As every month we begin with the headlines and then move on to the abstracts which this month have to do with work disability among people with diabetes, the need for eye care among older adults with diabetes in fee-for-service and managed care, and finally, the impact of overweight on chronic microvascular complications in type 1 diabetic patients. So get a glass of iced tea and join us.
Our first headline comes from the Juvenile Diabetes Foundation International and is dated April 21, 2005. It concerns Celiac disease and its incidence in type 1 diabetes. This disease is thought to be one of the most under diagnosed common diseases in the US today. One in ten people with type 1 diabetes are affected. The incidence of celiac among people with type 1 diabetes, especially children, has lead an increasing number of healthcare professionals and parents to call for routine screening of all people with type 1 to look for the presence of celiac. Ask your endocrinologist if he/she has heard about this and if you have any of the symptoms when a test is in your future.
Dr. Lucienne Chatenoud of Necker Hospital in Paris reports in the New England Journal of Medicine about a new experimental drug called anti-CD3 antibody which allows the body to retain the ability to make some insulin, potentially lessening the need for insulin injections to regulate blood glucose levels. There were some safety issues noted with this research nevertheless the JDF has funded the work and considered the results of a first small study encouraging enough to plan future large-scale studies. After 1 ½ years, the placebo group lost an average one-third of its insulin production and needed 50 percent more insulin in shots to regulate blood sugar. The group that got the medication lowered insulin dependence by 12 percent and increased insulin making capacity. The drug worked best in patients who still had about half of their insulin function remaining.
Dr. Ake Lenmark a professor of Medicine at the University of Washington wrote an accompanying editorial that more research is needed to address the drug’s safety. The problem being that most diabetic are diagnosed when they have lost 90% of their insulin making capacity.
Here’s good news. The Australian Minister of Health and Aging, Tony Abbott announced on April 8, 2005 the commitment of $30 million to the Juvenile Diabetes Foundation to fund research for a cure for type 1 diabetes. The funds will be used by JDRF to establish an islet transplant program in Australia.
The University of Alberta has reported on June 19,2005 that people with a high fat diet have an increased risk for developing type 2 diabetes, if they carry a particular type of common specific genetic trait known as polymorphism. While we need some fat in our diets, because it helps the body absorb some vitamins, is a good source of the essential fatty acids that the body can not make itself, having too much saturated fat can increase the amount of cholesterol in the blood, which increases the chance of developing heart disease. Trans fats have a similar effect on blood cholesterol; as saturated fats they raise the bad LDL cholesterol in the blood. Publishing their findings in the journal Diabetes, pharmacology professor Peter Light and graduate student Michael Reidel suggest that saturated and trans fats are much more effective activators of a specific potassium channel fund in the pancreas-known when activated to reduce secretion from the pancreas and increase blood sugar levels.
The effect, they say, is amplified in the polymorphic potassium channel. Polyunsaturated fats are poor activators of the potassium channel. “We are suggesting that people with this specific potassium channel polymorphism- about 2 million Canadians-may be more susceptible to type 2 diabetes if they have a high fat diet or are over overweight, two of the biggest risk factors for type 2 diabetes,” says Dr. Light. This may explain why 20 percent of type 2 diabetics carry two copies of this polymorphism in their genes compared to only 10 per cent in the non-diabetic Caucasian population. The researchers say this discovery “opens the distinct possibility of genetic screening of people at risk for type 2 diabetes,” which would give doctors additional information to advise their high-risk patients on preventative diet and exercise.
About 10 per cent of non-diabetic Caucasians who possesses this polymorphism may be at increased risk of developing 2 diabetes if they consume a diet high in saturated and trans fat, they add.
Finally, six people have now undergone islet transplantation in the UK and results continue to be encouraging according to Jo Brodie, Islet Project Coordinator at Diabetes UK. “The technique is complex but the islet consortium in the UK is having regular successes and the progress is being constantly refined. There is still a long way to go but we hope that eventually, islet transplantation may be offered as an effective treatment for Type 1 diabetes.”
Our first abstract is titled Work disability among individuals with diabetes in Diabetes Care 28:1326-1332, 2005 by Michael Von Korff, SCD et al. The researchers knowing that diabetes is becoming more and more prevalent wanted to examine the clinical characteristics that predict work disability in working-age people with diabetes. In a cohort of diabetic people enrolled in a large health maintenance organization, excluding homemakers and retirees, they assessed the relation of diabetes severity, chronic disease comorbidity, depressive illness, and behavioral risk factors with work disability. Three indicators of work disability were assessed: being unable to work or otherwise being unemployed; missing =5 days from work in the prior month; and having severe difficulty with work tasks.
In the study population, 19% had significant work disability: 12% were unemployed, 7% of the employed subjects had missed =5 days from work in the prior month, and 4% of employed subjects reported having difficulty with work tasks. Depressive illness, chronic disease comorbidity, and diabetes symptoms were associated with all three types of disability. Diabetes complications predicted unemployment and overall work disability status, whereas obesity and sedentary lifestyle did not predict work disability. Among subjects experiencing both major depression and three or more diabetes complications, > 50% were unemployed; of those with significant work disability, half met the criteria for major or minor depression. The researchers concluded that depressive illness was strongly associated with unemployment and problems with work performance. Disease severity indicators, including complication and chronic disease comorbidity, were associated with unemployment and overall work disability status. They concluded that effective management of work disability among diabetic patients may need to address both physical and psychological impairments.
Our second article is of special interest to those who are on Medicare and who have diabetes. It is titled Need for eye care among older adults with diabetes mellitus in fee–for–service and managed care, Archives Ophthalmology, 2005;123:669-675, by Arleen F. Brown, MD et al. The researchers set out to compare rates of need for eye care among Medicare beneficiaries with network-model Medicare+ Choice (MC) and fee–for–service (FFS) health insurance. This was a cross-sectional study of a random sample of MC and FFS community dwelling beneficiaries with diabetes who were older than 65 years of age in Los Angeles Country. Study ophthalmologists masked to the participants’ type of health insurance performed standardized dilated eye exams and indicated the need for ophthalmic care during the next 6 months.
To evaluate the association between type of insurance and need for treatment, they constructed a logistic regression model adjusted for participant sociodemographic and clinical characteristics. The results are interesting to all of us as we’re all heading toward Medicare at sometime in the future. The 311 MC and 107 FFS respondents reported comparable rates of eye care provider visits and preexisting eye diseases. However, on masked clinical examination, MC respondents were more likely to have diabetic retinopathy, visually significant cataract, glaucoma, or suspected glaucoma than FFS participants. In multivariate analyses, persons enrolled in MC were significantly more likely than FFS participants to require further treatment during the next 6 months. The authors concluded that their data suggest high rates of unrecognized and untreated eye diseases among Medicare beneficiaries enrolled in both FFS and MC and significantly higher rates of need for care among MC participants.
Our last abstract is close to all of our hearts; in fact it has to do with our hearts and gives us good reason to take care of ourselves. Diabetes Care 28:1649-1655, 2005 has an article titled Impact of overweight on chronic microvascular complications in type 1 diabetic patients by Christophe E.M. DeBlock, MD, PHD, et al. The researchers investigated the possible association of BMI with retinopathy and neuropathy in type 1 diabetes. Retinopathy and neuropathy may not only be related to glycemic control and diabetes duration but also to blood pressure and BMI. A total of 592 type 1 diabetic patients without nephropathy were studied. Patients were subdivided according to BMI: 168 men and 146 women with BMI < 25kg/m². Retinopathy was examined by fundoscopy and neuropathy by electromyography. Hypertension was present in 40%, retinopathy in 53%, and neuropathy in 43% of patients.
Overweight subjects had more retinopathy, odds ratio, and neuropathy than normal-weight patients. Patients with retinopathy were older and had a longer diabetes duration, a higher A1C, and a higher BMI than individuals without retinopathy. The same results are found for neuropathy. Logistic regression analysis showed that diabetes duration, blood pressure, and A1C, but not BMI, lipid levels, sex, or age, were independent risk factors for retinopathy. Likewise, duration, age, A1C, and sex but not BMI, lipid levels, or hypertension were independently associated with neuropathy. Men had more neuropathy than woman. Leptin and adiponectin levels did not differ between individuals with or without microvascular complications. The researchers concluded that retinopathy and neuropathy are more prevalent in overweight type 1 diabetic subjects. However, logistic regression analysis showed that diabetes duration and A1C remain the main determinants for retinopathy and neuropathy.
BSP
