Diabetes Treatments

4. Silent heart disease common in people with diabetes By contrast, young age at diabetes onset was tied to a reduced risk of low protein urine …

Issue 44 Q4 2007 Table of Contents 1 2 3 4 5 6 7 8 9 10 Risk factors for diabetic kidney disease identified Depression linked to neglect of diabetes Control of diabetes may prevent infertility Silent heart disease common in people with diabetes US FDA Amylin drug suspected in pancreatitis cases Sugar level affects behavior of diabetic children Benefits of a Plant-Based Diet Insulin Pen with Memory Results of October Reader Poll Ask Dr Hirsch: Flonase and Blood Sugar

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Risk factors for diabetic kidney disease identified
By Anthony J Brown, MD NEW YORK Reuters Health - High blood pressure and high lipid levels, as well as longer disease duration, elevated glucose sugar levels, and male gender, are all significant risk factors for kidney disease in patients with type 1 diabetes, according to a report in the current issue of Diabetes Care Diabetes care must continue to focus on improvement of metabolic control, but also on monitoringlipids and blood pressure High blood pressure and high blood lipid levels should be treated as soon as they are diagnosed, lead
author Dr Klemens Raile, from Charite Childrens Hospital in Berlin, told Reuters Health Our study is in agreement with other studies that show lower levels of kidney disease in patients who have good control over their blood glucose levels The researchers analyzed data from 27,805 patients included in the nationwide, prospective German Diabetes Documentation System survey The average ages at diagnosis and at last visit were 10 and 16 years old, respectively, while the average follow-up time was 25 years Overall, 26,605 subjects had normal urine test results, 919 had low levels of protein in the urine, 78 had high levels of protein in the urine, and 203 had end-stage renal kidney disease ESRD, the report indicates With further analysis, they found that for patients who had diabetes for 40 years 254 percent had low levels of urine protein and 94 percent had ESRD Predictors of low urine protein levels included longer diabetes duration, elevated glucose, elevated LDL cholesterol — the bad cholesterol — and high blood pressure, the researchers found By contrast, young age at diabetes onset was tied to a reduced risk of low protein urine levels, which is consistent with findings from
earlier studies

Male gender was identified as risk factor for high protein levels in the urine, the report indicates We are very pleased that the rate of kidney disease and particularly ESRD is relatively low, Raile said However, it is alarming that high blood lipid levels and high blood pressure are often not treated adequately The team concludes that prompt diagnosis and treatment of abnormal lipid levels and high blood pressure is mandatory in patients with type 1 diabetes SOURCE: Diabetes Care, October 2007 2007 Reuters Health Click for restrictions

Depression linked to neglect of diabetes
By Michelle Rizzo NEW YORK Reuters Health - In patients with type 2 diabetes, the adult on-set variety, depressive symptoms — even if they do not meet criteria for major depressive disorder — is associated with poor adherence to self-care, according to results of a study published in Diabetes Care Dr Jeffrey S Gonzalez, of Massachusetts General Hospital, Boston, and colleagues compared the effects of depression on 879 diabetic patients from two primary care clinics The participants were surveyed using the Harvard Department of Psychiatry/National Depression Screening Day Scale HANDS, the
Summary of Diabetes Self-Care Activities, and self-reported medication adherence Overall, 193 percent of the patients met HANDS criteria for probable major depression HANDS score at least 9 and 665 percent reported at least some depressive symptoms without meeting the criteria for probable major depression Only 142 percent of the subjects reported no depressive symptoms Of those with probable major depression, 594 percent had depression listed in their medical records, and 488 percent had been prescribed an antidepressant agent A significant association was observed between major depression and poorer adherence to diet, exercise, and glucose self-monitoring regimens after controlling for other health risk factors Patients with major depression had a had 23-fold increased odds of missing medication doses in the previous week compared with the other subjects Among the 709 subjects who did not meet the criteria for major depression, increasing HANDS scores were incrementally associated with poorer adherence to self-care behaviors, the investigators found

The presence of symptoms of depression in type 2 diabetes may hinder a patient\s ability to adhere to their self-care
routine,Gonzalez said in an interview with Reuters Health Depressive symptoms such as diminished interest, fatigue, concentration difficulties, and feelings of hopelessness could each interfere with the hard work that\s involved in diabetes selfmanagement These patients might benefit from extra support or from a referral to psychological services, especially when their symptoms are impacting functioning or causing distress, Gonzalez added Since we know that depression in diabetes is associated with higher risks of complications, poorer diabetes control, and even increased mortality, it\s really crucial to evaluate patients and offer appropriate treatment when necessary More generally, Gonzalez concluded, Our findings suggest that decreased ability to adhere to one\s medical regimen may be an important explanatory pathway through which depression affects health outcomes Treating depression in the context of chronic illness may be an increasingly important role for mental health providers as rates of chronic illness continue to increase and evidence mounts for the harmful effects of depression in patients with chronic illness SOURCE: Diabetes Care, September 2007 2007 Reuters
Health Click for restrictions

Control of diabetes may prevent infertility
By Michelle Rizzo NEW YORK Reuters Health - A Swedish study indicates that the fertility of women with type 1 diabetes was reduced prior to 1985, but since then is its begun to normalize, if diabetic complications were avoided Stricter metabolic control exercised in the past 20 years may have helped prevent subfertility, the researchers speculate in the September issue of Diabetes Care Dr Junmei Miaof Jonasson and colleagues from the Karolinska Institute, Stockholm, identified all 5,978 women who had been hospitalized for type 1 diabetes when they were16 years of age or younger These subjects were followed until the end of 2004 through linkage to nationwide registers The investigators used a standardized fertility ratio, the ratio of observed to expected number of live births, to express the relative fertility rate They also compared the proportion of newborns with congenital malformations with that of the general population A total of 4013 live births were recorded among the diabetic women during follow-up The team reports that the standardized fertility ratio was smaller than expected 080 For women with
retinopathy, nephropathy, neuropathy, or cardiovascular complications, the respective fertility ratios were 063, 054, 050, and 034

Stratification by year of first hospitalization showed that the reduced fertility was confined to women hospitalized before 1985 However, those with diabetic complications also had lower fertility rates in all calendar years There was also a decrease in the proportion of infants with congenital malformations born to women with type 1 diabetes, from 117 percent during 1973-1984 to 69 percent during 19952004 However, the proportion of congenital malformations was consistently higher than that for the general population Our results suggest that the new strategy with more rigorous metabolic control instituted in the mid- or late-1980s has been successful also with regard to fertility, Jonasson said in an interview with Reuters Health However, the risk of congenital malformations in live newborns of mothers with type 1 diabetes is higher than that of mothers in the general Swedish population although a decreasing trend has been observed in the last 30 years, she noted Thus, Jonasson said, we tell women that when they plan to have a baby the metabolic
control must be normal or near-normal, before and after conception and in early pregnancy Because the study is based on the Swedish population, Jonasson cautioned The results might not be generalized to other populations due to the difference in the quality of health care and strategies used to control diabetes SOURCE: Diabetes Care, September 15, 2007 2007 Reuters Health Click for restrictions

Silent heart disease common in people with diabetes
NEW YORK Reuters Health - A sizable minority of diabetic patients who have an impaired pumping ability of their heart do not have any symptoms, new research suggests As lead investigator Dr Panithaya Chareonthaitawee, told Reuters Health, one in every six diabetic patients who were assessed with SPECT, a nuclear imaging test, showed a drop in left ventricular ejection fraction LVEF, which simply means the heart is pumping abnormally low amounts of blood with each beat National guidelines, Chareonthaitawee added, indicate that patients who have reduced LVEF but not symptoms can benefit from commonly used blood pressure drugs called ACE inhibitors and beta-blockers In addition, the guidelines recommend that patients stop smoking and lose
weight As reported in the American Heart Journal, Chareonthaitawee and colleagues at the Mayo Clinic in Rochester, Minnesota, examined records of 1,046 diabetic patients with no heart disease symptoms and found that 167 percent had reduced LVEFs Moreover, the presence of reduced LVEF was associated with a reduced survival rate at 10 years — 29 percent versus 57 percent in patients with a normal LVEF

Because heart failure can be treated and outcomes improved, there is a potential role for screening patients who are in the asymptomatic stages of reduced LVEF, continued Chareonthaitawee Still, he emphasized that these findings are preliminary and will need to be confirmed in larger studies SOURCE: American Heart Journal, September 2007 2007 Reuters Health Click for restrictions

US FDA Amylin drug suspected in pancreatitis cases
WASHINGTON Reuters - Amylin Pharmaceuticals Incs and Eli Lilly and Cos diabetes drug Byetta may be linked to cases of acute pancreatitis in some patients, US health officials said in an alert issued on Tuesday The US Food and Drug Administration said it has reviewed 30 reports of pancreatitis in patients taking Byetta, known generically as exenatide An
association between Byetta and acute pancreatitis is suspected in some of these cases, an FDA alert said Amylin has agreed to add information about acute pancreatitis to the precautions section of Byettas label, the FDA said Officials at Amylin were not immediately available for comment A Lilly spokeswoman had no immediate comment Byetta mimics the effect of incretin hormones that are produced in the gastrointestinal tract and boost the release of insulin triggered by glucose This incretin pathway appears to be weakened in type 2 diabetes In 2005, the US Food and Drug Administration approved exenatide as add-on treatment for type 2 diabetes The FDA said doctors should tell patients taking Byetta to seek prompt medical care if they develop unexplained, persistent severe abdominal pain, which may or may not be accompanied by vomiting Byetta should be discontinued should pancreatitis be suspected, the FDA said Should pancreatitis be confirmed, Byetta should not be restarted unless an alternative cause is identified, the agency advised 2007 Reuters Health Click for restrictions

Sugar level affects behavior of diabetic children
NEW YORK Reuters Health - In children with type 1
diabetes, high blood glucose sugar levels are associated with an increase in externalizing behaviors, such as aggression, delinquency, and hyperactivity, the results of a study published in a recent issue of Diabetes Care indicate

It has always been important to try and normalize blood glucose levels for long-term health, Dr Fergus J Cameron commented to Reuters Health In addition to this it now appears that it is also important to normalize blood glucose levels to optimize behavior Cameron, of the Royal Childrens Hospital, Melbourne, Australia, and colleagues note in their paper that parents of children with type 1 diabetes often report that they can detect elevations in their childs blood glucose due to changes in outward behavioral patterns These reports, however, are entirely anecdotal, and to date, there has been little direct inquiry in this phenomenon The researchers therefore investigated this issue in a study of 42 children ages 5 to 10 years who had type 1 diabetes for more than 2 years The average A1C at recruitment was 82 percent A1C is a commonly used measure of blood sugar that reflects the average levels in the past 2 to 3 months; a normal level is less than 70
Forty children were receiving insulin in a twice-daily mixing regime and two were receiving insulin in a three to four injection regime Each subject wore a continuous glucose monitor over a 72-hour period on two occasions 6 months apart Parents completed the Behavior Assessment System for Children at both time points The overall average blood glucose value was higher than normal, as was the average externalizing behavior score The overall average percentage of time spent in the high glycemic ranges was 424 percent A statistically significant association was observed between the average blood glucose and the average externalizing behavior score For every 5-percent increase in time in the normal glycemic range, there was a decrease in the externalizing behavior score of 10 and that for every 5-percent increase in time in the high glycemic range, there was an increase in the externalizing behavior score of 10, Camerons team reports Externalizing behaviors in children such as aggression, hyperactivity, disruptiveness, etc, can impact upon family quality of life and the classroom environment, Cameron commented to Reuters Health Thus, our research has implications both for parents and
teachers of primary school-aged children with diabetes SOURCE: Diabetes Care, September 2007 2007 Reuters Health Click for restrictions

Staying on Target Benefits of a Plant-Based Diet
Jeanne Cullen, MS, RD, CD, CDE You may have heard of the phrase eating green There has been a lot of positive inform ation about the benefits of a plant-based diet over the past several years A plant-based diet refers to eating foods that come from plants instead of from animals, most of the time There are varying degrees to doing this, from being a strict vegan someone who eats no animal products, no meats or fish, no dairy and no eggs or vegetarian someone who eats no meats or fish to just eating less meat and more plant based foods such as beans, grains, fruit and vegetables There is some compelling evidence that moving in this direction can be beneficial for the health of our bodies, as well as the planet A few research studies show that eating a plant-based diet may be beneficial for people with diabetes The benefits may include weight loss, better blood glucose control, improved cholesterol levels and kidney function, and reduction of high blood pressure People who do not yet have diabetes may
be able to delay or prevent it Improvement in any one of these areas can result in better health and reduction of risk factors for people with diabetes Have I caught your attention yet? If so, read on Studies Demonstrate Benefits of Plant-Based Diet A 2006 study looked at the benefits of eating a low-fat, vegan diet to treat diabetes and heart disease The participants ate either a vegan diet or a calorie-controlled diet from the American Diabetes Association ADA Both of the diets showed benefits for weight loss, cholesterol, and improved A1c the measure of average blood glucose over a three month period of time, but the vegan diet resulted in more improvement in most of these areas1 The vegan diet allowed no meat, poultry, fish, dairy or eggs It allowed a very small amount of saturated fat and cholesterol, with total fat amounting to less than 25 of calories There were no restrictions on calories, carbohydrates and portions 1 The ADA group followed a low saturated fat, calorie-controlled diet designed by a registered dietitian, which allowed a wider range of foods in controlled portions 2 Both groups reported similar calorie intake and pedometer readings However, the vegan group
lowered their A1c by 123 points compared with a 038 point A1c drop in the ADA group3 This indicates that the vegan group had a better overall improvement in blood glucose control During the trial, people in the vegan group reduced their diabetes medication by 43, compared to a 26 reduction in the ADA group 4 Among those who did not change their cholesterol medicines, total cholesterol fell 17 in the vegan group and 10 in the ADA group Although the vegan group had no calorie restriction, they lost 143 pounds on average, compared to a 68 pound average weight loss in the ADA group, which had a calorie restriction 5 Since both groups showed improvement, the results do not necessarily mean that you have to become a vegan to gain benefit, but increasing plant foods in ones diet appears to be helpful Lets examine which components of a plant-based diet appear to offer the most advantage

Dietary fiber has been shown to be a beneficial part of a plant based diet, even when the diet is high in carbohydrates 60 70 of calories from carbs 6 These diets were studied and showed improved blood glucose levels, a reduced need for diabetes medication and lowered cholesterol levels, as long as
high-fiber carbohydrates were chosen 7 Another benefit of dietary fiber is that it helps people feel full so they tend to eat less, which can lead to weight loss Most people have heard the public health message to eat 5 servings of fruits and vegetables a day Fruits and vegetables are some of the most nutrient packed foods, containing vitamins, minerals and antioxidants, while having relatively low calorie content Fruits and vegetables also contain fiber, which is thought to displace saturated fats in the diet Another benefit of increasing fruits and vegetables has been shown in the Dietary Approaches to Stop Hypertension DASH diet8 This diet showed that eating 6 to10 servings of fruit and vegetable a day along with less salt and more calcium can lower blood pressure as much as one blood pressure lowering medication can Health Benefits In fact, plant based diets have attracted the most attention because they reduce the risk of cardiovascular disease CVD Since people with diabetes have a 3-5 times greater risk of heart disease and high blood pressure, this is significant Large studies of vegetarians have shown that they have reduced risk of CVD 9 A number of health claims for
specific components of plant foods have been approved by the Food and Drug Administration, based on their ability to lower cholesterol and promote heart health These health claims have been made for soluble fiber, soy protein and plant stanols and sterols Soluble fiber is found in oats, flax and psyllium seeds and specific fruits and vegetables Plant stanols and sterols are found in a variety of plant foods In recent years, some margarine products have been manufactured using these plant stanols and sterols Benecol and Take Control are two products that contain these substances, and have a cholesterol lowering effect when used in the recommended amounts

Food Sources Beans are one of the cheapest and healthiest foods that we consume They are a good source of protein, complex carbohydrates and fiber while providing a rich source of folic acid, potassium, magnesium, iron and antioxidants They are known as a low glycemic food, meaning that they are digested more slowly, and therefore have less impact on blood glucose levels Did you know that the 2005 Dietary Guidelines for Americans recommend that we eat 3 cups of beans per week? Soybeans have higher protein content than other beans
The jury is still out on whether soy protein has a cholesterol lowering effect, as study results have been mixed The one thing we do know about soybean products is that when they are used as a replacement for meat in the diet, it decreases the amount of cholesterol and saturated fat that we consume It has also been shown that in people with type 1 diabetes, plant proteins such as soy protein cause less stress on kidney function compared to animal protein 10 Nuts are another food that we are approaching differently based on a number of large population studies, such as the Nurses Health Study This study showed that eating small quantities of nuts on regular basis reduced the risk of heart disease and diabetes 11 Nuts are a good source of fiber, protein and healthy fats They are great for snacks, if you can stick with a handful or two

And if that isnt enough to convince you, plant-based diets are also more beneficial for the environment The vast amounts of manure produced by factory farming of cattle, pigs and chickens creates enough methane and nitrous oxide to contribute to the problem of global warming 12 Small changes in your diet can contribute large positive changes in your
personal health and the health of our planet You dont have to become a strict vegan, but eating more plant-based meals, a couple of times a week, can have a significant impact Following a vegan diet may be beneficial, as some of the recent research has shown, but it is a bit more challenging to get all of your nutrient needs met You must take care to educate yourself, and get adequate protein, omega-3 fats and certain nutrients, such as iron, calcium, zinc, vitamin D and vitamin B12 This is even more important when it comes to children, especially very young children, below the age of 2, because they need more fat in their diet than a vegan diet normally provides Therefore a vegan diet is generally not recommended for this age group I recommend consulting a Registered Dietitian, who is knowledgeable in this type of diet, before starting a vegan meal plan

Jeanne Cullen, MS, RD, CD, CDE is a Certified Diabetes Educator and trained Chef from the Culinary Institute of America She received her Masters degree in nutrition from Bastyr University Jeanne resides in Seattle, Washington where she combines her love of cooking and whole foods philosophy to work with prevention and management
of chronic diseases She specializes in diabetes education because she knows good nutrition practices can have such a positive outcome Jeanne is employed at Tacoma General Hospital and the Bastyr Center for Natural Health
References: 1 Neal D Barnard at al, 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, Vol 29, No 8, August 2006 2 Ibid 3 Ibid 4 Ibid 5 Good Medicine, Physicians Committee for Responsible Medicine /Autumn/ 2006/ Vol XV, No 4 6 Jenkins, David, JA et al, Type 2 Diabetes and the Vegetarian diet, Am J Clin Nutr, 2003; 78 suppl;610S-6S 7 Ibid 8 Heno F Lopes, Kelley L Martin, Khaled Nashar, Jason D Morrow, Theodore L Goodfriend, and Brent M Egan DASH Diet Lowers Blood Pressure and Lipid-Induced Oxidative Stress in Obesity Hypertension 41: 422-430 9 Jenkins, David, JA et al, Type 2 Diabetes and the Vegetarian diet, Am J Clin Nutr, 2003; 78 suppl;610S-6S 10 Ibid 11 NHS News, Special Edition Newsletter, Nurses Health Study, Autumn 2002 Nutrition Action Health Letter, Eating Green The Case for a Plant-Based Diet Center for health in the Public Interest, Vol 33, No
7, Sept 2006

Insulin Pen with Memory
When was your last dose? And how much insulin did you use? Weve all been there you think you remember whether you took your insulin, or your dose amount, but youre not always certain Thats why the introduction of the new HumaPen MEMOIRTM insulin pen from Eli Lilly and Company is such welcome news for many people

HumaPen MEMOIR automatically records the dose and the time of the dose, then remembers and digitally displays your last 16 insulin doses, including the priming doses Even better, HumaPen MEMOIR is reusable and looks more likea writing pen than an insulin pen, which may allow for more discreet injections in public HumaPen MEMOIR is designed for use with Humalog rapid acting insulin BD pen needles fit the HumaPen MEMOIR In fact, BD pen needles fit all insulin pens and dosers sold in the United States You can learn more about this pen at the wwwHumalogcom website Remember: Attach a new needle before each injection and remove it immediately after the injection Never carry a pen with the needle attached, as this leaves an open passageway into the insulin cartridge If you would like more information about the HumaPen MEMOIR, contact your
doctor

Humalog and MEMOIR are trademarks of Eli Lilly and Company

Results of October Reader Poll
394 readers answered the October poll about future newsletter topics Which topic would you like to see discussed in future issues of BD of people who UPdate? chose this topic: Dealing with an A1c over 7 What to do when diabetic retinopathy symptoms begin Reducing the risk of hypoglycemia when using premixed insulin The connection between diabetes, heart disease and stroke 30 28 14 28

We will develop articles on all of these topics for upcoming newsletter issues, starting with how to deal with an A1c that is over 7 Thank you for telling us your preferences

Ask Dr Hirsch
Dear Dr Hirsch, Q I take metformin for my diabetes This morning I did a finger stick and was 144 After using my inhaler generic Flonase, I rechecked half an hour later just before eating breakfast and was 188 My blood sugar also seems to be higher since I started on generic Lopid Should I be concerned? A Flonase fluticasone for nasal allergies and many other inhalers for treating breathing problems, belong to a class of drugs called corticosteroids They can cause insulin resistance and make blood glucose levels rise
particularly at high doses Does this mean that Flonase caused your blood glucose level to rise this morning? Probably no The amount of corticosteroid in a dose of Flonase is small, and its bioavailability the amount that actually gets into the blood, in this case, through the nose is very low, about 2 Generally, it should not cause measurable increases in blood glucose, so there is little cause for concern It is common for blood glucose levels to rise on their own in the morning, even in those with wellcontrolled diabetes When the body produces its usual hormones late at night and early in the morning, the liver tends to release extra sugar into the bloodstream To test this, check your blood glucose levels at the same times you tested this morning, but take your inhaler right after the second reading If the level rose without the inhaler, its most likely your normal metabolism causing the rise A more complete way to evaluate this pattern called the dawn phenomenon is to test your blood glucose level just before going to sleep, again around 3 am, and then when you wake up in the morning Most people find that their blood glucose level increases in the early-morning hours, due to
the normal release of growth hormone and of other hormones late at night Regarding your recent higher readings, remember that type 2 diabetes is a progressive disease It is harder to control over time Triglyceride-lowering medicines such as Lopid or the generic gemfibrozil do not cause a rise in blood glucose If your weight has increased recently, or you have decreased the amount of exercise you do, you may be becoming more insulin resistant Another possibility is that the secretion of insulin by your pancreas may be declining, which results in higher blood glucose levels If your A1c level is not in the target range, which is generally less than 7, it would be a good idea to speak with your doctor about ways to intensify your diabetes treatment

Laurence J Hirsch, MD Worldwide Vice President of Medical Affairs, BD Diabetes Care

Dr Hirsch graduated from the University of Roshester and then attended Harvard Medical School He is board-certified in Internal Medicine and in EndocrinologyMetabolism Prior to joining BD, he was Assistant Professor of Medicine at Northwestern University, and spent more than 17 years in various roles in clinical drug development at
Merck

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