Diabetes Treatments

I will be walking for a cure for diabetes in the JDRFI Tampa Bay Walk. proteins triggers insulin resistance, a key feature of most cases of diabetes. …

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DIABETES IN CONTROLcom NEWSLETTER
The Newsletter for Professionals in Diabetes Care April 23, 2002, Issue 101 From the Editors Desk Dr Walter Willett, MD, Professor of Epidemiology and Nutrition and Chair of the Department of Nutrition, Harvard University shares his comments on the current view that all complex carbohydrates are good, all fats are bad In an addition we recently carried a quote from Former Surgeon General Dr C Everett Koop, more than 300,000 Americans die each year from obesity-related illnesseswhere he blamed fat for these deaths According to Dr Koop this information was the tag line in the article by McGinnis and Foege, JAMA, 270:2207-2212,1993 However Robin E Levine, MA, RD, CDE, Assistant Director, Center for Nutrition in Sport and Human Performance, University of Massachusetts points out the actual title is Diet activity patterns linked to 300,000 deaths in United States in 1990 and nowhere in
this article do the authors attribute the 300,000 deaths to obesity or obesityrelated diseases In fact, they have even written letters to the editors restating their conclusions and the abundance of misquoting that has gone on This weeks Toolsfor your practice is a PDF file explaining in plain English what the HbA1c test is all about This is a great hand out for your patients New Product is the Tacticon Now you can detect sub-clinical neuropathy much earlier, and show your patients how to save their feet Dr Freedland continues his series on Why Focusing On Intensive Glucose Control With Drugs Alone Is Counterproductive Part 3 Endothelial Function and Diabetes On May 5th I will be walking for a cure for diabetes in the JDRFI Tampa Bay Walk If you would like to give something back to the community, click here Our top 3 contestants for the AADE scholarships are RB, JH, and CK, however we now have 9 runner up prizes, It s not to late to win, if you have more referrals for us please click here Dave Joffe Editor-in-Chief

Tools for Your Practice:
How you can explain in plain English the importance of the A1c test and what it means? Click on the link below to print out a feature that
explains it to the patient Requires Acrobat Reader

Patients

Results

Monthly Feature On Nutrition: Weight Matters Learn about Tips for Successful Weight Management and Behavior Change Tips
By Sherri Shafer, RD, CDE,

News Flash
Kidney Disease a Quiet Killer for Patients with Diabetes
Kidney disease is an under-recognized, under-diagnosed and under-treated Checking for urine microalbumin and protein are essential in catching it early See Item 2 for more information New Product information: The Tacticon Tacticon significantly reduces the cost associated with PN and Diabetes while enabling earlier diagnosis and interventions The Tacticon TM is a small, hand held, passive medical device that the FDA has recently allowed to be marketed to screen patients for evidence of subclinical peripheral neuropathy of the fingers and toes The Tacticon TM permits quantitative sensory testing QST as recommended by the American Diabetes Association Consensus Panels on Diabetic Peripheral Neuropathy Click To Learn More Dr Richard Bernstein Corner: s Check out Dr Bernsteins Corner for Insights for Controlling Blood Sugars http://wwwdiabetesincontrolcom/bernsteinarchivehtm This Month, Dr Bernstein
is providing us with Exercises That Facilitate Stomach-Emptying for those with Gastroparesis

This newsletter is the condensed version If you would like to see the full newsletter go to http://wwwdiabetesincontrolcom/Issue101indexhtm OPEN STUDY for your participation

Study 12
Room for a few more Don miss this opportunity t The Patient Experience Program We have over 50 educators and 500 patients registered for the study We still need 8 more educators who can provide 10 patients for the study The Patient Experience Program PEP seeks to bridge research and educational programs to healthcare professionals, patients and their families through a collaborative effort to promote public health and to help people with Type 2 diabetes improve their quality of life Honorariums Paid
Click Right Here

Study 15

WarmFeet Relaxation Study Educators who applied were notified
Will use the biofeedback assisted relaxation training program WarmFeet, to reduce pain and/or help in improving wound healing in the feet of a population with limited peripheral blood flow? Patient Benefits: non-invasive; it puts the patient in charge of his/her well-being; increases blood flow to the periphery of the body;
increases healing; reduces pain; increases sensory function over time; may lower blood pressure; nonpharmaceutical and it does not interfere with prescribed medications More information and to learn how to participate click below: Over 50 educators have signed up more than 125 patients; if you are interested, act NOW http://wwwdiabetesincontrolcom/studies/study15shtml 2 NEW STUDIES WILL BE STARTING NEXT MONTH

By referring your friends and colleagues to Diabetes in Control you can win a free scholarship to the 2002 AADE conference in Philadelphia http://wwwdiabetesincontrolcom/scholorshipshtml Did You Know: Scott Verplank, PGA Golfer, has had diabetes since he was 9, and now wears a MiniMed insulin pump while playing to regulate his medication Click here

This Weeks Items:
1 Scientists Close In On Trigger Of Insulin Resistance Click Here 2 Kidney Disease a Quiet Killer for Patients with Diabetes Click Here 3 ITEM Revisted Diabetes Prevention Falls Short, Far Short Click Here 4 Impact of Computer-Generated Personalized Goals on HbA1c Click Here 5 Exercise Will Lower Your Blood Pressure Click Here 6 Near-Sightedness Appears Linked to Excess Sugar in Diet Click Here 7 Splitting
Evening Insulin Regimen Improves Nocturnal Hypoglycemia Click Here 8 A Big Waist Diabetes Bigger Risk of Stroke Click Here

9 Blacks Hit by Diabetes Epidemic
Click Here 10 Final Results of Diabetes Prevention Program Published Click Here 11 How Safe Are Sibutramine, Orlistat and Metformin in the Treatment of Obesity Click Here 12 Losartan Versus HCTZ in Type 2 Diabetic Patients Click Here 13 Type 2 Diabetes Costs 47,000 for Every Patient Click Here 14 Metformin Offsets Weight Gain in Children on Psychotropics Click Here 15 Vascular Surgery Safer than Amputation for Diabetics Click Here ________________________________________________________________________________

ITEMS For The Week: Item 1 Scientists Close In On Trigger Of Insulin Resistance; Extra Sugar and Glucosamine Can Cause Insulin Resistance In Cells
Johns Hopkins scientists have discovered direct evidence that a build-up of sugar on proteins triggers insulin resistance

In experiments with fat cells, Johns Hopkins scientists have discovered direct evidence that a build-up of sugar on proteins triggers insulin resistance, a key feature of most cases of diabetes The results underscore the importance of glycosylation
attachment of a sugar to a protein — as a way cells control proteins activities, the scientists report in the April 16 issue of the Proceedings of the National Academy of Sciences The scientists found that at least two proteins involved in passing along insulins message were unlikely to work properly when coated in extra sugar Type 2 diabetes, the most common form in adults, occurs when muscle, fat and other tissues stop responding to insulins signals to mop up sugar from the blood The resulting high blood sugar, if uncontrolled, can lead to blindness, amputation and death Understanding sugars precise influence on insulins activity may help improve treatment and prevention, scientists hope Cells dont respond to insulin itself Instead, a whole cascade of events, set in motion by insulin, eventually causes cells to take in sugar, explains Gerald Hart, PhD, professor and director of biological chemistry in the schools Institute for Basic Biomedical Sciences We now have an explanation of how sugar can affect these signals, and even a hypothesis for how high blood sugar could cause tissue damage in diabetes — by improperly modifying proteins Harts lab discovered 18 years ago that
sugar is used routinely inside cells to modify proteins, turning them on and off The more commonly known protein-controller, phosphate, actually binds to some of the same building blocks of proteins as sugar does If proteins have too many sugars on them, they cant be controlled properly by the cell and are unlikely to work correctly, suggests Hart We think weve come across a major mechanistic reason for insulin resistance, says Hart These cells developed insulin resistance simply because their proteins, and specific proteins in fact, had more than the normal number of sugar tags If key proteins laden with sugar are present in patients with diabetes, the findings may provide a target for developing new strategies to deal with this growing public health threat, says Hart While diabetes can be fairly well controlled by diet and carefully monitoring ones blood sugar levels, finding a way to remove extra sugar tags may help treat or prevent diabetes someday, the researchers suggest Textbooks frequently and incorrectly show glycosylation only happening to proteins on the cell surface, says Hart Complex sugars are added only to proteins outside the cell, but simple sugars are used all the
time in the nucleus and cytoplasm to modify proteins Its this glycosylation that happens inside the cell, involving simple sugars, that is the key in insulin resistance The simple sugar to which he refers is O-linked beta-N-acetylglucosamine, a complex name that condenses to a difficult acronym — O-GlcNAc — with an ugly pronunciation — oh-gluck-nack But in many ways, O-GlcNAc is a beautiful and mysterious thing, says Hart O-GlcNAc is a modifier on many proteins, but if you didnt know to look for it, youd never find it, he says Instruments and the usual laboratory methods have a hard time measuring it, so we developed the techniques to detect it O-GlcNAc is added to proteins by one enzyme and removed from proteins by another By selectively blocking that removal, the scientists hoped to load up proteins with sugar without adding extra sugar the way other scientists have created insulin resistance We wanted to see the effect of glycosylation itself, so we used a molecular sledgehammer to increase the amount of sugar bound to proteins, says Hart, whose lab proved the ability of the blocker, a molecule called PUGNAc Not only did the blocker increase the amount of O-GlcNAc bound to
proteins, but that increase caused the cells to stop responding to insulin, say co-first authors and postdoctoral fellows Lance Wells and Keith Vosseller Looking for proteins in the insulin-signaling pathway that were more glycosylated than normal, Vosseller and Wells found two: beta-catenin and insulin receptor substrate-1 IRS-1 The crucial role these proteins play in passing along insulins messages is likely to be adversely affected by the extra sugars they carry, the researchers say Our experiments show that increasing O-GlcNAc on proteins is, by itself, a cause of insulin resistance, rather than an effect or a coincidence, says Vosseller

In the body, sugar glucose is changed into glucosamine, which is changed into O-GlcNAc Other scientists have shown that giving cells or animals excessive amounts of sugar or glucosamine, along with extra insulin, leads to insulin resistance The new findings provide an explanation for others experience with animal and laboratory models of insulin resistance There has been little study of glucosamine, a commonly used dietary supplement, in people It is suggested that people taking glucosamine consult their doctors if they are concerned about the
possibility of increasing their risk of developing diabetes
Johns Hopkins Medical Institutions

DID YOU KNOW?
Diabetes is so common among American Indians, affecting more than 25 of the population in some tribes, that casinos and public buildings on reservations are equipped with hazardous waste disposal boxes mounted in rest rooms for safe disposal of insulin syringes and lancets used in testing blood __________________________________________________________________________________ If you graduated and have some type of guaranteed student loan You can refinance those loans at a much lower rate, with out losing your guaranteed status Click here to get more info __________________________________________________________________________________ Item 2

Kidney Disease a Quiet Killer for Patients with Diabetes
Kidney disease is an under-recognized, under-diagnosed and under-treated Checking for urine microalbumin and protein are essential in catching it early More than 270,000 Americans have advanced kidney disease However, doctors warn that up to 13 million more are at risk for developing the deadly illness and they dont even know it 33 of those that have the disease also have
type 2 diabetes In its early stages, kidney disease has almost no symptoms, explains Dr William Keane, president of the National Kidney Foundation There are usually very few symptoms that would cause a patient to bring it to the attention of their physician, Keane says No pain, headache, upset stomach or chest pain Kidney disease is a silent disease Not surprisingly, many people have advanced kidney disease, called end-stage renal disease, before they even discover it At this point, the kidneys are so damaged patients often require dialysis — where they are hooked up to a machine that purifies the blood because the kidneys can no longer do the job — or a kidney transplant Kidney disease is an under-recognized, under-diagnosed and under-treated, says Dr Ellie Kelepouris, associate chief of nephrology at Temple University in Philadelphia And the incidence is rising tremendously Several hundred thousand people out there already have mild kidney disease, and dont know it However, there is some good news When caught early, the progression of the disease can be halted with medications, Kelepouris says We need to get the message out to primary care physicians that they need to refer
patients early to a nephrologist [kidney specialist], Kelepouris says About 270,000 people in the United States are being treated for end-stage renal disease, according to recent Health Care Financing Administration statistics The National Kidney Foundation projects this number will jump to 600,000 by 2010 Two primary reasons for the growing number of people with kidney disease is the increase in Type II diabetes and hypertension, Keane says Almost 33 percent of those being treated for end-stage kidney disease are diabetic High blood pressure is the culprit in about 25 percent of cases

Because diabetes and hypertension disproportionately affect minorities, blacks, Hispanics and Native Americans are at greater risk for kidney failure Other risk factors include a family history of diabetes or hypertension, as well as obesity and smoking Controlling diabetes, hypertension and the related protein in the urine is key to preventing kidney disease, Keane says Recently, doctors have also discovered that early in the course of kidney disease, many people become anemic While the precise mechanism is not understood, anemia is believed to cause an enlargement of the left ventricle of the
heart, which can lead to heart failure, Kelepouris says In other words, the cause of death in some people with kidney disease isnt kidney failure, but cardiovascular disease By treating the anemia with medications, the swelling in the left ventricle subsides, she says Treatments for this type of anemia include folic acid and a drug called erythropoietin This treatment can alter the course of the disease and save peoples lives, Kelepouris says Keane recommends patients who are at risk of kidney disease ask their doctors three questions: Whats my blood pressure? Whats my kidney function? Is there protein in my urine? These three simple questions are the most important in assessing kidney disease risk, Keane says What to Do: For more information about kidney disease, visit the National Kidney Foundation, the American Association of Kidney Patients or the American Diabetes Association
SOURCES: William Keane, MD, president, National Kidney Foundation, New York City; Ellie Kelepouris, MD, associate chief, nephrology, Temple University, Philadelphia KIDN

FACT:
Recent studies show that the health care expenditures are as much as five times higher for individuals with diabetes compared
to individuals without diabetes If your patients are having a problem paying for their medications go to wwwdiabetesmedsorg and download the application that will allow them to get all of their medications for 10 dollars or less for a 90 day supply

Item 3 Revisited from December 5, 2000, Issue 29 Diabetes Prevention Falls Short, Far Short
States are far from meeting 2010 goals Americans with diabetes arent receiving preventive treatments as often or as thoroughly as they should, a new study says Despite a variety of outreach efforts, preventive care for adults with non-insulin dependent diabetes Type II differs vastly depending on factors like age, race and income, according to the government scientists who prepared the report The findings, which are intended to be a benchmark for education efforts in the coming decade, shows that its clear theres plenty of room for improvement says the Centers for Disease Control and Prevention in Atlanta Some people feel that you cant do anything about diabetes Our take on that is that [patients] can do something about it to either delay or prevent the onset of complications You can be in control, you can improve your outcome, but its going to
take work More than 15 million Americans have diabetes Most have the adult-onset, or Type II, form of the condition, in which their cells lose their sensitivity to the hormone insulin, which helps the body extract sugar from blood The number of Americans with diabetes rose 33 percent between 1990 and 1998, the CDC says, thanks largely to a jump in how fat people are becoming

Although diabetes can be easily controlled — with drugs, regular injections of insulin, changes in diet and exercise — if unchecked it can cause serious health problems and even death Diabetes is the leading cause of adult blindness and a major source of kidney, heart and vessel disease, health officials say Nerve damage from the condition leads to more than 56,000 amputations a year, more then half of which could be prevented, experts say The study, based on a phone survey between 1997 and 1999, focused on several key measures of preventive treatment for diabetics: blood sugar self-testing, eye exams to watch for signs of blindness linked to the disease, and foot exams to catch nerve and tissue damage that can lead to amputation They also looked at rates of another blood test, for a protein called HbA1C,
which marks the progress of the disease For all gauges, the average percentages of diabetics who reported receiving these tests were far below the health goals set for the year 2010, which themselves stop below 80 percent of all patients Sugar monitoring rates ranged from about 30 percent of people surveyed in Hawaii, to 655 percent in Montana — the only state to meet the 2010 goal of 60 percent The percentage of people receiving yearly eye exams ranged from 47 percent in Arkansas to 81 percent in Massachusetts, one of just three states to meet the 2010 guideline of 75 percent for this test No state met the 2010 yardsticks for either annual foot exams or the HbA1C screening The use of preventive care ranged widely from state to state, but was generally low in the south and higher in the northeast, the researchers say Age was a factor, too People over 45 were more likely to have an annual eye exam, while those over 75 were less likely to check their own blood sugar, the study found Its really not clear from our data why some states are lower that others, Tierney says Possible factors include differences in demographics, attitudes among patients, variations in the way doctors
practice medicine, and social and economic forces, he says Not surprisingly, patients without health insurance were less likely to report getting preventive care for their diabetes What To Do Outreach efforts to patients and physicians should help improve access to preventive care, as should the increasing numbers of health insurers that are incorporating diabetes management into their treatment guidelines

FACT: More than 270,000 Americans have advanced kidney disease

Item 4 Impact of Computer-Generated Personalized Goals on HbA1c
Vast majority of patients with diabetes do not know their HbA1c status or goal The public is increasingly aware of the importance of HbA1c testing We set forth to evaluate the impact of a system that provides uniquely formatted and personalized reports of diabetes status and goals on changes in HbA1c levels A total of 150 patients with diabetes were randomized to receive either standard care or intervention inclusive of a computer-generated 11 x 17 color poster depicting an individual HbA1c status and goals along with personalized s steps to aid in goal achievement All patients enrolled received diabetes education during the 3 months before enrollment
HbA1c was performed at baseline and 6 months The study found at baseline, there were no significant differences between patient groups in terms of age, sex, education level, race, and HbA1c or lipid levels Among patients with baseline HbA1c 70, there was an 86 077 absolute reduction in HbA1c among control subjects compared with a 170 169 absolute decline in the intervention group P 0032 There were no differences between the control and intervention groups with respect to the frequency of patients experiencing any decline in HbA1c 63 vs 69, P 087; among these patients experiencing a decline, the most substantial reductions were seen with the control group, which had a 133 115

absolute decline compared with the intervention patients, who reduced their HbA1c by 242 226 absolute reduction; P 00048 At study close, 77 of the patients had their poster displayed on their refrigerator The study concluded that this unique and personalized computer-generated intervention resulted in HbA1c lowering comparable to that of hypoglycemic agents
Department of Internal Medicine, Division of Endocrinology, Washington Hospital Center, Washington, DC MedStar Research Institute, Washington,
DC
2

News Flash:

Doctors warn that up to 13 million more are at risk for developing the deadly illness, advanced kidney disease and they dont even know it In its early stages, kidney disease has almost no symptoms, explains Dr William Keane, president of the National Kidney Foundation Source: HealthSCOUT Publication date: 2002-04-13
Item 5

Exercise Will Lower Your Blood Pressure
A message for all couch-potatoes Researchers who reviewed more than 50 studies on the effects of exercise on blood pressure have a message for all couch-potatoes out there: Get moving Whether you are overweight or trim, have hypertension or normal blood pressure, engaging in regular exercise such as walking, cycling, jogging or swimming can help lower your blood pressure and your subsequent risk of heart attack and stroke The review of 54 clinical trials involving 2,419 previously sedentary adults concluded that regular exercise decreased systolic blood pressure–the upper number in a blood-pressure reading–by an average of 4 mm of mercury mm Hg and diastolic blood pressure, the bottom number, by an average of 26 mm Hg Even a small reduction in the overall populations average blood pressure level
should dramatically reduce the morbidity and mortality of heart disease and stroke in the US general population The new findings offer more evidence that exercise is important both for treating high blood pressure and preventing the condition from developing in healthy people, he said In addition to the cardiovascular risks, high blood pressure also can damage the kidneys, eyes and brain Blood pressure is considered elevated if the reading is 140/90 or higher Statistics show that about 25 of US adults have high blood pressure and up to 30 are sedentary While the study did not identify an ideal amount of exercise for lowering blood pressure, results showed that a variety of types of aerobic exercise at all frequencies were beneficial to people who were previously sedentary In other words, some activity was better than none US health officials advise that people aim to get at least 30 minutes of moderate exercise on 5 or more days a week
Annals of Internal Medicine April 2, 2002;136:493-503

DID YOU KNOW? Each pack of cigarettes sold in the United States costs the nation 718 in medical care and lost productivity, the government said The study by the Centers for Disease Control and
Prevention put the nations total cost of smoking at 3,391 a year for every smoker, or 1577 billion By referring your friends and colleagues to Diabetes in Control you can win a free scholarship or expense check for the 2002 AADE conference in Philadelphia http://wwwdiabetesincontrolcom/scholorshipshtml Item 6

Near-Sightedness Appears Linked to Excess Sugar in Diet
Diets high in refined starches such as breads and cereals increase insulin levels This affects the development of the eyeball

Myopia or near-sightedness is extremely prevalent It affects more than 25 - 35 of European descent populations and up to 50 or more of Asian descent populations If we did not have compensatory mechanisms for myopia and were left to mere Paleolithic resources, it is likely myopic individuals would not survive very long as clear distance vision is required for escape from predators, location of food, recognition of other species members and awareness of environmental dangers and benefits Studies carried out in hunter-gatherer societies and in recently westernized hunter-gatherer groups indicate that the prevalence of myopia normally occurs in 0-2 of the population, and most refractive errors are
less than minor Moderate to high myopia is either non-existent or occurs in about one person out of a thousand Diets high in refined starches such as breads and cereals increase insulin levels This affects the development of the eyeball, making it abnormally long and causing short-sightedness, suggests a team led by Loren Cordain, a n evolutionary biologist at Colorado State University in Fort Collins When these hunter-gatherer societies change their lifestyles and introduce grains and carbohydrates, they rapidly develop within a single generation myopia rates that equal or exceed those in western societies In Dr Cordain study of 229 hunter-gatherer societies, he found that although refined cereals and sugars were rarely s if ever consumed by groups living in their traditional manner, these foods quickly became dietary staples following western contact Hunter-gatherer diets are typically characterized by high levels of protein, moderate levels of fat and low levels of carbohydrate when compared to modern western diets The carbohydrates present in hunter-gatherer diets are of a low glycemic index: they are slowly absorbed and produce a gradual and minimal rise in plasma glucose and
insulin levels when compared to the sugars and refined starches in western diets Studies of recently acculturated hunter-gatherer populations that have adopted western dietary patterns frequently show high levels of hyperglycemia, insulin resistance, hyperinsulinemia and type 2 diabetes Conversely, huntergatherer populations in their native environments rarely exhibit these symptoms In industrialized countries, this dietary shift from hunter-gatherers occurred more slowly over the 200 or so years since the advent of the industrial revolution as more and more refined sugars were gradually included in the diet along with increasingly greater levels of refined cereals Although highly refined sugars and cereals are common elements of the modern urban diet, these carbohydrates were eaten sparingly or not at all by the average citizen in 17th and 18th century Europe and only started to become available to the masses after the industrial revolution Only with the widespread introduction of steel roller mills in the late 19th century did fiber-depleted wheat flour of a low extraction become widely available Hence, over the last 200-250 years the average glycemic load of foods in urban areas
of industrialized countries has risen steadily, primarily because of increasing consumption of refined cereals and sugars This increase in sugars is clearly related to increased levels of insulin Overnight Epidemics While fewer than one per cent of the Inuit and Pacific islanders had myopia early in the last century, these rates have since skyrocketed to as high as 50 per cent These overnight epidemics have usually been blamed on the increase in reading following the sudden advent of literacy and compulsory schooling in these societies But while reading may play a role, it does not explain why the incidence of myopia has remained low in societies that have adopted Western lifestyles but not Western diets, says Cordain In the islands of Vanuatu they have eight hours of compulsory schooling a day, he says, yet the rate of myopia in these children is only two per cent The difference is that Vanuatuans eat fish, yam and coconut rather than white bread and cereals The theory is also consistent with observations that people are more likely to develop myopia if they are overweight or have adult-onset diabetes, both of which involve elevated insulin levels The progression of myopia has
also been shown to be slower in children whose protein consumption is increased High Carbohydrate Intake Increase Insulin Levels

This elevated level of insulin from consumption of excess grains and sugars will serve to increase free insulin like growth factor IGF-1 which can then accelerate scleral tissue growth during critical developmental stages thus leading to myopia A variety of studies also suggest that high carbohydrate diets may cause permanent changes in the development and progression of refractive errors, particularly during periods of early growth and development High insulin levels from the carbohydrate loads could disturb the delicate choreography that normally coordinates eyeball lengthening and lens growth And if the eyeball grows too long, the lens can no longer flatten itself enough to focus a sharp image on the retina, Population studies have demonstrated that people of Asian and Chinese descent tend to be more insulin resistant than people of European descent The prevalence of myopia is also higher in Asian populations than it is in European populations; it is possible that the higher rates of myopia in Asian populations may, in part, be due to their increased
genetic susceptibility to insulin resistance Acta Ophthalmologica Scandinavica March 2002 vol 80, p 125

FACT:
The rate of depression in patients with diabetes is twice that than in the rest of the population Diabetes Care, 25:464-470, 2002 reported the increase in costs go up 45 times when the two disorders are together Thats depressing
ADVERTISEMENT: ADA Releases New Dietary Guidelines The new guidelines support the view that the total amount of carbohydrates consumed in meals and snacks is important in diabetes control, not the source of the carbohydrates The guidelines emphasize weight loss and physical activity and focus on individualized dietary plans based on lifestyle, diabetes management goals and other lifestyle factors Click Here For More Information —————————————————————–Item 7

Splitting Evening Insulin Regimen Improves Nocturnal Hypoglycemia
A split evening regimen reduces the risk of nocturnal hypoglycemia and improves control in patients with type 1 diabetes mellitus In a study supported by the Juvenile Diabetes Research Foundation International, investigators from the University of Perugia in Perugia, Italy, evaluated
the effects of splitting the evening insulin treatment regimen on the known risk for nocturnal hypoglycemia during intensive insulin treatment Twenty-two C-peptide-negative type 1 diabetics, mean age of 29 three years, were randomly assigned to receive one of two insulin regimens for four months and then switched to the other regimen for an additional four months The regimens were either a mixed treatment of human regular and NPH insulin administered before dinner or a split treatment with human regular insulin at dinner and NPH insulin at bedtime Results showed that fewer episodes of nocturnal hypoglycemia occurred per patient per day during the split regimen compared with the mixed regimen 010 002 versus 028 004 Patients also had significantly lower fasting blood glucose levels, less variable fasting blood glucose levels and lower hemoglobin A1c values while they were receiving the split regimen Splitting the evening insulin treatment regimen reduces the risks for nocturnal hypoglycemia and hypoglycemia unawareness, and decreases hemoglobin A1c, the investigators conclude Ann Intern Med 2002; 136: 504-514 Did You Know: The new recommendations from ACE is for people with
diabetes to keep their A1c as close to 65 as possible Since the A1c test is the best test to use in determining how well a patient diabetes is controlled s over time and it is critical that the patients know their A1c level and understand what it means so they can have goals that are attainable

To have an instant A1c test that gives results in 8 minutes and is approved for home and office use go to wwwA1cNownet Item 8

A Big Waist Diabetes Bigger Risk of Stroke
Losing Girth and Weight Shrinks Many Health Problems Too much body fat puts people at high risk of heart disease, diabetes, and cancer — we know that Now, it seems that extra girth in your stomach may mean a stroke, according to a study presented last week at the annual meeting of the American Academy of Neurology In it, researchers analyzed more than 570 stroke victims, and compared them with more than 1,100 people who didnt have a stroke They looked at the waist-to-hip ratio — how big their waist is relative to their hips The stroke group had the biggest waist-to-hip ratio — the biggest bellies Waist-to-hip ratio may be a critical indicator of stroke risk, says study author Seung-Han Suk, MD, of ColumbiaPresbyterian
Medical Center in New York, in a news release People should be educated about the waist-to-hip ratio factor — as well as general weight management — in stroke prevention programs, he says

Did You Know: Of the 16 million Americans living with diabetes today, three-fourths will develop cardiovascular disease CDC
Item 9

Blacks Hit by Diabetes Epidemic
Diabetes epidemic that is sweeping the US is hitting the African American community particularly hard The facts are clear: The, according to doctors They report: Of the 16 million Americans with diabetes, an estimated 23 million are African Americans For every six white Americans who develop diabetes, 10 African Americans develop the disease Death rates in people with diabetes are 27 percent higher for African Americans compared with whites African Americans with diabetes are more likely to develop diabetes complications and experience greater disability from the complications than whites These include kidney failure, vision impairment and amputations Meanwhile, the Joslin Diabetes Center in Boston has recently received initial funding from Alameda, CA-based TheraSense, which manufactures and markets the FreeStyle blood glucose
monitoring system, to begin a diabetes awareness campaign targeted specifically at African Americans This effort is particularly timely given the results of a recent study by the Harvard School of Public Health published in the March 13 issue of the Journal of the American Medical Association showing a gap in the quality of health care African Americans receive in many areas, including diabetes, said a spokesperson Research shows that people with diabetes can have a profound influence on how the disease affects them long-term and short-term People who effectively use weight management, diet, exercise, home blood sugar monitoring and medication to keep their blood sugars in as close to normal a range as possible can reduce their risk of diabetes complications by nearly 60 percent

FACT: High blood pressure affects 71 percent of people with diabetes but few of them receive adequate treatment to achieve recommended levels, according to a new study
Item 10

Final Results of Diabetes Prevention Program Published
Both lifestyle changes and treatment with metformin can significantly reduce the risk of diabetes in high-risk individuals, but lifestyle intervention is more efficacious
That, according to final findings from the Diabetes Prevention Program DPP Results from the DPP were initially reported last August by Department of Health and Human Services Secretary Tommy G Thompson Now the main results have been published in the New England Journal of Medicine The DPP enrolled 3,234 nondiabetic patients mean age, 51 years; mean BMI, 340 with elevated fasting and postload plasma glucose concentrations Women and members of minority groups comprised 68 and 45 of the study group, respectively Participants were randomized to receive placebo, metformin 850 mg twice daily, or a lifestylemodification program goals, /7 weight loss and /0 minutes of physical activity per week During an average follow-up of 28 years, diabetes incidence in the placebo, metformin, and lifestyle-modification groups was 110, 78, and 48 cases per 100 person-years, respectively Incidence of diabetes was reduced by 58 with the lifestyle intervention 95 CI, 48-66 and by 31 with metformin CI, 17-43 compared with placebo The reduction in diabetes incidence achieved with lifestyle intervention was significantly greater than that achieved with metformin During a 3-year period, the estimated number of
patients needed to treat was 69 with the lifestyle-intervention program and 139 with metformin Our results support the hypothesis that type 2 diabetes can be prevented or delayed in persons at high risk for the disease, the authors wrote These effects were similar in men and women and in all racial and ethnic groups Diabetes Prevention Program Research Group N Engl J Med 2002;346:393-403

Did you know?
How you can explain in plain English the importance of the A1c test and what it means? Click on the link below to print out a feature that explains it to the patient Requires Acrobat Reader

Patients

Results
Item 11

How Safe Are Sibutramine, Orlistat and Metformin in the Treatment of Obesity
Safe medications that reduce cardiovascular risk and can decrease the risk of type 2 diabetes mellitus in obese females Some of our obese patients who were receiving 10mg/day sibutramine reported feeling hunger at night To address this, we designed a randomized, prospective clinical trial to study the efficacy and safety of 10mg sibutramine twice daily bid, and compare this treatment with 120mg orlistat three times daily tid and 850mg metformin bid A total of 150 female patients with body
mass index bmi30kg/m2 were included The subjects were all out patients at the Baskent University Endocrinology and Metabolism Clinic Each individual was assigned randomly to receive 10mg sibutramine bid group 1; n50; mean age 4227140 years, 120mg orlistat tid group 2; n50; mean age 4213132 years or 850mg metformin bid group 3; n50; mean age 4358140 years All patients took the medications for 6 months Two patients from the sibutramine group and two from the orlistat group were withdrawn from the study because of side effects After 6 months of treatment, the sibutramine, orlistat, and metformin groups all showed significantly reduced bmi 1357, 906 and 990 respectively; waist circumference 1043, 664, and 810 respectively; fasting and postprandial blood glucose levels; insulin resistance as assessed by the homeostasis model for assessment of insulin resistance HOMA 3863, 3273 and 3928, respectively; levels of total cholesterol, low density lipoprotein LDLC cholesterol, very low density lipoprotein VLDLC cholesterol, triglyceride, lipoprotein a, and apolipoprotein B; uric acid level; pulse rate; and systolic and diastolic blood pressure None of the groups showed any significant changes
in levels of high density lipoprotein HDLC cholesterol, or apolipoprotein A1 There was a significantly greater fall in bmi in the sibutramine group than in either of the other groups p00001

The results of this study confirm that sibutramine, orlistat and metformin are all effective and safe medications that reduce cardiovascular risk and can decrease the risk of type 2 diabetes mellitus in obese females Overall, treatment with 10mg sibutramine bid is more effective than orlistat or metformin therapy in terms of weight reduction Diabetes,
Obesity and Metabolism Volume 4 Issue 1 Page 49 - January 2002

Did You Know:
Data from the third National Health and Nutrition Examination Survey of 1,507 adults with diabetes were used to estimate the blood pressure level, awareness and control The researchers found that 71 of adults with diabetes had high blood pressure The risk of high blood pressure increased with age Of those with high blood pressure, 29 were unaware that they had high blood pressure, 57 were treated for the condition, but only 12 had reduced their high blood pressure to less than 130/85 mm Hg
Reference: Am J Prev Med 2002; 22: 42-48

Item 12

Losartan Versus HCTZ in Type
2 Diabetic Patients
Losartan 50 mg was effective in reducing blood pressure and albuminuria in type 2 diabetic patients The study compared the effects of Losartan dose titration to 100 mg versus the addition of 125 mg of hydrochlorothiazide, in 90 type 2 diabetic patients with microalbuminuria and blood pressure 130/85 mmHg, receiving losartan 50 mg as initial treatment during 4 weeks With the first dose of losartan, systolic SBP and diastolic blood pressure DBP decreased from 1545 15211575 to 1444 14131475 mmHg P 0001 and from 911 894928 to 846 828864 mmHg P 0001, with 20 patients attaining the expected goal blood pressure 130/85 mmHg; albuminuria decreased from 1098 905 1333 to 835 6361095 mg per 24 h P 0006 Patients not attaining the target blood pressure were randomly allocated to titration or to the combination arm After an additional 4 weeks, patients titrated exhibited a fall in SBP and DBP from 1571 15271615 to 1421 13641478 mmHg P 0001 and from 924 895953 to 836 811 861 mmHg P 0001; albuminuria decreased from 1363 9781899 to 997 6931434 mg per 24 h P 0002 In the combination arm, there were similar reductions in SBP and DBP from 1553 15151591 to 1391 13211461 mmHg P
0001 and from 921 893949 to 809 774844 mmHg P 0001; while albuminuria fell from 1077 8221410 to 642 459899 mg per 24 h P 0001 Conclusions Losartan 50 mg was effective in reducing blood pressure and albuminuria in type 2 diabetic patients When the blood pressure target was not reached, the two strategies tested seem to contribute similarly to further reductions in blood pressure and albuminuria
JOURNAL OF HYPERTENSION 2002;20:715-719

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Item 13

Type 2 Diabetes Costs 47,000 for Every Patient
Complications of diabetes cost the health care system about
47,000 per patient over the course of the persons life According to a new study In the first five years after diagnosis, 85 percent of the costs are due to macrovascular disease — problems with blood circulation resulting from conditions such as high blood pressure and high cholesterol Patients in the study who were receiving intensive treatment for their diabetes rather than conventional therapy, however, had reduced costs of complications over a 10-year period Researchers from the Care Research Institute in Concord, Mass arrived at these findings after constructing a simulated model involving 10,000 patients with diabetes They looked at a wide range of complications of the disease, including macrovascular disease, nephropathy, retinopathy, neuropathy and hypoglycemia For the study, researchers assumed all patients had been treated for their diabetes for five years and had a mean HbA1c average blood sugar over three months of 84 Then they looked at how these patients would progress based on a the typical increase in HbA1c of 15 percent per year Over a lifetime, the study found problems related to blood circulation would account for 52 percent of all costs related to
complications, followed by nephropathy 21 percent, neuropathy 17 percent, and retinopathy 10 percent The researchers write: As macrovascular disease costs arise early and represent the major component of lifetime costs, this study supports the initiatives by the National Diabetes Education Program to promote awareness of the benefits of optimizing blood pressure and cholesterol levels as well as blood glucose levels Improving control of known risk factors for cardiovascular disease has an enormous potential for reducing the risk of developing complications and lowering health care costs associated with those complications SOURCE: Diabetes Care, 2002;25:476-481

DID YOU KNOW: Sixty-four percent of black men are overweight, compared with 65 percent for Hispanics and 62 percent for whites Twenty-three percent of black men are obese, compared with 19 percent for both Hispanics and whites
Item 14

Metformin Offsets Weight Gain in Children on Psychotropics
Metformin may help offset weight gain in pediatric patients taking psychotropic medications, according to an open label study reported in the April issue of the American Journal of Psychiatry In this preliminary evaluation of
metformin as a treatment for weight gain associated with psychotropic drugs, the steep increase in weight experienced from these drugs was arrested in all patients, write John A Morrison, PhD, from the Childrens Hospital Medical Center in Cincinnati, Ohio, and colleagues Of 19 children, aged 10 to 18 years, receiving olanzapine, risperidone, quetiapine, or valproate, 15 were white and 4 were black, and there were 12 boys and 7 girls Each patient received metformin, 500 mg three times daily, in a 12week open-label study Of the 19 patients, 15 lost weight, 3 gained up to 16 kg, and 1 patient had no change The mean changes in weight and body mass index at 12 weeks were highly significant One patient who gained 16 kg was also receiving intramuscular medroxyprogesterone acetate, which can also cause weight gain Despite several limitations of this preliminary study and the need for randomized controlled trials, the authors conclude that the pattern of sustained, continued weight loss suggests that the weight loss was not due to the placebo effect Metformin holds promise as a treatment for weight gain in pediatric patients taking psychotropic medications Am J Psychiatry 2002;1594:655-657

FACT:
Gestational diabetes develops in 2 to 5 of all pregnancies but disappears when a pregnancy is over However, women who have had gestational diabetes are at an increased risk for developing type 2 diabetes later in life In some studies, up to 40 of women with a history of gestational diabetes and obesity developed type 2 diabetes within 4 years of pregnancy Item 15

Vascular Surgery Safer than Amputation for Diabetics
New study shows a lower morbidity rate after vascular surgery and is even lower than those who don have the t disease Diabetics are often advised to avoid vascular surgery because the operation could make them worse instead of better; theyre even told theyre better off having a leg amputated than having the procedure However, a new study should put diabetics at ease It finds that, in the short run, their risk of dying after vascular surgery was actually lower than that of those who didnt have the disease Doctors at Bostons Beth Israel Deaconess Medical Center reviewed surgical outcomes of 6,565 patients over a 10year period, and found diabetics had just under a 1 percent mortality rate following major vascular surgery In previous studies, the death rate on the
procedure has been as high as 4 percent, says study author Dr Allen D Hamdan Having diabetes does not predict a higher risk for vascular surgery In fact, there was a lower morbidity rate, says Hamdan, a vascular surgeon at Deaconess and an assistant professor of surgery at Harvard Medical School What this means is that people with diabetes should be treated like anyone else, on a case-by-case basis, with regard to surgery There are about 16 million diabetics in the United States, and 800,000 new cases are diagnosed each year, Hamdan says The disease compromises the circulatory system, so diabetics have significantly more vascular problems such as clotting and risk of gangrene in their outer limbs It is an underlying truth that patients with diabetes have accelerated hardening of the arteries that leads to problems all over the body at an earlier age and at a more accelerated rate, he says This led to the belief that diabetics were felt to have a different type of vascular damage than non-diabetics The feeling was that those with diabetes had worse blockages than people without diabetes, Hamdan says Because of this, simply the presence of diabetes was thought to be an indicator of
higher risk for surgery As a result, he says, patients were — and still are — often advised to have amputations rather than vascular surgery that might improve circulation However, Hamden and his colleagues statistically analyzed outcomes for surgeries in the arteries of the neck and extremities, as well as arteries leading to the heart They found diabetics had a death rate of 096 percent, compared with a 146 percent rate for non-diabetics who had the same operation Hamden says the results were a surprise Diabetics are at much more higher risk for vascular problems, so the results are very surprising, says Renee Meehan, the diabetic clinical nurse specialist at Tampa General Hospital in Florida The study also found, however, that diabetics were at a slightly higher risk of having a heart attack after the procedure Moreover, the long-term survival rate was significantly lower among diabetics than in the non-diabetics
SOURCES: Allen D Hamdan, MD, vascular surgeon, Beth Israel Deaconess Medical Center, and assistant professor, surgery, Harvard Medical School, Boston; Renee Meehan, RN, BSN, MA, CDE, diabetic clinical nurse specialist, Tampa General Hospital, Tampa, Fla; April 2002
Archives of surgeryDIABHRTSSURG

Fact:

For every one-percentage point drop in the Hemoglobin A1c diabetes complication rates drop by more than 25 Source: Diabetes 2001: Vital Stats

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