New-Onset Diabetes May Help Guide Pancreatic Cancer Screening

A new diagnosis of diabetes may help identify older adults who will develop pancreatic cancerwhile there is still time for screening and early detection, researchers reported at a meeting on gastrointestinal cancers sponsored by the American Society of Clinical Oncology.

In an observational study of more than 20,000 older adults with pancreatic cancer, 10 antecedent diagnoses were found to be significantly associated with the cancer diagnosis.

Of these, a diagnosis of new-onset diabetes preceded the cancer diagnosis by the greatest amount of time – more than 2 years, on average – or potentially enough time to catch the cancer early with targeted screening. A diagnosis of abdominal pain was second, at 1.5 years.

Late diagnosis is a major contributor to the generally "dismal" survival of pancreatic cancer, lead investigator Dr. Elizaveta Ragulin-Coyne said in an interview.

"Colonoscopy screening works great, mammography works great. But those cancers are really a lot more common, so it makes sense to screen the whole population," she commented.

By contrast, pancreatic cancer is relatively uncommon, so population-based screening with current tests would generate many false positives. At present, only individuals from families having hereditary pancreatic cancers associated with certain mutations are screened.

The goal of the study was therefore to identify "the factors that can precede the diagnosis of pancreatic cancer, that sort of can act as red flags to identify that population at risk," she explained. "So we are trying to identify the risk-rich population of individuals who can benefit from potential future screening."

The investigators analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database for the years 1991-2005 and the linked Medicare database for the years 1991-2007 to identify older adults with a diagnosis of pancreatic cancer and diagnoses preceding the cancer.

They evaluated 30 possible antecedent diagnoses for their association with the pancreatic cancer diagnosis, and narrowed it down to 10 that were significantly associated (P less than .05) in a stepwise logistic regression analysis: acute pancreatitis, chronic pancreatitis, cyst-pseudocyst, other pancreatic disease, bile duct obstruction, diabetes, weight loss, jaundice, abdominal pain, and hepatomegaly.

The 22,493 study patients were 77 years old on average; 55% were women and 86% were white, according to results reported in a poster session at the meeting.

The 10 antecedent diagnoses ranged in prevalence in this population from a low of 4% for hepatomegaly to a high of 76% for abdominal pain. A diagnosis of diabetes was seen in 45%.

In most cases, the median time between the antecedent diagnosis and the pancreatic cancer diagnosis was less than 3 months. The exceptions were abdominal pain, diagnosed a median of 18 months before the cancer, and diabetes, diagnosed a median of 28 months before the cancer.

The latter intervals are long enough to provide a window of opportunity for intervention, according to Dr. Ragulin-Coyne, a surgical resident and research fellow at the University of Massachusetts Medical Center in Worcester.

"It doesn’t make sense if you have preceding diagnoses within a month before, it doesn’t really make a difference," she explained. "But if it’s over 6 months or over a year, it is actually clinically significant because you can hypothesize that those people are potentially at an early stage and could have more interventions that give you a possibility of cure."

The average number of antecedent diagnoses decreased with increasing stage of pancreatic cancer at diagnosis, from 3.91 among patients with stage 0 disease to 2.04 among patients with stage IV disease.

This finding initially seemed counterintuitive, Dr. Ragulin-Coyne said. But perhaps patients having more advanced cancer at diagnosis have had less contact with the health care system in general, and therefore have fewer diagnoses on record.

In a logistic regression model among just the patients with an antecedent diabetes diagnosis, the odds of the gap between that diagnosis and the pancreatic cancer diagnosis being greater than 24 months were higher for nonwhite versus white patients; for patients aged 75-84 years or aged 85 years or older, compared with those aged 65-74 years; and for patients in the Midwest versus the Northeast.

The reason pancreatic cancer is diagnosed earlier in some patients and later in others is not yet clear, but it is likely multifactorial, according to Dr. Ragulin-Coyne.

"We can make guesses, whether it is socioeconomic or cultural or there is something else in play." For example, some patients may "tell the doctor about all their symptoms and get worked up early and get their doctors concerned more," she said. "But if they never come to the physician or they never mention what’s going on, they get diagnosed late."

In any case, identifying the reasons will be critical to moving all patients into the early diagnosis group. "I think that will ultimately be the best thing if, when they come, we can offer them treatments and cure and options, versus just saying, unfortunately, it’s too late," she commented.

The investigators have obtained the SEER data for all similar older adults without a pancreatic cancer diagnosis, and using a matched analysis, plan to develop and test a prediction nomogram using the information from their study. "Stay tuned for that," she advised.

"Screening for pancreatic cancer will be a great future tool," Dr. Ragulin-Coyne concluded, while also cautioning that there is still much work to be done before some type of population-based screening becomes a reality.

By: SUSAN LONDON, Internal Medicine News Digital Network

Medication Education Key to Success of Diabetes Treatment

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

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

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

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

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

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

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

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

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

Source: UCSD News Centre

Genetic Variation Linked to Diabetes

Researchers at Stanford University School of Medicine have identified genetic variations in a hormone involved in insulin secretion that occur more frequently in some human populations than others. The variants are believed to have first occurred 2,000 to 12,000 years ago, and are associated with higher fasting levels of blood glucose compared with the ancestral form of the gene.

The researchers identified 207 genetic regions associated with diabetes or obesity, and then examined which had increased in prevalence in the time since humans moved out of Africa some 60,000 years ago. Their investigation yielded 59 genetic regions; the researchers were most interested in those occurring in at least 30% of people included in the HapMap project, a worldwide survey of genetic differences among people of Nigerian, Chinese, Japanese and European ancestry.

Fives genes with genetic differences that occurred frequently in Asians and Europeans, but infrequently in Africans, were identified. The researchers chose GIP, one of the five genes, to study further because of its known involvement in insulin secretion stimulation after a meal.

“We thought GIP was the most interesting because the newly selected form occurs in about 50% of people from Europe or Asia, but in only about 5% of Africans. That indicates this gene is highly adaptable to new environments,” Sheau Yu Hsu, PhD, assistant professor of obstetrics and gynecology at Chang Gung Memorial Hospital in Taiwan, said in a press release.

The researchers identified three individual changes in the regulatory region of GIP that were associated with reduced levels of the glucose-dependent insulinotropic polypeptide (GIP) hormone. The changes were also likely to occur with another mutation in the coding region, resulting in a different form of the protein. According to the press release, in human blood the alternate form is degraded more slowly.

“So now we know there are two different forms of the protein, which allowed one form to be selected in one population, and the other in a different population,” Hsu said. “But we still needed to show that these variants led to phenotypic differences in modern humans.”

Conclusive differences in GIP variants among human carriers have not been previously shown, so Hsu and colleagues focused their research on 123 East Asian pregnant women due to their important role in evolutionary success and their metabolically challenged nature.

According to their results, women carrying two copies of the new variant had significantly lower levels of circulating GIP in their blood and were at a significantly higher risk for fasting blood glucose levels exceeding the recommended 140 mg/dL (48.3% vs. 20.9% for those carrying the ancestral variant).

This finding could help clinicians identify pregnant women at higher risk for gestational diabetes, according to Hsu. In addition, the results demonstrate how our ancestors handled environmental change.

“Like other humans at the time, the Eurasian population really had to fight for survival. Now we’re starting to pinpoint how they did that on a molecular level. These gene variants, and the resulting higher blood sugar levels it fostered, may have helped women maintain successful pregnancies in the face of the inevitable famines that occur in an agriculturally based society. Now, in a more food-secure environment, variations in GIP could contribute to the development of diabetes or obesity.

“These studies are fascinating because it shows how much the selection process has affected human energy-balance regulation in just a few thousand years and how complex it could be for the future practice of personalized medicine,” Hsu said.

From endocrinetoday.com

Diabetes Alert: Avandia Warnings Updated To Reflect Restrictions on Use

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

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

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

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

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

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

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

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

All Diabetics Should Take Statins, Say Experts

The European Association for the Study of Diabetes (EASD) has recommended that all people suffering from diabetes should be taking statins, as research showed that the evidence for their effectiveness in reducing cardiovascular risk in diabetics, and even people without diabetes, is incontrovertible.

Professor John Betteridge, of University College London Medical School, pointed out at the EASD annual meeting in September 2010 that all people with diabetes should be taking statins to reduce their chances of having a heart attack or stroke, although he also warned that they should avoid any drug interactions with other medications being taken.

Betteridge has analysed a number of studies into the use of statins, such as the CollaborativeAtoRvastatin Diabetes Study (CARDS), funded by Diabetes UK, the Department of Health and Pfizer, which examined their benefits in people with type 2 diabetes who did not already have evidence ofcardiovascular disease .

In the CARDS study, atorvastatin 10mg/day was shown to reduce major cardiovascular events by 37 per cent and strokes by 48 per cent, reinforcing guidelines issued by the Joint British Society (JBS) regarding targets for low-density lipoprotein cholesterol in this high-risk group.

Betteridge argues that statins are safe if taken appropriately and drug interactions avoided, as they can lead to serious side effects, especially when patients are on a variety of drug treatments. Statins should also not be used by pregnant women at least six weeks before conception.

He realises that statins don’t always get a good press, and that many diabetics will be wary of this advice, but he points out that the evidence shows them to be highly effective in preventing major vascular events in patients with diabetes.

However, the idea of taking statins to offset the effects of junk food has been criticised by diabetes experts. New research had recommended that fast food outlets should give out free statin pills as a way of combating the impact of unhealthy food, as they can reduce the levels of bad cholesterol in the blood, which is why they are normally prescribed to decrease the risk of cardiovascular disease.

There are now worries that using statins could encourage people to lead unhealthier lives, eat more fast food and therefore increase the risk of developing type 2 diabets. Although studies have found that a single, cheap statin pill could offset the increased risk to the heart caused by the fat in a cheeseburger and a small milkshake, there are concerns that it is both irresponsible and dangerous to promote their use as a quick fix to counteract the effects of an unhealthy diet.

Zoe Harrison, Care Advisor at the charity Diabetes UK, said Statins can reduce the risk of cardiovascular disease by lowering the bad cholesterol in our blood which can be raised due to a high-fat diet. However, they don't prevent all the side effects that result from an excessive intake of fatty food.

Statins also have some serious side effects - such as damage to the liver, pancreas and muscles – which is why they should always be prescribed by your doctor who can then closely monitor how you are responding to the medication.

Here's an overview of Diabetes and Statins
Diabetes and statins have a complex relationship and are the focus of intense patient and healthcare debate. Statins are cholesterol-lowering drugs.

Statins are used in diabetes care due to the knowledge that people with diabetes face a greater likelihood of heart attack and stroke.

When used alongside good blood glucose control and other medication, the case for statins argues that they cut cholesterol levels and lower the risk of a cardiovascular event.

Type 2 diabetes in particular is certainly a disease of the circulatory system, and this argument has some weight.

How can I lower my risk of cardiovascular problems without taking statins?
There are many ways to lower your risk of stroke and cholesterol levels. These include stopping smoking and controlling your blood pressure. Diet and exercise can help to lower raised blood pressure, and a healthy lifestyle can cut cholesterol levels. However, some doctors prescribe statins to help reduce cholesterol levels.

What do statins do for people with diabetes?
Statins slow the action of the liver in manufacturing cholesterol, causing blood cholesterol levels to fall.

Do statins work for people with diabetes?
Statins definitely lower cholesterol, and major studies have shown that the risk of heart attack and stroke plummets amongst people with diabetes taking statins. Results indicate that statins can prevent cardiovascular disease by reducing heart attack and stroke risks.

What are the side effects of statins?
Statins are usually well-tolerated by people with diabetes. Side effects can include:

• Headaches

• Affect on liver function

• Stomach problems such as abdominal pain, constipation, flatulence, diarrhoea and vomiting

• Rashes

• Disorder of the muscles (myopathy)

Shouldn’t all people with diabetes therefore take statins?

Statins are the subject of current and ongoing healthcare debate when it comes to diabetes patients. Further research is in progress to make the wider use of statins in diabetes care more clear.

Often, people under 40 may not benefit from taking a statin.

A statin is also just one part of diabetes care and shouldn’t be used instead of good diet, exercise, smoking and excess drinking avoidance.

Source: diabetes.co.uk

How Tiny Nauru Became World's Fattest Nation

The world is facing a "population emergency" as soaring rates of obesity threaten a pandemic ofcardiovascular disease, scientists have warned.

The spread of Western fast food was blamed as the tiny Pacific nation of Nauru was named as the fattest in the world. Its average Body Mass Index is between 34 and 35, 70 per cent higher than in some countries in South-east Asia and sub-Saharan Africa.

More than one in 10 of the world's population is obese – more than half a billion adults – and rates have doubled since 1980. The biggest increases are in the richer nations but almost every country has seen rates rise.

Only Bangladesh, the Democratic Republic of Congo and a few countries in sub-Saharan Africa and east and south Asia have escaped the rise. Yet even in these regions neighbouring countries have had widely differeing experiences. The women of Southern Africa are among the fattest in the world.

The rise is being driven by increasing urbanisation, the growth of sedentary, office-based lifestyles and the substitution of Western-style fast foods for traditional diets. Researchers from Imperial CollegeLondon and McMaster University in Canada, writing in The Lancet, describe it as a "tsunami of obesity that will eventually affect all regions of the world".

In its wake comes an epidemic of heart disease and stroke, linked with high blood pressure and raised cholesterol levels. Remarkably, high-income countries such as the US and UK have managed to avoid this, by reducing blood pressure and cholesterol with drugs and dietary changes, such as reducing salt and fats. Smoking too, one of the key causes of heart disease, has fallen. (Japan is an exception where historically low cholesterol levels, associated with the nation's high consumption of fish, have risen to levels seen in western Europe, as the Japanese adopt a Western diet.)

But in middle and low-income countries the outlook is "dismal". "Considering all risk-factor trends together, the forecast for cardiovascular disease burden... comprises a population emergency that will cost tens of millions of preventable deaths, unless rapid and widespread actions are taken by governments and health care systems woldwide," the researchers say.

Treating the consequences of the obesity explosion with drugs will create an "unsustainable financial burden" in these countries and there is an "urgent need" to understand why unhealthy behaviours are adopted by both individuals and communities.

With an increasing trend towards globalisation and urbanisation, the problem is likely to get worse rather than better. "Ironically the economic growth of low-income and middle- income countries is now threated by the projected cardiovascular disease epidemic," they say.

Citing the noted British epidemiologist Geoffrey Rose, the authors say: "Mass disease and mass exposures require mass remedies. Mass remedies require the masses to be part of the solution."

The world obesity map
Fastest growing: US
The US saw the biggest rise in BMI of all developed nations between 1980 and 2008, more than 1kg a decade. Increasingly sedentary occupations, less walking and cycling, more driving in cars and rising consumption of fast foods and sugary drinks are behind the rise which affects all high-income countries.

Slimming down: Italy
Italy is the only high-income country in Europe where BMI declined - for women, from 25.2 to 24.8. Even among men, Italy saw one of the smallest increases. The classic Mediterranean diet - pasta, vegetables and fruit - is one of the healthiest in the world.

Fattening up: UK
The UK has the sixth highest BMI in Europe for women and the ninth highest for men (both around 27). The rate of increase has been second only to the US for men. One in four men and one in three women is overweight and about 12 million are obese.

South America's biggest: Chile
Chile with an average BMI of 27.0 for men and 27.9 for women, was the heaviest country in southern Latin America. The scale of increase in obesity in southern Latin America is second only to the US among men and ranks fifth among women. Rates of obesity soared in Chile with the end of its dictatorship in 1990 and a surge in fast food restaurants and some critics are now calling for a junk food tax to be imposed.

World's thinnest: Bangladesh
Bangladesh is the world's thinnest nation, with an average BMI of 20.5 for women and 20.4 for men. Rice is the staple diet and millions go without enough to eat. More than half of children - more than 9 million - are underweight and have stunted growth.

Fattest on earth: Nauru
Nauru is the world's fattest country, with an average BMI of 34 to 35. Located in the south Pacific it is the smallest island nation, with a population of less than 10,000. Obesity has grown as a result of the importation of Western foods paid for with proceeds from phosphate mining. The most popular dish is fried chicken and cola.

And here are the top ten overweight countries along with the percentages of their populations who are overweight: 

10. Kiribati - 73.6%
9. United States of America- 74.1%
8. Kuwait - 74.2%
7. Palau - 78.4%
6. Samoa - 80.4%
5. Niue - 81.7%
4. Tonga - 90.8%
3. Cook Islands - 90.9%
2. Federated States of Micronesia - 91.1%
1. Nauru - 94.5%

From The Independent

Diabetes Management System Could Be ‘iTunes of Diabetes Care’

With technology increasingly becoming part of diabetes management, here comes news of a development that may make a diabetic's life easier. (Of course, it'll put a further drain on your resources!)

London-based Cellnovo closes $48 million B round to fund commercialization of the first all mobile diabetes management system, which is drawing comparisons to Apple Inc.’s blockbuster iPhone and iPod platforms.

Cellnovo announced its presence as a major player in the diabetes race with $48 million in new funding for what industry observers have called the “iTunes of diabetes care.”

The B round for the London-based company was led by Edmond de Rothschild Investment Partners (EdRIP), with Forbion Capital Partners, Auriga Partners, NBGI Ventures and Credit Agricole Private Equity.

Previous investors Advent Venture Partners, HealthCare Ventures and NESTA also participated in the round, according to a prepared release.

Cellnovo officials said they would use the proceeds to commercialize and expand markets for its diabetes management system, which includes an insulin pump, mobile handset and online management system for diabetics. The pump’s appearance, size and interface have drawn comparisons to Apple Inc.’s iPhone and iTunes products by both industry observers and the company itself.

“If people understand Cellnovo as a device that sends data to a website, they are missing the point,” Cellnovo CEO Bill Mckeon told the medical device publication Invivo last year. “If you had asked Steve Jobs at Apple about his new MP3 player called the iPod, and how it compares to other MP3 players, he might have said, ‘I am not making an MP3 player. I’m bringing entertainment into your life in a number of ways.’”

Mckeon went on to tell the magazine that he puts the Cellnovo system in the same category.

“We believed that the rest of the world was looking at diabetes and the delivery of insulin with a very device-centric mindset. There is a device that pumps insulin, another device that measures blood glucose and another device with continuous sensors,” he said.

David Kliff, an independent diabetes analyst, who publishes the Diabetic Investor, wrote on his web site that Cellnovo’s approach is a “somewhat radical departure from the traditional approach to the market, which is more concerned with building a cheaper version of what’s already on the market while ignoring how patients actually use these systems in a real world setting.”

Kliff added that he believed Cellnovo would be able to attract the attention of the big players in the diabetes market if it’s in search of an exit. Currently, there’s a glut of companies duking it out in the insulin pump and diabetes management market including medical device goliath Medtronic Inc, Johnson & Johnson subsidiary LifeScan and smaller players like Insulet, which makes the OmniPod.