health updates

november 2006

November brings the beginning of party and holiday season. Please make sure you read our articles about how to negotiate this time of the year in our What’s Hot articles and do try the holiday recipes in our Entertaining section. Your family and friends will rave about your recipes. We wish you and your family and friends happy memories! Before we begin our regular monthly briefing, we were asked to review a book entitled The Sugar Solution by the Editors of Prevention magazine published by Rodale, Inc. First it seems fair that I give you my history with Prevention magazine. My sister swore by it and sent us a subscription for years. And so our history goes back at least two decades. Our goal here at diabetic-lifestyle.com is sharing medical answers to medical problems and this magazine has a t time been known for using alternative solutions at times. All that having been said this is a very good book for people who are newly diagnosed with type 2 diabetes. It gives the reader an excellent overview of how to live a healthier life although we have always had difficulty with diets that promise results in a short period of time. We all know that if you change the way you eat, the first month may well seem like a miracle. Unbeknownst to most of us, when we actually pay attention to what we eat, we tend to ingest fewer calories. Magic answers rarely work and we live in a nation that wants quick fixes and magic. The diet suggested sounds very much like the Mediterranean diet that has proven to a very healthy one. This is a diet with limited saturated fat from animal protein, whole grains, healthy non- hydrogenated fats used in limited quantities, certain nuts like walnuts and almonds in limited quantities, and lots of fresh fruits and vegetables. The book is correct when it talks about stress in our society and the need to learn to take the edge off this complicated emotion. It shares easy first steps to help control stress. The exercise sections are also good—simple and easy to follow. I even like the make ahead and buy ahead sections in the Putting it All Together section. Read the boxes; the information in these will help. I do have a few thoughts about having a diabetic use the recipes. Butter is probably a no-no, and whole grain flours are easy to cook with. In fact earlier in the book we are given substitution suggestions. To their credit, the amount of fat is restricted but there are trans fat free margarines that you can bake with. I also note that a few of the recipes have elevated levels of sodium which the book rightfully talks about limiting not only for diabetics but heart patients too. Finally, in doing research on the glycemic index which the book is based on, we noted that foods can be labeled low, medium, and high on the index. This is not detailed in the book so that readers will have to guess where a food falls. It’s easy to tell that a carbohydrate with a GI of 90 is higher than one with a 20, but the question is at what level do I have to think twice? Many organizations like the ADA do not tout the GI for diabetics. Having written a number of books I also know the problem with facts that change before publication. For example, the authors suggest that a reader can log on to the Internet for information; however, one of the sites written by the USDA currently outlines healthy eating patterns with individual pyramids rather than the Healthy Eating Index although they do refer the reader to pages from 2000. Having gone to this site when the revised pyramid was presented to the public, this is an excellent site. It is well worth your while.

So what would we suggest? For an overview, we like this book, but as they suggest, if you are concerned about a diagnosis of diabetes or pre-diabetes, ask for a referral through your health care team to a diabetes educator and/or nutritionist and keep going. Join a gym with friends or start an exercise group. Your friends will be at your door and excuses will melt away. Learn what works for you not what works for friends in terms of healthy weight loss and stress reduction. Keep talking about your concerns and make sure that you are well thought out answers from those you pay to keep you advised about diabetes. Most of all become an expert on diabetes and its long and short term complications so that when you meet with care team individuals you have the questions ready that you want answered and you know when you need extra help. This month we again start with headlines and then go on to present you with abstracts on the effects of type 2 diabetes on cochlear structure, the effect of medication nonadherence on hospitalization and mortality among diabetic patients, and finally one on the role of sleep duration and quality in the risk and severity of type 2 diabetes. Make yourself another cup of coffee or tea and get ready to learn something new. Remember you are the best friend you can have and reading about diabetes and its long and short term complications will truly make you a partner in your health care. It seems that each month we report that the incidence of diabetes is growing in young people. This month we found out that 1 in every 523 persons less than 20 years of age in the US has been diagnosed with the disease. This came out of the first comprehensive assessment of the disease in this age group. That means that diabetes is among the most common chronic illness of youth. The national study found that diabetes is more common in non-Hispanic whites than other ethnic groups, and that type 1 diabetes is the most common form in young people of all racial and ethnic groups, except for American Indians, in whom more than three-quarters of cases were type 2 diabetes. This study was paid for by the U.S. Centers for Disease Control and Prevention and the National Institutes of Health. It concluded that the average age of diagnosis was 8.4 years, and 96% of children under 10 with diabetes had type 1. Girls had a higher prevalence, at 1.88 per 1,000, than boys, at 1.77 per thousand. The study was published in October in the journal of Pediatrics. The first international, multi-center trial of the Edmonton Protocol—a standardized approach to the transplantation of insulin-producing islets—demonstrated that this may be an appropriate therapy that can dramatically benefit certain patients with severe complications of Type 1 diabetes. This report can be found in the Sept. 28, 2006 issue of The New England Journal of Medicine and was led by James Shapiro, M.D., Ph.D. The study included 36 adult volunteers at nine clinical trial sites in North America and Europe who received up to three infusions of islet cells. A year after the final treatment, 44% of the transplant recipients no longer needed insulin injections, and an additional 28% had partial islet function, which was associated with resolution of hypoglycemic unawareness—a severe complication of diabetes. Insulin independence did not persist indefinitely in most cases, and less than a third of the people who had been freed from insulin after one year remained so by two years. However, individuals with functioning islets had improved control of their diabetes, even though they still needed to take insulin shots. The 36 participants in the clinical trials (mean age 41) had lived with diabetes for an average of 17 years. Each received between one and three transfusions of islets. The majority had at least partial islet function after one year after the final transfusion, and almost all had resolution of hypoglycemic unawareness even if they were not freed from daily insulin injections. People who develop type 2 diabetes when they are younger than 50 years of age are more likely to experience a worsening of their disease than those diagnosed at an older age according to research presented in Copenhagen in September, 2006, at the 42nd annual meeting of the European Association of the Study of Diabetes. Dr. Targ Elgzyri from Lund University, Malmo, Sweden presented the research. The researchers looked at non-genetic factors that influence a continuous rise in HbA1c. They followed more than 1,200 patients with type 2 diabetes for 7 years after diagnosis. HbA1c improved at 1 years following diagnosis declining from 7.6 to 6.3%. During the subsequent 6 years, however, HbA1c increased from 6.3 to 7.0%, as expected. The patients required insulin therapy after an average of 1.5 years. After 7 years, 47% of study subjects were on insulin therapy. Among the non-genetic factors studied, age of diagnosis showed a significant influence on HbA1c change over time. Specifically, patients younger that 50 years of type 2 diabetes diagnosis experienced a steeper increase in HbA1c than did those 50 years of age or older at diagnosis. The rise in HbA1c concentrations in patients diagnosed before age 50 was related to an impaired ability of the pancreas to produce insulin. In a follow-up study, Elgzyri”s group hopes to teat whether genetic factors can modify these relationships. Eli Lilly and Company said in late September that U.S. regulators from the FDA want an additional three-year clinical trial for its treatment for eye problems brought on by diabetes. Lilly said it would take up to five years to complete. It is weighing options for the further development of the treatment, called ruboxistaurin mesylate, projected trade name Arxxant. “We still believe that ruboxistaurin had potential as the treatment for diabetic eye disease and are exploring the feasibility of further development of this molecule,” said Dr. John Lechleiter, Lilly president and chief operating officer, in a statement. Let’s look at the abstracts we’ve selected for you. Our first from the Archives of Otolaryngology Head and Neck Surgery 2006; 132:934-948 is titled Effects of Type 2 Diabetes Mellitus on Cochlear Structure in Humans, by Hisaki Fukushima, M.D. et al. The researchers evaluated the effects of type 2 diabetes on cochlear elements by using a comparative study of the histopathologic characteristics of temporal bones. Temporal bones from 18 patients with type 2 diabetes were divided into two groups according to the method of management of diabetes: insulin in 11 patients (mean age 51.9 years; age range, 44-65 years) and oral hypoglycemic agents in 7 patients (mean age 54.4 years; age range, 45-64 years). The diabetic groups and 26 age-matched controls were examined using light microscopy, and cochlear changes were compared between groups. Morphometric measurements of vessel wall thickness in the basilar membrane and stria vascularis were made in all turns of the cochlea at the midmodiolar level. Area measurements of the stria vascularis were made in all turns of the cochlea at the midmodiolar level. Cochlear reconstructions and standard cytocohleograms were prepared using an oil immersion objective. The number of spiral ganglion cells was determined for each segment of the cochlea. Comparisons were made in each segment between diabetic and control groups. Results indicated that in the insulin group, walls of the vessels of t he basilar membrane and stria vascularis in all turns were significantly thicker than those of the controls. Walls and vessels of the stria vascularis in the basal turn were also significantly thicker in the oral hypoglycemic group than in controls. Atrophy of the stria vascularis in most turns of the insulin group and the lower middle turn of the hypoglycemic group was significantly greater than in the controls. Loss of cochlear outer hair cells was significantly greater in the lower and upper basal turns in both diabetic groups. No significant difference was found in the number of spiral ganglion cells or inner hair cells between groups. The researchers concluded that cochlear microangiopathy and degeneration of the of the stria vascularis and cochlear outer hair cells are found in patients with type 2 diabetes. The Archives of Internal Medicine, 2006;166:1836-1841 has an interesting article for all of us who care for or live with a person with diabetes titled Effect of Medication Nonadherence on Hospitalization and Mortality Among People with Diabetes Mellitus, by P. Michael Ho, M.D., Ph.D., et al. This is a retrospective study of 11,532 patients with diabetes in a managed care organization. Medication adherence was calculated as the proportion of days covered for filled prescriptions of oral hypoglycemics, antihypertensives, and statin medications. The primary outcomes of interest were all-cause hospitalization and all-cause mortality. Multivariable regression analyses were performed to assess the independent association between medication adherence and outcomes. Nonadherent patients were younger and had less comorbidity compared with adherent patients. During follow-up, nonadherent patients had higher glycosylated hemoglobin, systolic and diastolic blood pressure, and low-density lipoprotein cholesterol levels. In unadjusted analyses, nonadherent patients had higher all-cause hospitalization and higher all-cause mortality. In multivariable analyses, medication Nonadherence remained significantly associated with increased risks for all-caused hospitalization and for all-cause mortality. The findings were consistent across patients subgroups and using different cutoffs for the proportion of days covered. The researchers concluded that medication Nonadherence is prevalent among patients with diabetes and is associated with adverse outcomes. Interventions are needed to increase medication adherence so that patients can realize the full benefit of prescribed therapies. The Archives of Internal Medicine 2006; 166:1768-1774 has an article titles Role of Sleep Duration and Quality in the Risk and Severity of Type 2 Diabetes Mellitus by Kristen L. Knutson, PhD et al. Evidence from laboratory and epidemiologic studies suggests that decreased sleep duration or quality may increase diabetes risk. The researchers examined whether short or poor sleep is associated with glycemic control in African Americans with type 2 diabetes. They conducted a cross-sectional study of volunteers with type 2 diabetes interviewed at the University of Chicago Hospitals. The final an analysis included 161 participants. Glycemic control was assessed by hemoglobin A1c level obtained from medical charts. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Perceived sleep debt was calculated as the difference between preferred and actual weekday sleep duration. The mean ±SD sleep duration was 6.0 ±1.6 hours, and 71% of the participants were classified as having poor quality sleep. They excluded patients with sleep frequency disrupted by pain. In patients without diabetic complications, glycemic control was associated with perceived sleep debt but not PSQI score. The predicted in HbA1c level for a perceived sleep debt of 3 hours per night was 1.1% above the median. In patients with at least 1 complication, HbA1c level was associated with PSQI score but not perceived sleep debt. The predicted increase in HbA1c level for a 5-point increase PSQI was 1.9% above the median. The researchers concluded that sleep deprivation and quality were significant predictors of HbA1c, a key marker of glycemic control. Combined with existing evidence linking sleep loss to increased diabetes risk, these data suggest that optimizing duration and quality should be tested as an intervention to improve glucose control in patients with type 2 diabetes. BSP