabolism Society, which is a small organization, is protesting this. But, where are the

thirty million diabetes patients? We don't hear a sound! I think the women with breast cancer areembarrassing us.

10. Diabetic Foot Ulcers and Calluses

Dr. Bernstein:Thanks for listening. Let's get right into the special topic for tonight, which is Diabetic FootUlcers. There are a lot of myths circulating about these ulcers. For example, on several occasions I waslecturing physicians, and a common question was: "How low must your blood sugars be to prevent diabeticfoot ulcers?" Ulcers do not sprout spontaneously. They always have a cause, other than high blood sugar. Thatcause is an injury to the skin of the foot. If you can prevent injury to the skin of your feet you're not going to

get ulcers. Yes, high blood sugars do pre-dispose you. For example, if you have years of elevated blood sugarsyou can develop insensitivity in your feet, otherwise known as peripheral neuropathy. Neuropathy issometimes painful, but it is also sometimes numbing, where you don't feel an injury. For example, I was doinga physical exam upon one of the very first patients whom I ever saw, and appropriately looked at the bottomsof his feet. I saw a hole about two inches across and a quarter of an inch deep. I asked him, "Do you knowyou have an ulcer on the bottom of your foot?" To which he replied, "Oh that must be where the smell iscoming from." His wife had complained of an odor coming from him. This ulcer was infected, and full of white


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vegetation. He didn't even know it was there; he couldn't feel it. So, diabetes patients and others with nerveinjury in the feet may not be able to feel injury. This also happens in people with advanced syphilis; peoplewith leprosy, and that's why you see many old woodcuts of lepers with legs amputated and on crutches. Themain threat is when you don't know you are being injured. Perhaps there is a little nail in your shoe, and itstarts gradually wearing a hole in your foot. If you can't feel it, you're going to get that hole, and it willeventually become infected. The infection can spread up the fascial planes in the muscles and lead to anamputation if it's not caught early. Another reason why diabetes patients are pre-disposed to infected ulcers isbecause all too frequently they have impaired micro-circulation or macro-circulation. If you have a wound

anywhere, you need a certain amount of blood flow to the wound so the body can heal the injury. If you don'thave enough circulation, nothing is going to heal. How do you prevent injuries to your feet? In my book,DIABETES SOLUTION, there is an appendix on foot care. We list nineteen dos and don'ts. If you adheremeticulously to these dos and don'ts, you will be guaranteed to never have an ulcer. I have never seen anulcer in a patient who adhered to all of these dos and don'ts. I'm not going to list them now; go into the footcare appendix of DIABETES SOLUTION. I will list one thing, however, right now. I have for many years beenthe director of the wound clinic at a major medical school. I've seen thousands of diabetic patients, and I'veinterviewed every patient who's ever come into the clinic in the past twenty-seven years. When I see adiabetes patient who's had an amputation on one leg, and he's coming to our clinic to take care of theremaining foot, I ask him what led to the amputation. In 100% of the cases it was someone attempting toremove a callus. Number one on the list of culprits in terms of frequency was podiatrists. Number two was thepatients themselves. Number three was a relative. Any attempt to remove a callus is absolutely

contraindicated. Calluses serve a purpose; they protect your skin from undue pressure or shear. If you find acallus to be unsightly or aesthetically disturbing for some reason, you can purchase orthotics off the shelf in adrug store to take the pressure off the metatarsal heads, which are the bony prominences on the bottoms ofyour feet, at the base of the toes. That's where most of the calluses occur, but they don't always occur there.Calluses can also be on the knuckles of the toes. There is a particular deformity of the diabetic foot caused bymotor neuropathy called the intrinsic minus foot that pre-disposes to hammertoes, and the knuckles of thehammertoes sometimes develop ulcers from rubbing on the shoes. Getting back to the problem with removingcallusesI had one case where a patient left my office on a Friday afternoon; it was the last day of ourtraining program. Unbeknownst to me, he went to a podiatrist that evening. The podiatrist filed off a callus.On Monday morning, I get a phone call from the podiatrist asking what antibiotic I wanted to give to thispatient. I asked him why he should have an antibiotic. He said the patient may have an infection. So I said to

send him in to see me. I removed five cc's of pus from his big toe. That's just between Friday evening andMonday morning. That's how fast this can happen. If you have a callus that aesthetically displeases you, youcan get the pressure off of it by getting either custom-made orthotics, or over the counter orthotics. If thepressure is on the upper part of your foot, you may have to have your shoes stretched, or have to get a newkind of shoe or sandal. The idea is to get the pressure off the site, so that you don't wear a hole in your foot.Once a wound occurs, it should immediately be taken, if possible, to a wound care center. All big cities and bigcity hospitals have wound care centers. In the rural areas, you may not find one, and that poses a realproblem. Even at wound care centers, perfect care is not always rendered. For example, I've read theprotocols of a number of wound care centers, and visited a number of them, too. The most crucial step inhealing a wound on the foot is frequently omitted, and that is what's called "off-loading," which means takingthe pressure off the site. If you have a hole in the bottom of your foot and you want it to heal, you don't walkon it and allow there to be pressure on it. Either you have to be totally non-ambulatory, or someone has to

create a modified shoe immediately that takes the pressure off the site of the wound. We do this in my clinicwhenever it is necessary. It's a very easy thing to do. I'm not going to go into the details. The point of this isthat ulcers of the feet are unnecessary. They should not happen. They can be prevented. If they occur, theone thing that absolutely must be done in addition to whatever other treatment is used is off-loading.


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11. Diabetic Foot Ulcers: Preventing Amputations, Venous Stasis Leg Ulcers

Dr. Bernstein:This is a condition that can affect the general population. It usually appears as sores on thefront or sides of the legs, usually between the ankles and the knees. The size of these sores can be from lessthan the diameter of a dime, to in extreme cases, one big sore wrapping around the whole leg. These can besometimes painful, though usually not. The reason I bring up this particular subject is because venous stasisulcers are more common in people with diabetes. I was in clinic today. We had about ten people with venousstasis ulcers, and half of them were diabetic. There are other predisposing conditions such as sickle celldisease and, most importantly, family history. If someone's parents had varicose veins in their legs, thesepeople are prime candidates for venous stasis ulcers. Why are these ulcers more common in diabetes patients?Probably because most type 2 diabetes patients are overweight, and have big bellies. These bellies press onthe iliac veins that bring blood back from the legs, into the trunk, so the blood can eventually go to the heart.When the abdominal mass is pressing on these veins, there is a back pressure. The superficial veins in thelegs, the veins just under the skin, get stretched by this back pressure, which can cause water to leak out ofthe veins into the surrounding subcutaneous tissue. The net result is you have edema or fluid in thesubcutaneous tissue that presses on the capillaries in the skin. The capillaries deliver blood that is necessaryfor the healing of minor wounds. So, if you bump your shin, you get a little bruise. But if you have edema inyour legs, that bruise might not heal, and might open up and become an ulcer. That's just what happens tothese people. It's interesting that most commonly these ulcers are above and behind the lateral ankle, becausethere's a patch there where muscle is absent. Next most common place is on the front of the shins, where the

skin is very thin, and blood supply is poor. So, people with big bellies are more susceptible to venous stasisulcers. How are they healed? The technique for healing these ulcers is very easy. It is wrapping a specialbandage around the entire leg from below the toes to just below the knees, at the crease at the back of theleg. This special bandage is called an Unna boot. It is a gauze bandage soaked in glycerin and zinc oxide. Itacts like a toothpaste tube. It becomes semi-hard after a while, and can be bent, but not stretched. Every timea person walks with an Unna boot on his leg, he flexes his foot, as we all do when we walk, and that bendsthe toothpaste tube. If we had a full tube of toothpaste and we remove the cap and suddenly bent the tube,the toothpaste would shoot out the top. With an Unna boot, when one takes a step or flexes the ankle, thepressure from the boot forces fluid out of the tissues of the leg and back into the general circulation. Bygetting rid of the edema, or fluid, the wound eventually heals. This is a very simple technique, butunfortunately, many of the wound centers I have visited didn't know the first thing about Unna boots. Inreading the literature on wound care, it seems that most of the people involved in this profession don't knowhow the Unna boot works. I just described it for you. The literature refers to it as a "compression bandage,"which it is not. It's a "foot pump," where every time you flex your ankle, you pump fluid out of the leg. Whatcan you do to avoid venous stasis ulcers? Keep the size of your belly down; don't get fat. I can't tell you toavoid bumping your shins, because everyone does that. I probably do it a few times a week. Fortunately, Idon't have a big belly, so I don't get venous stasis ulcers.

12. Discussion on the Use of Aspirin for People with Diabetes

Dr. Bernstein:As most of you know the American Diabetes Association has recommended, or has in their

guidelines, that all diabetes patients should be taking aspirin, a statin and an ACE inhibitor. For years, I'vebeen protesting that if you have normal blood sugars, and don't develop diabetic complications, you shouldn'trequire these things. I don't take any of them, and I've had diabetes since 1946, which is something well over60 years. Two articles came out this year, one of them just in the past month. I will read the abstract: AspirinUnproved for Primary Prevention of Cardiovascular Events in Patients with Diabetes. This is a meta-analysis of10,000 diabetes patients, and overall they found no lower risk of heart attacks in the overall populationamongst those who took aspirin. However, when it was stratified by sex, there was some benefit for men but


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none whatsoever for women. It leaves it pretty clear there is no value to this for women, and there maypossibly be some value for men. The review of the study points out that other studies have shown associationsbetween aspirin therapy and excess risk for bleeding, including hemorrhagic strokes. But yet another articlepublished in The Lancetpoints out that aspirin can slightly reduce the incidence of ischemic strokes, butincreases the incidence of hemorrhagic strokes to the same extent. So, it's sort of a washout. This prior studywas a meta-analysis of 95,000 patients without diabetes, and states no clear benefit for aspirin in primaryprevention of cardiovascular disease. This is for non-diabetics. So, the whole issue is sort of up for grabs rightnow. One warning I should give you, for those who are already taking aspirin, sudden discontinuation can lead

to a tripling of likelihood of a stroke. If you're taking it, you can't suddenly stop. How do you stop? There'sbeen no study of how to stop. I've told my patients who wanted to stop to either spread the timing outbetween doses, because the effects on platelets lasts a number of days; so you could take it instead of everyday, every other day, and then every third day, and spread it out, that might work. I don't know. It's neverbeen studied. Another way might be to slice a little bit off the aspirin pill; each day slicing a little bit more,each week slicing a little bit more. I can't predict if that will reduce the likelihood of a sudden stroke. So, as Isaid, what to do is sort of up for grabs. And, the risk stroke when you suddenly stop is very great. Those thataren't taking it have all the more reason to not start.

13. Do You Think You are Too Thin? How to Gain Weight without Disrupting your Blood Sugars

Dr. Bernstein:Before I get into this special topic, I wanted to disclose what sources I use for carbohydratecontent of different foods. I have two major sources: the most recent edition of "Pennington and Church: Food

Values of Portions Commonly Used," and "The Nutribase Complete Book of Food Counts." The Nutribase bookis fairly old, published in 2001, but it is easy to use and has a number of brands though it's out of date.However, the main value is for the carbohydrate and protein content of packaged foods. And, you can alwaysread it on the label of the packaged foods.

The special topic we are going to cover today addresses the frequent questions we've received from peoplewho are actually losing weight on our meal plan, and losing more than they wish, or they started out alreadytoo thin. How do you gain weight without messing up your blood sugars?

The easiest way to gain weight is to eat a lot of carbohydrate and take enough insulin so that your bloodsugars don't go up, causing you to urinate away your calories. However, doing that is not going to accomplishour major goal, which is to keep blood sugars normal. I found that with the high carbohydrate diet, there'sabsolutely no way to normalize blood sugars. So, what else do we do?

I've spoken before of my unsuccessful experiment using fat. And even though I disclose this experiment in mybook, DIABETES SOLUTION, people are writing to me saying they are using fat like I "recommended," andcan't gain weight. Well, I don't recommend using more fat to gain weight because my experiment wasunsuccessful. We tried feeding people nine hundred extra calories a day of fat in the form of olive oil and notone of the five people I treated gained even a pound during the six months of the experiment. Eating fat isnot a way to gain weight. The only way fat will build up is if you are taking a lot of carbohydrate, and mypatients are not doing that.

So, I came up with a solution that I use; it is slow, but it works. When done properly it always works. Mymethod is to increase the protein in your diet, and prevent the increase in blood sugars with insulin, if you areinsulin-dependent. If you are not insulin-dependent, and your blood sugars go up when you eat more protein,you have to start taking a little bit of insulin to cover that blood sugar increase. That's how simple it is; justprotein plus insulin. Ordinarily, if a diabetes patient were to eat protein without covering it with insulin, itwould be converted to glucose slowly, and his blood sugars would slowly go up. Gram for gram, protein foodsrequire much less insulin than carbohydrate foods, and are therefore much less likely to mess up your blood


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sugars. Furthermore, the protein foods raise blood sugar more slowly than carbohydrate foods. So, it's easierto cope with the protein insofar as blood sugar control goes. But, just realize that if your blood sugar goes upwhen you eat more protein, you are going to have to take more insulin for that particular meal.

Some people may feel too full if they eat a lot of protein at a meal. What I recommend is that initially they picka meal where they might want to add one or two ounces of protein. Then we see what happens to their bloodsugar, and we give added insulin in proportion to what happens to their blood sugar, using the methods thatare in my book. We then look at their weight in about two weeks. If we see there is no weight gain, or maybeonly a quarter of a pound in two weeks, we have the patient chose another meal to add to two more ouncesof protein. If you keep adding protein to meals, and eventually get to the point that you feel too stuffed at themeal, we might want to give you a snack instead of adding on to that particular filling meal. The snack willlikely have to be covered with insulin. Although slim non-diabetics can gain weight by adding protein, diabetespatients are probably going to have to take insulin to cover the additional protein. If you are a type 2, andmaking a lot of insulin of your own, maybe you could get by without the added insulin.

That's the story. It's quite simple.

14. Foot Care

Dr. Bernstein:There is a section in DIABETES SOLUTION that has nothing to do with the subject of thebook, which as the subtitle indicates is normalizing blood sugar in diabetes patients. There is a chapter thathas nothing to do with normal blood sugars. It's in the appendix, and it deals with foot care. Why on earthwould I include that unrelated subject in the book? It is simply because I consider it so important.

Just this past month, the journal Diabetologia, which is the foremost scientific journal for diabetes, publishedtwo articles on the severity and magnitude of the worldwide epidemic of amputations of diabetic feet and legs.They didn't, interestingly, find any explanation as to why this is so prevalent; they only knew what the riskfactors were, like high blood sugars, poor circulation, etc. But, I've had considerable experience in this area,because I have worked in the wound care clinic of a major New York City hospital for almost thirty years. For agood number of these years, I was the director of the clinic, although I am at this time semi-retired. I saw alot of diabetic people who had amputations. I asked each patient what had happened, and what led to the

amputation. In every case over the past thirty years, it was that someone tried to remove a callus. It wasusually a podiatrist, but sometimes it was the patient or a relative of the patient, or a pedicurist.

In my own private practice I've seen people with infected wounds, usually caused by a podiatrist, butsometimes by a pedicurist. I had a patient who is a typical example of what can happen. In those days weused to finish on Friday afternoon after three days of self-care training. Unbeknownst to me, he left my officeand went directly to his podiatrist. Monday morning I took a phone call from the podiatrist, asking me whatantibiotic he should give to this patient. I asked him why the patient needed an antibiotic, and the podiatristreplied he thought the patient had a slight infection. I asked that the patient come to me right away, becauseI wanted to see him. That morning I removed 5 ccs of puss from his big toe, which was red, inflamed andswollen, and just loaded with puss. This happened between Friday night and Monday morning. The patienttold me that the only thing the podiatrist did was to take a pumice stone and grind down a callus. This is goingon every day, all over the world, and it's not right.

The American Diabetes Association, in their guidelines for patient care, state that calluses should be debridedwith a sharp instrument by a trained professional. For my money, that is the worst thing you can do. Thetreatment of a callus is to remove the pressure, or sheer force, that caused it. You do that by stretching theshoe if it's too tight, or providing orthotic inserts in the shoes to transfer weight or force from the place wherethe callus is, to transfer that force to the arch. These pressure calluses are usually over the metatarsal heads


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at the balls of the feet. There are very simple solutions for treating calluses, and they should not bemechanically removed. Calluses are not harmful. They are protective. The most dangerous thing you can do isto allow anyone to try to remove a callus, or file it down. Many of the diabetes publications, including thosepublished by the ADA, are advertising little machines that grind down calluses, which is the worst thing adiabetes patient can do. They look like little dental drills with a rotating stone that is supposed to remove yourcallus, but it can also end up in the amputation of a foot or leg.

15. How Elevated Blood Sugars Cause Diabetes Complications

Dr. Bernstein:Before we begin, someone asked at the last session about the relative harm in terms ofdiabetic complications of up and down blood sugars, versus an elevated Hemoglobin A1c. Lo and behold, nosooner did we finish the conference, and two weeks later, an article appears in the journal, Diabetes, entitled"Oscillating Glucose is More Deleterious to Endothelial Function and Oxidative Stress than Mean Glucose inNormal and Type 2 Diabetic Patients." They're talking about the lining of blood vessels, and how abnormalendothelial function plays a role in many complications of diabetes; heart disease, which is a diabeticcomplication; retinopathy; kidney disease; and even neuropathy involves little blood vessels called vasanervorum. This small, limited study only covered blood vessels, but shows that oscillating blood sugars aremore deleterious than the steady elevation of blood sugars which reiterates what I said at the last session.

16. How Much Do I Pay Per Year to Treat My Diabetes?

Dr. Bernstein: Our special topic for today is what I use in the care of my diabetes, and how much I pay peryear. I will go down my list, item by item. The list has two columns: 1) What the cost of the product would beto me per year if I did not have insurance; and 2) What I pay after my insurance pays.

I use a relatively small number of products. I take Levemir insulin for long-acting basal insulin. Because it hasto be thrown out after 1 1/2 months, I use eight vials a year. The list price is $920. After insurance, I pay$280.

I use about ten blood sugar strips a day. They would ordinarily cost $5475. Amazingly, my insurance pays forall of it, so it costs me nothing.

I use Regular insulin before meals. I use about seven vials per year, at a cost of $385 before insurance; $245after insurance pays.

I use diluted Humalog for correcting elevated blood sugars. I use less than a vial per year, because I dilute it7:1. A bottle would last me years at that rate. That one bottle without insurance costs $63. After insurance, itcosts $18.

The syringes are an interesting story. In my book, DIABETES SOLUTION, we tell how you can get away withreusing syringes, and not spoiling your insulin. If you don't use the tricks we talk about, you will absolutelyruin your insulin if you reuse syringes. I use a syringe a day. It costs 26.4 cents, for a total of $95 a year, andmy insurance does not pay a penny for the syringes. Apparently, they will only pay for over a certain cost, andapparently my cost is not high enough for them to justify paying for the syringes.

I use Dex 4 glucose tablets that cost about 9 cents each. I break them in half, and sometimes into quarters. Iuse on average, maybe two whole tablets a day, but it's usually multiple small ones, called Dex 4 bits. Thistotals $66 per year. It is not covered by insurance. When I'm with patients or in the gym I use Dex 4 liquidglucose which would probably quadruple the above cost.


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I use the GLUCOGRAF forms that are illustrated in my book. Diabetes in Controlalso sells them on theirvarious web sites. One pad costs $13. A pad lasts a year, and is not covered by insurance.

When I was about eighteen years old and diabetic for six years, I already had sympathetic neuropathy of myfeet, meaning my feet did not sweat. The sweat glands that died from the high blood sugars never came back,so I still have to lubricate my feet every day. I use only a little bit of lubricant, so I get away with only one $10bottle per year, that is not covered by insurance.

If we look at the totals, if I had no insurance, I would pay $6823 a year; after insurance, I pay $718 a year.

That isn't a lot of money. It just reiterates that if you take good care of your blood sugars, and don't develop ahost of complications, you could treat this disease very inexpensively provided you have health insurance.

So, my message is, take good control of your blood sugars, and it will not cost very much. If you allow long-term complications to develop, you may become disabled and your costs will skyrocket.

17. How to Extend the Basal Insulin for Overnight

Dr. Bernstein:Those of you who inject long-acting basal insulin, that is supposed to cover the fasting statefor 24 hours, may have noticed by now that the new insulins like Lantus and Levemir do not last 24 hours. The

data submitted to the FDA sort of distorted the results by having patients inject more than a basal dose, morethan enough to hold blood sugars level. They injected large doses that forced users to eat during the day. But,when you inject a very large dose of any insulin, you can make it last a long time. John Galloway, of Eli Lilly,demonstrated about thirty years ago, that if you take Regular insulin, which then was the fastest acting insulinwe had, and inject enough at one time, you could make it last a week. In his particular experiment, the dosewas 70 units of insulin that should have been finished in ten hours. These so-called 24 hour insulins reallydon't last 24 hours. Not only that, many of you have found that even when you split it into two doses, onetaken on arising and the second dose at bedtime which is what I recommend in my book, DIABETESSOLUTION, the bedtime dose doesn't last overnight. What do we do? The best insulin we have, Ultralente, nolonger is available. The lady that runs my office, Pat Gian, came up with an idea when I was complainingabout the fact that the overnight insulins don't last. She said, "Why don't you split it into two shots, and take

one when you go to bed, and set the alarm in the middle of the night, and take the second shot in the middleof the night." I usually go to bed around 11:00 p.m., and what I've ended up doing is taking a shot at 11:00p.m. and a shot at 3:00 a.m. Since many nights I may get up to urinate in the middle of the night, I don'talways have to wake my wife with the alarm. This is sort of an inconvenient thing for some people to do. Forexample, what if you don't go back to sleep when the alarm rings in the middle of the night? That's a realproblem, and off hand, I don't know how to answer it. One can use medications like Trazadone to help you getback to sleep. This is the only way I know of to make my bedtime insulin last until morning, without makingmy blood sugar go too low in the middle of the night. Actually, the complaint I made to Pat was, I had to takeso much insulin that I go too low in the middle of the night, and she came up with this answer, and it works. Ihope some of you will try it. I've tried it on a number of my patients, and it is indeed working. Some patientswho make a substantial amount of their own insulin do not require the splitting of the bedtime dose. They justtake one dose at bedtime, and their endogenous insulin fills in. The amount of insulin that I take at bedtime is

relatively small. I take about 1.5 units of Levemir when I go to bed, and another 2.5 units at 3:00 a.m. andthat holds me for the whole night.


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18. How to Prevent Hospitals from Giving Glucose Solution While You Are in the Hospital

Dr. Bernstein:I once had to go to the hospital because a fishing hook got caught in my leg. I was not aphysician then, but I was already an engineer. While I was waiting to see the doctor, the nurse was setting upan IV, and said I had to be hooked up with a glucose drip. I told the nurse I had diabetes, but the nurse stillinsisted I had to have the glucose drip. By the time the doctor had come around, and clipped the tip off thefish hook and removed it from my leg, my blood sugar was up to 1500 mg/dl. If I had to wait much longer, Icould have died there. This is happening every day, probably all over the world. My main experience is withpatients from the USA, although we do get the same sort of story from other countries.

Now, I'll give you another true story. I had a patient, a three year old girl who was with her family vacationingin Florida. I got a call from her father, saying his daughter was vomiting and they didn't have any injectableTigan.

The little girl couldn't keep down any fluids because she was vomiting, so this was a real emergency. Thefather said there was a pharmacy an hour in one direction, and a hospital an hour in the other direction. Heasked where they should go. I said to take the little girl to the hospital.

They got to the hospital. Late that night I got a phone call from the doctor who was in charge of the ER.Apparently, the father asked her to call me, because she had wanted to give the daughter an IV glucose dripfor rehydration. I asked the doctor why she wanted to give glucose to a diabetic child. She answered that it

was the hospital rule. I asked her what the little girl's blood sugar was, and was told it was around 90. I askedthe doctor if she had any idea what the glucose would do to the patient, and the doctor replied that it wouldraise the patient's blood sugar. I asked her what the chance was that the glucose drip would put the patientinto ketoacidosis, which is often a fatal condition. The ER doctor replied it would be about a 50:50 chance thepatient would go into ketoacidosis. I then asked the ER doctor what the odds are that the patient will notsurvive ketoacidosis and that the patient would die. She replied saying about one out of three. I then askedthe ER doctor if she wanted to risk the life of the little girl because of the hospital rule. The doctor replied,saying she had no choice. I then asked the doctor what would happen if she wrote in the chart note that shespoke to the patient's doctor, and the patient's doctor insisted that the little girl be given normal saline, andnot glucose, and would that let the ER doctor off the hook. She said it would. This ER doctor was very niceand cooperative, but look what could have happened! How many times a year does this happen elsewhere in

this country, to say nothing of that particular hospital?

When I train a new patient, I teach them how to handle sick days. One particular sick day situation isvomiting, which can dehydrate you and prevent you from rehydrating, because you won't be able to drink ifyou feel nauseated. I have all my patients inject themselves with Tigan when they are vomiting because itstops the nausea and vomiting, and allows them to drink water. We also spike the water with certain salts. Butsometimes Tigan doesn't work, maybe about one out of every five times, in which case I tell the patient to goto the hospital and get IV saline. What usually happens is the hospitals want to give them glucose.

Here is how I train my patients to avoid getting glucose. The first thing to do is say you are a diabetes patient,are vomiting, and can't hold down any fluid, and need IV saline. If they are very cooperative, they might saywhat kind of saline, and you would tell them normal saline, which is 0.9% and matches the tonicity of blood

serum or plasma. The chances are that the hospital will say, sorry, but they don't give saline to diabetespatients, only glucose. So then you explain to them the glucose will raise your blood sugar, possibly put you inketoacidosis, and kill you.

Frequently what they say is that they could compromise since the patient is afraid of glucose. The hospital willgive fructose or lactose, and that won't raise blood sugar. That is an absolute lie as these sugars will raiseblood sugar, not as rapidly as glucose, but certainly will send your blood sugar very high. So, you have to sayno to the fructose or lactose.


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Another offer they may give is Ringer's solution. Ringer's solution is a balanced electrolyte solution that is veryappropriate provided it is not lactated. Unfortunately, most emergency rooms only have lactated Ringer's instock, which has lactose in it. So, you can say to the doctor, if Ringer's solution is not lactated, that will befine.

Another trick used is the doctor will say the bag the nurse is hanging up says saline, just what you asked for.But, if you read the print on the bag, it will say D5 saline, or D10 saline, which means 5% or 10% dextrose,which is glucose with saline. This is just as bad as having straight glucose solution. It's glucose with somesaline in it. This is absolutely a no-no.

Most patients don't realize that in the USA, virtually every state has a Patient's Bill of Rights. One of the rightsof a patient (or the patient's family) is the right to speak to the hospital administrator. So, you can demand totalk to the hospital administrator, and they have to connect you. My patients have used this method over andover. When you get the administrator on the phone, and usually it's a family member who talks to theadministrator because the patient is usually too sick to get into a war with everyone, you say, "It's lucky youpicked up the phone, because you can save yourself an indefensible lawsuit." You'd think the hospitaladministrator would say, "I'm so sorry you are having so much trouble, what can I do for you?" But that's notso. In every case they've asked why it is indefensible. You can see where their interests lie. The interest of thewhole system is not with the patient, it's with the institution or the doctor.

So what's the answer? Why is it indefensible? You tell the hospital administrator their attorneys are going tohave to hire a defense witness, an expert witness who is a specialist in diabetes who has to say that it's OK togive glucose to a diabetes patient whose blood sugar is not too low. Any specialist in diabetes is going to knowthe patient's lawyer is going to rip them to shreds, because it's such a stupid statement. He also knows thateven the judge is smart enough to rip him to shreds, so he's going to be made to look like an idiot in court.This law firm is never going to hire him again, because he was made to look stupid. So, he's smart enough totell the lawyer that he'd better settle this case, because he can't testify for the hospital. That's why thehospital has no expert witness, and no defense. That convinces them right away. Inevitably, what hashappened every time my patients have pulled this is either the hospital administrator talks to the doctor on thephone and yells at him, or he comes down and yells at him. And, the patient gets what he wants.

But, what if the administrator isn't there? That poses a big problem. The major hospitals have patient

advocates, usually in the social services department, whose job it is to talk to the doctor, not hysterically like apatient's family supposedly acts, but in a rational way to convince the doctor of the patient's point of view. Wilthe patient advocate succeed? I don't know. I would say the changes are 50:50. There's still a good chancethat if you can't reach the hospital administrator, you're not going to get anywhere with this doctor in the ER.

What do you do next? My patients have done this next tip a number of times. You get your things togetherand get ready to leave. You get a piece of paper; ask the nurses in the ER the name of the doctor who gaveyou all the trouble. You write his name down, put a star next to it. You ask any nurse that witnessed oroverheard the encounter to list her name, and how she can be reached. She'll usually give the number of thenursing office. Get the names of any people in the other exam bays in the ER, or the names of people whoheard the shouting.

By this time, certainly if you are in a large hospital, the nurse with the clipboard comes around. Her job is toprevent lawsuits. Her job is to defuse any situation like this. She knows that anyone who precipitates a lawsuitis going to be fired. Even if the hospital wins the lawsuit, the insurance company doesn't want people on thestaff who bring about lawsuits. This doctor in the ER, maybe a newcomer who hasn't had the medical

jurisprudence course that all the permanent employees have to take, and may not even realize that if he'scausing so much trouble, he can be fired if there's a lawsuit . So, this nurse will pull him aside and warn him


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that he'd better be conciliatory, or there's going to be a lawsuit, and he'll be the one to get fired. In everysingle case, this has worked.

19. Hypothyroidism

Dr. Bernstein:Hypothyroidism is an autoimmune disorder just like diabetes. Hypothyroidism is inadequateactivity of the thyroid gland. We find that autoimmune disorders come in clusters. I don't think I've ever found

a patient who had only one autoimmune disease. For example, almost 100% of my patients have bothdiabetes and psoriasis, at least mild psoriasis, with rough elbows. About 80 to 85% of my patients arehypothyroid. In some individuals, the hypothyroidism occurs long before the development of diabetes. In otherindividuals, it may develop long after the onset of diabetes. However, I had never seen a case ofhyperthyroidism (too much thyroid activity) in a diabetes patient until last week, when a young lady came inwhose thyroid levels were high. She had a rapid heart rate, and I was sure she was hyperthyroid. I ordered are-run of her blood tests and lo and behold, the tests came back normal. So she was not hyperthyroid after all,and I still haven't encountered in thirty years of medical practice any patient with hyperthyroidism.

Hypothyroidism can present with a number of symptoms, including no symptoms, whatsoever. I occasionallywill see a patient who feels perfectly fine, but has low thyroid levels. Quite frequently, we see lipidabnormalities, such as high LDL, and small, dense, atherogenic LDL particles, and possibly low HDL, all of

which are supposed cardiac risk factors. Indeed, low thyroid does have a strong association with heartdisease, and it possibly can be corrected by correcting the thyroid status, as we will discuss.

Tiredness is a very common symptom of hypothyroidism. Poor memory is another common symptom. Many ofmy new patients can't remember what I teach them. Luckily, I record everything I teach, and I give them therecordings. They don't remember the instructions because their thyroid is low. I have a memory test that Igive everyone when I first see them, and it tends to improve both with blood sugar control, and withcorrection of the low thyroid status.

Depression is a very common side effect of hypothyroidism. In fact, it is now standard protocol forpsychiatrists not to treat depression until they have gotten a thyroid profile. If the patient were hypothyroid,the thyroid status is corrected before any other kind of treatment is started.

Hair loss is very common, and it's most common to see loss of the outer third of the eyebrow hair, so it's notjust on the head, but also the outer third of the eyebrows.

Dry skin is common in hypothyroidism.

You can look up more hypothyroidism symptoms on the internet.

The thyroid gland makes two major hormones, and a number of minor hormones. The major ones are T4(levothyroxine) and T3 (liothyronine). T4 has four iodine atoms in the hormone molecule; T3 has three iodineatoms. T4 is less active; T3 is far more active than T4. T4 gets stored in the tissues throughout the body, andis converted to T3 as that particular tissue requires it. Each tissue has its own deiodinase enzyme that removes

one of the iodine atoms from the T4, so that it becomes T3. We can treat the disease by giving T4, and thenhoping that the patient will convert it to T3, as needed, but all too often, T4 does not get adequatelyconverted to T3. In fact, I find that many of my diabetic patients may at their first visit have a normal T4, buta low T3. These people lack the deiodinase that converts the T4 to T3. We can double check by looking intheir blood for Reverse T3, which is an inactive form of T3, and is frequently elevated in people who cannotmake adequate amounts of active T3.


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When we test for low thyroid, the most important test is the Free T3, which is the active form of T3. T3 boundto protein (globulins) in the blood is inactive. We want to see Free T3. We might also take a look at Free andTotal T4, but the most important is Free T3. I usually measure Free and Total T3, and Free and Total T4,although I might be wasting a little of the insurer's money, because I could get away with just the Free T3.

I will treat the patient, usually, with both T4 and T3. In a hypothetical patient who only has low T4, I will givethem Synthroid, or the equivalent, with is levothyroxine; but, that is rarely the case. Most often, people haveslightly low T4 and very low T3. We have to give those people T3 (liothyronine) replacement. In the marketplace, liothyronine comes under the brand name, Cytomel, but it only comes in multiples of 5 mcg. What if aperson needs 17 mcg a day? You cannot get it from Cytomel. Another problem with Cytomel is that it has anactive life of about eight hours, so you have to take it every eight hours. Almost everyone forgets theafternoon dose. I almost always prescribe a compounded form of liothyronine that we get from acompounding chemist, either a chemist near me, or one near the patient's home town. The compoundingchemist will make up timed release liothyronine, also called slow release T3. The T3 can be made in anystrength the doctor wants, and it's taken every twelve hours, not every eight hours like Cytomel.

Initially, I will make an educated guess at the starting dose. If we get reversal of symptoms without undo sideeffects, we'll start them off on a trial dose twice a day, every twelve hours. We will then measure the patient'sblood levels in two or three weeks. I may even have some samples in my office which I will try on the patientsfor a few days. We keep titering the T3 until we get blood levels in the middle of the normal range.

Let's look at the exact names of the tests we order from the laboratory. We do Free T4 by direct equilibriumdialysis radioimmunoassay; Total T4 by chemiluminescence. Free T3 and Total T3 testing is by tracer dialysis.We usually have the tests performed at Nichols Institute, in California. Mayo Clinic labs are also goodendocrine labs, and they can do these tests, too. The diagnostic code that we give the laboratory is 244.9.

When I order thyroid tests, I also get white blood cell count, because it tends to be under 5.6 for hypothyroidpeople. When we give them thyroid replacement, the white blood cell count tends to come back over 5.6,which makes it more normal.

Getting back to thyroid hormone replacement, you should not take it concurrently with high fiber foods likebran crackers. It should be at least two hours away from when you eat fiber. You should not take itconcurrently with metals like zinc, selenium, calcium, or magnesium; it should be taken at least two hoursaway. You should not take thyroid products concurrently with soy products, so you should be at least twohours away from metals, fibers, and soy. I doubt that a small salad would make much difference, but Icertainly would keep it away from bran crackers, or if you are taking psyllium powder for constipation. In anyevent, we titer up the T3, and in many cases simultaneously also T4, until the T4 and T3, on testing, are rightin the middle of the normal range. It takes two months for T4 levels to equilibrate once you are on a dose oflevothyroxine. It takes only about two or three weeks for the T3 levels to equilibrate, so we can rapidly finetune T3 levels; and we slowly fine tune T4 levels.

That is basically the story, except for a reference on the internet that I want to give you. I've been diagnosingand treating hypothyroidism in this manner for thirty years. It was born out of trial and error, and watchingthe results. Most doctors test the TSH, Thyroid Stimulating Hormone, on the assumption that it reflects hypo-

or hyperthyroidism. But I never saw any correlation with TSH of symptoms or with lipid profile, or with the lowwhite blood cell count. It seemed to bear no relationship to hypothyroidism, so I abandoned its use many,many years ago, even though it is much less expensive than the tests I use. All of this I'm telling you is basedon trial and error, and my observations. Then, all of the sudden, about a month ago, a patient of mine emailedme a long paper that I'm going to refer you to, that gives the story about the deiodinase enzymes that convertT4 to T3, and shows how what I'm doing in the way of thyroid testing and prescribing thyroid replacement isexactly what, according to science, should be done. The logic is complicated, and it is explained at the web


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site of the National Hypothyroidism Association. This is the internet address:www.nahypothyroidism.org/deiodinases/. This link will take you directly to the article about the deiodinases,and I urge you to get this article. It's really worth reading, and quite fascinating. You will get quite aneducation from this document. It supports what I've been teaching for thirty years.

20. Intermittent Claudication

Dr. Bernstein:This refers to a common complication of diabetes that also affects people without diabetes.It's a condition where you may walk for a block or two, and your legs get tired and you can't take anotherstep. This is due to poor circulation to the lower extremities. The reason I bring up the subject has to do withthe treatment that is commonly carried out upon people who have these symptoms. I should first point outthat intermittent claudication can be confused with that of a condition called spinal stenosis, which will givesimilar symptoms, but if you have spinal stenosis, and bend over forward while you are walking, you relievethe symptoms, so this is not a circulatory problem. If your symptoms are relieved when you bend forward, youdo not have intermittent claudication.

Let me tell you a little bit about my experience. My first experience was when I was still an intern, and I had aspecial rotation with the world's authority on the diabetic foot, whose name was Heinz Lippman, MD. We werein a nursing home where he was in charge of foot care. We came in one day and he asked where a particular

patient was, and they told him that the patient had a new doctor, and the new doctor sent him to our bigsurgical hospital for treatment of his intermittent claudication. The treatment they did at this hospital waswhat's called a femoral popliteal bypass graft. They would take either a vein or maybe some synthetic tubing,and bypass the narrowing in the arteries near the knee, enabling the patient to have free circulation thereagain so that instead of walking only a block or two, he could walk a mile. When Dr. Lippman heard this, hestarted to cry. He told me this surgical procedure would kill the patient. He said he'd been this patient's doctorfor five years, and it would be like losing a friend. I remained in touch with Dr. Lippman, even after myrotation, and I eventually ended up running his peripheral vascular disease clinic. We were very close foralmost 30 years. And, indeed, this man did die, but why did it happen?

Before I reveal the cause, I will tell you what happened to the mother of a friend of mine. I had a friend whowas a cardiologist. When I started in practice, he called me on the phone and said his mother was justadmitted to a major hospital in New York City, where they were going to do the same femoral popliteal bypassgraft surgery. He asked what I thought about that, and I asked why they were doing it. He said because whenshe goes to the supermarket her legs get tired; she has to stop and it makes it nearly impossible for her toshop. I told him the surgery should only be done to save a leg, not for convenience. I also told him whathappened to Dr. Lippman's patient. He called his brother, who is also a physician, who was at the hospital,and he said she was already prepped for surgery, and they couldn't stop. I said he should call his brotheragain, and tell him it can cost his mom her leg and her life. The brother refused to intervene. Anyway, thissame thing happened to this doctor's mother that happened to Dr. Lippman's patient. After something likethree months, she lost the leg that they operated on, and within the year she was dead.

Why does this happen? When someone develops intermittent claudication it takes years and years for the

circulation to decrease in that limb. While the circulation is decreasing in the main artery, collaterals developaround that artery to keep the leg alive. Although a person may have difficulty walking, the leg is still alive.When you do a bypass graft, you put in a tube to bypass the blockage, and you no longer get blood pressurein the collaterals that were keeping a leg alive. In fact, on the operating table, as soon as you make thebypass, the collaterals collapse. Ordinarily collaterals take at least three months to develop. However, overtime, these bypass grafts become blocked again, and when this happens, they don't block gradually over aperiod of three months, they block suddenly. Usually, the time frame is two months to six years, so a bypass


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graft may buy you six years. When they block, there are no collaterals; you get a sudden blockage, and youhave a cold dead leg unless the patient can somehow arrange for a vascular surgeon and an operating roomwithin three hours, and of course this never happens. So these people lose their legs, and when a diabetespatient loses a leg, especially if it's a poorly controlled diabetes patient, they usually die shortly thereafter. Theaverage maximum lifespan for a diabetes patient after amputation is five years.

So that's the story of intermittent claudication. You only allow surgery if the patient has a wound that won'theal, and you need to do the surgery to give it enough circulation to heal the wound.

When I have a patie

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DrRichard K Bernstein 37 Tips Tricks and Secrets to Defy Diabetes