Once again we begin with our headlines. We then share our abstracts about the Pathway study, the efficacy of inhaled insulin for those with type 1 diabetes, reduced hospitalizations and death with influenza vaccination in people with diabetes and CVD and retinal microvascular characteristics in type 1 diabetes. So fire up the coffee pot or tea kettle and get ready to read. The Nov.8 2004 Archives of Internal Medicine 161:1857-1862 had an article that pinpoints the reason for our monthly magazine that is the importance of the food we eat and the risk for illness. US investigators have found people that ate mostly western food- including French fries, refined grains such as white bread and red and processed meats-were 50 percent more likely to develop diabetes over a 14-year period than people who ate minimal of these types of food. The researchers based at Simmons College and the Harvard School of Public Health in Boston analyzed almost 70,000 women. Nearly 2700 developed type 2 diabetes and these ate large amounts of red or processed meats. Understanding this may help with selection of food during this holiday season and all during the year.
The latest findings of the Women’s Health Initiative Observational Study were announced in New Orleans at the American Heart Association. Dr. Judith Hsia of George Washington explained that among 100,000 post menopausal women in the study, 74,240 were white, 6465 were African American, 3231 Hispanic, 2444 Asian and 327 American Indian women. During the follow-up diabetes was reported by 2.2 percent of white women. 6.2 percent of African American, 4.5 percent of Hispanic, 3 percent of Asian and 5.7 percent of American Indian women. For white women exercise“demonstrated a strong inverse relationship with diabetes risk, but Hsia reported this did not hold true for other ethnic groups. She speculated that the differences between could be due to genetic influences, but she stressed that ‘this does not imply that exercise is of not benefit to minorities." Adjusting for other risk factors such as cholesterol, education and alcohol consumption showed that African American and Hispanic women were less likely to develop diabetes than their less active counterparts.
The FDA approved new labeling for Hoffman-LaRoche Inc.s weight loss medication orlistat (Xenical) which indicates that the compound delays the onset of type 2 diabetes in obese patients with impaired glucose tolerance. Approval of the new labeling was based on a 4-year study involving 3,304 obese patients with normal or impaired glucose tolerance. Roche said that this study marks the first time a weight-loss drug has been shown to prevent or delay the onset of type 2 diabetes.
Diabetes Care 27:2676-2681, 2004 has an article by Michael Stern, MD et al which examined the metabolic syndrome as a predictor of type 2 diabetes and cardiovascular disease (CVD). The sensitivities for predicting diabetes with metabolic syndrome were 66.3 and 62.4% in the San Antonio Study and Mexico City Diabetes Study respectively. The researchers concluded that metabolic syndrome is inferior to established predicting models for either type 2 diabetes or CVD.
The Archives if Internal Medicine 2004;164:757-761 had an article by Gavin Blake, MD et al examining Hemoglobin A1c levels and future cardiovascular events among women. They concluded a nested case-control study of the Women’s Health Study cohort and identified 464 case patients with incident myocardial infarction, stroke, or coronary revascularization and 928 unmatched control subjects who remained free of cardiovascular events at case diagnosis. The mean follow-up was 7 years. They concluded that the A1c level was associated with future cardiovascular with future cardiovascular risk women without diabetes, but this relationship is largely attributable to a strong correlation with other cardiovascular risk factors. In contrast, diabetes is a strong independent determinant of cardiovascular risk even after adjustment for A1c levels.
The Archived of General Psychiatry 2004;61:1042-1049 by Wayne J. Katon, MD et al wrote an article titled The Pathways Study, A randomized trial of collaborative care in patients with diabetes and depression. The researchers knowing that there is a high incidence of depression in people with diabetes wanted to determine whether enhancing quality of care for depression improves both depression and diabetes outcomes in patients who have both depression and diabetes. They conducted a randomized controlled trial with recruitment from March 1, 2001 to May 31, 2002 in nine primary care clinics from a large health maintenance organization. A total of 329 patients with diabetes and comorbid major depression and/or dysthymia were included. Patients were randomly assigned the Pathways case management intervention or usual care. The intervention provided enhanced education and support or antidepressant medication treatment prescribed by the primary care physician or problem solving treatment delivered in primary care. Independent blinded assessments at baseline and 3, 6, and 12 months of depression, global improvement, and satisfaction with care were the main outcome measures. Automated clinical data were used to evaluate adherence to antidepressant regimes, percentage receiving specialty mental health visits, and HbA1c. When compared with usual care, intervention patients showed greater improvement of adequacy of antidepressant medication treatment in the first 6-month period and the second 6-month period, less depression severity over time, a higher rating of patient global improvement at 6 months at 6 months and 12 months, and higher satisfaction with care at 6 months. Although depression outcomes were improved, no differences in HbA1c outcomes were observed. The researchers concluded that the Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression alone did not result in improved glycemic control.
This is for all of you who e-mail us about inhaled insulin. Diabetes Care 27:2622-2627, 2004 has an article titled Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy with patients wit type 1 diabetes by Teresa Quattrin, MD et al. The purpose of this study was to determine whether premeal pulmonary delivery of rapid-acting, dry-powder insulin (Exubera) plus Ultralente could provide glycemic control comparable to a conventional insulin regime in type 1 diabetes. Three hundred thirty-five subjects were randomly assigned to receive premeal inhaled insulin plus bedtime Ultralente or two to three injection of regular and NPH insulin for 24 weeks. The primary end point was a change in HbA1c. Mean decreases in HbA1c values were comparable for inhaled and conventional groups. There were greater reductions for inhaled verses conventional regimen in fasting and postprandial plasma glucose. Hypoglycemia was lower for the inhaled verses the conventional group. In subjects receiving inhaled insulin, increased insulin antibodies were observed, but there were no associated clinical or laboratory changes. Adverse were comparable between groups. Mild to moderate cough was more frequent in the inhaled group but decreased during the treatment. Pulmonary function tests were not different between the groups except for a greater decrease in carbon monoxide diffusing capacity in the inhaled group. Treatment satisfaction was greater in the inhaled than the conventional group. The researchers concluded that inhaled insulin is effective, well tolerated, and well accepted in patients with type 1 diabetes and provides glycemic control comparable to that with a conventional insulin regime.
Diabetes Care, 27:2581-2584, 2004 has an article titled Reduced hospitalizations and death associated with influenza vaccination among patients with and without diabetes by Anthony D. Heymann. MD MHA et al. The researchers assessed whether influenza vaccination of community dwelling, diabetic, elderly people is associated with reduced rates of hospitalization and death. This is an outcomes-research study, in which mortality and hospitalization rates of 15,556 patients aged 65 or older were followed using the diabetes registry in a large HMO to that of 69,097 members not suffering from chronic disease who were considered as a reference group. The study outcomes included all-cause death and hospitalization in internal medicine or geriatric wards for any reason over winter and summer (control) periods. Vaccination rates were 48.8 and 42.0% among patients with diabetes and the reference population, respectively. Influenza vaccination was associated with a 12.0 %% reduction in hospitalization rates for patients with diabetes compared to 23.0% in the reference group. The reduction in hospitalization rates was similar in both sexes among patients with diabetes. In addition, there was a significant reduction in mortality for the vaccinated group of patients with diabetes when compared with the nonvaccinated group except for female patients age great than or equal to 85 years. The researchers concluded that the study results support the use of influenza vaccine among the elderly population; however, there does not appear to be an additional benefit for patients with diabetes.
Archives of Internal Medicine 2004; 164:1917-1924 has an article titled Cardiovascular disease, mortality and retinal microvascular characteristics in type 1 diabetes, the Wisconsin epidemiologic study of diabetic retinopathy, by Barbara Klein, MD et al. Diabetic retinopathy and proteinuria, manifestations of microvascular abnormalities, occur early in the course of type 1 diabetes; in contrast, macrovascular cardiovascular complications usually occur later. Retinal vessel characteristics may be informative about risk of cardiovascular disease in persons with diabetes. The researchers evaluated this in a longitudinal cohort study. The population consisted of persons with type 1 diabetes who were receiving care in 11 counties in Wisconsin who were examined at baseline and 4, 10, 24, and 20 years later. Evaluations included medical history and measurements of height, weight, blood pressure and glycosylated hemoglobin. Fundus photographs were grated for diabetic retinopathy at baseline and the same photographs were graded later for the diameter of retinal blood vessels. At each examination, a history of cardiovascular disease events since the last examination was obtained. Mortality was monitored yearly. The results indicated that the 20 year age-adjusted cumulative incidences were 18.1% angina, 14.8% for myocardial infarction, and 5.9 % for stroke. Severity of diabetic retinopathy was associated with angina and stroke. Arteriovenous ratio was associated with myocardial infarction. Of 273 deaths, 176 involved heart disease. The severity of retinopathy and arteriovenous ratio was associated with heart disease mortality. Nephropathy was more informative about the cardiovascular end points than the blood vessel characteristics. The researchers concluded that incidences of cardiovascular disease, including mortality, were common with people with type 1 diabetes during a 20-year interval. Retinal vascular characteristics were associated with these points, but this association was confounded by nephropathy.
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