Biocontrol de la “Escoba de Bruja” del Mango, con Trichoderma spp., en Condiciones de Campo Biocontrol of "Witches' Broom" Disease in Mango with Trichoderma spp., Under Field Conditions Alejandro Casimiro Michel Aceves, Marco Antonio Otero Sánchez, Antonio Díaz Castro, Rubén Darío Martínez Rojero, Centro de Estudios Profesionales del Colegio Superior Agropec
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Feature_meijer(glycemic).qxdThis doctor has a way of getting his diabetic patients to improve their levels — without referral to a dietitian. “Eat as close to the
garden as possible,”
says this author.
ANDREW MCCLENAGHAN / PHOTO RESEARCHERS, INC.
It has never been easy to successfully counsel patients with type 2 diabetes about diet and lifestyle. Dietary changes, for many reasons, remain the mostunderused and poorly implemented part of diabetes management. In my practice, however, I have finally found some solutions that work without usingmuch time, extra staffing, or referrals to dietitians. My data indicate that glycemiccontrol can be achieved without the weight gain seen in other studies. Most diabetic patients are confused by the dietary information they receive from the mass media. They also expect too much from medications. The heart of my pro-gram is my own patient-education material (for an example, see page 46), whichsupplements regular office visits. I recently prepared a DVD as well. My material,which includes easy-to-remember slogans and mnemonics, is designed to convincepatients of the need to change their diet.
BY MARK ERIK MEIJER, MD
SEPTEMBER 2004 • CORTLANDT FORUM 45
I begin by making it clear that my approach is An example of Dr. Meijer’s patient handouts
a little unorthodox. Patients with type 2 diabetestypically have failed countless diets in the past The first step to staying alive is to stop killing yourself with bad food.
and don’t mind trying something unusual. Any You have two choices. Live to eat, or eat to live. Your diabetes can strategy requires the patient’s agreement. All control you, or you can control your diabetes. Life is worth dieting for.
management goals are divided into small steps.
Today is the second step toward your control of diabetes.
Small goals are set at each visit, and the degreeof success is checked at the next appointment.
Goals for STEP 2:
Everything you needed to know previously was in Step 1. Read all
Begin with fasting
handouts given to you in addition to these topics to complete Step 2.
The first step in managing glucotoxic type 2 This second step has two parts: Quality & Quantity diabetes patients is usually a three-day fast.
Fasting results in rapid glycemic control, which Improving the Quality of Food Consumed:
lowers insulin resistance. I believe fasting also A. Eat more fiber (e.g., eat fruit, don’t drink it). Eat high-fiber cereals helps these patients psychologically. They expe- (e.g., no grits or cream of wheat). Eat high-fiber brown bread (e.g., rience firsthand that less food improves how no biscuits or white bread). Eat more vegetables (e.g., less meat).
they feel. It’s easier to think optimistically about Over time, you will find more sources of “fiber.” future dieting if eating smaller meals is more B. Use common sense; cut out the “crap.” No junk food, i.e., no sodas, cakes, cookies, chips, fast food, pizza, fried or greasy food, candy, ice cream, sugar (including sweet tea and Kool-Aid), dairy creamer in Association nor NIH guidelines calls for fast- coffee, etc., etc., etc.). This will also help reduce “calories.” ing, but both organizations have recommended C. Start a food diary. Write down anything that goes into your mouth.
it in the past as a safe modality. Fasting fell out of This includes all food and drink except water. Check packaged food favor for political and financial reasons, not labels for calories and fiber. Try to keep good records so your doc- tor can see what you’re eating on your next office visit. This diary offers a well-referenced resource that addresses will help you to the degree you make it work (by doing it!). An important goal is to drink only water, Improving the Quantity of Food Consumed — Eat Less, but
avoiding alcohol, fruit juices, dairy beverages, More Often. Eat six times per day. “Eat less, but more often.” If you
sodas, coffee, and tea. Many patients consider are overweight, eat a lot less, but still more often. If you are over- fruit juice healthy and are surprised to learn weight, you need to read the following handouts as well: Why the big how many calories it contains. (I do recom- fuss?; Eat your vegetables; Fats, fads, facts, and fiction; and The battle mend whole fruit, which provides beneficial fiber.) Patients who can’t fast or change todrinking only water are unlikely to be able to Questions your doctor will ask you on your next visit:
— Did you bring all your medication bottles with you? Not everything in my plan is unusual. Some — Do you still want to live — in other words, are you trying to change patients are not candidates for fasting. I use the customary antiglycemic medications, but rarely — Did you write out and bring your food diary? on the first visit. I recommend a simple diet — — Do you have any questions, concerns, or problems? “Eat as close to the garden as possible” — andwarn that too much of anything, even if it’s [Editor’s note: This handout also includes questions asked by patients, healthy, is bad if it pushes total calorie con- along with Dr. Meijer’s responses. Regrettably, space doesn’t permit sumption too high. Patients are encouraged to to eat a balanced diet and maintain a food diaryto record their intake. Exercise (at least morephysical activity) is also recommended. 46 CORTLANDT FORUM • SEPTEMBER 2004
Understanding weight control
doctor. I stress this at the start. Patients must Historic data have repeatedly demonstrated that establish a regimen of six small meals a day treated diabetes patients gain weight more eas- before intensive glycemic control (glycosylated ily than other individuals. The landmark United hemoglobin [HbA ] <6.0%) using medications Kingdom Prospective Diabetes Study (UKPDS) (other than metformin) is attempted. Otherwise, found that patients who achieved intensive glycemic control (HbA <7) had greater weight My patients understand that diabetes manage- gain, thus making weight control for diabetes Weight gain
ment is assessed by both HbA measurements patients even more elusive.3 Many inexpensive and weight control. Frequency of follow-up is medications (e.g., insulin) can lower blood glu- increases
usually determined by patient success. Failure cose, but without simultaneously achieving weight control. The only exception in the resistance,
Some patients require a lot of follow-up. It’s UKPDS was metformin, but it did not maintain thus making
never easy to make permanent dietary changes, an HbA <7 for longer than four years.
and no one, especially a physician, should belit- Weight stabilization must precede weight loss.
tle how difficult it is. But neither should the truth Weight gain increases insulin resistance, thus glycemic
be sugar-coated. Patients need to diet or die try- making future glycemic control more difficult. In control more
ing. I help patients find simple goals (which the UKPDS, weight gain ceased only when the difficult.
accrue to larger ones) and use slogans (e.g., “Eat average HbA rose to >8 (after more than four to live rather than live to eat”) to motivate them.
years of follow-up). But an HbA >8 is no longer Nevertheless, some relapse is inevitable, and that intensive glycemic control. Weight loss was never is when I show my most sympathetic and sincere achieved. This may be why many studies do not support. No one is perfect, including me.
report weight change. The dilemma in treating“diabesity” (diabetes and obesity) seems to be Results from my patients
that most physicians and their patients are choos- To determine the effectiveness of my approach, ing between weight control and glycemic control. I used my office computer to find all patients Continues on page 48
with an ICD-9 code for type 2 diabetes (250.xx)over a two-year period. A total of 123 charts Table 1: Dr. Meijer’s results
were identified and retrospectively reviewed.
Two terminally ill patients were excluded. Out of 121 patients, 11 charts had no follow-up. The remaining 110 patients initially had significant — 8.8±2.5 (53 established patients who disease (baseline HbA >8). Ultimately, 91% — 8.8±2.6 (33 transfer diabetic patients) achieved a mean HbA of 6.9. A majority of • After 3.3-7.6 years of participation, HbA (mean: 6.0 [P <0.0001]). (For more details, see • No significant weight gain (baseline weight 205.3±48.0 lb vs. 204.9±50.8 lb at latest Many studies report HbA levels in treated diabetes patients to be around 8. For example, one large HMO reported that treated patients • 22 African Americans had better outcomes with a baseline HbA of 8.5 had an improved (baseline HbA 10.4±3.3 to HbA 6.6±1.2%) than 88 Caucasians (8.2±2.4% to 6.9±1.7%) outcome of 7.4, though only 12% of patients • Of 82 respondents surveyed, 70% said they remained to be included.2 I am not aware of any practice that has results as good as mine. (Ad- better than expected (75% had had previous mittedly, a retrospective study by an unavoidably diabetic counseling/education elsewhere).
2004 PHOTODISC, INC. biased physician has its intrinsic weaknesses.) SEPTEMBER 2004 • CORTLANDT FORUM 47
In contrast, my patients maintained intensive The doctor-patient relationship is ideal for glycemic control for four or more years without a behavior-modification program. Diabesity the expected weight gain. Improved long-term should be viewed as an eating disorder that runs dietary compliance and unique patient-educa- in families. Dietary behavior is not simply a mat- tion strategies are the most likely explanation.
ter of educated choices; it is also a matter of crav- Fear of hypoglycemia often prevents diabetic ings. The basic techniques for changing diet are patients and physicians from attempting better to identify negative behaviors and reduce the glycemic control. The intensive glycemic con- reinforcers, to reinforce positive behaviors, and “The ability
trol group in the UKPDS had a marked increase in hypoglycemia. Indeed, my patients did not to change
Feeling better is an excellent example of pos- want an HbA <7 if hypoglycemia was the one’s diet —
itive reinforcement. And reinforcing positive result. Hypoglycemia resolved when the HbA behavior is more successful than reducing neg- not obesity
goal was raised or when patients chose to eat six ative behavior (“honey works better than vine- or family
gar”), but a combination is most effective. history — is
Achieving normal blood glucose levels is usu- Drugs alone won’t compensate for bad diet
ally the physician’s goal, but it is not the patient’s The doubling in incidence of diabesity in the predictor of
ultimate goal. Diabetic patients initially seek United States in the past 15 years cannot be care because they feel bad. My methodology combating or
blamed on bad genes. Bad diet precedes obesity.
makes it brutally clear that they can only feel as preventing
The ability to change one’s diet — not obesity or well as they eat. Once motivated to diet, pa- family history — is the best predictor of success diabetes.”
tients’ dietary goals also have to be made clear. I do this one small, simple step at a time.
— Mark Erik Meijer, MD
The Western diet results in Western disease.
To keep visits short, only brief explanations No one dietary component, e.g., carbohydrates, are given in the office. Patients are expected to deserves all the blame. The greatest impact on read the details, which are written in a simple, weight control, morbidity, and mortality comes easy-to-read format. Important goals are rein- from diet. Many would agree that various forms forced by even briefer slogans. My patients of a low-calorie, high-fiber diet reduce disease.
know “you can only feel as good as you eat.” Additionally, it’s well-established that fiber also Diabesity needs to be controlled. If what you are doing is not working, you need to change if Many patients and physicians hope medica- you want your patients to change. The changes tions can fix dietary behavior. They cannot. The I implemented turned out to be the best profes- fact remains that diabetes and obesity require Dr. Meijer is a family physician in Chase City, Va. At a glance
● An initial fast shows patients that dietary References
1. Davidson JK. Clinical Diabetes Mellitus — A Problem- ● Weight gain makes future glycemic control Oriented Approach. 3rd ed. New York, N.Y.; Thieme: 2000.
2. Sidorov J, Gabbay R, Harris R, et al. Disease manage- ment for diabetes mellitus: impact on hemoglobin A1c. Am J Manag Care. 2000;6:1217-1226.
3. UK Prospective Diabetes Study (UKPDS) Group.
goal was raised or when patients ate six or more small high-fiber meals per day.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of ● Fixing only one component of the diet (e.g., complications in patients with type 2 diabetes (UKPDS 33).
lower carbohydrates) is not the solution.
48 CORTLANDT FORUM • SEPTEMBER 2004
O DELEGADO CARIOCA ORLANDO ZACCONE, TITULAR DA 52ª DP DE NOVA IGUAÇU E MESTRE EM DIREITO PENAL E CRIMINOLOGIA CONTA NESTA ENTREVISTA COMO TEM CONSEGUIDO BONS RESULTADOS AO TRATAR COM DIGNIDADE OS PRESOS DE SUA DELEGACIANum salão de uma delegacia em Nova Igua-nuir a criminalidade, por exemplo, diminuin-circula o dobro de drogas que em toda a Zona çu, RJ, 160 detentos se aglomeram para assis