April has arrived and the world is once again in bloom. As we write this article, the world is debating its future and we in the US sit and wait to see if we will go to war. With all of the crises in the world, some people may decide it's not worth taking care of diabetes. Not so! Now is the time to take better care because you will need your health. We all know the effects of stress on diabetes, so please take some time out and read the medical information presented in these journal abstracts. They can only help you as you make decisions everyday about how to care for your health. As always, we will begin with headlines and then we will talk about trends in mortality burden associated with diabetes, poor blood pressure control in type 2 diabetes, hypoglycemia in prepubertal children with type 1 diabetes, and diabetes and sleep disturbances.
Our headlines are important this month as always. We first look at one of the results of the Third National Health and Nutrition Examination Survey (NHANES III). The researchers estimated the percent and number of overweight adults in the U.S. with pre-diabetes who would be potential candidates for diabetes prevention. Overall, 17.1% of overweight adults aged 45-74 had impaired glucose tolerance (IGT), 11.9% had impaired fasting glucose (IFG), 22.6% had pre-diabetes, and 5.6% had both IGT and IFG. Based on that data, they estimated that in the year 2000, 9.1 million overweight adults aged 45-74 had IGT, 5.8 million had IFG, 11.9 million had pre-diabetes, and 3.0 million had IGT and IFG. Almost 12 million overweight people in this age group may therefore benefit from diabetes prevention intervention.
Heart Disease Weekly has an article by William R. Hiatt, M.D. et al in which they write about lowering blood pressure which can then reduce heart attacks and other cardiovascular events in diabetics who have clogged arteries. The authors examined peripheral arterial disease (PAD) that is a manifestation of generalized atherosclerosis as an independent predictor of cardiovascular events such as heart attack or stroke. "Despite the enormous prevalence and well-established risk of events, PAD is both unrecognized and under treated by primary care physicians compared with the patients with coronary artery disease". High blood pressure is a major risk factor for PAD and this study showed that intensive blood pressure control improves cardiovascular outcomes in patients with PAD who are given a calcium-channel blocker and/or an ACE inhibitor. They conclude that these results are consistent with the emerging theme that aggressive blood pressure control is especially advantageous in the diabetic population.
Diabetes care 2003;26:302-307 has an article titled Animal fat intake associated with diabetes risk by Dr. Basil G. Karamanos et al from Athens University, Greece. They examined the effects of dietary factors on the development of type 2 diabetes. The concluded that "increased animal fat in the diet may contribute to increased incidence of diabetes".
The costs of diabetes have spiked sharply over the last 5 years in the U.S. The annual cost of the condition climbed from $98 billion in 1997 to $132 billion in 2002 according to the ADA. The nation spends $13,243 on each diabetes patients, compared to $2,560 per person for those who do not have diabetes. These are excellent reasons to "fight this disease that touches so many of our lives," says Health and Human Services Secretary Tommy Thompson.
An experimental oral insulin product, hexyl-insulin monocinjugate 2, (HIM2) Nobex Corp., Research Triangle Park, N.C. may control postprandial glucose without causing peripheral hyperinsulinemia. It was more effective in tests than placebo and as effective as subcutaneous insulin with respect to 2-hour postprandial glucose concentration. Dr. Mark Kipnes of the Diabetes and Glandular Disease Clinic in San Antonio, TX said "HIM2 seems to have an advantage over subcutaneous insulin, other than ease of administration, in that it mimics normal physiology." Unlike subcutaneous insulin, oral HIM2 passes through the liver and this appears to decrease the peripheral insulin level.
Here we are at the last headline, but one that may amaze you. Dr. Edwin Gale, in Diabetes, has examined the numbers of type 1 diabetes in genetically stable population and examines the history of type 1 in the 20th century. Prior to the discovery of insulin in 1921, the diagnosis of type 1 diabetes was rare. From 1920 -1950 the incidence was relatively constant; however, since 1950 the incidence of type 1 has risen sharply. An average 3% annual increase was noted in the 60s, but it was not until the 80s that this rise was noted. These British researchers imply that the environment may play a large role in causing the disease, as well other factors, unknown, that affect the rate at which diabetes process unfolds, or something new has entered the environment. They conclude that "...gene expression may not be predetermined from birth but is actually influenced greatly by the environment." "Once scientists better understand the genetic/environmental interactive process and the patterns of change over time, juvenile diabetes could become a partly preventable condition," concludes Dr. Gale.
The Archives of Internal Medicine 2003;163:445-451 has an article titled Trends in the mortality burden associated with diabetes mellitus, by Randal J. Thomas, M.D. et al. Since you have already read of the financial burden of diabetes in the headlines this month, here we look at research about the mortality burden of the disease, which has been unclear. The researchers analyzed a population-based longitudinal database to address this issue. They looked at the medical records of all Rochester residents 45 years ands older who died between Jan 1, 1970 and Dec. 31, 1994 to identify those who met the criteria for diabetes mellitus before death. Of the 10,152 total deaths, 1384 (13.6%) met the criteria for prevalent DM. Between 1970-1974 and 1990-1994, the proportion of decedents with DM increased by 48.2 %. Mortality rates for persons with and without DM declined by 13.2% and 21.4% respectively. This disparity in mortality trends was most apparent for older women and younger men. There were temporal declines in the proportion of all persons dying of cardiovascular disease, but temporal declines in persons dying of cerebrovascular disease were found only in decedents without DM.
They concluded that the mortality burden associated with DM increased significantly between 1970 and 1994, probably due to increases in DM incidence and smaller declines in mortality in persons with DM. In the absence of improved DM prevention and treatment, the steady declines in mortality observed for the general population since the1960s will likely begin to slow or even reverse in this population.
The Role of organizational factors in poor blood pressure in patients with type 2 diabetes, The QuED Study Group-Quality of Care and Outcomes in Type 2 Diabetes, by Fabio Pellegrini, MS et al is found in the Archives of Internal Medicine 2003;163:473-480. There is a large body of evidence, which supports the need for reducing the cardiovascular burden of diabetes. The aim of this study was to explore the interplay of some potential key determinants of quality of anti-hypertensive care, including settings, physicians' beliefs and blood pressure (BP) control, and patients-related factors. The results indicated that only 16% of GPs and 14% of DOC (diabetes outpatient clinic) doctors targeted BP values of less than 130/85 mmHg. At study entry, 6% of the patients had values below 130/85mmHg, whereas 52% showed values of 160/90 mmHg or greater. Only 12% of subjects were treated with more than 2 drugs at study entry, compared with 16% at the 1-year follow-up. Multilevel analysis showed that patients attending DOCs had a more than 2-fold increased risk for inadequate BP control, compared with those treated by GPs. The risk for poor BP control was 2 times higher for patients treated by male physicians compared with those treated by female physicians, and it was halved when the physician responsible for the diabetes care specialized in diabetology or endocrinology. They concluded that in the model situation of co-morbidity, the overall quality of care depends on structural and organizational factors, which are likely to be influential rather than existing guidelines.
Diabetes Care 26:662-667,2003 has an article titled Hypoglycemia prevalence in prepubertal children with type 1 diabetes on standard insulin regime: use of continuous glucose monitoring system, by Rakesh Amin, MBCLB,MRCP et al. The research looked at the prevalence of hypoglycemia in prepubertal children on three daily and two daily insulin injections using the Medtronic MiniMed Continuous Glucose Monitoring System. Twenty-eight children ages <12 years wore the sensor for three consecutive days and nights. Hypoglycemia was defined as glucose <60 mg/dl for >15 minutes. Data was expressed as the percentage of time spent hypoglycemic. Hypoglycemia prevalence was 10.1%. It was more common at night compared to daytimes; 78 and 43% of subjects showed hypoglycemia on at least one night and two or more nights, respectively. Nocturnal episodes were prolonged (median 3.3h) and asymptomatic. On a TID compared with a BID regime, nocturnal hypoglycemia prevalence was reduced between 0400-0730 h, whereas hypoglycemia the following morning was greater. Nocturnal hypoglycemia risk is associated with decreasing age, increased insulin dose, insulin regime, and increased weight standard deviation score. They concluded that use of standard insulin regimes results in high prevalence and large intra-individual variation in hypoglycemia, particularly at night. Independent risk factors for nocturnal hypoglycemia were younger age, greater daily insulin dose, insulin regime and increasing weight.
Diabetes and Sleep Disturbances, Findings from the Sleep Heart Health Study by Helaine E. Resnick, PHD, MPH et al is found in Diabetes Care 26:702-709, 2003. The researchers tested the hypothesis that diabetes is independently associated with sleep-disordered breathing, and that diabetes is associated with sleep abnormalities of a central, rather than obstructive nature. Using baseline data from the Sleep Heart Health Study (SHHS), they related diabetes to the respiratory disturbance index (RDI; number of apneas plus hypo-apneas per h of sleep; obstructive apnea index; percent of sleep time <90% O2 saturation; central apnea index; occurrence of a periodic breathing pattern: and sleep stages. Initial analyses excluding persons with prevalent cardiovascular disease (CVD) were repeated included these participants. Of the 5,874 participants included in this report, 692 (11.8%) reported diabetes or were taking oral hypoglycemic medications or insulin, and 1,002 had prevalent CVD. Among the 4,872 persons without CVD, 470 (9.6%) had diabetes. Diabetic participants had worse CVD risk factor profiles then their nondiabetic counterparts, including higher BMI, waist and neck circumferences, triglycerides, higher prevalence of hypertension, and lower HDL cholesterol. Descriptive analyses indicated differences between diabetic and nondiabetic participants in RDI, sleep stages, sleep time, <90% O2 saturation, CAI, and periodic breathing.
The researchers concluded that the data suggest that diabetes is associated with periodic breathing, a respiratory abnormality associated with abnormalities in the central control ventilation. Some sleep disturbances may result from diabetes through the deleterious effects of diabetes on central control of respiration. The high prevalence of sleep-disordered breathing in diabetes, although largely explained by obesity and other confounders, suggests the presence of a potentiality treatable risk factor for CVD in the diabetic population.
BSP
