A big round of applause for the federal government and the President starts our headlines. In December, President Bush signed H.R. 5738, which will provide $1.5 billion for diabetes research and programs over the next 5 years. Signing this bill extends the Special Diabetes Program through fiscal year 2008. This program has two components: type 1 research at the NIH, and diabetes prevention and treatment programs for American Indians through the Indian Health Service. In recognition of the growing impact of diabetes, funding for each component of the program was expanded from $100 million annually to $150 million annually. Why not send a note of appreciation and need for even more future funding to the President and/or Secretary Tommy Thompson of Health and Human Services.
Next we share some more information about heart disease in the US. Last month we dedicated the magazine to cardiovascular disease because we, as people with diabetes, are at significant risk for developing heart disease. To bring home the point that appropriate health care is important; we noted an article from Harvard Medical School which stated that people who had a heart attack who were seen by a cardiologist were more likely to survive than those who saw a generalist doctor. It is thought that cardiologists were more likely to recommend cardiac procedures and rehabilitation.
Now we finish with four more bits of information that may interest you. First, the FDA has cleared an over-the-counter blood glucose test. The nonprescription MetrikaA1c, made by Metrika, Inc. of Sunnyvale, CA, measures blood levels of glycated hemoglobin. The result of this test tells us our average blood glucose levels over a period of 90-120 days which gives us information of how well our medications, etc., are working.
Five nationally known companies are starting a diabetes program in 2003 modeled after a successful initiative in Ashville, NC where trained pharmacists played an instrumental role in helping the city save millions in disease-related costs. The American Pharmaceutical Association's research and educational arm is orchestrating the national pilot from a grant from the pharmaceutical company Aventis. In the Ashville program, pharmacists were paid a fee to "coach" patients on diet, exercise, medications, provide foot exams, review glucose monitor readings and consult with doctors. The city's average cost for diabetes patients was cut by almost 1/3. The model allows pharmacists to provide services they are trained for and hopefully lower costs in the pilot cities. Keep looking to see if you are living in an area where it will be tried.
The JDF has reported that the NIH has revised its Human Embryonic Stem Cell Registry to acknowledge that there are only nine viable cell collections available for medical research , not the dozens that the Bush administration initially claimed. Paul Berg, a Nobel Laureate at Stanford University told the Milwaukee Journal Sentinel that "They're frozen cells, or they've died, or when they grew them out they weren't stem cells". The viable ones "are all of a limited genetic diversity. If we're ever going to explore and get full benefit of stem cell research, we need more cell lines."
Harvard and Aetna have found that HRT can cut the risk for developing diabetes but they do not suggest that women go on this therapy. They suggest just what we suggest here, more exercise, better eating habits and a healthier lifestyle.
Our first abstract comes from the American Journal of Cardiology 2002;90:927-931 and is written by Lori L. Boland et al of the University of Minnesota in Minneapolis. The article concludes that about 15 to 20% of heart attacks among middle-aged and older adults go unrecognized. While that number may sound high, it marks an improvement over earlier estimations. It is possible, the authors explain, that greater public awareness of heart attack symptoms and more sensitive cardiac tests have led to fewer unrecognized heart attacks in recent years. Boland's team analyzed data on more than 12,800 men and women who participated in a study of cardiovascular health between 1987 and 1998. All were free of coronary artery disease at the study's start. The researchers found that African Americans had a higher percentage of undetected heart attacks than whites did: 23%, compared with 19%. Although they could not be sure, the authors concluded that in the 1990's it became more likely that people sought medical care for possible attack symptoms. In addition recent advances in detection, such as cardiac enzyme tests, may have allowed doctors to diagnose cases of mild heart attack. If you have any symptoms of a heart attack, the authors advise calling 911, and if you are at risk for a heart attack, make sure you are aware of these symptoms.
The Journal of Pediatrics 2002; 141:611-617 has an article titled Infants of diabetic mothers at increased risk of oculo-auriculo-vertebral spectrum, by Dr. John Graham, Jr. et al from Cedars-Sinai Medical center in Los Angeles. The authors evaluated the Spanish Collaborative Study of Congenital Malformations (ECEMC), looking specifically for ocular malformations, vertebral defects, and facial defects (oculo-auriculo-vertebral spectrum, OAVS). They identified more than 25,000 malformed infants born between 1976 and 2001 who had no identified genetic syndromes and whose mothers' diabetic status was unknown. There were 112 infants born to women with preconceptional-onset diabetes and 594 born to mothers with gestational diabetes (GDM). Dr. Graham's group believes that the defects are due to defective neural crest cell migration, which occurs between the 4th and 7th weeks of gestation. The difference may "reflect the possibility that mothers with preconceptional-onset diabetes mellitus had a better first trimester glycemic control than their GDM counterparts, whose diabetes mellitus was diagnosed beyond the critical period of blastogenesis". Because congenital abnormalities may be due to undiagnosed diabetes, the authors' advice is that any infant with malformations undergo a workup that includes hearing evaluation, skeletal survey, echocardiogram and renal ulrasonogram. If immunodeficiency is suspected or if neonatal hypocalcemia is present, they also recommend a workup for the DiGeorge sequence. They emphasize that preconceptual glycemic control is absolutely necessary to protect infants from developing OAVS. In addition, prenatal care should be started as soon as possible to manage and diagnose gestational diabetes if there is any risk factor.
Annals of Surgery 2002 Nov;236(5):554-9 had an article titled the Potential of surgery for curing type 2 diabetes mellitus by Rubino, F and Gagner. M. The authors reviewed the effect of morbid obesity surgery on type 2 diabetes and analyzed the data that might explain the mechanisms of actions of these surgeries that could answer the question of whether surgery for morbid obesity can represent a cure for type 2 diabetes in non-obese patients as well. The authors reviewed data from the literature to address what is known about the effect of surgery for obesity on glucose metabolism and the endocrine changes that follow surgery. They found that long-term follow-up shows that gastric-bypass and biliopancreatic diversion achieve durable normal levels of plasma glucose, plasma insulin, and glycosylated hemoglobin in 80% to 100% of severely obese diabetic patients, usually within days after surgery. Available data show a significant change in the pattern of secretion of gastrointestinal hormones. They concluded that gastric bypass and biliopancreatic diversion seem to achieve control of diabetes as a primary and independent effect, not secondary to the treatment of overweight. Although they concluded that controlled trials need to be done to verify the effectiveness on non-obese individuals, they feel that gastric bypass has the potential to change the current concepts of the pathophysiology of type 2 diabetes and, possibly, the management of this disease.
JAMA Vol.287. No.19, May 15, 2002 had an article titles Predictors of acute complications in children with type 1 diabetes by Arleta Rewers, MD, PhD et al.
The authors examined a cohort of 1243 children from infancy to 19 years of age who lived in the Denver metropolitan area. They were followed up prospectively for 3994 person-years from Jan 1, 1996 through Dec 31, 2000. The researchers wanted to know about risk factors, which would predict diabetic ketoacidosis and severe hypoglycemia in children. Incidence of ketoacidosis leading to hospitalization or emergency room visits and severe hypoglycemia were the main outcome measures. The incidence of ketoacidosis was 8 per 100 person-years and increased with age in girls. In multivariate analyses, sex-adjusted and stratified by age, the risk of ketoacidosis in younger children increased with higher hemoglobin A1c and higher reported insulin dose. In older children, the risk for ketoacidosis increased with higher hemoglobin A1c, higher reported insulin dose, underinsurance, and the presence of psychiatric disorders. The incidence of severe hypoglycemia was 19 per 100 person-years and decreased with age in girls. In younger children, the risk of severe hypoglycemia increased with diabetes duration and underinsurance. In older children, the risk for severe hypoglycemia increased with duration, underinsurance, lower HbA1c, and the presence of psychiatric disorders. Eighty percent of episodes occurred among 20% of children who had recurrent events. The researchers concluded that some children remain at high risk for ketoacidosis and severe hypoglycemia. Age and sex specific incidence patterns suggest that ketoacidosis is a challenge in adolescent girls while severe hypoglycemia continues to affect disproportionally the youngest patients and boys of all ages. The pattern of modifiable risk factors indicates that underinsured children, those with psychiatric disorders, or at the extreme of HbA1c distribution should be targeted for interventions.
Our last abstract is from JAMA Vol.288, No.21. Dec.4, 2002 and is titled The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men by Hanna-Maaria Lakka, M.D., PhD. Metabolic syndrome is a concurrence of disturbed glucose and insulin metabolism, overweight and abdominal fat distribution, mild dislipidemia, and hypertension, and is associated with subsequent development of type 2 diabetes and cardiovascular disease (CVD). The researches look at the association of metabolic syndrome with cardiovascular and overall mortality using recently proposed definitions and analysis. The Kuopia Ischemic Heart Disease Risk Factor Study, a prospective cohort study of 1209 Finnish men aged 42 to 60 years at baseline (1984-1989) and initially without CVD, cancer, or diabetes were followed through Dec 1989. The prevalence of metabolic syndrome ranged from 8.8% to 14.3 % depending on the definition used. There were 109 deaths during the approximately 11.4 year follow-up. The researchers concluded that cardiovascular disease and all-cause mortality increased in men with metabolic syndrome, even in the absence of baseline CVD and diabetes. Early identification, treatment, and prevention of the metabolic syndrome present a major challenge for health care professionals facing an epidemic of overweight and sedentary lifestyle.
That's it for this month. Hope you found this information useful and, remember, we will look out for your areas of interests if you let us know.
BSP
