Diabetes Education and Research Center Philadelphia

Diabetes' Link To Bacteria

2012-01-24T09:54:00.000-05:00

Diabetes is often accompanied by chronic low-grade inflammation. Recent research indicates that inflammation may be linked to molecules derived from bacteria.

It has been hypothesized that bacterial endotoxins, lipopolysaccharides (LPS) located on the outer membrane of Gram-negative bacteria, can increase the risk for type 2 diabetes by activating components of the immune system which promote insulin resistance and other metabolic abnormalities.

In this large prospective study from last year:

Endotoxemia Is Associated With an Increased Risk of Incident Diabetes, Diabetes Care, February, 2011

Endotoxemia was associated with an increased risk for type 2 diabetes. Notably, the increased risk was independent of established diabetes risk factors such as blood glucose, serum lipids, C-reactive protein (CRP), and body mass index (BMI). The risk was also independent of factors known to affect serum endotoxin activity, such as total cholesterol, triglyceride levels, HDL cholesterol levels, and smoking.

"Our results indicate for the first time that endotoxemia is a key player in the pathogenesis of diabetes and that microbes may have a central role."

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This study from last month:

High Fat Intake Leads to Acute Postprandial Exposure to Circulating Endotoxin in Type 2 Diabetic Subjects, Diabetes Care, December 2011

Found that a high-fat meal elevated levels of endotoxins, especially in people with diabetes.

"These studies have highlighted that exposure to a high-fat meal elevates circulating endotoxin irrespective of metabolic state, as early as 1 h after a meal. However, this increase is substantial in IGT and type 2 diabetic subjects, suggesting that metabolic endotoxinemia is exacerbated after high-fat intake.

In conclusion, our data suggest that, in a compromised metabolic state such as type 2 diabetes, a continual snacking routine will cumulatively promote their condition more rapidly than in other individuals because of the greater exposure to endotoxin."

Previous studies implicated dietary fat in levels of endotoxins (LPS):

"In mice fed a high-carbohydrate diet, the increase in plasma LPS was blunted compared with mice fed a high-fat diet."
...
"In this large sample of healthy men from a population-based sample, we found a link between food intake and plasma LPS. Experimental data suggest that fat was more efficient in transporting bacterial LPS from the gut lumen into the bloodstream."
- Energy intake is associated with endotoxemia in apparently healthy men, American Journal of Clinical Nutrition, May 2008

How does dietary fat assist endotoxin absorption? It's been proposed that fat-soluble endotoxins mix with and are absorbed in conjunction with the fat contained in a meal:

"Dietary fat is incorporated from the gut into triglyceride-enriched lipoproteins, chylomicrons, whose formation promotes LPS absorption."
- Endotoxemia Is Associated With an Increased Risk of Incident Diabetes, Diabetes Care, February, 2011

Another hypothesis is that the absorption of endotoxins is assisted by inflammation present in the gut. This novel study found that orange juice, taken with a meal, could lower levels of circulating endotoxins:

"Whether this increase of endotoxemia is due to the lipid solubility of endotoxin and its absorption into the circulation with the fat contained in the meal or is secondary to other factors such as the inflammation of the intestinal epithelium is not clear. If it is secondary to other factors, the potential antiinflammatory effect of orange juice intake could lower postprandial endotoxin increase."
- Orange juice neutralizes the proinflammatory effect of a high-fat, high-carbohydrate meal and prevents endotoxin increase and Toll-like receptor expression, American Journal of Clinical Nutrition, April 2010

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The following study found a strong correlation between endotoxins and features of the Metabolic Syndrome (in line with the findings of the study at the top of this post which found an association between endotoxins and type 2 diabetes):

Bacterial Endotoxin Activity in Human Serum Is Associated With Dyslipidemia, Insulin Resistance, Obesity, and Chronic Inflammation, Diabetes Care, August 201

It is known that HDL cholesterol assists in the elimination of endotoxin from the circulation. (In healthy individuals, endotoxins are bound mainly to HDL). This study found that diabetic patients with low HDL often had high endotoxin activity.

"Of all the tested clinical variables, the strongest correlation was observed between the LPS/HDL ratio and serum triglyceride concentrations. High fasting concentrations of triglycerides predict postprandial hypertriglyceridemia and the development of insulin resistance."

The study also found an inverse correlation between serum LPS activity and insulin sentitivity in both diabetic and nondiabetic groups. High endotoxin activity was linked to insulin resistance.

The contribution of a high-fat diet was also noted:

"Human and animal studies have both highlighted the importance of the composition of the diet for its influence on the endotoxin absorption process. Consumption of an energy-rich high-fat diet may result in increased levels of gut-derived bacterial endotoxins in circulation."

The authors concluded:

"Taken together, these data show that endotoxins derived from gram-negative bacteria are strongly associated with the MetS variables in vivo. These observations may have clinical implications, because high LPS activity is more often found in subjects who show signs of dyslipidemia, insulin resistance, overweight, and inflammation—factors that increase the risk for diverse micro- and macrovascular complications."

Statins And Risk of Developing Type 2 Diabetes

2012-01-12T11:57:00.001-05:00

A new large study this week reported that postmenopausal women who took any statin had a 48% greater risk of developing diabetes:

Statin Use and Risk of Diabetes Mellitus in Postmenopausal Women in the Women's Health Initiative, Archives of Internal Medicine

It included 153,840 women from the the Women's Health Initiative. The risk remained after adjustment for confounders such as family history of diabetes, body mass index, physical activity, and a "propensity score" (women who were already at risk for developing diabetes).

The study's lead author, Annie Culver, said:

"It's still an area under scrutiny. ... Statins may affect the way the body manages insulin and glucose responses."
- Statins May Boost Diabetes Risk in Older Women

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A meta-analysis or study of studies was published in 2009 which hinted at this link:

Statin Therapy and Risk of Developing Type 2 Diabetes: A Meta-Analysis, Diabetes Care, 2009

This analysis looked at six studies:

West of Scotland Coronary Prevention Study (WOSCOPS)
Heart Protection Study (HPS)
Long-Term Intervention with Pravastatin in Ischemic Disease Study (LIPID)
Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT)
Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER)
Controlled Rosuvastatin Multinational Study in Heart Failure (CORONA)

The bottom 5 studies, when taken together, revealed "a small but statistically significant increase in diabetes incidence" associated with statin use. The increased risk did not appear to be drug- or dose-specific. The association was no longer significant when the first study (WOSCOPS) was included: (Click to enlarge.)

The authors concluded:

"We found no evidence for a protective role of statin treatment on incident diabetes but rather observed a small but significant increase in risk. By contrast, this effect was attenuated and no longer significant in a meta-analysis that included all available evidence, including the original hypothesis-generating data.

Although statin therapy greatly lowers vascular risk, including among those with and at risk for diabetes, the relationship of statin therapy to incident diabetes remains uncertain."

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How To Inject Insulin

2012-01-09T10:47:00.000-05:00

Nicely done video by Diabetes.co.uk:

Poll: How Much Diet Soda Do You Drink?

2012-01-03T07:46:00.000-05:00

How much diet soda do you drink each day?

Over $2 Million Raised At Philly's Walk For Diabetes

2011-10-24T06:51:00.003-04:00

Nearly 10,000 people walked along Benjamin Franklin Parkway to the Art Museum Sunday in support of a cure for type 1 diabetes.

Mayor Nutter was in attendance:

"This walk, this effort is critically important and it's great to see so many young people and families out. This really is a family event and a fantastic day as well."

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Diabetes Or Prediabetes Increases Risk For Dementia

2011-09-20T16:18:00.004-04:00

A new study out of Japan found that people with diabetes had double the risk for developing Alzheimer's Disease. Their risk for dementia was also higher (1.74 times) than people without diabetes:

Glucose Tolerance Status And Risk Of Dementia In The Community, The Hisayama Study, Neurology, September, 2011

Even among those without diabetes, those with a two-hour postprandial blood glucose over 7.8 mmol/L (142 mg/dl) had a significantly increased risk for dementia and Alzheimer's Disease. (There was no association observed for fasting glucose.)

The study involved more than 1000 men and women over the age of 60 who were followed for approximately 11 years. An oral glucose tolerance test was administered to determine postprandial blood glucose.

The link between diabetes and dementia:

"Diabetes could contribute to dementia in several ways, which researchers are still sorting out. Insulin resistance, which causes high blood sugar and in some cases leads to type 2 diabetes, may interfere with the body’s ability to break down a protein (amyloid) that forms brain plaques that have been linked to Alzheimer’s. High blood sugar (glucose) also produces certain oxygen-containing molecules that can damage cells, in a process known as oxidative stress."
- Study: Diabetes Doubles Alzheimer’s Risk, Ann Harding for Health.com

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To Lose Belly Fat: Jogging Better Than Lifting Weights

2011-09-01T12:12:00.006-04:00

Researchers at Duke University recently reported that aerobic exercise was better than resistance training (e.g. exercising with weights) for reducing belly fat:

The Effects of Aerobic versus Resistance Training on Visceral and Liver Fat Stores, Liver Enzymes and HOMA from STRRIDE AT/RT: A Randomized Trial, American Journal of Physiology, August, 2011

Their study involved 249 subjects (155 completed). They were between 18 and 70 years old, overweight, sedentary, and with moderately high LDL (130-190 mg/dL) or moderately low HDL (≤40 mg/dL men, ≤45 mg/dL women).

Subjects were randomly assigned to one of three groups for 8 months:

Resistance Training (RT) - 3 days/wk, 8 exercises, 3 sets/exercise, 8-12 repetitions/set.
Aerobic Training (AT) - about 19.2 km/wk (12 miles/wk).
Full Aerobic Training plus full Resistance Training (AT/RT).

Findings:

Aerobic Training led to significant reductions in:

Liver fat
Visceral fat (fat between abdominal organs, called belly fat)
Liver enzymes (ALT)
Insulin resistance (HOMA)
Both total and subcutaneous abdominal fat

Resistance Training led to significant reductions in:

Subcutaneous abdominal fat

RT did not significantly improve the other variables.

When it came to using energy, aerobic training burned 67% more calories than resistance training.

Results of AT plus RT were not different from AT alone.

The authors concluded:

"For overweight and obese individuals who want to reduce measures of visceral fat and fatty liver infiltration and improve [insulin resistance] and [liver enzymes], a moderate amount of aerobic exercise is the most time efficient and effective exercise mode."

Lead author Cris Slentz, PhD, added:¹

"When it comes to increased health risks, where fat is deposited in the body is more important than how much fat you have."

"Resistance training is great for improving strength and increasing lean body mass. But if you are overweight, which two-thirds of the population is, and you want to lose belly fat, aerobic exercise is the better choice because it burns more calories."

"What really counts is how much exercise you do, how many miles you walk, and how many calories you burn. If you choose to work at a lower aerobic intensity, it will simply take longer to burn the same amount of unhealthy fat."

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¹ Want To Lose Belly Fat? Aerobic Exercise Beats Weights, Medical News Today, August 30, 2011

Increasing Muscle Mass May Improve Insulin Resistance And Lower Risk For Diabetes

2011-07-28T14:24:00.003-04:00

Is it possible to improve insulin sensitivity and stave off a diagnosis of type 2 diabetes by increasing muscle mass?

Yes, according to this study:

Relative Muscle Mass Is Inversely Associated With Insulin Resistance And Prediabetes. Findings From The Third National Health And Nutrition Examination Survey, The Journal of Clinical Endocrinology and Metabolism, September, 2011

Analysis of data from 13,644 participants of NHANES III revealed:

In people with diabetes, each 10% increase in skeletal muscle index (SMI: the ratio of total skeletal muscle mass, estimated by bioelectrical impedance, to total body weight) was associated with:

11% reduction in insulin resistance (HOMA-IR)
12% reduction in prediabetes prevalence

Reductions were higher in people without diabetes.

Study author Dr. Preethi Srikanthan, an assistant professor of medicine in the division of endocrinology at UCLA, said in a press release:

"Our findings suggest that beyond focusing on losing weight to improve metabolic health, there may be a role for maintaining fitness and building muscle mass. This is a welcome message for many overweight patients who experience difficulty in achieving weight loss, as any effort to get moving and keep fit should be seen as laudable and contributing to metabolic change."

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Two New Studies Address Salt Intake And Cardiovascular Disease

2011-07-21T12:42:00.005-04:00

First study:

Fatal And Nonfatal Outcomes, Incidence Of Hypertension, And Blood Pressure Changes In Relation To Urinary Sodium Excretion, JAMA, May 2011

While an increase in sodium (as measured by sodium excretion) was associated with an increase in systolic blood pressure (but not diastolic blood pressure), "this association did not translate into a higher risk of hypertension or CVD complications."

Also, from news@JAMA which summarized the study:

"In the study, the researchers categorized the 3681 study participants according to sodium intake, using a procedure that measures sodium in the urine over a 24-hour period, considered the gold standard for such assessment. At a median of nearly 8 years later, participants in the group with the lowest sodium intake at the beginning of the trial were significantly more likely than the other 2 groups to die of cardiovascular disease."
- Author Insights: Questioning The Benefits Of Salt Restriction, JAMA News, May 3, 2011

Second study:

Reduced Dietary Salt For The Prevention of Cardiovascular Disease: A Meta-Analysis of Randomized Controlled Trials (Cochrane Review), American Journal of Hypertension, July 2011

Results:

“Relative risks (RRs) for all-cause mortality in normotensives and hypertensives showed no strong evidence of any effect of salt reduction CVD morbidity in people with normal BP.

Raised BP at baseline also showed no strong evidence of benefit.

Salt restriction increased the risk of all-cause mortality in those with heart failure.”

Neither of these studies lend strong support for the recommendation to restrict sodium ... for cardiovascular disease. However, other conditions may benefit from sodium restriction. High sodium intake has been associated with greater calcium losses and osteoporosis.¹ Also, the efficient renal mechanism that excretes excess sodium may not be fully effective if the kidney is compromised - as it is with diabetes, hypertension, or existing kidney and vascular disease.
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¹ Salt Intake, Hypertension, And Osteoporosis, Journal of Endocrinological Investigation, 2009

Diet Soda Linked To Larger Waist, Higher Blood Glucose

2011-06-30T13:53:00.007-04:00

Results of two studies presented at the American Diabetes Association's 71st Scientific Sessions last week described risks of consuming diet soft drinks.

The first study found that users of diet soda, on average, experienced a 70% greater increase in waist size compared with non-users. Those with the greatest consumption - two or more diet sodas a day - experienced waist size increases that were 500% greater (5 times greater) than those of non-users:

Diet Soft Drink Consumption Is Associated With Increased Waist Circumference In The San Antonio Longitudinal Study Of Aging

There were 474 participants, aged 65 to 74, who were followed for approximately 9.5 years. To lessen the effect of confounders, results were adjusted for gender, age, beginning waist circumference, diabetes and smoking status, education, ethnicity, leisure-time activity, neighborhood, and length of follow-up.

The authors concluded:

“The promotion of diet sodas as healthy alternatives [to sugar-sweetened drinks] may be ill-advised: they may be free of calories, but not of consequences.”

The second study found a link between artificial sweetener consumption and blood glucose in mice:

Aspartame Consumption Is Associated With Elevated Fasting Glucose In Diabetes-Prone Mice

After three months of eating aspartame-spiked chow, mice had higher fasting glucose levels (144 vs. 105 mg/dl) and lower insulin levels than control mice.

As to mechanism, Sharon Fowler, coauthor of both studies, said in an interview with the Daily Mail:

"Artificial sweeteners could have the effect of triggering appetite but unlike regular sugars they don’t deliver something that will squelch the appetite."

It was noted that artificial sweeteners may also damage or inhibit brain cells that are involved in feelings of satiety.
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High-Dose Statin Therapy May Increase Risk For Type 2 Diabetes

2011-06-23T11:10:00.002-04:00

Research in the recent issue of the Journal of the American Medical Association found that intensive-dose statin therapy increased the risk for type 2 diabetes:

Risk of Incident Diabetes With Intensive-Dose Compared With Moderate-Dose Statin Therapy, JAMA, June 22, 2011

The study was a meta-analysis, a study of studies, in this case 5 statin trials that included over 32,700 participants. Compared with moderate-dose therapy, the high-dose statins increased the risk for diabetes by a small but significant 12%.

In an interview with HeartWire, Lead investigator Dr. Kausik Ray said:

"However, lowering LDL-cholesterol levels is probably more important than the increase in blood-sugar levels."

In fact, those on high-dose statins lowered their cardiovascular events such as heart attacks by 16% compared with those on moderate-dose statins.

Daily intake of 80 mg of drugs such as Lipitor (atorvastatin), Pravachol (pravastatin), or Zocor (simvastatin) was considered high-dose therapy.

There was no mechanism proposed for the increased diabetes risk, however the New York Times' Well blog stated:

"Animal studies suggest that statins can increase muscle resistance to insulin, resulting in higher levels of circulating blood sugar."

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The "Chameleon-Like" Quality Of HDL Cholesterol

2011-05-26T12:54:00.006-04:00

This is an older study (2001) but it addresses an evolving topic - the "chameleon-like" quality of HDL cholesterol - sometimes anti-inflammatory, sometimes pro-inflammatory:

HDL and the Inflammatory Response Induced by LDL-Derived Oxidized Phospholipids, Arteriosclerosis, Thrombosis, and Vascular Biology, 2001

The development of fatty streaks in arteries results in part from an inflammatory response, one that involves the oxidation of phospholipids in LDL cholesterol.

HDL is “good” or anti-inflammatory when:

"In the sense that normal HDL can prevent the formation of or inactivate these inflammatory LDL-derived oxidized phospholipids, normal HDL is anti-inflammatory."

HDL can become pro-inflammatory during an acute-phase reaction:

“In contrast, during an acute-phase [AP] reaction, AP-HDL favors the conversion of LDL to the proinflammatory [mildly-oxidized]-LDL.”

An acute-phase reaction can be the result of an infection, or it may be a chronic acute-phase reaction - such as the low-grade systemic inflammation associated with being overweight.

This link between HDL and LDL, and their pro-inflammatory nature during an acute-phase reaction, “probably evolved to protect against infection, particularly in the young, and appears to be activated in susceptible mouse strains by an atherogenic diet.”
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Seafood-Rich Diet Of Alaska Natives May Reduce Risk Of Diabetes

2011-03-30T11:10:00.004-04:00

A new study of Yup’ik Eskimos in Alaska suggests that high intake of omega-3 fats, the type found abundantly in seafood, may protect against obesity-related diseases such as diabetes:

Associations of obesity with triglycerides and C-reactive protein are attenuated in adults with high red blood cell eicosapentaenoic and docosahexaenoic acids, European Journal of Clinical Nutrition, March 2011

Of the 330 people living in the Yukon Delta region of Alaska who took part in the study, 70% were either overweight of obese, yet only about 3.3% had type 2 diabetes, compared to 7.7% for the total US population.

Senior author Alan Kristal, Dr. PH:

"The new finding was that obesity did not increase [risk factors for heart disease and diabetes] among study participants with high blood levels of omega-3 fats.”

Lead author Zeina Makhoul, Ph.D:

“Interestingly, we found that obese persons with high blood levels of omega-3 fats had triglyceride and CRP concentrations that did not differ from those of normal-weight persons.” ... “It appeared that high intakes of omega-3-rich seafood protected Yup’ik Eskimos from some of the harmful effects of obesity.”

This was an epidemiological study. To determine whether it was indeed the omega-3 fatty acids in seafood that protected the Yup'ik people, or some other genetic or lifestyle factor, a clinical trial is needed. Lead author Makhoul cautioned against taking high doses of supplements based on this research.
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Results of poll: How often do you eat seafood?

________The study was led by researchers at the Fred Hutchinson Cancer Research Center. Their press release:
Study of Yup'ik Eskimos suggests high consumption of Omega-3 fats reduces risk of obesity-related disease
Photo of salmon drying outside an Alaskan home by Camille Lieske from The Center for Alaska Native Health Research.

Diabetes: Perhaps It's More About Fat Than Glucose

2011-01-01T06:39:00.003-05:00

While there is much said and written about the role of glucose in diabetes, the role of fat - that which we consume as well as the management of lipid within the body - has gained importance. The late Dr. McGarry's¹ eloquent treatment of this lipid dysregulation theory back in 2001 deserves a revisit:

Banting Lecture 2001: Dysregulation of Fatty Acid Metabolism in the Etiology of Type 2 Diabetes, Diabetes, 2002

His essential argument:

"... an abnormal accumulation of fat in muscle and other tissues plays an important role in the etiology of insulin resistance and possibly also in the demise of the β-cell in type 2 diabetes."

Some combination of the above characterize type 2 diabetes:

Insulin resistance (impairment in glucose clearance, as well as inability to suppress glucose output from liver).
Insulin insufficiency (impaired function of pancreatic β-cell).

According to McGarry, these dysfunctions may not result from the diabetic state, but may in fact be instrumental in its development.

The Connection Between Fat, Muscle, And Diabetes

Fat within muscle (intramuscular), as opposed to fat in layers and pockets between muscles (extramuscular), "was found to correlate more tightly with insulin resistance than any of the other commonly measured indexes, such as BMI, waist-to-hip ratio, or total body fat."

It may matter more where fat is located than how much fat is present. McGarry notes that:

One may be obese but if the fat is not intramuscular it's been shown to result in less insulin resistance.
One may be lean but if there is substantial intramuscular fat it's been shown to result in more insulin resistance.

Which came first, the insulin resistance or the intramuscular fat? Likely it was the fat:

When plasma free fatty acid levels were elevated in healthy people, it resulted in "a very significant suppression of insulin-mediated glucose uptake (IMGU) into muscle," in just a few hours.

In a rat model, restricting food by 30% led to lower triglyceride levels in plasma, liver, pancreas, and muscle, which in turn led to improved insulin sensitivity and lower glucose levels. McGarry says:

"Diet-induced lowering of tissue TG levels improves insulin sensitivity and essentially reverses the diabetes in animal models of type 2 diabetes."

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¹ John Denis McGarry, PhD

The SmartPill

2010-10-20T13:42:00.003-04:00

Do you have diabetic gastroparesis (delayed emptying of food from the stomach)? The SmartPill may help determine if you do.

After swallowing, the pill travels through your digestive tract for a day or two collecting data such as:

Gastric (stomach) emptying time
Small bowel transit time
Colon transit time
Whole gut transit time
Temperature
Pressure patterns
pH

The data is sent wirelessly from the pill to a device you wear on your body for 3 to 5 days. After the pill passes ("painlessly and naturally within 24-48 hours"), data from the receiver is reviewed by you and your physician.

I've included an image of the SmartPill capsule. It measures 26mm by 13mm (about 1 inch by 1/2 inch).

Source: SmartPill Corp.
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1,200 Rite Aid Stores To Host Free Screenings During November

2010-10-07T17:49:00.002-04:00

Rite Aid is teaming up with the American Diabetes Association to raise awareness and funds for its national Stop Diabetes campaign, offer incentives for patients to take Diabetes Risk Tests, distribute diabetes guides at every pharmacy counter, and host more than 1,200 free diabetes clinics during American Diabetes Month in November.

Here's their press release:
Rite Aid Joins American Diabetes Association in Fight to Stop Diabetes®

"In November 1,200 Rite Aid stores will host Diabetes Solutions Days offering free blood glucose, cholesterol, blood pressure screenings and Body Mass Index (BMI) readings. Visitors to these annual clinics also can try free samples of over-the-counter medications and other diabetes products, discuss diabetes management with a Rite Aid pharmacist, and get a potentially life-saving flu shot."

Visit their site to locate Rite Aid stores near you that offer flu shots.
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NSAIDS Linked To Heart Attack, Stroke

2010-09-19T08:04:00.004-04:00

Earlier this year, a study in the American Heart Association's journal Circulation reported an increased risk of heart attack with use of nonsteroidal anti-inflammatory drugs (NSAIDs) in healthy individuals (over 1 million individuals included in the analysis).¹ It wasn't the first study to find this risk with NSAIDS; however, prior studies looked at those who had heart disease or were at increased risk for it, not apparently healthy people.

Last month at the European Society of Cardiology's 2010 Congress, the same authors reported an increased risk for stroke with use of NSAIDS in a similar large and healthy Danish population. Speaking to Heartwire, Dr. Gunnar Gislason, one of the authors said:

"This is very serious, as these drugs are very widely used, with many available over the counter. ... We need to get the message out to healthcare authorities that these drugs need to be regulated more carefully."

Gislason thinks NSAIDS need better management, preferring they not be available without a prescription:

"If half the population takes these drugs, even on an occasional basis, then this could be responsible for a 50% to 100% increase in stroke risk. It is an enormous effect."

Examples of NSAIDS currently available in the US without prescription are ibuprofen (e.g. Motrin and Advil) and naproxen (Aleve). Diclofenac (e.g. Voltaren and Cataflam), celecoxib (Celebrex), and rofecoxib (Vioxx, now withdrawn) are NSAIDS that require a prescription.

Mechanism

NSAIDS are thought to increase cardiovascular and cerebrovascular risk via:

Increased coagulative effect, with risk of thrombus.
Increased bleeding, especially associated with stroke.
Increased blood pressure. (This is an effect of all NSAIDS.)²
Adverse effects on kidneys. (NSAIDS can lead to sodium and water retention, and a decrease in glomerular filtration rate (GFR).)³

Sometimes benefit outweighs risk. NSAIDS are effective pain relievers. The decision to start NSAIDs should be based on an individual's cardiovascular risk and the specific need for pain relief.
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¹ Cause-Specific Cardiovascular Risk Associated With Nonsteroidal Antiinflammatory Drugs Among Healthy Individuals, Circulation, 2010
² NSAIDs, Coxibs, and Cardio-Renal Physiology: A Mechanism-Based Evaluation: Coxibs and Hypertension, Medscape, 2002
³ Renal Effects Of Cyclooxygyenase-2-Selective Inhibitors, Journal of Pain and Symptom Management, 2002

"[NSAIDS] are associated with adverse renal effects caused by the reduction in synthesis of renal prostaglandins through inhibition of cyclooxygenase (COX)."

Green Leafy Vegetables May Cut Diabetes Risk

2010-09-16T14:50:00.004-04:00

A recent meta-analysis of 6 prospective cohort studies, which included more than 223,000 people, found that:¹

"Increasing daily intake of green leafy vegetables could significantly reduce the risk of type 2 diabetes."

The reduction in risk was modest, just 14% for consuming a little over a serving a day. And the benefit was seen specifically with green leafies, not with vegetables on the whole, with fruit, or with fruit and vegetables combined.

Green leafy vegetables in these studies included spinach, kale, lettuce, and other greens. Had the definition of "green leafy vegetables" been broad enough to include other members of the cabbage and lettuce families, and green herbs such as parsley, dill, and fennel, there might have been a more pronounced benefit, suggest the authors.

Possible mechanisms for the benefit include omega-3 fatty acids, magnesium, and numerous antioxidant compounds all of which are found in green vegetables and all of which have been linked to a lower risk of diabetes or insulin resistance on their own.
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¹ Fruit And Vegetable Intake And Incidence Of Type 2 Diabetes Mellitus: Systematic Review And Meta-Analysis, British Medical Journal, August 2010

High-Fat, High-Protein Diet May Worsen Sleep Apnea

2010-09-12T14:36:00.005-04:00

Can what we eat affect how well we breath while we're asleep? By the looks of this study, yes:

Associations Of Dietary Intake And Physical Activity With Sleep Disordered Breathing In The Apnea Positive Pressure Long-term Efficacy Study (APPLES), Journal of Clinical Sleep Medicine, 2008

It's one of the first examinations of diet in people with sleep disordered breathing (SDB), including sleep apnea. It found:

"The results indicated that even after adjusting for BMI, age, and daytime sleepiness, subjects with very severe and extremely severe SDB (RDI ≥ 50*) consumed a diet that was higher in cholesterol, protein, total fat, and total saturated fatty acids. These findings were most evident among women."

* RDI is Respiratory Disturbance Index. Individuals with an RDI ≥ 10 events/hour were considered to have obstructive sleep apnea.

Although obesity is a risk factor for sleep apnea, this study found that - apart from being overweight - a high-fat, high-protein diet led to disordered nighttime breathing. Cholesterol and protein, nutrients typically found in foods of animal origin, were especially strong indicators. Trans fats, total fat, and saturated fat followed.

Below is a chart from the study. It shows that people with apnea tended to eat fewer carbohydrates than recommended, and more total fat and saturated fat. (Goals were based on the 2005 USDA Dietary Guidelines.) Although it shows protein consumed near goal, it's misleading and in actuality "high when considered in absolute terms, partly as a consequence of high overall caloric intake."

Click to enlarge.

Correcting sleep apnea is desirable since it's linked to high blood pressure, heart disease, and stroke.

If you're experiencing sleep apnea, take note if cutting back on meat, cheese and other dairy products improves your nighttime breathing.

Related post: Sleep Apnea: Common Among People With Diabetes
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Medicinal Mushrooms For Palliative Care

2010-09-09T08:04:00.008-04:00

Although about 65 percent of people with diabetes die from heart disease or stroke, diabetics also experience a significantly higher risk of certain forms of cancer, including cancers of the pancreas, liver, endometrium, colon, breast, and bladder. At some point, palliative care may become the therapy of choice.

Given the promising results of recent investigations, palliative care, that is, any therapy that seeks to reduce severity of symptoms and pain related to an illness rather than seeking to halt or cure the illness, may one day include the use of medicinal mushrooms.

The following study sought to establish the safety and efficacy of psilocybin, a hallucinogenic compound found in a variety of mushrooms, for the anxiety, depression, and physical pain associated with terminal cancer:

Pilot Study of Psilocybin Treatment for Anxiety in Patients With Advanced-Stage Cancer, Archives of General Psychiatry, September 2010

A dose of 0.2 mg/kg psilocybin was found to be safe and better than placebo at reducing anxiety and improving mood for these patients.

The summary of the study on ABCNews (Magic Mushrooms Can Ease Anxiety of Late-Stage Cancer) included the following poignant interview with Pam Saduka who took part in the study. At 55, she was diagnosed with metastatic cancer and given 6-14 months to live. In 2005 she signed up for the study.

Pam:

"[Negative emotions] started to dissipate and I started to look at it differently and I think that's the beauty of having, being able to, expand your consciousness, change the way you're feeling about things.

I don't think the drug is the cause of these things. I think it's the catalyst to release your own thoughts and feelings from someplace that you've bound them very tightly.

I began to realize that all this negative fear and the guilt was such a hindrance to the actual positive part of making the most of, and enjoying, the healthy time that I'm having, however long it may be, that I was basically not utilizing it to the best and enjoying my life because I was so afraid of what wasn't there yet.

There was a tremendous feeling of relief, and of happiness, and of hope ... that it was something I could deal with.

I can't discount the fact that a state of mind, the amount of rest you get, and your emotional condition, just fortifies your own defenses and that it boosts your own physical ability to fight the disease.

I would like to see this become part of the mainstream treatment of stage IV cancer."

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Diabetic Retinopathy Vs. Macular Degeneration

2010-09-08T13:29:00.005-04:00

Many people with diabetes wonder if their blurred vision signals the beginning of diabetic retinopathy or perhaps another common cause of vision loss, macular degeneration.

While blurred vision occurs with both conditions, there are distinct differences between diabetic retinopathy and macular degeneration.

First, macular degeneration generally results in central vision loss while diabetic retinopathy results in dispersed areas of vision loss.

Here's a normal view:

Here's that same view through the eyes of someone with macular degeneration:

Here's that same view through the eyes of someone with diabetic retinopathy:

You may be able to turn your head to compensate for central vision loss. Compensation for dispersed loss from retinopathy is more challenging.

Another difference between the two is the age at which they develop.

Where age-related macular degeneration usually occurs in an older age group (60 years and older), diabetic retinopathy can and does strike a younger population.

The ADA states:

"After 20 years of diabetes, nearly all patients with type 1 diabetes and >60% of patients with type 2 diabetes have some degree of retinopathy."
- American Diabetes Association: Diabetic Retinopathy

The average age for diagnosis of type 2 diabetes has shifted from the 40s and 50s in recent years towards a younger population, occurring with troubling frequency in adolescents. Type 1 diabetes can occur in children as young as 2 years old.

Twenty years on from childhood or the teen years places someone with diabetes at risk of losing their eyesight at the height of midlife. The ADA says:

"Diabetic retinopathy is estimated to be the most frequent cause of new cases of blindness among adults aged 20–74 years."

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Photos of vision loss from NIH National Eye Institute via Wikipedia.

Having Diabetes Increases Cancer Risk

2010-09-08T08:33:00.005-04:00

According to a report issued jointly by the American Diabetes Association and the American Cancer Society, people with diabetes are at a significantly higher risk of certain forms of cancer.^{1, 2}

They are at least twice as likely to get cancer of the liver, pancreas and endometrium. Their risk of colon, breast and bladder cancer is 20 to 50 percent higher than people without diabetes.

Just how diabetes (primarily type 2 diabetes) increases cancer risk is not well understood. (It should be said ... the etiology of type 2 diabetes is not completely understood either.) Current thinking includes:

Shared risk factors such as poor diet, smoking, inactivity, and obesity.
Exposure to higher levels or insulin and blood glucose, either of which may promote cancer growth.
Diabetes characteristics such as insulin resistance and chronic inflammation.
Multidrug therapy for diabetes treatment.

People with diabetes and their healthcare providers should be attentive to changes that may indicate early signs of cancer.
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¹ Diabetes and Cancer: A Consensus Report, CA: A Cancer Journal for Clinicians, June 2010
² Mysterious Link Connects Diabetes And Cancer, NPR, June 2010

New Guidelines For Insomnia: British Report Rounds Up The Research

2010-09-03T15:11:00.006-04:00

Recognizing that...

"Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners,"

... the British Association for Psychopharmacology (BAP) on Tuesday released guidelines for the diagnosis and treatment of insomnia and other sleep disorders. The recommendations do not address sleep problems from apnea/hypopnea, restless legs, narcolepsy, and other conditions:

British Association For Psychopharmacology Consensus Statement On Evidence-Based Treatment Of Insomnia, Parasomnias And Circadian Rhythm Disorders, Journal of Psychopharmacology, Sept, 2010

The guidelines emphasize that insomnia should be diagnosed and treated because it is associated with increased risk for depression, anxiety, and cardiovascular disorders.

Treatments included:¹

Cognitive behavioral therapy (CBT). This is talk therapy which "consists of sessions with a therapist that focus on helping you change your habits and thoughts in a way that helps you sleep."² It is considered so effective and long lasting (compared to drugs) that BAP says it should be offered as first-line treatment.
Hypnotic drugs (sleeping pills). BAP recommends that efficacy, safety, duration of action, and history of substance abuse or dependence be considered. They also say patients should take breaks from these meds every 3 or 6 months to reduce risk of dependency.
Antidepressants.
Antipsychotic drugs. Because of adverse effects and possible abuse these aren't indicated as first-line treatment for sleep disorders.
Antihistamines (Sominex, Nytol). These have a limited role and can cause drowsiness.

Other treatments noted for special populations included:

Hormone therapy for women after menopause
Melatonin
Scheduled light exposure
Behavioral strategies

Do you suffer from insomnia? What have you found helpful?
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¹New Guidelines Issued For Insomnia And Other Sleep Disorders, Medscape, Sept 2 2010
² Talking Therapy ‘Best Option For Insomnia’, WebMD, Sept 2 2010

Mouth and Throat Exercises For Sleep Apnea

2010-08-31T10:08:00.005-04:00

The most effective treatment for obstructive sleep apnea (OSA) is a continuous positive airway pressure (CPAP) machine. It maintains blood oxygen levels by keeping airways open via pressure. Airways narrow when muscles relax naturally during sleep, which may lead to pauses in breathing in some people.

CPAP virtually eliminates episodes of apnea (cessation of breathing) and hypopnea (low or shallow breathing) as well as associated snoring. As a result, sleep quality improves and daytime sleepiness is significantly lessened, even after just one use.

There are alternatives to CPAP however. One is mouth and throat exercises. The following study found that oropharyngeal exercises significantly reduced the severity of sleep apnea, leading to improved sleep quality and reductions in snoring and daytime sleepiness:

Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome, American Journal of Respiratory and Critical Care Medicine, 2009

Thirty one patients were assigned to either sham therapy (deep breathing and nasal lavage) or treatment (throat exercises).

After 3 months, those in the treatment group had a significant decrease in:

Neck circumference (39.6 vs. 38.5 cm)
Snoring frequency
Snoring intensity
Daytime sleepiness
Sleep quality score (a decrease in this score indicated improvement)
Obstructive sleep apnea severity measured by an apnea-hypopnea index (AHI)

The authors made this comparison:

"The reduction in the AHI observed in patients with moderate OSAS was remarkable and in the same order of magnitude as that previously reported by a review of randomized studies that used a mandibular advancement appliance for OSAS."

Study subjects performed the exercises throughout the day for about 30 minutes total. Here's a summary of the exercises from the study:

Soft Palate

Pronounce an oral vowel intermittently (isotonic exercise) and continuously (isometric exercise). Repeat daily for 3 minutes.

Tongue

Brush the top and sides of the tongue while the tongue is sitting on the floor of the mouth. Five times each movement, 3 times a day.
Place the tip of the tongue against the front of the palate (against back of upper front teeth) and slide the tongue backward. A total of 3 min throughout the day.
Forced tongue sucking upward against the palate, pressing the entire tongue against the palate. A total of 3 min throughout the day.
Force the back of the tongue against the floor of the mouth while keeping the tip of the tongue in contact with the inferior incisive teeth (back of lower front teeth). A total of 3 min throughout the day.

Facial

Orbicularis oris muscle pressure with mouth closed. (This may mean pursing your lips, but your interpretation is welcome.)
Suction movements.
Recruitment of the buccinator muscle (cheek muscle) against the finger that is introduced in the oral cavity, pressing the buccinator muscle outward. (I think this means placing a finger in your mouth and pushing your cheek outwards. It's shown in the video below.)
Breathing and Speech: Forced nasal inspiration and oral expiration in conjunction with phonation of open vowels, while sitting. (Breathe in through nose and out through mouth while pronouncing the vowels.)
Swallowing and Chewing: Alternate bilateral chewing and deglutition (swallowing), using the tongue in the palate, closed teeth, without perioral contraction, whenever feeding. Use this chewing and swallowing form whenever eating.

The article was accompanied by this short video which demonstrates some of the exercises:

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Sleep Apnea: Common Among People With Diabetes

2010-08-30T07:38:00.004-04:00

About half of people with diabetes experience sleep apnea, episodes of shallow or absent breathing while asleep.¹

Sleep apnea is not uncommon. It affects about 1 in 5 adults, whether they have diabetes or not. As with diabetes, many who have it don't know. Being overweight is likely to put someone in that 20% prevalence rate though.² It's typically diagnosed by an overnight sleep test called a polysomnogram or "sleep study."

Disordered nighttime breathing is serious. Inadequate air flow to the lungs leads to decreased blood oxygen, which signals the brain to wake you up so you can breathe better. The cycle of falling asleep, disturbed air flow, and waking up - over and over - increases levels of stress hormones that raise heart rate and blood pressure.

Hypertension has been strongly and independently associated with sleep apnea in cohort studies. Behavioral problems, heart disease, and other elements of the metabolic syndrome (insulin resistance and blood glucose abnormalities) are also linked.²

What can you do? You don't have to be overweight to have sleep apnea, but if you are, losing weight lessens it. In upcoming posts I'll discuss other lifestyle changes you can make, including diet and, yes, throat exercises.
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¹ Prevalence Of Sleep Apnea In A Population Of Adults With Type 2 Diabetes Mellitus, Endocrine Practice, 2007
² Epidemiology Of Obstructive Sleep Apnea, American Journal of Respiratory and Critical Care Medicine, 2002

Red Meat And High-Fat Dairy May Increase Heart Disease Risk

2010-08-24T08:37:00.004-04:00

Where do you get your protein? If it's from red meat (steak and pork), processed meat (bacon and salami), and high-fat dairy foods, it may be increasing your risk of fatal and non-fatal heart attack.

That was the finding of a recent assessment of the very large Nurses' Health Study which followed over 84,000 women for 26 years.¹

It found:

Higher intakes of red meat, red meat excluding processed meat, and high-fat dairy were significantly associated with elevated risk of coronary heart disease (CHD).
Higher intakes of poultry, fish, and nuts were significantly associated with lower risk.

And concluded:

"These data suggest that high red meat intake increases risk of CHD."

The study was unique in that it investigated how substituting one source of protein for another, e.g. nuts, fish, or poultry for red meat, affects heart disease risk. It found, for example, that substituting one serving of nuts for one serving of red meat reduced CHD risk by 30%; substituting a serving of fish for red meat reduced it by 24%.

Although the study was conducted on women, the researchers say men are likely to benefit from the findings as well.

Lead author of the study, Adam Bernstein:

"Our research adds to the growing and convincing body of evidence that red meat intake should be minimized or excluded from the diet in order to maintain cardiovascular health."

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¹Major Dietary Protein Sources And Risk Of Coronary Heart Disease In Women, Circulation, August 2010

Shifting Protein Sources Away From Red Meats May Reduce Risk Of Heart Disease In Women, Harvard School of Public Health, Press Release, August 2010

Why People With Diabetes Need To Be Vigilant About Food Safety

2010-08-22T08:03:00.006-04:00

As of Friday, the number of eggs recalled in the latest salmonella-in-eggs debacle reached half a billion. The FDA considers this "one of the largest shell egg recalls in recent history."

Thoroughly cooking eggs kills salmonella, but it doesn't prevent infection via cross-contamination (or undercooking).

People with diabetes are more susceptible to infection from contaminated food. The USDA's Food Safety and Inspection Service (FSIS) explains:

The diabetic's immune system may not readily recognize harmful bacteria. This delay in fighting off foreign invasion places a person with diabetes at increased risk for infection.
Diabetes can damage cells that create stomach acid and nerves that help move the food through the intestinal tract. Stomach and intestines may hold on to food for a longer time, allowing harmful bacteria to grow.
The diabetic's kidneys may not be functioning properly and may hold on to harmful bacteria, toxins, and other pathogens.

Not only are people with diabetes more susceptible to infection, but if they do get sick it may last longer, it may require hospitalization, and there is a higher risk of death.

FSIS' brochure, Food Safety for People with Diabetes (pdf), goes into more depth about:

Specific pathogens.
Which foods are more likely to be contaminated (namely uncooked produce and animal products). Eggs are notorious carriers of Salmonella.
How to handle food safetly.
Cooking and storage guidelines.
Wise choices when eating out.

The FDA is maintaining a page to update which brands have been recalled and how to determine if your eggs are part of the recall. (Check Plant Number and Julian Date.):
FDA: Salmonella Enteritidis Outbreak in Eggs
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Convert A1C To Average Blood Sugar (And Vice Versa)

2010-08-20T07:46:00.005-04:00

Here's ACCU-Chek's A1C calculator. (The pic should take you to their site.)

A handy tool. But their caveat is important:

* This tool uses average plasma blood sugar readings — the measure used by most meters available today. It should not be used to predict an A1C and is not a substitute for a clinical test performed by your doctor. It is intended to show the relationship between a healthy A1C and self-monitoring results, and give you an idea of how you can help prevent long-term diabetes complications.
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Dietary Fiber May Reduce Risk Of Death From Heart Disease

2010-08-19T09:15:00.007-04:00

Research from Japan this month finds that dietary fiber from fruit and cereals/grains, but not from vegetables, reduced the risk of death from cardiovascular disease:

Dietary Fiber Intake Is Associated with Reduced Risk of Mortality from Cardiovascular Disease among Japanese Men and Women, The Journal of Nutrition, August 2010

The study which involved over 58,000 men and women was prospective with a 14-year follow-up.

Both soluble and insoluble fiber provided benefit, but insoluble reduced risk more than soluble. Fruit fiber reduced risk more than cereal/grain fiber.

The findings are in good company:

"The inverse associations of fruit and cereal fiber intakes, but not vegetable fiber intake, with mortality from [coronary heart disease] in the present study were consistent with findings from previous studies: the Women's Health study, Nurse Health study, Cardiovascular Health Study, and the pooled analysis of 10 American and European cohort studies."

Possible mechanisms:

Fiber, especially soluble, may improve lipid profile via cholesterol lowering.
Fiber may lower blood pressure
Fiber may reduce abdominal obesity
Fiber may improve insulin sensitivity
Fiber may inhibit a postprandial rise in glucose and triglycerides
Fiber, especially insoluble, may improve fibrinolytic activity (reduce blood clotting)

Those in the highest fiber intake group consumed about 14 grams/day, about double what those in the lowest intake group consumed. The authors state this may have been underestimated and that the actual mean (not maximum) fiber intake was about 15 grams/day.

The hazard ratio, in the highest vs. lowest quintile, for insoluble fiber:

For men: 0.48
For women: 0.49

Insoluble fiber cut their risk of death from coronary heart disease in half.

The American Heart Association recommends adults consume about 25 grams of fiber a day from foods rather than supplements.

These finding don't bode well for low-carb, low-cereal-fiber Atkins-like diets.
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US Cheese Consumption On The Rise

2010-08-18T07:12:00.002-04:00

The US Department of Agriculture has been tracking cheese consumption:

Some cheese facts:

Average US cheese consumption nearly tripled between 1970 and 2003, from 11 pounds per person to 31 pounds.
60% of our cheese comes from eating out (or ordering in).
In 2000 cheese contributed:
- 26% of the calcium in the US diet (up from 11 percent in 1970)
- 12% of the saturated fat (up from 5 percent in 1970)
- 16% of the sodium (up from 6 percent in 1970)

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Laughter Raises Good Cholesterol, May Lower Heart Attack Risk

2010-08-16T09:15:00.002-04:00

A study presented at the American Physiological Society's annual meeting last year found that a daily bout of humor could affect very tangible changes in blood lipids and markers of inflammation.¹

Here's a short video that describes the study's findings:

In the study, 20 diabetes patients with hypertension and hyperlipidemia were assigned either to a laughter group or a control group. All received meds for diabetes (glipizide, thiazolidinediones, metformin), hypertension (ACE inhibitor or ARB) and hyperlipidemia (statins). The laughter group watched at least 30 minutes a day of a self-selected humor video. (Self-selected ... "Funny" is very subjective.)

At the end of a year:

HDL cholesterol rose 26% in laughter group.
HDL cholesterol rose 3 % in control group.
C-reactive protein decreased 66% in the laughter group.
C-reactive protein decreased 26% in control group.

C-reactive protein is a marker of inflammation. The laughter group also had lower levels of the inflammatory markers TNF-α, IFN-γ, and IL-6, as well as lower epinephrine and norepinephrine levels by the second month, which may indicate reduced stress.

"The authors conclude that mirthful laughter may thus lower the risk of cardiovascular disease associated with diabetes mellitus and metabolic syndrome."

One of the authors, Dr. Berk, added:

"The best clinicians understand that there is an intrinsic physiological intervention brought about by positive emotions such as mirthful laughter, optimism and hope."

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¹ Mirthful Laughter, As Adjunct Therapy In Diabetic Care, Increases HDL Cholesterol And Attenuates Inflammatory Cytokines And C-RP And Possible CVD Risk, The FASEB Journal, 2009

American Physiological Society Press Release:
"Mirthful Laughter," Coupled With Standard Diabetic Treatment, Raises Good Cholesterol And May Lower Heart Attack Risk, April 2009

PA Fair Care For Uninsured Residents

2010-08-13T14:06:00.001-04:00

Last week, the state of Pennsylvania launched a temporary health plan for uninsured adults with preexisting conditions. PA Fair Care is a transitional plan intended to provide coverage until 2014, when new federal health insurance reform kicks in. Pennsylvania is one of a number of states offering such plans.

Enrollment is on a first come, first serve basis. You are not eligible if you are enrolled (or eligible for) Medicare or Medicaid. You can apply online at www.PaFairCare.com.

The monthly premium is about $283.00 plus copays and coinsurance. Benefits include prescription drugs but not vision or dental care. A summary of what the plan does and does not cover is at PA Fair Care Benefits.

To apply, you'll need the following information:

Social Security Number if a US citizen
Alien Registration Number or I-94 Number if a noncitizen
PA Driver’s License Number or PA Identification Number

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Posttraumatic Stress Among Military May Increase Risk For Diabetes

2010-08-13T07:41:00.004-04:00

Does military deployment affect risk for diabetes later in life? It may, if the military experience was associated with posttraumatic stress disorder (PTSD). That was the finding in a study published in this month's Diabetes Care:

Risk of Diabetes in U.S. Military Service Members in Relation to Combat Deployment and Mental Health, Diabetes Care, August 2010

Researchers analyzed data from 44,754 participants of the ongoing Millennium Cohort Study, the largest prospective health project in US military history, launched in 2001. Follow-up was 3 years from baseline, a relatively short time.

Findings:

"In summary, we found that symptoms of PTSD but not depression were independently associated with an increased risk of diabetes in military service members. To our knowledge this is the first report of a prospective association between PTSD and diabetes, and confirmation by additional research is needed."

The authors speculated a possible mechanism between PTSD and diabetes "might involve the stress response associated with these conditions contributing to inflammation and insulin resistance."
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Caffeine Prevents Exercise-Induced Fall in Blood Glucose

2010-07-02T08:51:00.005-04:00

People with type 1 diabetes are at risk for low blood glucose (BG) during and after exercise.

An abstract¹ presented at this year's 70th Scientific Sessions of the ADA found that supplementing with caffeine prior to exercise prevented low BG:

"Caffeine ingestion prior to exercise reduces the fall in BG, and the requirement for glucose ingestion during exercise in type 1 diabetes mellitus (T1DM), but does not alter respiratory exchange ratio (RER) and thus fuel oxidation. This implies that caffeine augments endogenous glucose production with exercise. Caffeine may be an additional tool to reduce hypoglycaemia during exercise in T1DM."

It was a small study, only 5 participants. They took a 5mg/kg dose of caffeine. That works out to 340mg of caffeine for a 150 lb woman, or 454mg caffeine for a 200 lb man. An 8 ounce cup of regular brewed coffee has about 100mg caffeine.
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¹ Caffeine Supplementation Reduces Exercise Induced Decline in Blood Glucose and Subsequent Hypoglycaemia in Adults with Type 1 Diabetes (T1DM) Treated with Multiple Daily Insulin Injection (MDI), Abstract ADA 70th Scientific Sessions, June 2010

B Vitamin Supplements May Advance Kidney Decline In People With Diabetes

2010-06-02T14:55:00.004-04:00

About 40% of people with diabetes will develop kidney disease (diabetic nephropathy); 44% of cases of renal failure are linked to diabetes.

B vitamins lower blood homocysteine levels, high levels of which are thought to raise the risk for diabetic nephropathy.

Can taking B vitamins lower the risk of kidney disease among diabetics? Researchers from Canada set out to answer that question:

Effect Of B-Vitamin Therapy On Progression Of Diabetic Nephropathy, Journal of the American medical Association, April 2010

They reported that people with diabetes and nephropathy who took supplemental vitamin B had a greater decline in kidney function than those taking placebo. Supplementers also had a higher rate of heart attack and stroke.

Patients took a tablet containing placebo or:

Folic acid (2.5 mg/d)
Vitamin B6 (25 mg/d)
Vitamin B12 (1 mg/d)

The RDA for those vitamins:

Folic acid (400 mcg/d = 0.4 mg/d)
Vitamin B6 (1.3 to 1.7 mg/d)
Vitamin B12 (2 to 3 mcg/d = .002 to .003 mg/d)

Note the high doses in the supplement.

Not only was the folic acid/B6/B12 blend not helpful, it likely did harm.

Science Daily has a good summary:
High Doses of B Vitamins Associated With Increased Decline in Kidney Function for Patients With Kidney Disease from Diabetes
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Diabetes Prevalence Statistics From CDC

2010-05-01T17:41:00.002-04:00

The Centers for Disease Control (CDC) has some great maps that estimate the percentage of US adults with diabetes. Here's our state, Pennsylvania:

It records down to the county level. The prevalence for diagnosed diabetes in Philadelphia County as of 2007 is 10.0%, the second highest in the state after Fayette County.
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Getting Fat May Be Protective, If Just For A Little While

2010-04-01T16:06:00.003-04:00

Researchers reporting in this month's issue of Trends in Endocrinology and Metabolism explain a novel purpose for the acquisition of fat: it may protect against metabolic syndrome:

Gluttony, Sloth And The Metabolic Syndrome: A Roadmap To Lipotoxicity

The authors put forth that the body may be shuttling away excess fat into fat cells (adipose cells) before it can damage heart muscle or pancreatic cells - which it has been shown to do in rodents. Thus, obesity and insulin resistance may be viewed not as causing metabolic syndrome, but as methods the body employs to fend it off. (Cells that become resistant to insulin would be protective by slowing absorption of blood glucose, thus slowing production of lipid from that glucose.)

At some point, however, adipose cells become less efficient at taking up lipids making other cells vulnerable to their toxic effects. Getting fat is only temporarily protective.

If insulin resistance could ever be considered a good thing, that may alter thinking on how pharmaceuticals are employed. Would we want to lessen it? And removal of fat cells, liposuction, may in fact thwart the body's protective mechanisms by eliminating the source of hormones than manage lipids.

The Economist has a great article on their paper:
A Game of Consequences?
One of the scourges of modern life may have been profoundly misunderstood
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Diets High In Fat And Meat May Increase Diabetes Risk

2010-03-01T15:53:00.002-05:00

A group of researchers from Hawaii found that diets high in fat and meat (meat, eggs, cheese) were associated with increased risk for diabetes among several ethnic groups.¹

The researchers analyzed diets from participants of the Hawaiian component of the Multiethnic Cohort Study. The group was comprised of over 35,000 Japanese Americans, 29,000 Caucasians, and 10,000 Native Hawaiians, and followed for 14 years. After adjusting for body mass index (BMI):

Fat and meat was associated with increased diabetes risk in overweight men and overweight Japanese women.
Vegetables lowered diabetes risk in men but not in women.
Fruit and milk seemed to be more beneficial in women than in men.

They concluded:

"Foods high in meat and fat appear to confer a higher diabetes risk in all ethnic groups, whereas the effects of other dietary patterns vary by sex and ethnicity."

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¹ Dietary Patterns and Risk for Diabetes: The Multiethnic Cohort, Diabetes Care, March 2010

Antioxidants Promote Insulin Resistance In Mice

2010-02-01T14:26:00.003-05:00

Antioxidants fight oxidative stress. And oxidative stress is thought to increase the risk for type 2 diabetes. You might think that the more antioxidants you take, the less your risk for diabetes. This study found that more is not necessarily better, and may in fact raise the risk for diabetes:

Reactive Oxygen Species Enhance Insulin Sensitivity, Cell Metabolism, October 2009

Mice that were fed a high-fat diet, but that lacked an enzyme that acts like an antioxidant (glutathione peroxidase), were less likely to develop insulin resistance - a precursor to diabetes - than normal mice who had this enzyme. When the enzyme-deficient mice were given an antioxidant (N-acetylcysteine), they became more insulin resistant.

Oxidized compounds may be beneficial by acting as signals - inhibiting the action of enzymes that can slow the action of insulin.

This study found that, at least in mice, antioxidants promote insulin resistance.
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Are You At High Risk For Diabetes? Here's How to Avoid Getting It

2010-01-06T13:37:00.002-05:00

In 2002, the Diabetes Prevention Program Research Group published this study in the New England Journal of Medicine:

Reduction In The Incidence Of Type 2 Diabetes With Lifestyle Intervention Or Metformin

Researchers found that:

"Type 2 diabetes can be prevented or delayed in persons at high risk for the disease [by following] a lifestyle-modification program with the goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week."*

The study compared these lifestyle changes with the drug metformin. The researchers found "lifestyle intervention was more effective than metformin," reducing the incidence of diabetes by 58% compared with 31% in the metformin group. (Comparisons were made against a placebo group.)

* Participants were considered at high risk if they had either impaired glucose tolerance (IGT), defined by a glucose level of 140-199 mg/dl, 2 hours after a 75 g glucose challenge, or impaired fasting glucose (IFG), defined by a fasting glucose level of 100-125 mg/dl, or both.
________
Fast forward to November 2009 and this study which appeared in the Lancet:

10-Year Follow-Up Of Diabetes Incidence And Weight Loss In The Diabetes Prevention Program Outcomes Study

Researchers investigated the long-term effect of the original interventions - lifestyle changes or metformin - in the original participants. Although differences in incidence rates lessened between the groups, "the cumulative incidence of diabetes remained lowest in the lifestyle group." In the 10 years since the original study, diabetes incidence was reduced by 34% in the lifestyle group compared to 18% in the metformin group. (Comparisons were made against a placebo group.)

What Constituted Lifestyle Change

The original study set forth the following goals for their lifestyle-modification group:

To achieve and maintain a weight reduction of at least 7% of initial body weight through a healthy low-calorie, low-fat diet
To engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week.

In addition:

"A 16-lesson curriculum covering diet, exercise, and behavior modification was designed to help the participants achieve these goals. The curriculum, taught by case managers on a one-to-one basis during the first 24 weeks after enrollment, was flexible, culturally sensitive, and individualized. Subsequent individual sessions (usually monthly) and group sessions with the case managers were designed to reinforce the behavioral changes."

Lifestyle changes, including weight loss, exercise, and a healthful diet, have repeatedly been shown to be effective at delaying the onset of diabetes.
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Quarterback Jay Cutler Talks About His Diabetes

2009-11-05T07:33:00.001-05:00

Eli Lilly recently hired Chicago Bears quarterback Jay Cutler to star in a series of videos where he talks openly about his diabetes - how it was diagnosed and how he manages it. You can watch the videos on Lilly's "Touchdowns for Diabetes" site. Clicking the photo to the right will also take you there.

Culter was diagnosed with type 1 diabetes in April 2008, after losing 33 pounds. The transition to daily diabetes management has been challenging for him:

"Whenever you have to jab yourself with a needle, that's, ah, that's where it gets a little iffy."

"You're 24 years old, you don't expect things like that to happen in life."

"It's tough, you wake up with it and you go to sleep with it."

"I miss a lot of foods. I used to love desserts. I miss sweet tea. I miss lemonade. Do I ever cheat? Yes, I do. Reese's peanut-butter cups is my cheat-food."

"I'm still struggling with this, still trying to overcome stuff. I think, over time, you just get used to it and it becomes part of you. And, I'm not to that point yet."

Related: Chicago Tribune article:
Jay Cutler Discusses His Diabetes In Webisodes, Offers Encouragement To Others
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November 14 is World Diabetes Day

2009-10-27T07:51:00.001-04:00

Diabetes education and prevention is the World Diabetes Day theme for the period 2009-2013:

For people with diabetes, this is a message about empowerment through education.
For governments, it is a call to implement effective strategies and policies for the prevention and management of diabetes to safeguard the health of their citizens with and at risk of diabetes.
For healthcare professionals, it is a call to improve knowledge so that evidence-based recommendations are put into practice.
For the general public, it is a call to understand the serious impact of diabetes and know, where possible, how to avoid or delay diabetes and its complications.

This is a great time to review the warning signs of diabetes:

Frequent urination
Excessive thirst
Increased hunger
Weight loss
Tiredness
Lack of interest and concentration
Vomiting and stomach pain (often mistaken as the flu)
A tingling sensation or numbness in the hands or feet
Blurred vision
Frequent infections
Slow-healing wounds

Any of these signs should be discussed with your health care provider.
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November is American Diabetes Month

2009-10-27T07:34:00.003-04:00

The American Diabetes Association gives these statistics on diabetes prevalence:

24 million children and adults in the US live with diabetes.
57 million Americans have prediabetes, putting them at risk for developing type 2 diabetes.
1 out of every 3 children born today will face a future with diabetes if current trends continue.

And these figures on the impact of diabetes on health:

60-70% of people with diabetes have mild to severe forms of nerve damage.
The rate of amputation for people with diabetes is 10 times higher than for people
without diabetes.
2 out of 3 people with diabetes die from heart disease or stroke.
Diabetes is the leading cause of new cases of blindness among adults.
Diabetes is the leading cause of kidney failure.

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Clues That Inflammation Is At The Heart Of Type 2 Diabetes, Part 2

2009-08-13T09:11:00.007-04:00

This is a continuation from my last post, Clues That Inflammation Is At The Heart Of Type 2 Diabetes, Part 1.

Last year, Joslin researchers reported that the inexpensive, non-steroidal anti-inflammatory drug (NSAID) salsalate reduced blood glucose in overweight adults:

Salsalate Improves Glycemia And Inflammatory Parameters In Obese Young Adults, Diabetes Care, February 2008

Fasting glucose was reduced by 13%
Response to an oral glucose tolerance test (OGTT AUC) was reduced by 20%
Glycated albumin was reduced 17%
Adiponectin* increased 57%
C-reactive protein** was reduced by 34%

*Adiponectin is a hormone produced by fat cells, found in lesser amounts in overweight individuals. Lower levels are associated with an increased risk for type 2 diabetes.

** C-reactive protein is a marker for inflammation

They concluded:

"These data support the hypothesis that subacute-chronic inflammation contributes to the pathogenesis of obesity-related dysglycemia and that targeting inflammation may provide a therapeutic route for diabetes prevention."

________
Later in 2008, Joslin researchers reported similar findings; the anti-inflammatory drug salsalate again showed benefits for blood glucose control:

Use Of Salsalate To Target Inflammation In The Treatment Of Insulin Resistance And Type 2 Diabetes Clinical and Translational Science, Clinical and Translational Science, May 2008

Results of the three, small, proof-of-concept trials in this study included:

Reduced fasting* and post-meal glucose
Reduced circulating free fatty acids
Increased levels of adiponectin
Reduction in inflammation markers

* "Fasting glucose levels fell by approximately 1.1 mmol/L (20 mg/dl) in both 4.5 and 3.0 g/d cohorts [of salsalate]."

The above is noteworthy, since the 4.5 g/d salsalate group had prestudy fasting glucose near normal levels (6.2 mmol/L = 112 mg/dl), and as the authors state, "it is more difficult to improve glycemia within the near-normal range than when glucoses are less well controlled."

Indeed, these participants started with a fasting glucose of 112 mg/dl, and after 2 weeks, without weight loss, had a fasting glucose of 91 mg/dl ... merely by taking several grams/day of a generic, inexpensive NSAID.
________
Note: Salsalate is a nonsteroidal antiinflammatory drug similar to aspirin and available without a prescription. One way it differs from aspirin, or acetylsalicylic acid, is that it is not acetylated. As such, it does not inhibit cyclooxygenase enzymes, Cox 1 and Cox 2, it does not inhibit platelets, and is not associated with internal bleeding. It can however result in hearing difficulties and tinnitus ("ringing in the ears") when taken in amounts of several grams/day, such as those used in this study.

Clues That Inflammation Is At The Heart Of Type 2 Diabetes, Part 1

2009-08-01T15:50:00.005-04:00

Dr. Steve Shoelson, professor of medicine at Harvard Medical School and a researcher at Joslin Diabetes Center has been investigating the role of inflammation in the development of insulin resistance and type 2 diabetes.

He notes:

1. "Epidemiologists have found that patients with type 2 diabetes and cardiovascular disease have slightly elevated levels of inflammatory markers in their bloodstream, raising the possibility that inflammation might be associated with the development of these diseases."

2. "Proinflammatory cytokines such as TNF-α and IL-6 promote insulin resistance in experimental models."

3. "A third series of investigations really provided a breakthrough for our understanding. Drawing upon earlier studies suggesting that anti-inflammatory salicylates reverse hyperglycemia in diabetic patients, we identified the NF-κB pathway as a target of this effect and found it to be activated by obesity. We found that activation of the inflammatory NF-κB pathway in fat and liver by weight gain leads to the production of inflammatory mediators that cause both local and systemic insulin resistance."

Here's the study which supports that last point:
Local And Systemic Insulin Resistance Resulting From Hepatic Activation Of IKK-Beta And NF-Kappab, Nature Medicine, February 2005

It investigated the effect of activation of this inflammatory pathway on both transgenic mice (bred to exhibit type 2 diabetes), and mice fed a high-fat diet. It concluded:

"These findings indicate that lipid accumulation in the liver leads to subacute hepatic 'inflammation' through NF-kappaB activation and downstream cytokine production. This causes insulin resistance both locally in liver and systemically."

Of note:

"Oral salicylate* therapy reversed insulin resistance in LIKK mice."

* Salicylate is an anti-inflammatory drug similar to the active component in aspirin (acetylsalicylic acid)
________

Inaccuracies In Blood Glucose Monitors

2009-07-29T16:00:00.006-04:00

A story in the New York Times this month reported that the FDA, under Commissioner Hamburg, is pressuring the international group that sets standards (International Organization for Standardization: IOS) to tighten allowable errors for in-home blood glucose monitors.

If the IOS fails to act, the FDA may change the standards for meters in the US.

Self-monitoring of blood glucose devices (SMBG devices) are currently allowed to be inaccurate by up to 20%. However:

"A study by government researchers found that when comparing tests from five different popular monitors, results varied by as much as 32 percent.

For a class science project recently, Morgan DiSanto-Ranney, 16, of Bishop O’Connell High School in Arlington, Va., bought seven different glucose monitors and had her father, a diabetic, use all of them.

“What I found was that almost all of the meters were off from one another by 60 to 75 points,” Morgan said in an interview. Two of the meters — Ascensia Breeze and Ascensia Breeze II, both made by Bayer — differed by an average of 62 points, she said."

An inaccuracy of 75 mg/dl is not trivial.
________

Link Between Lantus Insulin And Cancer

2009-06-30T20:43:00.000-04:00

The European Association for the Study of Diabetes (EASD)'s journal, Diabetologia, has four papers and an Editorial in press, addressing a possible link between insulin glargine (Lantus insulin) and cancer.

You can access their studies and press release here.

From their press release:

"The concerns about a possible link between use of Lantus insulin and increased cancer risk were raised by a German study of around 127,000 insulin-treated patients in an insurance database. The research identified a statistically significant link between patients who had used Lantus insulin and those who had been diagnosed with cancer. Compared with people using similar doses of human insulin, out of every 100 people who used Lantus insulin over an average of about one-and-a-half years, one additional person was diagnosed with cancer. Of particular note in this study was the finding that the increased risk of cancer was dose-dependent. Thus for patients given a dose of 10U, Lantus insulin alone increased the risk of cancer by 9% compared with human insulin; but for a dose of 50U, the increased risk was 31%."

Additional studies were carried in Sweden, Scotland, and the UK:

The Swedish study found that compared with patients on insulins other than Lantus insulin, patients on lantus insulin alone had double the risk of breast cancer.
The Scottish study found a non-significant increased risk for breast cancer specifically.
The UK study found no link between insulin glargine and cancer.

The studies are observation and not conclusive. More research is needed. The EASD is advising patients not to stop taking Lantus insulin without contacting their healthcare provider. Alternatives may be available.
________

Low-fat Vegan Diet Surpasses ADA Diet

2009-06-01T09:46:00.003-04:00

Recent research from the American Journal of Clinical Nutrition supplies more evidence that a low-fat vegan diet is better than a conventional diabetes diet for managing blood glucose and cholesterol.¹

People with type 2 diabetes were assigned to either a low-fat, vegan diet (49 participants) or a diet adhering to the 2003 American Diabetes Association (ADA) guidelines (50 participants).

After about a year and a half (74 weeks), members in both groups lost weight, but the difference between them wasn't significant: 4.4 kg (9.7 lbs) wt. loss in the vegan group, 3.0 kg (6.6 lbs) weight loss in the ADA group.

However, there was a significant difference between the groups in the following measures:

Hb A1c:
-0.40 for the vegan diet
-0.01 for the ADA diet
Total cholesterol (mg/dL):
-20.4 for the vegan diet
-6.8 for the ADA diet
LDL cholesterol (mg/dL):
-13.5 for the vegan diet
-3.4 for the ADA diet

The authors concluded:

"Both diets were associated with sustained reductions in weight and plasma lipid concentrations. In an analysis controlling for medication changes, a low-fat vegan diet appeared to improve glycemia and plasma lipids more than did conventional diabetes diet recommendations."

________
¹ A Low-Fat Vegan Diet And A Conventional Diabetes Diet In The Treatment Of Type 2 Diabetes: A Randomized, Controlled, 74-Wk Clinical Trial, AJCN, May 2009

Photo of vegan pyramid: Nutrispeak.com, the home page of Vesanto Melina, MS RD.

Vitamins C and E Reduce Gains In Insulin Sensitivity From Exercise

2009-05-14T19:35:00.006-04:00

Researchers in Germany reporting in an online edition of the Proceedings of the National Academy of Sciences (PNAS) this week found that antioxidant supplements prevented some blood glucose benefits of exercise.¹

As the article states, and as we've posted previously:

"Physical exercise has been shown to be effective in preventing type 2 diabetes in high risk individuals and may be even more effective than the most widely used anti-diabetic drug, metformin."

How does the presence of antioxidants curtail this?

During exercise our muscles produce free radicals, or reactive oxygen species (ROS). These free radicals can be beneficial - they act as signals to produce more mitochondria (energy-producing factories inside cells), and to produce more endogenous (made by our body) antioxidants. Supplemented antioxidants, such as vitamins C and E, can prevent this signaling:

"Taken together, physical exercise induces numerous molecular regulators of insulin sensitivity and antioxidant defense, most of which are almost completely inhibited by antioxidant pretreatment in healthy young men."

In this study, 40 healthy men underwent physical training, 5 days a week for 4 weeks. Half of the men received 1000 mg vitamin C and 400 IU vitamin E daily along with the taining. Researchers found:

"Exercise increased parameters of insulin sensitivity only in the absence of antioxidants in both previously untrained and pretrained individuals."

Another recent study produced similar findings. In the January 2008 issue of the American Journal of Clinical Nutrition, healthy men were given 1000 mg of vitamin C or placebo, then exercised for 8 weeks. Men who took vitamin C experienced reduced endurance, reduced mitochondria production, and reduced levels of endogenous antioxidants, compared to those who didn't supplement.²
________¹ Antioxidants Prevent Health-Promoting Effects Of Physical Exercise In Humans, PNAS, May 2009.
² Oral Administration Of Vitamin C Decreases Muscle Mitochondrial Biogenesis And Hampers Training-Induced Adaptations In Endurance Performance, AJCN, January 2008.

Even Later In Life, Most Cases Of Diabetes Linked To Lifestyle

2009-04-29T09:00:00.003-04:00

A recent study in the Archives of Internal Medicine investigated the effect of combined lifestyle factors on the development of type 2 diabetes in older adults.¹

Researchers analyzed data from participants of the Cardiovascular Health Study:

4883 men and women 65 years or older
Followed for a 10-year period (1989-1998)

Five lifestyle factors were studied:

Physical activity level.
Dietary score. A low-risk score reflected:
- Higher fiber intake
- Higher polyunsaturated-to-saturated fat ratio
- Lower trans-fat intake
- Lower glycemic index
Smoking. Never smoked or former smoker greater than 20 years reflected low-risk.
Alcohol use. Light or moderate intake reflected low-risk.
Body fat. Low-risk reflected:
- BMI less than 25 (Calculate your BMI here.)
- Waist circumference 88 cm or less for women (34.6 in), 92 cm for men (36.2 in)

The study found:

"The rate of incident diabetes was 35% lower for each 1 additional lifestyle factor in the low-risk group.

Participants whose physical activity level and dietary, smoking, and alcohol habits were all in the low-risk group had an 82% lower incidence of diabetes.

When absence of adiposity (either body mass index < 25 or waist circumference ≤ 88/92 cm for women/men) was added to the other 4 low-risk lifestyle factors, incidence of diabetes was 89% lower.

Overall, 9 of 10 new cases of diabetes appeared to be attributable to these 5 lifestyle factors."

The authors concluded:

"Even later in life, combined lifestyle factors are associated with a markedly lower incidence of new-onset diabetes mellitus."

________
¹ Lifestyle Risk Factors And New-Onset Diabetes Mellitus In Older Adults, Archives of Internal Medicine, April 27, 2009

Swine Flu: CDC Recommends People With Diabetes Take Antivirals While Traveling

2009-04-28T11:44:00.004-04:00

The Centers for Disease Control and Prevention (CDC) recommends that people with diabetes who travel, even within the US, should take the antiviral medications Tamiflu or Relenza:

"Antiviral Medications: Persons traveling within the US that are at high risk of severe illness from influenza (for example persons with chronic conditions such as diabetes, lung disease, heart disease, and the elderly) are recommended to take antiviral medications for prevention of swine influenza during travel. The recommended antiviral drugs for swine influenza are oseltamivir (brand name Tamiflu®) and zanamivir (brand name Relenza®). Both are prescription drugs that fight against swine flu by keeping flu viruses from reproducing in your body. These drugs can prevent infection if taken as a preventative. Talk to your doctor about correct indications for using influenza antiviral medications. Always seek medical care if you are severely ill."

More information can be found at the CDC's site:
Outbreak Notice: Swine Influenza in the United States
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Insulin Action Times

2009-04-28T11:04:00.003-04:00

Joslin Diabetes Center posted a great, easy-to-read table on the different insulins (rapid-, short-, intermediate-, long-acting), and the time periods in which they work (onset, peak, duration):

Click table to enlarge.________

Topical Corticosteroids And Blood Glucose

2009-04-02T12:09:00.003-04:00

Many drugs can affect blood glucose. Even preparations applied topically can be absorbed and cause systemic reactions.

Medscape reviewed an article that appeared in the January 15 issue of American Family Physician (AFP):

Use of Topical Corticosteroids for Dermatologic Conditions Reviewed, Medscape, January 21, 2009

The authors of the AFP review had this to say about topical absorption (via Medscape's Laurie Barclay MD):

"Topically applied high- and ultra-high potency corticosteroids can be absorbed well enough to cause systemic side effects," the review authors write. "Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension, and other systemic side effects have been reported. It is difficult to quantify the incidence of side effects caused by topical corticosteroids as a whole, given their differences in potency."

If you've been on a topical steroid regimen and you've been experiencing unexpected blood glucose readings, you may want to consult with your prescribing physician.

Even over-the-counter, low-potency ointments that contain hydrocortisone, when used regularly and for longer than several months, may induce a blood glucose effect.

Dr. Barclay's advice for physicians:

"To avoid adverse effects, continuous use of low-potency to high-potency topical steroids should not exceed 3 months."

________

American Diabetes Association Alert Day Video

2009-03-25T18:38:00.006-04:00

The American Diabetes Association and Liberty Medical teamed up to produce this short 2-minute video that explains the symptoms and risk factors for type 2 diabetes:

See the American Diabetes Association's 21st Annual Alert Day for more.
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Bittman's "Vegan Until Six" Plan Results In Weight Loss, Lower Blood Sugar, Lower Cholesterol

2009-03-23T09:19:00.005-04:00

Laurel Miller, via Salon.com, reviewed Mark Bittman's new cookbook, "Food Matters: A Guide to Conscious Eating With More Than 75 Recipes." (Bittman writes a food column for the New York Times and blogs for the NYTs at Bitten.)

How To Live What Michael Pollan Preaches, Salon.com, January 2009

Here are some excerpts from her article:

"[Bittman's book is] an unusual blend of manifesto, self-help manual and cookbook designed to convince people that they can drastically improve their diets with relatively little discomfort."

Bittman's formula: "Eat less of certain foods, specifically animal products, refined carbs, and junk food; and more of others, specifically plants, in close to their natural state."

"At 57, [Bittman had] gained 50 pounds over his college weight and had developed high cholesterol, high blood sugar (especially scary for someone with a family history of diabetes) and sleep apnea, a condition caused by his excess weight."

Bittman's specific tactics ...

"With a colleague, Kerri Conan, Bittman devised a plan they called "vegan until six." They ate almost no animal products at all until dinnertime, no simple carbohydrates and no junk food. (Simple carbs are sugars, white flours and other processed grains like white rice.) At dinner, they ate as they had before, although in time Bittman found that even his evening meals came to include more "vegetables, fruits, legumes and whole grains and less meat, sugar, junk food, and overrefined carbohydrates."

"It was easy, and in a matter of months he'd lost 35 pounds, lowered his cholesterol and blood sugar, and had no trouble sleeping through the night. Most important, he continues to eat this way and is content to do so for the rest of his life."

________

30-Second Sprints Several Times A Week Could Prevent Diabetes

2009-03-02T10:26:00.004-05:00

If you're having difficulty keeping your resolution to exercise 30 minutes a day, 5-days-a-week, then you're going to like this study.

Researches put young men through some very brief, but strenuous, workouts and found their sensitivity to insulin (and so their blood sugar levels) improved:

Extremely Short Duration High Intensity Interval Training Substantially Improves Insulin Action In Young Healthy Males, BMC Endocrine Disorders, January 2009

A total of 16 men, average age 21, underwent 6 sessions of exercise over 14 days.

A session of exercise consisted of:

30 seconds of cycling as fast as possible
4 minutes of rest
The above repeated 4 to 6 times

An exercise session lasted 17 to 26 minutes, but only 2 to 3 minutes of that was actual exercise.

Compared to before training (baseline):

Postprandial glucose levels declined 12% (measured by AUC: Area Under the Curve)
Postprandial insulin levels declined 37% (AUC)
Postprandial free fatty acid levels declined 26% (AUC)
Insulin sensitivity improved 23% (measured by Cederholm index)
Aerobic cycling performance improved 6%

The authors concluded:

"The efficacy of a high intensity exercise protocol, involving only ~250 kcal of work each week, to substantially improve insulin action in young sedentary subjects is remarkable. This novel time-efficient training paradigm can be used as a strategy to reduce metabolic risk factors in young and middle aged sedentary populations who otherwise would not adhere to time consuming traditional aerobic exercise regimes."

________

Government Twitter Accounts

2009-02-12T14:16:00.001-05:00

I suppose it's not fair to post just one government Twitter account (CDC on Twitter) when there are literally hundreds. The number has grown exponentially in the last few months.

Here's a directory of government agencies using Twitter:

GovTwit Directory

It includes Twitter accounts for each branch - Executive, Legislative Judicial - as well as state and local government, international sites, industry, academia, and news media.
________

CDC On Twitter

2009-02-12T13:58:00.002-05:00

Speaking of the CDC, they're now using the social networking service Twitter. You can follow their tweets (short 140-character posts) at: CDC_eHealth.
________

New CDC Website For Diabetes Statistics

2009-02-12T13:40:00.002-05:00

The CDC (Centers for Disease Control and Prevention) recently posted a "New and Improved" website for diabetes' statistics:

CDC - Diabetes Data and Trends

New features include:

Separate gateways for national and state surveillance data
Maps, easy-to-read graphs, and data tables illustrating state surveillance data
Ability to view state-specific trends by age or sex
Quicker access to data tables

________

Resistant Starch Increases Levels of Anti-Diabetes and Anti-Obesity Hormones

2009-02-01T15:12:00.002-05:00

Researchers reporting in the November, 2008 issue of the American Journal of Physiology, Endocrinology and Metabolism, found improvements in blood glucose levels in mice fed resistant starch.¹

Resistant starch (RS) is simply starch that resists digestion and travels to the colon where it undergoes fermentation by resident bacteria.

It is the fermentation of that starch that is thought to offer benefit.

During fermentation, colonic bacteria produce short chain fatty acids (SCFAs). These SCFAs were found to stimulate secretion of two gut hormones: Glucagon-like peptide-1 (GLP-1) and peptide YY (PYY).

These hormones can slow gastric emptying and encourage insulin secretion - keeping blood glucose levels in check. They are also know to reduce appetite.

Specifically, the authors found that:

RS stimulates GLP-1 and PYY secretion in a substantial day-long manner, independent of meal effect or changes in dietary glycemia.
Fermentation and the liberation of SCFAs in the lower gut are associated with increased proglucagon and PYY gene expression.
Glucose tolerance, an indicator of increased active forms of GLP-1 and PYY, was improved in RS-fed diabetic mice.

Food Sources For Resistant Starch

The HealthyEatingClub.com lists these foods as containing resistant starch:

Intact wholegrain cereals/seeds/nuts, e.g. oats, rye, wheat, barley, semolina, corn, linseed, sesame
Processed starchy foods, e.g. some breakfast cereals (cornflakes), white bread, rice, pasta
Processed starchy foods with added RS called Hi-Maize (derived from corn)
Legumes, e.g. lentils, beans (Legumes have the highest content of RS.)
Unripe fruit, especially banana
Cooked cold rice, cold pasta salad, cold boiled potato salad (Cooking and cooling food can increase RS content.)

________¹ Dietary Resistant Starch Upregulates Total GLP-1 And PYY In A Sustained Day-Long Manner Through Fermentation In Rodents

Good Dental Hygiene May Lower Medical Costs For People With Diabetes

2009-01-28T11:07:00.002-05:00

A recent report from the University of Michigan found that people with diabetes who get regular dental cleanings can lower their medical bills. ¹

How? According to George Taylor, the lead researcher in the study:

"In periodontal disease, the body reacts to the bacteria causing the gum infection by producing proteins or chemicals called inflammatory mediators. Ulcers and open sores in the gums become passageways for these proteins and for the bacteria themselves to enter the body's blood circulation. These inflammatory mediators, as well as some parts of the bacteria, prevent the body from effectively removing glucose, or sugar, from the blood."

Higher blood sugars lead to more diabetic complications, which lead to higher medical bills.

Dental cleanings can remove the lodged bacteria before they have a chance to cause gum infection or subsequent systemic problems.

Patients in the study who received 1 or 2 periodontal treatments a year could lower their monthly medical costs by an average of 11% - that's $55 off a $500 bill.
________¹ Treating Gum Disease Linked To Lower Medical Costs For Patients With Diabetes

Low-Glycemic-Index Diet Vs. High-Cereal-Fiber Diet

2009-01-14T15:04:00.003-05:00

Which of these two diets - a low-glycemic-index (LGI) diet or a high-cereal-fiber (HCF) diet - do you think would produce the better blood sugar control?

Researchers from Toronto set out to answer that question. Their results were published in the December 17 issue of the Journal of the American Medical Association:

Effect of a Low-Glycemic Index or a High-Cereal Fiber Diet on Type 2 Diabetes

I'll give you the answer up front: The low-glycemic-index diet was better, but only moderately.

The 210 participants with type 2 diabetes followed their respective diets for 6 months, at the end of which:

For those who followed the LGI diet:

HbA1c went down by 0.50 (from 7.14 to 6.64)
HDL went up by 1.7 mg/dl

For those who followed the HCF diet:

HbA1c went down by 0.18 (from 7.07 to 6.89)
HDL went down by 0.2 mg/dl (HDL is the good cholesterol, you want this to go up)

How Did The Diets Differ?

Low-Glycemic-Index Diet

"The following foods were emphasized: low-glycemic index breads (including pumpernickel, rye pita, and quinoa and flaxseed) and breakfast cereals (including Red River Cereal [hot cereal made of bulgur and flax], large flake oatmeal, oat bran, and Bran Buds [ready-to-eat cereal made of wheat bran and psyllium fiber]), pasta, parboiled rice, beans, peas, lentils, and nuts."

Fruit in the LGI diet leaned toward temperate: apples, pears, oranges, peaches, cherries, and berries.

High-Cereal-Fiber Diet

"Participants were advised to take the "brown" option (whole grain breads; whole grain breakfast cereals; brown rice; potatoes with skins; and whole wheat bread, crackers, and breakfast cereals)."

Fruit in the HCF diet leaned toward tropical: bananas, mangos, guavas, grapes, raisins, watermelon, and cantaloupe

Both Diets

Everyone was advised "to avoid foods such as pancakes, muffins, donuts, white buns, bagels, rolls, cookies, cakes, popcorn, French fries, and chips."
________

Butter Worse For Arteries Than Olive Oil

2009-01-01T09:25:00.003-05:00

Meals high in saturated fat (SAFA), as opposed to monounsaturated fat (MUFA), may impair artery function. That was the finding of a small study published in the December issue of Diabetes Care:

Differential Effects Of Two Different Isoenergetic Meals One Rich In Saturated And One Rich In Monounsaturated Fat On Endothelial Function In Subjects With Type 2 Diabetes Mellitus, Diabetes Care, December 2008

After 33 participants with type 2 diabetes consumed either a meal high in saturated fat (butter), or high in monounsaturated fat (olive oil), (meals had the same number of calories) their artery function was assessed.

Flow-mediated dilation (FMD):

Declined by 16.7% after the saturated-fat-rich meal
Increased by 5.2% after the monounsaturated-fat-rich meal

FMD measures the relaxation of an artery due to increased blood flow. FMD is a marker for heart disease risk. As FMD decreases, blood flow is impaired.

The authors concluded:

"Consumption of an SAFA-rich meal is harmful for the endothelium, while a MUFA-rich meal does not impair endothelial function in subjects with type 2 diabetes."

________

Bioaccumulation of PCB's

2008-12-23T11:20:00.004-05:00

In my last post, I wrote about a study that found a link between development of type 2 diabetes and exposure to PCBs earlier in life.

It's not the only study to document such a link. I summarized two of Dr. Duk-Hee Lee's studies here, both of which described an association between persistent organic pollutants (POPS, a collective term that includes dioxins and PCBs) and diabetes.

The risk for exposure to PCBs doesn't have to occur through an accident. We take in small amounts of PCBs regularly through our diet, especially when we eat animal foods. Quoting Dr. Lee:

"Greater than 90% of POPs comes from animal foods."

Why are animal foods more likely to harbor PCBs? The Wisconsin Department of Natural Resources explains:¹

"PCB molecules attached to sediment particles eventually sink to the river bottom, where they are eaten by tiny organisms. Small fish eat these organisms and retain the PCBs they carry in their body fat, and so on up the food chain to larger fish, birds of prey, and people. This process is called bioaccumulation or biomagnification."

PCBs and other POPs are dissolved and stored in an animal's fat tissue. When we consume animal foods, we may be consuming dissolved dioxins along with them.
________
¹ What Are PCBs?, Wisconsin Department of Natural Resources

PCB Exposure May Increase Risk For Diabetes

2008-12-10T16:01:00.004-05:00

In light of the recent contamination of pork in Ireland (On Saturday, Ireland recalled all pork products because they were contaminated with high levels of PCBs. PCBs are polychlorinated biphenyls, highly toxic petroleum products. Yesterday, the Irish government reported that cattle were also testing positive for dioxins), I bring the unfortunate news that exposure to PBCs can increase the risk for diabetes.

In 1978-1979, people in central Taiwan were poisoned by PCB-contaminated rice bran oil that they used for cooking. Between 1993 and 2003, researchers in Taiwan investigated the incidence of type 2 diabetes in these Yucheng ("oil disease") victims.

When compared to non-poisoned controls, women who were exposed to the dioxin-laced oil were twice as likely to have developed diabetes in the ensuing 24 years.

For women whose PCB exposure was greatest (as evidenced by the presence of chloracne - an acne-like skin disorder caused by exposure to toxic chlorinated chemicals), diabetes risk was five and a half times that of matched controls (hypertension risk was 3.5 times that of matched controls).

Men exposed to dioxin also experienced an increased risk for diabetes but it was not significant. The researchers speculated that "women tend to have a greater fat percentage than men, which might result in a longer half-life of these lipophilic compounds."

One of the study's authors, Dr. Yueliang Leon Guo, commented to Reuters Health on the implications of their findings:

"Guo said that since "everyone" has detectable PCB levels in his or her body, it's possible that exposure to such pollutants has helped feed the widespread rise in diabetes in recent decades."

The authors advised:

"When planning treatments against diabetes, the body burden of PCBs and dioxins should be carefully considered, especially for women."

The study appeared in the August, 2008 issue of Diabetes Care:
Increased Risk of Diabetes and Polychlorinated Biphenyls and Dioxins
________

Screening During Hospital Admission An Opportunity To Identify Unrecognized Diabetes

2008-12-08T14:43:00.004-05:00

Dr. Deborah Wexler and her colleagues at Massachusetts General Hospital in Boston screened 695 adult patients admitted during 11 days in 2006.

How many of those had an HbA1c greater than 6.1% (indicating probable diabetes) but had no diagnosis?

"Nearly one in five adult patients admitted to a large general hospital had unrecognized probable diabetes, based on elevated HbA1c levels."

That rate, the authors said, was "roughly 5-fold higher than in the general outpatient population."

Also, random blood sugar tests performed during the patients' hospital stay were found to be poorly predictive of diabetes. In this case, sampling blood glucose with a meter was not as effective as assessing blood glucose over the prior few months, which an HbA1c test can measure.

Unfortunately, only 15% of those with elevated HbA1c were diagnosed within a year, pointing to a area where more attentive follow-up could prevent diabetes-related complications.

Dr. Wexler's research was published in the November issue of the Journal of Clinical Endocrinology & Metabolism:
Prevalence Of Elevated Hemoglobin A1c Among Patients Admitted To The Hospital Without A Diagnosis Of Diabetes
________

Daily Egg Consumption Increases Risk For Diabetes

2008-11-20T15:44:00.003-05:00

A new study in Diabetes Care found that eating eggs may raise the risk for developing type 2 diabetes:¹

"These data suggest that high levels of egg consumption (daily) are associated with an increased risk of type 2 diabetes in men and women."

The data came from two large cohorts, the Physicians' Health Study I (1982–2007) that included 20,703 men, and the Women's Health Study (1992–2007) that included 36,295 women.

Men experienced an increased risk for diabetes of:

18% for 2-4 eggs/week
46% for 5-6 eggs/week
58% for 7 or more eggs/week

Women experienced an increased risk for diabetes of:

19% for 2-4 eggs/week
18% for 5-6 eggs/week
77% for 7 or more eggs/week

An earlier study from May of this year that used the same Physicians' Health Study I cohort found that men who ate more eggs had a higher risk of dying during a 20-year follow-up than men who ate fewer eggs. For men who also had diabetes, the increased risk rose from 25% to 200%.
________
¹Egg Consumption and Risk of Type 2 Diabetes in Men and Women, Diabetes Care, published online ahead of print November 18, 2008.

Cost of Diabetes Drugs Double In 6 Years

2008-11-12T15:52:00.004-05:00

This isn't going to surprise anyone: Diabetes is getting more costly to treat, both for individuals, and for the nation as a whole.

A study last month in the Archives of Internal Medicine reported that drug costs for type 2 diabetes just about doubled in the six short years between 2001 and 2007 (from $6.7 billion in 2001 to $12.5 billion in 2007).¹

The costs are increasing because more people are being diagnosed with diabetes, and because the cocktail of drugs patients are being prescribed is getting more complex. In 1994, 82% of patients were being treated with just one diabetes drug. In 2007, only 47% received one diabetes drug.

The cost of the drugs is rising too. The average price of a diabetes-related prescription rose from $56 in 2001 to $76 in 2007. Keep in mind, that's $76 per prescription and by 2007 more people were being written more than one prescription. (Those are averages. Many drugs are more costly, e.g. a one-month supply of Januvia is going for $181 at Drugstore.com.)

This study just looked at drug costs. According to Merck spokeswoman Amy Rose, drug costs represent less than one-fifth of the total public health costs of diabetes. The bulk of costs, more than 80%, were due to hospitalizations and outpatient care - areas of treatment that are also experiencing price increases.

There's an alternative, but according to Dr. Stuart Weiss, an endocrinologist at New York University Medical Center, it's not being embraced:²

"Diet and exercise is the best thing we can do for our diabetic patients, but they are not very comfortable accepting diet and exercise as the treatment for diabetes."

"There is no medication that can't be overwhelmed by a bad diet."

The findings in this report beg the question:²

"Are these changes going to lead to overall significant improvement in the outcomes that matter to patients and their doctors?"
- G. Caleb Alexander MD, lead author and associate professor of medicine at the University of Chicago

The jury is still out on that.
________
¹ National Trends in Treatment of Type 2 Diabetes Mellitus, 1994-2007, Archives of Internal Medicine

² Cost of Diabetes Care Has Doubled, Washington Post, October, 2008

Incidence of Diabetes Doubles in Just 10 Years

2008-11-04T17:23:00.002-05:00

Last week, the Centers for Disease Control and Prevention (CDC) said:¹

"The rate of new cases of diagnosed diabetes rose by more than 90 percent among adults over the last 10 years."

Specifically:

"The incidence (new cases) of diagnosed diabetes has increased from 4.8 per 1,000 people during 1995-1997 to 9.1 per 1,000 in 2005-2007 in 33 states."

Below shows states with the highest number of new cases (in dark blue):²

Click for larger.

Minnesota had the lowest number of new cases (5 per 1000).
West Virginia (12.7 per 1000) and Puerto Rico (12.8 per 1000) had the highest.
Other states with high rates included the mostly Southern states of Alabama, Florida, Georgia, Kentucky, Louisiana, South Carolina, Tennessee, Texas, and Arizona.

This is the first report to describe geographic patterns in diabetes incidence.

These figures are only new cases (incidence rate). They don't represent how many people are thought to have diabetes at any one time (prevalence rate). According to the NIDDK, about 8% of the US population were thought to have diabetes in 2007 (prevalence). About a quarter of that 8% were undiagnosed. Since the present study only asked about diagnosed diabetes, it likely is underreporting the problem.
________
¹ CDC Press Release: New Cases Of Diagnosed Diabetes On The Rise, State-Specific Data Provide Glimpse Into Geographical Differences
² CDC Full Report: State-Specific Incidence of Diabetes Among Adults --- Participating States, 1995--1997 and 2005--2007

Vegan Diet Scores Better than American Diabetes Association Diet, Again

2008-10-14T16:14:00.003-04:00

The first time was in 2006:

A Low-Fat Vegan Diet Improves Glycemic Control and Cardiovascular Risk Factors in a Randomized Clinical Trial in Individuals With Type 2 Diabetes, Diabetes Care, 2006

Our post from February, Vegan Diet Outshines ADA Diet, outlines some findings of this study and gives a short description of a vegan diet.

The new analysis appears in the October 2008 issue of the Journal of the American Dietetic Association:

Changes in Nutrient Intake and Dietary Quality among Participants with Type 2 Diabetes Following a Low-Fat Vegan Diet or a Conventional Diabetes Diet for 22 Weeks

The 22-week study randomly assigned 99 people with type 2 diabetes to either a low-fat vegan diet or a diet based on the American Diabetes Association (ADA) recommendations.

Their findings:

"Vegan diets increase intakes of carbohydrate, fiber, and several micronutrients, in contrast with the ADA recommended diet. The vegan group improved its AHEI score whereas the ADA recommended diet group's AHEI score remained unchanged."

The AHEI score, or Alternate Healthy Eating Index score, reflects diet quality - a higher score is associated with lower risk for cardiovascular disease.

Some nutrients the vegan group consumed more of:

Beta carotene
Vitamins K
Vitamin C
Folate
Magnesium
Potassium

The vegan group also lost more weight, had lower HbA1Cs, and lower LDL cholesterol. Over half those in the vegan group reduced or eliminated medications compared to about a quarter of those in the ADA group.
________

World Diabetes Day: November 14

2008-10-12T15:21:00.004-04:00

Do you Google? Would you like to see a Google Doodle on November 14 for World Diabetes Day?

If so, add your name to the petition:
Ask Google for a World Diabetes Day Doodle

TuDiabetes.com and DiabetesDaily.com, the sponsors of the petition, feel that 20,000 signatures by the end of October might be enough to get Google's attention.

Here are some examples of past Google Doodles.

For more information:
Grassroots Effort Underway To Get A World Diabetes Day Google Doodle
________

Whole Diet, Rather Than Individual Foods, May Be Better Predictor Of Diabetes

2008-10-08T17:42:00.003-04:00

Often, studies investigate the effect of a particular food or food group, for example whole grains or processed meat, with its impact on developing diabetes. A study appearing in the September issue of Diabetes Care instead investigated the effect of multiple food groups.¹

It found:

"Multiple food groups collectively influence type 2 diabetes risk beyond that of the individual food groups themselves."

The food group that was associated with a decreased risk for diabetes (15% lower risk) included (not surprisingly) whole grains, vegetables (especially leafy greens), fruit, nuts and seeds, low-fat dairy foods, and coffee.

The food group that was associated with an increased risk for diabetes (18% greater risk) included red meat, processed meat, high-fat dairy foods, refined grains, and soda.

Interestingly, tomatoes and beans were part of the group that increased diabetes risk. The authors speculated that consumption of these foods may reflect a less-than-nutritious diet, since they're often found in highly-processed, high-fat convenience foods such as pizza and tacos.

In this study, no individual food group was associated with diabetes risk.

Participants were 5,011 White, Black, Hispanic, and Chinese-American men and women who took part in the Multi-Ethnic Study of Atherosclerosis (MESA).
________
¹ Dietary Patterns and Risk of Incident Type 2 Diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA)

Pain Relieving Drug Found To Protect Against Retinopathy In Diabetic Mice

2008-09-29T14:10:00.004-04:00

The top two causes of vision loss in this country are diabetic retinopathy and glaucoma.

Researchers from the Medical College of Georgia (MCG) School of Medicine recently published results of a study in mice that show the pain-relieving drug pentazocin may be able to prevent the retinal damage associated with these conditions ... preserving vision.¹

The study appears in this month's issue of Investigative Ophthalmology & Visual Science.²

Diabetic mice received injections of pentazocine (a morphine-like narcotic) for 22 weeks. The photo shows strikingly preserved retinas in mice that received the drug compared to mice that did not. (Click photo for larger version.)

The drug had no effect on insulin levels. Dr. Sylvia Smith, the study's lead author and co-director of the Vision Discover Institute at MCG:

"It does not solve that problem of diabetes; however our findings do suggest that just because you are hyperglycemic does not mean you will have diabetic retinopathy."

________
¹ Receptor Activation Protects Retina From Diabetes Destruction
² In Vivo Protection Against Retinal Neurodegeneration By Sigma Receptor 1 Ligand (+)-Pentazocin

Lifestyle Changes Or Drugs?

2008-09-24T15:34:00.003-04:00

You've been told by your doctor that your blood sugars are high, not high enough to be diagnosed with diabetes but they're going in that direction.

What should be your primary course of action? Lifestyle changes or drugs?

The conclusion from what HeartWire called "a lively debate" at this month's annual meeting of the European Association for the Study of Diabetes is ... lifestyle changes. ¹

Defense for lifestyle changes:

Drugs may have no proven benefits as preventative medications.
Drugs can have undesirable side-effects.
Lifestyle changes, even if stopped, have long-lasting effects.
Lifestyle changes are more cost-effective.
Lifestyle changes get at the root of type 2 diabetes. ("Not only are they effective at reducing diabetes risk, but they also have "halo effects," including anthropometric, physiological, metabolic, psychological, behavioral, and quality-of-life benefits," claimed Dr. Nick Wareham.)
Drugs may discourage people from making lifestyle changes.

Defense for early drug intervention:

Effective lifestyle changes are difficult to enact and challenging to upkeep. ("Environmental, cultural, economic, and sociopolitical forces work against lifestyle changes in developed countries," claimed Dr. Paul Zimmet.)
Lifestyle changes alone may not be effective for high-risk individuals.
There is a lack of evidence from long-term studies on the benefits of specific lifestyle interventions.

________
¹ Lifestyle, Not Drugs, For Preventing Type 2 Diabetes: "Gladiatorial" Debate Concludes, HeartWire, September 11, 2008

Chamomile Tea May Lower Blood Glucose and Reduce Damage to Eyes, Nerves, and Kidneys

2008-09-18T11:41:00.003-04:00

It's not a panacea. Diet and exercise play a larger role in mitigating complications of diabetes. But if you enjoy tea, or are open to having a cup with meals, choosing one with chamomile may help you manage your diabetes.

A study from the September 10 issue of the American Chemical Society's Journal of Agricultural and Food Chemistry reported:¹

"These results clearly suggested that daily consumption of chamomile tea with meals could contribute to the prevention of the progress of hyperglycemia and diabetic complications."

The researchers, from Japan and the United Kingdom, fed a chamomile hot water extract to diabetic mice for 21 days, after which the chamomile-fed rats' blood glucose was found to be 26% lower than that of control diabetic mice. (I can't tell if they measured a fasting glucose. It looks like they did, since they refer to glucose in the blood being derived from liver glycogen. In fact, one of their suggested mechanisms for blood glucose reduction was inhibition of hepatic glycogen breakdown. Indeed, chamomile-fed rats had consistently higher levels of liver glycogen, as did those who received quercetin, one of chamomile's major flavonoid components.)

The enzyme aldose reductase (ALR2) was also found to be inhibited by the chamomile extract. ALR2 converts glucose to sorbitol. In people with diabetes, sorbitol accumulates in greater amounts in cells and has been implicated in the development of cataracts, retinopathy, nerve damage, and kidney damage.

A few related points the study made:

"Chamomile is one of the richest sources of dietary antioxidants. [These compounds] are soluble in hot water, and the amounts obtained from frequent consumption of tea are not negligible."

"There is substantial evidence that these compounds have suppressive activity on oxidative damage to skins, membranes, proteins, and DNA by inhibiting free radical scavenging activity and contribute to protection against chronic health disorders such as atherosclerosis and hypertension."

"A recent study demonstrated that chamomile plant extract suppresses the growth of human cancer cells."

I just added chamomile tea to my shopping list.

________
¹ Protective Effects of Dietary Chamomile Tea on Diabetic Complications (HTML - abstract) (PDF - full article)

Hospital Compare Website - US Health And Human Services

2008-09-01T15:21:00.009-04:00

The US Centers for Medicare and Medicaid Services (CMS) debuted their Hospital Compare website in 2005. It allows patients, healthcare providers, insurers, and others to compare the quality of care provided by selected hospitals. It includes information on:

Process of care
Outcome of care, including mortality scores
Patient experiences and satisfaction

The site was recently updated with specific death rates (including a new rate for pneumonia deaths), process of care measures for children's asthma, and maps.

Hospitals can be selected for comparison based on specific conditions, or location.

CMS is still working out the kinks - which measures to include, how to rate a measure - but you can't beat the increased transparency. Patients armed with this kind of information may motivate hospitals be more accountable.

Give it a try!

________

Byetta Under More Scrutiny After Deaths

2008-09-01T13:58:00.005-04:00

The injectable diabetes drug exenatide (marketed as Byetta, by Amylin Pharmaceuticals and Eli Lilly) was launched in 2005.

In 2007, the FDA issued an alert warning of a possible association between Byetta and acute pancreatitis, after 30 reports of the condition surfaced. Pursuant to that warning:

"FDA has asked and the maker of Byetta, Amylin Pharmaceuticals, Inc. has agreed to include information about acute pancreatitis in the PRECAUTIONS section of the product label." ¹

That was in October of last year. This August, the FDA said they received 6 more reports of "hemorrhagic or necrotizing pancreatitis in patients taking Byetta." Two of those patients died. (The Wall Street Journal is reporting that Amylin and Eli Lilly told the FDA of 4 additional deaths.)

Pursuant to those reports:

"FDA is working with the maker of Byetta, Amylin Pharmaceuticals, Inc., to add stronger and more prominent warnings in the product label about the risk of acute hemorrhagic or necrotizing pancreatitis." ¹

The FDA is strongly advising that patients stop taking Byetta immediately if they develop signs or symptoms of acute pancreatitis.

The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) lists the following symptoms for acute pancreatitis:

Symptoms can arise suddenly
Pain in the upper abdomen, may be severe or begin as mild discomfort that worsens after eating
Pain may radiate to the back and other areas
Abdomen may swell and become tender
Pain may be associated with nausea and vomiting
Fever
Rapid pulse
Breathing problems

________
¹ FDA: Information for Healthcare Professionals, Exenatide (marketed as Byetta)

Fructose Stimulates Fat Production

2008-08-06T09:30:00.006-04:00

Fructose is a type of sugar found naturally in fruits, and unnaturally in processed foods to which sweeteners such as high fructose corn syrup have been added.

A very small study out of Texas, published in The Journal of Nutrition in June, found that intake of fructose can stimulate lipogenesis (fat production) more than intake of glucose. ¹

Four men and two women were given a beverage containing 85g of either: 100% glucose, 50% each glucose and fructose, or 25% and 75% each glucose and fructose as a morning meal. Blood was analyzed immediately after consumption, and after a standard lunch 4 hours later.

"When fructose was consumed, absolute lipogenesis was 2-fold greater than when it was absent."

That triglyceride production was enhanced both after the morning beverage was consumed and again after lunch, revealing a carry-over effect.

The 85g morning beverage contained one of the following:

85g glucose and 0g fructose
42.5g glucose and 42.5g fructose
21g glucose and 64g fructose

For comparison (quantities are approximate): ²

1 medium peach contains 3g glucose and 2g fructose
1/2 cup blueberries contains 4g glucose and 4g fructose
1 tablespoon pure corn syrup (100% glucose) contains 0g fructose
1 tablespoon high fructose corn syrup (45% glucose and 55% fructose) contains about 6g sugar, 2.7g glucose and 3.3g fructose
1 teaspoon sugar (sucrose, 50% glucose and 50% fructose) contains about 4g sugar, 2.0g glucose and 2.0g fructose ³
1 medium (21 ounce) cola beverage that contains about 58g of sugar, if it was sweetened with high fructose corn syrup, might contain about 26g glucose and 32g fructose.
1 medium (21 ounce) cola beverage that contains about 58g of sugar, if it was sweetened with sugar, might contain about 29g glucose and 29g fructose.

It is likely not the fructose in fruit, nor even in sugar or high fructose corn syrup alone, that may be problematic. It is the sheer quantity of these isolated sweeteners added to foods that's the issue.

________
¹ Dietary Sugars Stimulate Fatty Acid Synthesis In Adults, Journal of Nutrition, 2008

² NutritionData.com is a great site for looking up nutrients in foods. It's the site I used for these figures.

³ The fructose bound in the disaccharide sucrose may not be as readily available for absorption as free fructose in high fructose corn syrup.

Two active discussions about this study:
Does Fructose Make You Fatter? (New York Times, Well Blog)
What's Making Us Fat? Maybe It's All That High-Fructose Corn Syrup (Los Angeles Times)

DIRECT Study Compares Weight-loss Effects Of Three Diets

2008-07-28T14:11:00.003-04:00

Researchers reporting in the July 17 issue of the New England Journal of Medicine published results of their two-year investigation into three popular diets: A low-carbohydrate diet (based on Atkins guidelines), a Mediterranean diet, and a low-fat diet (based on American Heart Association guidelines).

The full study can be found at:

Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet

Weight Loss

For weight loss, the low-carbohydrate and Mediterranean diets performed best, and were just about tied at 2 years:

Low-carbohydrate Diet: 4.7 kg (approximately 10 pounds)
Mediterranean Diet: 4.4 kg (approximately 10 pounds)
American Heart Association (AHA) Diet: 2.9 kg (approximately 6 pounds)

Women did better on the Mediterranean diet, while men did better on the low-carbohydrate diet.

Diabetes

There was an unexpected finding that applied specifically to participants with diabetes. Fasting blood glucose of people with diabetes who followed the Mediterranean dropped an average of 32.8 mg/dl; while the fasting glucose of diabetics in the other groups increased by 1.2 mg/dl in the low-carb group and 12.1 mg/dl in the AHA group.

People with diabetes who followed the Mediterranean diet also had the lowest fasting insulin and lowest insulin resistance (HOMA-IR).

Differences Between Diets

All participants reduced their intake from baseline and were eating about the same amount of calories, 1500/day for women and 1800/day for men, regardless of group assignment. Physical activity also increased from baseline but was not different between groups.

The low-fat AHA diet derived about 30% of its calories from fat and 50% from carbohydrate. "The participants were counseled to consume low-fat grains, vegetables, fruits, and legumes and to limit their consumption of additional fats, sweets, and high-fat snacks."

The Mediterranean diet derived about 33% of its calories from fat and 50% from carbohydrate. This group had the highest ratio of monounsaturated-to-saturated fat, probably owing to olive oil and nut consumption: "the main sources of added fat were 30 to 45 g of olive oil and a handful of nuts (five to seven nuts, <20 g) per day." It was a diet "rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb." Members also consumed the greatest amount of dietary fiber.

The low-carbohydrate diet derived about 39% of its calories from fat and 40% from carbohydrate. Members consumed the least amount of carbohydrates (consuming about 120 g/day after the first 2 months and throughout) and the most amount of fat, protein, and cholesterol. It diverged from Atkins' protocol by advising vegetarian sources of fat and protein. This was the only diet that was unrestricted in calories. However, participants averaged about the same amount of calories as the other groups. Notably, even though limits were not placed on how much members of this group could eat, the low-carb group had the highest drop-out rate.

Conclusion

"Mediterranean and low-carbohydrate diets may be effective alternatives to low-fat diets. The more favorable effects on lipids (with the low-carbohydrate diet) and on glycemic control (with the Mediterranean diet) suggest that personal preferences and metabolic considerations might inform individualized tailoring of dietary interventions."

________

Knols On Diabetes

2008-07-28T10:39:00.003-04:00

Google last week debuted a new project called Knol, a term Google defines as "unit of knowledge". It is a collection of web pages, or articles, on specific topics. There are just a few hundred Knols so far, but they include a couple on diabetes that are worth a visit:

Type 1 Diabetes

Type 2 Diabetes

Anyone may write a Knol. These particular two were written by Anne Peters MD, FACP, CDE, a diabetologist and director of the USC Clinical Diabetes Programs in Los Angeles, CA.

Anyone may rate, comment on, or suggest edits to Knols, too. So, stop by. Maybe there's something you'd like to contribute.
________

Exercise Restores Insulin Sensitivity

2008-07-23T12:02:00.006-04:00

In the following study:

Reversal Of Diet-Induced Insulin Resistance With A Single Bout Of Exercise In The Rat: The Role Of PTP1B And IRS-1 Serine Phosphorylation, The Journal of Physiology, 2006

Researchers fed mice either a control diet or a high-fat diet for three months. The high-fat diet produced obese mice with greater insulin resistance.

Researchers then submitted some of the high-fat-fed, insulin-resistant, obese mice to a bout of exercise. The exercise increased insulin sensitivity in the obese mice, such that:

"The decrease in the glucose disappearance rate induced by the high-fat diet, returned to the basal levels 16 hours after acute exercise."

It did not return to basal levels in mice that did not exercise.

The authors hypothesized that the mechanism for this improved glucose uptake may be linked to the action of certain proteins known to regulate glucose metabolism in muscle cells.
________
Another group of researchers hypothesized that the mechanism for improved glucose uptake after exercise may be related instead to activity of mitochondria in muscle.

In their study:

Setting The Stage: Possible Mechanisms By Which Acute Contraction Restores Insulin Sensitivity In Muscle, American Journal of Physiology - Regulatory, Integrative, and Comparative Physiology, 2008

When obese rats were exposed to bouts of exercise:

"Our group found that acute muscle contraction synergistically improved insulin-stimulated glucose transport in skeletal muscle. ... The improved insulin sensitivity was associated with a robust increase in mitochondrial energy flux."

How exercise works to improve insulin sensitivity may be under consideration, but that it works has been shown consistently.
________

Renal Threshold For Glucose

2008-07-13T14:38:00.004-04:00

You've just been to the doctor. He found sugar in your urine. But your blood sugars are usually in the 90s fasting, and around 140 mg/dl after meals, at least when you check. And isn't the renal threshold, or the level of blood glucose above which kidneys fail to reabsorb, and thus spill glucose into urine, often stated as 180 mg/dl?

Might your sugars be going higher without you knowing it?

In addition to home testing, a simple A1C test might indicate that fact. ¹

However, there's the possibility you could be spilling glucose at levels below 180 mg/dl. A fair amount of normal variability exists in the renal threshold - both among individuals and within an individual - which makes urine testing not a very dependable tool for detecting a high blood glucose.

Here are a few references I found to that effect:

Tests Of Glycemia In Diabetes, Diabetes Care, 2004

"Reasons why the use of urine glucose testing to estimate blood glucose concentrations in diabetes management is undesirable include the following:
Although the renal threshold for glucose in healthy adults corresponds to a plasma glucose concentration of ~180 mg/dl (10 mmol/l), there is wide individual variation. Of particular importance are findings that adults, especially those with long-standing diabetes, may have substantial increases in this threshold, resulting in underestimation of the blood glucose level. Conversely, children and, particularly, pregnant women may have very low or variable renal thresholds, resulting in overestimation of the blood glucose level.
Fluid intake and urine concentration affect urine test results.
The urine glucose value reflects an average level of blood glucose during the interval since the last voiding and not the level at the time of the test.
A negative urine glucose test does not distinguish between hypoglycemia, euglycemia, and mild or moderate hyperglycemia. Thus, urine glucose testing is of limited value in preventing hypoglycemia and hyperglycemia.
Urine glucose testing, which uses a color chart with which the test strip color is compared, is less accurate than capillary blood glucose monitoring, which typically uses a digital readout from a reflectance meter.
Some drugs interfere with urine glucose determinations.
Evaluation of urine dipsticks reveals high imprecision at low glucose concentrations. Manufacturers claim that the test strips are positive if urinary glucose concentrations are 100 mg/dl or greater, but the data indicate this does not always occur."

Here's an older study that found pretty wide margins, +/- 150 mg/dl, in estimates of blood glucose from urine glucose...

Validity Of Urine Glucose Measurements For Estimating Plasma Glucose Concentration, Diabetes Care, 1983

"Although our observations show a significant correlation (P less than 0.0001) between plasma glucose concentration and urine glucose concentration or urine glucose excretion rate, the wide confidence limits [95% confidence limits (minimum) +/- 150 mg/dl] on plasma glucose concentration estimated from urine glucose measurements limit the clinical applicability of such estimates."

And one that found a mean of 130 mg/dl, much lower than 180 mg/dl, although it was a special population...

The Influence Of Renal Threshold On The Interpretation Of Urine Tests For Glucose In Diabetic Patients, Diabetes Care, 1980

"In a group of 65 insulin-dependent diabetic patients there was a wide variation in renal threshold, with a mean of 130 mg/dl (range 54-180 mg/dl). Threshold tended to rise with age, and it is suggested that the higher the renal threshold, the higher is the mean blood glucose achieved by the patient."

And a even older study, but telling ...

Renal Threshold For Glucose: Normal And In Diabetics, British Medical Journal, 1940

"The study of the renal threshold in diabetics and normals with healthy renal function shows frequent upward and downward deviations from the accepted "normal" figure of some 170 mg. per 100 c.cm.

The conception of a "normal" threshold is false. There is an average renal threshold, just as there is an average blood pressure, and the many deviations from it should be looked upon as physiological -- a matter of individual idiosyncrasy, and of no pathological significance."

________
¹ HbA1C or just A1C is an abbreviation for glycosylated hemoglobin, blood levels of which can identify average glucose levels for an individual over approximately 120 days, the life span of a red blood cell.

Statins For Children?

2008-07-12T14:44:00.005-04:00

If the child has diabetes, is 8 years of age or older, with an LDL ≥ 130 mg/dl, yes, statins and other cholesterol-lowering drugs should be considered.

Those are the recommendations of the nutrition committee of the American Academy of Pediatrics. The new guidelines were made public last week in the Academy's journal Pediatrics:

Lipid Screening and Cardiovascular Health in Childhood, July, 2008

The guidelines advise screening children, via a fasting lipid profile, "after 2 years of age but no later than 10 years of age" if they present with the following risk factors:

Positive family history of dyslipidemia or CVD
Patients for whom family history is not known
Overweight or obesity
Hypertension
Cigarette smoking
Diabetes mellitus

What is an acceptable LDL cholesterol level?

"Targets as low as 130 mg/dL or even 110 mg/dL may be warranted when there is a strong family history of CVD, especially with other risk factors including obesity, diabetes mellitus, the metabolic syndrome, and other higher-risk situations."

The prospect of an indefinite period of pharmacological intervention, beginning in childhood, may make lifestyle changes such as diet and exercise* that much more inviting.

* The guidelines recommend adherence to the USDA's Dietary Guidelines for Americans, which list recommended servings for grains, fruits, vegetables, and milk/dairy, as well as fat and calorie limits, according to age and gender. The USDA Guidelines also recommend that "children and adolescents engage in at least 60 minutes of physical activity on most, preferably all, days of the week."
________
If you click on the little astronaut up there, it will take you to an interactive computer game the USDA designed for children as an introduction to the food pyramid. They can "reach Planet Power by fueling their rocket with food and physical activity."

Lifesaving Lessons

2008-07-10T09:59:00.004-04:00

He was 58. He had diabetes and coronary artery disease (CAD). But his CAD was under control with medications and he had no symptoms. He exercised and performed well on stress tests.

Yet on a Friday afternoon, while preparing for his Sunday broadcast of Meet The Press, Tim Russert's heart stopped beating. All efforts to resuscitate him failed. Less than an hour after he collapsed, on June 13, 2008, Tim Russert was pronounced dead. The cause? A blood clot resulting from a ruptured cholesterol plaque.

What could have been done to save him?

According to Russert's doctor, Michael Newman:

"He had done everything he was supposed to do to manage the disease [CAD], although his weight was a problem." ... He "struggled with it."

Dr. Newman added that the incident made us "appreciate the uncertainty of our lives."

Perhaps, as Dr. Newman said, attacks such as Mr. Russert's can't be anticipated. But once they present themselves, how a heart attack victim acts, or how those around him act, could save a life. Dr. Newman claims that a defibrillator could make a difference.

However, being sensitive to how you feel, and responding to it, can also make a difference.

The following story appeared in Tuesday's New York Times:

Not a Moment Too Soon, I Thought of Tim Russert

Its author, Michael Bicks, related a profile eerily similar to Mr. Russert's:

"Though I am a 50-year-old guy with a stressful job and a little too much around the middle, I had a clean bill of health. I had good cholesterol numbers and a great doctor, and recently I had passed a cardiac stress test."

During an early morning bike ride, Mr. Bicks began to feel nauseous and developed a cough. He had only mild chest discomfort, but expressed "an overwhelming feeling that something was not right." He stopped riding, took a rest, and decided to check himself into the hospital.

"A doctor attached some wires to my body and conducted a quick EKG. “Mr. Bicks,” he said minutes later, “you are suffering a heart attack.” "

Mr. Bicks may not have been able to anticipate his heart attack, but paying attention to the signals his body was giving, and acting on them, saved his life.
________

Antioxidants Improve Memory

2008-06-28T15:18:00.003-04:00

While I'm on the topic of diets, and what makes a healthful one, I saw this study in the July issue of Nutrition Research:

Antioxidant Vitamins Reduce Acute Meal-Induced Memory Deficits In Adults With Type 2 Diabetes

Some background:

"Memory impairment is observed in adults with type 2 diabetes mellitus, with further acute deficits after meal ingestion."

Those memory problems after eating are thought to arise from damage to brain tissue wrought by free radicals that are produced during metabolism of food components.

The researchers were investigating whether consumption of antioxidant vitamins along with a meal could lessen memory problems, possibly by quenching those free radicals. They fed a group of 16 adults with type 2 diabetes one of the following (in a crossover design):

High-fat meal
High-fat meal with vitamin C (1000 mg) and vitamin E (800 IU)
Water

Indeed, they found they could lessen memory problems:

"Relative to water consumption, the high-fat meal resulted in poorer performance at 105 minutes postingestion on measures of delayed verbal recall (word list and paragraph recall) and working memory (Digit-Span Forward). Coconsumption of antioxidant vitamins and high-fat meal prevented this meal-induced deficit such that performance on these tasks was indistinguishable from that after water intake."

ScienceDaily has a nice summary, including this statement from the study's lead author Michael Herman Chui:

"Our bottom line is that consuming unhealthy meals for those with diabetes can temporarily further worsen already underlying memory problems associated with the disease. We've shown that antioxidant vitamins can minimize oxidative stress from the meal and reduce those immediate memory deficits."

It remains to be seen whether antioxidant vitamins were working by reducing damage from free radicals, or by another method.

The senior author of the study, Dr. Carol Greenwood added:

"While our study looked at the pill form of antioxidants, we would ultimately want individuals to consume healthier foods high in antioxidants, like fruits and vegetables."

________

Blood Glucose-To-A1C Conversion Tool by ACCU-CHEK

2008-06-27T08:25:00.005-04:00

I like this tool so much I'm going to post it again:

By the way, it works backwards too. You can either enter your blood glucose (and it will calculate your A1C), or you can enter your A1C (and it will calculate your blood glucose).

These are only estimates!
________

What Makes A Healthful Diet? Large Epidemiological Studies Are Finding Out

2008-06-26T15:06:00.006-04:00

A study due in the upcoming July 15 issue of the American Heart Association journal Circulation will be reporting that: ¹

"Greater adherence to the prudent pattern [of eating] may reduce the risk of cardiovascular and total mortality, whereas greater adherence to the Western pattern may increase the risk among initially healthy women."

What did the researchers define as a "prudent pattern"?

"High prudent pattern scores represented high intakes of vegetables, fruit, legumes, fish, poultry, and whole grains, whereas high Western pattern scores reflected high intakes of red meat, processed meat, refined grains, French fries, and sweets/desserts."

It was a large prospective evaluation of the diets of 72,113 women who participated in the Nurses Health Study. They were followed for 18 years.

The prudent diet reduced risk of cardiovascular death by 28% when compared to the Western diet. It reduced risk of all-cause death by 17%.

The Western diet increased risk of cardiovascular death by 22%, cancer death by 16%, and all-cause death by 21%.

These findings are similar to those reported earlier this year in the same journal.² In that study, the diets of 9,514 participants of the ARIC cohort (Atherosclerosis Risk in Communities study) were evaluated over the course of 9 years. Those men or women who ate a Western pattern - high in meat and fried foods - had a higher risk of developing metabolic syndrome. Metabolic syndrome is a constellation of risk factors for heart disease. These include insulin resistance, diabetes, hypertension, high blood lipids, high uric acid levels, and obesity - especially weight carried around the waist.

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¹ Dietary Patterns And Risk Of Mortality From Cardiovascular Disease, Cancer, And All Causes In A Prospective Cohort Of Women, Circulation, 2008

² Dietary Intake And The Development Of The Metabolic Syndrome. The Atherosclerosis Risk In Communities Study, Circulation, 2008

Napping

2008-06-24T09:03:00.003-04:00

In line with yesterday's post about the heart benefits of napping, here's an excellent graphic from the Boston Globe about technique:

How To Nap

Click for larger. Better yet, visit the whole article.

To nap or not to nap:

"Napping reduces stress and lowers the risk of heart attack and stroke, diabetes, and excessive weight gain."

When to nap:

"If you're a lark ... you're going to feel your nap need around 1 or 1:30 p.m. If you're an owl ... closer to 2:30 or 3."

How long to nap:

20 minutes or less "enhances alertness and concentration, elevates mood, and sharpens motor skills."
Between 45 and 90 minutes and you may wake up with "grogginess and disorientation that can last for a half hour or more."
90 minutes or more "helps to clear your mind, improve memory recall, and recoup lost sleep."

The article includes many more tips, including this heartening finding:

"Last year, a British study suggested that just knowing a nap was coming was enough to lower blood pressure."

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Napping Helps The Heart

2008-06-23T12:13:00.004-04:00

Researchers reporting in the February 12, 2007 issue of Archives of Internal Medicine analyzed data from 23,681 participants of the Greek EPIC Study (European Prospective Investigation into Cancer and Nutrition Cohort):

Siesta in Healthy Adults and Coronary Mortality in the General Population

... and found that:

"Siesta [midday napping] in apparently healthy individuals is inversely associated with coronary mortality, and the association was particularly evident among working men."

This finding was independent of other lifestyle factors that contribute to heart health, including education, diet, exercise, BMI, waist-to-hip ratio, and smoking.

No matter how often or how long the nappers napped, they experienced benefit. Although those who made it part of their routine benefited more.

Data reported about napping placed a participant in one of two groups:

Occasional Napper (less than 3 times/week, or less than 30 minutes)
Systematic Napper (at least 3 times/week, and at least 30 minutes)

When data for men and women were combined:

Those who occasionally napped had a 12% lower rate of coronary death.
Those who systematically napped had a 37% lower rate of coronary death.

However, when data for men were analyzed separately:

Those who occasionally napped had a 42% lower rate of coronary death.
Those who systematically napped had a 50% lower rate of coronary death.

And when data for men who were still working (not retired) were analyzed separately:

Those who occasionally napped had a 64% lower rate of coronary death.
Those who systematically napped had a 64% lower rate of coronary death.

For working men, just some quick shut-eye on the weekends offered benefit similar to regular napping.
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Gout Hurts

2008-06-19T17:45:00.002-04:00

And by the looks of it, more people are hurting - currently over 5,000,000 in the US with prevalence on the rise, as is prevalence of a similar condition called pseudogout. There are double the number of (known) cases today compared to just 20 years ago.

To answer the question from my previous post, gout is now the most common inflammatory arthritis in men in the US. (Gout strikes men about three times more often than women.)

Background

Area Affected:

Gout often affects peripheral joints - toes, ankles, fingers, wrists.
Pseudogout often affects central joints - hips, shoulders.

Type of crystals:

Gout is inflammation caused by monosodium urate monohydrate (MSU) crystals.
Pseudogout is inflammation caused by calcium pyrophosphate (CPP) crystals.

These crystals collect inside joints, leading to inflammation, pain, and eventually loss of function.

On The Rise

Baby boomers are maturing. But that's not the only reason there are more cases. It's hitting the middle-aged and younger, mirroring the increasing prevalence and younger age-at-diagnosis of diabetes. In fact, having diabetes raises the risk of developing gout, as do high blood pressure and high levels of fat and cholesterol in the blood.

MedlinePlus, a service of the National Institutes of Health, provides excellent and current information related to gout on their site. It includes a basic description and symptoms, how gout is diagnosed and treated, photographs, clinical trials, and findings of recent research.
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Most Common Inflammatory Arthritis In Men

2008-06-18T15:52:00.002-04:00

That's the question. What is the most common inflammatory arthritis in men (in Western countries)?

Guess.
No Googling.
I'll be back.

Answer: See here.
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Are Studies Measuring What Matters To Patients?

2008-06-04T16:01:00.002-04:00

There are hundreds of studies being conducted right now investigating the effects of diabetes drugs.

Are these studies investigating whether these drugs will help us live longer? Feel better? Reduce the pain and loss of function associated with diabetes complications?

A study in the current issue of JAMA reviewed outcomes in 436 ongoing trials. It says most of them aren't measuring what matters to patients: ¹

"In this sample of registered ongoing RCTs in diabetes, only 18% included patient-important outcomes as primary outcomes."

Less than 1 in 5 trials are measuring the kind of physiological outcomes that are important to patients and the doctors who treat them. What are they measuring instead? Laboratory values such as HbA1c, insulin, and cholesterol levels - values that don't necessarily predict risk for, say, a heart attack. Why? Because it saves money:

"One potential reason for the apparent increase in trials measuring surrogate end points is the preference of researchers and funding agencies to obtain results faster, with fewer patients and at lower costs."

Below is a 2-minute clip featuring Victor Montori MD from the Mayo Clinic, lead author of the study, discussing the implications of trials which don't ask questions that matter to patients, leaving doctors and patients to imagine what the effect of a treatment will be:

"And imagining what the effect of treatment will be on those outcomes, they will make mistakes," says Montori.

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¹ Patient-Important Outcomes In Registered Diabetes Trials, JAMA, June 4, 2008.

ADA 68th Scientific Sessions

2008-06-02T16:32:00.005-04:00

The American Diabetes Association's 68th Scientific Sessions are coming up. They begin this Friday, June 6th and run until Tuesday, June 10th. San Francisco hosts the conference this year.

Some background:

"The Scientific Sessions are held in June each year and provide an opportunity for members of the diabetes community from around the world to participate in the largest annual research and clinical meeting on diabetes. Sessions focus on the latest information in the areas of basic and clinical research and on the application of this information to clinical practice. The program includes symposia, oral and poster abstract presentations, interactive workshops, poster discussions, and other small group learning sessions."
- American Diabetes Association

The ADA has a glossy e-newspaper for the conference called Diabetes Dispatch. You can access it at:
68th Scientific Sessions Diabetes Dispatch

Below are the ADA's official bloggers for the Sessions:

Anita Manning, a retired senior medical writer for USA Today, at the American Diabetes NOW blog.

Tesch West, the 2007-2008 ADA National Youth Advocate, at her Tesch West Blog.
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Diabetics Experience Improved Blood Flow From 3 Cups Of Cocoa A Day

2008-05-31T16:05:00.006-04:00

A study in this month's Journal of the American College of Cardiology found that 3 cups a day, for 30 days, of flavanol-rich cocoa improved blood flow through the brachial artery (the main blood vessel of the upper arm) by 30%.

All 41 participants in the randomized, double-blind study had diabetes and took medications. Three times daily, participants blended an 18-gram cocoa mix into 250 ml of water (8 oz). The mix contained either 25 mg (control) or 321 mg (intervention) total flavanols.

It's important to note that the high-flavanol cocoa used in the study was not the same as cocoa you can buy in grocery stores. It was a product called CocoaPro, developed in a proprietary process by Mars, Inc., to retain flavanol content. Mars lent funding to this study.

Flavanols In Foods

Flavanols are a class of flavonoids present in a variety of foods. Besides cocoa and chocolate, which are especially good sources, carob, tea, pinto beans (and other beans), wine, grapes, apples, apricots, bananas, blueberries, cranberries, and other berries contain flavanols (flavanols are not the same as flavonols). The USDA maintains a database of flavanols, and other flavonoids, in foods. You can access it at:

USDA Database for the Flavonoid Content of Selected Foods, Release 2.1 (2007)

Below are some specific foods along with their flavanol content.² (Catechin and epicatechin are both flavanols.) Values are given in milligrams of flavanols per 100 grams of food - that would be about 1/4 pound of grapes, apples, etc.

Click for larger.

Note that none of these foods (per 100 gram serving) contain the amount of flavanols used in one cup of cocoa from the study (321 mg). In fact, they come closer to the amount found in the control. Unless you're consuming Mars' patented CocoaPro - 3 times daily - you likely won't consume enough flavanols regularly to achieve the results seen in this study.

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¹ Sustained Benefits in Vascular Function Through Flavanol-Containing Cocoa in Medicated Diabetic Patients, Journal of the American College of Cardiology, 2008

² Cocoa Flavanols And Cardiovascular Health, 2004

Eggs: To Eat Or Not To Eat

2008-05-30T16:34:00.003-04:00

A study in the April edition of The American Journal of Clinical Nutrition (AJCN) found:

"Egg consumption was positively related to mortality, more strongly so in diabetic subjects."

Men in the study who reported eating 7 or more eggs per week had an almost 25% increased risk of death during the 20-year follow-up compared to men who ate 1 or fewer eggs per week.

For those with diabetes the risk rose to 200%. That is, diabetic men who consumed the most eggs had double the risk of dying compared to those who ate the fewest.

The men in the study were 21,327 Harvard-educated participants of the Physicians Health Study I.
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¹ Egg Consumption In Relation To Cardiovascular Disease And Mortality: The Physicians' Health Study, AJCN, April, 2008

For a commentary of this study in the same AJCN issue:
Egg Consumption In Relation To Cardiovascular Disease And Mortality: The Story Gets More Complex, AJCN, April, 2008

Oprah Goes Vegan For 21 days

2008-05-29T13:12:00.006-04:00

And she's blogging about it:
Oprah's 21-Day Cleanse

A vegan diet excludes meat, fish, eggs, and dairy food. For her cleanse, Oprah is also shunning caffeine, sugar, alcohol, and products made with gluten. I believe she's also cutting the fat.

Why go vegan? In an earlier post (Vegan Diet Outshines ADA Diet), I wrote about a study which found:

" ... that people with diabetes who followed a low-fat, vegan diet saw improvements in HbA1c, body weight, BMI, waist circumference, total cholesterol, and LDL cholesterol that were significantly greater than improvements in a group following an ADA diet (which adhered to American Diabetes Association guidelines)."

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Cow's Milk Responsible For Destruction of Beta Cells in Type 1 Diabetes?

2008-05-28T09:17:00.004-04:00

One of my earlier posts (Think Twice Before Feeding Your Child Cow's Milk) discussed the possibility that early ingestion of cow's milk can increase the risk for type 1 diabetes.

Last month, an article in a journal of the American Chemical Society reviewed the literature for this association:

Relation of Time of Introduction of Cow Milk Protein to an Infant and Risk of Type-1 Diabetes Mellitus, Journal of Proteome Research, April, 2008

It's author, Marcia Goldfarb, described a set of conditions which could explain how pancreatic beta cells are destroyed - leading to type 1 diabetes - when cow's milk products are fed to infants:

"The newborn intestine does not have complete "closure" and can pass food antigens. Beta Lactoglobulin could generate antibody to glycodelin undermining T cell regulation of beta cells."

Mechanism

Beta-lactoglobulin is a protein present in cow's milk, but not human milk. "It has the largest concentration of any whey protein in bovine milk. (Goldfarb)" Glycodelin is a human protein that affects our immune system, regulating our T-cells.
The cow beta-lactoglobulin and the human glycodelin have similar structures, such that an infant's body may generate antibodies not just for the foreign beta-lactoglobulin, but also for the endogenous glycodelin.
Type 1 diabetes is thought to be caused by autoimmune destruction of pancreatic beta cells by T-cells. Destruction of glycodelin (by the antibodies generated to destroy the foreign cow's milk protein) may allow proliferation of these beta-cell-destroying T-cells.

In a small investigation, Goldfarb indeed found antibodies to beta-lactoglobulin in the serum of children with type 1 diabetes. Those she tested who did not have diabetes did not have these antibodies.
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Smoking Increases Risk For Diabetes

2008-05-27T10:01:00.002-04:00

My previous post discussed the link between smoking and death from heart and lung diseases (and showed benefit for quitting). Here's a study, actually a study of studies or a meta-analysis, from 5 months ago that reasserted the often observed link between smoking and type 2 diabetes:

Active Smoking and the Risk of Type 2 Diabetes, JAMA, December, 2007

Of the 25 studies included in this analysis, 24 reported a positive association between smoking and diabetes, specifically:

"The pooled adjusted RR was 1.44."

An RR (Relative Risk) of 1.44 means that there was a 44% increased risk for developing diabetes among active smokers vs. non-smokers. Among heavy smokers, the risk increased to 61%:

"The risk of diabetes was greater for heavy smokers (≥20 cigarettes/day; RR 1.61) than for lighter smokers (RR 1.29) and lower for former smokers (RR 1.23) compared with active smokers, consistent with a dose-response phenomenon."

The link was so consistent that the authors stated there was "no need for further cohort studies to test this hypothesis." They recommended instead "that future studies focus on plausible causal mechanisms or mediating factors such as obesity, lack of physical activity, dietary habits, and stress levels."

One mechanism they noted which has appeared in previous studies is smoking's link to insulin resistance or inadequate insulin secretion - a mechanism which should bear scrutiny in future investigations.
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It's Never Too Late To Stop Smoking

2008-05-27T07:12:00.002-04:00

A study in the May 7 issue of the Journal of the American Medical Association is reporting: ¹

"Approximately 64% of deaths among current smokers and 28% of deaths among former smokers were attributable to cigarette smoking."

But there's good news. Many of the risks involved with smoking are reversible:

Very soon for heart disease:

"Most of the excess risk of vascular mortality due to smoking in women may be eliminated rapidly upon cessation."

A little longer for lung diseases:

"Within 20 years for lung diseases."

Much of the reduction in risk for cardiovascular disease occurred within the first five years after quitting. However, to reduce your risk for lung cancer and COPD (Chronic Obstructive Pulmonary Disease), down to the risk for those who never smoked, you would need to have given up the habit for 30 years (lung cancer) and 20 years (COPD).

When researchers looked at the relationship between number of cigarettes smoked per day and increased risk of death, they found:

"The trend was less pronounced for deaths due to vascular disease, suggesting that the first few cigarettes account for most of the increased risk; in contrast, an increase in the number of cigarettes smoked per day substantially increased the risk of death from respiratory disease."

So even if you only smoke a few cigarettes a day, you may be increasing your risk for a heart attack.

The researchers also found that smoking was associated with an increased risk for death from colorectal cancer.

These findings are based on data from 104,519 women who took part in the Nurses' Health Study. For this analysis participants were followed for 22 years.
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¹ Smoking and Smoking Cessation in Relation to Mortality in Women, JAMA, May 2008