Q: I’m a healthy 75-year-old male. I’m a bit frustrated after seeing my regular doctor for a checkup and receiving a call from his medical assistant that he is suggesting a low-fat, low-carb diet. I asked for more specific diet suggestions, as I admit I am nutritionally ignorant (my late wife always bought groceries and prepared meals for us). Other than beef and bread, I’m not even sure what a carbohydrate is.
My LDL cholesterol is 152 mg/dL, my triglyceride levels are 256 mg/dL, and my A1c level is 5.8 percent. Ever since I was in my 20s, my A1c has been 5.6 percent or more in spite of the fact that I am very active and quite thin, and I do not eat desserts or add sugar to coffee, tea or cereals. I do suffer with severe neuropathy, but I simply work through that each day, as sitting isn’t part of my nature.
My weekly exercise routine consists of three days of strength training, plus running on the treadmill at the gym, and three days of walking 2.5 to 3.5 miles on days I do not go to the gym. I try to eat a good variety of vegetables, have fresh fruit every meal and seldom eat beef or anything fried, since fat causes stomach problems for me.
Looking at books online for information about low-fat/low-carb diets has been confusing and frustrating. So much contradictory material seems to be available. Do you know of any good resources? Obviously, my doctor isn’t going to be helpful.
A:
Before I give my opinion on a low-fat, low-carbohydrate diet on a 75-year-old person with diabetes, let me explain what this means. There are three types of macronutrients where we get energy from: carbohydrates, fat and protein. A well-balanced diet requires all components, although the proportions may vary greatly depending on an individual’s food choices.
Carbohydrates mean both simple sugars and chains of sugars, such as those found in starches like bread, pasta and rice. Fiber is also made of carbohydrates, but humans can’t use fiber for energy well at all. Fiber has many benefits, including helping regulate blood sugar in people with diabetes. Most fruits are essentially 100 percent carbohydrates, and vegetables, grains and legumes are mostly carbohydrates, with just a little amount of protein and negligible fat.
Fats are very large, energy-rich molecules found in oils, nuts, most animal meat and in a few fruits like avocados. While fats have a bad reputation, there are four major kinds of fats, with the unhealthy fats being saturated (found in meat and tropical oils) and trans-saturated fats (not found in nature at all, only in processed foods, and fortunately being phased out). Polyunsaturated fats (in vegetable oils) and, particularly, monounsaturated fats (in olive and nut oil, with variable amounts in other oils) are healthy in reasonable amounts. Omega-3 is a type of healthy polyunsaturated fat.
Proteins are long strands of amino acids, found in meat and enriched plant foods like tofu. Beef has lots of protein, variable amounts of fat (much of which is saturated) and few carbohydrates.
So, a low-carb, low-fat diet really means a high-protein diet. It’s not so easy to get high protein without high fat, unless you know a lot more than your doctor or assistant told you. However, I just don’t agree with a high-protein diet for someone like yourself. Good amounts of healthy fats like those found in olive oil and fatty fish, along with fruits, greens and legumes, are all part of a healthy diet for people with and without diabetes.
A registered dietitian or nutritionist can give you much more information.
Q: In a recent column, you noted that “atorvastatin can increase blood sugar.” Is this true of all statins? If not, are there statins that are better or safer for someone with diabetes in the family?
A:
Yes, it is true that all statins may increase blood sugar. Higher dosage and higher potency of the statin may have more of an effect. On average, statins raise the A1c level by about 0.3 percent, which is not that much. A 2016 analysis estimated that high-dose statin therapy, such as 40 mg of atorvastatin daily, would lead to somewhere between 50 to 100 new cases of diabetes in 10,000 treated individuals.
It’s very important to remember that people with diabetes are at such a high risk for heart disease that the benefit from statins greatly outweighs the risk, which has been shown in multiple large clinical trials.
Q: A physician recently diagnosed me with an inguinal hernia. I’ve had it for about eight months on my left side. I do wear a support belt most of the time. I’m a 71-year-old man in good health, and I recently retired. The hernia doesn’t cause any pain or discomfort and doesn’t present any physical limitations.
My question is, should I treat it via surgery? If so, what method? I read so much about lawsuits over botched hernia procedures (especially those using mesh).
A:
A hernia is a defect in the abdominal wall, through which abdominal contents can bulge. The goal of hernia surgery is to relieve symptoms and prevent the abdominal contents from getting trapped outside the abdominal cavity (an emergency case known as incarceration). There are many locations for hernias, including the umbilicus (belly button) and prior scars, but the most likely location is still inguinal — in the groin.
Since you have no symptoms, the only reason to operate would be to prevent problems. A 20-year-old has a lot more time for the hernia to stretch out than you do, so surgeons are a bit more circumspect about operating on older people.
Although, if you needed it, the surgeon would certainly operate. However, the likelihood of an emergency developing is small (less than a 5 percent risk over the next 20 years), and it’s entirely reasonable to watch if any symptoms develop and wait to do the surgery until then.
If you do require surgery, you should get advice from your surgeon. I never second-guess the surgeon’s choice of technique, as that is the surgeon’s expertise. For a typical patient, most surgeons choose tension-free mesh repair done via a laparoscope.
Q: My husband and I are confused about the guidelines concerning when older men should be screened for osteoporosis. All the information seems to suggest that it is only needed for men over 70 who have had a fracture. In my husband’s case, he was only told to get a DEXA (dual-energy X-ray absorptiometry) scan after he had back pain and several compression fractures of the thoracic spine (up to 70 percent) at the age of 72. His T-score was -2.8 for the spine.
I can’t help feeling that because he is male, weighs 200 pounds, has an active lifestyle and was, previously, 6 feet, 2 inches tall, the issue of osteoporosis just never came up during his yearly primary care visits (even though his height had decreased since, at least, 2019, and he is now just 6 feet). This is a potentially life-threatening condition for older women and men, but the risks for women seem to get all the attention. What’s the reluctance to order a simple, fast, painless, not-too-expensive test to screen men earlier?
A:
In general, screening tests (by definition, a test done on a person with no symptoms of the condition) are done when there is good evidence that the screening will lead to an improved outcome in a screened group compared with an unscreened group. The data in women is strong enough that all women over 65, and women younger than 65 with additional risks for osteoporosis, should be screened for osteoporosis with a DEXA scan, but there is not data strong enough to support screening in men.
Osteoporosis screening in men is controversial. While one of the most influential groups does not recommend screening in all men over 70, some groups do, despite an absence of proof of benefit. They base this recommendation on the fact that, as you say, it’s not a particularly dangerous test (the radiation dose is small), nor is it expensive (the average cost is $150, but can be higher in some states). One major downside of testing in general is that no screening test is perfect. As such, an unexpected finding of osteoporosis in a man should be repeated to be sure that the test result is accurate.
Even though men are not always recommended for screening, there are some medical findings that should prompt a test. One is a loss of height — losing more than 1.5 inches of height should have prompted a DEXA scan. (Strictly speaking, this is no longer screening; it’s an evaluation of the cause of an unexpected medical finding.)
A low testosterone level (either by itself — hypogonadism — or as a result of medical treatment for prostate cancer); primary hyperparathyroidism; inflammatory bowel disease; and long-term use of prednisone and similar drugs are all known risk factors for osteoporosis that should, at least, trigger a discussion of a DEXA scan. Similarly, the finding of osteoporosis in a man should prompt consideration of the underlying reason behind it, which could include the risk factors listed above.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected] or send mail to 628 Virginia Drive, Orlando, FL 32803.
