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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 Death Dr.
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 Counting What 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 Blood
Sugars
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 the
Clinical Journal of the American Diabetes Association
28. Recommendations for the General Flu and H1N1 Vaccines for Adults and Children with
Type 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 autonomic
nerves control functions of the body that are not within our conscious control, things like heart rate, digestion
of food, penile erections, amongst other things, such as the closing down of blood vessels in the legs upon
standing. Ordinarily, when a non-diabetic, or a person without neuropathy stands, there are muscles in the
walls of the large arteries in the legs that automatically constrict, instantly, like a reflex, so that blood will not
pool in the legs. This happens so that when you stand, your brain gets enough oxygen, and you don't pass
out. 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 if
you have autonomic neuropathy.
2. I test blood pressure when a person is lying down, or supine, and then standing. The person lies down for
however 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 blood
pressure that may occur. Then she asks the patient to stand, and the blood pressure is checked directly upon
standing, 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 pressure
may even decrease, and in some, it decreases by a lot. In patients where it decreases a lot, my assistant asks
them if they feel funny, as if they are going to pass out. These patients say they do feel like they are going to
pass out, and in fact, they feel like they need to lie down. This is commonplace amongst people who have had
elevated 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 been
put on the ADA diet. He was referred to me by his son, who is a physician. This patient's blood sugars were
very high, and he had lost a lot of weight by peeing away calories, and wasting away. He came to me with
very high blood sugars. He looked extremely sick. We were able to rapidly get him back to normal blood
sugars with the help of a low carbohydrate diet and insulin injections. He did very well; played golf and drove
his 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. I
warned him, just the same as I warn all the others, that when you get up at night for any reason, you sit at
the edge of the bed and dangle your feet for a minute before standing up. If you don't, sooner or later, you're
going 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 a
bloody 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 he
hadn'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% blockage
in 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 material
on the inside of the artery; or carotid stenting, which is inserting a device that holds the artery open. If the
stenosis is as much as 70%, or perhaps even higher, but there are no neurologic symptoms, you don't
operate. I reminded the son of this, and he said he'd do his best, but his other brother, also a physician, was
in 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, but
the neurosurgeon decided to operate, anyway, in spite of my pleas. I warned them there was good likelihood
the 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 to
see me, and he had a droopy lip and slightly slurred speech, so it wasn't a severe stroke, but it was a good
warning. I warned everyone, including the wife, to not let this happen again, that if you do this again, you will
kill 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 this
patient's blood sugar went up to 500 mg/dl when they hooked him up to IV glucose! In any event, the patient
had the second surgery, and this time he had a stroke on the operating table and was in a coma for six
months, which cost the family, the hospital, and insurance companies a fortune, and lots of agony for a lot of
people, and this very nice gentleman eventually died. This sort of thing is going on every day with diabetes
patients.

2. According to the ACCORD Study, Tight Control May Increase Your Risk for Death Dr.
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 in
a 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]; or
they were sure it was the lower A1c; or people were sure it was the hypoglycemia, and none of these have
been proven to be true. It was important to see these data to see that it was really not the people with the
lower A1c who had the problems; it was actually those who had the higher A1c, who despite intense efforts
we 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 high
carbohydrate diets and then give them large doses of potent medications, such as insulin and sulfonylurea
agents, which can cause problems if you do not use them properly. In large doses we cannot get predictable
results. 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 who
died 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 what
I'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 not
seeking anywhere near normal blood sugars, and they are boasting it is because normal blood sugars kill
people. 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 joint
announcement urging that diabetes patients not be encouraged to use artificial sweeteners, because they
might then reward themselves by eating a lot of fat. Those of you who have read my book know how
ridiculous that sounds. It assumes the diabetes patient is immature, and can't control themselves, and it is an
absurd 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: "The
American Diabetes Association is fighting for those affected by diabetes." Sometimes it seems like they are
fighting 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-steroidal
anti-inflammatory drugs (NSAIDs) can inhibit the absorption of thyroid medications; and they can inhibit even
if taken a half day, or one or two days away from the medication. Apparently, drugs like Motrin, Advil, aspirin
salsalate, 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 your
thyroid 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 of
benfotiamine for the treatment of diabetic neuropathy. I came upon an article entitled, "Prevention of Insipient
Diabetic Neuropathy by High Dose Thiamine and Benfotiamine." Benfotiamine is a derivative of thiamine, so
it's related to thiamine. Apparently both high doses of thiamine and/or benfotiamine can reduce symptoms of
painful neuropathy. It's not just hiding the symptoms. It apparently does ameliorate the ailment to some
degree.

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 ketones
to keep the brain alive. The brain can live off of ketones. This is an essential element of the survival of the
human race. In addition to low carbohydrate diets being essential for the treatment of diabetes, there was an
article in one of the journals that I picked up off the American Diabetes Association web site. It didn't tell
which journal. It gave the name of the authors, but not the journal. However, the title is "A Low Carb Diet is
Bad for the Brain." They are really talking about ketogenic diets. They point out how ketogenic diets are widely
being used to treat childhood epilepsy, and also epilepsy in adults. The ketogenic diet is being used to treat
diseases due to free radical damage, such as Parkinson's disease, and a number of neurologic diseases. If you
read this article, you'd think that ketones, per se, were the fountain of youth. I imagine they are beneficial for
many situations, and of course, low carbohydrate diets are beneficial for not just people with diabetes, but to
anyone 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 diabetic
neuropathy. What was astounding about this, and very upsetting, was that all they did was try to put the
various drugs on the market for treating diabetic neuropathy in a sequence of what you start with first. They
totally 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) it
can 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 away
in two steps. There is what is called metabolic neuropathy, where the nerves are swollen with fluid and
sorbitol that can go away in a matter of weeks; and there is what I call anatomic neuropathy where nerves
have 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 that
you can actually treat the neuropathy, rather than mask it by giving drugs that relieve the pain. As you are
relieving the pain using their method, the neuropathy will get worse and worse, so that eventually, your limbs
will 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 the
bottom 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 was
published in Vancouver, BC. This was a study on laboratory animals, a particular breed of mice which have a
high likelihood of developing cancer. These mice were fed either the typical western diet, or a low
carbohydrate diet. The mice on the western diet had tumors by middle age. But, none of those on a low
carbohydrate diet had tumors by middle age. So, here is another benefit of a low carbohydrate diet, which of
course, the ADA calls a ketogenic diet. So, a ketogenic diet not only can prevent diabetes and treat those with
diabetes, 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 the
authors were all Asian: Hu, Lee, Zu, Yu, etc. What they did was put people under very tight blood sugar
control with essentially normal blood sugars for two weeks. They apparently were attempting to duplicate
what Gerald Reaven did about thirty years ago, which I talk about in my book, DIABETES SOLUTION, where
he 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. This
recent study just looked after one year, and found that their patients had much less severe diabetes than they
did 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 partially
reversible. I'm willing to bet that every one of the people in the study, if they go back to their old habits and
have 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 2
diabetes, 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 Nutraceuticals
promoting their new Sun Crystals which they claim to be stevia. If you read the package and the letter of
introduction carefully you'll see this stuff is mostly what they call cane sugar, which I expect would be table
sugar, 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 tablet
sweeteners are virtually free of sugar, whereas with the exception of stevia, powdered sweeteners inevitably
are mostly sugar, usually 96% sugar. The sugar could be glucose, lactose, or sucrose (table sugar). Up to this
point, any stevia that you purchased was likely pure stevia, which has essentially no carbohydrate in it. But
now, 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 to
stay 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 history
leading 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 worse
and worse. When I was a business executive I used to have a vaporizer on my desk, and would put my nose
right up to the vaporizer to inhale the steam. I would do this for most of the winter. I went through medical
school, became a doctor, and started practicing medicine. As I got older, the sinusitis became so bad that it
became disabling. I knew how to treat it with antibiotics. I became an expert at treating sinusitis with
antibiotics. I frequently had green, infected material coming out of my nose. Eventually it got to the point
where the antibiotics no longer worked. I was virtually disabled by severe sinusitis. I finally wised up and
thought to myself that I must have some kind of immune deficiency. So, I tested myself by having blood
drawn for immunoglobulins. These are the basic antibodies: IgA, IgG, and IgM. I discovered I was very low in
IgA 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 developed
severe diarrhea. I was living on Lomotil until I discovered that codeine was cheaper, and I started using
codeine in order to not have diarrhea. I also did a complete blood count (CBC) because I knew that immune
deficiency 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 for
other 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 causing
disabling sinusitis and disabling diarrhea, I was put on gamma globulin. In other words, my missing
immunoglobulins were being replaced every two weeks by intravenous infusion. When I started on the gamma
globulin, the sinusitis went away immediately. The diarrhea went away. I'm sure as a result of these frequent
infusions, my lymphoma thus far has not returned after ten years. In order to stay alive, I have to get gamma
globulin 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, I
would test him for immunoglobulins. Or, if on the routine blood chemistry his total globulins were low, or low
normal, I would test his immunoglobulins. The normal range for globulin in the blood is about 1.9 to 3.9. If
someone is 2 or 2.1, or 2.2, I will get a breakdown of the immunoglobulins. Another factor that can be
abnormal when you have an immunoglobulin deficiency, not always, but frequently, is serum beta 2
microglobulin 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 2
microglobulin, I'll look at his serum creatinine, BUN, cystatin C, and other kidney tests. If they are not
abnormal, I'll test his immunoglobulins. I've been doing this now for about eight years. I've tested about fifty
patients. 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 two
hundred forty-seven patients, between the first one I'd detected with immune deficiency, and the last one at
the time that they came to look at the records. However, I had only tested about fifty out of the two hundred
forty-seven patients. But, nevertheless, we found forty-eight who were immune deficient, and the kind of
immune deficiency they had is called common variable immune deficiency (CVID.) Forty-eight people out of
two hundred forty-seven is 19%, let's say about 20%. If we were to project onto the entire diabetic
population, which maybe we can do and maybe we can't do, because I don't have a cross section of all
nationalities, and so on, but nevertheless, I would suspect from this data that at least 19% of diabetes
patients 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 blood
count, and I look for abnormalities. A few of them have had very significant problems. For example, one lady
was having a growth removed from her back as an outpatient in a hospital, and she got MRSA (methicillin
resistant staphylococcus aureus.) Those of you who do not know about this organism, it's highly resistant to
antibiotics. It spreads around the body, almost like a malignancy. You'll get one sore at the site of the initial
infection, and you'll get more sores all over your body. That was happening to this lady. Fortunately, when her
blood sugars went up because of the infection, she called me to ask what to do about the blood sugars. I had
reminded 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 gamma
globulin; within a few days the infection disappeared. A similar thing happened to another patient, a man who
developed pneumonia. He had it for three months. When he finally called me to deal with his elevated blood
sugars, we put him on gamma globulin. Within a couple of days, it was cured. There are other stories with
other patients. For example, there's one who developed chronic lymphocytic leukemia. She elected watchful
waiting rather than treatment with gamma globulin. On top of that, my sister with CVID developed a skin
cancer that's treatable only with gamma globulin. It's the only thing that worked. So, she is a first degree
relative of mine. My mother had lymphoma, and also CVID. My sister has CVID; I have CVID; my mother had
CVID, so this thing is inherited. It's not caused by diabetes, but I'm willing to bet that an awful lot of diabetes
patients have CVID. It is my guess that this is the major reason why the incidence of so many malignancies or
cancers in diabetes patients is much greater than in the general population. There are many articles that have
been 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 have
chronic sinusitis, chronic diarrhea, a new malignancy, I urge you to get your IgA, IgG, and IgM checked. If any
of them is abnormal, you should see an immunologist right away, who should put you on gamma globulin. We
learned from my out of town patients who needed gamma globulin that the local immunologists did not know
how to administer it, or how to dose it, or what brand to get, etc. What they learned was that they should go
through the following protocol that I actually suggested to them. They should call the cancer infusion center at
a 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 locality
who is prescribing the most gamma globulin at the local cancer infusion center is the doctor you would need
to 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 to
estimating carbohydrate at a meal. What does the 6-12-12 you read about in my book really mean? It all boils
down to a very wise question someone asked for this teleconference. The listener asked: "When I have no
carbohydrate, 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 I
mention in DIABETES SOLUTION, I noticed that every fifteen years or so during the 20th century, a new
vitamin was discovered. I assumed that perhaps vegetables had nutrients in them that you could not get in
supplement 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 in
vegetables. There are probably very many that we can't get in supplements. I recommend that we eat
vegetables in order to get whatever nutrients that are in them that we know about and that we don't know
about yet. That's how I came up the 6-12-12. Because I believed we needed to eat a little bit of vegetables at
most 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 6
grams 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 bulky
foods that distend the gut, and raises blood sugar. Years later after I discovered this effect, other people
noticed this, too, and called it the "incretin effect." It is a real effect. I mention in my book that if I were to eat
a handful of sawdust, or pebbles, my blood sugar would go up. So, I fudged the numbers. I said that two cups
of salad would "act like" 12 grams of carbohydrate, and this is the term I use in my book. It's not that they are
twelve 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 the
carbohydrate content of salad and cooked vegetables, but because of their bulk and the Chinese restaurant
effect, 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 not
have 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 I
would suggest is that if an average person with an average build had two cups of salad for lunch and either
one cup of salad or 2/3 cup of cooked vegetables for dinner, this would probably give them enough in the way
of vegetation to get adequate nutrients. That's about what I eat. For those who can tolerate nuts, these can
be 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 not
eat them. Sometimes for lunch I'll eat pistachio nuts instead of salad, which are measured out in a little bowl
with a piece of tape on it that correlates to twenty nuts, and I don't go back for more. Acceptable nuts are
pistachio, macadamia, pecans, walnuts, and almonds, but only a small amount. Cashews are too high in
carbohydrate to be acceptable.
This is really all I have to say about the carbohydrates in vegetables, that you keep the vegetables to
minimum, and the only purpose for eating vegetables is to get the nutrition, and not the carbohydrate. This
listener who said he did better with zero carbs was probably right. However, I think that you need the
nutrients in the vegetables I list in my book. Really, it's a matter of guessing for yourself how much in the way
of vegetables you eat to give you adequate nutrition. The carbohydrate load is an unfortunate side effect that
we 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 my
immunologist. He is a co-author of a paper about Common Variable Immunodeficiency, CVID, which I've
discussed in the recent past.
I've had a number of patients complaining that even when their thyroid levels, especially the FT3 is right on
the nose of mid-normal range, they were still tired. I asked the immunologist if he'd ever encountered this. I
was asking on a guess because thyroid issues are not his specialty. Lo and behold, he's done some studies on
this, and he's observed the same thing. What he found was that people who had normal thyroid levels after
treatment, but were still tired, responded to L-carnitine supplementation. They took 500 mg tablets, about six
times a day, and then weren't tired anymore. He said these were people who had high levels of antibodies to
the 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 mid
normal 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
10

your FT3 mid-normal, and you are still tired, try L-carnitine, which is an amino acid. It's unbelievable. I can't
get 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 of
Diabetes, 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's
interesting that they sort of got out of the problem that was facing them in the past when they put a lower
limit on the amount of dietary carbohydrate. They said no less than 137 grams of carbohydrate per day, or
your brain will die. That is an absolute lie, and they got caught in it. It was so embarrassing that they don't
say that anymore. But, they now say to eat a lot of fruit and whole grain breads. These foods are sure to raise
your blood sugar sky high.
With regard to blood sugar guidelines, they say that hemoglobin A1c should be around 7%, and you should
not change the mode of treatment of your patient until the hemoglobin A1c exceeds 9%. So they want A1cs to
be between 7 and 9. Blood sugar-wise, this means an average blood sugar of anywhere from 180 to 260
mg/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 treat
breast cancer. It's a last resort for people who are dying of breast cancer. It was shown to give women maybe
another four months of life, and it was very expensive, about $8000 a dose. So, the FDA allowed it to be on
the market briefly, and then took it off the market. But, the protest from women with cancer and their families
was 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 ADA
recommending the kind of blood sugars that I just stated. The ADA is telling doctors all over the world that
these are the blood sugars that patients should have. Do we hear any protests? I haven't heard anything on
the 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 are
embarrassing 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 Foot
Ulcers. There are a lot of myths circulating about these ulcers. For example, on several occasions I was
lecturing physicians, and a common question was: "How low must your blood sugars be to prevent diabetic
foot ulcers?" Ulcers do not sprout spontaneously. They always have a cause, other than high blood sugar. That
cause 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 sugars
you can develop insensitivity in your feet, otherwise known as peripheral neuropathy. Neuropathy is
sometimes painful, but it is also sometimes numbing, where you don't feel an injury. For example, I was doing
a physical exam upon one of the very first patients whom I ever saw, and appropriately looked at the bottoms
of his feet. I saw a hole about two inches across and a quarter of an inch deep. I asked him, "Do you know
you have an ulcer on the bottom of your foot?" To which he replied, "Oh that must be where the smell is
coming 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 nerve
injury in the feet may not be able to feel injury. This also happens in people with advanced syphilis; people
with leprosy, and that's why you see many old woodcuts of lepers with legs amputated and on crutches. The
main threat is when you don't know you are being injured. Perhaps there is a little nail in your shoe, and it
starts gradually wearing a hole in your foot. If you can't feel it, you're going to get that hole, and it will
eventually become infected. The infection can spread up the fascial planes in the muscles and lead to an
amputation if it's not caught early. Another reason why diabetes patients are pre-disposed to infected ulcers is
because 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't
have 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 adhere
meticulously to these dos and don'ts, you will be guaranteed to never have an ulcer. I have never seen an
ulcer in a patient who adhered to all of these dos and don'ts. I'm not going to list them now; go into the foot
care appendix of DIABETES SOLUTION. I will list one thing, however, right now. I have for many years been
the director of the wound clinic at a major medical school. I've seen thousands of diabetic patients, and I've
interviewed every patient who's ever come into the clinic in the past twenty-seven years. When I see a
diabetes patient who's had an amputation on one leg, and he's coming to our clinic to take care of the
remaining foot, I ask him what led to the amputation. In 100% of the cases it was someone attempting to
remove a callus. Number one on the list of culprits in terms of frequency was podiatrists. Number two was the
patients 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 a
callus to be unsightly or aesthetically disturbing for some reason, you can purchase orthotics off the shelf in a
drug store to take the pressure off the metatarsal heads, which are the bony prominences on the bottoms of
your 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 by
motor neuropathy called the intrinsic minus foot that pre-disposes to hammertoes, and the knuckles of the
hammertoes sometimes develop ulcers from rubbing on the shoes. Getting back to the problem with removing
calluses I had one case where a patient left my office on a Friday afternoon; it was the last day of our
training 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 this
patient. 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 and
Monday morning. That's how fast this can happen. If you have a callus that aesthetically displeases you, you
can get the pressure off of it by getting either custom-made orthotics, or over the counter orthotics. If the
pressure is on the upper part of your foot, you may have to have your shoes stretched, or have to get a new
kind 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 big
city hospitals have wound care centers. In the rural areas, you may not find one, and that poses a real
problem. Even at wound care centers, perfect care is not always rendered. For example, I've read the
protocols of a number of wound care centers, and visited a number of them, too. The most crucial step in
healing a wound on the foot is frequently omitted, and that is what's called "off-loading," which means taking
the pressure off the site. If you have a hole in the bottom of your foot and you want it to heal, you don't walk
on 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 clinic
whenever it is necessary. It's a very easy thing to do. I'm not going to go into the details. The point of this is
that ulcers of the feet are unnecessary. They should not happen. They can be prevented. If they occur, the
one 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 the
front or sides of the legs, usually between the ankles and the knees. The size of these sores can be from less
than the diameter of a dime, to in extreme cases, one big sore wrapping around the whole leg. These can be
sometimes painful, though usually not. The reason I bring up this particular subject is because venous stasis
ulcers are more common in people with diabetes. I was in clinic today. We had about ten people with venous
stasis ulcers, and half of them were diabetic. There are other predisposing conditions such as sickle cell
disease and, most importantly, family history. If someone's parents had varicose veins in their legs, these
people 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 on
the 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 the
legs, the veins just under the skin, get stretched by this back pressure, which can cause water to leak out of
the veins into the surrounding subcutaneous tissue. The net result is you have edema or fluid in the
subcutaneous tissue that presses on the capillaries in the skin. The capillaries deliver blood that is necessary
for the healing of minor wounds. So, if you bump your shin, you get a little bruise. But if you have edema in
your legs, that bruise might not heal, and might open up and become an ulcer. That's just what happens to
these people. It's interesting that most commonly these ulcers are above and behind the lateral ankle, because
there'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 stasis
ulcers. How are they healed? The technique for healing these ulcers is very easy. It is wrapping a special
bandage around the entire leg from below the toes to just below the knees, at the crease at the back of the
leg. This special bandage is called an Unna boot. It is a gauze bandage soaked in glycerin and zinc oxide. It
acts like a toothpaste tube. It becomes semi-hard after a while, and can be bent, but not stretched. Every time
a person walks with an Unna boot on his leg, he flexes his foot, as we all do when we walk, and that bends
the 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, the
pressure from the boot forces fluid out of the tissues of the leg and back into the general circulation. By
getting rid of the edema, or fluid, the wound eventually heals. This is a very simple technique, but
unfortunately, many of the wound centers I have visited didn't know the first thing about Unna boots. In
reading the literature on wound care, it seems that most of the people involved in this profession don't know
how 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. What
can you do to avoid venous stasis ulcers? Keep the size of your belly down; don't get fat. I can't tell you to
avoid bumping your shins, because everyone does that. I probably do it a few times a week. Fortunately, I
don'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've
been protesting that if you have normal blood sugars, and don't develop diabetic complications, you shouldn't
require these things. I don't take any of them, and I've had diabetes since 1946, which is something well over
60 years. Two articles came out this year, one of them just in the past month. I will read the abstract: Aspirin
Unproved for Primary Prevention of Cardiovascular Events in Patients with Diabetes. This is a meta-analysis of
10,000 diabetes patients, and overall they found no lower risk of heart attacks in the overall population
amongst 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 may
possibly be some value for men. The review of the study points out that other studies have shown associations
between aspirin therapy and excess risk for bleeding, including hemorrhagic strokes. But yet another article
published in The Lancet points out that aspirin can slightly reduce the incidence of ischemic strokes, but
increases the incidence of hemorrhagic strokes to the same extent. So, it's sort of a washout. This prior study
was a meta-analysis of 95,000 patients without diabetes, and states no clear benefit for aspirin in primary
prevention of cardiovascular disease. This is for non-diabetics. So, the whole issue is sort of up for grabs right
now. 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's
been no study of how to stop. I've told my patients who wanted to stop to either spread the timing out
between doses, because the effects on platelets lasts a number of days; so you could take it instead of every
day, every other day, and then every third day, and spread it out, that might work. I don't know. It's never
been 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 I
said, what to do is sort of up for grabs. And, the risk stroke when you suddenly stop is very great. Those that
aren'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 carbohydrate
content 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 book
is 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 always
read 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 people
who are actually losing weight on our meal plan, and losing more than they wish, or they started out already
too 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 blood
sugars don't go up, causing you to urinate away your calories. However, doing that is not going to accomplish
our major goal, which is to keep blood sugars normal. I found that with the high carbohydrate diet, there's
absolutely 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 my
book, DIABETES SOLUTION, people are writing to me saying they are using fat like I "recommended," and
can't gain weight. Well, I don't recommend using more fat to gain weight because my experiment was
unsuccessful. We tried feeding people nine hundred extra calories a day of fat in the form of olive oil and not
one of the five people I treated gained even a pound during the six months of the experiment. Eating fat is
not a way to gain weight. The only way fat will build up is if you are taking a lot of carbohydrate, and my
patients 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. My
method is to increase the protein in your diet, and prevent the increase in blood sugars with insulin, if you are
insulin-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; just
protein plus insulin. Ordinarily, if a diabetes patient were to eat protein without covering it with insulin, it
would be converted to glucose slowly, and his blood sugars would slowly go up. Gram for gram, protein foods
require much less insulin than carbohydrate foods, and are therefore much less likely to mess up your blood
14

sugars. Furthermore, the protein foods raise blood sugar more slowly than carbohydrate foods. So, it's easier
to cope with the protein insofar as blood sugar control goes. But, just realize that if your blood sugar goes up
when 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 pick
a meal where they might want to add one or two ounces of protein. Then we see what happens to their blood
sugar, and we give added insulin in proportion to what happens to their blood sugar, using the methods that
are in my book. We then look at their weight in about two weeks. If we see there is no weight gain, or maybe
only a quarter of a pound in two weeks, we have the patient chose another meal to add to two more ounces
of protein. If you keep adding protein to meals, and eventually get to the point that you feel too stuffed at the
meal, we might want to give you a snack instead of adding on to that particular filling meal. The snack will
likely have to be covered with insulin. Although slim non-diabetics can gain weight by adding protein, diabetes
patients are probably going to have to take insulin to cover the additional protein. If you are a type 2, and
making 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 the
book, which as the subtitle indicates is normalizing blood sugar in diabetes patients. There is a chapter that
has nothing to do with normal blood sugars. It's in the appendix, and it deals with foot care. Why on earth
would 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, published
two 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 risk
factors 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 a
good number of these years, I was the director of the clinic, although I am at this time semi-retired. I saw a
lot 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 was
usually 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, but
sometimes by a pedicurist. I had a patient who is a typical example of what can happen. In those days we
used to finish on Friday afternoon after three days of self-care training. Unbeknownst to me, he left my office
and went directly to his podiatrist. Monday morning I took a phone call from the podiatrist, asking me what
antibiotic he should give to this patient. I asked him why the patient needed an antibiotic, and the podiatrist
replied he thought the patient had a slight infection. I asked that the patient come to me right away, because
I wanted to see him. That morning I removed 5 ccs of puss from his big toe, which was red, inflamed and
swollen, and just loaded with puss. This happened between Friday night and Monday morning. The patient
told me that the only thing the podiatrist did was to take a pumice stone and grind down a callus. This is going
on 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 debrided
with a sharp instrument by a trained professional. For my money, that is the worst thing you can do. The
treatment of a callus is to remove the pressure, or sheer force, that caused it. You do that by stretching the
shoe if it's too tight, or providing orthotic inserts in the shoes to transfer weight or force from the place where
the callus is, to transfer that force to the arch. These pressure calluses are usually over the metatarsal heads
15

at the balls of the feet. There are very simple solutions for treating calluses, and they should not be
mechanically removed. Calluses are not harmful. They are protective. The most dangerous thing you can do is
to allow anyone to try to remove a callus, or file it down. Many of the diabetes publications, including those
published by the ADA, are advertising little machines that grind down calluses, which is the worst thing a
diabetes patient can do. They look like little dental drills with a rotating stone that is supposed to remove your
callus, 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 of
diabetic complications of up and down blood sugars, versus an elevated Hemoglobin A1c. Lo and behold, no
sooner 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 in
Normal and Type 2 Diabetic Patients." They're talking about the lining of blood vessels, and how abnormal
endothelial function plays a role in many complications of diabetes; heart disease, which is a diabetic
complication; retinopathy; kidney disease; and even neuropathy involves little blood vessels called vasa
nervorum. This small, limited study only covered blood vessels, but shows that oscillating blood sugars are
more 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 per
year. I will go down my list, item by item. The list has two columns: 1) What the cost of the product would be
to 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 has
to 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 for
all 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; $245
after insurance pays.
I use diluted Humalog for correcting elevated blood sugars. I use less than a vial per year, because I dilute it
7:1. A bottle would last me years at that rate. That one bottle without insurance costs $63. After insurance, it
costs $18.
The syringes are an interesting story. In my book, DIABETES SOLUTION, we tell how you can get away with
reusing syringes, and not spoiling your insulin. If you don't use the tricks we talk about, you will absolutely
ruin your insulin if you reuse syringes. I use a syringe a day. It costs 26.4 cents, for a total of $95 a year, and
my insurance does not pay a penny for the syringes. Apparently, they will only pay for over a certain cost, and
apparently 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. I
use on average, maybe two whole tablets a day, but it's usually multiple small ones, called Dex 4 bits. This
totals $66 per year. It is not covered by insurance. When I'm with patients or in the gym I use Dex 4 liquid
glucose which would probably quadruple the above cost.
16

I use the GLUCOGRAF forms that are illustrated in my book. Diabetes in Control also sells them on their
various 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 my
feet, 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 $10
bottle 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 a
host 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 state
for 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, more
than 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 insulin
we had, and inject enough at one time, you could make it last a week. In his particular experiment, the dose
was 70 units of insulin that should have been finished in ten hours. These so-called 24 hour insulins really
don't last 24 hours. Not only that, many of you have found that even when you split it into two doses, one
taken on arising and the second dose at bedtime which is what I recommend in my book, DIABETES
SOLUTION, the bedtime dose doesn't last overnight. What do we do? The best insulin we have, Ultralente, no
longer is available. The lady that runs my office, Pat Gian, came up with an idea when I was complaining
about 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 middle
of the night." I usually go to bed around 11:00 p.m., and what I've ended up doing is taking a shot at 11:00
p.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't
always have to wake my wife with the alarm. This is sort of an inconvenient thing for some people to do. For
example, what if you don't go back to sleep when the alarm rings in the middle of the night? That's a real
problem, and off hand, I don't know how to answer it. One can use medications like Trazadone to help you get
back to sleep. This is the only way I know of to make my bedtime insulin last until morning, without making
my blood sugar go too low in the middle of the night. Actually, the complaint I made to Pat was, I had to take
so much insulin that I go too low in the middle of the night, and she came up with this answer, and it works. I
hope some of you will try it. I've tried it on a number of my patients, and it is indeed working. Some patients
who make a substantial amount of their own insulin do not require the splitting of the bedtime dose. They just
take 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. and
that holds me for the whole night.



17

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 a
physician then, but I was already an engineer. While I was waiting to see the doctor, the nurse was setting up
an IV, and said I had to be hooked up with a glucose drip. I told the nurse I had diabetes, but the nurse still
insisted I had to have the glucose drip. By the time the doctor had come around, and clipped the tip off the
fish hook and removed it from my leg, my blood sugar was up to 1500 mg/dl. If I had to wait much longer, I
could have died there. This is happening every day, probably all over the world. My main experience is with
patients 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 vacationing
in Florida. I got a call from her father, saying his daughter was vomiting and they didn't have any injectable
Tigan.
The little girl couldn't keep down any fluids because she was vomiting, so this was a real emergency. The
father said there was a pharmacy an hour in one direction, and a hospital an hour in the other direction. He
asked 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 drip
for 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 asked
the doctor if she had any idea what the glucose would do to the patient, and the doctor replied that it would
raise the patient's blood sugar. I asked her what the chance was that the glucose drip would put the patient
into ketoacidosis, which is often a fatal condition. The ER doctor replied it would be about a 50:50 chance the
patient would go into ketoacidosis. I then asked the ER doctor what the odds are that the patient will not
survive ketoacidosis and that the patient would die. She replied saying about one out of three. I then asked
the 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 she
spoke to the patient's doctor, and the patient's doctor insisted that the little girl be given normal saline, and
not glucose, and would that let the ER doctor off the hook. She said it would. This ER doctor was very nice
and 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 is
vomiting, which can dehydrate you and prevent you from rehydrating, because you won't be able to drink if
you feel nauseated. I have all my patients inject themselves with Tigan when they are vomiting because it
stops the nausea and vomiting, and allows them to drink water. We also spike the water with certain salts. But
sometimes Tigan doesn't work, maybe about one out of every five times, in which case I tell the patient to go
to 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 say
what 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 diabetes
patients, only glucose. So then you explain to them the glucose will raise your blood sugar, possibly put you in
ketoacidosis, and kill you.
Frequently what they say is that they could compromise since the patient is afraid of glucose. The hospital will
give fructose or lactose, and that won't raise blood sugar. That is an absolute lie as these sugars will raise
blood sugar, not as rapidly as glucose, but certainly will send your blood sugar very high. So, you have to say
no 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 very
appropriate provided it is not lactated. Unfortunately, most emergency rooms only have lactated Ringer's in
stock, which has lactose in it. So, you can say to the doctor, if Ringer's solution is not lactated, that will be
fine.
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 some
saline 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 rights
of a patient (or the patient's family) is the right to speak to the hospital administrator. So, you can demand to
talk to the hospital administrator, and they have to connect you. My patients have used this method over and
over. When you get the administrator on the phone, and usually it's a family member who talks to the
administrator because the patient is usually too sick to get into a war with everyone, you say, "It's lucky you
picked up the phone, because you can save yourself an indefensible lawsuit." You'd think the hospital
administrator would say, "I'm so sorry you are having so much trouble, what can I do for you?" But that's not
so. In every case they've asked why it is indefensible. You can see where their interests lie. The interest of the
whole 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 to
have to hire a defense witness, an expert witness who is a specialist in diabetes who has to say that it's OK to
give glucose to a diabetes patient whose blood sugar is not too low. Any specialist in diabetes is going to know
the patient's lawyer is going to rip them to shreds, because it's such a stupid statement. He also knows that
even 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 to
tell the lawyer that he'd better settle this case, because he can't testify for the hospital. That's why the
hospital has no expert witness, and no defense. That convinces them right away. Inevitably, what has
happened every time my patients have pulled this is either the hospital administrator talks to the doctor on the
phone 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 a
patient's family supposedly acts, but in a rational way to convince the doctor of the patient's point of view. Will
the patient advocate succeed? I don't know. I would say the changes are 50:50. There's still a good chance
that 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 together
and get ready to leave. You get a piece of paper; ask the nurses in the ER the name of the doctor who gave
you all the trouble. You write his name down, put a star next to it. You ask any nurse that witnessed or
overheard the encounter to list her name, and how she can be reached. She'll usually give the number of the
nursing office. Get the names of any people in the other exam bays in the ER, or the names of people who
heard the shouting.
By this time, certainly if you are in a large hospital, the nurse with the clipboard comes around. Her job is to
prevent lawsuits. Her job is to defuse any situation like this. She knows that anyone who precipitates a lawsuit
is going to be fired. Even if the hospital wins the lawsuit, the insurance company doesn't want people on the
staff 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's
causing 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 every
single case, this has worked.

19. Hypothyroidism
Dr. Bernstein: Hypothyroidism is an autoimmune disorder just like diabetes. Hypothyroidism is inadequate
activity 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 both
diabetes and psoriasis, at least mild psoriasis, with rough elbows. About 80 to 85% of my patients are
hypothyroid. In some individuals, the hypothyroidism occurs long before the development of diabetes. In other
individuals, it may develop long after the onset of diabetes. However, I had never seen a case of
hyperthyroidism (too much thyroid activity) in a diabetes patient until last week, when a young lady came in
whose thyroid levels were high. She had a rapid heart rate, and I was sure she was hyperthyroid. I ordered a
re-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 occasionally
will see a patient who feels perfectly fine, but has low thyroid levels. Quite frequently, we see lipid
abnormalities, 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 heart
disease, 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 of
my new patients can't remember what I teach them. Luckily, I record everything I teach, and I give them the
recordings. They don't remember the instructions because their thyroid is low. I have a memory test that I
give everyone when I first see them, and it tends to improve both with blood sugar control, and with
correction of the low thyroid status.
Depression is a very common side effect of hypothyroidism. In fact, it is now standard protocol for
psychiatrists 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 not
just 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 iodine
atoms. T4 is less active; T3 is far more active than T4. T4 gets stored in the tissues throughout the body, and
is 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 then
hoping that the patient will convert it to T3, as needed, but all too often, T4 does not get adequately
converted to T3. In fact, I find that many of my diabetic patients may at their first visit have a normal T4, but
a low T3. These people lack the deiodinase that converts the T4 to T3. We can double check by looking in
their blood for Reverse T3, which is an inactive form of T3, and is frequently elevated in people who cannot
make 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 bound
to protein (globulins) in the blood is inactive. We want to see Free T3. We might also take a look at Free and
Total 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 give
them Synthroid, or the equivalent, with is levothyroxine; but, that is rarely the case. Most often, people have
slightly low T4 and very low T3. We have to give those people T3 (liothyronine) replacement. In the market
place, liothyronine comes under the brand name, Cytomel, but it only comes in multiples of 5 mcg. What if a
person needs 17 mcg a day? You cannot get it from Cytomel. Another problem with Cytomel is that it has an
active life of about eight hours, so you have to take it every eight hours. Almost everyone forgets the
afternoon dose. I almost always prescribe a compounded form of liothyronine that we get from a
compounding chemist, either a chemist near me, or one near the patient's home town. The compounding
chemist will make up timed release liothyronine, also called slow release T3. The T3 can be made in any
strength 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 side
effects, we'll start them off on a trial dose twice a day, every twelve hours. We will then measure the patient's
blood levels in two or three weeks. I may even have some samples in my office which I will try on the patients
for 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 equilibrium
dialysis 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 good
endocrine 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 hypothyroid
people. 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 like
bran crackers. It should be at least two hours away from when you eat fiber. You should not take it
concurrently with metals like zinc, selenium, calcium, or magnesium; it should be taken at least two hours
away. You should not take thyroid products concurrently with soy products, so you should be at least two
hours away from metals, fibers, and soy. I doubt that a small salad would make much difference, but I
certainly would keep it away from bran crackers, or if you are taking psyllium powder for constipation. In any
event, we titer up the T3, and in many cases simultaneously also T4, until the T4 and T3, on testing, are right
in the middle of the normal range. It takes two months for T4 levels to equilibrate once you are on a dose of
levothyroxine. It takes only about two or three weeks for the T3 levels to equilibrate, so we can rapidly fine
tune 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 diagnosing
and treating hypothyroidism in this manner for thirty years. It was born out of trial and error, and watching
the 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 low
white 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 based
on trial and error, and my observations. Then, all of the sudden, about a month ago, a patient of mine emailed
me a long paper that I'm going to refer you to, that gives the story about the deiodinase enzymes that convert
T4 to T3, and shows how what I'm doing in the way of thyroid testing and prescribing thyroid replacement is
exactly 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 an
education 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 another
step. This is due to poor circulation to the lower extremities. The reason I bring up the subject has to do with
the treatment that is commonly carried out upon people who have these symptoms. I should first point out
that intermittent claudication can be confused with that of a condition called spinal stenosis, which will give
similar symptoms, but if you have spinal stenosis, and bend over forward while you are walking, you relieve
the symptoms, so this is not a circulatory problem. If your symptoms are relieved when you bend forward, you
do 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 a
special rotation with the world's authority on the diabetic foot, whose name was Heinz Lippman, MD. We were
in 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 big
surgical hospital for treatment of his intermittent claudication. The treatment they did at this hospital was
what'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 there
again so that instead of walking only a block or two, he could walk a mile. When Dr. Lippman heard this, he
started to cry. He told me this surgical procedure would kill the patient. He said he'd been this patient's doctor
for five years, and it would be like losing a friend. I remained in touch with Dr. Lippman, even after my
rotation, and I eventually ended up running his peripheral vascular disease clinic. We were very close for
almost 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 who
was a cardiologist. When I started in practice, he called me on the phone and said his mother was just
admitted to a major hospital in New York City, where they were going to do the same femoral popliteal bypass
graft surgery. He asked what I thought about that, and I asked why they were doing it. He said because when
she goes to the supermarket her legs get tired; she has to stop and it makes it nearly impossible for her to
shop. I told him the surgery should only be done to save a leg, not for convenience. I also told him what
happened 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 brother
again, and tell him it can cost his mom her leg and her life. The brother refused to intervene. Anyway, this
same thing happened to this doctor's mother that happened to Dr. Lippman's patient. After something like
three 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 develop
around 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 pressure
in the collaterals that were keeping a leg alive. In fact, on the operating table, as soon as you make the
bypass, the collaterals collapse. Ordinarily collaterals take at least three months to develop. However, over
time, these bypass grafts become blocked again, and when this happens, they don't block gradually over a
period of three months, they block suddenly. Usually, the time frame is two months to six years, so a bypass
22

graft may buy you six years. When they block, there are no collaterals; you get a sudden blockage, and you
have a cold dead leg unless the patient can somehow arrange for a vascular surgeon and an operating room
within three hours, and of course this never happens. So these people lose their legs, and when a diabetes
patient loses a leg, especially if it's a poorly controlled diabetes patient, they usually die shortly thereafter. The
average 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't
heal, and you need to do the surgery to give it enough circulation to heal the wound.
When I have a patient who comes in with intermittent claudication, and they tell me they can only walk half a
block or across the room, the following is what I do. I ask them if they have any stairs where they live. If they
have stairs, I tell them to grab the railing, and to put their feet on the steps so that their heels extend beyond
the step. Then slowly lower and raise the heels, and do this as many times as they can. Then, in an hour or
so, they are to do it again. If you do this every day, by the end of the week you might be able to do 10 heel
lifts, when at the beginning of the week you could only do two or three. If you could only walk across the
room at the beginning of the week, and if you do this for a year, you may be able to walk a block or two. If
you keep doing this, you should be able to walk further and further.
Another thing you could do while you are practicing this exercise is take a supplement called L-carnitine, 2 g
per day. The L-carnitine does not improve the circulation, but it enables the muscles to perform with less
circulation, so you can get more output from your heel lifts, or more steps when you go out and walk. If you
do these exercises regularly, you'll be building collaterals that will help keep your leg alive.

21. Is Glucose a Continuous Risk Factor for Cardiovascular Mortality?
Dr. Bernstein: Why did I bring up this subject? The reason is because frequently we get questions in the
monthly teleconferences from people who say their endocrinologists tell them their hemoglobin A1c is too low,
and to not come back until they get their A1cs back to 6 or 7%. This is a chronic problem. What do you say
when they tell you that? We get phone calls at my office from strangers, diabetes patients who run into the
exact same problem, whose endocrinologists object to the notion of blood sugar normalization. I have a file
called, "Blood Glucose Control, Supporting Data." It has in it about fifty articles of studies that show that with
progressive increase in blood sugar all kinds of things happen to people, even to non-diabetics.
The most impressive study, in my opinion, was done in New Zealand in 2008, where they looked at forty-nine
thousand non-diabetics, categorized them by HbA1c results, and then studied them for many years, looking at
mortality. What they found is that mortality went up as blood sugar went up. To give you a rough idea, an
HbA1c of 4-5% is essentially the normal non-diabetic range. In the 4-5% range, the relative risk of all-cause
mortality was 1.0, in other words, they were the control group. In the A1c of 5-6% range, the relative risk was
1.33; in other words, there is a 33% greater risk of dying of all cause, usually the cause was cardiovascular,
but all-cause mortality went up by a third. A1cs of 6-7%, which is clearly diabetic in my mind, the relative risk
was 2.12; in other words, the all-cause mortality doubled. Over 7%, the relative risk was about 2.6. It's very
clear from a very large study that even among people who are supposedly not diabetic; the risk of all cause
death goes up dramatically with increased A1c.
Here is another article from Diabetes Care, a journal of the American Diabetes Association, which as you know
advocates high blood sugars (A1cs over 6%.) The title of this article is, "Glycated Hemoglobin Predicts all-
cause Cardiovascular and Cancer Mortality in People without a History of Diabetes." These people were
undergoing coronary angiography in the coronary catherization lab, and the researchers looked at the A1cs,
and then waited a specified number of years to see if they would die; and indeed, the death rate went up with
higher HbA1c.
23

There is another article that I just had to grab, because it reads, "Exposure to chronic high glucose induces
beta cell apoptosis (cell death)." This means that the exposure to high blood sugar makes diabetes more
severe and/or accelerates the onset of the disease.
Here is another article: "Glycosylated Hemoglobin and Cardiovascular Risk in Non-diabetic Adults. Baseline A1c
was Associated with a Fifteen Year Risk for Cardiovascular Disease." For example, those with A1c levels of 6.0-
6.5% had two-fold higher fifteen year risk for coronary disease and stroke than those with HbA1cs of 5.0-
5.5%.
Next article, "Intensive Treatment of Diabetes is Associated with a Reduced Risk of Peripheral Arterial
Calcification."
Another article studied non-diabetics. In this case, they studied nineteen thousand men, and gave them a
glucose tolerance test with a small amount of glucose. This is what the article says: "Upward Inflection [which
means the curve went up] Risk of Death from Stroke." The researchers were looking at the risk of death from
stroke at a blood sugar of 83 mg/dl. In other words, if two hours after giving some glucose these people had a
blood sugar higher than 83, their likelihood of stroke increased. For every 18 mg/dl increase in blood sugar,
there was as 27% increase risk of death from stroke. So, just an 18 mg/dl increase in blood sugar led to 27%
increase risk of death from stroke.
Here is yet another article that relates to retinopathy. "More than 60% of retinopathy cases were amongst
patients with fasting glucose below 126 mg/dl." In other words, diabetes patients who had mildly elevated
blood sugars accounted for the majority of retinopathy cases.
Another article which was a study perhaps from Korea, but I'm not sure, and was in one of the ADA journals
published in 2011: "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." Basically, these people
repeated in principle the study done by Gerald Reaven about forty years ago where they gave new diabetes
patients normal blood sugars for a few weeks, and found that even after a year, their production of insulin had
increased, because of the brief period of normal blood sugars. So, this just reiterates the value of normal
blood sugars in preventing diabetes from getting more severe.
Another article, again in the journal, "Diabetes Care, 2011:" "Post Prandial Blood Glucose Predicts
Cardiovascular Events and All-Cause Mortality in Type 2 Diabetes in a Fourteen Year Follow-up."
Another article: "Average Blood Glucose and Mortality in Patients Hospitalized with Acute Myocardial
Infarction." Here, they looked at people in the hospital after heart attacks. Mortality increased with each 10
mg/dl incremental rise in mean blood sugar over 120 mg/dl.
Here is another article from 2005: "High Sugar Levels Increase Cancer and Mortality Risk." This is also in "non-
diabetics." Notice that "cancer" keeps appearing in the diabetes literature. In the journal Diabetologia, there
are many published articles about the association of high blood glucose levels with cancer.
Another recent article: "High Blood Glucose Levels Associated with Increased Mortality in the Intensive Care
Unit." In other words, they looked at the blood sugars of patients in intensive care units, and found that if
their blood sugars were elevated, and in these cases only slightly, mortality increases.
So why are so many doctors advocating that diabetes patients should not have normal blood sugars? We see
this over and over again. So many patients call us, so upset that their endocrinologists, but usually not their
family practice physicians, tell them to have higher blood sugars.
The first reason: they are not taught in medical school how to control blood sugars. I'm on the faculty of two
medical schools. I run the Peripheral Vascular Disease clinic in one of them. I spoke to the doctor who is
24

responsible for the four one-hour diabetes courses that are taught to students, and I offered to conduct a
session on blood sugar normalization. She said to me, "That's abnormal! It is unnatural for diabetes patients to
have normal blood sugars. That's odd-ball. We will not teach anything odd-ball." Amazing! So, doctors are not
even taught how to normalize blood sugars.
The second reason was demonstrated when I first became a physician. I was invited to speak at the Henry
Ford Hospital in Detroit, MI. I summarized how we could normalize blood sugars. At the end of my talk, I got a
very intelligent question. "Who is going to pay for this?" It sort of knocked me for a loop. When I look at my
own practice, which I have to support out of my earnings from a prior career and my investments (thanks to
the teachings of Benjamin Graham you could look him up on the internet.) I cannot make big money, and
can't even make a profit out of my medical practice where I put in thirteen hours with each new patient.
There's no way to make money teaching patients one at a time. So, doctors can't make money doing this. In
groups, doctors could make money, but that is another story. I spend three hours examining the patients for
diabetes complications, but if you have paramedical people such as nurses or medical assistants, they can
examine the patients instead of the doctor. So, it takes a different kind of organization than most doctors have
in order to survive financially, treating this disease.
The third reason why the specialists are against normal blood sugars was told to me several times when I
spoke to people who actually devised the guidelines. I asked them why the ADA advocated such high A1cs of
6.5%, or whatever over 6. I was told this: "If a patient goes blind, or has to go on dialysis, or dies of
congestive heart failure, or loses a limb, these are all 'natural consequences' of diabetes. But, if a patient dies
of hypoglycemia, the doctor gets sued, therefore, I am not going to allow my patients to have even remotely
near normal blood sugars, because that's too close to hypoglycemia." So, the ADA seeks numbers that are
double normal, such as an A1c of 7, which is an average blood sugar of 180 mg/dl. So this is what we are up
against, and this is what I've been battling for the past thirty or forty years.
Now, to just give you a little example of what happens with blood sugar normalization, is a letter I got
yesterday from the parent of a patient I started treating a few months ago: "It's been a joy to watch our
daughter gain control over her diabetes, and come out of the fog she's been in for the past ten years. She tells
us she hardly feels diabetic anymore. It's not the shots and diet that made her feel diabetic, but high numbers
that turned her into someone else. Thanks so much for returning her to us." This is possible for everybody,
and it's the reason I wrote my books, because you don't need a physician to do all this. You can do it all
yourself if you can get your doctor to write the proper prescriptions as recommended in my books.

22. Joint Diabetes Associations' A1c Recommendations
Dr. Bernstein: An announcement came out today that three international professional diabetes association's
made recommendations with regard to hemoglobin A1c targets for type 2 diabetes patients. They came out
with a recommendation of A1cs between 7 and 7.5%, which means average blood sugars between 180 and
190 mg/dl, which is more than double normal. Fortunately, they were much lower than the American Diabetes
Association targets, which recommends not changing treatment until A1c gets above 9, which is such a high
number in terms of blood sugar that I can't calculate off hand. Here we have both the ADA with fantastically
high numbers, and this international consortium of professional diabetes associations, all recommending very
high blood sugars for diabetes patients.
One might ask how this came about. Why are doctors recommending such high blood sugars? I know why
they do it in the USA, because many years ago I spoke to one of the physicians who was involved with writing
the guidelines. He said the following to me: "I see over 1000 diabetic patients. If all of these people were to
go blind, have their legs amputated, die of kidney disease or congestive heart failure, these would be natural
consequences of the disease. But, if one single patient died of hypoglycemia, I'd be blamed, and I would get
25

sued. So, I cannot afford to have even one of these thousand patients die of hypoglycemia. I'm going to keep
all my patients' blood sugars at least double or triple normal just to protect myself." What you are seeing is
physicians' self- protection, and the patient doesn't count. This is happening on a huge scale in the USA and
on a somewhat lesser scale internationally.

23. Legal and Medical Issues for Kids with Type 1 Diabetes
Dr. Bernstein: I have a letter from the director of a large diabetes center threatening the parents of a little
child. These parents objected to the fact that he was keeping their daughter's A1c at around 9%. I think that's
an average blood sugar of somewhere around 290 mg/dl and the parents objected. They found a new
physician, and asked for copies of the child's records for the new physician. The former physician who believed
in high blood sugars sent them the letter, and he's threatening them saying that unless they tell him who the
new doctor is, it leaves him no other option than to report the parents to the Department of Health and
Human Services. I guess such a department exists, at a federal or state level. But, this is a threat. This is not
the first time we've seen poor parents of young children threatened by endocrinologists who believe in high
blood sugars. It looks like this is the thing to do nowadays. This seems to be particularly problematic if the
family is poor.
Poor families usually do not have ready access to a lawyer, and may not know or be able to afford a lawyer,
with a net result that the physician is less likely to be sued by that family. However, the one thing that
concerns physicians more than anything else except for, perhaps, income, is the threat of malpractice suits.
Harassing the family of a young patient like this certainly should invite some sort of legal attention. Just
getting a lawyer to phone the doctor's office is enough to stop this kind of bullying.
I was able with effort to secure the phone number of a federally owned corporation that provides free legal
services to people with low income, the disabled and elderly individuals who can't afford it themselves. It's
called, The Legal Services Corporation http://www.lsc.gov/. Their main headquarters is in Washington, DC.
The phone number is 202-295-1500. All that the Washington, DC office can do is give you the phone number
of the office in your state, which in turn, can tell you where the nearest office to you is located. We tried to
phone the office in Washington, DC. All we got were answering machines, and we left messages. So, this may
not be easy. If you are being threatened by a physician, and cannot afford your own lawyer, you should call
the above office early on, because it may be tough getting through to them.
You can also try this web site, which lists information by state http://www.lsc.gov/local-programs/program-
profiles. You may have more success using this link for contacting the office near where you live. Getting a
letter like this is a terrible thing. It's apparently quite common and it would be nice if it were stopped.
I want to reiterate once again what I said a little earlier: It was demonstrated by a large study at the recent
ADA meeting that even a tiny decrease in the A1c has a substantial reduction in cardiovascular risk.

24. Metabolic Ketones
Dr. Bernstein: This topic is an important subject that I teach all of my patients, but it is not in the book. Let's
first take a look at how non-diabetic humans make insulin. When they are not eating, they make a small
amount of insulin twenty-four hours a day; that stops the body from metabolizing its own tissues. When they
have a meal, they make insulin over the course of the meal and while they are digesting the meal in order to
prevent a blood sugar rise from the meal. The insulin is also needed to put away the glucose generated by the
meal into the cells of the body, and to put proteins into muscle. If someone is not eating for a day or two,
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what is going to maintain their blood sugar? The liver has a supply of a starch called glycogen, which it can
break down into glucose. Glycogen is also stored in the muscles, and the muscles can utilize it as they would
glucose. The human body, on average, only has about 300 grams of glycogen, or about 1200 calories, which
isn't very much. That might be good for a day, or so.
Let's take a look at our pre-historic ancestors. You may recall they lived mostly on animal flesh; vegetables
were few and far between, and were not a major portion of their diet. At the time of a famine, when there is
no game around for them to kill, they would die if there wasn't another source of energy. Let's say they go a
day or so without eating while they are hunting for game. Their basal insulin is going to drop. This is a natural
phenomenon. When you are not eating food, the basal insulin is supposed to cover the fasting state, but as
soon as you use up all the glycogen, something else happens. The basal insulin level drops to a point where
hormone sensitive lipase gets activated. This is an enzyme present in fat cells that does a very specific job.
The storage form of fat in the body is called triglyceride. Triglyceride resembles a limb with three branches on
it. The limb is glycerol, which is derived from glucose; it is half of the molecule. As you've heard before, fat is
partially derived from carbohydrate (glucose). Attached to this limb are three branches, called fatty acids. This
limb with the three fatty acids is the body's storage form for fat. Hormone sensitive lipase breaks the bond
between the middle fatty acid branch and the limb so that this fatty acid can flow out into the blood stream.
Once that first fatty acid is gone, other lipases can access the bonds that connect the other two fatty acids to
the limb, so all three fatty acids are now removed from the glycerol limb. These three fatty acids are now
floating around in the blood. The hormone sensitive lipase, which broke away the first fatty acid, is the rate
limiting step. In other words, you can't totally break down triglycerides until you've activated hormone
sensitive lipase. Hormone sensitive lipase is turned off by insulin. So, in the presence of significant amounts of
insulin, we cannot break down fat. But here, this person is starving; his basal insulin has gone down. He's now
going to activate hormone sensitive lipase, and he's freed up fatty acids, which are now floating around in the
blood stream. When the liver sees a lot of fatty acids in the blood stream, it gets permission to metabolize
proteins. Proteins are made up of building blocks called amino acids. Amino acids come off muscles when you
are not eating, and when you are exercising. They come out of protein in the diet and go back into the
muscles when you are eating. Ordinarily, you don't want the liver to be metabolizing your amino acids. But if
you are starving, this is a source of energy, because the liver can convert amino acids to glucose. The glucose,
then, gives the energy to the muscles, and also keeps the brain alive. You can go for a period of time wasting
away your muscles. Eventually with the low level of insulin in the blood, other lipases come along and start
breaking down more fat; not only breaking down fat, but taking the free fatty acids that have been floating
around in the blood stream, and oxidizing them, converting them to energy. This energy is used by the
muscles. When you metabolize fatty acids, you produce by-products called ketones. The most familiar ketone
is acetone, which we find in nail polish remover. So now, you are going to have a high level of ketones in the
blood, because you've been starving. The brain can subsist on ketones. So, the ketones keep the brain alive
while the oxidation of the fats keeps the muscles alive. We owe our survival, at least the survival of our
ancestors, to the ability of the brain to metabolize ketones. Humanity would not have survived were it not for
that ability. So, ketones are very essential for life. This little message gives us two lessons. One lesson goes
back to the time I was first diagnosed with diabetes. I was drinking and peeing for two months before my
parents finally sent me to a doctor, who made the diagnosis. But during those two months, I lost twenty
percent of my bodyweight. I weighed one hundred pounds, and then went down to eighty pounds. What did I
lose? I lost fat and muscle, because I did not have adequate basal insulin. My blood sugar was probably near a
thousand when I was diagnosed. Basal insulin is very essential to stop you from converting your tissues to
glucose.
Doctors like to take away basal insulin from their patients under certain circumstances, such as if they are
going to have a fasting blood test, or if they are going to have a medical procedure or surgery. If the patient is
instructed to be fasting, the doctor tells them to not take their insulin. When I had my surgery recently, I had
a phone call from a nurse who said that because I am a diabetes patient, and I wasn't going to eat breakfast,
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I wasn't to take any insulin. I would have been in ketoacidosis from surgery if I hadn't taken my basal insulin.
The stress of surgery raises your blood sugar, and being without insulin certainly raises your blood sugar if you
have diabetes. So, I could have died in surgery if I had listened to the nurse. She gave me the standard
instructions that are given to all diabetes patients. So this is a bit of a warning. If you are having a procedure,
and anyone tells you to skip your insulin, that's the wrong instruction. You need your basal insulin. So, if you
are on a proper insulin regimen (which means a long-acting insulin twice a day for basal and a rapid-acting
insulin for meals) if you need to skip breakfast, you should also skip the rapid-acting insulin you would take
before breakfast. That is the appropriate response, not to listen to the instructions if the doctor said to skip
your basal insulin dose. The other lesson from this little bit of history is that ketones are essential for life. They
are not toxic to life. Doctors learn this in medical school. I learned it in biochemistry in my first year of medical
school. But then, I went out on the wards, and on the wards, doctors continually see small children dying of
diabetic ketoacidosis. They assume the children are killed by the ketones. But diabetic ketoacidosis is a
severely dehydrating condition that involves very high blood sugars. So, what these kids are dying of is
cerebral edema, or in extreme cases shrinkage of the brain, caused by the dehydration. The treatment of
diabetic ketoacidosis is twofold: insulin to lower blood sugar; and rehydration with intravenous fluids, saline.
So, these warnings that you see about the Atkins diet, or low carbohydrate diets that the patient is going to
make ketones, are nonsense. Having ketones in your blood or urine is not a tragedy. I don't test my urine for
ketones, but there is a good chance that when I get up in the morning I will have a trace of ketones in my
urine. I have patients who have more than a trace. Pregnant women, because they have two creatures living
off the same supper the prior night, frequently have ketones in their urine; and those ketones are not doing
any harm.

25. Other Causes of Gastroparesis
Dr. Bernstein: I spent much of the day with an interesting patient who reminded me of something I've been
teaching for years. He has severe gastroparesis. We did an R-R Interval study on him, and I demonstrated
that it was not caused by his diabetes. He has several other possible reasons that are worth mentioning for his
gastroparesis. One, he was taking a statin drug, and had very high CPK blood levels, indicating muscle
breakdown, so it could be that even stomach muscles were being weakened by this drug. He also, on
examination by a gastroenterologist, was found to have gastritis which can cause erratic stomach emptying,
and that has to be investigated. On top of that, he had the lowest values on thyroid tests that I can remember
ever seeing, so he has severe hypothyroidism, which likewise can impair stomach emptying. So, it's just a
reiteration of the fact that the R-R Interval study is the gold standard for diagnosing diabetic gastroparesis.
Other tests will not necessarily make this specific diagnosis.

26. Pancreatitis and Pancreatic Cancer Are More Common in Diabetes Patients
Dr. Bernstein: The reason I bring up these subjects relates to an article that just appeared in the journal
Nature, correcting a misapprehension that most of the world has had for many years. This relates to the
evolution of pancreatic cancer. Pancreatic cancer is relatively rare. Even so, I have lost four close friends in the
past five years or so to this disease, and so I feel this acutely. It affects diabetes patients at a much greater
frequency than non-diabetics; ditto for pancreatitis, which is an inflammation of the pancreas that could be
from an unknown cause, or could be due to an infection, etc. Pancreatitis is reversible if treated very rapidly
and properly. In any event, this very important article involves a study where the researchers looked at the
pancreases of a number of people who had died from pancreatic cancer. The researchers looked at individual
tumors within the pancreas and elsewhere in the body. The researchers specifically studied genes of the tumor
cells and how they mutated over time. As you may recall, it was thought that pancreatic cancer supposedly
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starts all of a sudden, out of the blue, and progresses so rapidly that people might be dead within a month,
most often within a year. According to this study, however, the time frame from initial insult to metastases to
sites outside the pancreas turns out to be seven to ten years. So instead of a rapidly growing tumor,
pancreatic cancer is a slow growing tumor. Therefore, if it can found and diagnosed early, it's reversible and
curable. Treatment, at the worst, might be removal of the entire pancreas. Or, if it is caught very early, you
could remove a small part of the pancreas, and perhaps not even make the patient diabetic. It would be nice if
we could diagnose this condition early. I do not know of any early tests for discerning pancreatic cancer. We
can, however, pick up pancreatitis early. Pancreatitis is also a very rare condition, but it can be associated in
animals by some of the medications that we are actively using in the treatment of diabetes, such as the
incretin mimetics. A recent study discloses that thirty-six cases of pancreatitis in humans are associated with
10,000 patient years of use of an incretin mimetic. The one major sign of pancreatitis is abdominal pain that
goes right through the body, from the front of the abdomen to the back. There are several minor signs, as
well. I therefore recommend that if you are taking an incretin mimetic, that before you get the usual signs of
pancreatitis, before you even get any pain, ask your doctor once every year to do early screening tests for the
pancreatic enzymes lipase and amylase. If you develop pancreatitis and stop the causative agent, the
pancreatitis will reverse. So, I repeat that if you are taking an incretin mimetic, you might get tested once a
year for pancreatic enzymes. If they are normal, but creeping up, then you might want to consider
discontinuing the medication. The big problem here is that for many people, the incretin mimetics are the only
products that will stop them from overeating. Without the incretin mimetics, they won't be able to control their
diabetes because of the overeating. Since pancreatitis is reversible, if you are not getting any pain, but do see
gradual increasing of the enzymes, you might want to bear with it, and watch the enzymes every month. As
far as the pancreatic cancer goes, now that we know from this new research that we have seven to ten years
before it metastasizes, I imagine a lot of investigators are going to be looking for some sort of diagnostic blood
tests that would enable them to pick up pancreatic cancer early, and the appropriate treatment can thus begin
early, too.

27. Rebuttal to the Article, Hypoglycemia: from the Laboratory to the Clinic, Published in the
Clinical Journal of the American Diabetes Association
Dr. Bernstein: There was an article in the clinical journal of the American Diabetes Association this month,
entitled Hypoglycemia: From the Laboratory to the Clinic. It's a scientific article covering a lot of the scientific
aspects of hypoglycemia. Toward the end there is a brief discussion of how to prevent it, because the article
maintains this is a major obstacle to preventing, or to thwarting, any efforts at normalizing blood sugars. It
actually points out how we should prevent it. It comes out with two brilliant ideas. One is that patients ought
to be intensively trained, meaning that it's the patient's fault they get hypoglycemia. And two, that someday
we will have an artificial pancreas and that will take care of it. And that's it, that's the end of the suggestions
on how to prevent hypoglycemia. I wrote a letter to the editor pointing out the major reason for the severe
hypoglycemia that they're worried about, and that is the high carbohydrate diet. If you are going to give a
diabetic patient large amounts of carbohydrate, and cover it with either industrial doses of insulin, or large
amounts of a sulfonylurea drug, which is the most potent of the oral hypoglycemic agents, you are inevitably
going to be causing hypoglycemia, with sooner or later severe hypoglycemia, and sooner or later in most likely
every patient. So the answer is a low carbohydrate diet. I submitted this letter to the editor, and did some
calculations to show how things would come out with the current dietary guidelines and with my dietary
guidelines. The letter was rejected within a day, without any peer review. This journal, Diabetes Care, purports
to be a peer-reviewed journal. So I sent an e-mail asking, "Why didn't I get peer-reviewed?" I got a very nice
return note from the editor, saying, "I censor fifty percent of the articles that are submitted." So, this
supposed peer-reviewed journal is censoring out half of anything that is submitted. So if one of their articles
contains errors, and someone points out the truth, and you don't want the readers to know the truth, you
censor it. You don't have to submit it to outside reviewers for independent review. So this was pretty
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frustrating, to say the least. And lo and behold, in The New York Times, there was an article about the current
dilemma over whether or not to aggressively treat diabetes. And here, they're talking about the high risk of
seizures that can be fatal if you try to aggressively treat diabetes. It's a dilemma, but the consensus seems to
be that you don't attempt to treat aggressively. Aggressive to the ADA means more and more carbohydrate,
and more and more of potent medications like insulin and sulfonylureas. Again, I wrote a letter to the editor of
The New York Times. I haven't heard anything. If it's published I'll be amazed. I also wrote a letter to the op-
ed column. But this is what's going on today, and one wonders doesn't anyone care about the best interest of
the patient?

28. Recommendations for the General Flu and H1N1 Vaccines for Adults and Children with Type
1 or Type 2 Diabetes and Supplements That Might Help
Dr. Bernstein: I have already had many encounters with both the standard Type A and Type B influenza
shots and the new H1N1 vaccines. I have one patient who went to a camp, where the entire camp came down
with H1N1. On my advice, the parents brought him home. But, against my advice, after he was home a couple
of weeks, they sent him back to camp, and lo and behold, there was another outbreak and he got sick again.
One lesson, at least with the H1N1 virus, you can be infected more than once. How prevalent is the H1N1? I
don't know. From what I hear on television it is not as severe as had been expected, but it's as prevalent as
had been expected. I don't see any reason not to take the vaccine. The vaccine is processed in exactly the
same fashion as the standard flu vaccines. The virus is grown on eggs, so if you're allergic to eggs, you don't
want to take the vaccine. I plan to try taking it if I can get it. It seems right now that the best place to go if
you want to get the H1N1 vaccine, is to your local chain pharmacy. Many of these big chains are administering
flu and H1N1 shots at marginal cost, something like $25 for the shot, and maybe nothing for the vaccine. I
think it's a good idea. This fellow, who was a teenager and who got infected with H1N1 in the middle of the
summer, was really out of it and incapacitated for about two weeks or so. His mother took care of him while
he had a high fever.
Let's take a quick look at the ordinary flu vaccines. When I started in practice I deliberately decided not to give
my patients influenza vaccinations because I figured I'm practicing medicine totally differently from probably
anyone else in the world. Almost everything I do is opposite of what the ADA recommends. So, I'm a sitting
duck for any conventional bodies that want to go after me. If I give someone a flu shot, and they get a sore
arm, or they get a fever, when their blood sugars go up, or whatever, there are plenty of physicians who
would join a lawsuit, or would assist the lawsuit against someone who is such a maverick in their treatment of
diabetes. So, I was afraid to give flu shots until I got the flu. I was sick for two weeks, and very miserable. I
said I can't let my patients get the flu; I'm going to start giving flu shots. That was about twenty years ago,
and I've been giving them ever since. I have never seen anyone get a side effect. On a rare occasion,
someone will complain of a sore arm overnight. That's unusual. I've seen no problems with it. I have never
gotten the flu after getting flu shots. I did have a closer experience with the flu a couple of weeks ago. My
wife had a severe case. We only got the vaccine about a week ago, so I couldn't immunize her in advance. I
didn't get immunized in advance. She got a bad case of the flu. I figured that for reasons I won't go into, I'm
going to be immune to this, so I did not take anything precautionary. The flu vaccine had not yet arrived. After
she was sick for about 2 weeks, I started to get it. I, unfortunately, waited several days before taking any
antiviral medications. I then started, and started feeling better right away, and had some symptoms for
another ten days or so, but they were far milder than what my wife had. So, I not only recommend flu
vaccination, but I also recommend that if anyone in your house, or who works next to you, develops the flu,
that you take antiviral medications. Not just a single antiviral agent, but three of them. I got the idea of taking
three, so I took Flumadine, Tamiflu, and Sambucol, which we talk about in my book. (Sambucol is an extract
of the black elderberry tree.) I was on all three for about a week when I read an article in one of the medical
journals, advising people who get the flu to take three antivirals at the same time. So, I got the jump on the
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article. In any event, it made my life much more bearable. I had a very mild case, and it only lasted a short
time. My wife had it over a month, and it was far more severe. All of you know that if you get sick with the flu,
your blood sugars are likely to go up. Fortunately, mine did not go up while I was taking the antivirals. If you
want to keep your blood sugars under control, I urge you to get vaccinated, and have antivirals on hand. One
catch with the Tamiflu, and it has to do with cost. I ended up using two packages of Tamiflu. There are ten
capsules in a package. The packages cost me $60 co-pay per package. The total price for the packages was
$80 each, but my insurance only paid $20 per package. So, Tamiflu is very expensive. For those of you who
are pressed for funds, it's a tough decision to go ahead with the Tamiflu. But, at least you can take Sambucol,
and Flumadine.

29. Statins Increase Artery Calcium Score
Dr. Bernstein: Before we get into the special topic, I have to give some background that's sort of unrelated.
About a month ago, the American Diabetes Association released new guidelines for the treatment of type 2
diabetes, where they raised the target hemoglobin A1c values, and stated that no changes in regimen should
be made until the A1c exceeds 9%, which is an unbelievably high average blood sugar of 260 mg/dl. At the
end of the ADA meeting that occurred over the past week or so, an announcement came out that I'll give:
"Reducing A1c a little less than one percent reduces cardiovascular risk by 45%."
So, if your A1c drops from 9% down to 8%, your cardiovascular risk drops by 45%. If your A1c drops from 6
to 5%, your heart attack risk drops by 45%, a huge amount. This is just additional reiteration that everyone
should have normal blood sugars, and that the higher the blood sugar, the higher the risk of all causes of
death.
Another big piece of news came out this week, also at the ADA meeting. An article titled, "Statin Use Tied to
Faster Plaque Buildup." If a person already has a high coronary calcium score with a lot of plaque in her
arteries, and is given a statin drug, it will accelerate the build-up of plaque, not reduce it. What I advocated a
month ago was that you should only give statins to high risk individuals, because their adverse effects are
outweighed when there are not benefits to be gotten from them in low risk individuals. Now they are saying
that if you give a statin to high risk individuals, you are going to make them worse. So, if you are going to give
it to anyone, give it to a low risk individual, to the people who are least likely to need it. This puts us in a big
dilemma. I'm now reluctant to ever use statins, but I'm sure that more research will come about, and maybe
we'll get more information over the next few years. But, for the meanwhile, we have this horrendous piece of
news that statin use in high risk individuals makes things worse, not better.

30. Statin Pros and Cons (communicated before the new data on arterial calcium came out)
Dr. Bernstein: This is a difficult subject to me because so much is written about it. I decided on this topic
about two months ago, and have been building up a file by accumulating articles as they come across my
desk. I have in a folder about fifty pages that I accumulated only in the last two months. I will give you my
conclusions without wasting your time on details of the various studies.
My conclusions are very simple. We can arbitrarily break coronary artery disease down into two groups:
severe, existing coronary disease, and non-existing, or mild coronary disease. The treatment of someone with
severe disease is called secondary prevention. The treatment of someone with no disease or very mild disease,
or merely a high LDL, is called primary prevention. The majority of the evidence appears to indicate that
statins are essentially ineffective for primary prevention. These are, however, effective for secondary
prevention, and the more severe the heart disease, the more likely they will be of some value.
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Now, on the other hand, statins can have adverse side effects. It's very interesting, the majority of the studies
that have been published show very low incidences of adverse effects, but these studies were usually
sponsored by the manufacturers of the statins, and participants were screened out if they had any condition
that might predispose them to adverse consequences. So, people with hypothyroidism were screened out,
which is probably the majority of diabetes patients. People with diabetes were screened out. People with
kidney disease were screened out, because statins could adversely affect the kidneys. People with liver disease
were screen out, because statins could adversely affect the liver. The net results ended up being that there
were only 2% or fewer incidences of adverse effects in many studies. But, there was a study done in England
where they didn't screen out people because of these pre-existing conditions; they just took a general,
randomized segment of the population, gave them statins, and it turned out that twenty percent of the users,
one out of five, developed side effects. This is clearly quite high.
Some of the effects are trivial. For example, if you have a small elevation of liver enzymes, that might not do
any harm, at all. It might increase your risk for liver disease if you are an alcoholic, or have other conditions
that might expose you, but just a slight elevation of liver enzymes would not be very significant. However, we
just had an announcement by the FDA, a black box warning on all statins, that they predispose to diabetes,
and cause impairment of cognition and memory. Those are very significant adverse effects.
I've encountered many people who get muscle pain from statins. Some have it mild, and others complain of
unbearable pain, and have to stop the statins. I have one patient, who after being put on a statin, developed
severe pain all over his body, in many of his muscle groups. When he stopped the statins, the pain did not go
away. I did a search of the literature to see if he was the only one in the world where the pain did not go
away, or if this was commonplace. Indeed, there have been other people who have severe pain that does not
go away when they stopped the statin. So, there are, indeed, major problems that affect some of those twenty
percent if you are looking at a general population and not those that are specially selected.
In my opinion, since the evidence is strong for value in treating severe coronary artery disease, statins should
be used for secondary prevention in those who already have severe disease. However, there is little evidence
indicating value in giving a statin for primary prevention, in other words, treating people who do not have
coronary disease. This would mean that the American Diabetes Association guideline, which is to give all
diabetes patients a statin, an aspirin, and an ACE inhibitor, is not a wise thing to do; it can be doing more
harm than good, especially in people who are walking around with normal blood sugars. Remember, however,
that the majority of the diabetic population is going to die of either congestive heart failure or coronary artery
disease, because of their high blood sugars. But, if you have read my books, and are following them, and are
walking around with normal blood sugars, unless you already have coronary artery disease, you're not likely to
get coronary artery disease from your diabetes. Why be an experiment in primary prevention?
I ask all of my patients over the age of thirty to get a coronary artery calcium score, which was spoken about
before in these broadcasts. This is an imaging study that counts the number of calcified plaques in coronary
arteries, and also computes the total volume of plaques. I have many patients with calcium scores of zero;
they have no coronary artery disease. Yet, their doctors wanted to put them on a statin. Of course, the ADA
would automatically have put them on a statin. It is my intent with a new patient to give them normal blood
sugars. Clearly, these individuals should not be treated with statins if they have very low calcium scores.
On the other hand, maybe two or three times a year, I encounter new patients who have very high calcium
scores. I had one patient whom we tested about two weeks ago who had a high calcium score. On top of that,
on a cardiac stress test he ran out of breath. During his consultation, he complained to me of shortness of
breath when climbing one flight of stairs, or even walking a couple of blocks. So, this guy is a good candidate
for treatment of his coronary artery disease. He is a person who should receive a statin. But, he should get a
lot more than that. He should get normal blood sugars, and be put on a cardiac exercise program. Over the
next few years, we will slowly get his heart rate up during exercise. We start him at a very low, safe heart
32

rate, and we might increase his heart rate one beat per minute per month, until over a period of years we get
him to a point where he's exercising at above his theoretic maximum. This is what I did for myself. Note that
this type of exercise cannot be performed by people taking beta blockers, as these severely limit the maximum
possible heart rates.
I have one other comment. Much of the modern literature seems to indicate that the principle risk factors that
you can measure in the blood for coronary artery disease are not lipids, but rather are the signs of
inflammation, such as C-reactive protein, lipoprotein a (Lpa), and CPK, possibly. It appears that the statins
have their cardio-protective effect, not by virtue of their effect on LDL, but rather by their ability to reduce
inflammation. That is what seems to be the picture.
Other recent studies looking at lipids say that we should be looking at HDL because it is much more significant
than LDL. For example, one study showed that seventy-five percent of people hospitalized with heart attacks
had LDLs that were not considered high risk. But, half of them had very low HDL, so it looks like the HDL is a
much more important blood-measured risk factor. Of course, the most significant risk factors I can find are the
coronary artery calcium score, close relatives with heart attacks at early ages, and chronically elevated blood
sugars.
A more recent study of about 1,000 war veterans showed that statins actually increase arterial plaque in those
who already have high plaque levels. But since this group was so small we cannot project the outcome to
large populations.
In any event, it is my conclusion that we should use statins for secondary prevention if you already have
significant heart disease, or the above three risk factors, but they are essentially of no value for primary
prevention for the rest of us.

31. Studies Define Normal A1c as 6.5 to 7%
Dr. Bernstein: Most, if not all, diabetes studies call intensive management treating to an A1c of 6%, so they
do not get the results you get when you can treat to an A1c of normal which is 4.2 to 4.6%, without
hypoglycemia.
Before we answer questions, I want to cover two special subjects. Steve Freed asked me to point out that
many of the studies cited by the American Diabetes Association as evidence for no value in blood sugar control
had as their targets Hemoglobin A1cs ranging from 6% to 7.5%, meaning blood sugars that were anywhere
from 60% above normal to more than double normal. Of course, we wouldn't expect benefits from such
targets. In particular, the now very famous ACCORD study supposedly showed that the intensive care arm in
the treatment of diabetic patients resulted in more mortality and adverse consequences than the usual care
arm. But, when the intensive care arm was studied more carefully, it was found that the only people who
suffered adverse consequences were those whose blood sugars did not reach the target A1c goal of 6%, but
remained at higher levels. So, indeed, those who had the lowest blood sugars survived the best.
Something else has come up. In yesterday's issue of The New York Times, (October 25, 2011), in the Science
Times section, Jane Brody wrote an article entitled, "More Ways to Cope with Type 1 Diabetes." In this article
she claims, and I quote: "The severe limitations on carbohydrates of past generations no longer exists,
especially if most of those consumed are whole grain." Basically, this new "authority" on the treatment of
diabetes is advocating that you can give whole grain bread as a treatment for type 1 diabetes. Those of you
who are type 1 diabetes patients might eat a slice of whole grain bread and see how much it raises your blood
sugar. Then you can send an email to the editor of The New York Times, and tell them how much that slice
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raised you blood sugar. If you want to do that, you send it to: <letters@nytimes.com>. Let's see what kind of
response we get, and whether The New York Times will print a retraction. I doubt that they will.

32. Telephone Consultations Cost Effective for Diabetes Management
Dr. Bernstein: Before we get started on the special subject today, I saw something in the New England
Journal of Medicine that was very encouraging, because it reinforces something I've been doing for twenty-
seven years. It is a study of 142,000 people. It's hard to believe that any study could be formed with so many
people receiving medical care over the telephone. It was found that not only was there a goodly amount of
cost savings, but that hospitalizations were dramatically reduced. My patients come from all over the world.
For example, in the past week, I've spoken to patients in Moscow, Russia; in Australia; and in the United
Kingdom, and so on, as well as many patients throughout the USA. Initially, patients come in to see me in my
office. I train them, work them up and test them for diabetic complications. But, the rest of their blood sugar
control is done by faxing or emailing data sheets to me. We speak over the phone while I fine tune their blood
sugars. I've been doing this for twenty-seven years, and now it appears that the NEJM is supporting this. Up
to this point, insurance companies have been very leery about paying for this kind of medical care. But, this
kind of care seems to be generally effective, according to this study.

33. Update about Statins and Incretin Mimetics
Dr. Bernstein: There have been a couple of other things that have come up, some new stories in the
literature that are worth mentioning. There is an ongoing meeting of the European Association for the Study of
Diabetes (EASD). Apparently, there is a big discussion on the subject of requiring that all newly diagnosed
diabetes patients and pre-diabetics be put on a statin. The other side of the argument, apparently, is that the
statins can cause non-diabetics to become diabetic. Basically, what the discussion entailed was comparing the
odds of getting a heart attack because you're not on a statin versus developing diabetes because you are on a
statin. I might point out that it is not just statins that can cause blood sugar elevation; it's also beta blockers
and thiazide diuretics. So, some very common medications used for heart disease can raise blood sugars, and
can push someone over the cliff. If they are on the border of becoming diabetic, it can make blood sugars get
much worse all of a sudden.
Here is another interesting report in the literature. You may recall me saying that in incretin mimetic studies in
animals, Byetta, Symlin, and Victoza were shown to cause recovery of damaged beta cells in animals. Well, the
first article of studies in humans came out just this week in the journal, Diabetes Care; here they were
studying Byetta. The title reads "The Effects of Exenatide on Measures of Beta Cell Function after Three Years
of Metformin-Treated Patients with Type 2 Diabetes." They show significant beta cell recovery. This was really
a surprise to me. I've only seen meager indications of this in the patients that I've treated with these drugs,
but apparently, it's now been documented in humans, so another reason for using incretin mimetics.
("The Effects of Exenatide on Measures of Beta Cell Function After Three Years of Metformin-Treated Patients
with Type 2 Diabetes." Diabetes Care September 2011 34:2041-2047.
http://care.diabetesjournals.org/content/34/9/2041. abstract)
Next is an article that comes to the conclusion that blood sugar variability can affect the Hemoglobin A1c. It's
not just the average blood sugar, as I've thinking for many years, that affects the A1c. But, if the blood sugar
is fluctuating a lot in the course of each day, it pushes the A1c up. This is brand new information published in
Diabetes Care.
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("Does Glucose Variability Influence the Relationship Between Mean Plasma Glucose and HbA1c Levels in Type
1 and Type 2 Diabetic Patients?" Diabetes Care August 2011 34:1843-1847.
http://care.diabetesjournals.org/content/34/8/1843.abstract)
There is another article showing that if you give insulin to type 2 diabetes patients, and normalize their fasting
blood sugar, you get beta cell recovery. Again, I've maintained this in my book for many years. We've spoken
about studies from other investigators such as Dr. Gerald Reaven, that if you normalize blood sugars in type 2
diabetes patients, you get partial recovery of beta cells. This is just another study reiterating this.
("Short-Term Intensive Therapy in Newly Diagnosed Type 2 Diabetes Partially Restores Both Insulin Sensitivity
and -Cell Function in Subjects With Long-Term Remission," Diabetes Care August 2011 34:1848-1853
http://care.diabetesjournals.org/content/34/8/1848.abstract)
One more subject... I had major surgery a few days ago. I learned a few lessons, things that I've not known
before that are important enough to discuss. The surgery was the removal of a benign tumor from one of my
salivary glands. So far, I'm OK, but there are some minor complications. However, several important things
occurred. Initially, I was required to get a physical exam, including a chest x-ray, blood chemistries, and an
EKG. I tried to get a physical exam in the hospital where I run a clinic. They typed up a clinic card for me,
spelled my name wrong, and gave me the wrong year of birth, making me 34 years old. I tried to get that
reversed, and was told I can't do it unless I wait online at the medical records office with an original birth
certificate. I got the physical exam, but it had the wrong name and the wrong date of birth on it. I could not
get them to change it. It was on their computers. They sent me a copy, and I actually had to use Photoshop
to match the typeface and change my name back and my put my correct date of birth on the physical exam
form, which I brought to another university hospital, where the surgery was done. The night before surgery, I
received a phone call from a very nice nurse, to make sure that they were going to do the right surgery, and
that my history was correct. It turned out that their computer had me down for removal of all my parathyroid
glands, instead of removal of the tumor of the left parotid salivary gland. A big difference! I thought to myself,
"I hope I got that corrected." But, the next day when I was actually in the hospital, the error was still in the
computer! Anyway, this lady asking me about my medical history seemed to know an amazing amount about
diabetes, in fact, more than any physician that I've ever spoken to. I asked her why she knows so much about
diabetes. She replied her husband is a diabetes patient, and she had read DIABETES SOLUTION. She asked if
I would autograph it when I arrived for the surgery, which I did. I was promised a meeting with the
anesthesiologist, because I wanted special measures to be taken to correct my blood sugar if it went out of
line. Some of you veteran listeners may remember that I get gamma globulin every few weeks which causes a
random recovery of beta cells where you can be hit with severe hypoglycemia out of the blue. I was very
worried about this, and I wanted them checking my blood sugar every 30 minutes, and correcting it with
glucose as necessary. I knew that anesthesia could send your blood sugars sky high, and I didn't want to get
diabetic ketoacidosis, so I told them how to correct elevated blood sugars. Well, when they were ready to roll
me in to the operating room, they introduced me to the anesthesiologist, who is a very nice lady, and I started
giving her instructions about checking and correcting blood sugars. She told me that she isn't authorized to
check blood sugar. This is a major, world famous university hospital, and the anesthesiologists are not
authorized to measure blood sugar in the patients. This is a real warning for all of us, because this sort of
regulation may appear in other hospitals around the world, maybe even in your hospital. If you are a diabetes
patient using insulin, and you go under general anesthesia, and the anesthesiologist is not permitted to
measure your blood sugar, you could die! This is terrible! I was lucky. I thought right away of the very nice
nurse whose book I had autographed, and I asked the surgery team if this nurse could check my blood sugars
every half hour. Sure enough, she came running in, and she promised to check my blood sugars. That kept
things going pretty nicely throughout the surgery. They did have to make small corrections with glucose. At
one point toward the end, my blood sugar went up to 165 mg/dL, and they gave me a unit of insulin.
Unbeknownst to me, my pancreas must have kicked in after I came to, and finally getting ready to go home,
because all of a sudden, I passed out! I was being watched by a nurse all the time, and my son-in-law was
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with me. He checked my blood sugar, and it was 31 mg/dL! They now knew how much glucose to inject into
the IV drip that was still connected. I immediately came to, almost instantly. They rechecked my blood sugar,
and it was still 31 mg/dL. It remained in the 30s for the next 20 minutes, or so. This told me something I
never knew. The central blood glucose can be increased instantly by injecting glucose into a vein. It gets into
the blood much faster than it does if it is taken by mouth in a drink. But, it takes a while to get into your
fingertips. It takes a long time to get into your fingertips, longer than it takes to get into the brain. When I
passed out and came to, I asked them how long I was out, and they said they were able to quickly correct the
blood sugar, and that I was out only about a minute. That glucose brought me around, but the fingertip blood
sugar was still very low. So, this is a warning that fingertip blood sugars are going to lag behind the central
blood sugar if you are treated with intravenous glucose. Likewise, we got a lesson from the intravenous
insulin. When I was given insulin via the IV, I knew from history with other patients that it takes, perhaps, an
hour or two to fully work, and indeed, takes a long time to get into the fingertips, if you give it into a vein.

34. Updated Info on Pancreatitis and the Truth About a New Drug, Cycloset
Dr. Bernstein: Before we start, I want to go back to a previous teleconference, when we sought help trying
to get the truth out to diabetic patients. We accomplished one minor breakthrough. The current issue of
Diabetes Forecast, which arrived yesterday, has on the cover the headline "Are Carbs the Enemy?" In this
issue, both Mary Gannon and I, and a few other investigators who have been studying dietary carbohydrate
restriction versus fat restriction are quoted, and evidence is presented. Since Diabetes Forecast is published by
the American Diabetes Association, they come to the conclusion that there is no hard answer, that everything
should be tailored to the individual. But the conclusion is only because that is their policy. Nevertheless, at
least they did open people's eyes to the fact that it's carbohydrate that raises blood sugar and kills people, not
the fat. Even so, as I said, they do challenge the wisdom of recommending carbohydrate in the article.
We have two medical subjects to cover before we get into the questions. The first one relates to pancreatitis
that I brought up several months ago. I mentioned that there was some evidence that the incretin mimetic
drugs might increase the risk of pancreatitis. A new study came out that finds that there's no increased risk
from this class of drugs. So, it looks like the evidence goes back and forth. In any event, when there was a
risk, it was very minimal. And, now there is supposedly no risk.
There's been an announcement about a new oral agent for treating blood sugar in type 2 diabetes. It's called
Cycloset. This is a new form of bromocriptine. Bromocriptine is a substance that is used to treat Parkinson's
disease. I want to read to you what the prescriber's letter says about this product. The prescriber's letter,
rather than quoting press releases, tends to give a more objective statement of the efficacy and hazards of
various new drugs. In this letter, they say: "Reps are promoting Cycloset, a new form of bromocriptine for
type 2 diabetes. That's right, for diabetes. We usually think of bromocriptine as the dopamine agonist for
treating Parkinson's disease, or to lower prolactin levels. But, bromocriptine can also lower blood glucose a
little. Reps will promote Cycloset as an adjunct to metformin and other diabetes drugs. They will emphasize its
cardiovascular safety, and low risk of hypoglycemia, and low risk of weight gain. But, there is not much bang
for the buck. Cycloset only lowers A1c about a half of a percent, and costs up to $360 a month. Plus,
bromocriptine comes with lots of side effects: nausea, drowsiness, dizziness, and fainting. Try other meds first
for type 2 diabetes. Avoid bromocriptine in women who are breast feeding because it decreases milk
production (by lowering prolactin levels)." This basically summarizes it. Stay away from it. It's not going to buy
you anything significant, and it has quite a list of adverse effects.


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35. What Happened When I Fed Patients 900 Extra Calories Daily, of Pure Fat?
Dr. Bernstein: About ten or fifteen years ago, I simultaneously had four diabetic patients who were
underweight. This is sort of a rare occurrence, trying to put weight on diabetic patients. A typical patient was a
man in his sixties, who had been an obese type 2, and had poorly controlled diabetes. He lost beta cells, and
eventually became a type 1, and was treated with insulin to keep him alive. He came in with a blood sugar
over 400 mg/dl. He was with his wife, and he looked like death. He was very pale, very thin, and tired. The
wife said to me, "Doc, you've got to put some weight on him." I said, "We'll surely be able to get some weight
on him just by normalizing his blood sugars, because he'll stop peeing away calories." And indeed, over the
next month or so he gained twenty-five pounds. But, the wife still said he looked too thin. I had three other
people who looked too thin. They all wanted to gain weight. What was I going to do? I knew the way to build
fat is to feed people carbohydrate, and that you could gain weight rapidly by eating carbohydrate; but if we
did that, we wouldn't be able to control their blood sugars, because even if you give someone insulin to cover
this excess carbohydrate, you lose predictability of blood sugars, and you will not be able to get stability.
Therefore, I threw away that option. Another option, and the wisest option, would be to increase protein
consumption, and only increase insulin dosing just a little bit. Some of these people may not have even been
on insulin. I approached each of them with that possibility, and they all said they were getting enough to eat,
and couldn't eat anymore. So, what was I going to do? I suddenly got what I thought was a brilliant idea. I'll
feed them pure fat! But, how could I feed them pure fat without getting into trouble with their family
physicians? I decided to feed them olive oil. In those days, all the doctors were big on olive oil. That was a
very safe fat to give people. And even today, there is, perhaps, some evidence that monounsaturated fats of
olive oil may be of some benefit. I figured I would give them two 1 ounce shot glasses of olive oil a day, one
in the morning and one in the afternoon, so they wouldn't have to consume it all at once. Right away, we had
a rebellion, because the patients didn't like the taste of the olive oil. So, I had to figure out how to flavor it.
First we started adding flavors from the baking aisle of the supermarket, but that didn't help too much. Then I
got the most brilliant idea of all: we'll flavor it with Meyer's Dark Rum; and they all liked it. They were then
very happy to drink the olive oil twice a day. We continued that for at least six months. Not one person gained
one pound! I was astounded. I could hardly believe it. Like everyone else, I had been taught that if we eat fat,
we will gain weight. I then called the Chairman of Biochemistry at my medical school, who is a friend of mine,
and his specialty was carbohydrate and fat metabolism. I asked him if he'd ever heard of anything like this,
and he said no, and he couldn't imagine what was going on. He said he would check around, and get back to
me. After a month or two, I heard back from him, and none of his friends had any idea why this should be.
For years I puzzled over this until April, 2000 when the journal, Diabetes Care, had an article where ten non-
diabetic men were given a high carbohydrate/high fat diet, and then switched to a low carbohydrate/high fat
diet. Both diets had the same number of calories, because they varied the protein to make them iso-caloric.
Some of them started on one diet, and finished on the other diet, and vice versa, so there was a random
distribution of which diet the study subjects started on. They also gave these people radioactive carbon that
would be absorbed into the fats, and would appear wherever the fats ended up. If they ended up around the
middle, that's where the radioactive carbon would appear. If you metabolized the fat, you'd get radioactive
carbon dioxide in your breath. The result of the study was those on the high carbohydrate/high fat diet stored
the radioactivity around their waist. They got fat. Those on the low carbohydrate/high fat diet exhaled the
radioactivity in their breath. Now, this doesn't give the answer to the problem, but when I heard that, I
immediately saw the answer. In medical school, we were taught about an enzyme called hormone sensitive
lipase. This is an enzyme that executes the first step in breaking down fat. It removes the first fatty acid from
triglyceride, which is the storage form of fat. It is also the form of fat you may eat in your diet. Hormone
sensitive lipase is turned off by insulin. So, if you are a non-diabetic, and you are eating a lot of carbohydrate,
you are going to be making a lot of insulin, and you are going to turn off the enzyme that kicks off the
metabolism of fat. You also won't be able to burn fat or break it down, because insulin can be a fat building
hormone, and you'll only be able to build up fat. But, if you are on a low carbohydrate diet, and you are not
diabetic, you will make very little insulin, and the hormone sensitive lipase will have a free reign to do its work,
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which is to metabolize fat. So, that's what happened, and after all these years I got an explanation that I
figured out on my own, of why this occurs.

36. What to Do if Your Blood Sugar Increases during Exercise or Public Speaking Engagements
Dr. Bernstein: This is a fairly common phenomenon. I experienced it when I first started appearing on
television, about the time my first book came out, around 1982. I found that if I checked my blood sugar
before and after appearing before the camera, my blood sugar would easily go up by 100 mg/dl. Over the
course of numerous appearances it became less of an emotional challenge, and eventually, had no effect on
my blood sugar. But, there are people whose livelihood depends upon either athletics or appearing before
people. For example, I have many patients who are teachers, some who are performers, and many of these
people find that every time they teach or perform, their blood sugar goes up a lot. So, what do we do about
this? There is one thing I've tried, and it does work, is the use of what are called non-cardio selective beta
blockers like propranolol. This is a medication that blocks the effects of adrenaline, or epinephrine, which is
one of the stress hormones. This is the hormone that causes your heart rate to speed up, gives you tremors,
and so on. If you can block the effects of this hormone, since it also raises blood sugar, you will not get the
blood sugar increase. I found for patients who experience this problem that using propranolol could
circumvent the effect of adrenaline without significant side effects. There are rare side effects of propranolol,
such as depression. If you were taking it every single day, a small fraction of the users experience depression,
so they would have to stop using it. The dosing range for propranolol is very wide, probably because it's a very
safe drug. You can get tablets of 10 mg, but the dosing goes up to as much as 240 mg a day. I usually start
people at 10 mg, about 60 or 90 minutes before their performance, or before their exercise. Many of my
patients who exercise actually have their blood sugars go up during exercise. For years I've been teaching not
to exercise in the morning because of the dawn phenomenon, when blood sugars will very likely go up. But,
there are people where even exercising in the evening will raise their blood sugars. This is the case for the
propranolol. So, you'd ask your doctor to prescribe the small, 10 mg tablets as a starter. Then, before you
exercise or do a performance, you take one 10 mg tablet. If that had no effect, the next time you take two
tablets, and you work your way up until you find the dose that works. Another effect that you will find is that
your heart rate will slow, which for most people this is not a problem. As a matter of fact, if you are making a
lot of epinephrine, your heart rate will go up too much, and the propranolol will slow it back down again.

37. Why You Should Try to Avoid Unnecessary Steroid Treatments
Dr. Bernstein: Steroids, as you know, are anti-inflammatory agents. They are used to treat a number of
autoimmune diseases, and some pain syndromes. They are frequently used inappropriately. They can have
many adverse side effects, so they must be used very cautiously. For example, high doses of systemic steroids
can actually cause swelling of the brain, and psychotic behavior, even suicide. Chronic use of systemic steroids
reduces bone mineral density and can cause bone fractures. I had an aunt who was receiving prednisone for
the treatment of an autoimmune disease called pemphigus, and she fractured a hip without even falling. That,
in turn, cut an artery, and she bled to death. So, there are potential problems with steroids. They can be very
valuable, and are necessary for certain situations, such as use with chemotherapy in the treatment of cancer.
One big problem is that many physicians use steroids frivolously without appropriate need. What prompted me
to bring up this subject was having three patients in one week, all of whom were put on steroids by other
physicians who did not consult me for instructions on steroid use. Their blood sugars went sky high, and the
high blood sugars lasted for about a month. In each of these cases, the doctor had told them that the steroid
would have little or no effect on their blood sugar, or that the effect would only last for a day, and not to
38

worry about the steroid. Apparently, however, the doctors who prescribe steroids just don't know about this,
maybe because most of their patients aren't diabetic.
Two of the three patients were given steroids for the treatment of their frozen shoulder, the pain of which can
be temporarily relieved by steroids, but over the long run, they can actually make the situation worse. The
appropriate treatment for diabetic frozen shoulder is trigger point massage, which is a lot different than
injecting a steroid into a joint.
I, personally, have been adversely affected several times by steroids. About fifty-five years ago, I had diabetic
frozen shoulder. The chief of orthopedics at a major and well-known New York hospital injected steroids into
my shoulder. My blood sugars went sky high for about a month. It relieved the pain for about two weeks, and
a few months later it came back even worse. Again, the proper treatment would have been trigger point
massage. He had no way of knowing that.
I had years of chronic sinusitis. My personal physician was a doctor who specialized in asthma and breathing
problems. He prescribed inhaled steroids, which I used for a period of five years. He did not realize that I had
an immune deficiency disorder that should have been treated with gamma globulin. I read an article telling
how inhaled steroids can cause cataracts, so I stopped using the inhaled steroids after five years. I went to my
ophthalmologist, and he said I had early cataracts. The ophthalmologist talked me into allowing him to remove
the cataracts, which I should never had done, because I developed cystoid macular degeneration from the
surgery. Then, I went to a retinologist, who treated the cystoid macular degeneration. He injected steroids
into one eye, which caused total blindness, and had to be removed surgically. This went on and on, one thing
after another, eventually causing glaucoma.
So, you have to think twice before getting talked into the use of steroids. If taking oral steroids, then most
diabetes patients have to cover the dose with an injection of insulin, usually fast-acting such as Regular. My
book, DIABETES SOLUTION, gives you some ideas on how to estimate the amount of insulin to take to cover
one pill. You might have to take insulin several times a day. Long-acting steroids injected into a joint, muscle,
bursa, or tendon may have to be covered with daily long-acting insulin for days, weeks, or months.
If a doctor says this steroid pill will not affect your blood sugar, don't believe him. It will, but it's up to you to
find out how much, and how long it will last, and so on. If the steroid is optional, you probably shouldn't take
it. It's only for when it's absolutely essential. As I said, doctors all too frequently use steroids when it's not the
appropriate treatment.

Copyright 2013 Dr. Richard K. Bernstein, Diabetes In Control, Inc.