Effect of Beverage Sweeteners on Blood and Urine Chemistry ...



Title: Does Walnut Consumption at Bedtime Alter the Fasting Glycemic Response?Introduction: Diabetes can come in two different forms called Type 1 and Type 2. Juvenile Onset (Type 1) diabetes occurs when a person’s Beta-islet cells are unable to release insulin after a meal because these pancreatic cells are either dysfunctional or dead. Adult Onset (Type 2) diabetes occurs when the beta cells of the pancreas can and do produce insulin, but the adipocytes and skeletal muscle cells stop recognizing insulin as a signal for increased glucose absorption (this is usually observed in older persons who are over weight). Gestational diabetes is another type that mostly occurs during pregnancy. In either case, when a diabetic person consumes sugar-rich food or drink, their blood-glucose levels may become elevated (“Spiked”) and stay elevated for an extended period of time because the glucose cannot be removed from the blood and the person becomes hyperglycemic. A glycemic response that includes insulin secretion with an extended spike in blood glucose is a tell-tale sign that the person has either Type II diabetes and has become “insulin resistant”. Some persons experience a problem related to blood glucose called the “Sunrise” or “Dawn” effect. These persons, often diabetics, experience a decrease in insulin sensitivity at about 3-6 AM and an increase in glycogenolysis in the liver resulting in an increase in blood glucose. As a result their highest daily blood glucose value and lowest insulin sensitivity will occur around the time they wake up in the morning to the sunrise. The hyperglycemia is harmful to them and results in deleterious glycosylation of hemoglobin and other important proteins. The hyperglycemia can also lead to a diuretic effect resulting in diuresis, urination, dehydration, and sleep disruption.Standards of Medical Care in Diabetes—2011: American Diabetes AssociationDiabetes Care January 2011 vol. 34 no. Supplement 1 S11-S61A person is considered diabetic if any one of the following are observed:1) Hemoglobin A1C greater than 6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*OR 2) Fasting Plasma Glucose greater than 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*OR 3) 2-h plasma glucose greater than 200 mg/dl (11.1 mmol/l) during an OGTT. The test shouldbe performed as described by the World Health Organization, using a glucose loadcontaining the equivalent of 75 g anhydrous glucose dissolved in water.*OR 4) In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, arandom plasma glucose _200 mg/dl (11.1 mmol/l)*In the absence of unequivocal hyperglycemia the results should be confirmed by repeat testing.Categories of increased risk for diabetes (PREdiabetes)*1) Fasting Plasma Glucose 100–125 mg/dl (5.6–6.9 mmol/l)OR 2) 2-h plasma glucose in the 75-g OGTT 140– 199 mg/dl (7.8–11.0 mmol/l)OR 3) Hemoglobin A1C 5.7–6.4%*For all three tests, risk is continuous, extending below the lower limit of the range and becomingdisproportionately greater at higher ends of the range.Question we are addressing in this study: Does consumption of walnuts at bedtime alter insulin sensitivity and glycemic response on the following morning? The protocol in our laboratory activity will permit students to self-form groups that seek to determine if consuming walnuts at bed-time alters (improves) the glycemic and insulinemic response 9-hours later to an oral glucose tolerance test (standard 75 gram glucose/240 ml). Prior anecdotal observations by Dr T. Wilson here at Winona State University have looked at glycemic response to Red Bull, and raisins in type 2 diabetics and healthy persons strongly suggests that a high-protein snack administered at bed-time improve glycemic status the following morning and improved insulin sensitivity. This study seeks to determine if walnuts (rich in protein and relatively low in sugar) could lead to improvements in the response to an oral glucose tolerance test. It is the hypothesis of this study that consumption of walnuts at bed-time may improve insulin sensitivity and glycemic status on the following morning. Confirmation of this effect would be highly beneficial to many persons who suffer from high blood glucose and poor insulin sensitivity in the morning (especially those with type 2 diabetes). The results of this study could improve the health outcome for these persons.The goal of this exercise is to determine if eating walnuts at bedtime improved human health.Students in this class will complete an online Human Subjects Education module that lets them become WSU-Human Subjects committee approved researchers. By having the persons who volunteer for the glycemic response measurement and sign an informed consent document, it means their data can be collected and presented outside of class. If we did not get WSU-IRB approval and we did see that walnut “was” beneficial for improving glycemic response and insulin sensitivity, we would be legally barred from telling anyone that walnuts were “helpful”. What is the use in asking a clinical question if you can help anyone with the answer?Who gets to eat walnuts and Oral Glucose Tolerance Beverage?If you want to evaluate your glycemic response, then you need to be the “volunteer” who is 18 years of age or older, without diabetes, not pregnant, and able to fill out an informed consent document. You also need to choose 2-4 people who will be your helpers. Their role will be to measure blood pressure, record time, make sure you get your beverages on time and they are the folks who write down your blood glucose numbers. You as volunteer come up with a team name and write down when you want to arrive in the lab to start this experiment. The participant for your group will be randomly assigned to one of these treatments by the instructor (See the sign-up sheet to determine which beverage your teams volunteer is to consume). Treatment Assignments: Find your treatment on the sign-up sheet on Monday!The Two Treatments Used in this Experiment: Treatment is randomly assigned by the study investigators1) Volunteer eats gummy bears at bedtime (1 ? oz; 285Calories) OR2) Volunteer eats walnuts (1 ? oz; 42 grams; 285 Calories)-Walnuts are provided by investigators the evening 9 hours before the scheduled lab arrival time, the walnuts should be consumed exactly 9 hours before your scheduled lab time. Example: Lab arrival time is 6:30 am, so participant cannot eat or drink anything except water after 6:30 pm the night before. At exactly 9:30 pm the participants either eats (serving size) of gummy bears or (serving size) of walnuts. They continue to fast till lab arrival the following morning 15 minutes prior to the 6:30 am start time. They collect a finger blood sample upon lab arrival (0-minutes; 6:30 am). They then drink their Orange Flavored Glucose Tolerance drink (240 ml; 50 gram; 200 Calories) and repeat the blood collections 30-, 60- and 120- minutes after the last drop of OGTT was drunk.The volunteer cannot eat or drink anything for 12 hours prior to coming to the lab or until the lab activity is completed two hours after starting the lab! The participant for your group will be randomly assigned to one of these treatments by the instructor.(See the sign-up sheet to determine which food your teams volunteer is to consume). Treatment Assignments: Find your treatment on the sign-up sheet on Monday!It is quite important that the volunteer DOES NOT EAT OR DRINK anything (except the gummy bears or walnuts) for 12 hours before arrival in the lab the following morning night before the experiment and until the experiment is completed (except for the test beverage you will consume on the following morning). Remember to eat the gummy bears or walnuts exactly 9 hours before lab arrival. Fasting like this can be difficult, BUT IS CRITICAL for the experiment to function properly. In addition, your volunteer cannot exercise or work out prior to coming to lab for during the experiment.All members need not be in lab for entire 2 hours, between sample times you can go to class, hangout in the hall way and study, take a nap, but your volunteer cannot go to the gym and “work out” because this would affect blood glucose levels. You the volunteer DO need to be in the AP lab to collect your samples at the 0, 30, 60, and 120 minute times. If everyone in your group cannot be in lab the whole time, perhaps they could do extra work on the lab write-up to make up for the absence. The volunteer needs to be at AP lab at the 0-, 30-, 60-, and 120-minutes samples times, so if they have class conflicts the group will need to find a new volunteer. Remember to be in the lab 15 minutes prior to the start time to get organized before your start time!Be Safe with blood: USE GLOVES AT ALL TIMES! WASH HANDS WHEN DONE!Blood Analysis: Review methods for collecting blood with a finger prick and for determining the hematocrit and safety considerations mentioned in Blood Lab your performed back in January and at end of this lab! Record Data on Sheets: You keep one sheet…..You hand other sheet in when done (5pts)Blood Glucose Measurement Protocol with an Accu-Check Analyzer:A Biology Department Capstone Research student will help you do this in lab, always go to the same Station for blood glucose testing. Finger prick and blood analysis is to be completed at 0-minutes (experiment starts when 0-minute blood collection has been completed), 30-minutes, 60-minutes, 120-minutes, and 180-minutes after the start of the experiment.Put on gloves and keep all materials at the station next to the window. At the station you will use a Unistik 2 to draw blood from the finger. 1) Wipe lateral edge of finger with alcohol swab. 2) Let it dry before drawing blood (it hurts if alcohol has not dried off) 3) Follow instructions in illustrations below:PLACE UNISTIK FIRMLY AGAINST FINGER PRIOR TO RELEASING THE FIRE BUTTON, it will make a click sound and the lancet will strike finger then retract. 4) Immediately throw Unistik in “Sharps Container” after use… DO NOT REUSE!5) Put finger below level of heart and let a drop of blood form,,,,,you may “GENTLY” message blood out if you need to until a large drop is present.6) Blood Glucose Measurement Protocol with an Accu-Check Analyzer:a) Insert test strip into slot at rounded face of analyzer, with analyzer sitting flat on bench. Insert with metal strips UP and INTO slot.b) Analyzer will “beep” and a LCD image of a drop of blood will then appear when it is ready.c) Dangle this drop over and touch it into the “yellow” analysis box of the test-strip. Be sure the entire “box” is filled with a large drop of blood and that No Tan color remains. If you can still see “tan” color, add a bit more blood to the test strip. You have 10 seconds to complete the filling of the box prior to needing a new test strip!d) The LCD image of a clock will blink for 30-90 seconds and a “beep” will precede the display of the glucose concentration of the sample in mg glucose/dL. Record data on sheet!7) After blood collection, wipe finger with a KimWipe, apply a band-aide and clean up supplies at your station. Be Safe with blood: USE GLOVES AT ALL TIMES! WASH HANDS WHEN DONE!Alternative Assignments:1) If for any reason you wish to write a library report as an assignment instead of participating in the lab with a lab group, you are welcome to do so and earn the same credit. Please see the instructor so they know that this is your choice (15 points). Alternative assignment needs to compare-contrast type 1, type 2 and gestational diabetes, as well as discussing the “dawn effect” with respect to glycemic control. Length should be a minimum of 3 pages single spaced with five different references (include title, introduction, body, discussion and references sections). References need to be from professional sources, i.e. WebMD is for lay-public and not a professional source, these would be national organizations (i.e. American Dietetic Association) or sources you found in PubMed. You still need to complete separate 10 point D2L human subjects assignment for the alternative assignment.2) If you initially wanted to participate as a study volunteer, but decide at the last minute or part way through the project to withdraw (maybe you did not feel well, or maybe you decided it just wasn’t something you wanted to do after all), you are free to quit at any time. Just simply tell the instructor, “I don’t wish to continue” and your group will be given a data set of fake data to use with respect to writing your laboratory report. No problem and no questions asked and you can still receive the same points as with groups who complete the lab.Laboratory Write-up: 10 points What will you need to write up as a group for this laboratory exercise?You will compare the data collected from your anonymous volunteer with the average data collected for the members of the four different treatment groups. This data will be available approximately 1 week after the lab has been completed at Dr. Wilson’s website.1pt: Title Page: Lab Title, Your Name, Your Lab Time and Your group Assignment1 pts: Introduction: About ? page or 100-200 words that describes the basics of the experiment. What is the goal of the experiment and what is your hypothesis with regards to the two treatments and the dawn effect? 2 pts: Methods: About ? page (100-200 words) that describes what you did in the experiment and “HOW” you did it. You also explain where you down loaded the measurements taken from your “volunteer”. You should also describe (age, wt, sex, but NO Names) of your volunteer or the volunteers in the other groups. To maintain volunteer anonymity at no time should you give the name of any volunteer.3 pts: Results: (Length is variable; data tables look really nice). In the results section you describe the response of the volunteer from your group. You also describe the results of the other groups (these results will be down-loaded from the A and P laboratories website). Describing results means using means or other statistical measures to illustrate your findings.3 pts: Discussion: In this section you need to address several things (6 separate sections of at least one paragraph each). This is where you discuss your findings. 1) Address whether you think the data you collected from your volunteer was valid. How well did your group follow instructions? (50-100 words)2) Address whether your volunteer’s results were the same as, or different from, others assigned to the same treatment. ? (50-100 words)3) Did the data from all the group support of disprove each of your hypotheses? (50-100 words each)-What was your hypothesis about the effect of milk on the fasting blood glucose and insulin before the OGTT was administered?-What was your hypothesis about the effect of milk after the OGTT test-beverage was administered? -What was your hypothesis about the effect of milk on blood pressure and heart rate?4) What did your experiment mean? Did you prove/disprove your hypotheses? Why or Why not? (50-100 words)References Cited: You will need to use at least three references in this laboratory write-up: Professional webpages (i.e. American Society for Nutrition; ), a book, and at least one peer-reviewed journal reference collected from PubMed/Medline/Science Direct (See search engines at WSU library webpage or ). If all three of your sources are from peer-reviewed journals your report will look “Even Better” . Yes you are welcome to use more than three sources. You need to be sure that each source is used in this paper somewhere and cited in the paper. Put the reference source immediately after where the fact is used in your paper. For example: “In our experiment, the blood pressure of our female volunteer started at 120/80 and increased to 140/80 two hours later, the normal female blood pressure is 12080 (Saladin 2011). We believe that water was absorbed into the plasma from the gut causing the blood volume to be enlarged.” This explains your observation to the reader and lets the reader know what facts came from what sources. It also lets the reader ask if your facts sound believable. All of your sources need to be used in the text of your write-up at some point in your write-up.Caution About Exposure to Pathogens in this Laboratory Activity: BE CAREFUL AND BE SAFE! Like all other body fluids, blood can house viruses and bacterial agents -- pathogens that can cause disease.? AIDS (HIV) and Hepatitis are just two examples of such contaminants that you are probably familiar with.? You need not worry about exposure to these contaminants from your own blood -- you are already exposed.? But you must be much more diligent when working with the fluids from someone else.? There are a few precautions that must be taken when working with the body fluids from someone else.? You must wear gloves.? Do not assume a sample is disease-free, instead assume it is contaminated.? Do not re-use any lancet, needle or object that has been exposed to the blood sample. All products contaminated with blood must be disposed of in the appropriate containers.? For example, the lancets must be disposed of in the red Sharpee container.? All paper towels with blood must be placed in the dishpan labeled such.? All hematocrit tubes must be considered sharp objects and should be placed in the Sharpee container.? Used gloves should be disposed of in these pans as well. You will be pricking your finger and collecting your blood.? If you already know that you cannot do this, you will not be forced to participate.? Data from the experiment will be available for everyone to analyze.? If you can collect your own blood, attempt to do so.? If at anytime during the course of the lab you feel dizzy, faint or if your lab partner notices that you are "very absent minded", contact your lab instructor and then sit down on the floor.? Do not attempt to leave the classroom.? If you are about to faint and attempt to leave the class, you may make it past your desk, into the front of the room or into the middle of the hallway.? In any of these cases, your lab instructor will be all over you for not following instructions, once they determine you are OK.? And you will be escorted to the health center for complete evaluation.? The easiest way to minimize the risk to your body, if you do faint, is to minimize the distance your body must travel to reach the floor.? That is why you are asked to sit down.? It is partly the responsibility of the lab partners to help monitor this situation.? Everyone needs to talk to the blood donor and make sure that they are "in the moment" and responding to your discussion.? This is part of that personal touch, that compassion and caring the health care profession relies on. All students in AP 212 must complete the following package whether or not you intend to take part in this laboratory activity as a volunteer or helper:Who needs to complete the WSU Human Subjects Education Module?Documentation of successful completion of the WSU Human Subjects Education Module (80% score on an online, 20-question quiz) must be submitted with IRB protocol requests. How do you self-enroll in D2L to complete the Human Subjects Education Module?Login to D2L (Desire to Learn) at . Click Self-Registration the toolbar. Select Human Subjects Education Module. Click Register. Click Submit. Click Finish. A Registration Summary will appear. Click Go to Human Subjects Module. Complete the course and quiz.How do you download the Human Subjects quiz results for submission with a protocol request?Login to D2L (Desire to Learn) at the + sign to the left of the word No semesterClick Human Subjects Education Module. Click Grades. To save an image of the screen to a file:On a PC, click and hold the ctrl button and the print screen button. Open up a blank word document and click paste. Save the document to a file on your computer.On a MAC, click and hold the shift, command and 3 buttons. The file will automatically be saved your desktop with the name “Screen shot (with date and time given).” Save the document to a file your computer.OPTION: There is another way to print your grade as a .pdf file. After clicking grades, click print. Choose the option to save the file as a pdf file your computer. Click print. The document will open. Save the file your computer. (Note: If you do not have a pdf prompt when you click print, you may need to install Adobe Professional your computer. This is available for installation your computer. Go to Start, Control Panel, Add or Remove Programs. In Add New Program, select Adobe Acrobat Professional 9. Click Add.)Contact TLT Services via ext. 2900 if you have any problems with accessing the course. What do I do with the results? Print off a copy of your results and bring it to your instructor on the day of the lab. You will sign off on a class list. This will be considered a sign off as a co-investigator on the research project.You may want to keep the copy of the results on your computer in case you get involved in a future IRB project. That way you will not have to re-take the quiz for any future projects.Print this Human Subjects D2L Quiz Approval/Completion: (over 80%).When you hand it in, write your name on it/sign it/ and date the print out. Bring this to your lecture instructor for 10 points.Walnuts and Dawn Effect: Raw Data Recording Sheet: “Group Copy”Volunteer Weight:______lbs; Height:______inches; Age:______years; Sex: Male or FemaleYour Team Name:_____________________ Team Treatment Assignment:_________________What is the Day and Time you are arrive in the lab (see sign-up chart): Tue or Thur _____AMWhat time did your participant start their fast the night before (and eat the gummy bears or walnuts)______PMTime to Start:___________Time to Finish:___________Remember to be in the lab 15 to 20 minutes prior to the start time to get organized!At what times in the day will you collect your small blood samples?0min-_______ 30min-________ 60min-_______ 120min-________0-Minutes: Immediately after this data is recorded your subject can drink their beverage (group #1 drinks nothing during the experimental period) and the experiment has begun.What time does clock say?___________What was your blood pressure and heart rate?_____________________What is your subjects blood glucose?_____________________mg/dLWhat plasma collected for insulin analysis? Yes or NoComments:_________________________________________________________________________________________________________________________________________________30-Minutes: Clock Time:_____________ (do not measure heart rate/blood pressure at 30 minutes)What is your subjects blood glucose?______________mg/dLComments:_________________________________________________________________________________________________________________________________________________60-Minutes: Clock Time:_____________What was your subjects blood pressure and heart rate?_____________________What is your subjects blood glucose?______________mg/dL Comments:_________________________________________________________________________________________________________________________________________________120-Minutes: Clock Time:_____________What was your subjects blood pressure and heart rate?______________What is your subjects blood glucose?______________mg/dL Comments:_________________________________________________________________________________________________________________________________________________Walnuts and Dawn Effect: Raw Data Recording Sheet: “Your group volunteer Hands In This Copy When they Leave the Lab”: Group member names (do not identify subject by name- privacy laws):Volunteer Weight:______lbs; Height:______inches; Age:______years; Sex: Male or FemaleYour Team Name:_____________________ Team Treatment Assignment:_________________What is the Day and Time you are arrive in the lab (see sign-up chart): Tue or Thur _____AMWhat time did your participant start their fast the night before (and eat the gummy bears or walnuts)______PMTime to Start:___________Time to Finish:___________Remember to be in the lab 15 to 20 minutes prior to the start time to get organized!At what times in the day will you collect your small blood samples?0min-_______ 30min-________ 60min-_______ 120min-________0-Minutes: Immediately after this data is recorded your subject can drink their beverage (group #1 drinks nothing during the experimental period) and the experiment has begun.What time does clock say?___________What was your blood pressure and heart rate?_____________________What is your subjects blood glucose?_____________________mg/dLWhat plasma collected for insulin analysis? Yes or NoComments:_________________________________________________________________________________________________________________________________________________30-Minutes: Clock Time:_____________ (do not measure heart rate/blood pressure at 30 minutes)What is your subjects blood glucose?______________mg/dLComments:_________________________________________________________________________________________________________________________________________________60-Minutes: Clock Time:_____________What was your subjects blood pressure and heart rate?_____________________What is your subjects blood glucose?______________mg/dL Comments:_________________________________________________________________________________________________________________________________________________120-Minutes: Clock Time:_____________What was your subjects blood pressure and heart rate?______________What is your subjects blood glucose?______________mg/dLComments:_________________________________________________________________________________________________________________________________________________At the end of this lab we would be delighted if you (the volunteer) choose to turn this data sheet in so we can look at the response. However, if you any reason you chose to not hand this in, you can be assigned to an alternative model data set and use that data to write up your report. ................
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