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.

Diabetes Alert Day: Alarm Bells Ring as Childhood Obesity Epidemic Fuels Type 2 Diabetes Among Adolescents

Today is Diabetes Alert Day. And a good day as any to remind ourselves that diabetes ‒ afflicting around 26 million Americans and nearly 300 million worldwide ‒ is not only a raging epidemic among the adult population but consuming younger people as well. We are not talking about Type 1, or “juvenile”, diabetes here, but Type 2, normally associated with adults.

Indeed, as recently as the mid-1990s, Type 2 diabetes was almost exclusively a disease of adults. But apparently fueled by the childhood obesity epidemic, cases in people younger than 20 have ramped up from virtually zero to tens of thousands in the United States alone in little more than a decade. The children who have it are breaking new scientific ground: No one has any idea how they will fare over the course of a lifetime.

Today, about 3,700 Americans of 20 receive a diagnosis annually of what used to be called “adult-onset” diabetes, according to the Centers for Disease Control and Prevention. That relatively small number makes it a rare disease in children, but it represents a trend with larger ramifications.

“In a little more than 10 years, the numbers went from nothing to something,” says Larry Deeb, a pediatric endocrinologist and past president of the medicine and science division of the American Diabetes Association. “And that’s something to worry about.”

Those statistics are grim enough when patients are in their 60s. When the diagnosis is made decades earlier, new fears are raised: Will these children suffer heart attacks in their 20s, need kidney dialysis in their 30s or go blind before they see their own children graduate from high school?

Because about 80 percent of Type 2 diabetes patients are overweight or obese, it’s not surprising that patients ask if they’ve done this to themselves. But there are other risk factors that no one can control: family history, ethnicity (blacks, Hispanics and American Indians have higher rates of diabetes), genetics or a mother who had diabetes during her pregnancy. Instead of wallowing in regret, doctors suggest that young patients and their parents seize the opportunity for a crash course on how to improve their health.

“I used to wear a button that said ‘Stamp Out Guilt,’ ” says Fran Cogen, director of the Child/Adolescent Diabetes Program at Children’s National Medical Center. “I try to tell people that no one caused their diabetes. I emphasize that they can make changes now.”

Alarm bells are going off among those who study diabetes in children because of what they know about the adult version of the illness. More than 25 million Americans have diabetes (more than 90 percent have Type 2), according to the National Institute of Diabetes and Digestive and Kidney Diseases — but an additional 79 million have a condition called pre-diabetes, in which blood sugar levels are higher than normal but not as high as in diabetes.

Pre-diabetes isn’t a disease requiring medical treatment — it’s a wake-up call. A large national study showed that adults with pre-diabetes who lost 7 percent of their body weight reduced their risk of diabetes by 58 percent.

Officials are concerned that the number of children already identified as having Type 2 diabetes is just the tip of the iceberg. In a national study of 2,000 eighth-grade students from communities at high risk for diabetes, more than half of the kids were overweight or obese. Only 1 percent had diabetes — but almost a third of them had pre-diabetes, according to Lori Laffel, chief of the Pediatric, Adolescent and Young Adult Section of the Joslin Diabetes Center in Boston and a principal investigator on the study.

It’s crucial, she says, to find those children before their condition progresses to diabetes so that it can be reversed by lifestyle changes, without medication.

If there is any good news in childhood diabetes, it is that pediatricians are starting to look for it. “It’s in the news, and all over the medical literature,” says Susan Conrad, a pediatric endocrinologist at Inova Fairfax Hospital. “Pediatricians are on top of it.”

For example, sometimes children whose bodies are beginning to have problems regulating insulin develop a telltale dark, velvety rash around their necks. A decade ago, such a child might have been referred to a dermatologist. In addition, CDC guidelines suggest that a child with a family history of diabetes, or one whose weight is above the 85th percentile for age and sex should be screened, with blood and urine tests, for diabetes.

Excerpted from a report in the Washington Post

Diabetes Management: Caring Doctors Improve Patients' A1c, LDL Scores

A doctor's empathy can improve the care of diabetes patients, a three-year study between 2006 and 2009 involving 891 diabetes patients treated by 29 doctors at the Thomas Jefferson University Hospital in Philadelphia has confirmed. This will reinforce the popular belief that acaring doctor plays a big role in a patient’s disease management.

The findings – published in the March issue of the journal Academic Medicine ‒ indicate that empathy on the part of doctors can contribute to patient satisfaction, trust and compliance with therapy.

For the study, results of the most recent HbA1c and LDL-C tests were extracted from the patients' electronic records. The results of HbA1c tests were categorized into good control (<7.0%) and poor control (>9.0%). Similarly, the results of the LDL-C (“bad” cholesterol) tests were grouped into good control (<100) and poor control (>130).

The physicians, who completed the Jefferson Scale of Empathy (JSE) in 2009, were grouped into high, moderate, and low empathy scorers. (The JSE was developed by researchers at the Center for Research in Medical Education and Health Care at Jefferson Medical College to measure empathy in physicians and health professionals, medical students, and health professions students. The scale is a self-administered 20-item test comprising a 7-point Likert scale that can be completed in 5-10 minutes. The JSE scales are used extensively in the United States and abroad.)

When associations between physicians' level of empathy scores and patient outcomes were examined, it was found that patients of physicians with high empathy scores were significantly more likely to have good control of HbA1c (56%) than were patients of physicians with low empathy scores (40%, P < .001).

Similarly, the proportion of patients with good LDL-C control was significantly higher for physicians with high empathy scores (59%) than physicians with low scores (44%, P < .001). Logistic regression analyses indicated that physicians' empathy had a unique contribution to the prediction of optimal clinical outcomes after controlling for physicians' and patients' gender and age, and patients' health insurance.

In other words, while the researchers assessed the doctors' level of empathy for patients, the quality of patient care was determined by an LDL ("bad") cholesterol test and an HbA1C test for blood glucose levels. Patients whose doctors had high empathy scores were more likely to have good control of their blood sugar and low LDL cholesterol levels than patients whose doctors had low empathy scores.

"Our results show that physicians with high empathy scores had better clinical outcomes than other physicians with lower scores," study author Mohammadreza Hojat, research professor of psychiatry and human behavior at Jefferson Medical College, said in a university news release.

"These findings, if confirmed by larger scale research, suggest that empathy should be viewed as an integral component of a physician's competence," he concluded.

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."

South Asians' Impaired Ability to Burn Fat Makes Them More Prone to Diabetes

With more than 50 million diabetics ‒ mainly type 2 ‒ India is facing a full-blown diabetes epidemic. Another100 million are at the stage of pre-diabetes. Only China suffers from far more cases of diabetes.

While anecdotal evidence suggests diabetes has assuming epidemic proportions in the subcontinent as a result of improved incomes but poorer lifestyle and dietary choices, especially among the middle class, a new study reveals that people from South Asia are at greater risk of developing type 2 diabetes because of the way their muscles burn and store body fat.

Researchers from the University of Glasgow, Scotland, analyzed the rates of fat metabolism in 20 men of South Asian origin and 20 white European men.

Their findings suggested that South Asian men have a lower rate of fat metabolism during exercise than their European counterparts, as well as reduced sensitivity to insulin – indicating a possible tendency towards glucose intolerance and type 2 diabetes.

The scientists said the association between fat metabolism rate and insulin sensitivity was due to key differences between the muscles of south Asians and Europeans.

They discovered that the expression of genes key to fat metabolism was lower in the muscles of south Asians, affecting their ability to process fat and thus increasing the risk of insulin resistance - a major factor in the development of type 2 diabetes.

Dr Jason Gill, who led the study, said: "Our results suggest that the ability of south Asians' muscles to use fat as a fuel is lower than in Europeans."

"In other words, if a south Asian man and a European man were walking alongside each other at the same speed, the south Asian man's muscles would be burning less fat and this may contribute to a greater risk of developing diabetes.”

Dr Victoria King, from British charity Diabetes UK, said: "This new insight could provide the basis for future studies looking at lifestyle, or drug interventions to enhance the uptake and burning of fat in muscles, reducing the risk of type 2 diabetes in this high risk group."

The study was published in the peer-reviewed medical journal PLoS One.

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

NIH Unveils 10-Year New Strategic Plan to Combat Diabetes

A new strategic plan to guide diabetes-related research over the next decade was announced today by the National Institutes of Health. The plan, developed by a federal work group led by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), identifies research opportunities with the greatest potential to benefit the millions of Americans, and ultimately nearly 250 million people worldwide, who are living with or at risk for diabetes and its complications.

"By setting priorities and identifying the most compelling research opportunities, the strategic plan will guide NIH, other federal agencies and the investigative community in efforts to improve diabetes treatments and identify ways to keep more people healthy," said NIDDK Director Griffin P. Rodgers, M.D. in a press release.

The promise of prevention, treatment, and cure for diabetes can only be realized through the vigorous support of scientific research. This research must be conducted through a multi-pronged effort that addresses the complex challenges posed by diabetes, from dysfunctions in the most fundamental molecular and cellular processes, to the need for new approaches to translate scientific findings into improved health for patients, the release states.

The purpose of this research plan - Advances and Emerging Opportunities in Diabetes Research: A Strategic Planning Report of the Diabetes Mellitus Interagency Coordinating Committee (DMICC) - is to serve as a scientific guidepost, identifying compelling opportunities for research on diabetes and its complications over the next decade.

The goal is to accelerate the discovery of: the relationship between obesity and type 2 diabetes, and how both conditions may be affected by genetics and the environment, the autoimmune mechanisms at work in type 1 diabetes, the biology of beta cells, which release insulin in the pancreas, development of artificial pancreas technologies to improve management of blood sugar levels, prevention of complications of diabetes that affect the heart, eyes, kidneys, nervous system, and other organs and the reduction of the impact of diabetes on groups disproportionately affected by diabetes including the elderly and racial and ethnic minorities.

The plan focuses on 10 areas of diabetes research with the most promise. The goal is to accelerate discovery on several fronts, including:
the relationship between obesity and type 2 diabetes, and how both conditions may be affected by genetics and environment
the autoimmune mechanisms at work in type 1 diabetes
the biology of beta cells, which release insulin in the pancreas
development of artificial pancreas technologies to improve management of blood sugar levels
prevention of complications of diabetes that affect the heart, eyes, kidneys, nervous system and other organs
reduction of the impact of diabetes on groups disproportionately affected by the disease, including the elderly and racial and ethnic minorities

Under the plan, NIH will continue to emphasize clinical research in humans, which already has led to highly effective methods for managing diabetes and preventing complications, Rodgers said.

The NIH strategy for fighting diabetes addresses type 1 and type 2 diabetes. Type 1 diabetes, which affects about 5 percent of individuals with diagnosed diabetes, is an autoimmune disease that most often develops during childhood. Type 2 diabetes accounts for 90 to 95 percent of diagnosed diabetes cases in the United States, and is strongly associated with overweight and obesity.

In addition, the plan addresses gestational diabetes, a condition that some women develop during pregnancy, but which usually goes away after their child is born. Women who develop gestational diabetes during pregnancy are at increased risk for developing type 2 diabetes, and the child of that pregnancy may also be at increased risk for obesity and type 2 diabetes.

The NIDDK plans to continue its emphasis on clinical trials in humans, "which already [have] led to highly effective methods for managing diabetes and preventing complications," Rodgers said.

Within each broad area, the strategic plan lists some specific areas of focus.

For instance, in the area of beta cell research, the plan includes five areas: integrated islet physiology, beta cell dysfunction and failure, prevention and treatment of diabetes through restoration and preservation of beta cell function, cellular replacement therapies, and imaging the pancreatic islet.

Obesity is another focus of the plan because of its status as a major risk factor for diabetes.

Areas of interest in obesity include:

Obesity, inflammation, insulin resistance, and macrophage function: "Macrophages and inflammation appear to be activated by excess nutrients and subsequently play a role in eliciting insulin resistance as a consequence of obesity," the report authors noted. "Research is needed to clarify the mechanisms and outcomes of tissue-specific inflammation in obesity."

Mechanisms underlying energy homeostasis: "Untangling the complex networks of hormonal and neural mechanisms that control energy balance in the body could point to new therapeutic targets to prevent or treat obesity," according to the report.

Central nervous system control of thermogenesis: "New technologies are needed to facilitate study of the complex control of energy expenditure and how it contributes to weight maintenance and obesity in people," the authors wrote.

Discovering genetic and intrauterine determinants of obesity susceptibility that predispose people to developing diabetes.

Adipose tissue biology: "Adipose tissue research is key to the development of treatments for obesity and type 2 diabetes," the authors noted. "Understanding the mechanisms that regulate fat cell number, size, distribution, and signaling, and developing new technologies for studying adipose tissues are urgent research goals."

Obesity prevention and treatment: "Behavioral strategies are needed to prevent inappropriate weight gain and promote or maintain weight loss in individuals across the lifespan, as well as in communities or large populations," the authors wrote. "The development and testing of such strategies would be supported by research on the nonbiological determinants of obesity and obesity prevention and the use of technologies to tailor the delivery of interventions to individuals."

Currently, about 1 in 10 adults in the United States has diabetes, according to the Centers for Disease Control and Prevention. About 1.9 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010. In addition, an estimated 79 million American adults have pre-diabetes, a condition in which blood sugar levels are higher than normal but not high enough to be diagnosed as diabetes.

By 2050, as many as 1 in 3 adults could be diagnosed with diabetes if current trends continue, according to the CDC.

The projection assumes that recent increases in new cases of diabetes will continue and people with diabetes will also live longer, which adds to the total number of people with the disease.

Diabetes eventually damages nearly every organ system in the body. People with diabetes are at increased risk for blindness, kidney failure, and lower limb amputation. Overall, the risk for death among people with diabetes is about twice that of people of similar age without diabetes.

In addition, it is a very expensive disease to manage. Total costs of diabetes, including medical care, disability, and premature death, reached an estimated $174 billion in 2007 in the United States.

The plan was developed by the Diabetes Mellitus Interagency Coordinating Committee (DMICC), a congressionally authorized workgroup chaired by the NIDDK. Established in 1974, the DMICC facilitates cooperation, communication, and collaboration on diabetes research across the federal government.

Key elements of the report were identified by multiple public and private stakeholders, including representatives of DMICC member agencies, health advocacy groups and external scientists who are leaders in the diabetes research field.

To ensure broad input, a draft of the strategic plan was also posted for public comment prior to publication. The strategic plan is available electronically here. Printed copies can be requested from the National Diabetes Information Clearinghouse beginning April 1, 2011, at 1-800-860-8747 and by email at ndic@info.niddk.nih.gov. Single copies are free.