Diabetes: Vegetarians Better Off Than Non-Vegetarians On All Counts Including Blood Sugar, Blood Pressure, Waist Size, BMI & Blood Fats

People who follow a vegetarian or meat-free diet may be at a lower risk of developing diabetes and heart disease, a new study suggests. The study of lifestyle habits of more than 700 adults showed researchers that 23 out of every 100 vegetarians have at least three metabolic syndrome factors, compared with 39 out of every 100 non-vegetarians and 37 out of every 100 semi-vegetarians.

The researchers measured a suite of factors ‒ blood sugar, blood fats, blood pressure, waist size, and body mass ‒ that when elevated add up to "metabolic syndrome," and found that vegetarians were lower than non-vegetarians on all counts except cholesterol.

Metabolic syndrome is a combination of health disorders that increase the risk of developing coronary artery disease, stroke, and diabetes. The risk factors include conditions like abdominal obesity, blood fat disorders, elevated blood pressure, insulin resistance or glucose intolerance.

Vegetarianism excludes high-calorie foods and animal products laden with saturated fats. It instead concentrates on foods that give necessary minerals and vitamins that help give diabetics a better chance of blood glucose control. These include whole grains, legumes, fruits and vegetables.

The Vegetarian Pyramid

Vegetarian diets are rich in fiber, which has numerous benefits. When a diabetic eats a fiber-rich meal, the desire for further food disappears. Fiber also plays a protective role for pre-diabetics, and can lead to lower daily requirements of insulin amongst type 1 diabetics.

Fiber is well known as being important in the improving blood sugar control, lowering cholesterol levels and providing folate, thereby reducing the risk of complications like heart disease. Considerable research is available as evidence for the role of fiber in diabetes.

Research has shown vegetarian diets promote a healthy weight since they are often lower in calories than non-vegetarian diets. They also improve blood sugar control and insulin response since eating vegetables, fruits, whole grains, legumes and nuts — features of a vegetarian diet — can improve blood sugar control and make your body more responsive to insulin. Most importantly, a vegetarian diet reduces the risk of cardiovascular disease since it is cholesterol-free, low in saturated fat and usually high in soluble fiber.

The new study ‒ published in the journal Diabetes Care ‒ has confirmed that vegetarians are lower than non-vegetarians on all counts including blood sugar, blood pressure, waist size, body mass index (BMI), and blood fats except cholesterol.

The findings show the vegetarians' average BMI of 25.7 was four points lower than that of non-vegetarians, who, on average, had BMIs close to 30. However, semi-vegetarians fell in the middle. A BMI greater than 25 is considered overweight, and greater than 30 is considered obese. Moreover, the findings suggested that while vegetarians, on average, were 3 years older than the meat-eaters, they were in better shape and health status.

"I was expecting there should be a difference….but I didn't expect that it would be that much," lead researcher Nico Rizzo of Loma Linda University was quoted by Reuters as saying, adding he was not sure what's behind the differences and wondered whether it was primarily the meat intake, the plant food intake or a combination of both.

It's possible that diet is not the cause because the research showed only an association between food choices and health factors, not cause-and-effect. High BMI, for instance, one of the traits that make up the metabolic syndrome profile, itself contributes to high blood pressure, and indirectly, blood sugar, and thereby potentially raising a person's risk of heart disease and diabetes.

One of the shortcomings of the study is that the researchers didn't study the reasons behind the differences between vegetarians and non-vegetarians even though the scientists suggest it may be caused by the meat intake, eating the plant food or a combination of both. The researchers also did not follow the subjects over the long term to see whether those who abstained from meat actually had lower rates of diabetes or heart disease.

The data for this research, which was funded by the National Institutes of Health, came from the Adventist Health Study 2, a long term study of Seventh Day Adventists. This Christian religious group has considerably more vegetarians than the general population.

In this study, 35 percent of the subjects did not eat meat, whereas only about five percent of all Americans are vegetarian. One of the differences Rizzo discovered between the groups was age. Vegetarians, on average, were 3 years older than the meat-eaters. "Even though they're older, they're in better shape," Rizzo said. "That's something I found quite interesting."

Diabetes: Autonomic Neuropathy Far Worse Than ‘Pins & Needles’ in the Feet

For around 50 percent diabetics, living with diabetic peripheral neuropathy ‒ that "pins and needles" feeling you get after your foot falls asleep, along with a burning sensation, and possibly numbness and loss of balance and no way to relieve it ‒ is a daily reality. When the peripheral nervous system fails, the patient becomes a vegetable.

Diabetic neuropathy is categorized as autonomic and peripheral diabetic neuropathy, depending on which particular nervous system it affects. The third category, focal diabetic neuropathy, affects individual nerves, not a system.

Diabetes can cause dysfunction of any or every part of the autonomic nervous system, leading to a wide range of disorders. And these are serious. Among the most troublesome and dangerous of the conditions linked to autonomic neuropathy are known: silent myocardial infarction (MI), cardiac arrhythmias (abnormal heart rhythm), ulceration (formation or development of an ulcer), gangrene, and nephropathy (damage to or disease of the kidney).

The prognosis is bleak: While treatment relieves pain and can control some symptoms, the disease generally continues to get worse.

What is Autonomic Neuropathy?

The peripheral nervous system controls the sensory and motor functions. This helps us to become aware of our environment and to control muscular activity. Patients with diabetic neuropathy might also develop autonomic neuropathy, leading to incontinence, constipation, diarrhea, acid reflux, difficulty breathing, sexual dysfunction (impotence) and inability to regulate blood pressure.

This happens because autonomic neuropathies affect the nerves that regulate vital functions, including the heart muscle and smooth muscles. Indeed, the autonomic nervous system is at the very core of our existence. It controls the vital life functions like heartbeat and respiration. So, when the autonomic nervous system fails, the patient dies.

In other words, autonomic neuropathy is a form of peripheral neuropathy. It is a group of symptoms, not a specific disease. There are many causes. Damage to the autonomic nerves affects the function of areas connected to the problem nerve. For example, damage to the nerves of the gastrointestinal tract makes it harder to move food during digestion (decreased gastric motility). Damage to the nerves supplying blood vessels also causes problems with blood pressure and body temperature.

Essentially, diabetic autonomic neuropathy impairs the ability to conduct activities of daily living and lowers quality of life. Autonomic neuropathy is also associated with an increased risk of sudden death. It also accounts for a large portion of the cost of care. (See my earlier related post 'Don't Ignore Diabetic Nerve Pain' here.)

Remember, diabetic autonomic neuropathy is a stealthy complicationof diabetes, developing slowly over the years and quietly robbing diabetic patients of their ability to sense when they are becoming hypoglycemic or having a heart attack. It can affect any organ of the body, from the gastrointestinal system to the skin, and its appearance portends a marked increase in the mortality risk of diabetic patients.

Eventually, autonomic neuropathy damages the nerves that run through a part of the peripheral nervous system and are used for communication to and from the brain and spinal cord (central nervous system) and all other parts of the body, including the internal organs, muscles, skin, and blood vessels.

Telltale Signs
Clinical symptoms generally do not develop for many years after the onset of diabetes. However, subclinical autonomic neuropathy can often be identified by quantitative functional testing within 1 year of diagnosis in patients with type 2 diabetes and within 2 years in those with type 1 diabetes. The most important causative factors are poor glycemic control, long duration of diabetes, increasing age, female sex, and higher body mass index. (See my earlier related post 'All Eyes on Research That May Provide Cure for Diabetic Neuropathy' here.)

Leading causes of death in diabetic patients with either symptomatic or asymptomatic autonomic neuropathy are heart disease and nephropathy. Increased urinary albumin excretion is related to autonomic neuropathy in diabetic patients.

Impairments in the autonomic nervous system may also contribute to the pathogenesis of diabetic nephropathy and cardiovascular disease. Autonomic neuropathy is also an independent risk factor for stroke.

Consequences
The cardiovascular manifestations of autonomic neuropathy appear to be the most widely studied ones and justifiably so because they are likely to be potentially lethal. Postural giddiness and syncope (temporary loss of consciousness and posture, described as "fainting" or "passing out") are the only autonomic symptoms referable to the cardiovascular systems.

Undeniably, the cardiovascular system bears the brunt of autonomic neuropathy in diabetics and this may be responsible for certain disabling symptoms, painless myocardial infarction and even sudden death during surgery. (It is therefore desirable to evaluate in detail the cardiovascular and autonomic status of all diabetics before major surgery.)

Cardiovascular autonomic neuropathy causes abnormalities of heart-rate control and vascular dynamics. It has been linked to postural hypotension, exercise intolerance, enhanced intraoperative cardiovascular lability (susceptible to change, error or instability), increased incidence of asymptomatic ischemia (showing no evidence of inadequate blood supply), myocardial infarction (heart attack), and decreased likelihood of survival after myocardial infarction.

Besides, failure to recognize symptoms in a diabetic as due to autonomic neuropathy may lead to a lot of unnecessary investigations and sometimes to wasteful treatment such as testosterone in sexual impotence. Indeed, sexual impotence is now recognized to be a common and sometimes the only manifestation of autonomic neuropathy followed closely by nocturnal polyuria (passing large volumes of urine at night but normal amounts during the day).

Gastrointestinal manifestations of autonomic neuropathy also include nausea and vomiting due to diminished gastric motility (the ability to move spontaneously); diarrhea and nocturnal fecal incontinence (bedwetting) due to exaggerated sympathetic hypofunction (a diminished or inadequate level of activity of an organ system or its parts) during sleep; and asymptomatic, functional disturbances of the gall bladders and the esophagus. Localized bouts of sweating on the face during eating are also reported to be diagnostic of diabetic autonomic neuropathy.

Outlook (Prognosis)
Once autonomic abnormalities are present, they are permanent, sometimes showing progressive deterioration but rarely, if ever, improving. They can affect multiple organ systems in the body, can cause disabling symptoms and have a lethal potential. It is therefore, necessary to be constantly aware of them and to screen the diabetics periodically, and most certainly pre-operatively. Therein lies their safety.

Of patients with symptomatic autonomic dysfunction, 25% to 50% die within 5 to 10 years of diagnosis. The 5-year mortality rate in patients with diabetic autonomic neuropathy is three times higher than in diabetic patients without autonomic involvement.

Undeniably, neuropathy is one of the most common complications of diabetes. And when it affects the autonomic nervous system, it can damage the cardiovascular, gastrointestinal, and genitourinary (reproductive and urinary) systems and impair metabolic functions (necessary for the maintenance of a living organism) such as glucose counter-regulation (unrestrained eating).

This is because the autonomic nervous system is primarily efferent (conveying away from a center), transmitting impulses from the central nervous system to peripheral organs. However, it also has an afferent (carrying toward the center) component. Its two divisions—the parasympathetic (part of nervous system that serves to slow the heart rate, increase intestinal and gland activity, and relax the sphincter muscles) and the sympathetic (that accelerates the heart rate, constricts blood vessels, and raises blood pressure) nervous systems— work in balanced opposition to control the heart rate, force of cardiac contraction, dilatation and constriction of blood vessels, contraction and relaxation of smooth muscle in the digestive and urogenital systems, the secretions of glands, and pupillary (affecting the pupil of the eye) size.

Ipso facto, the reported prevalence of diabetic autonomic neuropathy varies, with community-based studies finding lower rates than clinic-based and hospital-based studies, in which the prevalence may be as high as 100%.

Prevention
Intensive glycemic control is critical in preventing the onset and slowing the progression of diabetic autonomic neuropathy. The Diabetes Complications and Control Trial (DCCT) showed that intensive glycemic control reduced the prevalence of autonomic dysfunction by 53%.

It is also the first therapy to be considered when diabetic autonomic neuropathy is diagnosed. In addition, a variety of pharmacologic and nonpharmacologic therapies are available to treat the symptoms of autonomic neuropathy.

In addition, regular foot care can prevent a small infection from getting worse. This is why no appointment for diabetes care is complete without a thorough foot examination.

Treatment
For patients with both type 1 or type 2 diabetes, glycemic control is important, although methods to achieve target levels may differ. The methods for achieving euglycemia (normal glucose content of the blood) and the target blood glucose and HbA1c levels are given in a position statement from the American Diabetes Association.

The goals of treating diabetic neuropathy are to prevent the disease from getting worse and to reduce the symptoms of the disease. Tight control of blood sugar (glucose) is important to prevent symptoms and problems from getting worse.

Medications may be used to reduce the symptoms in the feet, legs, and arms. These medications include antidepressant drugs, such as amitriptyline (Elavil), doxepin (Sinequan), or duloxetine (Cymbalta); antiseizure medications, such as gabapentin (Neurontin), pregabalin (Lyrica), carbamazepine (Tegretol), and valproate (Depakote); drugs that block bladder contractions may be used to help with urinary control problems.

Erythromycin, domperidone (Motilium), or metoclopramide (Reglan) may help with nausea and vomiting. Pain medications (analgesics) may work for some patients on a short-term basis, but in most cases they do not provide much benefit. Capsaicin can be used topically to reduce pain.

Phosphodiesterase type 5 (PDE-5) drugs, such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are safe and effective for treating impotence in patients with diabetes.

Regular foot exams are important to identify small infections and prevent foot injuries from getting worse. If foot injuries go unnoticed for too long, amputation may be required.

Possible Complications
Injury to the feet due to loss of feeling; muscle breakdown and imbalance; poor blood sugar control due to nausea and vomiting; skin and soft tissue breakdown (ulceration) that may require amputation.

In addition, neuropathy may mask angina, the warning chest pain for heart disease and heart attack.

When to Contact a Medical Professional
Promptly call your health care provider if you develop symptoms of diabetic neuropathy.

Sources: American Diabetes Association (ADA), Neurology, National Institute of Health (NIH), Aaron I Vinik, National Diabetes Information Clearinghouse (NDIC)

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 and Marital Conflict

Depression due to the psychological stress that a diagnosis of diabetes brings is quite common. This manifests as a feeling of sadness, confusion and helplessness.

Anger against self and others due to the perceived ‘ill luck’ of developing diabetes and having to follow a particular dietary pattern is also manifested in some individuals with diabetes, while some others are thoroughly embarrassed about having to carry about their medications and blood sugar monitoring equipments and give themselves injections at very odd places.

All of these can definitely lead to stress and conflicts in relationships that individuals with diabetes are involved in. It is indubitable that the social and emotional support accruable from functional marital and other relationships goes a very long way in improving the rate of recovery from illnesses.

Individuals with chronic disorders like diabetes who have very supportive relationships are able to adapt better psychologically to the condition and engage in more healthy behaviours that will lead to an improvement in their clinical condition. The other side of the coin is that in which there is a great deleterious effect on health as a consequence of marital conflict with associated manifestation of unhealthy behavior and poor psychological adaptation by the individual who is ill.

The diagnosis of diabetes as does other chronic illnesses can lead to a dysfunction in family dynamics if not properly handled. Hence, as in all human relationships, thoughtful words and rational communication can help to ameliorate the physical and mental stress associated with the management of diabetes.

Science has clearly proven that hostility between couples does impair health while thoughtfulness between couples has potential health benefits. It has also been proven that stress, whatever the origin, not only raises the blood sugar level, but also impairs health generally. Individuals with poorly controlled diabetes will then do well to ask themselves; is my poor blood sugar control due to disharmony in my marriage or due to work and financial stress?

A study christened IDEATel that compared higher marital stress and diabetes outcomes concluded that higher marital stress leads to poor blood glucose control and higher depression while lower marital cohesion leads to higher blood pressure levels.

How else does marital conflict apart from increasing the level of stress hormones lead to poor blood glucose control? Certain unhelpful behaviours that may hamper blood glucose control have been identified in the spouses of individuals with diabetes. Principal among these is nagging about diet in individuals who are yet to comply with dietary advice. This constant criticism raises the stress level in the person with diabetes with consequent elevation of the blood sugar level. Others include poor communication and poor support.

Helpful behaviours include general relational support, reminders about medication and exercise, hospital visits and dietary support which include food purchase and preparation. Spousal support can thus lead to improved knowledge about diabetes, better blood sugar control and reduced stress level.

Individuals with diabetes should involve their spouses in the day to day management of their diabetes while spouses should not be overly worried to the point of distraction about the health status of their partner as it may be counter-productive. One must however sound a word of caution here that some individuals with diabetes, especially of the male gender sometimes carry their carefree attitude too far so as much as to cause an unnecessary death.

It is known that for many people with diabetes, the strain of living with it does not put any stress on their marital relationships, while it does in some others. For those that are currently having poor control due to marital strain and stress one cannot but ask, do you want your blood sugar to be under control? Then improve your marriage!

When you do fight, be careful with your words, if the words used are strong ones, they not only damage your health but your partner’s too. Family equilibrium should be maintained by avoiding recriminations and attributions of guilt especially in the area of diet.

Thank you Dr Olubiyi Adesina, Consultant Diabetologist/sunnewsonline.com

Diabetes: Stress Hormone's Surprise Powers

A hormone that can wreak havoc with the body by setting off harmful effects of stress may have a far more positive use: in a new way to treat diabetes.

The hormone, known as corticotropin-releasing factor, or CRF, has been implicated in anxiety, obesity, addiction and even Alzheimer's disease. The brain and other organs make CRF. It triggers a cascade of chemicals that ultimately produce cortisol and adrenaline and activate the body's "fight or flight" response. Under chronic stress, cortisol breaks down muscle, suppresses the immune system and raises the risk of high blood pressure.

But recently, researchers have showed that CRF increases both insulin secretion and production of the cells that make insulin in the pancreas, known as beta cells. Diabetes, which affects nearly 24 million Americans, involves the body's inability to properly use insulin to convert sugar into usable energy. The findings, which support a hunch that others in the field have had, point to a possible pathway for treatment of diabetes.

"The machinery that allows the cell to respond to the hormone has been found," says Wylie Vale, a professor of molecular neurobiology at the La Jolla, Calif., Salk Institute for Biological Studies, who discovered the structure of CRF in 1981. "We are exploring how this machinery is controlled under conditions such as diabetes and obesity. What we really want to do is understand the system." The research of Dr. Vale and his colleagues was reported in a December paper published in the Proceedings of the National Academy of Sciences.

With Type 1 diabetes, formerly known as juvenile diabetes, the body doesn't produce enough insulin. This happens because the immune system attacks and kills beta cells. These patients are treated with insulin injections.

The most common form of diabetes, associated with obesity, is Type 2. Here, the body doesn't produce enough insulin and the cells from insulin-responsive tissues like muscle are unable to efficiently use the insulin that is produced. The beta cells go into overdrive to try to produce insulin but become overworked and ultimately stop functioning, according to Patricia Kilian, head of the beta-cell-regeneration program at the Juvenile Diabetes Research Foundation, which partially funded the study.

Most Type 2 treatments have focused on drugs to overcome the resistance to insulin in tissues or to promote insulin output by the beta cells. But there's been a recent focus on finding ways to keep beta cells alive in the body and restoring the ability to grow new ones, Dr. Kilian says. That could help prevent or delay long-term complications of diabetes, like kidney failure and nerve damage, she says.

An early clue to CRF's role in insulin production came when Dr. Vale and a group of colleagues identified a group of hormones called urocortins about 10 years ago and later found that one of them stimulated insulin production in the pancreas. Some urocortins bind at the same receptor sites on the surface of cells that CRF does.

Recently, Dr. Vale and Mark Huising, a post-doctoral researcher, along with Nils Billestrup, a colleague at the University of Denmark, decided to see whether CRF itself might have a similar effect on beta cells. Stimulating mouse and later human beta cells with CRF, the researchers found that it not only increased insulin release but also promoted growth of the beta cells.

The next step: to learn whether CRF could stimulate insulin production in mice. This presented new challenges. Exposing the mice to CRF would trigger the production of cortisol, usually part of the stress response, which in turn boosts bloodstream sugar and so sets off the release of insulin. This response would make it difficult to figure out whether CRF or cortisol was responsible for the insulin release.

To avoid that problem, Dr. Huising inactivated the cortisol response in the mice. He then administered CRF to the pancreas of the mice and showed that it was the reason for the increased insulin production. This finding "helps us better understand how blood-sugar control works in healthy individuals and in diseases such as diabetes and obesity," says Dr. Huising.

Researchers don't know yet how to use CRF to stimulate insulin in humans without initiating the chain of stress-related events that CRF usually triggers, as well as associated effects such as increased blood pressure. And, for Type 1 diabetes, CRF would not stop the body's immune system from attacking the beta cells in the first place.

At the same time, researchers are investigating the benefits from blocking CRF. Its suppression reduces anxiety in animals, and several major drug companies are working to turn that into treatments for anxiety and depression. CRF blockers are also being developed for irritable bowel syndrome, since research has shown that stimulation of CRF receptors in the colon leads to diarrhea and pain. Also, CRF receptors in the skin might be targets for treating conditions like psoriasis, and in the bladder for overactive bladder, according to Eric Zorrilla, associate professor at the Scripps Research Institute, who studies CRF, stress and addiction.

Limiting Salt Lowers Blood Pressure and Health Risks in Diabetes

For patients living with diabetes, reducing the amount of salt in their daily diet is key to warding off serious threats to their health, a new review of studies finds.

In the Cochrane review, the authors evaluated 13 studies with 254 adults who had either type 1 or type 2 diabetes. For an average duration of one week, participants were restricted to large reduction in their daily salt intake to see how the change would affect their blood pressure.

“We were surprised to find so few studies of modest, practical salt reduction in diabetes where patients are at high cardiovascular risk and stand much to gain from interventions that reduce blood pressure,” said lead reviewer Rebecca Suckling. “However, despite this, there was a consistent reduction in blood pressure when salt intake was reduced.”

Suckling is part of the Blood Pressure Unit at St. George’s Hospital Medical School, in London.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Patients with diabetes need to be extra cautious to maintain their blood pressure at an acceptable range of less than 130/80 mmHg. However, in the 2003-2004 period, 75 percent of adults with diabetes had blood pressure greater than or equal to 130/80 mmHg or used prescription hypertension medications, according to the American Diabetes Association (ADA).

High salt intake is a major cause for increased blood pressure and, in those with diabetes, elevated blood pressure can lead to more serious health problems, including stroke, heart attack and diabetic kidney disease. The ADA also reports that diabetic kidney disease is the leading cause of chronic kidney disease, accounting for 44 percent of new cases in 2005.

In the Cochrane review, the participants’ average salt intake was restricted by 11.9 grams a day for those with type 1 diabetes and by 7.3 grams a day for those with type 2.

The reviewers wrote that reducing salt intake by 8.5 grams a day could lower patients’ blood pressure by 7/3 mmHg. This was true for patients with both type 1 and type 2 diabetes. The reviewers noted that this reduction in blood pressure is similar to that found from taking blood pressure medication.

Suckling acknowledged that studies in the review only lasted for a week and that the type of salt restriction probably would not be manageable for longer periods.

“The majority of studies were small and only of a short duration with large changes in salt intake,” she said. “These studies are easy to perform and give information on the short-term effects of salt reduction.”

However, Suckling said, the review also found that in studies greater than two weeks, where salt was reduced by a more achievable and sustainable amount of 4.5 grams a day, blood pressure was reduced by 6/4 mmHg.

Diabetes specialist Todd Brown, M.D., of the Division of Endocrinology and Metabolism at Johns Hopkins University, said that practicing low-salt diets of these types is quite challenging for most patients with diabetes even though they know the health risks.

“The effects of salt on blood pressure are well known to health professionals and most patients, but what is less well known is where the salt comes from in our diet,” Brown said.

“The overwhelming majority comes from the processed foods that we eat,” he said. “If we are going to realize the benefits of sodium reduction on blood pressure and other health outcomes, we should focus less on the salt shaker and more on what we buy in the supermarket and at chain restaurants.”

Thank you Health Behavior News Service

Treating High Blood Pressure With Radio Waves

Researchers at Baker IDI Heart and Diabetes Institute in Melbourne will this week publish the results of a world-first trial of a new minimally invasive procedure for the treatment of difficult-to-treat high blood pressure by using radio waves.

In the first international randomized controlled trial of the technology, sympathetic nerves leading into and out of the kidneys were silenced using radio frequency energy emitted by a catheter device inserted into the renal arteries through the groin.

The Symplicity Catheter System – the device used to perform renal denervation - has now received TGA approval in Australia and it is anticipated that it will be available for routine clinical application within the next 12 months.


Known as ‘renal denervation', this minimally invasive day procedure has been proven to be extremely effective in reducing blood pressure in patients with uncontrolled blood pressure – that is, blood pressure that is not responsive to medication.


Research has shown that each incremental 20/10 mmHg increase of blood pressure above normal levels is associated with a doubling of cardiovascular mortality over a 10 year period and that reducing systolic blood pressure by as little as 5 mmHg can reduce the risk of stroke by almost 30 per cent.


Professor Murray Esler, Associate Director, Cardiovascular Neurosciences at Baker IDI was the Chief Investigator for the international trial which involved 106 randomized patients in Europe and Australia across 24 separate sites.


In a presentation to the American Heart Association this week, Professor Esler will discuss the results of the trial. The key finding, which will be published simultaneously in The Lancet, was that the procedure resulted in an average blood pressure reduction of 33/11mmHg when compared to the control group that did not undergo the procedure.


The procedure is highly effective with 84 per cent of patients who underwent renal denervation experiencing a reduction in systolic blood pressure by more than 10 mmHg. The study also found that the therapy was safe, with no serious device or procedure-related events, no cardiovascular complications and no kidney-related complications.


Hypertension is the biggest killer worldwide with around 7.1 million deaths per year directly attributed to uncontrolled blood pressure. In Australia, between 25 to 30 per cent of the adult population is affected by high blood pressure and about half of those patients' blood pressure is not controlled to target through medication.


Commenting on the trial, Professor Esler said; "Combined with findings from the earlier Symplicity HTN-1 study, which demonstrated the safety and durability of the therapy out to two years, these results, show that this procedure has the potential to become a truly revolutionary treatment with the scope to significantly impact the standard of care for the large number of patients suffering from uncontrolled blood pressure."


Principle investigator Professor Markus Schlaich of Baker IDI said; "Hypertension often has no symptoms yet significantly increases a patient's risk of heart attack, stroke or death.


"We know the renal sympathetic nerves play a crucial role in blood pressure elevation and this study proves they can be specifically targeted with our novel approach. Renal denervation is a safe, quick and minimally invasive procedure that leads to a substantial and sustained blood pressure reduction without major side effects. "


In addition to hypertension, the therapy may hold promise for treating heart failure, diabetes and chronic kidney disease, conditions also characterised by elevated sympathetic nerve activity.


About the Symplicity Catheter System
The Symplicity Catheter System is used to perform a procedure termed renal denervation (RDN). In a straightforward endovascular procedure, similar to an angioplasty, the physician inserts the small, flexible Symplicity Catheter into the femoral artery in the upper thigh and threads it into the renal artery.


Once in place within the renal artery, the device delivers low-power RF energy to deactivate the surrounding renal sympathetic nerves. This, in turn, reduces hyper-activation of the sympathetic nervous system, which is often the cause of chronic hypertension.


The one-time procedure aims to permanently reduce blood pressure. RDN may also allow patients to reduce or eliminate the need for lifelong antihypertensive medications.


For more information, visit http://www.ardian.com/patients/symplicity.shtml


SOURCE: Baker IDI Heart and Diabetes Institute

Some Health Factors May Be Linked To Cognitive Problems For People With Type 2 Diabetes

Type 2 diabetes is linked with a number of health problems, but a new study finds that older diabetics who have high blood pressure, gait and balance problems or think their health is poor may be at higher risk for cognitive problems.

Researchers looked at 13 potential variables that could affect cognition, including grip strength, blood pressure, involvement in physical activities, social engagement, gait and balance, and a subjective measure of a person's health.

The study participants, from British Columbia, included 41 people with Type 2 diabetes age 55 to 81, and a matched group of 458 healthy people that served as a control. They were given cognitive tests that measured memory, verbal fluency, neurocognitive speed, and other abilities.

Three health-related variables were found to be most associated with a higher risk of cognition problems: high systolic blood pressure (the top number that measures the heart's contractions), walking more slowly and being unstable, and thinking that one's health is bad.

Blood pressure might be a factor, the study authors said, because of its role in other metabolic issues such as insulin resistance and hyperglycemia, which may be risk factors for cerebrovascular impairment. Walking and balance could figure in since diabetes may influence the areas of the brain that control gait, balance and cognition. And because Type 2 diabetes can affect stress and depression, those factors could influence results on cognitive tests.

Though the study points out that these related health issues may not always produce learning or memory problems, they are important enough risk factors to be noted.

"Awareness of the link between diabetes and cognition could help people realize how important it is to manage this disease; and to motivate them to do so," said study co-author Roger Dixon of the University of Alberta, in a news release.

The study appears in the September issue of the journal Neuropsychology.

Thank you Jeannine Stein/Los Angeles Times

What Is Prediabetes? Is It A Serious Condition?

Recently, a friend wrote saying she was "mildly diabetic". I wrote back straight away saying: "There's nothing like being 'mildly diabetic'; you're probably prediabetic..."

Anyway, that set me off on a hunt to find a precise definition of "prediabetes". I got the most reasonable answer from Michael Dansinger, MD at WebMD. This is what he has to say: 

Many folks come to the diabetes community upon being diagnosed with "prediabetes". These people are usually concerned about progressing to type 2 diabetes and want to know how to delay or prevent such progression. The diagnosis of prediabetes also typically serves as a "wake-up call" to make healthier lifestyle choices.

Interestingly, the term "prediabetes" was recently discredited by the concensus panel of diabetes experts. The experts encouraged replacing "prediabetes" with the concept of "increased risk of diabetes" which is reflected by a continuum of risk ranging from A1c levels of around 5.8 to 6.5. The experts argued that not everyone in this range progresses to diabetes and it is more accurate to see it as a risk spectrum rather than as a category unto itself.

I personally favor the old system of calling it "prediabetes" rather than "increased diabetes risk". I just like the name better. It used to be called "borderline diabetes", but that name seems so outdated to me. In any case, I urge people to see this as a strong warning that diabetes is probably coming, and lifestyle changes are the main way to slow or stop the progression.

I, too, think "prediabetes" is a much more forceful term than "increased risk of diabetes" - the former rings alarm bells, as it should, while the latter seems like a problem that can be taken care of later after more pressing issues like planning a vacation or buying a new computer are taken care of. Bad idea.

Remember, prediabetes (technically "impaired glucose tolerance") is a health condition with no symptoms. It is almost always present before a person develops the more serious type 2 diabetes. Million of people over age 20 have prediabetes with blood sugar levels that are higher than normal, but are not high enough to be classified as diabetes.

More and more, doctors are recognizing the importance of diagnosing prediabetes as treatment of the condition may prevent more serious health problems. For example, early diagnosis and treatment of prediabetes may prevent type 2 diabetes as well as associated complications such as heart and blood vessel disease and eye and kidney disease. Doctors now know that the health complications associated with type 2 diabetes often occur before the medical diagnosis of diabetes is made.

 

Who's at Risk for Developing Type 2 Diabetes?

Those at risk for type 2 diabetes include:

• People with a family history of type 2 diabetes.
• Women who had gestational diabetes or have had a baby weighing more than 9 pounds.
• Women who have polycystic ovary syndrome (PCOS).
• African Americans, Native Americans, Latinos, and Pacific Islanders, minority groups that are disproportionately affected by diabetes.
• People who are overweight or obese, especially around the abdomen (belly fat).
• People with high cholesterol, high triglycerides, low good 'HDL' cholesterol, and a high bad 'LDL' cholesterol.
• People who are inactive.
• Older people. As people age they are less able to process sugar appropriately and therefore have a greater risk of developing type 2 diabetes.

 

What Are the Symptoms of Prediabetes?

Although most people with prediabetes have no symptoms at all, symptoms of diabetes may include unusual thirst, a frequent need to urinate, blurred vision, or extreme fatigue.

A medical lab test may show some signs that suggest prediabetes may be present.

 

Who Should Be Tested for Prediabetes?

You should be tested for prediabetes if:

• You're over 45 years of age.
• You have any risk factors for diabetes.
• You're overweight with a BMI (body mass index) over 25.
• You belong to a high risk ethnic group.
• You were known to previously have an abnormal glucose tolerance test (see below) or have an impaired fasting glucose level (see below).
• You have a history of gestational diabetes or delivering a baby that weighed more than 9 pounds.
• You have clusters of problems seen in the metabolic syndrome. These problems include high cholesterol and triglycerides, high LDL cholesterol and low HDL cholesterol, central obesity, hypertension, and insulin resistance.
• You have polycystic ovary syndrome.

 

How Is Prediabetes Diagnosed?

To determine if you have prediabetes, your doctor can perform two different blood tests – the fasting plasma glucose (FPG) test and the oral glucose tolerance test (OGTT).

During the FPG blood test your blood sugar level is measured after an 8 hour fast. This laboratory health screening can determine if your body metabolizes glucose correctly. If your blood sugar level is abnormal after the fasting plasma glucose (FPG) test, you could have what's called "impaired fasting glucose," which suggests prediabetes.

 

Understanding the FPG Test Results

Condition	FPG
Normal	Less than 100 mg/dL (milligrams per deciliter)
Prediabetes	100 mg/dL - 125 mg/dL
Diabetes	Greater than 126 mg/dL on two or more tests

The other laboratory health screening test your doctor can perform is the oral glucose tolerance test (OGTT). During this test, your blood sugar is measured after a fast and then again 2 hours after drinking a beverage containing a large amount of glucose. Two hours after the glucose beverage, if your glucose is higher than normal, you have what's called "impaired glucose tolerance," which suggests prediabetes.

 

Understanding the OGTT Test Results

Condition	OGTT
Normal	Less than 140 mg/dL
Prediabetes	140 mg/dL to 199 mg/dL
Diabetes	Greater than 200 mg/dL

 

Why Is It Important to Recognize and Treat Prediabetes?

By identifying the signs of prediabetes before diabetes occurs, you can prevent type 2 diabetes altogether and lower your risk of complications associated with this condition, such as heart disease.

A large 3-year medical study in patients at risk of developing type 2 diabetes found that lifestyle changes with exercise and mild weight loss, and treatment with medications that work to sensitize a person to the actions of insulin, can decrease the chance that a person with prediabetes will get type 2 diabetes by up to 60%. 

Changing a person's lifestyle habits with increased physical activities and mild weight loss was more effective than medications at reducing the risk of developing type 2 diabetes. For some people with prediabetes, intervening early can actually return elevated blood sugar levels to the normal, healthy range.

 

What's the Treatment for Prediabetes?

To successfully treat prediabetes:

• Eat a heart healthy diet and lose weight. A 5% to 10% weight loss can make a huge difference.
• Exercise. Try to exercise 30 minutes a day, 5 days a week. The activity can be split into several short periods: 3 sessions of 10 minutes. Select an activity that you enjoy such as walking. In the study mentioned above, the total amount of exercise per week was 150 minutes.
• Stop smoking.
• Treat high blood pressure and high cholesterol. 

Preventing Diabetes And Literacy Key To Beat Dementia

According to a BBC report, preventing diabetes and depression could have a dramatic impact on cutting cases of dementia, a study suggests. Boosting levels of education and upping fruit and vegetable consumption would also have a big effect, the British Medical Journal said. It comes as another study showed dementia patients are missing out on vital early treatments because GPs are being slow to diagnose them.

Several risk factors for the disease have been identified, including obesity, high blood pressure and high cholesterol. But British and French researchers wanted to assess what public health interventions could have the biggest impact on reducing the burden of dementia in the population.

They took a group of 1,400 elderly people and tested them for signs of dementia after two, four and seven years. Alongside this they recorded height, weight, education level, monthly income, mobility, dietary habits, alcohol consumption, and tobacco use and asked participants to do a reading test as a measure of intelligence.

Eliminating depression and diabetes and increasing fruit and vegetable consumption were estimated to lead to an overall 21% reduction in new cases of dementia. Increasing education would also lead to an estimated 18% reduction in new cases of dementia across the general population over the next seven years, they reported. By contrast, removing a gene linked with the disease would only cut new cases by 7%.

The team concluded that early screening for diabetes and treatment of depression would be the most useful approach for trying to reduce the future burden of dementia. And they added that encouraging literacy at all ages and trying to increase population intake of fruit and vegetables would also have an important effect but admitted that these aims were harder to achieve. Further studies including younger adults are needed to test the impact of such approaches, they added.

In the second study also in the BMJ, analysis of health records of over 135,000 people in the UK found that people with dementia were three times more likely to die in the first year after diagnosis than those without the condition.

That suggests that diagnoses are being made in the later stages of the disease.

Study leader Dr Greta Rait from the Medical Research Council said: "GPs are going to be dealing with more and more dementia cases in future and primary care must get better at detection."

Rebecca Wood, chief executive of the Alzheimer's Research Trust, said the links between depression, diabetes and dementia were well known. "Any policy that urges clear diagnosis and monitoring of these conditions could help make an impact on dementia.

"What is painfully evident from the study is the gaping hole that remains in our understanding and ability to diagnose or treat dementia effectively, a hole that can only be filled by more research."

Professor Clive Ballard, director of research at the Alzheimer's Society said a healthy lifestyle is key. "Effective prevention of diabetes, depression and heart disease could potentially improve the lives of millions of people affected by this cruel condition and reduce the billions spent on dementia care each year."

Dr Victoria King, head of research at Diabetes UK, said there is a growing body of evidence suggesting links between diabetes and Alzheimer's disease. "Finding ways to stop the type 2 diabetes epidemic in its tracks can only be seen as a good thing - especially as this could prevent millions of people developing the serious complications of the condition, which include heart disease, stroke, kidney failure, blindness and amputation." 

Recommended Blood Pressure Level Differs For Heart Patients With Diabetes

The best blood pressure range for patients with diabetes and heart disease appears to be slightly higher than what is recommended for healthy adults, according to a study. Blood pressure greater than 140 is still associated with a nearly 50 percent increase in cardiovascular risk in these patients.

In fact, the blood pressure range considered normal -- less than 120 systolic and less than 80 diastolic -- may actually be risky for those with a combined diagnosis of diabetes and coronary artery disease, report University of Florida researchers from the International Verapamil SR-Trandolapril study, known as INVEST.

According to Rhonda Cooper-DeHoff, Pharm D, an associate professor of pharmacy and medicine at UF, optimum systolic blood pressure levels should be between 130 and 140 for patients coping with the diabetes-heart disease combination.

Efforts to reduce systolic blood pressure to below 130 did not offer any additional benefit to patients with diabetes and coronary artery disease, compared with reduction of systolic blood pressure to between 130 and less than 140.

"Sustained blood pressure lower than 120 is considered optimal for healthy people," Cooper-DeHoff said. "But, our data show that for these patients with diabetes, the range may actually cause an increased risk for heart attack, stroke, and death."

As many as two out of three adults with diabetes have high blood pressure. Blood pressure greater than 140 is still associated with a nearly 50 percent increase in cardiovascular risk in these patients.

"While lowering blood pressure to less than 140 is very important, based on our data and data recently published by others, it is now clear that in patients with diabetes, it is not necessary, and may be harmful to lower blood pressure too much," Cooper-DeHoff said.

In addition, the study for the first time reveals that this group of patients had an increased risk for death when their blood pressure was controlled to lower than 115 systolic -- the range recommended as normal by the American Heart Association.

The findings in the Journal of American Medical Association formalize a report Cooper-DeHoff made at the American College of Cardiology's 59th annual scientific session earlier this spring.

Heart disease or stroke is the top cause of death for people with diabetes, affecting more than 60 percent of patients, according to the AHA. High blood pressure, common in diabetes, doubles the risk of cardiovascular disease.

The INVEST study is the first to evaluate the effects of blood pressure-lowering in diabetic patients diagnosed with coronary artery disease. Researchers analyzed data collected from 6,400 patients from fall 1997 to spring 2003. The patients, who were 50 or older, were recruited from more than 850 sites in 14 countries.

The researchers further consulted the national death index for US-enrolled patients for an additional five years to compare death rates of patients based on their blood pressure category ranging from tightly controlled to non-controlled hypertension.

Journal of the American Medical Association, July 10, 2010

Diabetes Symptoms To Never Ignore

Watch out for signs of heart disease, uncontrolled blood sugar, infection, eye problems, and more

People living with diabetes learn to manage their disease with proper diet, regular exercise, and medication.  Success is measured by how well you can control your blood sugar. 

However, many factors can affect blood sugar besides diet and activity. Illness, stress, social drinking, and women’s menstrual cycles can all influence blood sugar levels and upset your normal routine. 

If you have diabetes, you may know that and make adjustments accordingly.  But some symptoms of trouble are always reasons to seek medical advice, whether it’s a call to your doctor or a trip to the emergency room. 

“Truthfully, with the ability of people to test their blood sugar at home, we can treat many more things at home than we used to be able to,” says Andrew Drexler MD, who directs UCLA's Gonda Diabetes Center. 

This does not mean you should problem solve without your doctor’s help, he adds, but rather, that you might be able to substitute a phone call for a trip to the emergency room.    

Here are the diabetes symptoms you should never ignore. 

Frequent Urination, Extreme Thirst or Hunger, or Blurry Vision

These are three common warning signs of uncontrolled blood sugar.

With any of these symptoms, you should test your blood sugar and call your doctor.  Depending on how high your blood sugar is, medication may fix the problem or you may have to seek medical care to replace fluids and electrolytes and to get blood sugar back under control. 

If left unchecked, high blood sugar can lead to serious, life-threatening conditions.  Type 1 diabetes patients can develop diabetic ketoacidosis, which happens when the body starts breaking down fats instead of sugars and a dangerous buildup of ketones (byproducts of fat metabolism) occurs.

 In type 2 diabetes patients, hyperosmolar coma can occur.  “It’s essentially uncontrolled diabetes, which leads to dehydration and altered consciousness and which could be fatal if untreated,” says endocrinologist Adrian Vella, MD, of the Mayo Clinic in Rochester, Minn. 

Acting Drunk

Strange behavior can also signal low blood sugar. This can happen when a person’s medication works too well and overshoots the target. 

Drinking some juice or eating a snack usually is enough to raise sugar levels and normalize behavior.  Often, however, the diabetic patient is not in the state of mind to recognize that something is wrong.  If no one else is around to prompt you, your blood sugar may sink low enough to cause you to lose consciousness. 

Most of the time, patients will recover on their own, but if they are taking certain medications, emergency medical treatment may be required. 

“If it’s either a long-acting pill that can cause hypoglycemia,” such as the sulfonylurea drugs chlorpropamide, glyburide, or glimepiride, “or a long-acting insulin that can cause hypoglycemia, then it very well may be necessary to go to the emergency room,” Drexler tells WebMD. 

Infections, Swollen or Bloody Gums, Foot Sores

Have your doctor check a cut that’s infected, swollen or bloody gums, or a wound that won’t heal. And watch out for a sore on the foot, which may be the first sign of a diabetic foot ulcer. 

All diabetes patients should get regular foot exams by a health care professional -- and check their own feet on a daily basis -- even if sores are not present. And remember to bathe your feet daily in warm (but not hot) water, following up with a moisturizer, to prevent dry skin, which may crack and lead to infection.

“Infections in diabetics can get out of control and they need to be taken very seriously,” says Drexler. 

Fungal infections occur more frequently in diabetes patients, Vella tells WebMD.  “Fungal infections of the skin are more likely to occur when your blood sugar is consistently above the magic number of about 180-200 [mg/dL],” he says.  “That’s because hyperglycemia itself actually interferes with the white blood cells’ ability to respond to such infections.” 

A red, itchy rash -- especially in moist areas such as skin folds -- can signal a fungal infection.

Eye Problems, Including "Floaters"

If you develop sudden changes in vision, experience eye pain, or see spots or lights floating in your field of vision, call your doctor. You may need to see an ophthalmologist. People with diabetes are at increased risk of an eye condition called retinopathy, which can lead to vision loss.

Even without eye symptoms, diabetes patients should see an ophthalmologist yearly for a routine eye exam.

Heart Disease Symptoms -- and Not Just Chest Pain

Patients with diabetes have an increased risk of cardiovascular disease and twice the normal rate of related emergency events, such as heart attack and stroke. 

So get any potential heart disease symptoms checked out.And keep in mind that heart symptomsaren't always predictable.

 “It can sometimes be shoulder pain, it can sometimes present just as nausea," Drexler says. "But if there’s any suspicion that it’s cardiac in origin, it’s very important to go to the ER." 

It's also possible to have heart disease that doesn't have obvious symptoms, so make sure you see your doctor regularly and have your cardiovascular risk factors evaluated.

Taking Precautions

Will Ryan of Alford, Mass., who has had diabetes for 30 of his 70 years, was driving home one night a felt a sharp pain in his chest.  “It was more intense than just a muscle pull,” says Ryan, author of a blog called the Joyful Diabetic.  It lasted only a few seconds, but it happened again before he got home.  He went to the ER, where an ECG showed normal heart function. 

Taking Precautions continued...

Less than a week later, he woke up with his heart pounding and his pulse racing at 90 beats per minute - higher than usual for Ryan.  A second ECG was also normal, but given two possible heart-related events, a cardiologist ordered a heart monitor. 

Over two weeks, the monitor picked up more curiosities.  “I had a number of instances where my heart rate dropped below 40,” Ryan says.  “I was not aware of it because I was sleeping.” 

Ryan agreed to a stress test, which showed his heart was oxygen deprived, suggesting that one of the blood vessels feeding his heart was blocked.  Cardiac catheterization confirmed the blockage, but also showed that Ryan’s other blood vessels had taken up the slack such that no treatment was required. 

“I probably had a heart attack, but I never knew it,” Ryan says, adding that doctors told him this was not uncommon in people with diabetes. 

Ryan says he’s very aware of his body’s signals from living with his disease, but he has never been complacent. This recent experience has only reaffirmed that unusual symptoms deserved medical attention. 

Thank You WebMD

Diabetes: Controlling Blood Sugar Is Not Enough

I'm sure all of you who live with diabetes or know someone who carries the burden of the disease will find their diabetes management has been inadequate.

This is because nearly all diabetics are fixated on keeping their blood sugar under control. As long as glucose levels are within acceptable limits, they feel the disease is under control.

Nothing can be farther from the truth. In fact, you may be deluding yourself that all is good even as your heart, kidneys, eyes etc are just rotting away, as it were.

In fact, my good friend Dr Shiv Harsh MD, a heart specialist, says he considers diabetes to be basically a heart disease.

To get this blog going, I'm paraphrasing a great article from New York Times that I came across a few years ago. It is made a difference to my diabetes management.

Most people discover they have Type 2 diabetes by accident, mostly after a routine urine test. The test reveals your blood sugar level is sky high and glucose is spilling into your urine.

"You've got diabetes," confirms your doctor.

So, from then on, like most others with diabetes, you become fixated on your blood sugar. Your doctor has warned you to control it or the consequences could be dire - you could end up blind or lose a leg. Your kidneys could fail.

You try hard. When dieting does not work, you begin counting carbohydrates, taking pills to lower your blood sugar and pricking your finger several times a day to measure your sugar levels. When they remained high, you agree to add insulin to your already complicated regimen. Blood sugar is always on your mind.

But in focusing entirely on blood sugar, you end up neglecting the most important treatment for saving lives — lowering the cholesterol level. That protects against heart disease, which eventually kills nearly everyone with diabetes.

Like I said in the beginning, Dr Shiv Harsh considers diabetes a heart disease. (I'm putting this in layman's language; Dr Shiv Harsh has a more nuanced approach. I'll get him to write on this blog sometime.)

Moreover, most diabetics also miss a second treatment that protects diabetes patients from heart attacks - controlling blood pressure. Most assume everything is taken care of if you can just lower your blood sugar level.

Blood sugar control is important in diabetes, specialists say. It can help prevent dreaded complications like blindness, amputations and kidney failure.

But controlling blood sugar is not enough.

Yet, largely because of a misunderstanding of the proper treatment, most patients are not doing even close to what they should to protect themselves. What is going on? We can only conclude that people are not aware of their risks and what could be done about them.

In part, the fault for the missed opportunities to prevent complications and deaths lies with the medical system. Most people who have diabetes are treated by GPs (family doctors) who have had just a few hours of instruction on diabetes, while they were in medical school. Then the doctors typically spend just 10 minutes with diabetes patients, far too little for such a complex disease, specialists say.

In part it is the fault of proliferating advertisements for diabetes drugs that emphasize blood sugar control, which is difficult and expensive and has not been proven to save lives.

And in part it is the fault of public health campaigns that give the impression that diabetes is a matter of an out-of-control diet and sedentary lifestyle and the most important way to deal with it is to lose weight.

Most diabetes patients try hard but are unable to control their disease in this way, and most of the time it progresses as years go by, no matter what patients do.

Ninety per cent of diabetes patients have Type 2 diabetes, the form that usually arises in adulthood when the insulin-secreting cells of the pancreas cannot keep up with the body’s demand for the hormone. The other form of diabetes, Type 1, is far less common and usually arises in childhood or adolescence when insulin-secreting pancreas cells die.

And, like many diabetes patients, you end up paying the price for your misconceptions about diabetes.

Most diabetics think the biggest risk from diabetes is blindness or amputations. You never think about heart disease and have no idea how important it is to control cholesterol levels and blood pressure mostly because doctors do not advise you to take a cholesterol-lowering or blood pressure drug. And you do not think you need them.

Indeed, most people with diabetes are unaware of the danger that heart disease poses for them.

A survey by the American Diabetes Association found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.

Yet, when you think about it, it’s not the diabetes that kills you, it’s the diabetes causing cardiovascular disease that kills you.

So, if you are one of those who don’t think you are at increased risk, finding out that you are and that you can decrease that risk substantially could literally change your life.

The science is clear on the huge benefits for people with diabetes of lowering cholesterol and controlling blood pressure.

With cholesterol, levels of LDL cholesterol, the form that increases heart disease risk, should be below 100 milligrams per deciliter and, if possible, 70 to 80. Yet, diabetes patients with LDL cholesterol levels of 100 to 139 often are told that their levels — ideal for a healthy person without diabetes — are terrific.

But many practicing doctors just don’t know that an LDL cholesterol number that is normal for someone without diabetes is not normal for someone with diabetes.

Not surprisingly, most diabetics do not know the other measures proven to prevent complications in diabetes.

Sure, high blood sugar is dangerous. It can damage the small blood vessels in the eyes, leading to blindness; the nerves in the feet, leading to amputations; and the kidneys, leading to kidney failure. But no matter how carefully patients try to control their blood sugar, they can never get it perfect — no drugs can substitute for the body’s normal sugar regulation.

So while controlling blood sugar can be important, other measures also are needed to prevent blindness, amputations, kidney failure and stroke. But, alas, most diabetics are doing none of them.

The common assumption that Type 2 diabetes is simply a consequence of being fat. And that losing weight will help cure it.

Obesity does increase the risk of developing diabetes, but the disease involves more than being obese. Only 5 percent to 10 percent of obese people have diabetes, and many with diabetes are not obese.

To a large extent, Type 2 diabetes is genetically determined — if one identical twin has it, the other has an 80 per cent chance of having it too. In many cases, weight loss can help, but most who lose weight are not cured of the disease. You can lose 20 kg but still have diabetes.

So if you're diabetic worried only about blood sugar levels, get ready for a new diabetes regimen: a statin to drive your cholesterol level very low, drugs to lower your blood pressure, besides insulin and drugs to reduce his blood sugar levels.

Remember, you’ll never be out of the woods. You’ve got to face that.

And it is not just that many diabetes patients are overweight, as people with Type 1 diabetes, who often are thin, also have a high risk of heart disease. There is something about diabetes itself, researchers say, that leads to high levels of LDL cholesterol and a form of LDL cholesterol particles that is particularly dangerous. Diabetes also leads to increased levels of triglycerides, which are fats in the blood that increase heart disease risk, and in diabetes is linked to high blood pressure.

Being obese or overweight, in contrast, are supposed to be “weak contributors to heart attack risk.”

Type 2 diabetes does not exist in isolation. Underlying diabetes are all these cardiovascular risk factors.

It has taken quite a while for the alarm bells to go off because it is heart disease researchers, not diabetes researchers, who have conducted the seminal studies.

The key to saving lives is to reduce levels of LDL cholesterol to below 100 and also control other risk factors like blood pressure and smoking. The cholesterol reduction alone can reduce the very high risk of heart attacks and death from cardiovascular disease in people with diabetes by 30 per cent to 40 per cent. And clinical trials have found that LDL levels of 70 to 80 are even better for people with diabetes who already have overt heart disease.

Studies of blood sugar control have been more problematic than those of cholesterol lowering.

In Type 2 diabetes, the most ambitious effort was a huge study in Britain. It found that rigorous blood sugar control could lower the risk of complications that involved damage to small blood vessels, a list that includes blindness, nerve damage and kidney damage. But there was no effect on the overall death rate. There was a small decrease in the number of heart attacks but it was not statistically significant, meaning it could have occurred by chance.

Since researchers are still groping in the dark, as it were, cholesterol lowering, for patients with Type 1 and Type 2 diabetes, is the most effective and easiest way by far to reduce the risk of heart disease and the only treatment proven to save lives. But doctors say achieving the recommended cholesterol levels usually means taking a statin.

Some patients resist, wary of intense drug company marketing to patients and afraid of side effects like muscle or liver damage which, although extremely rare, have frightened many away from the drugs.

Yet lowering cholesterol with statins is much simpler than anything else diabetes patients are asked to do. And the drugs are among the best studied and the safest on the market.

My own doctor says if he had to rate the different regimens for a typical middle-age person with Type 2 diabetes, the first priority would be to take a statin and lower the LDL cholesterol level. (I take one statin after dinner.)
Besides, two other measures to protect against heart disease, blood pressure control and taking an aspirin to prevent blood clots, should not be neglected.

Right now, without waiting for lots of exciting things that are almost in the pipeline or in the pipeline, starting tomorrow, if everyone did these things — taking a statin, taking a blood pressure medication, and maybe taking an aspirin — you would reduce the heart attack rate by half.

But even when you do take the right steps to control diabetes, the grueling process can simply wear you down.

In fact, a fistful of prescriptions, including a statin, blood pressure medications and one for the drug that most diabetics dread – insulin – besides regular checks for eye, nerve and kidney damage and watching what you eat and count carbohydrates is enough to drive anyone crazy.

Diabetes specialists say they are well aware of how daunting the program can be. Many go to the doctor once or twice and walk away saying, “I don’t want to do this.”
Meanwhile, no matter what they do, most people with Type 2 diabetes get worse as the years go by. Patients make less and less insulin and their cells become less and less able to use the insulin they do produce.

That is why it is not uncommon to start initially with diet therapy, then after a few years you need to add a drug that improves insulin sensitivity. Then when that drug isn’t enough, the doctor adds a second drug that improves insulin sensitivity by a different mechanism. Then he add a drug that stimulates that pancreas to make more insulin.”

Then patients with Type 2 diabetes may need insulin itself, but when that happens they have to take even more than a person with Type 1 diabetes — two or even three times as much — because their cells no longer respond adequately to the hormone.

Nevertheless, while it is not easy to re-energize burned-out patients, at the very least doctors and patients should know what is important.

We already have the miracle pills - statins and blood pressure medications – that are cheap but what is imperative is patient education and physician training that this stuff is out there and this is what doctors should be focusing on to make a difference in lives.

Note: I am NOT an expert. I am managing diabetes with moderate success and want to share published material appearing elsewhere. DO NOT start any medication without consulting your doctor. Get your lipid profile (12 hours fasting before test) and BP checked before you meet your doctor next.

If you have anything to share with other diabetics, do post your experiences on this blog