for Professionals in Diabetes Care. September 10, Genes Link Birth Weight, Diabetes In Adulthood Low Vitamin D Levels Increases Risk of Type 2 Diabetes …
The Newsletter for Professionals in Diabetes Care September 10, 2008 Issue 433
DIABETES IN CONTROLcom Newsletter
Top Current Diabetes News:
Obesity Not A Red Flag For Diagnosing Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6072 Genes Link Birth Weight, Diabetes In Adulthood http://wwwdiabetesincontrolcom/resultsphp?storyarticle6069 Low Vitamin D Levels Increases Risk of Type 2 Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6068 Telmisartan Fails as Substitute for ACE Inhibitors http://wwwdiabetesincontrolcom/resultsphp?storyarticle6065 Adiponectin A Marker for Type 2 Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6063 New Analysis Shows Lower Not Necessarily Better When It Comes to BP http://wwwdiabetesincontrolcom/resultsphp?storyarticle6062 Normal Weight Obesity: A Real Health Risk http://wwwdiabetesincontrolcom/resultsphp?storyarticle6060 Bypass Surgery For Heart Patients Better Than Stents In The Long Term http://wwwdiabetesincontrolcom/resultsphp?storyarticle6058
From the editor desk: s
Dr Sheri Colberg, PhD, FACSM, knows what parts of the body need the most help and the parts that most people want to fix this week
she focuses on a major concern to all of us with Abdominal and lower-back resistance exercises: Crunches and the Waist Worker http://wwwdiabetesincontrolcom/resultsphp?storyarticle6073 We see our patients and think if they are taking care of their diabetes all is well but often there are other things that seem to sabotage them This is often happens to children more often than adults Recently I read about the problems a young girl and her mom were having with her the school field hockey team She was told that if she were to continue to miss practice due to testing her blood sugar or being high or low, playing time would be taken away Her mom had some other things to say To find out what happened click here: Hockey Moms and Diabetes http://wwwchildrenwithdiabetescom/dteam/2008-09/d_0d_fb4htm Many times you click on a publication about diabetes and you find out that most of the people involved have no real relation to diabetes Everyone knows that Steve and I have been involved in patient care for years We have taken it one step further with Andrew Young, coming on board as our VP of Marketing Andrew who has type 1 diabetes and has worked on diabetes related websites before offers us a
unique perspective He penned Transforming Your Worst Habit for Diabetes Wellness News and we have a copy of it for you here http://wwwdiabetesincontrolcom/resultsphp?storyarticle6074 The Diabetes Day of Hope is coming to Chicago and maybe a city near you Check it out and let us know if you would like to do the same for your city http://wwwdiabetesdayofhopecom/
dLifeTV on Sept 14, 7PM ET on CNBC Find out about a little-known complication that affects over 10 percent of people with diabetes — are you at risk? Plus, a mouthwatering Barbeque Brisket that inexpensive and easy to make; s listening in on kids talking about diabetes; and a look at how to handle the diabetes police Be inspired by another all-new episode of dLifeTV: Sundays on CNBC at 6:00 PM ET, 5:00 PM CT, and 3:00 PM PT
We can make a difference
More Current News on Diabetes
Item 2: Novel Short-Term Weight-Loss Approach Works Long-Term Item 3: Januvia/Byetta Becoming First and Second-Line Therapy for Type 2 Diabetes Item 6: Study 2008: Healthcare Costs To Rise AGAIN Item 7: Benefits of Intensive Lipid Lowering in CVD, Diabetes and CKD Item 9: Why Gastric Bypass Helps Diabetics Item 12: Creating Subspecialty Seen as a
Remedy for Obesity Epidemic Item 14: Familial Clustering of Proliferative Retinopathy Seen in Type 1 Diabetes
Check out this weeks Test Your DIABETES Knowledgequestion
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6075
Dave Joffe, Editor-in-chief
NEWS FLASH:
Results from European Association for the Study of Diabetes EASD coming in next week newsletter s
This Week Product: s InsuCalc Insulin Dosage Wheels
A helpful aid for individuals with Type 1 or Type 2 diabetes on todays modern tight control Wheels are available in 12 different combinations of insulin:carbohydrate ratios and blood glucose correction factors, to accommodate the needs of most individuals with Type 1 and Type 2 diabetes on multiple daily injection regimens InsuCalc http://wwwinsucalccom/
This week Tool: s The Quality of Life TestA1c-eAGrevised
Let your patients know what the New Mean Average Blood Glucose eAG means and how the A1c is now related to the eAG This tool shows you what the new blood glucose numbers are for the different levels of A1c numbers It also explains the importance of the eAG The Quality of Life Test pdf http://wwwdiabetesincontrolcom/issues/Issue 433/qolpdf
This Week
Items: s 1 Obesity Not A Red Flag For Diagnosing Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6072 2 Novel Short-Term Weight-Loss Approach Works Long-Term http://wwwdiabetesincontrolcom/resultsphp?storyarticle6071 3 Januvia/Byetta Becoming First and Second-Line Therapy for Type 2 Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6070 4 Genes Link Birth Weight, Diabetes In Adulthood http://wwwdiabetesincontrolcom/resultsphp?storyarticle6069 5 Low Vitamin D Levels Increases Risk of Type 2 Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6068 6 Study 2008: Healthcare Costs To Rise AGAIN http://wwwdiabetesincontrolcom/resultsphp?storyarticle6067 7 Benefits of Intensive Lipid Lowering in CVD, Diabetes and CKD http://wwwdiabetesincontrolcom/resultsphp?storyarticle6066 8 Telmisartan Fails as Substitute for ACE Inhibitors http://wwwdiabetesincontrolcom/resultsphp?storyarticle6065 9 Why Gastric Bypass Helps Diabetics http://wwwdiabetesincontrolcom/resultsphp?storyarticle6064 10 Adiponectin A Marker for Type 2 Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6063 11 New Analysis Shows Lower Not Necessarily Better When It Comes to BP
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6062 12 Creating Subspecialty Seen as a Remedy for Obesity Epidemic http://wwwdiabetesincontrolcom/resultsphp?storyarticle6061 13 Normal Weight Obesity: A Real Health Risk http://wwwdiabetesincontrolcom/resultsphp?storyarticle6060 14 Familial Clustering of Proliferative Retinopathy Seen in Type 1 Diabetes http://wwwdiabetesincontrolcom/resultsphp?storyarticle6059 15 Bypass Surgery For Heart Patients Better Than Stents In The Long Term http://wwwdiabetesincontrolcom/resultsphp?storyarticle6058
ITEMS For The Week:
Item 1
Obesity Not A Red Flag For Diagnosing Diabetes
Obese people with diabetes are just as likely to go undiagnosed as their slimmer peers with the disease, Harvard Medical School researchers report
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6072
Its well recognized that obesity increases the likelihood of developing diabetes, yet obesity does not increase the likelihood that an individuals diabetes will be diagnosed, Dr Christina C Wee and her colleagues from Harvard and Beth Israel Deaconess Medical Center in Boston report There is no consensus on who should be screened for diabetes, Wee and her team
note in their report in the medical journal Diabetes Care Early diagnosis of diabetes is particularly important for obese people, they add, because research shows they are less likely to be offered the preventive care that can help stave off serious complications of the disease To investigate the impact of a persons body mass index BMI on their odds of having undiagnosed diabetes, the researchers looked at 5,514 people participating in the 1999-2004 National Health and Nutrition Examination Survey Almost 10 percent of the study participants had diabetes, and 28 percent of them had not been diagnosed with the disease A persons BMI made no difference from a statistical standpoint in whether or not they went undiagnosed; 22 percent of normal weight people with diabetes were undiagnosed, 32 percent of overweight people were, and about 33 percent of obese people were Further research is needed to understand whether including overweight and obesity in diabetes screening initiatives may be beneficial for public health, Wee and her colleagues add Meanwhile, they add, Clinicians and policy makers may want to consider the underlying risk of diabetes associated with body weight in making
decisions concerning whom should be screened for diabetes
Diabetes Care, September 2008
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Item 2
Novel Short-Term Weight-Loss Approach Works Long-Term
A study by researchers from the Joslin Diabetes Center has shown for the first time that more than half of patients with type 2 diabetes who enrolled in a novel short-term weight management program were able to maintain the weight loss they achieved during the program on their own long-term The focus was on weight loss and not as much on glucose control
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6071
In addition, participants were able to keep their blood glucose in control on fewer medications and had significant reductions in their total cholesterol, triglycerides, LDL or badcholesterol and C-reactive protein a measure of inflammation linked to heart attack risk The study, showed patients with type 2 diabetes enrolled in Joslin Weight Achievement and Intensive s Treatment program Why WAIT lost on average 235 pounds or 98 percent of their initial body weight during the 12-week
program At the conclusion of one-year of follow-up, the average weight loss was 182 pounds or 76 percent of initial body weight Participants also saw an average of 37 inch reductions in waist circumference and a significant reduction in body fat percentage while keeping their lean body mass up
Our study shows that the Why WAIT program novel combination of diet changes, an exercise plan and s medication change, in association with behavioral support and education, works long-term when patients are back on their own in the real world,said Osama Hamdy, MD, PhD, medical director of the Obesity Clinical Program at Joslin and the study lead investigator s Why WAIT is a 12-week multidisciplinary diabetes weight management program designed for clinical practice The program, which is mostly covered by insurance, includes a change in diabetes medications to enhance weight reduction by eliminating or reducing medications that can cause weight gain, structured dietary intervention with about 40 percent of daily calories from carbohydrates and 30 percent from protein, high fiber, no trans fats and reduced saturated fats, meal replacement drinks that follow the same dietary composition, an
exercise program with an emphasis on strength training, and weekly educational and behavioral support sessions the last few years, we have been looking for a new target to treat type 2 diabetes,Hamdy said For Lowering blood glucose levels alone doesn seem to help to prevent the cardiovascular complications t associated with type 2 diabetes This is why we created the Why WAIT weight-management program Reductions in blood pressure, cholesterol levels and inflammation markers indicate that the Why WAIT approach may eventually reduce the risk of cardiac and cerebral events, which are the main causes of death in individuals with diabetes, Hamdy added In addition to weight-loss and reductions in cardiovascular risk factors, Why WAIT participants also saw significant decreases in the amounts of diabetes medications they were taking, as well as an associated reduction in medication costs Patients saved, on average, 561 per year on their diabetes medications alone and the study projected an annual decrease of total health care costs of about 1,619 per patient Many participants were able to stop their diabetes medications altogether,Hamdy said According to the paper, 21 percent of
participants on short-acting insulin were able to stop it completely by the end of the program Remaining patients on insulin therapy were able to reduce their daily dose of long-acting insulin by an average of 55 percent and their daily dose of short-acting insulin dropped by 54 percent Almost two-thirds of patients on sulfonylureas were able to stop them while remaining participants reduced their doses by between 35 and 41 percent treating type 2 diabetes, we have been glucose-focused for several decades It may be the time to In switch our efforts to target body weight as the core of the problem,he said The Why WAIT program clearly shows that weight-based diabetes management is a future potential alternative model to glucosebased management It resulted in a reduction in medication use and cost, and more people were on target for diabetes control with improved quality of life
August issue of Obesity Management
DID YOU KNOW:
finding that heart rate, specifically a heart rate more than 70 beats per minute, increased the risk of cardiac events in heart failure patients was the top take-home message for the Dutch cardiologist who chaired the European Society of Cardiology program
committee
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Item 3
New research reports that Januvia is currently prescribed most
often as a third- or later-line of therapy for the treatment of type 2 diabetes
Januvia/Byetta Becoming First and Second-Line Therapy for Type 2 Diabetes
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6070
Surveyed endocrinologists and primary care physicians expect to shift their third- or later-line Januvia use to earlier lines of therapy in the next two years — 44 percent and 48 percent of surveyed endocrinologists and primary care physicians, respectively, expect to increase their first-line prescriptions for Januvia and 35 percent and 33 percent of surveyed endocrinologists and primary care physicians, respectively, expect to increase their second-line use of Januvia between 2008 and 2010 The PPAR-gamma agonists, Januvia and Amylin/Eli Lillys Byetta are each competing for positioning in second- and third-line therapy because of the dominance of generic metformin and sulfonylureas in earlier lines of treatment The new report entitled Treatment Algorithms in Type 2 Diabetes finds that since the May 2007 Nissen meta-analysis first publicized the cardiovascular risks of GlaxoSmithKlines PPAR-gamma agonist Avandia, physicians have reduced their use of the PPAR-gamma
agonist drug class in second-line treatment From January 1, 2005 to June 30, 2006, PPAR-gamma agonists captured 323 percent of second-line patient share, but between April 1, 2006 and September 30, 2007 their patient share in this line of therapy fell to 234 percent These dynamics reflect not only a decline in Avandias second-line patient share but also a lack of growth in second-line patient share for Takedas PPARgamma agonist Actos The classic pattern of type 2 diabetes treatment is metformin, a sulfonylurea and then a PPAR-gamma agonist states Madhuri Borde, PhD, analyst at Decision Resources However, due to hypoglycemia concerns with sulfonylureas and cardiovascular concerns with Avandia, this pattern is changing as drugs from the DPP-IV inhibitor, GLP-1 analogue and insulin analogue classes are gaining patient share in second- and third-line treatment
Decision Resources Research Report PharMetrics
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Item 4
Genes Link Birth Weight, Diabetes In Adulthood
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6069
A large study of Swedish twins indicates that a common genetic cause underlies both low birth weight and the propensity to develop type 2 diabetes While low birth weight is more common among individuals with type 2 diabetes, poor fetal nutrition and other environmental factors leading to low birth weight do not cause diabetes, according Dr Stefan Johansson and colleagues Rather, data from their study suggest that common genes may be responsible for both reduced fetal growth and development of diabetes in adulthood, said Johansson, of the Karolinska Institute in Stockholm In the journal Epidemiology, Johanssons group describes their study of 18,230 fraternal and identical twins 592 with type 2 diabetes, born between 1926 and 1958 Twins share the same early environment, but identical twins, of course, also share the same genetic makeup, whereas fraternal twins have different sets of genes Johansson stated that, the investigators first examined all twins as independent individuals
Similar to previous research, the current analysis found that low birth weight was more common among adults with type 2 diabetes Johanssons group further analyzed the twins as pairs when one had diabetes and the other did not This showed a continued link between low birth weight and diabetes among fraternal twins but no such link between identical twins who share all their genes Explaining what this means, Johansson said: Within a fraternal twin pair, the lighter twin would face an increased risk of diabetes But within an identical twin pair, the lighter and the heavier twin have the same risk of developing diabetes later in life These findings support the idea that genetic factors are important in understanding the link between birth weight and type 2 diabetes, and environmental factors, such as poor fetal nutrition, are less important than previously proposed, commented Johansson
Epidemiology, September 2008
Focusing on Weight Loss and Not on Glucose Works: A new study showed that focusing on
weight loss and not on blood glucose can improve blood glucose and let patients maintain the weight loss over the long-term See This Weeks Item 2
FACT:
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Item 5
Low Vitamin D Levels Increases Risk of Type 2 Diabetes
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6068
New research shows that low vitamin D levels can increase the risk for developing diabetes
Dr Paul Knekt of the National Public Health Institute in Helsinki, Finland and colleagues found that men with the highest serum vitamin D levels were the least likely to have developed type 2 diabetes 22 years later Lack of vitamin D interferes with insulin secretion, and studies suggest a link between low vitamin D and diabetes, Knekt and his team note But most research has been cross-sectional, meaning it only focused on a single time point Prospective studies, which follow people over time, are a better way
to investigate potentially causal relationships The researchers looked at men and women who were 40 to 74 years old and free of diabetes when they enrolled in a health examination survey Investigators followed them for 22 years, during which time 412 developed type 2 diabetes Knekt and colleagues compared baseline levels of blood vitamin D in the 412 cases and 986 control individuals who remained diabetes free They found that men in the top fourth based on their blood levels of the vitamin were 72 percent less likely to have developed type 2 diabetes than men in the lowest quartile, after the researchers adjusted for body weight, physical activity and other factors No such relationship was seen for women Certain lifestyle and diet factors could also be partially responsible for the vitamin D-diabetes risk link, the researchers note, concluding: Further studies are needed before firm conclusions can be made about the role of vitamin D in diabetes prevention
Epidemiology, September 2008
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Item 6
Study 2008: Healthcare Costs To Rise AGAIN
We continue to see healthcare costs rising and those with diabetes will certainly feel it the most Let s hope that the new president will do something to help Consider getting involved with one of the presidential candidates after viewing their ideas on improving healthcare in this country
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6067
Fifty-nine percent of companies intend to keep down rising health care costs in 2009 by raising workers deductibles, copays or out-of-pocket spending limits, according to a survey by the Mercer consulting firm
On average, health care costs will rise by an estimated 57 percent next year for both workers and their employers That is equal to this years increase and a 61 percent hike in 2007 The growth of health care costs has hovered at around 6 percent since 2005, according to Mercer Thats down from the double-digit growth in previous years, but its still moving at a faster rate than inflation or workers wages The study also found between 2003 and 2007, the average deductible for an individual grew from 250 to 400 For a family, it
rose from 1,000 to 1,500 Once workers spend that out of pocket amount for medical care, they begin sharing costs with employers, with the company covering an average of 80 percent The Mercer survey also found 47 percent of companies said they are encouraging enrollment in plans with lower premiums and higher deductibles It reported 19 percent of employers would start offering a consumer-directed health plan, which has high-deductible and employee-controlled spending accounts Last year, 12 percent of all employers said they were very likely to implement such a plan by 2009 About half of the 3,000 large companies surveyed responded Mercer is a global provider of consulting, outsourcing and investment services The company is a subsidiary of Marsh McLennan Companies Inc
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Item 7
The use of 80mg of atorvastatin reduced the relative risk of major cardiovascular events by 35 in patients with diabetes and CKD 209 vs 139 and by 10 in patients with diabetes and normal eGFR 141 vs
128
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6066
Benefits of Intensive Lipid Lowering in CVD, Diabetes And Chronic Kidney Disease
The aim of this study by researchers from the UK was to investigate the effect of intensive lipid lowering with high-dose atorvastatin on the incidence of major cardiovascular events compared with low-dose atorvastatin in patients with coronary artery disease and type 2 diabetes, with and without chronic kidney disease CKD Following 8 weeks open- label therapy with atorvastatin 10 mg/d, 10,001 patients with coronary artery disease were randomized to receive double-blind therapy with either 80 mg/d or 10 mg/d of atorvastatin between July 1, 1998, and December 31, 1999 Of 1501 patients with diabetes, renal data were available for 1431 Patients with CKD were defined as having a baseline estimated glomerular filtration rate eGFR below 60 mL/min per 173 m2, using the Modification of Diet in Renal Disease equation They found that after a median follow-up of 48 years, 95 174 of 546 patients with diabetes and CKD experienced a major cardiovascular event vs 119 134 of 885 patients with diabetes and normal eGFRs hazard ratio [HR], 132 Compared with
10 mg of atorvastatin, 80 mg of atorvastatin reduced the relative risk of major cardiovascular events by 35 in patients with diabetes and CKD 209 vs 139 and by 10 in patients with diabetes and normal eGFR 141 vs 128 The absolute risk reduction in patients with diabetes and CKD was substantial, yielding a number needed to treat of 14 to prevent 1 major cardiovascular event over 48 years Both treatments were well tolerated A significant difference in dose with a moderate risk reduction However the risk of harm was not established
The researchers concluded: Patients with diabetes, stable coronary artery disease, and mild to moderate CKD experience marked reduction in cardiovascular events with intensive lipid lowering, in contrast to previous observations in patients with diabetes and end-stage renal disease
Mayo Clin Proc August 2008;83:870-879:Mayo Foundation for Medical Education and Research Intensive Lipid Lowering With Atorvastatin in Patients With Coronary Artery Disease, Diabetes, and Chronic Kidney Disease James Shepherd, MD; John J P Kastelein, MD, PHD; Vera A Bittner, MD; et al
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Telmisartan Fails as Substitute for ACE Inhibitors
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6065
The angiotensin receptor blocker telmisartan Micardis failed to significantly prevent ischemic events among patients who cannot tolerate angiotensin-converting enzyme ACE inhibitors, researchers found After almost five years of treatment, telmisartan reduced the primary outcome by just 8 P022, Koon K Teo, MB, PhD, of McMaster University in Hamilton, Ontario, reported at the European Society of Cardiology The findings were simultaneously published online by The Lancet The TRANSCEND Telmisartan Randomized AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease trial randomized 2,954 high-risk patients to 80 mg telmisartan and 2,972 to placebo All patients had confirmed cardiovascular disease or diabetes and were
ACE-inhibitor intolerant Median age of patients was 67; 75 were taking aspirin, and more than half were taking a beta blocker, a statin, or both After a median follow-up of 56 months, 465 patients in the telmisartan group 157 experienced the primary composite endpoint of cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure compared with 504 patients 169 in the placebo group, a difference which was not significant HR 092, 95 CI 081 to 105 Dr Teo said that the main secondary endpoint — reducing a composite of cardiovascular-caused death, myocardial infarction, and stroke — was achieved Treatment with telmisartan resulted in a 13 decrease in these events compared with placebo HR 087, 95 CI 076 to 100, P00475, he said He reported that 384 patients 13 on telmisartan experienced the endpoint compared with 440 148 of those on placebo However, this difference became non-signi?cant after statistical adjustments were made for multiple comparisons P0068 None of these endpoints were individually significant
Telmisartan did reduce hospitalizations for cardiovascular reasons and left-ventricular hypertrophy, and fewer patients had the combination of
macrovascular and microvascular events plus microalbuminuria In a commentary, also published in The Lancet, Toni L Ripley, PharmD, and Donald Harrison, PhD, of the University of Oklahoma College of Pharmacy in Oklahoma City, noted that although the TRANSCEND findings are too limited to reach definitive conclusions, the clinical effect of angiotensin-receptor blockers seems less robust than that of angiotensin-converting-enzyme inhibitors They pointed out that the higher use of lipid-lowering therapy, ß blockers, and antiplatelet drugs in TRANSCEND compared with other studies, re?ects the current standard of care and would be expected to lower event rates and in?uence the size of the effect from additional therapies Drs Ripley and Harrison concluded that ACE-inhibitors should remain the preferred renin-active agent to prevent vascular events in patients with or at high-risk for cardiovascular events Karl Swedberg, MD, of the University of Gothenburg in Sweden, and discussant at 
the session at which the TRANSCEND trial was presented, said the failure of telmisartan to perform at least as well as an ACEinhibitor in the trial was mystifying He noted that telmisartan effectiveness
compared with placebo appeared to emerge only after at least six months of therapy Primary preventive vascular effects by angiotensin receptor blocker therapy are at best modest, said Dr Swedberg said ACE-inhibitors should remain the first-line therapy for vascular protection Although he noted that the receptor blockers have not been found superior to ACE-inhibition, he said that the use of telmisartan and other angiotensin receptor blockers still appears reasonable as an alternative in ACE-inhibitor-intolerant patients Practice Pearls:
??
Explain to interested patients that in this study telmisartan Micardis did not work any better as an alternative to ACE-inhibitors than placebo Note, however, that there are several other angiotensin receptor blockers that may prove better in preventing events than telmisartan
??
European Society of Cardiology 2008/The Lancet: TRANSCEND investigators Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomized controlled trial Lancet 2008; Published online Aug 31
DID YOU KNOW:
Fat Not Sugar Causes Diabetes: Doctors know obese
patients are at an increased risk of
diabetes, cardiovascular disease and metabolic syndrome But researchers now say the fat itself could be causing these diseases Fat biopsies of lean and obese patients revealed to researchers that the fat tissues in obese patients were actually sick compared to the fat in lean patients The obese fat samples themselves were more inflamed than lean fat samples and showed significant stress on the endoplasmic reticulum ER — a component of all cells that helps synthesize proteins and monitor how they are folded When stressed, ER produces several proteins that ultimately lead to insulin resistance, which plays a major role in the development and progression of type 2 diabetes and metabolic syndrome According to the National Institutes of Health, each time a body mass index BMI greater than 25 is raised by one point, the risk for diabetes increases 25 percent and the risk for heart disease increases 10 percent Diabetes, 2008
Item 9
Why Gastric Bypass Helps Diabetics
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6064
New evidence explains why patients who undergo gastric bypass surgery get their diabetes symptoms under control quickly –
often within days — while those who have lap-band surgery do not
The key, researchers say, is the change in the position of the intestines During gastric bypass surgery, the portion of the intestines closest to the stomach is removed so that it no longer receives nutrients The lower portion is then attached directly to the stomach, thus receiving all of the incoming nutrients Researchers say these positional changes ramp up production of blood sugar by the small intestines, which then send signals to the liver to decrease glucose production Besides removing a substantial portion of the stomach, gastric bypass reorganizes the intestines into two parts, study co-author Dr Gilles Mithieux, from Universite de Lyon, said in a statement The proximal portion no longer receives nutrients directly from the stomach, whereas the more distal portion of the intestines now receives direct output from the stomach These changes, according to Dr Mithieux, cause an increase in glucose production Specifically, the lower portion, which usually produces little glucose, increases its production, more closely resembling the upper portion in this regard Sensors in the liver detect the elevated glucose
and send an appetitesuppressing signal to the brain, which contributes to the satiety and weight loss seen with gastric bypass In the current investigation, the authors examined the effects of gastric bypass and gastric banding in mice In addition to the link between gastric bypass and intestinal gluconeogenesis, they found that a glucose transporter called GLUT-2 is needed for the liver to sense glucose levels in the portal vein Mice lacking GLUT-2 did not experience the enhanced glycemic control usually seen after gastric bypass These changes in the intestines increase insulin sensitivity and lower blood sugar, thus improving the symptoms of diabetes often within days of surgery; well before any weight loss takes place In contrast, gastric banding — also called lap-band surgery — causes weight loss by placing a prosthetic band around the stomach, cutting hunger Researchers say because it does not alter the intestines at all, it lacks the immediate metabolic benefits of bypass Furthermore, they note, sensors in the liver detect the elevated glucose and send an appetitesuppressing signal to the brain, which contributes to the satiety and weight loss seen with gastric bypass Study
author Gilles Mithieux of Institut National de la Sante et de la Recherche Medicale in France advises patients considering either surgery to talk to their doctor about the risks and benefits of the procedures He says these results support the notion that gastric bypass could be an effective treatment for diabetes in obese patients and could even have potential for patients who are diabetic but are not obese
Cell Metabolism, 2008
Item 10
Adiponectin A Marker for Type 2 Diabetes
Adiponectin is inversely linked with the risk for type 2 diabetes in women, but resistin is not, according to the results of a prospective, nested case-control study The study authors suggest that adiponectin may be a marker for type 2 diabetes
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6063
Adiponectin and resistin are recently discovered adipokines that may provide a molecular link between adiposity and type 2 diabetes, write Christin Heidemann, DrPH, MSc, from Harvard School of Public Health, Massachusetts General Hospital in Boston The goal of this study was to determine whether total adiponectin and resistin and high-molecular-weight adiponectin and resistin are linked to a subsequent
risk for type 2 diabetes, independent of obesity and other known risk factors for diabetes The study cohort consisted of 1038 women enrolled in the Nurses Health Study who were initially healthy at baseline but who went on to have type 2 diabetes after blood sampling 1989-1990 through 2002 Plasma concentrations of total adiponectin and resistin and high-molecular weight adiponectin and resistin in these case participants were compared with those in 1136 matched-control participants Adiponectin levels were associated with a significantly lower risk for type 2 diabetes in multivariate models that adjusted for body mass index BMI For the highest quintiles vs the lowest quintiles, odds ratio OR was 017 for total adiponectin and 010 for high-molecular-weight adiponectin Even after adjustment for total adiponectin, a higher ratio of high-molecular-weight adiponectin to total adiponectin was associated with a statistically significantly lower risk for type 2 diabetes OR, 045; 95 CI, 031 065 Higher resistin levels were associated with a higher risk for diabetes in the multivariate model without BMI However, this association was no longer statistically significant after adjustment for BMI
Limitations of this study include study sample composed mainly of white women; possible residual confounding from imperfectly measured or unmeasured variables; and results based on single measurements of the adipokines, which therefore may not reflect long-term exposure to these hormones Adiponectin is strongly and inversely associated with risk for diabetes, independent of body mass index, whereas resistin is not, the study authors write The ratio of high-molecular-weight to total adiponectin is related to risk for diabetes independent of total adiponectin, suggesting an important role of the relative proportion of high-molecular-weight adiponectin in diabetes pathogenesisIn contrast, the positive association between resistin and type 2 diabetes was largely explained by BMI Adipose tissue secretes various hormones and cytokines, known as adipokines, which may be a connecting molecular link between adiposity and type 2 diabetes Adiponectin and resistin are adipokines that may be especially important in the relationship of excess adiposity to type 2 diabetes In contrast to other adipokines, adiponectin concentrations are paradoxically decreased in obese persons vs lean persons
Prospective studies have shown a decreased risk for type 2 diabetes with increasing concentrations of total adiponectin Although high-molecular-weight adiponectin is the most biologically active form, few epidemiologic studies have evaluated high-molecular-weight adiponectin separately from total adiponectin Practice Pearls Adiponectin is strongly and inversely associated with the risk for diabetes, independent of BMI and markers of insulin resistance or inflammation, whereas resistin is not The inverse association with the risk for diabetes was particularly marked in the lower ranges of total adiponectin and high-molecularweight adiponectin distributions The ratio of high-molecular-weight adiponectin to total adiponectin is related to the risk for diabetes independent of total adiponectin, suggesting an important role of the relative proportion of highmolecular-weight adiponectin in diabetes pathogenesis
Ann Intern Med 2008;149:307-316
Item 11
New observational analysis of the ONTARGET study shows that lower is not necessarily better when it comes to blood pressure in this patient population, with coronary heart disease or diabetes plus additional risk factors Although there
was evidence that lower was better in terms of stroke, there was a suggestion of harm when BP was reduced below 130 mm Hg systolic for the outcome of cardiovascular death in diabetics The findings suggest that in high-risk people, the [current] guidelines of the lower, the better may not apply
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6062
New Analysis Shows Lower Not Necessarily Better When It Comes to BP
Dr Peter Sleight Oxford, UK stressed that these observational data have limitations and that the ONTARGET population was not a typical hypertension-trial cohort The 25 260 patients were elderly and were at high risk, but their blood pressure was not particularly high high-normal or stage 1 hypertension, and they were already well-treated before they entered the study The findings suggest that in high-risk people, the [current] guidelines of the lower, the better may not apply, he notedStudy discussant Dr Frank T Ruschitzka University of Zurich, Switzerland said that the treasure box that is ONTARGET has already shown that the combination of the ACE inhibitor ramipril and the angiotensin-receptor blocker ARB telmisartan Micardis, Boehringer Ingelheim–despite
lowering blood pressure more than either drug alone–fails to translate into clinical benefit He added that recent findings from the secondary-prevention stroke trial, PROFESS, where telmisartan was pitted against placebo, show that the ARB does not prevent recurrent strokes These new findings from the blood-pressure analysis of ONTARGET show that we should certainly not go too low, he concluded Puzzling Findings; Diabetics at Risk of CV Death With Lower BP The landmark ONTARGET trial showed that telmisartan was noninferior to ramipril in 25 260 patients with coronary heart disease or diabetes plus additional risk factors who were over the age of 55 years of age but did not have evidence of heart failure And the combination of the two drugs was associated with more adverse events without an increase in benefit The average BP on study entry was 142/82 mm Hg, and patients were randomized to receive ramipril 10 mg per day, telmisartan 80 mg a day, or the combination of the two The mean duration of follow-up of the study was 55 months Results showed that mean blood pressure was lower in the telmisartan a 09/06-mm-Hg-greater reduction and the combination-therapy a 24/14-mm-Hg-greater
reduction groups than in the ramipril group In the new analysis, Sleight said the 25 260 patients were divided into four quartiles based upon blood pressure, regardless of which study arm they had been randomized to The analysis showed that only the very highest quartile of BP systolic BP 154 mm Hg had a significantly higher risk of the primary end point: cardiovascular death, stroke, MI, or heart-failure hospitalization p0001 When the end points were considered separately, there were no differences between the four BP quartiles for cardiovascular death or for MI, which some may say is puzzling, as lowering blood pressure doesnt seem to do anything, Sleight notedThere was a benefit to lowering blood pressure in terms of stroke, however Those in the lowest quartile of BP systolic 130 mm Hg had significantly less risk of stroke than those in the highest quartile But there was also evidence of potential harm among diabetics: although those with diabetes in the highest quartile of blood pressure did have a higher risk of the primary outcome, when it came to cardiovascular death alone, those in the lowest quartile seemed to have an increased risk of death, Sleight said Ruschitzka
concluded that these findings and others put a little bit of a cloud over the class of sartans The overwhelming message from ONTARGET in terms of BP, he said, was that ACE inhibitors or calcium channel blockers [CCBs] come first, and Im not so sure about the sartans anymore Also, dont go below 140/90 mm Hg in this type of patient, and if more BP lowering is needed on top of ACE inhibitors and CCBs, a beta blocker should be use
European Society of Cardiology 2008 Congress
DID YOU KNOW:
Initial Weight Loss After Type 2 Diagnosis Doubles Positive Outcomes: People who lose weight soon after a diagnosis of type 2 diabetes have better control of their blood pressure and blood sugar and are more likely to maintain that control even if they regain their weigh This is the first clinical study to show that benefits remain even if patients regain their weight The study followed more than 2,500 adults with type 2 diabetes for 4 years Those who lost weight within an average of 18 months after diagnosis were up to twice as likely to achieve their blood pressure and blood sugar targets as those who didnt lose weight Those benefits can prevent diabetes-related heart disease, blindness, nerve
and kidney damage, and death Diabetes Care, Aug 2008 Help us keep this newsletter free-update your profile http://wwwdiabetesincontrolcom/surveys/indexphp
Item 12
Creating Subspecialty Seen as a Remedy for Obesity Epidemic
As part of a bipartisan push to quell the nations obesity epidemic, those gathered at the Republican National Convention heard speakers call for more targeted physician training in keeping patients at ideal weights
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6061
In an Obesity Society forum held in conjunction with the convention, panelists suggested that establishing an internal medicine obesity subspecialty could be a big help The Obesity Society held a similar discussion in Denver at the Democratic National Convention Most medical students are only required to have three hours of education about food and nutrition, said Tommy Thompson, a former HHS secretary in President Bushs administration There are not enough training programs to prepare physicians for talking to patients about obesity, the root of many health problems that they might encounter in their careers, said Caroline Apovian, MD, director of the Center for Nutrition and Weight
Management at Boston Medical Center The forum was held to emphasize what a new administration must do to combat obesity In the Denver forum, Rep John Conyers D-Mich said until universal healthcare is a reality, the obesity epidemic will continue to grow, noted Dr Apovian But most of the panelists here emphasized personal responsibility for health and weight needs instead of sweeping changes in health policy and healthcare from the government Change attitudes first so that the law can be changed without an absolute revolution taking place, said former Arkansas Gov Mike Huckabee, who dropped 110 pounds in his personal obesity struggle He also said insurance companies should reevaluate what obesity-related procedures they cover, saying that a 150 visit to a dietitian isnt covered by most plans, but a quadruple bypass is Thompson said business-based initiatives like hiking up the price of junk food in the cafeteria would be a start to getting the nations weight down
However, he wasnt opposed to getting HHS and the Department of Agriculture involved in promoting healthy eating by subsidizing healthy school lunches or expanding food stamps for the purchase of health food He also said
that the federal government should subsidize a nutrition class in schools According to Dr Apovian, this is the first time that the Republican platform has mentioned obesity The platform, approved Monday, says, To reduce the incidence of diabetes, cancer, heart disease, and stroke, we call for a national grassroots campaign against obesity, especially among children Both Huckabee and Thompson campaigned for the Republican presidential nomination in 2007 Huckabee was asked by discussion moderator Leslie Stahl of CBS why he didnt express his strong views on healthcare then He said in the first nine debates moderators only asked a single healthcare question
Item 13
Normal weight obesity isn an oxymoron t The definition of obesity is having excess fat, not excess weight
http://wwwdiabetesincontrolcom/resultsphp?storyarticle6060
Normal Weight Obesity: A Real Health Risk
Dr Lopez-Jimenez was the lead researcher in a Mayo Clinic study that found more than half of Americans who are considered normal weight have high levels of body fat Women with more than 30 percent body fat and men with more than 20 percent are considered obese, even if they have a normal body mass index Typically,
obesity is determined by calculating body mass index BMI using height and weight This makes a lot of sense on the surface because people with excess weight for their height often are at high risk of health problems, but it doesn tell the whole story,says Dr Lopez-Jimenez t The calculation of body fat determines how many pounds of body weight correspond to fat The most common technique to measure body fat is bioimpedance, a method that uses an electrical current to look at body composition These measurement devices are available at many fitness centers and some clinics The Mayo Clinic study, which looked at 2,127 people with normal BMI levels, found that those who had the highest body fat were at increased risk of high blood pressure, high levels of triglycerides a type of blood fat and abnormal cholesterol levels and insulin resistance These metabolic abnormalities significantly increase the risk of type 2 diabetes and cardiovascular disease Another way to determine an unhealthy level of body fat is by measuring your waist In women, a waist measurement of 35 inches or more indicates an increased risk of developing obesity-related health problems The solution to excess body fat,
even for those of normal weight, is to exercise more and eat a healthier diet
September issue of Mayo Clinic Women HealthSource Francisco Lopez-Jimenez, MD, Mayo Clinic cardiologist s
FACT:
Study Finds Most People Underestimate the Health Risks of Diabetes: In a recent focus
group conducted by the American Diabetes Association, participants were asked to rank the severity of various health problems including cancer, heart disease and diabetes On a scale 1 to 10, cancer and heart disease were received 9s and 10s while diabetes/type 2 diabetes only got 4s and 5s The general consensus seems to be, Theres medication, Look how good people look with diabetes or Ive never
heard of anybody dying of diabetes, said Larry Hausner, chief executive of the American Diabetes Association, which held the focus groups
Item 14
Finnish researchers report evidence that proliferative diabetic retinopathy, like diabetic nephropathy, clusters in families, suggesting that genetic factors play a role in its pathogenesis http://wwwdiabetesincontrolcom/resultsphp?storyarticle6059 The finding, , comes from the Finnish Diabetic Nephropathy Study, a nationwide study aimed at identifying genetic and
environmental risk factors for complications of type 1 diabetes To date, the study has characterized 20 of adults with type 1 diabetes in Finland, a total of 4800 patients According to Dr Per-Henrik Groop from Helsinki University Central Hospital, Helsinki, and colleagues, in 188 families, there were at least two siblings with type 1 diabetes These 188 sibships yielded 369 study patients, of whom 115 31 had proliferative retinopathy The researchers estimated the familial risk of proliferative retinopathy in 168 of the 188 sibships, adjusted for hemoglobin A1C, duration, and mean blood pressure Results showed a greater than twofold increased risk odds ratio, 276 of proliferative retinopathy in siblings of probands with proliferative retinopathy in type 1 diabetes The observation cannot be accounted for by conventional risk factors, the investigators noteT he degree of familial clustering, they also point out, is similar to the previously reported clustering for diabetic nephropathy in type 1 diabetic patients and suggests that genes may play a major role also for the development of severe retinopathy
Diabetes 2008;57:2176-2180
Familial Clustering of Proliferative Retinopathy Seen
in Type 1 Diabetes
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Item 15
Bypass Surgery For Heart Patients Better Than Stents In The Long Term
For heart patients with clogged arteries, the choice between bypass surgery or an angioplasty may come down to one question: How many procedures would you like to have? http://wwwdiabetesincontrolcom/resultsphp?storyarticle6058
In research presented last week at the European Society of Cardiology meeting in Munich, experts concluded that while bypass surgery and angioplasty offer comparable results, patients who have angioplasties are twice as likely to require another procedure within a year
If you dont want to have another heart operation for at least a decade, you should pick the surgery, said Dr Heinz Drexel, professor of medicine at the
University of Innsbruck in Austria and spokesman for the European Society of Cardiology Drexel was not connected to the research But that means you have to have your chest cracked open, he said When arteries become blocked, doctors have two main options Traditionally they have done a bypass surgery, which reroutes blood vessels to detour around blockages But in recent years, angioplasties have become increasingly popular An angioplasty is a non-surgical procedure where a balloon is pushed into a blood vessel to flatten the blockage, leaving a stent to prop the artery open In the study results announced Monday, European doctors compared the effectiveness of open-heart surgery versus angioplasty in a trial of more than 3,000 patients in Europe and the United States They excluded patients who had acute heart attacks and included those who had single and multiple vessel blockages About a third of the patients had medical conditions that required surgery The remaining patients were randomly assigned to receive either surgery or an angioplasty Patients who got an angioplasty needed an average of nearly five stents The study was paid for by Boston Scientific, makers of the drug-coated
stent used in the trial After one year, researchers found that patients who had surgery had a lower death rate Among surgery patients, the death rate was 35 percent; in angioplasty patients, it was 43 percent In patients who had an angioplasty, nearly 14 percent needed another procedure after a year, compared with about 6 percent of surgery patients But patients who had surgery had about a 2 percent stroke risk versus nearly zero risk for patients who had an angioplasty Doctors said that any surgery had an inherent stroke risk, compared with an angioplasty In January, a study published in the New England Journal of Medicine found that bypass surgery was still the best option for heart patients with more than one clogged artery Surgery still comes out as the winner in a head-to-head trial, said Dr Douglas Weaver, president of the American College of Cardiology, who was unconnected to the research This comes down to a conversation with patients and making sure they know that with an angioplasty, there will be a higher rate of revascularization, he said, referring to the need for repeat procedures Patients typically need at least a month to fully recover from an open-heart surgery, a
five-hour long operation under general anesthesia Angioplasty patients, however, are often up and walking around after three days You invest more in terms of recuperation with surgery, said Dr Tim Gardner, president of the American Heart Association But the advantage is durability When drug-coated stents were first introduced in 2003, they became the fastest-selling medical device in recent history Doctors thought that the tiny tubes, which leak drugs to prevent tissue regrowth, would make angioplasty a much better alternative to surgery for patients
But in 2006, studies began to emerge showing that patients with the drug-coated stents were more likely to develop potentially fatal blood clots months and even years after they were implanted Stent sales plummeted and doctors have become more wary of their use, saving them only for certain patients with no other options Doctors cautioned that more data is still needed about the pros and cons of bypass surgery versus angioplasties, and that patients needed to be tracked for at least five years This only tells us what happens after one year, Drexel said We need to wait for at least five years to get a good answer about which therapy is
really better
http://wwwescardioorg
Quote of the Week
Knowing is not enough; we must apply Willing is not enough; we must do
Johann Goethe 1749-1832 German dramatist, poet novelist
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