As every month, we start out with our headlines and then go on to the abstracts. This month we will share articles on Modulation of food intake by glucose in patients with type 2 diabetes, Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care, and Duration of lactation and incidence of type 2 diabetes.
Our first headline which brings good news comes from the November, 2005 Journal of Pediatrics and is written by Dr. Timothy W. Jones from Perth, Australia. The authors stated that it has been thought that children who develop type 1 diabetes very early in life and suffer from severe hypoglycemic events may show declines in metal abilities. This same population has the potential for severe hypoglycemic insult which may affect the region of the brain called the hippocampus. In investigating this association, the researchers compared 41 type 1 diabetic children and adolescents with a history of hypoglycemia with seizure or coma to 43 similar diabetic subjects without a history of severe hypoglycemic events. The good news is that after comprehensive learning and memory teats, the researchers observed no significant differences between the seizure and non-seizure groups. The number of severe hypoglycemic events was also not associated with neurological impairment. The researchers concluded that the results" provide some reassurance to those treating children with type 1 diabetes with intensive treatment that seizures/coma at a young age does not necessarily result in gross cognitive impairment."
The November, 2005 issue of The Journal of Alzheimer’s disease has an interesting study by Suzanne M. de la Monte from Brown University Medical School. Her group found that brain levels of insulin and its related cellular receptors fall precipitously during the early stages of Alzheimer’s. Insulin levels continue to drop progressively as the disease becomes more severe—adding to evidence that Alzheimer’s might be a new form of diabetes. In addition the team found low levels of acetylcholine—a hallmark of Alzheimer’s—are directly linked to loss of insulin and insulin-like growth factor in the brain. In the most advanced stages of the disease insulin receptors were nearly 80% lower than in the normal brain. The researchers showed that insulin impairment happens early in Alzheimer’s and that this is linked to major neurotransmitters responsible for cognition. They showed that it’s linked to poor energy, metabolism, and to abnormalities that contribute to the tangles characteristic of advanced Alzheimer’s. The work ties several concepts together and demonstrates that Alzheimer’s disease “is quite possibly a type 3 diabetes."
The European Heart Journal, October,2005, has an article that should make us all sit up and take note. Dr. Xavier Jouven of the Universite Paris-5, France and his colleagues examined the relationship between blood sugar level, diabetes and the risk of sudden cardiac death among people enrolled in the Group Health Cooperative of Puget Sound. The study included 2,040 subjects which experienced out-of-hospital cardiac arrest between 1980 and 1994. They were compared with 3,800 randomized control subjects. The researchers classified the subjects as having no diabetes, borderline diabetes, diabetes without disease of the small blood vessels, and diabetes with disease of small blood vessels. After accounting for potential contributing factors, the team found a progressively higher risk of sudden cardiac death associated with borderline diabetes (24%), diabetes without disease of the small vessels (73%), and diabetes with disease of small vessels (266%) compared with no diabetes. The relationship between diabetes and sudden cardiac death may involve heart disease, atherosclerosis or a combination of processes, Jouven’s team suggests. High blood sugar levels can promote disease of the small blood vessels without causing symptoms, they note, which might contribute to sudden cardiac death risk.
Diabetes Care, 28:2884-2889, 2005, has an article titled Modulation of food intake by glucose in patients with type 2 diabetes by Bernd Schuultes, MD et al from the University of Luebeck, Germany. The objective of the study was to examine the common weight gain effect of glucose-lowering therapies in patients with type 2 diabetes, a problem which is not completely understood. Blood glucose is considered to play a crucial role in the regulation of food intake. Using this background information, the researchers hypothesized that a short-term reduction of blood glucose concentration to normal values acutely increases food intake in type 2 diabetics. To test this, 12 patients with type 2 diabetes were examined twice, once during a euglycemic clamp experiment and other time during a hyperglycemic clamp. The experiments were performed in a single-blind fashion with the order of conditions balanced across patients. On both clamp conditions, insulin was infused at a constant rate. Simultaneously, a glucose solution was infused at a variable rate to achieve target levels. During the final 30 minutes of the clamps, the patients were allowed to eat as much as they liked from a standard breakfast buffet.
The results indicate that compared with the hyperglycemic condition, the patients on average 25±10% more energy during euglycemia. The increased energy intake during euglycemia was equally distributed across macronutrient components, i.e. during euglycemia the patients ate more carbohydrates, fat, and proteins than during hyperglycemia. Circulating levels of insulin, amylin, leptin, ghrelin, and glucagons-peptide-1 did not differ between the euglycemic and hyperglycemia clamp, excluding a major contribution of these hormones to the difference in food intake. Summing up, the glucose administered intravenously and the food ingested yielded a remarkably similar total energy influx in both conditions. The researchers concluded that their data suggests that total energy supply to the organism is tightly regulated on short-term basis independent of the route of influx. Alternately, it can be hypothesized that euglycemia stimulated or that hyperglycemia suppressed food intake at the subsequent buffet meal in type 2 patients in the study. Regardless of these different interpretations, the researchers interpreted their data to indicate an important regulatory role of glucose for food intake in type 2 diabetic patients that is of considerable clinical relevance.
Diabetes Care, 28:2864-2870,2005, has another article of interest titled Race, Ethnicity, Socioeconomic position, and quality of care for adults with diabetes in managed care, by Arleen F. Brown, MD, PhD, et al. The objective of this study was to examine racial/ethnic and socioeconomic variations in diabetes care in managed-care. They studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes managed care. Cross-sectional analysis using hierarchical regression models assessed process of care (HbA1c, lipid, and proteinuria assessment; foot and dilated examinations; use or advice to use of aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure). The results indicated that most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1c levels. Compared with whites, African Americans had lower rated of A1C and LDL measurement and influenza vaccinations, higher rated of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main socioeconomic position difference was lower rated of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or ore appropriate intensification of therapy relative to whites or those with higher SEP. The researchers concluded that in managed-care settings, minority race/ethnicity was not consistently associated with worse process or outcomes, and not all differences favored whites. The only notable SEP disparity was in rate of dilated eye examinations. Social disparities in health may be reduces in managed-care settings.
JAMA, 2005;294:2601-2610, has an article titled Duration of lactation and incidence of type 2 diabetes, by Alison M. Stuebe, MD et al. The researchers wanted to examine the association between lactation history and the incidence of type 2 diabetes. The prospective observational cohort study of 83,585 parous women in the Nurses’ Health Study (NHS) and retrospective observational cohort of 73,418 parous women in the Women’s Health Study II (NHSII) made up the participants and setting. In the NHS. 5145 cases of type 2 diabetes were diagnosed during 1.239,709 per-years of follow-up between 1986 and 2002 and in the NHS II, 1132 cases were diagnosed during 778,876 person-years of follow-up between 1989 and 2001. Among parous women, increasing duration of lactation was associated with a reduced risk for type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% among NHS participants and 14% among NHS II participants, controlling for body mass index and other relevant factors for type 2 diabetes. The researchers concluded that longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women. Lactation may reduce risk of type 2 diabetes in young and middle-aged women by improving homeostatis.
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