As always, we begin with our headlines. Here we bring you a quick synopsis of articles that are of interest. Since we bring you the citation, you can easily find the whole article at the library if it is of interest. We then discuss other articles in more detail. We will bring you information about advanced heart failure associated with the development of diabetes, insulin resistance predicting CAD in type 1 diabetes, multiple hospitalizations for people with diabetes, the association of hypoglycemia and cardiac ischemia, and finally, an article on the relationship of dietary fats and hyperlipidemia in children with diabetes.
Our first headline has to do with the Ashville Project and can be found in the Journal of the American Pharmaceutical Association posted 4/30/03 written by Carole W. Cranor et al. This article is of interest to us because we have been a part of these education projects in the past. The research assesses the persistence of outcomes for up to 5 years following the initiation of community-based pharmaceutical care services for people with diabetes. The education was done by certified diabetes educators. Long-term community pharmacist follow-up by consultations was used. This research demonstrated that educational interventions by health care educators at pharmacies help people with diabetes to make behavioral changes needed to improve glycemic control. However, such improvements in glycemic control tend to decline three months after the educational intervention ceases. Because people visit pharmacies often, these interventions at pharmacies should be expanded, according to the article.
Every year we bring you dire statistics on diabetes in the US and around the world. This month we bring the projection that the prevalence of diabetes is expected to double in Germany on the next ten years. Ten percent of the population currently has diabetes. A recent study by the German Diabetes Research Institute found that 36% of the people 55 to 75 who lived on Augsburg, Bavaria had diabetes. Dr. Scherbaum. The Clinical Director of the German Diabetes Research Institute in Düsseldorf predicts the numbers will grow from five to ten million because people live longer, lead inactive life styles and are increasingly overweight. Sounds very familiar, doesn't it?
Diabetes Care 2003;26:1110-1113 has an article by Dr. Shereta Hill Golden et al which suggests that blood pressure rises 20-25 years before type 2 diabetes develops. The researchers at Johns Hopkins School of Medicine used data from the Johns Hopkins Precursors Study involving 1152 former white male medical students to study blood pressure in this longitudinal study. They found 77 cases of incident diabetes occurred over a medium follow-up of 38 years. The mean age of diagnosis was 58. The researchers suggest that higher BP is a predictive symptom, which may contribute to vascular disease at the time of diagnosis of type 2 diabetes. They questioned whether this can be prevented by treatment of high blood pressure in young adulthood.
Finally, we look at an article from Circulation 2003;107 by Dr. Earl S. Ford et al from the Centers for Disease Control and Prevention. It states than mean total cholesterol levels in the adult US population have dropped only 2mg/dL in recent years. This report in the May 6 journal compared 4148 subjects enrolled in the National Health and Nutrition Examination Survey (MHANES) from 1999 to 2000 who had a total cholesterol determination or who reported using cholesterol-lowering medication. The only groups which had significant reductions were among men at least 75 years of age, black men, and Mexican-American women.
We now begin our abstracts. Please read on, as your being educated can help your relatives and friends as well as yourself. You'll note the continued number of articles about cardiovascular diseases and diabetes. We hope that this is a subject you speak of often with your physician.
The American Journal of Medicine 20003;114:271-275 had an article titled Advanced heart failure associated with development of diabetes by Dr. Alexander Tenenbaum et al from Tel-Hashomer, Israel. The team knew advanced heart failure can be associated with an increased risk of developing diabetes, starting six years after the diagnosis of heart failure. Recent studies have pointed to a decreased functional capacity with this condition that may be associated with abnormalities of glucose metabolism. They examined this association in 2616 nondiabetic patients with previous myocardial infarction or stable angina pectoris over 7.7 years. The study was conducted at 18 university hospitals. The patients were between the ages of 45 and 74. They were divided into 3 criteria groups based on the severity of disease modeled after the New York Heart Association (NYHA).
13 percent and 15 percent of patients with class l and ll heart failure, respectively, developed diabetes during the follow-up, compared to 20% in class III, the one with most advanced heart failure. Multivariate analysis revealed that NYHA class III independently predicted the development of diabetes.
Insulin resistance, not hyperglycemia, predicts CAD in type 1 diabetes in Diabetes Care 2003;26 by Dr. Trevoe J. Orchard et al. According to the results of the prospective Pittsburgh Epidemiology of Diabetes Complications, traditional risk factors appear to be more important than glycemic control in predicting coronary artery disease (CAD), The good news here is that not all type 1 diabetes patients are insulin resistant, and for them the risk of heart disease may not be as high. The researchers examined 603 with type 1 diabetes, mean age 28 years, who were free of prevalent CAD. During the 10 years of follow-up, incident CAD events occurred in 108 subjects. These included 5 CAD deaths, 25 nonfatal myocardial infarctions, 12 cases of coronary stenosis of 50% or greater, 39 cases of angina and 17 of ischemia ECG changes.
Diabetes duration, hypertension, WBC, HDL-cholesterol, non-HDL cholesterol and smoking history independently predicted CAD. The average estimated glucose disposal rate, which is based on HbA1c,waist/hip ratio and hypertension, was lower in patients with incident CAD and was an independent predictor of CAD, MI and coronary stenosis. There was no positive association between HbA1c and CAD, a finding that the authors call "concerning and intriguing". They point out that earlier research has indicated a relationship between HbA1c and lower extremity arterial disease. Therefore, they theorize that "though hypoglycemia leads to more extensive atherosclerosis, the plaques so formed are more stable and thus less likely to rupture and cause acute coronary events. Also noted was that HbA1c and the Beck Inventory scores were independent predictors of angina.
Multiple hospitalizations for patients with diabetes, is an article I Diabetes Care, 26:1421-1426,2003 by H. Jonna Jiang, PhD et al. The researchers examined the extent to which hospitalizations for people with diabetes reflect multiple stays by the same person as well as how hospitalizations vary by patient demographic and socioeconomic characteristics. Using discharge data for 5 states in 1999, they identified 658,748 non-neonatal, non-maternal patients who had one or more hospitalizations listing diabetes. Total hospital costs were examined as were percent of patients with multiple stays, percent of total stays represented by multiple stays, and average number of stays per patient. The results showed that among patients with diabetes who had been hospitalized, 30% had two or more stays, accounting for greater than 50% of total hospitalizations and hospital costs. Controlled for patients' age, sex and clinical characteristics, the likelihood of having multiple hospitalizations was higher for Hispanics and non-Hispanic blacks compared with non-Hispanic whites, as well as for patients covered by Medicare or Medicaid and those living in low-income areas. They concluded that multiple hospitalizations are common among patients with diabetes but vary by age, race/ethnicity, payer, and income, with those populations traditionally vulnerable experiencing higher likelihoods of multiple stays.
Association of hypoglycemia and cardiac ischemia, by Cyrus Desouza. M.D. et al is presented in Diabetes Care 26:1485-1489,2003. In some studies, intensive diabetes treatment in patients with type 2 diabetes may be associated with increased cardiovascular events. It is not clear whether these events are related to hypoglycemic episodes. To determine whether episodes of hypoglycemia were more likely to be associated with cardiac ischemia than normoglycemia or hyperglycemia, the researchers carried out a study in 21 patients with coronary artery disease (CAD) and type 2 diabetes who had good glycemic control. They carried out 72 hour continuous glucose monitoring along with subcutaneous cardiac Holter monitoring for ischemia. Patients also recorded symptoms of cardiac ischemia and symptoms of hypoglycemia. Satisfactory continuous glucose monitoring system recordings were obtained in 19 patients. Researchers recorded 54 episodes of hypoglycemia and 59 episodes of hyperglycemia. Of the 54 episodes of hypoglycemia, 10 were associated with symptoms of chest pain, during 4 of which electrocardiographic abnormalities were documented. In contrast, only 1 episode of chest pain occurred during 59 episodes of hyperglycemia. No chest pain or electrocardiographic abnormalities occurred when blood glucose was within the normal range. The researchers concluded that hypoglycemia is more likely to be associated with cardiac ischemia and symptoms than normoglycemia and hyperglycemia. They suggest that this data may be important in planning insulin treatment and attempting to gain near-normal glycemia in patients with known CAD. Further research is warranted.
Our last journal abstract is from Diabetes Care 26:1356-1362,2003 and is titled Dietary fats do not contribute to hyperlipidemia in children and adolescents with type1 diabetes written by Esko J. Wiltshire, MD et al. The researchers set out to determine the relative influence of diet, metabolic control, and familial factors on lipids in children with type 1 diabetes and control subjects. They assessed fasting serum cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, and lipoprotein in 79 children and adolescents with type 1 diabetes and 61 age and sex matched control subjects, together with dietary intakes using a quantitative food frequency questionnaire. The results are very interesting in that they found lipid abnormalities remain common in children and adolescents with type 1 diabetes who adhere to current recommendations, and they relate to metabolic control but not to dietary intake.
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