Aspirin Use In Patients With Diabetes Requires Careful Consideration

ASPRIN has been proven to be effective in reducing the risk for cardiovascular events; however, patients with diabetes are a unique population that requires special considerations before treatment. While aspirintherapy is recommended, further exploration into dosing strategies, strongerantiplatelet therapy and the clinical interaction between aspirin and patients with diabetes is essential.

“A landmark stage published in 1990 really set the stage as to why diabetics are different and why antiplatelet therapy may be effective in this population,” Jeffrey S. Berger, MD, of the NYU Cardiac and Vascular Institute at the NYU Langone Medical Center in New York, said during a presentation. “Compared with non-diabetics, diabetics had greater platelet activity.” He was speaking at the American College of Cardiology (ACC) 60th Annual Scientific Sessions in New Orleans earlier this week.

Berger noted that one study currently being conducted at NYU suggests that markers of platelet activity correspond well with an increasing prevalence of diabetes. Data from other trials support this association, and these results raised an important question: Can measuring platelet activity prevent a future event? At present, this question remains unanswered but warrants further investigation, he said.

A Closer Look
In addition, physicians must consider dosing when treating with aspirin. Berger explained that aspirin inhibits COX-1 and, thus, reduces amounts of platelet activation and vasal constriction. However, aspirin also reportedly inhibits prostacyclin, which causes the opposite effect on thromboxane. Therefore, Berger emphasized that physicians be careful not to prescribe too much aspirin, even among patients with diabetes.

Many physicians believe that patients with diabetes respond differently to aspirin than those without the disease. Berger pointed out that this is a misconception, however, and cited data from one study indicating no significant differences in aspirin’s interaction in patients with diabetes compared with those without the disease. Most importantly, he said, research showed no significant differences in how aspirin prevents cardiovascular (CV) events between patients with the disease and those without.

Despite aspirin’s efficacy, the medication has been linked with serious adverse events, such as hemorrhagic stroke, with research showing a low number needed to treat and a low number needed to harm.

“Thinking about it this way, for every 1,000 patients treated for 5 years, three ischemic events are avoided, but three major bleeds are caused,” Berger said. “So when you’re thinking about who should get aspirin, you should think about the absolute benefit and the absolute risk.”

Future Studies
Because patients with diabetes are a special population, researchers and physicians should consider whether stronger antiplatelet therapies are required. Berger said future studies must take other medications into account. Statins, fish oil and ACE inhibitors, for example, have antiplatelet activity and this effect may be sufficient for patients with diabetes.

He also noted that dosing strategies may have to be altered, such as administering aspirin twice a day instead of once daily. Additionally, improved tools for monitoring aspirin’s effect on preventing CV events would also be extremely valuable, according to Berger.

“There is no significant clinical interaction between diabetics and non-diabetics regarding the effect of aspirin, how diabetics may need a different strategy of dosing or a stronger antiplatelet therapy, and I think future clinical trials should address these issues,” Berger said.

Commenting, Rhonda Cooper-DeHoff, Associate Professor in the Department of Pharmacotherapy and Translational Research at the Colleges of Pharmacy and Medicine, University of Florida, said: “Dr. Berger raised some very provocative points, particularly about what dose of aspirin should be used. The fact that he showed data that suggest that a lower dose of 81 mg may not be as effective as we think in patients with diabetes is an important take-home message. I don’t think that message is really out there.

“The other very provocative point he raised is that we need better tools to monitor the effect of aspirin like we have to monitor the effect of cholesterol-lowering and blood pressure-lowering drugs. We are really missing that with aspirin. Some of the focus for future trials that he discussed would be incredibly useful to the overall care for the patient with diabetes.”

Reported by Endocrine Today

Diabetics May Have Increased Risk of Developing Parkinson's Disease

The two diseases share some underlying mechanisms, a study of 289,000 adults suggests

Symptoms of Parkinson's Disease

A new study ‒ published in the April issue of the journal Diabetes Care ‒ suggests that diabetics may have a slightly increased risk of developing Parkinson's disease. Though the reasons for the link are far from clear, the connection between diabetes and Parkinson's risk could mean that the two diseases share some underlying mechanisms.

One possibility is chronic, low-level inflammation throughout the body, which is suspected of contributing to a number of chronic diseases by damaging cells. Oxidation ‒ the process fought by anti-oxidants ‒ is another.

The study, of nearly 289,000 older U.S. adults, found that those with diabetes at the outset were more likely to be diagnosed with Parkinson's over the next 15 years. Of 21,600 participants with diabetes, 172 (0.8 percent) were eventually diagnosed with Parkinson's. That compared with 1,393 cases (0.5 percent) among the 267,000 men and women who were diabetes-free at the study's start.

When the researchers accounted for other factors ‒ like age, weight and smoking habits ‒ diabetes itself was linked to a 41 percent increase in the risk of future Parkinson's. That, however, does not prove that diabetes is a cause of Parkinson's, and the reasons for the connection remain unknown.

Other large studies, too, have looked at the diabetes-Parkinson's link before, with conflicting results. However, the current study included a larger number of people with Parkinson's. And unlike most past studies, it looked at the duration of people's diabetes.

In general, the researchers found, the higher Parkinson's risk was largely seen among people who'd had diabetes for more than 10 years before the start of the study. That supports the idea that diabetes came first, before Parkinson's, rather than the other way around. But more studies are needed to understand why the connection exists, and what, if anything, can be done about it.

The evidence at this time is very preliminary, the researchers say, and diabetics should simply continue to do the things already recommended for their overall health ‒ eating a well-balanced diet and getting regular exercise. Still, there might be something about diabetes ‒ like a problem regulating insulin ‒ that contributes to Parkinson's. But that remains to be proven.

Diabetes Management: Tight Cholesterol, BP Control Does Little Good for Diabetics

Lower isn't always better in diabetes management. In fact, pushing too hard may not help, and may actually hurt in some cases. This has been proved, once again, by the landmark Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, results released last week reveal. Indeed, the new lipid and blood pressure results round out the negative portrait of aggressive risk factor management in diabetes patients.

(ACCORD is one of the largest studies ever conducted in adults with type 2 diabetes who were at especially high risk of cardiovascular events, such as heart attacks, stroke, or death from cardiovascular disease. The multicenter clinical trial tested three potential strategies to lower the risk of major cardiovascular events: intensive control of blood sugar, intensive control of blood pressure, and treatment of multiple blood lipids. The lipids targeted for intensive treatment were high density lipoprotein (HDL) cholesterol and triglycerides, in addition to standard therapy of lowering low density lipoprotein (LDL) cholesterol. Read the Questions & Answers about the ACCORD Trial here.)

According to received wisdom, intensive blood pressure and blood fat management could drive down diabetics' higher risks of heart problems. But results from the ACCORD trial prove that when it comes to traditional measurements of heart disease risk, a blood pressure target of 120 mm Hg rather than the general population standard of 140 did not reduce nonfatal heart attacks, nonfatal strokes or death from cardiovascular causes.

Likewise, adding the cholesterol-busting drug fenofibrate to standard statin therapy did not reduce the chances of major adverse cardiovascular events. Indeed, tribal behavior by physicians that is no doubt driven by the big pharma marketing machinery, has raised concerns about the ramifications of recommending costly medications that don't confer real benefits to patients. (See my post ‘Increased Use of Fibrates in US Could Be A Triumph Of Marketing Over Medicine' here.)

Both studies ‒ part of the complex ACCORD trial ‒ were presented at the American College of Cardiology meeting in Atlanta, Ga. and released simultaneously online in the New England Journal of Medicine.

[A third part of this research ‒ one which examined intensive lowering of blood sugar to see if this had a positive effect ‒ was prematurely halted in 2008 because it turned out that patients receiving this approach actually had an increased, instead of decreased, risk of death. (See a related post ‘Aggressive Diabetes Therapy May Raise Death Risk’ here.)]

As for the newly released findings, the lipid arm of ACCORD included 5,518 patients with high risk of heart problems because of cardiovascular disease or at least two risk factors. LDL, or bad, cholesterol levels had to be between 60 and 180 mg/dL; HDL, or good cholesterol, levels had to be under 50 mg/dL or 55 mg/dL for women and blacks; and triglycerides had to be under 750 mg/dL if the patients were not on any therapy, or 400 mg/dL otherwise. Patients either received fenofibrate or a placebo in addition to statins.

What the researchers found was that lipid and triglyceride levels responded as expected. Despite this, however, the patients appeared to receive no benefit when it came to major heart problems such as heart failure, stroke and nonfatal heart attacks.

Meanwhile, the blood pressure portion of ACCORD compared a strategy of keeping systolic blood pressure under 120 mm Hg to one of under 140 mm Hg in 4,733 diabetes patients with high risk of cardiovascular events because of clinical or subclinical heart disease or at least two risk factors. In this trial, treatment effectively lowered blood pressure. But again, there was no impact on aspects of patient health including death risk, death related to heart problems and nonfatal heart attacks.

ABC News reported that the U.S. Food and Drug Administration will conduct a full review of findings from the ACCORD study. An FDA spokesperson said the agency planned to include a review of the labeling and indications for fenofibric acid (Trilipix) ‒ even though the trial used fenobrate (TriCor). Asked about the timing of the announcement, the spokesperson said the FDA was attempting to be more proactive.

Both Trilipix and TriCor are marketed by Abbott, and Trilipix is "the active metabolite of TriCor," according to Dr. Marshall Elam of the Memphis VA Medical Center. Elam, who was involved in the design of the lipid treatment arm of ACCORD said that "neither TriCor nor Trilipix has a label indication for cardiovascular disease."

In a statement released after the ACCORD results were reported, but before the FDA said it would conduct a review of the ACCORD findings, Abbott said the data from the ACCORD Lipid trial "supports the appropriate patient type and current treatment guidelines for fibrates. The top-line results of the study were widely expected, given that two-thirds of patients in the trial would not be recommended for fibrate therapy under current guidelines."

Diabetes: Increased Use of Fibrates in US Could Be A Triumph Of 'Marketing Over Medicine'

U.S. prescriptions for cholesterol-lowering medications predating statins have increased steadily despite uncertain benefit, suggesting that aggressive marketing has trumped scientific evidence.

These drugs, called fibrates, modestly reduce blood levels of artery-clogging bad cholesterol, raise good cholesterol and are most effective at lowering levels of other damaging blood fats called triglycerides, although the overall picture from clinical trials remains confusing.

Fibrates include gemfibrozil (Lopid), which got the regulatory nod in 1981; fenofibrate (TriCor, Triglide), approved in 2007, and the closely related drug fenofibric acid (TriLipix, Fibricor), which entered the U.S. pharmaceutical marketplace in December 2008. In 2009, fenofibrate and fenofibric acid together accounted for almost 74 percent of the U.S. market share of fibrates.

According to Dr. Cam Patterson, cardiology chief and physician-in-chief of the Center for Heart and Vascular Care at the University of North Carolina, Chapel Hill, "Statins are the only cholesterol-lowering drugs that have been shown conclusively to save lives. Fibrates may be an option as add-on therapy, but there is no compelling case to use them as first-line therapy" for patients with elevated cholesterol, he warns.

Patterson feels the substantial increase in fibrate use demonstrated "unfortunate tribal behavior by physicians that is no doubt driven by the big pharma marketing machinery" and expressed concern about the ramifications of "recommending costly medications that don't confer real benefits to our patients. We've been burned before."

"The use of fibrates in America is very troubling," says Dr. Steven E. Nissen, chairman of cardiovascular medicine at the Cleveland Clinic Foundation. Describing the increasing use of fibrates as an expensive failure to educate doctors and regulators, he notes that fibrates are among medications advertised directly to consumers. “This is a classical example of marketing triumphing over science," he feels.

Dr. James H. Stein, director of preventive cardiology at the University of Wisconsin-Madison School of Medicine and Public Health, says most people don't realize the influence of marketing on health care. Pointing out that negative studies about fibrates have been "spun to focus on the possible benefits", he cautions that fenofibrate is associated with significant side effects, including "increased creatinine, which might indicate kidney dysfunction; gallstones, and more serious complications like pancreatitis, blood clots, and pulmonary embolism."

In the past five years, two major studies have found fenofibrate failed to reduce heart disease risks among diabetic men and women. Last year, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which involved 10,000 patients with diabetes, found that those who took both simvastatin and fenofibrate suffered about as many heart attacks, strokes and deaths as diabetic patients treated with simvastatin alone.

The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trial, which involved nearly 10,000 patients and has reported results since 2005, found that fenofibrate failed to decrease cardiovascular deaths more than a placebo.

Yet a new study published in the current issue of the Journal of the American Medical Association found that U.S. prescriptions for fibrates grew from 336 per 100,000 people in January 2002, to 730 per 100,000 people in December 2009. That's a 117.1 percent hike. At the same time, Canadian prescriptions for fibrates held nearly steady, at 402 per 100,000 in early 2002 and 474 per 100,000 in late 2009.

The increase in fibrate prescriptions, driven by a 200 percent jump in the use of fenofibrate, has outpaced the growth of statins. But, to keep things in perspective: statins, which are among the most commonly prescribed medications, remain blockbuster drugs that dominate lipid-lowering treatment, with fibrates accounting for just 9.4 percent of the U.S. lipid-lowering market in 2009.

Based on a news report in ABC News

Wake-up Call: 50% Adult Americans Face Serious Health Risk

Nearly 50 percent of all adult Americans have high cholesterol, high blood pressure or diabetes. All conditions increase the risk of cardiovascular disease. Diabetics, of course, are at greater risk of having the other two conditions as well, and heart disease is one of the most common complications resulting from poor diabetes management.

A report released online Monday by the national Centers for Disease Control and Prevention said nearly 13 percent Americans have at least two of the conditions and three percent have all three, sharply increasing their risk. Of those with at least one condition, 15 per cent have not been diagnosed.

(Diabetes affects 8.3 percent of Americans of all ages, and 11.3 percent of adults aged 20 and older, according to the National Diabetes Fact Sheet for 2011. About 27 percent of those with diabetes—7 million Americans—do not know they have the disease. Prediabetes affects a whopping 35 percent of adults aged 20 and older.)

"The number that really surprises me is the penetration of these conditions into the U.S. population," said Dr. Clyde Yancy of Baylor University Medical Center, president of the American Heart Association. "When that number is nearly 50%, that's a huge wake-up call." It means there are a large number of people "who think they are healthy…but are working under a terrible misconception."

The data come from the ongoing National Health and Nutrition Examination Survey, which releases new figures every two years. The survey consists of interviews conducted in participants' homes, standardized physical examinations given to some participants and laboratory tests using blood and urine specimens.

"This report is so timely and important because it crystallizes exactly what the burden is," Yancy said. "It tells us the challenge we now face that could stress and potentially defeat any healthcare system we could come up with."

Personal responsibility plays a big role in creating these three health problems, he said. "This trio begins with a quartet of smoking, a junk diet, physical inactivity and obesity. Those are all things we can do something about."

Though researchers should be able to use the new data to plan interventions, "the main thing here is for people to be aware that they have these conditions and know that lifestyle modifications and medications can control them and reduce their risk for cardiovascular disease," said epidemiologist Cheryl D. Fryar of the CDC's National Center for Health Statistics, one of the study's authors.

Peer Support Improves Diabetes Self-Management

Diabetes patients who receive peer support benefit from improved control of their blood sugar levels. Research carried out at the University of Michigan Medical School and published in the Annals of Internal Medicine reveals that phone calls to peers facing the same self-management challenges helped diabetics manage their conditions better than those who used traditional nursing care management services.

For the study, researchers randomly assigned 244 male patients with uncontrolled diabetes to either peer support or nurse care management. After six months, those in the peer-support group saw a significant drop in their HbA1c levels (a measure of blood sugar over time) ‒ from an average of 8.02 to 7.73 per cent, which represented a 0.58 per cent decrease from those who received care from a nurse.

The researchers also monitored changes in insulin therapy, blood pressure and adherence to oral treatment regimens, and found that patients who received peer support managed their conditions better.

Michele Heisler, lead author of the study, said "Our model was testing the hypothesis that a good way to activate patients was to give them some skills and encouragement to both help and be helped. Just as in education they say that the best way to learn something is to try to teach it."

"Our program hoped to mobilize patients themselves to realize how much they themselves had to offer another person with diabetes and enjoy the sense of meaning and pleasure that being needed and helping another can provide. That's why I think people did well – they were very motivated when they felt they were helping someone else."

She concluded: "Most chronically ill patients need more support for self-care than most health care systems can provide. That's why programs like this, that increase the quality and intensity of assistance through peer support, deserve further exploration."

All Eyes on Research That May Provide Cure for Diabetic Neuropathy

All

An Australian optometrist researching how contact lenses affect the eye accidentally discovered a new way to study diabetic neuropathy. The discovery holds the key to monitor nerve degeneration over time.

The extreme magnification of a special microscope, called a corneal confocal microscope, allowed Nathan Efron, a professor at the Queensland University of Technology's School of Optometry at Brisbane, Australia, to see fine nerves in the cornea that had never been seen before.

Efron found that the nerves affected by neuropathy are an exact match to nerves found in front of the eye, and is testing whether looking at their level of degeneration in these nerves over a period of time would match the nerve degeneration found in arms and legs.

"We want to see how well the degeneration of the nerves in the cornea matches the degeneration of nerves throughout the body, and if it matches it will mean that we can monitor diabetic neuropathy using a simple eye test," Efron says.

The breakthrough is so profound and important that Efron was honored last November with the Glenn A. Fry Lecture Award from the American Academy of Optometry for his research into non-invasive ophthalmic diagnosis of diabetic nerve damage.

As the principal researcher of a five-year study ‒ Expanding the Role of Optometry in Diabetes Management: Determining the Discrimination Capacity of a Novel New Ophthalmic Marker of Diabetic Neuropathy ‒ Efron says early indications are promising and he is presenting his findings at the Asia Pacific Academy of Opthamology Congress in Sydney this week.

When he first saw the nerves, Efron, who has type 2 diabetes, knew at once that what he was seeing was something unique. One of the serious consequences of the disease is diabetic neuropathy – a condition that causes nerve damage and can result in ulcers and amputations ‒ that affects about half of diabetics in varying degrees of severity, which causes the degeneration of nerves, mostly in the arms and leg. (See my post ‘Don’t Ignore Diabetic Nerve Pain’ here.)

"I wondered if my own diabetes specialist might be interested in the technology and it turned out he was a world authority on diabetic neuropathy. He thought it was astonishing,” recalls Efron. It was ideas generated by discussions with his diabetes specialist that led Efron to investigate linkages between the nerves in the eyes and nerves elsewhere in the body with the aim of developing a relatively simple and non-invasive eye test to identify neuropathy (or diabetic nerve disease).

Neuropathy is typically measured by taking skin biopsies from the foot and running a series of specialized tests that can take up to a week to complete. In many cases, this debilitating condition is not identified until serious, and irreparable, damage has already been done.

On the other hand, the quick and non-invasive eye tests would see results in a matter of minutes. In short, the importance of Efron’s discovery lies in the fact that since the eye is a transparent structure, it is the only place in the body where you can look directly at nerves and their degeneration over time.

Efron and his team have established a four-year clinical trial assessing the optimal method of ophthalmic neuropathy diagnosis. This will hopefully lead to a standard protocol for optometrists and ophthalmologists to quickly and simply identify people at risk of neuropathy, anticipate the level of damage and assess treatment outcomes.

There are multiple benefits of being able to measure the onset of neuropathy, one being that there are drugs in development that aim to cure diabetic neuropathy. "When these drugs are ready to come onto the market, we will, using our method, be able to detect nerve degeneration early and then hopefully cure it," he says.

For the tests, patients would receive a drop of anesthetic in the eye, then a corneal confocal microscope would capture a 20 second "movie" of their eye for analysis.

There are also three more tests being looked at - the first, called non-contact corneal aesthesiometry, measures how nerve degeneration is affecting the function of the cornea, by projecting tiny puffs of air into the eye, growing progressively stronger until the patient can feel it.

Two more eye tests will look at the effect of nerve degeneration on the retina.

"Diabetic patients currently go for yearly eye tests anyway, so we are saying that these tests could be done at the same time, and only take a few minutes," Efron says.

Efron hopes his discoveries will lead to early testing for diabetic neuropathy that will motivate sufferers to better manage their disease. Testing could be carried out at the same time as diabetes patients are tested for other eye problems caused by the disease.

The test has been used to monitor nerve regeneration in patients who have undergone kidney and pancreas transplants, and it could help track the effects of new treatments.

Based on a news report in Sunday Star Times

Diabetes: Is the ADA Shifting its Stance About Carbs?

Carbohydrates are a very touchy subject with diabetics. And for me at least, understanding carbs in a diabetic diet is more difficult than quantum mechanics (or double-entry accounting if you’re not a science type). Diabetologists and dieticians, too, have differing views. I found this article by LAURA DOLSON very instructive and am reproducing it here for those who may have missed it. You can find the lively discussion that followed the article’s publication here.

You may be surprised to know that for the past couple of decades, the American Diabetes Association has been sort of a cheerleader for carbs. Yes, I'm talking about the organization who's mission it is to promote education and research in ways aimed at preventing diabetes and alleviating the suffering of diabetics.

What is diabetes? It is essentially a disorder of the body's ability to process carbohydrates. This includes Type 1 and Type 2 diabetes, pre-diabetes, metabolic syndrome, insulin resistance, and all the other points on the diabetes spectrum. (The Endocrine Society suggests that anyone with a fasting blood glucose of 89 or above is at risk for damage to their health.)

In light of this, you'd think that limiting carbohydrate intake would be a priority in educating people about handling these disorders. And yet, the ADA jumped right onto the Food Pyramid bandwagon and began to advise people to get at least 55% of their calories from carbohydrate, such as in the Food Pyramid for Diabetes (see illustration above).

In 2008, they made one exception: diabetics trying to lose weight could follow a low-carb diet for up to one year; this was later loosened further to two years. But still they did not recommend a low-carb diet for health, blood sugar control, or preventing progression of the diabetes.

Now, in the March 2011 edition of the ADA magazine "Diabetes Forecast" are three rather remarkable articles. The first is called The "ADA Diet" Myth, which claims that there is no such thing as the ADA Diet! (Who else was having this hallucination?) Instead, Stephanie Duncare, director of nutrition and medical affairs for the ADA says, "For more than 15 years now, ADA has recognized that people with diabetes should eat in a way that helps them reach their blood glucose, cholesterol, blood pressure, and weight goals. For some, this means a relatively higher-carbohydrate diet, and for others, the diet may be lower in carbohydrate". Well, hallelujah to that, especially if the goal is "normal blood glucose" (normal meaning "a blood glucose level that will not cause further damage in the pancreas").

Even more bold is an article called, "Are Carbs the Enemy?" which attempts to cover the debate. They first present a sort of wimpy pro-carb stance. This section of the article has a notable absence of anything to do with science, instead relying on statements such as "Gone are the days of 'diabetic diets' that were meager and confining" and "as long as people eat less or cover their carb intake with medications, they can keep blood glucose levels in check with a healthy diet" ("healthy" in this case meaning "high-carb").

The article then goes on to describe a low-carb approach, citing Dr. Richard Bernstein. This section cites actual evidence, and makes what I think is a much stronger case for controlling blood glucose by limiting carbohydrates. The article goes on to a section on saturated fats which is much more balanced than usual, and then the normal "we don't have the long-term studies". The article concludes with the statement: "In the end, the best diet is the healthy one you're able to follow."

The only thing I would add is that people need support in making those changes, and as far as I can tell they are still leaving an awful lot up to the individual to figure it out for themselves. There has been quite a defeatist attitude coming from the organization that is supposed to be helpful - along the lines that it is asking just too much of people to cut carbs in any significant way. Are dietitians now actually going to support people in finding a diet that achieves as close to a normal blood glucose as possible? It would be a very big change if this happened any time soon.

But wait, there's more! A follow-on short piece called "Eating With Diabetes: 3 Approaches" lists the low-carb approach first, and then follows with "Moderate-Carb" and "Vegan/High-Carb". The weird thing is that the three approaches are described as "less than 10% carb", "40-50% carb" and "75% carb". What about people who normalize their blood glucose with 20% carb or 30% carb? Why not just say, "it's a spectrum disease, with a spectrum of carb that will treat it effectively"? In any case, I don't want to complain too loudly, because this is SO great to see in an ADA publication!

Now, to be sure, the ADA is not yet changing their basic stance. Nowhere on the latest update of the diabetes.org Web site is it stated that diabetics should follow a low-carb diet. On the other hand, there is no longer anything I can find that says to eat over half of calories from carbohydrate, either. The former food pyramid, as far as I can tell, has vanished, and there are several hints that low-carb eating is becoming a bona-fide option.

There are statements such as, "Understanding the effect of carbohydrate on blood glucose levels is key to managing diabetes. The carbohydrate in food makes blood glucose levels go up." Although diabetics are still advised that "a place to start is at about 45-60 grams of carbohydrate at a meal.", (yikes) it goes on to say to adjust from there. Even though this is not what most of us would call a low-carb diet, for most people it is a reduction from their previous advice.

[Side note: I also notice it doesn't actually say 45-60 g/meal is a good place to start. If that actually controls someone's blood glucose, that's great, but I would think that in the cases where it doesn't, it would be more disheartening to subsequently take more carb away. Why not start lower, and then add? Also, most likely, the person for whom this works is losing weight - a phase which doesn't last forever.]

To me this looks like the beginnings of a real change in approach from the ADA. The Titantic may actually be turning around! This could make a difference to the health of millions of people, and nothing could make me smile more than that.

By Laura Dolson/about.com
Image courtesy about.com

Don’t Take Diabetes Lightly ‒ It Can Even Lead To Suicide

There is a general attitude that diabetes is a treatable disease, that's it's no big deal, that you just take medicine and you have a normal life.

The truth is diabetics have a 2.5 increased rate of death, meaning people with diabetes are 80 percent more likely to die prematurely than those without the disease.

A new British analysis ‒ published in the March 3 issue of the New England Journal of Medicine ‒ confirms that diabetes is associated with higher mortality.

And it's not just diabetes that's killing them. Besides dying from vascular problems caused by diabetes, people with the blood sugar disease are also more likely to die prematurely from many other causes, including cancer, infections, falls, liver disease, mental disorders and even suicide.

Although all the reasons that result in the greater risk of death among diabetics aren't known, high blood sugar and inflammation are key players. These can decrease the body's ability to fight off infections and even cancer.

A team lead by John Danesh, a professor of epidemiology and medicine at the University of Cambridge in the UK analyzed deaths among 820,900 people who took part in 97 studies. Among those in these studies, 123,205 died.

The risk of premature death was closely associated with blood sugar levels, with an excess risk of death at blood glucose fasting levels exceeding 100 milligrams per deciliter. There was no excess risk of death at fasting levels of 70 to 100 mg per dL, the researchers found.

The risk of dying from vascular disease, not surprisingly, was much higher in people with diabetes. But people with diabetes were also at increased risk for death from liver and kidney disease, pneumonia, other infectious diseases and chronic obstructive pulmonary disease, among other ills.

Danesh's team also found that people with diabetes were 25 percent more likely to die from cancer, with scientists finding a moderate association between the disease and death from liver cancer, pancreatic cancer, ovarian cancer, colorectal cancer, and lung, bladder or breast cancer. They were also 70 percent more likely to die from falls than people without diabetes.

In addition, diabetics were 64 percent more likely to die from mental disorders and 58 percent more likely to die from suicide, mostly because they were more likely to be depressed. Indeed, another study showed that management of diabetes can cause chronic stress and strain, which in the long run, may increase risk of depression - the two are linked not only behaviorally but biologically. (See my post 'Diabetes, Depression Can be a Two-Way Street' here.)

Broken down, the hazard ratios for people with diabetes vs. people without diabetes were:
   * 2.32 for death from vascular causes
   * 1.80 for death from any cause
   * 1.73 for death from other causes
   * 1.25 for death from cancer

Summing up, the study authors write: "These findings highlight the need to better understand and prevent the multi-system consequences of diabetes."

The challenge before researchers therefore is to continue to find a cure and to prevent diabetes ‒ it cannot just be managed with drugs.

Diabetes: Don't Ignore Diabetic Nerve Pain

Fact: About 50% of people with diabetes have some form of nerve damage known as diabetic neuropathy

Fact: 64% of Diabetic Nerve Pain sufferers report that their pain interferes with the daily activities that matter to them

Fact: 71% of Diabetic Nerve Pain sufferers say their pain interferes with the daily activities and makes it hard for them to fall asleep

Fact: 49% of diabetics had not had a discussion with their doctor about Diabetic Nerve Pain or its symptoms in the last 12 months, according to one survey

Fact: 65% of Diabetic Nerve Pain sufferers say the pain decreases their general motivation

Does Diabetic Nerve Pain get in the way of doing things that you like to do or need to do? Do you find it difficult to work, care for your family, travel, and enjoy hobbies? For many people with Diabetic Nerve Pain, the answer is yes.

When a person has pain that is caused by nerve damage from diabetes, it is simply called Diabetic Nerve Pain or, to use the medical term, painful Diabetic Peripheral Neuropathy (pDPN). Approximately 26% of patients with diabetes have pDPN.

The most common cause of Diabetic Nerve Pain is poorly controlled blood sugar levels. Over time, high blood sugar levels can result in nerve damage. Controlled blood sugar levels may help prevent, stabilize, and delay further nerve damage.

The most common type of diabetic neuropathy is peripheral neuropathy (burning, throbbing, or painful tingling in your hands or feet). In the early stages of peripheral neuropathy, some people have no signs. Some may have numbness or tingling in the feet. Because nerve damage can occur over several years, these cases may go unnoticed. The patient may only become aware of neuropathy if the nerve damage gets worse and becomes painful.

Most diabetic neuropathy is caused by peripheral artery disease, in which the small blood vessels are obstructed or partially obstructed and cannot carry oxygenated blood to areas of the body. These areas have pain or other difficulties due to the lack of oxygen.

Diabetic Nerve Pain may make it hard to do what is needed to manage your diabetes. It can create a cycle where one problem just leads to another problem, which makes the first problem even worse.

• Pain may make it difficult to stay physically active and focus on other areas of diabetes care
• If you are not physically active and focusing on diabetes care, it may be hard to keep your blood sugar levels close to the normal range
• In turn, if your blood sugar levels are raised for long periods of time (many months or years), you may be more likely to develop more health problems. This may include more nerve damage
• Finally, people with Diabetic Nerve Pain also have more risk for symptoms of depression, which can further lower the drive to focus on the day-to-day parts of good diabetes care

Nerve pain is different from other types of pain, like pain from a muscle ache or sprained ankle. Common pain medicines like aspirin may not work for nerve pain. Nerve pain is unique and feels different than muscle pain. Since all pain is not the same and nerve pain treatment is different from muscle pain treatment, it’s important to understand the source of your pain.

Muscle pain is a "protective" form of pain which sends a warning signal that an injury occurred. The pain tells you that more activity might be harmful. Nerve pain, on the other hand, is a "non-protective" form of pain which will not necessarily be improved by changing or limiting your activities.

In fact, with Diabetic Nerve Pain, decreasing your activity level is a problem, making it harder to manage your diabetes. (We all know it’s important to be physically active to keep your blood sugar level under control.) With nerve pain, your nerves repeatedly send extra electrical signals to the brain. These extra signals can cause pain when you do something that is not normally painful, e.g. putting on shoes. If this pain is not properly diagnosed and treated, it can cause difficulties with walking, working, or even being in social situations.

Over time, elevated blood sugar levels could potentially lead to different diabetes complications, like kidney and eye (retinopathy) conditions besides leading to nerve damage, especially in the feet. Therefore annual foot exams are crucial to check for diabetic peripheral neuropathy. Indeed, regular examinations are important because a diabetes patient can have peripheral neuropathy without pain, especially in the early stages of the neuropathy.

Many Diabetic Nerve Pain sufferers try to ignore the symptoms. They may not tell their doctors right away. Or even if they do bring up their pain, the discussion can easily veer toward other important aspects of diabetes management—such as blood sugar control. The sufferer may not get around to asking about pain relief.

Unfortunately, nerve pain can be one of the most intense pains that people feel. Diabetic Nerve Pain can make normal daily activities more difficult.

It is therefore important to discuss ways to reduce your pain at your next doctor’s visit. You may have many topics you want to discuss with your doctor. This list probably includes the very important issue of your blood sugar level control and it may be tempting to put your pain at the bottom of your list. Not a good idea. Avoiding the subject doesn’t make this common complication go away. Indeed, even if your pain seems just bothersome now, the nerve damage can get worse over time.

To be sure, Diabetic Nerve Pain care is an important part of overall diabetes care. And it is a part you may be able to actively improve. With less pain, you’ll feel better and may even increase your physical activity level. This is a key component of good diabetes care.

If you have Diabetic Nerve Pain, it’s very important to keep your blood sugar levels as close to the normal range as possible. This may help stabilize and prevent further nerve damage. It’s also important to keep your pain under control. Then you may be able to return to activities that are important to you.

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

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.

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.

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.

Medication Education Key to Success of Diabetes Treatment

Researchers at the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of California, San Diego, say that medication education is a key factor in helping patients with diabetes better stick to their drug treatments plans. The study, currently online in the February issue of the journal Annals of Pharmacotherapy, points to the need for pharmacists and other health care providers to assess reasons why some patients don't adhere to their medication plans, and to provide counseling opportunities to help them.

"Counseling can be more effective if pharmacists recognize that individual patients are each motivated to adhere to their drug regimens in different ways," said Candis M. Morello, PharmD, associate professor of clinical pharmacy at UC San Diego's Skaggs School of Pharmacy. "By understanding these differences, and knowing what actually works for individual patients, pharmacists can provide a very important service."

Diabetes is a complex disorder, typically requiring multiple medications to achieve control of the patient's blood sugar levels. Medication adherence — taking medications as instructed at the right time of day, frequency and dosage — is a significant factor for a patient's successful management of their disease. Therefore, knowing which methods diabetes patients and caregivers report help for improving adherence can provides valuable knowledge to make counseling opportunities more effective.

Morello and colleagues surveyed more than 1,200 individuals over age 18, most of whom (about 75 percent) had type 2 diabetes. Nearly half of this number took only oral medications, and the vast majority (86.8 percent) of the patients with diabetes reported taking medications two or more times per day.

Their goal was to determine methods that patients and their caregivers have used to improve medication adherence, assess the perceived helpfulness of such methods and identify motivating factors or medication characteristics that might help patients stick to their regimen.

Taking medications as part of a daily routine and utilizing pill boxes were the most frequently reported helpful methods to improve adherence. The three most motivating factors that patients identified were their knowledge that diabetes medications work effectively to lower blood glucose, understanding how they could manage side effects of their medications and a better understanding of the drugs' benefits.

Conversely, non-adherence involved not only a patient's forgetfulness, but also such factors as inability to afford a prescription or adverse reactions to a drug such as weight gain or nausea. As a result, health care providers might deem such regimens unsuccessful and prescribe even more or different drugs.

"To empower patients to overcome medication adherence barriers, we conclude that pharmacists are well-positioned to provide more proactive and thorough counseling sessions to include education of how diabetes drugs work and why they are so important," said Morello. She added that while seemingly simple tools such as using a seven-day pill box may improve a patient's adherence, improvement is often very patient-specific.

"Pharmacists should incorporate an assessment of individual variances into their counseling sessions ... and patients should know that their pharmacist is an excellent resource for medication education and advice."

Source: UCSD News Centre

Diabetes Alert: Avandia Warnings Updated To Reflect Restrictions on Use

GlaxoSmithKline has finalized an update for the warning label and medication guide of their diabetes drug Avandia, which includes information on new FDA required restrictions on use and concerns about potential heart problems with Avandia.

In a press release issued Monday, the company said that the changes will affect all rosiglitazone-based drugs; including Avandia, Avandamet and Avandaryl.

The labels and guides will note that Avandia is only available to patients who are already taking the drug or who have failed to control their diabetes with other medications. It also includes an updated black box warning that notes that clinical trials show a “statistically significant” increased risk of myocardial infarction and notes that trials have indicated that Takeda Pharmaceuticals’ Actos, a competing drug, does not appear to carry the same risks.

Avandia (rosiglitazone) was first approved in the United States in 1998 to treat type 2 diabetes by helping control blood sugar levels. The drug has been used by millions of diabetics, but sales plummeted following the concerns about potential Avandia heart risks.

In September 2010, the FDA determined that the black box warning added in 2007 was not enough and issued stronger warnings about Avandia and restricted use. The agency determined that only patients who have failed to control their diabetes through every other available medication should be given access to the medication, and ordered the drug’s maker, GlaxoSmithKline, to develop a risk evaluation and mitigation strategy (REMS) to make sure the drug is adequately restricted. The decision came after an FDA advisory committee narrowly voted this summer not to issue an Avandia recall.

GlaxoSmithKline said in its press release that it continues to work with the FDA on developing a REMS program.

The drug maker faces thousands of Avandia suits filed by people who allege that they suffered an injury as a result of the drug maker’s failure to adequately warn about the risk of heart problems.

A number of Avandia settlements have reportedly been reached by GlaxoSmithKline in an effort to resolve the Avandia litigation.

Brazil to Provide Free Hypertension, Diabetes Medicine

Brazilian President Dilma Rousseff said on Thursday that the government will provide free medicine for diabetes and hypertension to Brazilians, starting from mid-February, reports Xinhua.

The measure is part of the Popular Pharmacy Program, which grants discounts to over 100 types of medication for diseases, such as Parkinson, osteoporosis, glaucoma and asthma.

The government will cover 90 percent of the expense of the medicine and the patient pays the rest.

In order to receive the free medicine, patients must show the doctor's prescription and identification at the pharmacy.

The free medicine was one of Rousseff's campaign promises. According to the president, offering free medicine is a step forward to eradicate poverty in Brazil.

The Health Ministry estimated that over 33 million people, or 17 percent of Brazil's population suffer from hypertension and some 7.5 million suffer from diabetes. The two diseases are responsible for 34 percent of the deaths in the country.