Diabetes: Understanding Charcot Foot

For diabetics, foot care is one of the most important aspects of managing the disease. Four out of ten people with diabetes are thought to have lost some feeling in their feet, and nearly half will suffer a foot wound or ulceration in their lifetime. But there are some conditions that are out of the ordinary and one of them is the Charcot foot.

The Charcot foot is a rare condition that can occur in some people with diabetes. The underlying factor that contributes to the development of this condition is a loss of sensation in your feet—nerve damage that is referred to as peripheral sensory neuropathy.

Neuropathy is a common complication of diabetes, seen in people with both type 1 and type 2. The earliest sign of the Charcot foot may be a sudden and unexpected change in the appearance of your foot or ankle, characterized by redness, swelling, and warmth. You may have no recollection of injury.

X-rays of the foot may initially look perfectly normal, or there may be very subtle changes that can be easily missed. This is the most important stage of the Charcot foot for the physician to recognize the problem and to start treatment immediately. The treatment involves rest, elevation of your foot, and, most important, staying off of the affected foot until inflammation subsides and the foot is stable.

Sometimes there is collapse of the arch with the development of bony deformity, a “rocker-bottom foot,” with formation of an open sore (ulcer) on the bottom of the foot. Your doctor will first need to confirm the diagnosis by eliminating other conditions that might have a similar appearance, such as infection or gout.

Most diabetic foot specialists will apply a short non-weight-bearing cast and monitor the condition closely. Serial X-rays are taken to evaluate the healing of fractures and dislocations of one or more joints.

Although we have not yet learned how to prevent the development of a Charcot foot, we can sometimes minimize the extent of deformity with early recognition and prompt treatment. The likelihood of success decreases as the patient passes through the chronic stage of this condition.

Immobilization in a cast can sometimes take three months or longer. Patients are often transitioned from a cast to a removable walking brace, and then to a special shoe. In most cases, patients can be treated with non-surgical care; in the most difficult cases, surgery may be necessary.

Treatment of the Charcot foot is often prolonged, challenging, and frustrating. If you are at high risk—if you have peripheral neuropathy and loss of protective sensation—you should learn the implications of sensory loss, as well as the importance of diabetes self-management.

Foot inspection should be an important part of your daily routine. Compare one foot to the other and look for changes in size or shape. Is one foot swollen? Are there changes in the color or temperature of the skin? If you notice any of these changes, call your podiatrist, diabetes specialist, or family physician, and request an appointment as soon as possible.

Source: American Diabetes Associaltion

Hypoglycemia: Don'y Rely on the Doctor's Prognosis - Tell Him What Needs to be Done to Save Your Life

Here’s yet another episode of doctors who are clueless about treating complications arising from diabetes. If only the doctors at the hospital attending on him had more knowledge of treating hypoglycemia (low blood sugar), the 46-year-old man would have been alive today.

The diabetic, a self-employed electrical technician, identified only as Mr H, weighed 150kg and was taken by ambulance to the North West Regional Hospital in Burnie, Tasmania, Australia with a very low blood sugar level of just 27 mg/dl (a normal blood sugar level is about 90 mg/dl).

Three sets of clinical observations were taken, at 5.52pm, 6.35pm and 6.40pm, including his blood pressure, which was low. He was provided with sandwiches to eat, which he tolerated, and was observed for an hour and remained well.

After being discharged at 7pm, Mr H went home. About 12.34am, Mrs H awoke but could not rouse her husband. She called an ambulance but, by the time they arrived, Mr H was in cardiac arrest.

An investigation by Coroner Rod Chandler found the 46-year-old was discharged at 7pm and died at home about 1.45am the next day. "Mr H was considered to have suffered a hypoglycemic episode, most likely related to poor oral intake combined with his oral anti-diabetic medication," the post-mortem report said. In these circumstances the decision to permit Mr H to go home about 7pm on 10 January, 2009, was a regrettable misjudgment," the coroner said.

"Had he remained in hospital for a longer period and been subject to close monitoring and to more intensive investigations, then it is likely in my view that the seriousness of his condition would have become evident and life-saving treatment put in place. These matters give rise to the question whether the decision to permit Mr H to go home without further monitoring and/or investigation was, in all the circumstances, a reasonable one."

After carrying out an autopsy, pathologist Terry Brain recommended the case be reviewed by an experienced diabetic physician, "particularly [whether] the decision to allow him to go home played a significant role in his death and what could have been done to prevent this outcome".

Royal Hobart Hospital Diabetes and Endocrine Services clinical director Tim Greenaway said severe hypoglycemia was a "clinical red flag" and should have attracted careful assessment. "Mr H's falling blood sugar at the time he was allowed to leave hospital should have resulted in action by the emergency department staff," he said, adding there were measures that could have been implemented by the medical staff. "Such investigation and treatment is standard practice," he said.

Indeed, such investigation and treatment is standard practice around the world. Even an intern should know them. But the doctors on duty at the emergency room were ignorant of these procedures. “Regrettable misjudgment” is a terrible understatement, to say the least.

It was reported that the health authorities have implemented new procedures (sic) after Mr H’s death. But that’s no relief for his family.

My advice to all diabetics: If you suffer a hypo episode, instruct your family members to tell the doctors what to do. Also carry a note detailing the measures to be taken ‒ in case you have passed out ‒ in your wallet along with your card that identifies you as a diabetic. Unlike Mr H, you may not be another victim of an ill-trained doctor’s regrettable misjudgment.

Based on a news report in themercury.com.au

How Insulin-Producing Cells Die - Research Offers Potential for New Diabetes Diagnostic Test

The death of insulin-producing beta cells in the pancreas is a core defect in diabetes. Scientists in Italy and Texas now have discovered a new way that these cells die — by toxic imbalance of a molecule secreted by other pancreatic cells.

"Our study shows that neighboring cells called alpha cells can behave like adversaries for beta cells. This was an unexpected finding," said Franco Folli, M.D., Ph.D., professor of medicine/diabetes at The University of Texas Health Science Center at San Antonio. He is co-lead author on the study with Carla Perego, Ph.D., assistant professor of physiology at the University of Milan.

Alpha and beta cells are grouped in areas of the pancreas called the islets of Langerhans. Alpha cells make glucagon, the hormone that raises blood sugar during fasting. In the same environment the beta cells make insulin, the hormone that lowers sugars after a meal. Imbalance ultimately leads to diabetes.

"We found that glutamate, a major signaling molecule in the brain and pancreas, is secreted together with glucagon by alpha cells and affects beta cell integrity," Dr. Folli said. "In a situation where there is an imbalance toward more alpha cells and fewer beta cells, as in Type 1 and Type 2 diabetes, this could result in further beta cell destruction."

Glutamate toxicity is a new mechanism of beta cell destruction not previously known, Drs. Perego and Folli said. It has not been typically thought that alpha cells could themselves be a cause of beta cell damage, they said.

The study also found a protection for beta cells, namely, a protein called GLT1 that controls glutamate levels outside the beta cells. "GLT1 is like a thermostat controlling the microenvironment of beta cells with respect to glutamate concentration," Dr. Perego said.

A diagnostic test for glutamate toxicity in the islets of Langerhans is being developed by the authors, Dr. Folli said. Eventually an intervention to slow the process could follow.

Glutamate poisoning is a new candidate mechanism for beta cell destruction in diabetes. Others are high glucose, buildup of a protein called amyloid, and free fatty acids, which are found in patients with type 2 diabetes.

"The vicious cycle in diabetes is that there are several substances that have been shown, also by us, to be toxic to beta cells," Dr. Folli said. "And now we have found a new one, glutamate."

Aspirin May Help Diabetics With Kidney Disease Avoid Heart Complications

A new study from a team of Japanese researchers at the Nara Medical University shows that low daily doses of aspirin may help reduce risk of heart disease in patients who have both type 2 diabetes and kidney disease.

Heart disease, as we all know, is the most common cause of death for individuals who have type 2 diabetes because persistently high levels of blood sugar in the veins causes inflammation that leads atherosclerosis, which is a hardening of the arteries that causes the heart to work harder, eventually causing it to wear out.

The research, published in the journal Diabetes Care, concludes that there appears to be a strong relationship between diabetes-induced kidney disease and aspirin therapy. If future studies bear out these results, aspirin could provide a simple solution to a major problem that affects millions of people.

"The current study demonstrated that low-dose aspirin therapy reduced the risk of atherosclerotic events in type 2 diabetic patients," the researchers wrote in their report.

For the study, researchers gave a group of more than 2,500 participants who had type 2 diabetes and kidney disease either an 81 mg daily dose of aspirin, a 100 mg daily dose or no aspirin at all. The researchers then tracked the participants' medical records for nearly five years. During this time they checked for instances of stroke, heart disease and peripheral artery disease.

They found that individuals who were in either of the groups that received aspirin had significantly fewer atherosclerosis-related incidences than those who did not receive aspirin.

"The current study demonstrated that low-dose aspirin therapy reduced the risk of atherosclerotic events in type 2 diabetic patients," the researchers conclude.

Confirmed: Fatty Liver Ups Type 2 Diabetes Risk

If you get diagnosed with a fatty liver during a routine check-up, sit up and take notice. Fat deposits in liver are an invitation to diabetes. Although fatty liver and insulin resistance are known to be associated, the relationship between the two in the development of type 2 diabetes mellitus (T2DM) is unclear.

However, a recent study published in The Endocrine Society's Journal of Clinical Endocrinology and Metabolism (JCEM) found that individuals with fatty liver were five times more likely to develop type 2 diabetes than those without fatty liver.

This higher risk seemed to occur regardless of the patient's fasting insulin levels, which were used as a marker of insulin resistance. People who consume more oily food, have a sedentary lifestyle, especially those who consume large quantities of alcohol, are at risk of getting the disease.

In recent years, fatty liver has become more appreciated as a sign of obesity and resistance to insulin, a hormone that controls the body's glucose levels. This new study ‒ 'Interrelationship between Fatty Liver and Insulin Resistance in the Development of Type 2 Diabetes' by Ki-Chul Sung and Sun H. Kim of Kangbuk Samsung Hospital, Sungkyunkwan University at Seoul, South Korea ‒ shows that fatty liver may be more than an indicator of obesity but may actually have an independent role in the development of type 2 diabetes.

There seems to be little awareness about the disease even among the physicians. “It is not as innocuous as it looks. It is known to develop into liver failure or liver cancer. Recent studies have shown that fatty liver also increased chances of diabetes,” says Dr Mishra, who is chairman of the Fortis-CDOC Centre for Excellence for Diabetes at New Delhi in India.

According to Kim, "Many patients and practitioners view fat in the liver as just 'fat in the liver,' but we believe that a diagnosis of fatty liver should raise an alarm for impending type 2 diabetes…Our study shows that fatty liver, as diagnosed by ultrasound, strongly predicts the development of type 2 diabetes regardless of insulin concentration."

In the Seoul study, researchers examined 11,091 Koreans who had a medical evaluation including fasting insulin concentration and abdominal ultrasound at baseline and had a follow-up after five years.

Regardless of baseline insulin concentration, individuals with fatty liver had significantly more metabolic abnormalities including higher glucose and triglyceride concentration and lower high-density lipoprotein cholesterol (sometimes called "good cholesterol") concentration.

Individuals with fatty liver also had a significantly increased risk for type 2 diabetes compare to those without fatty liver.

"Our study shows in a large population of relatively healthy individuals that identifying fatty liver by ultrasound predicts the development of type 2 diabetes in five years," said Kim. "In addition, our findings reveal a complex relationship between baseline fatty liver and fasting insulin concentration."

Also see my earlier report “Fatty Liver a Forerunner to Diabetes”

Lap-Band & Bypass Surgery Find Match in EndoBarrier

The cacophony surrounding the news that a pair of studies has found that a different, older procedure ‒ the Roux-en-Y gastric bypass procedure - is "more effective" and "no riskier" than either the Lap-Band or the “less-drastic” (sic) sleeve gastrectomy surgery, has drowned out a news of a new British implant devise that helps weight loss and lowers blood sugar levels.

It has been reported that surgeons at a British hospital have pioneered a new treatment that could remove the need for medication to treat type 2 diabetes while helping sufferers lose weight.

Medics at Southampton General Hospital have performed the first 15 implants of a new device called the EndoBarrier.

The EndoBarrier is implanted under a short general anaesthetic and performed as a day case procedure, with all 15 patients participating in the trial discharged home within hours of completion.


Use of the EndoBarrier means that food bypasses a part of the upper intestine, so the body has less time to digest it, and also allows more control over metabolic rate and potentially lower blood sugar levels. It was shown the device could achieve weight loss of over 20 per cent of total body weight.

The sleeve is also performing as well so far as the more invasive gastric band procedure in helping weight loss.

In a 12-month study, patients fitted with the EndoBarrier achieved weight loss of more than 20% (on average 3.5 stone) of their total body weight. The sleeve is also performing as well so far as the more invasive gastric band procedure in helping weight loss.

Southampton University Hospitals NHS Trust is one of three centres in the UK participating in a study to evaluate the effectiveness of the device in patients who are overweight and suffer with type 2 diabetes. The other two are Trafford General Hospital in Manchester and St Mary's Hospital, London.

Consultant general surgeons Jamie Kelly and James Byrne at Southampton are the first to complete the initial part of the project and say they are pleased with the early findings.

"Initial results among the 15 patients who have had the EndoBarrier inserted have been really encouraging and we are very excited about the potential impact of this new treatment for patients. We are already seeing the benefit to our patients with reductions in the treatment required to manage diabetes as well as significant weight loss. The weight loss so far is tracking as well as we typically see achieved with the more invasive gastric band procedure,' Bryne explained.

Kelly added: "The procedures performed in this initial study were performed on NHS patients and further evidence of the effectiveness of this treatment will hopefully ensure it will be offered to NHS patients in the future." At present EndoBarrier is available only to private paying paients.

Anyway, the biggest danger is that new weight-loss options like EndoBarrier, Lap-Band, Roux-en-Y gastric bypass and sleeve gastrectomy surgery have the potential to encourage overweight people to abandon traditional diet and exercise for procedures that carry some serious risks. That should be a big worry for all diabetes educators and activists.

Diabetes: Why do Doctors Miss the Wood for the Trees?

I find it very strange that when you are hospitalized, the doctors looking after you are concerned only with the problem you have reported at the time of admission and not much else. I mean what you say is wrong with need not necessarily be the only thing a doctor should be worried about – there could be other unknown reasons for your hospitalization.

Back in 1998 when I was hospitalized for “abdominal pain” (my complaint), the doctor’s (correct) prognosis was acute pancreatitis. I went through a battery of tests which confirmed this. However, the CT scan also showed the presence of a number of stones in the gallbladder.

My wife pointed this out to the doctor who dismissed the finding as a “secondary” issue that “could be tackled later. We have to treat the pancreatitis first.”

To cut the long story short, I was soon developing obstructive jaundice periodically. At the same time it was discovered that I had developed Type 2 diabetes and was put on insulin (my choice, since I had researched the problem). And, finally, 3 ERCPs and stentings later, in 2003 it was finally decided that my gall bladder had to be removed surgically (cholecystectomy) because the common bile duct was blocked by a gallstone the size of a small marble.

That is not the end of the story. Five years later, I had chronic pancreatitis and developed pancreatic abscess, and as a result, intestinal adhesions that required emergency surgery. Uncontrolled hyperglycemia added to the problems and I was in hospital for 2 months.

My saga does not end here. Fearing that I might develop an infection during the 2008 surgery (it was touch-and-go for me at that stage), the surgeon decided not to place a mesh to strengthen my abdominal wall. So a year later an incisional hernia developed, which required another surgery a few months ago.

My point is that if the gallstones had been removed laparoscopically in 1998, maybe, just maybe, I might not have developed type 2 diabetes.

I have brought this up with many doctors time and again. My argument is: Gallstones are also a cause for pancreatitis (though not necessarily in my case), which means damage to the pancreas that produce insulin. So why weren’t the gallstones attacked earlier? I may have been a healthier individual today. But, alas, I still have to get an honest, in-your-face answer. As with any profession, in the world of medicine, too, dog doesn’t eat dog.

But this just strengthens my belief – and I’ve written about thisbasing my argument on empirical evidence – that in the age of ‘superspeciality’, our medical schools are producing graduates who miss the wood for the trees.

I can therefore empathize with a British pensioner who developed diabetes after battling pancreatic cancer and nearly died because medics failed to diagnose the condition.

According to a news report, Raymond Ellerby, 67, lost three stone in four weeks because his diabetes was not spotted. It was only when he slipped into a diabetes-induced coma – a life-threatening condition – that doctors discovered what was wrong with him.

Diabetes is always a risk following pancreatic surgery when part of the pancreas, which produces insulin to regulate the body’s sugar levels, is removed. And Ellerby had an operation to remove part of his pancreas at Castle Hill Hospital at Hull, East Yorkshire, in December 2009. Initially, he seemed to recover well but his health then started to deteriorate late spring, with his weight plummeting and feelings of dizziness, constant nausea and pain.

“It was like being drunk all the time – I didn’t know what I was doing…I was having hallucinations and I knew I didn’t feel like myself. Eventually I was found collapsed on the floor of my lounge by my daughter. If she hadn’t found me, I wouldn’t be here now,” he recalls.

The great-grandfather was taken to Hull Royal Infirmary where doctors told his family he could die within hours. But he came round and was on the Intensive Care Unit for about a week.

Following his recovery, Ellerby complained to the UK Patient Advice and Liaison Service for Hull and East Yorkshire Hospitals NHS Trust. He has now been told procedures to identify diabetes in patients with pancreatic cancer have been “changed completely”.

A letter from Jenny Barker, assistant service manager in digestive diseases at Castle Hill Hospital, dated February 11, contained an apology from Dr Anthony Maraveyas, senior lecturer in oncology. She said: “Dr Maraveyas would like to reassure you that since this incident, the Trust has changed practice completely and all patients with a newly-diagnosed pancreatic cancer, who come to the unit, have a baseline glucose test, which is reviewed at regular intervals. He would like to apologize once again for any distress or anxiety caused due to your diabetic symptoms not being identified initially.”

Wow, even a layman would have thought that if damaged pancreas is involved, “a baseline glucose test, which is reviewed at regular intervals,” would be the first thing ANY doctor would order.

In essence, thanks to the doctor’s incompetence, Ellerby had received a death sentence. That he survived to tell the tale is another story. And all he got in return was a letter from the British NHS Trust chief executive Phil Morley, saying, “Please accept my apologies for the distress you and our family have experienced.”

So my advice to everyone is: Research your condition and take a second opinion. And DON’T put your faith in just one doctor ‒he may be clueless about treating diabetes-related problems.

Victoza: Is It the New "Miracle Drug" for Type 2 Diabetes?

I had reported last year that Danish pharma giant Novo Nordisk’s gamble on Victoza, its new drug for Type 2 diabetes, often looked like a long shot.

The company’s scientists had spent nearly 10 years trying to develop a molecule that would act like a naturally occuring hormone called GLP-1. Once they did, there were still costly setbacks, puzzling questions and enormous doubts, none of which managed to thwart one researcher’s passionate belief in the hormone’s ability to be turned into a drug for lowering blood sugar.

GLP-1 is short for glucagon-like peptide 1, a naturally occuring compound that works on different organs to lower the levels of blood sugar. For overweight diabetics, there’s another benefit: GLP-1 attaches to a receptor in the brain to decrease appetite, which over time, leads to weight loss.

Since then, Victoza has been used by thousands of diabetics, all with varying results. While the majority are seeing lower blood sugars (some in the double digits) and weight loss, others are seeing no change or too much change. Many have claimed Victoza to be a type 2 diabetes "miracle drug". That said, doctors are quick to use Victoza as a second line drug when Metformin and other first line drugs aren't doing their jobs.

Newer drugs to combat diabetes is always good news for those who are living with the disease. As all of us know, managing diabetes is not easy. In fact, for most diabetics it seems like a losing battle. Then a new drug hits the market, raising hopes. But many a time, expectations are dashed when its is discovered that the so-called wonder drug has some rather unpleasant side effects.

In fact, in the case of Avandia, a landmark meta-analysis in 2007 showing a 43% increase in the risk of heart attack on rosiglitazone. People with diabetes are already at increased risk of heart problems.

Last year, GlaxoSmithKline spent billions of dollars last year settling claims. And Avandia has been banned in most countries and in the US its use is severely curtailed. For all practical purposes, diabetics around the world have stopped using Avandia even though its supposed to be a "wonder drug".

How Victoza was ‘Discovered”

Before we get down to finding out more about Victoza, a little background is in order.

Lotte Bjerre Knudsen, a senior scientist at Novo Nordisk, led the 20-year effort to develop Victoza. Before the drug received its brand name, it was known by its scientific name, liraglutide. And in the research laboratory, Knudsen’s dedication earned her the nickname “Mrs. Liraglutide.’’

“There were doubts about whether this would ever be a drug,’’ Knudsen said in an interview last year. “When you’re making something completely novel, it’s not so untypical.”

The promise of the GLP-1 class of drugs fueled the company’s efforts through major setbacks, including a flawed dosing study that cost researchers 18 months. With each setback, Knudsen had to defend the project to management.

Knudsen said her team postponed celebrating Victoza’s development until the drug was approved by US regulators. “It wasn’t good enough until we received that,” she said.

So What Exactly is Victoza?

Victoza (liraglutide injection) is a non-insulin once-daily injectable medication that may help improve blood sugar levels in adults with type 2 diabetes. It comes in an injectable pen form with three dosage levels. The first level (0.6 mg) is usually used for a week and then increased to the second level (1.2 mg). If the third level (1.8 mg) is needed, it is easily "dialed" and may be started after the body has adjusted to the 1.2 mg level.

Victoza works by helping the pancreas release the right amount of insulin. Victoza is 97% similar to a hormone in our bodies called GLP-1. This hormone is what helps us move sugar from our blood into our cells. Victoza has the same effect as GLP-1, and it also helps food move much more slowly through the stomach. Another benefit of Victoza is that it blocks the liver from releasing too much sugar by lowering the amount of glucagon, a hormone that tells the liver to release glucose into the bloodstream in order to bring glucose levels to normal.

How Do I use Victoza?

One of the great things about Victoza is that it is made for once-daily usage. The pen only has to be refrigerated up until the first use, and then it can be kept conveniently in a non-refrigerated spot, such as a purse or bedside table. Victoza can be injected at any time of day, regardless of food intake. It is recommended to inject Victoza at approximately the same time each day, however, for consistency.

To do the injection, a special needle (which must also be prescribed by your doctor) is placed on the tip of the pen. The dial at the bottom of the pen is then turned to the dosage prescribed by your doctor. The injection may be given in the stomach, thighs or arms (subcutaneously). Throw the needle away, replace the cap, and you're done!

Side Effects of Victoza

The most common side effects of Victoza are nausea, vomiting and diarrhea until the body is used to the medication. Most patients start out at the 0.6 mg level for this reason. Lightheadedness has also been reported. A list of all side effects can be found on Victoza's website.

Victoza and Thyroid Cancer

During Victoza's testing process, the medicine caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer in people.

Victoza and Weight Loss

Many people have claimed to lose a great deal of weight while on Victoza. Although Victoza is not a weight loss drug, medical studies have shown that most people taking it do lose weight. Since weight loss is an important component of living with type 2 diabetes, this is definitely an added benefit.

Important Points About Victoza

• Victoza is not insulin, and it is not known if it is safe and effective when used with insulin.
• Victoza is not recommended as the first choice for treating type 2 diabetes.
• Victoza can be used on its own or with other diabetic medications.
• Victoza should not be used with people with type 1 diabetes or with people with diabetic ketoacidosis.
• Victoza should not be used with children.
• Doctors may recommend that small increases be made when going from 0.6 mg to 1.2 mg and then to 1.8 mg. This is accomplished by increasing by "clicks" on the dial. This is very helpful when side effects are severe.
• Victoza can be costly, depending on insurance. Depending on the dosage, Victoza can cost up to $500 when not covered by insurance. Check with your pharmacy, and visit Victoza's website for coupons and information on getting your diabetes medication for free.

Making the decision to start Victoza is one that is strictly between a patient and his or her doctor. One must weigh the side effects against the benefits and make an informed choice. Victoza may be called a miracle drug for type 2 diabetes, but it is up to individuals to draw that conclusion when it comes to treating their own diabetes.

Diabetes News: Microworms That Monitor Blood Sugar; New Approach to Bariatric Surgery; Stem Cells to Cure Diabetes

It is now recognized that it is the low- and middle-income countries that face the greatest burden of diabetes. However, many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries.

However, seeing the business potential of investing in diabetes research, pharmaceutical companies are now feverishly developing new drugs and technologies to cater to a booming market. Companies are now moving beyond just drug research and are pushing the frontiers of science from nanoworms that monitor blood sugar to a permanent cure for diabetes using stem cells.

In today’s post I’m highlighting three exciting developments which, if successful, spell new hope for diabetics.

Glowing Microworms to Monitor Blood Sugar

Tiny, glowing 'microworms' implanted under the skin could be used to give blood sugar readings for diabetics, or other biomedical information, say researchers at MIT and Northeastern.

Their tube-shaped microparticles, unlike existing spherical versions, won't be swept away from the initial site over time, they say. The tubes’ narrow width keeps their contents close to blood or body tissue, while their length keeps them anchored for months on end.

The nanoparticles are created by using chemical vapor deposition (CVD) to coat an aluminum oxide layer that's been etched to contain tiny pores. Then, the coated material is dissolved away, leaving a series of hollow tubes where the pores used to be.

Before that, though, another material can be added that fluoresces in the presence of a specific chemical such as glucose. This means that when the 'microworms' are injected under the skin, they form a glowing tattoo that could be used to monitor diabetic patients.

"Tight control over glucose levels can help individuals stave off the devastating side-effects of diabetes - the number-one cause of kidney failure, blindness in adults, nervous system damage, and amputations," says MIT chemical engineering professor Karen Gleason.

"In principle, this could open the way for avoiding blood tests, which need a central lab, expert nurses, extra time and extra costs. It could be done in a doctor's office, or even at home," says Professor Raoul Kopelman of the University of Michigan. "It will also avoid complications for patients with 'difficult', or 'used-up' veins, patients on blood thinners, etc."

However, he warns that there could be concerns about long-term toxicity and bio-elimination, as well as complications such as blood clots.

Minimally Invasive Approach to Bariatric Surgery

There are scores of startups offering different approaches to obesity and diabetes eager to address the $174 billion in costs related to diabetes each year.

Now, MetaModix, a Minnesota medical device company, is moving ahead with plans to develop a minimally invasive approach to bariatric surgery and better solve the problem of type 2 diabetes.

The company is “developing a cost-effective minimally invasive therapy for type 2 diabetes” that mimics “certain elements of bariatric surgery through an endoscopic procedure.”

The process would be an out-patient procedure that would last about 30 minutes, according to Kedar Belhe, the company’s chief executive officer.

Bariatric surgery often eliminates a patient’s type 2 diabetes. However, there are concerns over the procedure itself: from post-operative side effects to the long-term impact of the surgery.

Meanwhile, the U.S. Food and Drug Administration just broadened the use of Allergan’s Lap-Band device to include more patients, for example, and other approaches range from stomach stapling, embedding sensors or inserting sleeves in the body.

Stem Cell Research Seeks Permanent Cure for Diabetes

In India, which has about 50.8 million people suffering from diabetes, another start-up, Stempeutics Research, is investing in stem cell research in the hope of discovering a permanent cure for diabetes.

Stempeutics Research has received clearance from the Drug Controller General of India (DCGI) for its investigational medicinal product Stempeucel for conducting phase II clinical trials on patients with diabetes.

“Stem cell therapy aims at addressing the root cause of the disease rather than the symptoms. Our goal is to bring out stem cell based drug in the near future. We will hit the market with our first product by end of 2011.

While the initial foray of Stempeutics is in bone marrow derived mesenchymal stem cells, Stempeutics is investing heavily on its R&D to bring out some innovative products in the near future based on adult stem cells.

There will be continuous research for each disease so as to improve product development for effective therapy. Research will be conducted on effective cell number, route of transplantation,” Stempeutics Research president BN Manohar President said.

According to the procedure, 10 patients will get one particular dosage of stempeucels, another 10 will get a higher dosage and the remaining 10 will get placebo (no drugs). “It will take at least 12 to 14 months to complete the study,” said Manohar.

Promoting Self-Management is Essential to Properly Treat Type 2 Diabetes

One of the most important aspects of diabetes management is educating the patient to manage their condition themselves. This is known as Diabetes Self-Management Education, better known by its acronym DSME. It has been demonstrated by many studies that education works.

DSME is defined as the ongoing process of facilitating the knowledge, skill and ability necessary for effective self-management and is guided by evidence-based standards. Patients with diabetes who do not receive DSME are found to be four times more likely to develop a major complication of diabetes and incur higher diabetes-related hospital costs.

I support the concept of DSME, given the fact that many family doctors do not have enough knowledge to effectively advise diabetes patients (see my earlier post ‘Why most doctors are clueless about treating diabetes’) and visits to a specialist involve long waiting periods and longer commutes.

In this interesting interview conducted by Endocrine Today, Linda Siminerio, RN, PhD, CDE, director of the University of Pittsburgh Diabetes Institute, and associate professor at the University of Pittsburgh School of Medicine and the School of Nursing answers many questions regarding DSME.

How can physicians effectively educate patients who currently have type 2 diabetes?
I think it is always helpful when physicians have access to additional resources to support team-based care. For example, referral to dietitians and diabetes education programs can be a powerful adjunct for comprehensive, quality care given the limited time they have available to spend with their patients. I have been involved in many studies and national surveys on referral practices, and we found that physicians often do not refer patients to these programs.

How can physicians effectively educate patients who are at risk for developing type 2 diabetes?
It is important for physicians to know what lifestyle intervention resources that address weight reduction and physical activity are available in their communities so that they can refer patients appropriately. Local YMCAs that offer lifestyle programs can be a valuable resource for physicians and patients. For example, in Indiana, some YMCAs have adapted the Diabetes Prevention Program (DPP) into a 16-week diabetes reduction program in the community setting. In Pittsburgh, the Diabetes Prevention Resource Center offers a 12–week Group Lifestyle Balance (GLB) program adapted from the DPP that is offered at community sites and in primary care practices. Physicians and practice staff should explore their respective communities to find community-friendly resources for their patients at risk for chronic disease.

What are your recommendations for creating collaboration between physicians and educators?
Physicians can refer their patients to the American Diabetes Association Web site to learn about community-based, recognized self-management education programs. Additionally, the American Association of Diabetes Educators Web site provides a variety of education materials that can be downloaded.

Even if patients obtain referrals from their physicians to participate in a program, they may not attend. I recommend that educators be integrated in the practice so that the educator becomes a part of the practice team. Educators and physicians should work together. Other support mechanisms are available in communities, but they are not always used. Primary care physicians should work with others in the community, such as local pharmacists, to effectively educate patients.

How can physicians promote diabetes self-management?
Diabetes self-management education (DSME) should always be considered as part of the treatment plan, even if a patient is reported to have excellent metabolic control. Attention to self-care behaviors and psychosocial needs are equally as important as metabolic outcomes when managing a burdensome, chronic disease like diabetes. Active listening, providing accurate information and building a patient’s confidence are all important tools used in diabetes education. It is essential that physicians and everyone on the diabetes care team work together to support patient self-management by developing patient-centered goals that will be more likely to be achieved.

How do you determine the best treatment option for patients?
Every patient and situation is individual. Thus, it is important for everyone on the diabetes care team to take time to listen to the patient’s needs and desires. The physician, along with the team, should provide patients with the necessary information to build a realistic care plan. Patients need to be informed so they can make informed decisions about their own care.

Do patients who have received this sort of patient-centered care have better results in the long run versus patients who may not receive ongoing support?
Research shows that diabetes self-management is an important component of diabetes care and has an impressive effect on HbA1c levels. In a meta-analysis, diabetes education was reported to reduce HbA1c by 0.76%. Since a 1% decrease in HbA1c is associated with a dramatic reduction in myocardial infarctions, micro-vascular disease and death, a 0.76% reduction can be considered an enormous benefit. Further, duration of contact time between a patient and an educator is the only significant predictor of the DSME effect. This suggests that DSME alone is not sufficient to maintain improved behaviors and that sustained improvements require contact and follow up.

We also know that if education is not sustained or supported, then HbA1c levels go back up. So, we need to continue to explore opportunities for continued support. Community-based programs, like wellness programs, YMCAs, churches and senior centers are potential forums for community friendly self-management support systems.

Hospitalized Diabetics Should Have Higher Than Normal Sugar Levels

After hospitalization for hernia surgery two months ago, my blood sugar levels, which had been reasonably good, suddenly went haywire. Readings of 200+ mg/dl were common for a couple of days after surgery. My doctors said they were looking at a target of around 180 mg/dl, which they said was optimal. Still, I was unhappy that my A1c levels would be compromised.

So it was with interest that I read the new guidelines released by the American College of Physicians recommending that doctors not attempt intensive insulin therapy designed to achieve normal blood sugar levels in patients in medical or surgical intensive care units. These guidelines are for both people with diabetes and without the condition.

The college recommends that doctors should maintain blood sugar levels between 140 and 200 milligrams per deciliter (mg/dl) for anyone in medical or surgical intensive care.

These recommendations ‒ published in the February 15 issue of Annals of Internal Medicine ‒ are similar to the guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). However, those guidelines recommend that blood sugar levels should be kept below 180 mg/dl to reduce the risk of infection and other complications.

For reference, in a healthy person with type 2 diabetes, normal blood sugar levels would be between 70 mg/dl and 130 mg/dl before eating. And, even after eating (postprandial), the recommendation from the ADA is to keep blood sugar levels under 180 mg/dl.

Talking to Serena Gordon of Health.com Dr. Amir Qaseem, director of clinical policy in the medical education division of the American College of Physicians explained, “[High blood sugar] is a common finding in hospitalized patients, and it’s associated with a lot of complications, like delayed healing, increased infection, cardiovascular events, you name it. The prevailing thought in the past was that tightly controlling the blood sugar levels would reduce inflammation, clotting and other problems. But, there are also harms that are associated with lowering the blood glucose levels too much. [Low blood sugar] can be very dangerous.”

“The evidence isn’t clear on what range of blood sugar is best, but 140 to 200 mg/dl seems to minimize the risk of hypoglycemia [in surgical or medical units],” said Qaseem. “We felt it was better to stick with a range that is a little bit higher.”

The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) have also published updated guidelines for treating high blood glucose while avoiding low blood glucose in hospitalized patients.

The main objectives of the 2009 AACE/ADA recommendations were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. For most patients a blood glucose target of 140-180 mg/dl is recommended and appropriate use of insulin is the preferred approach for achieving safe, optimal glucose control.

“Hyperglycemia in hospitalized patients is common and associated with increased risk of infection, mortality, and increased cost,” said AACE President Daniel Einhorn, MD, FACP, FACE. “Although near normalization of glucose in these patients appears to be of no greater benefit than moderate glycemic targets, ignoring hyperglycemia in this population is no longer acceptable.”

There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Although initial small studies suggested that intensive glycemic control (insulin infusion with goal blood glucose targets of 80-110 mg/dl) improved outcomes in surgical ICU and medical ICU patients, subsequent trials have failed to show a benefit or have even shown increased mortality of intensive targets compared to more moderate targets (140-180 mg/dl). Moreover, these recent studies have highlighted the risk of severe hypoglycemia resulting from attempts to completely normalize blood glucose.

“Both over treatment and under treatment of hyperglycemia in hospitalized patients are patient safety issues,” said Robert R. Henry, MD, President, Medicine and Science for the American Diabetes Association. “Coordinated, interdisciplinary teams have been shown to achieve both safe and effective control of hyperglycemia in hospitalized patients.”

The recent ACP guidelines are for the most part consistent with the AACE/ADA recommendations. AACE/ADA maintains that the upper limit of 180 mg/dl is safe and justified by data on benefits of glycemic control and the harms of uncontrolled hyperglycemia. Practitioners should take heart in the commonality of recommendations among all the organizations to address hospital hyperglycemia in the safest manner.

Dr. Mary Korytowski, a professor of medicine at the University of Pittsburgh School of Medicine, and a member of the board of directors of the American Diabetes Association, concurs that intensive insulin management in medical and surgical units isn’t the best way to manage blood sugar any more. “(But) 200 mg/dl is probably too high. The 2009 ADA/AACE guidelines recommend 180 mg/dl, which is consistent with postprandial numbers in diabetes care. The problem is that if you set the target too high, those numbers may be even higher when someone starts giving insulin to bring those numbers down,” she explains.

“These guidelines should not be interpreted to mean that glucose control isn’t important for critically ill patients: It is. And it’s important not to let the blood sugar get too high because of the risk of complications, like a higher risk of infection and fluid and electrolyte abnormalities,” she says, adding that it’s important to remember these guidelines give a range of options. “Managing blood sugar closer to the lower end is probably better,” she concludes.

Also see how illness can affect blood sugar levels in people with diabetes from the American Diabetes Association.

10-year Study Proves High Blood Sugar Linked With Retinopathy Risk

Here is more evidence that uncontrolled blood sugar (hyperglycemia) increased the risk of diabetic retinopathy (blindness). Individuals who have poorly controlled type 1 or type 2 diabetes may be at greater risk of developing retinopathy, according to a new study from a team of French researchers. They found that persistently high levels of blood sugar are a strong indicator of future retinopathy risk.

In a cohort study, the risk of the condition shot up markedly when fasting plasma glucose and glycated hemoglobin (HbA1c) reached levels that are used to indicate diabetes risk, according to Beverley Balkau, PhD, of the Institut National de la Santé et de la Recherche Médicale in Villejuif, France, and colleagues.

The finding allows physicians to set threshold values that define patients at risk of the eye condition, they argued in the February issue of Archives of Ophthalmology. They said the information helps clear up some debate over the role that blood sugar levels play in the development of retinopathy and could provide medical professionals with a way of measuring a patient's risk for the condition.

For the study, Balkau and colleagues studied more than 700 men and women taking part in the DESIR study, which enrolled volunteers ages 30 to 65 in western France from 1994 to 1996. At the outset, doctors examined participants' retinas and took blood sugar readings. The individuals were then followed for a period of ten years.

The goal was to study the frequency of retinopathy in individuals 10 years after measuring baseline levels of fasting plasma glucose and HbA1c and to evaluate positive predictive values for retinopathy at various levels of the glycemic variables.

After a baseline health exam, all participants were asked to return for subsequent examinations three, six, and nine years later. Those who were diagnosed with diabetes or who had had a fasting glucose level of at least 126 mg/dL at any point during the study were asked to undergo testing for retinopathy using a nonmydriatic digital retinal camera.

For comparison, two groups of matched participants also had the retinal exam ‒ those who had had an impaired fasting glucose level (from 110 through 125 mg/dL) at any time during the study and those whose glucose levels had always been below 110 mg/dL.

By the end of the study period, the researchers noted a strong correlation between initial blood sugar readings and the development of retinopathy. Participants with the condition had 22 percent higher fasting blood sugar levels and 12 percent higher HbA1c levels at the start of the study compared to participants who did not develop retinopathy.

All told, the researchers found 44 participants with retinopathy, including 19 of 237 in the diabetes group, another 19 of 246 with impaired glucose levels, and six of 249 in the normal glucose group.

Those with retinopathy had higher baseline fasting glucose and HbA1c levels on average -- 106 versus 130 mg/dL and 6.0% versus 6.4%, respectively (P<0.001).

And a higher percentage were treated for hypertension ‒ 36.4% of those with retinopathy compared with 19.6% (P=0.008), and they had a trend toward higher systolic blood pressure.

Analysis also showed that:

• Fasting plasma glucose levels of 108 and 116 mg/dL had positive predictive values of 8.4% and 14.0%, respectively, for retinopathy.

• HbA1c levels of 6.0% and 6.5% had positive predictive values of 6.0% and 14.8%, respectively.

Because of the sharp increase, they argued, the lower levels of each marker should be used as thresholds to identify those at risk of retinopathy 10 years down the road. "We propose that thresholds of 108 milligrams per deciliter for fasting plasma glucose concentration and 6.0 percent for HbA1c level could be used to define those who are at risk of retinopathy," they wrote.

Balkau and colleagues noted that the study's strengths included a large sample size and long follow-up.

However, they cautioned that the study participants were self-selected individuals who volunteered for the study after a free health checkup and the sample size of those with retinopathy was small, allowing evaluation only of risk factors strongly associated.

Women With Diabetes Are 50% More Likely To Die If They Have Breast Cancer

Here is some alarming news: A new analysis from Johns Hopkins University shows that women with diabetes are 50 percent more likely to die if they have breast cancer. Why? The challenges of diabetes management play a role, as well as women's overall health.

According to Kimberly Peairs, an assistant professor of medicine at Johns Hopkins University School of Medicine and the study's lead author, "When patients are faced with a diagnosis of breast cancer, which they see as an imminent threat to their lives, diabetes care often goes on the back burner."

The study, published in last month's issue of the Journal of Clinical Oncology, showed that diabetic women faced multiple problems. They were more likely to be diagnosed with an advanced form of breast cancer. And because of their pre-existing illness, they were more likely to be treated with less effective drugs or suffer from toxic side effects of chemotherapy.

But that's not all. As is often the case with diabetes, an array of risk factors are par for the course.

Type 2s are more likely to suffer from a constellation of health problems, including obesity and high blood pressure, research shows, along with a higher breast cancer risk. That overall health picture could contribute to their increased death rate, Peairs said.

"This research suggests we may need to proactively treat the diabetes as well as the cancer," she said.

Where do researchers go from here? They may look at how insulin levels affect tumor growth. They're also interested in seeing if improvements in diabetic control can also improve cancer outcomes.

The study was a meta-analysis of previously published studies that collected data about patients dealing with cancer and diabetes, and the outcomes of those illnesses. It was funded by the National Institutes of Health and the American Cancer Society, among others.

Omega-3s May Fight Diabetic Retinopathy

A healthy intake of omega-3 fatty acids, found in fish and fish oil supplements, has been shown to protect against retinopathy, a leading cause of blindness, particularly among people with diabetes. Now researchers have clarified how fish oil helps.

Previously, researchers from Children's Hospital Boston showed that mice fed a diet rich in omega-3s had less abnormal blood-vessel growth in the retina and less of an inflammatory response compared with mice fed omega-6 fatty acids, a less beneficial fatty acid. In the new study, published Wednesday in the journal Science Translational Medicine, the researchers showed that omega-3s promote healthy blood-vessel growth and inhibit abnormal growth. They found that a specific small molecule in omega-3s was the key to the blood-vessel stabilization.

"Our new findings give us new information on how omega-3s work that makes them an even more promising option," the lead author of the study, Dr. Lois Smith, said in a news release.

In addition, the study revealed that substances called COX enzymes, which are found in aspirin and other pain medications called NSAIDs, don't interfere with the benefits of omega-3s. However, a drug used for asthma, called zileuton, does.

The ability of fish oil to prevent eye problems is of great interest. The federal government is sponsoring a major clinical trial examining the benefits of omega-3 supplements in people with age-related macular degeneration. Smith is exploring the value of omega-3s for premature infants who are susceptible to an eye disease called retinopathy of prematurity.

Few Diabetics Aware of Potential Kidney Complications

Too many people who have diabetes don't know about their increased risk of kidney disease, a British researcher says.

Researchers led by Gurch Randhawa of the University of Bedfordshire in England conducted a multicultural study -- including 23 white and 25 South Asian patients with diabetes. The residents of England were between the ages of 34 and 79 years and had all been referred to a kidney specialist.

The study, published in the Journal of Renal Care, said most diabetes patients are completely unaware of how diabetes can affect their kidneys until sent to a specialist. He added "Many of the patients we spoke to were much more aware of how diabetes could affect their eyes and feet than their kidneys. We believe this study highlights a serious need for more information about the risks that diabetics face from kidney disease."

"The people we spoke to experienced feelings of surprise, fear and regret when they found out their kidney had been affected," Randhawa said in a statement.

"Some patients saw their kidney referral as a 'wake-up call' that they needed to manage their diabetes more seriously, while others were concerned about their lack of knowledge about the disease."

However, the study finds South Asian patients tend to be a lot younger than their white counterparts. The finding confirms, says Randhawa, that South Asian patients tend to develop diabetic-related kidney problems at an earlier age.

Why Most Doctors Are Clueless About Treating Diabetes

I have a host of friends who are doctors. So when I was diagnosed with diabetes back in 2002, I was confident I would never be short of good advise on how to manage my condition. Alas, my hopes were misplaced. Except for a few, most of my friends confessed they did not know enough about diabetes to guide me.

Mind you, these guys are good cardiologists, nephrologists, urologists, gastroenterologists, neurologists, oncologists ‒ all “hip and happening” disciplines ‒ but diabetes wasn’t/isn’t their cup of tea. Reason? They claim diabetes management, especially Type 2, was never really an important part of the curriculum. Surely, you must be joking, I would remark in all seriousness; but they assured me in all seriousness that this was indeed the case. Anyway, I dismissed these claims as meaningless till I came across a study recently that really validates this anecdotal evidence.

It seems that even in the US, many recent graduates of medical school programs may have very little training in how to care for chronic disease, which could greatly impair their ability to treat a patient who has type 1 diabetes or type 2 diabetes, according to a new study from Johns Hopkins University.

The researchers said that their study, which was published in the American Journal of Medicine, shows that there is currently an imbalance in the training of primary care physicians. Despite the fact that 90 percent of doctor visits are outpatient, most medical schools focus on inpatient situations. This leaves future primary doctors unprepared to deal with chronic disease like diabetes.

"When I graduated from residency here, I knew much more about how to ventilate a patient on a machine than how to control somebody's blood sugar and that's a problem," said Dr. Stephen Sisson, who led the study. "The average resident doesn't know what the goal for normal fasting blood sugar should be. If you don't know what it has to be, how are you going to guide your diabetes management with patients?"

For the study, Sisson and his team of researchers administered a test commonly used to gauge the knowledge of medical students to a group of first-, second- and third-year residents who were practicing at either an academic medical center or community hospital. All of the first-year residents were poorly prepared to treat chronic illness. However, knowledge improved somewhat among community hospital residents over time.

The study points out, “At the end of residency training, graduates from community hospitals have greater knowledge than graduates from university hospitals on chronic disease management (especially diabetes) and symptom-based/acute management, but not on preventive care. Training for all residents is particularly poor on outpatient diagnosis and management of diabetes, lipid disorders, dizziness, anemia, and alcoholism.

Our results also suggest that university hospitals do not do as good a job as community hospitals at teaching residents about ambulatory care. The culture of a training program has a significant impact on residents. Some have noted that the culture at university hospitals, where specialists often assume leadership roles in resident education, is not hospitable toward primary care, where specialized medicine is emphasized over a broad education in general internal medicine

Knowledge on topics in chronic disease management was poor among all trainees. Competent management of chronic diseases is a core skill of general internists, and as the prevalence of chronic diseases such as diabetes, hypertension, obesity, lipid disorders and others increase, more general internists will be needed. Symptom-based and acute care knowledge among PGY3 residents was only marginally better than knowledge of chronic disease management.

If the mission of internal medicine residency programs is to train physicians to meet society's health care needs, then our results suggest that they are failing. We note with irony that all surveyed programs use our ambulatory curriculum, most for several years, yet performance among all trainees, including PGY3 residents, was poor.

More than just didactic modules on ambulatory care are needed to improve ambulatory training during internal medicine residency. The inpatient and specialty-based orientation of university hospital-based residency programs represents a large barrier to improving training on chronic disease management,” the study noted.

Given the current demands being placed on the healthcare system by the high number of patients with chronic diseases, such as type 2 diabetes, which requires intensive care, Sisson said that medical schools need to consider changing the way they do business and incorporate more general teaching.

Now that we have a worldwide diabetes epidemic on our hands, we can only hope that the shrinking number of general internists and the shortcomings of internal medicine residency training which may be contributing to suboptimal care of common chronic diseases such as diabetes and hypertension receive adequate training in chronic disease management, and that training is redesigned to improve teaching in ambulatory care.

Bran Cuts Death Risk in Type 2 Diabetes Mellitus Patients

Type 2 diabetes mellitus in many cases can be prevented by following a modified lifestyle. Studies have suggested that even those who have acquired the disease may well control or even reverse their condition by following a healthy diet.

For example, eating whole grain cereal particularly bran supplemented foods may help reduce risk of premature death in women with type 2 diabetes mellitus, a new study recently published in the journal Circulation suggests.

The study led by Meian He Ph.D. and colleagues from Harvard School of Public Health in Boston Massachusetts found eating high amounts of bran was not only associated with significantly reduced risk of death from all causes, but also from cardiovascular disease (heart disease and stroke) or CVD in women with type 2 diabetes mellitus.

Bran is a hard outer layer of cereal grains such as rice, corn, oats, barley, millet and wheat and consists of combined aleurone and pericarp. It is full of dietary fiver and omegas and contains high amounts of starch, protein, vitamins and dietary minerals.

Type 2 Diabetes mellitus is a health condition that can lead to serious complications including bladder control problems for women, heart disease and stroke, nerve damage, eye disease, erectile dysfunction, foot problems, and kidney failure.

Whole-grain consumption has early been associated with lower risk of heart disease and stroke and mortality in the general population, according to the background in the study report.

The study was meant to determine the association of whole grain, cereal fiber, bran and germ with all-cause and CVD-specific mortalities in women with type 2 diabetes mellitus.

For the study, 7,822 U.S. women with type 2 diabetes mellitus enrolled in the NUrse' Health Study were followed for up to 26 years during which 852 all-cause deaths and 295 CVD deaths were identified. Subjects' dietary intakes and potential confounders were assessed regularly with questionnaires.

The subjects were divided into five groups based on their intakes of whole grain, cereal fiber, bran and germ. After adjusted for age, the highest intakes of whole grain, cereal fiber, bran and germ were associated with a 16 to 31 percent reduction in the risk of death from all causes compared to the lowest intakes.

After further adjustment for possible lifestyle and dietary risk factors, only bran intake was correlated with reduced risk.

Specifically, women in the group with the highest intake of bran were 28 percent less likely to die from all causes compared to those in the group with the lowest intake. This is an inverse association with higher intake leading to lower risk of all-cause death.

Bran intake was also inversely associated with CVD-related death with the highest intake linked with 45 percent reduction in the risk of heart disease and stroke or CVD compared to the lowest intake.

The researchers concluded "Whole-grain and bran intakes were associated with reduced all-cause and CVD-specific mortality in women with diabetes mellitus. These findings suggest a potential benefit of whole-grain intake in reducing mortality and cardiovascular risk in diabetic patients."

Previous studies have suggested Mediterranean diet, green leafy vegetables, breastfeeding,brown rice, plant-based diet, soy foods, black tea, vitamin D, L-carnitine, turmeric, selenium,bitter melon, fish oil, psyllium fiber and drinking coffee may help prevent type 2 diabetes mellitus.

Meanwhile, half way across the world, S. Haripriya and S. Premakumari from Pondicherry University and Avinashilingam University for Women in India conducted a small trial and proved that eating wheat bran help type 2 diabetes mellitus patients better control their condition.

The trial involved 30 patients aged 45 to 50. Half were assigned 20 grams of wheat bran, which consisted of 42.8 percent dietary fiber, each day for a 6-month period. And another group of 15 diabetics were not given any bran supplements.

For the trial, blood samples were collected at baseline and at the end of the trial to analyse biochemical factors including serum fasting glucose levels, postprandial glucose levels, and glycosylated hemoglobin levels or HbA1C in all the type 2 diabetes mellitus patients.

In the group of diabetes mellitus patients receiving wheat bran supplements, compared to the levels at baseline, the fasting glucose levels at the end of the trial were reduced by an average of 22.8 mg/ml. Controls did not experience any significant change.

Those on the bran supplement also reduced serum postprandial glucose levels by 39.80 mg/ml and the glycosylated hemoglobin or HbA1C by nearly 2 percent while controls did not have any significant change.

HbA1C is considered the most reliable index of long term diabetes control. Blood sugar tends to fluctuate from day to day and even from hour to hour while HbA1C reflects a true average index of glucose control for a period of 2 to 3 months.

Both groups of diabetes mellitus patients at baseline had 8.39 to 8.45 percent, a level of HbA1C considered by the definition of American Diabetic Association under unsatisfactory control.

After the supplementation trial, diabetes mellitus patients reduced the index by 1.96 percent, pushing the index down to 6.41 percent, a level which is considered under good control.

Clinical Trial Will Test Whether Surgery Is the Best Option for Type 2 Diabetes, Even for Patients Who Aren't Obese

A new clinical trial at NewYork-Presbyterian Hospital/Weill Cornell Medical Center is among the first to test surgery specifically for Type 2 diabetes. The aim of the study is to understand whether surgery can control diabetes, as well or even better than the best medical treatment available today. This is the first study of its kind open to patients who are overweight or mildly obese.

Under current guidelines, bariatric surgery is only indicated for the treatment of severe or morbid obesity, defined as having a body mass index (BMI) of 35 or greater. By contrast, the new study is open to patients with a BMI as low as 26. Normal-weight individuals have BMI ranging between 19 and 25 and overweight individuals have BMI between 26 and 29, whereas a BMI above 30 defines obesity. Patients with a BMI below 26 and above 35 will not be considered for enrollment in the trial.

Previous research has shown that in severely obese patients (BMI greater than 35) gastric bypass surgery is a safe and effective way to treat Type 2 diabetes. It has been shown to improve or normalize blood glucose levels, reduce or even eliminate the need for medication, and lower the risk for diabetes-related death.

"There is preliminary evidence suggesting that that these results are attainable even in overweight or mildly-obese patients," says Dr.Francesco Rubino, chief of the gastrointestinal metabolic surgery program at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and associate professor of surgery at Weill Cornell Medical College.

In support of this belief, recommendations from the American Diabetes Association's January 2009 issue of Standards of Care: Diabetes Care, and from the Diabetes Surgery Summit Consensus Conference, published in the March 2010 issue Annals of Surgery, suggest that randomized clinical trials for the study of surgery in patients with BMI below 35 are priority for diabetes research.

"Having a potentially effective surgical option against diabetes does not mean that surgery is the best choice for every diabetic patient," Dr. Rubino adds. "We need rigorous, comparative clinical trials, like this one, in order to better understand when to prioritize surgery and when to recommend traditional medical treatment."

The new study is enrolling 50 patients with Type 2 diabetes who will be randomized to receive surgery -- specifically, Roux-en-Y Gastric Bypass -- or traditional medical therapy and intensive lifestyle modification. All patients will be counseled in lifestyle modification techniques like diet and exercise.

Dr. Rubino expects that there will be medical advantages for patients in both arms of the trial since those assigned to the medical arm will receive the most rigorous medical diabetes therapy available. A multidisciplinary team of diabetes and nutrition experts will take care of patients using the most current, approved drugs for diabetes as well as an intensive approach to lifestyle changes. Patients in the medical arm will also be offered the chance to switch study arms and have surgery free of charge after the study is complete, or earlier should their diabetes remain poorly controlled after medical and lifestyle therapy.

Beyond BMI

Dr. Rubino and his co-investigators believe their study may also help identify better criteria than BMI for selection of surgical candidates. "Using strictly BMI-based criteria may be practical, but it is medically inappropriate because, on its own. BMI does not accurately define the severity of diabetes or identify patients who are best suited to benefit from a surgical approach," says Dr. Rubino. "New criteria would not only help patients and clinicians, but also payers."

Because insurers use BMI-based criteria, bariatric surgery is currently not covered for patients with a BMI less than 35, regardless of the severity of their disease. Consequently, the study at NewYork-Presbyterian/Weill Cornell is supported by a research grant from Covidien covering the cost of surgery for patients enrolled in the study.

A Look at How Diabetes Surgery Works

Previous research by Dr. Rubino studied how bariatric surgery alleviates diabetes, showing that the effect on diabetes is not entirely explained by a person's weight loss. In fact, the gastrointestinal tract serves as an endocrine organ and a key player in the regulation of insulin secretion, body weight and appetite, which is why altering the GI tract has such profound metabolic effects.

The current study aims to shed more light on the mechanisms of action of gastric bypass on diabetes. To do this, Dr. Rubino and his co-investigators will measure gut hormone responses to meal stimulation when an equivalent amount of weight loss has been achieved in both surgically and conventionally treated patients. This design may help uncover endocrine effects specific to gastric bypass surgery beyond those associated with non-surgical weight loss.

"Understanding how gastric bypass surgery functions may help us learn how diabetes works," Dr. Rubino says. "This knowledge has the potential to lead to the development of new minimally invasive procedures, devices interventions and better pharmaceutical treatments."

Toward an International Consortium

Dr. Rubino hopes that the current study will be a template for larger, international studies. "We intend this study to serve as a core protocol for similar randomized clinical trials independently run at other institutions as part of a worldwide consortium coordinated through the Diabetes Surgery Center at NewYork-Presbyterian/Weill Cornell," he says. "The consortium will provide a larger pool of patients allowing researchers to better evaluate the impact of surgery on various health measures, including cardiovascular risk and life expectancy."

The global prevalence of Type 2 diabetes is rising dramatically. "If proven successful, diabetes surgery has the potential to help millions of patients in the U.S. and worldwide," Dr Rubino says.

According to International Diabetes Federation (IDF), there are currently 285 million people with the disease around the world, a number that is expected to rise to 438 million by 2030. Diabetes is one of the greatest public health threats in the 21st century and a risk factor for vascular damage and eye, kidney and cardiovascular diseases, as well as death. Type 2 diabetes results from inadequate insulin production and action, and is associated with metabolic dysfunctions involving lipid metabolism and blood pressure regulation.

Interested patients with Type 2 diabetes may contact the Diabetes Surgery Center at NewYork-Presbyterian/Weill Cornell at (212) 746-5925 or ant2026@med.cornell.edu.

For more information, visit www.nyp.org and weill.cornell.edu.

Social but Safe? Diabetes Patients Warned About Safety on Internet

In this digital age, many individuals who receive positive HbA1c tests for diabetes turn to the internet for answers to their questions about the condition. However, a new study has found that this may be a dangerous practices, as many community sites for people with the condition contain unqualified information that may be misleading and even dangerous.

Nearly one-half of U.S. adults who use the Internet participate in social networks. While these increasingly include health-focused networks, not much is known about their quality and safety. In one of the first formal studies of social networking websites targeting patients, researchers in the Children's Hospital Boston Informatics Program performed an in-depth evaluation of ten diabetes websites.

Their audit found large variations in quality and safety across sites, with room for improvement across the board. As reported online January 24 in the Journal of the American Medical Informatics Association, only 50 percent of the sites presented content consistent with diabetes science and clinical practice. Even fewer offered both scientific accuracy and patient protections such as safeguarding of personal health information, effective internal and external review processes and appropriate advertising.

For instance, seven of the ten sites did not allow members to restrict the visibility of their profiles. Five carried advertisements that were not labeled as such. And three sites went as far as to advertise unfounded "cures."

"We saw that people are sharing incredible amounts of personal health information on these sites, including highly identifiable information," says Elissa Weitzman, ScD, MSc, lead author on the study and an assistant professor in the laboratory of Kenneth Mandl, MD, MPH. "They are eager to accelerate their understanding of the disease, obtain support, find treatments and see if their experience is common or different."

"There is on the one hand an enormous focus in the U.S. on health information privacy," Mandl adds. "But privacy in a social network is somewhat of an oxymoron. On the whole, these networks tend to be about exposing your information online."

The team evaluated diabetes websites that appeared prominently in Google searches and allowed members to create personal profiles and interact with each other. They looked at four key factors:

(1) agreement of content with diabetes science and clinical practice standards,

(2) practices for auditing content and supporting transparency,

(3) accessibility and readability of privacy policies, and

(4) the degree of control members had over the sharing of personal data.

The average number of members per website was 6,707. Activity ranged widely among the sites, from over 100 new posts per day to less than 5 new posts per day.

The majority of sites studied did not include a "disclaimer" encouraging patients to discuss their care regimen with a healthcare provider. Many sites also missed opportunities to communicate essential diabetes information, such as the definition of "A1c"—a biomarker commonly used by diabetics to access blood glucose levels.

In addition to recommending improvements in these areas, the authors saw a need for increased moderation, for the credentials of moderators to be more visible and for periodic external review. Further, potential conflicts of interest—such as ties to the pharmaceutical industry—needed to be more clearly disclosed, and privacy policies easier to understand.

Diabetes is only one illness in the rapidly growing list for which there are online social networks with thousands of users. The researchers chose to study diabetes-related networks because they were among the earliest to emerge and remain among the most active. They and colleagues in the Children's Hospital Informatics Program are further studying how these sites are used—how people choose to interact with them and how specifically they share their medical information.

Last year, Mandl and Weitzman developed an application for the social networking website TuDiabetes that allows users to submit their A1c levels to be displayed in a worldwide map, as part of an effort to encourage diabetes management and inform public health efforts and research.

The two believe that the emergence of online health communities and their large number of participants reveal unmet needs for information and support of patients and families. "Social networking activity is clearly replacing or adding value that is missing in the standard healthcare system," Mandl says.

"We sought to jump start a conversation about how to balance patients' safety with their autonomy," Weitzman says, "as we're in an era where terrific levels of healthcare communication are happening outside of the usual channels."

This study was funded by the Centers for Disease Control and Prevention and the National Institutes of Health, including the National Institute on Alcohol Abuse and Alcoholism.

Safety Tips for Patients Using Online Social Networks
1. Look for sites where the basic description of the disease and how to care for it is consistent with information provided by your doctor. Be very cautious of sites that advertise miracle "cures."

2. Find the privacy policy of any website where you register as a member, and make sure that you understand it.

3. Try to use sites where you have maximal control over the sharing of your health data—where you can designate whether the information you disclose will be available to anyone online, members only or members who are "friends."

4. Look for websites that clearly label advertisements and disclose conflicts of interest.

5. Try to use sites that have moderators and at least periodically undergo external review.

6. Always remember that going online is not a replacement for visiting your doctor.


SOURCE: Children's Hospital Boston