Tag Archives: diabetes

Sleep Too, Early Waking

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Some people fall asleep fine but cannot stay asleep. Like other sleep pathology this can be due to a complex interplay of underlying reasons. Often the 24H cortisol circadium rhythm has become dysregulated and the early morning peak is coming earlier than it should, waking people up at 3, 4 or 5am. What can be done? There are some prescription sleep medications that can be helpful, and global stress management skill building is also important. Underlying anxiety disorder may need to be treated and substance use disorders are also major players in sleep-wake disorders.

Alcohol is an obvious player in the 3am waking game. For people who drink regularly, depending on what time one goes to bed and therefore stops drinking, at some point the alcohol with start to wear off and the withdrawal will start bringing agitation, heart palpitations, sweating, and headache. This can cause early morning waking between 3-5am. Chinese medicine correlates each organ to a 24H clock, and this time of day is the Liver time. Ironic, yes? Accurate, yes? Decreasing evening alcohol can certainly result in better sleep. Alcohol free evenings may take some time to produce better sleep but after about 7 days of abstinence the sleep cycle will begin to regulate. If full abstinence is not desired, start by at least assessing the effect of alcohol and considering your own motivations for changing drinking patterns as they do certainly effect sleep negatively. Having some protein closer to bed time can be stabilizing to blood sugar and alcohol metabolism overnight.

This is true for diabetics as well as for people using alcohol. This is not my area of expertise, but diabetes is related to increased cortisol levels due to the connection between fasting blood glucose, blood sugar, and the liver and pancreas control of blood sugar during the overnight fasting period. There are several studies on sleep disorders in people with diabetes which have evidenced that there are clinical correlations. If you have diabetes and poor sleep, I recommend working with your PCP or Diabetes specialist to make sure your blood sugar issues are not the root cause before moving into more behavioral or psychiatric sleep medications and sleep medicine studies.

The first botanical medicine I turn to when faced with early waking is a version of several different formulations using standardized botanical extracts of magnolia. The first agent that was trademarked was called Relora and was a Canadian product. This standardized extract regulates disorderde circadiuan rhythms. Whan taken at night it helps smooth out early morning cortisol spikes, decreasing early morning waking related to stress and anxiety. It also has some evidence to decrease stress related eating, and improve subjective mood and wellbeing.

Relora vs placebo effects

A similar American product is Cortisol Manager by Integrative Therapeutics. This product also uses the honokiol standardized extract with magnalol rather than berberine. This product is combined with ashwaganda (Withania somniferol). Ashwaganda also has evidence that it adjusts dysregulated cortisol circadian rhythms for improved early morning waking. There are many sleep formulations available that contain Ashwaganda. Gaia brand “Sleep Thru” formulation is another similar product for use when early waking is the issue rather than difficulty falling asleep.

These botanical formulas are generally safe for people without significant health conditions. If you are taking more than 5 medications, have kidney disease CKL3 or greater, or are on immunosuppressive drugs for transplants, autoimmune disease or any other indication, supplements should not be taken randomly without supervision by a licensed Naturopathic doctor or trained herbalist as there could be real drug-herb interactions.

 Finally, as mentioned at the beginning, emotional stimuli do go thru hypothalamic-pituitary-adrenal axis to effect cortisol secretion. Lifestyle modifications are necessary in every case to at least consider the underlying causes of the stress. A pill alone cannot regulate a deeply engrained habit or pattern. Most health care providers would like to hear about what is keeping you up at night, in order to troubleshoot with you ways to improve coping and reduce suffering. These plant based medicines are allies in your journey towards improved health and are only part of the team based approach that real change towards health entails.

lDeshpande A, Irani N, Balkrishnan R, Benny IR. A randomized, double-blind, placebo-controlled study to evaluate the effects of ashwagandha (Withania somnifera) extract on sleep quality in healthy adults. Sleep Med. August 2020;72:28-36.

Talbott, S.M., Talbott, J.A. & Pugh, M. Effect of Magnolia officinalis and Phellodendron amurense (Relora®) on cortisol and psychological mood state in moderately stressed subjects. J Int Soc Sports Nutr 10, 37 (2013). https://doi.org/10.1186/1550-2783-10-37

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Intermittent Starving vs Fasting

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My IG and twitter feeds keep sending me promoted ads for intermittent fasting and young thin women in my Internal Medicine residency program keep telling me they are doing it. As someone with an inherent red flag signal for anorexia and eating disorders, I am triggered. As someone with a 4 year nutrition degree and as a gal raised with a spiritual practice of fasting, I do understand the value behind the concept. The problems start when restriction/binging/restriction patterns are overlayed on the foundational evidence.

This is the best nutritional protocol and evidence I found to implement intermittent fasting into a food plan for weight loss or for longevity. There is good reasoning and practice behind the idea that the liver stores glycogen for storage, and that this “immediate use” supply needs to be used up before the body creates new glucose from adipose cells and muscle. This is reasonable: fasting uses up the supplies . Then fasting decreases fat or muscle from stores.

Some fasting articles I’ve read suggest 16 hours between eating every day. This sounds alot like the “don’t eat food after 7” rule that has quite a few generations of folks waking up covered in cookies from night eating.

Some articles suggest 16 hours between meals twice a week. This seems more reasonable to me as it allows for some pre-planning to have restful, quiet time during the fasting period. Our human bodies are not designed to “run on empty.” I grew up in a yoga community where fasting was part of the practice towards enlightenment, but work was not done during the fast. One’s time in the fasting state is to be spent meditating, reflecting, and processing (like while we sleep.) Yoga is also an acceptable practice during this time as it stimulates glands and organs as well as the musculoskeletal body to return to homeostasis. Fasting is designed as a parasympathetic state to rebalance CYP liver enzymes and clear the intestines. Pushing through fasting with sympathetic, highly motivated activity like mental or physical labor requires the adrenal glands to overachieve and drive metabolism through adrenaline and sheer will aka cortisol.

The one place where hard work on a fasting belly IS indicated is for anyone looking to lower insulin resistance by using the biochemistry of exercise. This could be someone requiring huge doses of insulin for only moderate blood glucose control, or someone trying to beat type 2 diabetes in the pre-diabetic state. Exercising on an empty stomach is one of the few ways to upregulate cellular receptors called GLUT_4 for insulin to bring blood sugar into cells. I have tried this and its oddly satisfying. Nerd out on biochemistry and GLUT-4 here.

I don’t intermittent fast intentionally myself. Some weekend days I wont eat food until 2-3 in the afternoon, just based on my natural appetite; however, I do have black coffee and water and sometimes juice during that time. To be my best self, I need frequent and regular fuel to keep this brain and body going for the intense work weeks I do. Not allowing myself to eat when I am hungry in not helpful for my mental health either – not only do I get edgy or feel anxious, my own disordered eating and body dysmorphia can easily be motivated towards restrictive eating patterns.

Aside from mental health, some people also have genetic metabolic imbalances if their lineage experienced a traumatic food restriction. This has been researched in Irish descendants as well as Jewish folks. Caloric restriction can actually trigger a survival metabolism where minimal resources are burned and every morsel of fat possible is stored. This is ancestral trauma that has caused permanent alterations in the genome that get triggered by environmental circumstances.

The science is compelling: improved metabolism, destruction of cancer cells, immune regulation, cortisol balancing, cellular rejuvenation…. benefits are numerous!

Here is what I would do if I was either doing a period of cleansing/detox and intentionally working on restoring health or if I was committed to a defined period of intentional weight loss (8 months from this algorithm.)

  1. Style 1: two mornings a week, fast until 12-1pm depending on your 16 hour window. On these mornings drink warm water, organic green tea or herbal tea, stretch and do yoga or go for a gentle walk, get into nature, rest/ meditate, write or reflect. Eat a Mediterranean style diet the remainder of the time.
  2. Style 2: For a more intensive weight loss experience, follow the algorithm for 2 days a week of restricted caloric intake from the JAMA article referenced at the beginning of this post. I would not also follow the time restricted feeding patterns myself as I find this too rigid for modern life and overrides the natural appetite instincts which are essential. Eat a Mediterranean type diet or Paleo. Consider pairing this with the Whole 30 protocol or an elimination diet for true restorative food as medicine. Follow the above guidelines for your calorie restricted days with rest, nature, reflection, massage, acupuncture or other healing practices, whole organic foods, teas and water. Once you have completed month 4, return back up the protocol until you are back at full weekly caloric intake and reassess.
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Insulin Resistance

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Insulin is a hormone that is produced by the pancreas that helps cells to absorb glucose in the blood. When we eat a lot of sugar or carbs, there is a rush of glucose (sugar) absorbed into the bloodstream and the pancreas responds by releasing  insulin, signaling the cells to  allow the sugar in. When blood sugars dip low from chronic hunger or lack of food, there is very little insulin produced.

A lifetime of sugar rushes and sugar deficits can lead to Type II Diabetes, a blood sugar disorder that is characterized by insulin resistance. Insulin resistance happens when your cells stop being able to efficiently respond to the presence of insulin. Imagine you live next to a train track, or by a fire station. Eventually the constant trains or sirens become background noise – we stop hearing them out of habituation. Insulin resistance is kind of like this – chronically elevated blood glucose results in cellular apathy. Each little cell stops posting the GLUT4 receptors in the presence of insulin and the glucose cannot be absorbed. This results in a starvation state for the cells with an overabundant state in the blood, with resulting nerve damage from high blood sugar and cellular aging from nutritional deficit. Can you imagine how this could be improved with nutritional regulation of blood glucose?

The good news is it is possible to improve insulin sensitivity at a cellular level, especially at the pre-diabetes stage. The first step is to adjust your eating habits and diet. The chronically elevated blood glucose needs to stop happening as it is the flooding of the system and causing the habitual “resistance.” This can be achieved with high protein and vegetable meals with abundant healthy fats eaten every 6 hours or so.

Our cells like a slow, steady amount of glucose and insulin in the blood. The logic is as follows: protiens and fats and high fiber carbs like vegetables and grains break down slowly in the digestion, giving a slow steady stream of nutrients and building blocks. Processed carbs, sugar and fruits are broken down quickly and result in a rush of glucose. Therefore, to slow the rush of blood sugar one needs fiber, fat and protien present with each meal. This makes sense – it is always easier to handle any situation in life when things come at us in a moderate, orderly fashion. The microcosm is the macrocosm.

look up healthy fats and high protein foods!

The ginseng family including Panax Ginseng and American Ginseng are also used to lower blood sugar while increasing the ability to adapt to stress. This adaptogenic action exhibits effects across multiple endocrine organs including reproductive, adrenal and pancreas, making it a great herb for modern medicine. The ginsengs work at the plasma membrane level as well as improving steroid hormone receptor sites, which may explain their benefit and use in improving insulin resistance.  http://www.ncbi.nlm.nih.gov/pubmed/10571242. There are many other botanicals that have a history of use in blood sugar management including bilberry, cinnamon, gymnemna and more.

Vitamin and mineral deficiency can also worsen existing insulin resistance and exacerbate high blood sugar. The trace minerals chromium and vanadium are both cofactors in the glucose-insulin complex and deficiencies in either of these will worsen blood sugar issues. Chronic magnesium deficiency is also commonly found in people with insulin resistance. This could be due to a deficient dietary intake as magnesium is found in leafy green vegetables and broccoli as well as fish, raw nuts and seeds, avocados, bananas and dark chocolate.

Finally, high intensity, short-term exercise is essential for improving insulin resistance. This kind of exercise shifts metabolism into fuel-burning mode, instead of fuel saving mode. Being active multiple times a day is even better for shifting into glucose utilization mode and improving cell receptor activity. http://www.thebloodcode.com/type-2-diabetes-recovery-needs-daily-exercise/ . Exercise is the only thing that will independently stimulate individual cells to produce those Glut 4 insulin-regulated glucose transporters found primarily in fat and muscle cells, instantly improving insulin resistance and decreasing blood sugar.

In summary, insulin resistance is a complicated condition that is essential to address in the treatment of diabetes. Fundamental nutritional changes and lifestyle basics are essential starting points for anyone interested in improving blood sugar parameters and taking an empowered stance towards metabolic recovery.

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I Always Bring My Lunch

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I was in NYC in August this summer, doing a short 4th year medical elective at the Center for Transgender Medicine and Surgery. I did some couch surfing, and stayed at an Air BnB in Williamsburg my last week. Medically it was an outstanding experience, and in my dream future, I will get to be a physician working at this clinic in Manhatten. Being away from home, I realized how much I rely on having my own kitchen! Making my lunch is I keep my body feeling good despite spending most of my time working in a hospital or relaxing in bed.

What do you do for lunch every day?  By lunchtime every day, I will eat basically anything. I sometimes eats my lunch at 10:30 AM I am so hungry. The more glucose my brain is burning, the more I need that hit of fat, phytonutrients and fiber.

Therefore, my cunning plan is to eat super healthy sometimes boring basics for lunch – lots of veggies, good quality fats, high fiber fruits, raw vegetables and very few processed carbs. Then,  I dont have to think as hard about what’s for dinner and still maintain a good nutrient balance.

So, what do I actually eat? Greens and grains, with cheese, avocado or nuts/seeds and random chopped veggies like carrots, cucumber, tomato, radish. In summer I love to put flowers in my food. A grain free diet is popular with the keto crowd, but I advocate to have at least a few cups of whole grains in the diet per week. The fiber, magnesium, B vitamins and serotonin release metabolically help keep the mind-gut axis regulated. We rotate our grains between short grain brown rice, wild rice, quinoa, and millet to maintain variety of flavor and nutrient profiles.

I heard once in a conference lecture that nutritional studies were done evaluating T4 –> T3 conversion activation (active thyroid hormone.) Subjects were fed fat based diets, protein based diets or carbohydrate (CHO) based diets. Only the diets with carbohydrates evidenced thyroid hormone conversion. Since I am a huge fan of having optimized T3 production for an effective metabolic mileau, I advocate for having a moderate amount of whole grains in ones basic nutritional foundation.I wish I had the study in-hand to back this up but I dont; maybe once I am out of medical school I will have time to research these things more fully. The bottom line is that whole grains are good for health and tasty and I like them in my lunch. They are filling and delicious and beneficial.

I like to layer the grains on the bottom, then a huge handful of greens – whatever has the latest expiry date when I am shopping! We rotate spring mix with herbs, arugula, baby spinach, crispy green leaf lettuce, and occasional kale salad (leftover.) I need fat with my lunch to feel satisfied, so I douse the whole thing with yummy olive oil and a delicious vinegar like balsamic or umeboshi or fire cider vinegar. Then, I add some protein: cheese is the easiest and I love cheese.  Tuna, egg or chicken salads are always a win too.

I also love toasted walnuts, pecans, pumpkin seeds or sunflower seeds. I buy them raw, and toast them in a dry cast iron pan until they are warm and smell nutty but not burnt. Make sure to stir! I store these in glass jars in the cupboard. The pumpkin seeds are best toasted with some Chalula hot sauce and cumin! Yum. These add a crunch, some richness, protein, and delicious essential fats. Finish the lunch with 2 chopped veggies for color, fiber, and variety: an organic carrot, cucumber spears with pepper, pepper slices, whatever floats your boat.

If you are a hard paleo and refuse grains, or if you are like me and sometimes need a second lunch or a hearty snack then organic nitrite free salami is a good addition. It is filling, savory, and works well with olives, carrot rounds and other veggies for finger snacks. Just veggies is not enough for me.

Lunch Plan B: huge leftovers fan here. If I go out to dinner, I almost always save half for lunch the next day. This is a win-win, because I stop eating when I am full (or save room for dessert) AND I have a pre-made meal to go. I hate waking up extra early to deal with lunch, so I usually get lunch ready the night before. We generally also cook for more than two, planning a lunch or two and maybe even a supper into every meal we co-create. Leftovers are exciting to me because these are usually rich yummy comfort foods like pasta, steak, curries and other “real meals”.

Finally, making lunch saves me money. The first day of my August rotation I went to the nearby Whole Foods for lunch. I wasted 15 minutes wandering around the hot and cold bars, trying to figure out what to eat. My $15 salad ended up being an awkward mish-mash of flavors that did not blend well. That day after work I went and bought $40 worth of groceries (almond flour crackers, apples, greens, cheese, nuts, yogurts and paleo granola for breakfast)  and brought my lunch to work every day for the next week, supplementing with enchilada leftovers.

Bringing your lunch ensures you know exactly what you are eating. It keeps you committed to your intentions with food, and lines up the healthy choices for you in moments of  “Im Starving” brain meltdowns that would otherwise allow for easy Trash. It is also a great way to plan your daily insulin for diabetics! Finally, it frees up dinner for more social food activities that may be less greens and grainy.

Oh, and bring a snack, maybe two. For Fall and Winter I find an apple is the hardiest fruit. Combined with nuts and raisins, it’s a great choice. Someone once said, if you dont want to eat an apple, you are not actually hungry. This holds true as long as your teeth are in good shape.  In winter and summer, cut up fruit like citrus or stone fruits an berries are refreshing and delightful. I also love dried mango slices from Trader Joe’s. If you crave yogurt and aren’t having it for breakfast, it’s a good option too. I love the dairy-free yogurts too like soy, almond and coconut singles, which are far better choices than anything a vending machine or a cafeteria might offer.

My basic formula is eating good quality food 65% of the time. Then I can easily process about 35% cheeseburgers, nachos, pizza, sweets, and other junk. To change your body composition this may need to become more like 75:25 and exercise has to be added in. I eat at least 60% of my daily food at work between 9-5pm. If I make sure these foods are healthy, wholesome and invigorating to my brain and bowels, my nutritional work is done for the day. Yay!

 

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Will Power

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I am two weeks into second year medical school, and the majority of our content has been NeuroAnatomy and Brain Diseases. As a physician it is pretty darn important to be able to figure out when someone is having a life threatening stroke impinging on brain tissue,  versus a flare up of a genetic disorder that is starting to show neurological signs and symptoms. Knowing the anatomy of the brainstem, and the arrangement and progression of the long tracts of nerve fibers throughout the spinal cord, medulla, pons, brainstem and beyond can create a Cartesian like diagram where one can fairly accurately isolate the nature and location of the lesion. That is, if you can remember where and how everything goes.

Brainstem_07-02_smallI never quite knew where the medulla was even located, and now I know more than I probably ever will again about the arrangement of nerves, radiations and nuclear cell bodies in its little bulbous body. This tiny part of the body has nerve fibers that do cardiorespiratory regulation, the trigeminal cranial nerve nucleus, tracts, and radiations for face sensation, ascending dorsal column and spinothalamic sensory tracts for the entire body, descending corticospinal and pyramidal motor tracts for the entire body, and some complicated cranial nerve regulating nucleii that coordinate the eyes and hearing. As you go up fun things show up like the olives, and the solitary nucleus and nucleus ambiguous (both associated with the vagus nerve.) And, the tongue. Problems with the tongue can be from a medullary lesion including slurred speech and not being able to stick your tongue out at someone very effectively, because it points wiggly off to the side the damage has occurred. There is probably more things in this tiny medulla oblongata, but I cant remember them right now.

Starting back into school is also an exercise in letting go. I am fairly certain this is a cerebral condition, and not a brainstem function.  Letting go of free time, of relaxation, of life without an alarm clock. It takes a lot of will power to focus for so many hours at a time. I personally also find myself needing to cut back on alcohol, Netflicks and social time with the advent of academics.  I have been having a lot of conversations about this topic of will power lately, as in, do I have enough, or am I lacking? I have such restricted foods from all of my food sensitivities that I feel like I have pretty good will power overall but maybe, just maybe I could work on a higher level control of some of my more primitive impulses (stay tuned for amydala updates next week.)

untitledBack to the topic of stroke. And willpower. Smoking is a huge risk for stroke, especially intraparenchymal stroke. 45% of people die within the first 30 days of having a stroke. Why? Because the brain is special. And when you put pressure on it, by adding more fluid (blood) into a closed small area (the skull, or calverium as I love calling it) then, the brain tissue simply LIQIUIFIES in an effort to make more room. Disgusting right?! When your brain liquefies, you get signs and symptoms associated with damage in that place – if you hit a small area and just nerves and radiations of nerves, your body can often recover loss of sensation or muscular weakness on one side of your body. When you hit a nerve nucleus, like the facial nerve cell body nuclei, you probably wont recover those functions because the cells themselves are dead.

Apparently I still need to learn more about strokes, especially the ones that can kill you. What I do know, is high blood pressure, diabetes and smoking are huge risk factors for stroke, and those are all related to will power. So, you do have a choice, like I do, about how to live on a day to day basis. I am choosing to decrease my daily alcohol content to improve my studying. What will your choice be?

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