Get your coupon for 25.00 off Novolog—click here and we will send you one. (This Newsletter is not affiliated with the American Diabetes Association) ============================= DIABETES IN CONTROL.com NEWSLETTER The Newsletter for Professionals in Diabetes Care October 29, Issue #179 s From the Editor’ Desk: Last week Steve Freed, Publisher, and I were at the National Community Pharmacist Association Annual Conference in Seattle. We were just in time to see the record for the most rain in one day in Seattle. Even though our sightseeing of the city was dampened, we got to see plenty of what was going on with Diabetes and Pharmacists. The conference started out with 2 programs, Diabetes Care Certificate Program and Therapeutic Foot Care Certificate Program. Each of these programs gave the over 300 pharmacists who attended important knowledge to help all diabetes patients. The diabetes program covered such topics as insulin pattern management; patient assessments; nutrition, exercise, and sick-day planning; insulin administration devices, blood glucose monitoring and management. While the foot care program delivered information on anatomy of the foot; common foot complications and treatment options; patient evaluation; selection, measurement, and fitting of shoes, inserts, and custom footwear casting. This training has allowed your local pharmacist to become a spot to refer your patients to. We will soon have a list of the certified pharmacists for you to send patients to. While we were in Seattle we had a chance to meet with Dr. Paul Chous. Paul is an optometrist who has had type 1 diabetes since 1968 and sees only diabetes patients in his practice. Paul has recently completed a book on Diabetic Eye Disease. Our discussions revealed how little most of us know about Dilated Eye Exams and the medicines used for dilation. This week we have a stellar summary of Dilated Eye Exams from Dr. Chous Starting next week, we will be featuring excerpts from his new book: Diabetic Eye Disease: “Lessons from a Diabetic Eye Doctor: How to Avoid Blindness and Get Great Eye Care”Keith Campell, RPh, CDE has said “this is the most informative book on diabetes eye care I have ever read”. If you want to determine if you are at the forefront of patient care, judge your practice by the standards discussed by Dr. Timothy S. Hollingshead, in his feature Are We There Yet? After reading this I was able to see ways to make my practice more effective and professionally rewarding, I am sure you will benefit also. s This week’ overview: Item#4: Grafts Help Heal Diabetic Foot Ulcers Item #8: Pancreatic Beta-cell Loss and Preservation in Type 2 Diabetes Item #11 Metformin Treatment Leads to Increased Homocysteine, Decreased Vitamin B12 and Folate in Type 2 Diabetes Patients* Check out this weeks “ Test Your Knowledge”question. If you get it right on the first try, you will be entered into a special drawing for your choice of 3 special prizes. Dave Joffe, Editor-in-Chief ================================== NEWS FLASH: Coca-Cola to Launch Cholesterol-Reducing Orange Juice See Item #14 Betagenon & Astrazeneca sign collaboration for therapies for type 2 diabetes Betagenon AB a Swedish biotechnology company focused on the discovery and early stage development of drug therapies for treatment of type 2 diabetes. The long-term goal of the collaboration is to enable AstraZeneca to develop new drugs that restore ability of the beta cells to meet the increased demand of insulin in type 2 diabetics. Betagenon has access to unique in vivo models in which the beta cells fail to produce and/or secrete enough insulin in a regulate manner, and which develop diabetes that closely mimics type 2 diabetes in man. These models will be used in the collaboration to develop a superior drug discovery platform. The terms of the deal were not disclosed. ================================== Studies: Insulin Pump infusion device : If we sent you an Email, please respond by Friday or we will have to replace you in this study— Please no new participants Coming soon— a new device to carry your glucose monitor— will it increase compliance- We will need your help to find out. If you were selected for the neuropathy study you should have your product by now— if not then let me know ================================== Tools for your Practice: $25 dollars off coupon for your patients who use Novolog Click here and we will send you one ==================================== New Product: Pendragon Medical presents first non-invasive “sensorwristwatch”Pendra, to monitor and predict glucose levels. Paris. August 25, 2003 – Swiss medical technology company Pendragon Medical Ltd. presented its device Pendra® at the IDF conference. Pendra® continuously monitors the blood glucose level every minute without the need for a blood sample. It also contains alarm functions to predict critical Hypoglycemia levels. Having been approved by the appropriate European regulatory body in May 2003 as a Type II b Medical Device, Pendra® will be launched in early 2004 in the first five European markets. More info, click here: Pendra® ==================================== This newsletter is the condensed version. If you would like to see the full newsletter go to http://www.diabetesincontrol.com/Issue179ndex.htm ==================================== =================================== s This Week’ Items: 1. Cholesterol Drugs Work Best in Evening Click Here 2. Depression Improves With Weight Loss Click Here 3. Good Diabetes Control Benefits Last Many Years Click Here 4. Grafts Help Heal Diabetic Foot Ulcers Click Here 5. Younger Adults With Type 2 Diabetes 14 Times More Likely to Suffer Heart Attacks* Click Here 6. Poorly Controlled Diabetes Can Lead To Liver Problems Click Here 7. Extended Delay in Progression of Diabetic Nephropathy Seen in Patients who Received Intensive Diabetes Treatment Click Here 8. Pancreatic Beta-cell Loss and Preservation in Type 2 Diabetes Click Here 9 Type 2 Diabetes, Cardiovascular Risk, and The Link to Insulin Resistance Click Here 10. Cause of Diabetes Affects Response to Treatment Click Here 11. Metformin Treatment Leads to Increased Homocysteine, Decreased Vitamin B12 and Folate in Type 2 Diabetes Patients* Click Here 12. Diabetes Can Cause Breast Lumps* Click Here 13. Steps for your Health Click Here 14. Coca-Cola to Launch Cholesterol-Reducing Orange Juice Click Here 15. How to Eat More and Still Lose Weight* Click Here ________________________________________________________________________________ ITEMS For The Week: Item 1 Cholesterol Drugs Work Best in Evening New research confirms at least one common statin and probably most off the statins may be most effective when taken at night as opposed to the morning. Researchers from England studied 83 patients who were taking either 10 milligrams or 20 milligrams of simvastatin, otherwise known as Zocor. They were taking the drug for primary or secondary prevention of coronary heat disease, stroke, or peripheral vascular disease. Patients were randomized to take the drug in the mornings or in the evenings. Fifty-seven patients completed the trial. Most manufacturers of statins recommend the drugs be taken at night, but doubt has been cast on whether that is the best time. Researchers found when patients switched from taking their nighttime pill to the morning, there were significant increases in total cholesterol and LDL, or the bad, cholesterol. Authors of the study write, “ Simvastatin is probably best taken at night because concentrations of total cholesterol and of low density lipoprotein are significantly greater when it is taken in the morning. This finding has implications for compliance in preventing coronary heart disease.” British Medical Journal, 2003;327:788 ==================================================== FACT: Obesity doubles for women, more than doubles for men since 1985 The prevalence of obesity among Canadian women has doubled over the last 15 years, new data show. For men it has more than doubled. The fat isn't just creeping up on Canadians, it's galloping. Canadian men continue to be fatter than women on average, but women are catching up. Forty per cent of men were overweight in 2001. From 1985 to 2001, the percentage of women defined as overweight increased to 26 per cent from 19 per cent. Health Canada guidelines define overweight as a body mass index of 25. We have upgraded our Tools for Your Practice page. Check out how easy it is to get all the tools you will ever need. http://www.diabetesincontrol.com/tools.shtml ==================================================== Item 2 Depression Improves With Weight Loss Severe obesity is associated with a high risk for depression, especially those with diabetes and among young women with poor body image. However, depression improves with loss of weight. Dr. John B. Dixon and colleagues from Monash University, in Melbourne, Australia, note that the association between depression and severe obesity is unclear. In a study reported in the September 22nd issue of the Archives of Internal Medicine, they examined depression before and after gastric-restrictive weight loss surgery. The researchers report that 487 consecutive patients completed Beck Depression Inventory (BDI) questionnaires before and at yearly intervals after surgery, to follow changes with time. The team used paired preoperative and 1-year postoperative scores from 262 patients to identify predictors of change in BDI scores. The mean preoperative BDI score for the 487 patients was 17.7. Younger age, female sex, a history of depression, poor physical function, and poor body image were independently associated with higher depression scores. "Body mass index, weight, waist, hip, and neck circumference, and waist-hip ratio did not predict higher BDI scores," Dr. Dixon and colleagues found. Also, fasting plasma glucose and insulin levels and calculated insulin resistance index were not predictive of BDI scores. The investigators observed an association between weight loss and a significant and sustained fall in BDI scores. The mean scores at 1 and 4 years after surgery were 7.8 and 9.6, respectively. Female sex, younger age, a greater percentage of excess weight loss, and a poorer preoperative appearance evaluation were independently associated with greater falls in BDI score at 1 year. There was a significant correlation between fall in BDI score and improved appearance evaluation (p < 0.001). Dr. Dixon and colleagues conclude that the findings support the notion of depression as a comorbidity of obesity, and that those most affected by depression derive the greatest mental health benefit from bariatric procedures. Arch Intern Med 2003;163:2058-2065. ================================ Did you know: The Diabetes Education Society offers online accredited continuing education programs. Got an hour, take a course. Visit www.MedEdOps.org, take the free sample course and review the Course Catalog. Then update yourself and your staff to meet your Education Recognition requirements. For more information call (800) 659-5808. ================================ Item 3 Good Diabetes Control Benefits Last Many Years In diabetics, intensive control of blood sugar levels seems to slow the progression of kidney disease many years after such control has ended, new research shows. Started in 1981, the Diabetes Control and Complications Trial (DCCT) compared the benefits of intensive and conventional therapy in 1441 type 1 (i.e., insulin-dependent) diabetics. The intensive therapy consisted of at least three daily insulin injections with frequent sugar monitoring. In contrast, conventional therapy consisted of no more than two daily injections and one blood or urine sugar test. The results from DCCT revealed that intensive therapy was better than conventional therapy at controlling sugar levels and at slowing the progression of kidney disease. After DCCT ended in 1989, patients in the conventional group were offered intensive therapy supervised by their own physicians, while those in the treatment group were encouraged to continue the intensive therapy. The current study, known as the Epidemiology of Diabetes Interventions and Complications (EDIC) study, represents eight years of additional follow-up for former DCCT participants. The results are reported in the Journal of the American Medical Association. Dr. David M. Nathan, from Massachusetts General Hospital stated that, "Over time, the glycemic levels of the former control group began to drop, while those of the former intervention group rose, so that during the EDIC study the levels in each group were no longer substantially different." Interestingly, although each group now had similar levels, a kidney benefit was still seen in the former intensive therapy group, Nathan noted. The new findings complement those reported in 2000, which showed that intensive therapy also provides a persistent reduction in the risk of diabetic eye disease. In addition to slowing the progression of kidney disease, intensive therapy reduced the risk of high blood pressure, the authors point out. "The take-home message is that early, intensive intervention is very important," Nathan emphasized. "The earlier that patients can intervene to (control blood sugar) the better effect they're going to get and the better long-term outcomes they're going to have." Journal of the American Medical Association, October 22/29, 2003. ============================= Cholestech GDX™ A1C Testing System With Instant Results CLIA-waived - A1C results in 5 minutes - Increased office revenue – NGSP-certified – Reimbursable. Find out More! A new Thyroid Test for Home use is now available. More Info The 10,000 STEP STUDY: “The Results” A simple answer to a difficult problem. CLICK HERE ================================ Item 4 Grafts Help Heal Diabetic Foot Ulcers Now, new research has shown that grafts derived from a patient's skin cells can help some diabetic ulcers heal faster, These findings come from a study, published in the current issue of Diabetes Care, that compared such grafts with standard gauze dressings in 79 diabetics with ulcers on the top or bottom of their feet. The grafts were created by taking skin samples from each patient and then growing the skin cells in a lab to form a sheet that could be used to cover the patient's ulcer. All of the patients had their ulcers cleaned thoroughly, received antibiotics if needed, and were given casts to relieve pressure if the ulcer was on the bottom of the foot, lead author Dr. Carlo Caravaggi, from the Ospedale di Abbiategrasso in Milan, and colleagues note. Grafting was safe and well tolerated, the authors report. Among patients with ulcers on the top of the foot, 67 percent of grafted ulcers healed compared with just 31 percent of gauze-treated ulcers. Among patients with ulcers on the bottom of the foot, however, about 52 percent of ulcers healed regardless of treatment type. Although grafting appears to be more effective for top-of-foot ulcers, the authors note that it may still be of use for bottom-foot ulcers, especially when the optimal pressure-relieving cast cannot be used. Diabetes Care, October 2003. ================================ Start your own 10,000 step program. Pedometers available at special prices. See the results of the 10,000 Step Program. Step Program Purchase your own pedometers and receive the Steps To Health Program Patient Book at no charge with free shipping. Click Here DID YOU KNOW: Did you know: Prandin and Lopid Interact: Finnish researchers have discovered that 2 drugs commonly used by people with diabetes interact. These drugs are repaglinide (Pranding and gemfibrozil s (Lopid). When the 2 are taken together, repaglinide’ blood sugar-lowering effects become stronger and last longer. As a result, severe hypoglycemia (too-low blood sugar levels) can occur. Announced results in March 2003 Diabetologia. =========================== Item 5 Younger Adults With Type 2 Diabetes 14 Times More Likely to Suffer Heart Attacks Young adults, age 18-44, who get type 2 diabetes are 14 times more likely to suffer a heart attack and up to 30 times more likely to have a stroke than their peers without diabetes Stroke Risk Increased Up to 30 Times. Young women account for almost all the increase in heart attack risk, while young men are twice as likely to suffer a stroke as young women. The study by two researchers at Kaiser Permanente's Center for Health Research (CHR), funded by the American Diabetes Association, will appear in the November issue of Diabetes Care. "This means that huge numbers of people are going to get heart disease, heart attacks and strokes years, sometimes even decades, before they should," says Teresa Hillier, MD, an endocrinologist and investigator at CHR and lead author of the article. "Young adults are increasingly likely to be overweight and diabetic. Our study is the first to look at the health outcomes of young adults who get diabetes, and the greatly increased risks of heart attack and stroke are very alarming." To conduct the study, Dr. Hillier and her colleague used electronic medical records to identify 7,844 individuals who were newly diagnosed with type 2 diabetes from 1996 to 1998 (1,600 were under age 45 and 6,244 were 45 or older). Other findings included the following: -- People with early-onset type 2 diabetes are 80% more likely to need insulin therapy within two years than people with usual-onset type 2 diabetes. -- People with early-onset diabetes were significantly more obese on average than people with usual-onset diabetes (BMI 37 vs. 33).(1) -- Younger adults with diabetes were more than twice as likely as older adults with diabetes to develop any heart disease compared to their peers without diabetes. "We are clearly facing a very serious public health problem," says Dr. Hillier. "The CDC is predicting that at least one out of every three Americans born after 2000 are going to develop diabetes, and the trend we've seen of diabetes affecting young adults -- and even teenagers -- is going to continue. Young women with diabetes who have a heart attack are more likely to die from it in the hospital than men, so our finding that young women with diabetes are 14 times more likely to have a heart attack is especially alarming." Reference: (1) Note: a 5'10" man with a BMI of 37 weighs 258 pounds, a 5'5" woman with a BMI of 37 weighs 222 pounds. Source: Kaiser Permanente ================================================================ Item 6 Poorly Controlled Diabetes Can Lead To Liver Problems A case of poorly controlled insulin-dependent diabetes led to liver glycogen deposition and abnormal liver enzymes. That, from researchers at the 68th Annual Scientific Meeting of the American College of Gastroenterology. Seth D. Hoffman, MD, and colleagues, Loyola University Medical Center, Maywood, Illinois, United States, discussed the case of a 22-year-old woman who presented to the emergency department with a 1 month history of increasing abdominal girth, right upper quadrant pain and a 13.5 kg weight gain. She had been diagnosed with insulin-dependent diabetes 13 months previously and hospitalised with diabetic ketoacidosis five times in 1 year. Physical examination revealed anasarca and a mildly tender liver palpable 7 to 8 cm below her midcostal margin. Laboratory tests demonstrated high serum glutamic oxaloacetic transaminase (AST) and glutamic pyruvic transaminase (ALT), and normal alkaline phosphatase and bilirubin levels. Computed tomographic scan of the liver revealed an enlarged liver, and liver biopsy was performed. Biopsy showed findings consistent with the presence of glycogen and indicated diffuse glycogenosis. The patient's liver enzymes, oedema and abdominal pain markedly improved after 7 days of tight glycaemic control. Dr. Hoffman said that in cases of abnormal liver enzymes without hepatitis, other causes must be ruled out and a normal workup carried out to identify abnormal liver function. He thinks the present case of liver glycogenosis is uncommon, though 8 to 10 cases have been reported in patients of all ages with poorly controlled diabetes. He believes that when tight glycaemic control was initiated, the glycogen deposits were mobilised by insulin. "Get the diabetes under control," he said, "and the problem resolves." Dr. Hoffman recommends considering the diagnosis of liver glycogenosis whenever a poorly controlled diabetes patient has liver enzyme abnormalities. =========================== Eye Disease: Lessons from a Diabetic Eye Doctor: How to Avoid Blindness and Get Great Eye Care Book Description: Diabetes affects every part of the eye, not just the retina. Presenting critical information about seven different kinds of diabetic eye disease as well as important steps all diabetics must take to preserve vision, Dr. Chous clearly and comprehensively guides you through the fundamentals of good diabetes management and great eye care. Written by an eye doctor, diabetes educator and patient advocate, this book is dedicated to helping you or someone you love avoid blindness and other complications by taking charge of your diabetes. More Info: =========================== Item 7 Extended Delay in Progression of Diabetic Nephropathy Seen in Patients who Received Intensive Diabetes Treatment Intensive diabetes treatment to sustain near-normal glycemia has an extended benefit of delaying the progression of diabetic nephropathy. That, according to the most recent findings of the Epidemiology of Diabetes Interventions and Complications (EDIC) study. The EDIC trial, which originated in 1993 after the closeout of the Diabetes Control and Complications Trial (DCCT), followed 1349 participants of DCCT for the development of microalbuminuria, clinical-grade albuminuria, hypertension, or an increase in their serum creatinine level. "Follow-up of the DCCT cohort for 8 additional years in the EDIC study has shown persistent differences in nephropathic outcomes between the former intensive-treatment and conventional- treatment groups," writes David M. Nathan, MD, Massachusetts General Hospital, Boston, United States, and members of the combined DCCT/EDIC Research Group. They report results by intention-to-treat analyses of 676 patients in the original DCCT intensive treatment group and 673 patients in the original DCCT conventional treatment group. During the EDIC study, new cases of microalbuminuria occurred in 6.8% of the DCCT intensive group compared with 15.8% of the DCCT conventional treatment group. New cases of clinical albuminuria occurred in 1.4% of the DCCT intensive group compared with 9.4% of the conventional DCCT group. The investigators note there was no difference in the prevalence of hypertension between groups at the end of the DCCT (11% for both) but by year 8 of the EDIC follow up they report the prevalence of hypertension was 29.9% in the intensive group but was 40.3% in the conventional group. The DCCT/EDIC Research Group found that, since the DCCT baseline through year 8 of the EDIC trial, a doubling of serum creatinine level occurred in 10 of the intensive treatment group and in 17 of the conventional treatment group. At EDIC year 8, only 5 patients in the intensive versus 19 in the conventional group reached serum creatinine levels of 2 mg/dL or greater and 4 of the patients in the intensive group compared with 7 in the conventional group required dialysis and/or kidney transplantation. "The current results reaffirm that intensive treatment of type 1 diabetes should be initiated as early as is safely possible in order to provide strong and durable protection from the development and progression of diabetic microvascular disease," the authors conclude adding, "the protection initiated by intensive treatment appears to outlast the intensive treatment itself, although the duration of the effect remains to be determined." JAMA 2003;290:2159-2167 ================================ s Dr. Richard Bernstein’ book the Diabetes Solution NEW AND REVISED Special Pricing for Subscribers of Diabetes In Control-32% Discount 512 pages packed with new information on Diet, Exercise, Curbing Carbohydrate cravings, new insulin regimens, monitoring blood sugars, helping physicans and patients to regulate blood sugars plus much, much more. “RUN T DON’ WALK TO GET THIS BOOK” -- Michael R. Eades, M.D. Author of Protein Power. “ Please read this book, if you really want to be proactive in the lifelong battle against diabetes and its complication.”-- John A. Colwell, M.D., Ph.D., former President, ADA. This book should be in the library of every diabetic patient, and especially s Physician’ who treat diabetes.” — Barry Sears, Ph.D., author of THE ZONE. “ ================================ Item 8 Pancreatic Beta-cell Loss and Preservation in Type 2 Diabetes. Current clinical management of type 2 diabetes is focused on treatment of the signs and symptoms of late-stage disease rather than addressing potential underlying causes. In most individuals, the need to respond to progressive states of insulin resistance is met by increasing insulin production. For insulin-resistant patients, however, the balance between insulin supply and demand may fail from the progressive loss of pancreatic beta-cell function, eventually leading to type 2 diabetes mellitus. The aim of this review was to discuss the current concepts underlying potential pancreatic beta-cell failure in the progression toward type 2 diabetes and therapies that may alter the process. Data included in this review were identified through a MEDLINE search for articles published from 1966 to April 2003. Search terms used were beta cell, diabetes, insulin resistance, obesity, cardiovascular disease, thiazolidinediones, and metformin. Evidence of the progressive loss of beta-cell function may include altered conversion of proinsulin to insulin, changes in pulsed and oscillatory insulin secretion, and quantitative reductions in insulin release. Potential underlying mechanisms are glucose toxicity, lipotoxicity, poor tolerance of increased secretory demand, and a reduction in beta-cell mass. CONCLUSION: Current clinical management of type 2 diabetes is focused on treatment of the signs and symptoms of late-stage disease rather than addressing potential underlying causes, which may be amenable to currently available therapies, based on a broad understanding of existing data, practice experience, and rational speculation. Clin Ther. 2003;25 Suppl B:B32-46. =============================== FACT: IRS reconsiders blood glucose meters: Because only 6 percent of taxpayers claim medical expenses on their tax returns, probably due to the fact you can only claim medical expenses that exceed 7.5 percent of their adjusted gross income. But on May 15th the Internal Revenue Service made it a bit easier for those with diabetes to reach the cutoff mark of 7.5%. On a May 15, 2003 ruling, IrRS determined that this limitation will no longer apply to other nonprescription medical care items such as bandages, crutches, and blood sugar checking kits and equipment. This means that blood glucose meters and strips are now an allowable medical expense. So if you claim medical expenses on your taxes, don’ forget to include the money spent on your supplies come next April 15th. t ============================== Item 9 Type 2 Diabetes, Cardiovascular Risk, and The Link to Insulin Resistance Early data suggest that, in addition to reducing hyperglycemia, pioglitazone and rosiglitazone effect changes in the dyslipidemic profile, hemodynamics, vascular inflammation, and endothelial functioning of patients with type 2 diabetes Patients with type 2 diabetes mellitus frequently have coexistent dyslipidemia, hypertension, and obesity, and are at risk for microvascular and macrovascular disease complications such as myocardial infarction, stroke, retinopathy, and microalbuminuria. To optimize cardiovascular health outcomes for patients with type 2 diabetes, strategies to reduce the risks of microvascular and macrovascular disease are needed in clinical practice. This article provides an overview of the cardiovascular risk profile of patients with type 2 diabetes and discusses the cardiovascular consequences of use of the thiazolidinediones (insulin-sensitizing agents) in the treatment of type 2 diabetes. A literature search of MEDLINE/PubMed was performed to identify relevant articles published from 1966 to April 2003. Search terms used were diabetes, cardiovascular disease, atherosclerosis, dyslipidemia, obesity, hypertension, blood pressure, hyperglycemia, inflammation, C-reactive protein, fibrinolysis, plasminogen activator inhibitor type-1, microalbuminuria, thiazolidinediones, safety, hepatotoxicity, and edema. Bibliographies within the identified articles were also evaluated for additional relevant articles and information. Recommendations for cardiovascular risk reduction through preventive and therapeutic strategies that target the symptoms of insulin resistance may reduce the microvascular and macrovascular sequelae of diabetes and ameliorate the impact of other components of the metabolic syndrome, including hypertension, hyperglycemia, and obesity. In this regard, thiazolidinediones are promising therapies. CONCLUSIONS: Early data suggest that, in addition to reducing hyperglycemia, pioglitazone and rosiglitazone effect changes in the dyslipidemic profile, hemodynamics, vascular inflammation, and endothelial functioning of patients with type 2 diabetes. Additional research is needed to further distinguish the cardiovascular benefits of these drugs. Clin Ther. 2003;25 Suppl B:B4-31 Breakthrough in Diabetes Education for Children dbaza inc. has created a product can help you use your education time more effectively, allowing you to spend your time on the more difficult issues. More Information ================================ Item 10 Cause of Diabetes Affects Response to Treatment Findings have important implications for patient management and selection of treatment. Individuals with maturity-onset diabetes of the young caused by heterozygous mutations in the hepatocyte nuclear factor HNF-1a gene have a greater response to sulphonylurea than do patients with type 2 diabetes according to the findings from a randomised crossover trial. Ewan R. Pearson, MA, of Peninsula Medical School, Exeter, United Kingdom, and colleagues compared the responses to the sulphonylurea gliclazide and the biguanide metformin in 18 patients with HNF-1a diabetes and another 18 patients with type 2 diabetes who were matched for body-mass index (BMI) and fasting plasma glucose. Patients received 500 mg daily metformin for 1 week, increased to 500 mg twice daily for 1 week then to 1 g twice daily for 4 weeks or 40 mg daily gliclazide for 1 week, increased to 40 mg twice daily for 1 week then to 80 mg twice daily for 4 weeks. The groups had a 1-week wash out period before crossing over from one drug regimen to the other. Patients in the type 2 group had diabetes for a mean duration of 4.8 years and were a mean age of 66 years while those in the HNF-1a group had diabetes for a mean duration of 18.3 years and were a mean age of 44 years. The researchers found that patients with HNF-1a diabetes had a 5.2-fold greater response to gliclazide than to metformin. Among this group the fasting plasma glucose reduction was 4.7 mmol/L for gliclazide compared with 0.9 mmol/L for metformin. Conversely, the patients with type 2 diabetes showed no difference in response to gliclazide and metformin. When compared with the type 2 diabetes group, the HNF-1a group had a 3.9-fold greater response to gliclazide while the response to metformin was similar in the 2 groups. Fructosamine assay testing in the patient groups during the last 2 to 3 weeks of taking each drug revealed that fructosamine was 136 micromol/L lower in the HNF-1a group while taking gliclazide compared with metformin. In the type 2 diabetes group the fructosamine was 23 micromol/L higher while on gliclazide compared with metformin. The investigators also noted that the HNF-1a group "had a strong insulin secretory response to intravenous tolbutamide despite a small response to intravenous glucose, and were more insulin sensitive than those with type 2 diabetes." The researchers conclude, "the cause of diabetes affects the response to treatment." They suggest that these findings have important implications for patient management. Lancet 2003;362:1275-81. ================================ "Diabetes in Control 10,000 Step Study 30 Million Steps and 15,000 Miles Later" Because of the Diabetes In Control Study, more than 12000 patients have started the Step Program. Have a program for your office. More Information Then check out www.firststepprogram.com ================================ Item 11 Metformin Treatment Leads to Increased Homocysteine, Decreased Vitamin B12 and Folate in Type 2 Diabetes Patients Metformin treatment leads to an increase in homocysteine levels in patients with type 2 diabetes who take insulin. Adding B6, folic acid and B12 to treatment regimen, might lower homocysteine levels and reduce the risk of CVD. This comes from a recent report from Bethesda General Hospital, Hoogeveen, Netherlands. Homocysteine is a sulphur-containing amino acid that has recently been recognised as an independent potential risk factor for cardiovascular disease in patients with type 2 diabetes. Homocysteine requires folate and vitamin B12 to be properly metabolised, and serum vitamin B12 levels are known to decrease during metformin treatment. However, the effect of metformin on homocysteine levels was unclear based on previous studies. To address this concern, investigators led by M.G. Wulffele performed a placebo-controlled randomised trial to examine the effects of metformin treatment on serum levels of homocysteine, vitamin B12 and folate in type 2 diabetics. The patients (N=390) were randomised to receive either metformin (mean dose, 2163 mg/day) or placebo in addition to insulin for a period of 16 weeks. Among the patients who completed the study (n=353), 171 received metformin (mean age, 63.2 ± 9.8 years; 95 females) and 182 received placebo (mean age, 58.9 ± 11.1 years, 91 females). The researchers found that, compared with placebo, metformin was associated with an increase in serum homocysteine levels (4% [0.2 to 8 µmol L-1]; P=0.039), and decreases in vitamin B12 (-14% [-4.2 to -24 pmol L-1]; P<0.0001) and folate (-7% [-1.4 to -13 nmol L-1]; P=0.024). In addition, they used structural equation modelling to demonstrate that metformin therapy did not affect homocysteine directly. Rather, the increase in homocysteine was an indirect effect mediated by direct effects on folate and vitamin B12. The researchers comment that, "the clinical significance of such an increase [in homocysteine] is not yet clear but may not be negligible." In support of this idea, they note a recent analysis demonstrating that a persistent increase in serum homocysteine of 3 µmol L-1 was associated with an increased risk of coronary heart disease and stroke in nondiabetic individuals. "There is evidence that such risk increases may be greater amongst diabetic individuals," they add. J Intern Med 2003 Nov;254:5:455-463 Did YOU KNOW: Caffeine Shown to Lower Insulin Sensitivity Data from a study in Feb 2002 Diabetes Care showed that caffeine decreases insulin sensitivity by 15% in people without diabetes. But it was noted that exercise helps to reduce caffeine-induced insulin resistance. It was concluded that exercise reduces the detrimental effects of caffeine on insulin action in muscle. ================================ Item 12 Diabetes Can Cause Breast Lumps FINDING A LUMP in your breast can be terrifying and your first thought may be that it is Cancer! Did you know that diabetes could be the cause? s But breast lumps have many causes. One surprising cause that’ little known— even among doctors— is diabetes and it is harmless. Diabetes can cause dense fibrous lumps in the breasts. This condition is called “scierosing lymphocytic lobulitis”or “diabetic mastopathy. It usually occurs in people who have an autoimmune disease (one in which the immune system s attacks the body’ own tissues). The typical person with diabetic mastopathy is a premenopausal woman with type 1 and complications. However; men can get mastopathy, too. So can people wit.h type 2 diabetes and people without any known autoimmune condition. A person with diabetic mastopathy has one or more hard lumps in one or both breasts. The lumps are not tender and tend to be irregularly shaped. t If you find a new lump in your breast, you should see a doctor right away. Don’ assume the lump is diabetic mastopathy, even if you have had diabetic mastopathy before. Cancer can also start as a hard lump. so each new lump requires testing. t The first test would be a mammogram or an ultrasound scan. If your doctor can’ make a diagnosis after that, tissue needs to be examined under the microscope. Sometimes, cells and fluid can be removed from the lump with a fine needle. But it can be difficult to pierce the dense, scarlike tissue of a diabetic mastopathy lump with a needle. So the doctor may need to surgically remove part or all of the lump and examine it in the lab to make a diagnosis. After a lump is removed, it often comes back. The number and size of lumps tends to increase as people get older Diabetic mastopathy lumps are harmless. They do not turn into cancer or increase cancer risk.. However, lumps can be uncomfortable if several occur in one breast. In that case, the lumps may be removed. You should know about diabetic t. mastopathy because many doctors don’ The disease was newly discovered in 1984 and is uncommon. In a case s reported in Diabetes Care in 1998, surgeons removed both of a woman’ breasts because cancer was suspected; the woman turned out to have diabetic mastopathy. If you have type 1 diabetes and develop a breast lump, ask your doctor whether diabetic mastopathy might be the cause. ============================== Item 13 Steps for your Health Latest data show only 15 percent of adults over 18 exercise at least 30 minutes a day, five days a week. In a national survey, the highest percentage of regular walkers was found among men 65 years and older. Experts are s urging more people to take it on. walk everyday for 30 minutes.”That’ right. In addition to eating low-fat meals, you need to pound the pavement. All “ you really need is a good pair of shoes, walking improves balance and strengthens bones and muscles. So, not only are you living longer, but the quality of those years is better. Walking lowers your risk of diabetes, hypertension, high cholesterol, heart attack, osteoarthritis, obesity and stroke. It is recommended you work up to walking 30 minutes a day, five days a week. t Studies have shown that you don’ even have to go it all at once. Get 10 minutes in this morning, 10 minutes in this afternoon and 10 minutes in this evening. So, park far away. And use the stairs. Brisk walking one mile in 15 minutes burns about the same number of calories as jogging an equal distance in eight and a half minutes. Need another reason to walk? A recent study in the Annals of Internal Medicine shows regular exercise among men age 50 to 90 reduced incidence of erectile dysfunction by 30 percent t If you don’ have a program to increase physical activity for your company or practice, then go to www.firststepprogam.com ================================ FACT: Diabetes Masks Signs of Carpal Tunel Syndrome Carpal tunnel syndrome (CTS) might not be detected by standard testing methods in people with diabetes, according to researchers in the US and Canada, who urge doctors to evaluate clinical symptoms In a study published in the March 2002 issue of Diabetes Care. Because electrodiagnostic testing often fails to detect carpal tunnel syndrome in people with diabetes, the researchers recommend that doctors make therapeutic decisions based on symptoms of carpal tunnel syndrome in individuals with diabetes, independent of electrodiagnostic findings. ================================ Item 14 Coca-Cola to Launch Cholesterol-Reducing Orange Juice Launching a cholesterol-reducing orange juice this week. The world's largest soft drink maker will begin rolling out Minute Maid Premium Heart Wise on Monday in the United States. It expects the drink to be widely available throughout the nation by the Thanksgiving holiday in November. The product will contain plant sterols, an additive that has been used in cholesterol-fighting margarine and other food products. Plant sterols have been shown to cut LDL cholesterol levels by about 10 percent when used consistently. Coca-Cola spokesman Ray Crockett said, "People with moderately high cholesterol will find this product will help them reduce their cholesterol significantly." Crockett said the company had conducted a clinical trial to back up the drink's health claims and had obtained approval from the Food and Drug Administration to market the drink. Results of the clinical test will be available next month. Atlanta-based Coca-Cola first revealed its plans to launch Heart Wise in an interview with Beverage Digest. John Sicher, the trade publication's editor, said the drink was on the cutting edge of a new wave of innovative beverages. "This is real innovation in that it provides a true functional benefit," Sicher said. "It uses a beverage as a delivery system for an ingredient that will really help people." Consumers would have to drink two 8-ounce servings of Heart Wise per day to get the suggested daily 2 grams of sterols needed to lower cholesterol, according to Coca-Cola. Each serving contains about 110 calories. ================================ Diagnostic Tests for Home or Office: Total Cholesterol, Cholesterol Panel, TSH (Thyroid Test), PSA, and A1c. More Info: =========================== Item 15 How to Eat More and Still Lose Weight It's the energy density of foods -- not the amount we eat or even the overall fat content -- that most contributes to weight gain. When it comes to dieting, bigger food is better. That may be surprising to dieters who've struggled to cut calories by eating less food This information comes from a study presented at the annual meeting of the North American Association for the Study of Obesity, Penn State researchers studied how eating salad before a meal could affect total calories a diner ends up consuming. A food has a low energy density if it has few calories relative to its weight. An easy way to choose these low-energy- dense foods is to choose "big" foods -- those that are bulked up by fiber and water. Chicken and rice soup, for instance, has a low energy density, with just 0.5 calorie per gram. And it will be just as filling and less fattening as a similar amount of cheese ravioli, which has 3.2 calories per gram. Food labels don't tell you about energy density, so you have to do the math yourself to calculate calories per gram. Foods that have up to 1.5 calories per gram are low energy dense. Foods with 1.5 to four calories per gram are considered medium, while high-energy-dense foods have four or more. It might seem obvious that low-energy-dense foods such as chicken soup are less fattening than the same amount of, say, potatoes au gratin. But there are some surprises. Even a decadent-sounding cream of broccoli soup with cheese has an energy density of just 0.8. But graham crackers, though low in fat, have a high energy density, with 4.2 calories per gram. Here's how to lower the energy density of your diet so you can eat more without increasing your caloric intake: -Switch to soups: Even creamy soups and rich stews have a lower energy density than many foods. -Add bulk: Adding vegetables to pasta or casseroles or more veggies to a salad lowers the energy density. -Beat your food: Smoothies and shakes fill you up longer the longer they are whipped. Substitute: Switch to low-fat dressings, cheeses and cooking oil in recipes And the energy-density idea works with indulgence foods, as well. M&M's are considered a high-energy-dense food, with 4.9 calories per gram. But for about the same calories of a package of M&M's, you could have a slice of chocolate cake with frosting, at just 3.7 calories per gram, or vanilla pudding made with 2% milk, at just one calorie per gram. And you'd be left feeling far more satisfied. The push to focus on the energy density of foods is backed by numerous studies that show hunger tends to be satisfied by a certain volume of food, regardless of the calorie content. In one Pennsylvania State University study, researchers found that healthy women instinctively ate about three pounds of food a day. It didn't matter if the foods were high- calorie or low-calorie -- the women were driven by volume, not calories. Because we are accustomed to a certain volume of food, when we try to cut back on the amount we eat, we feel hungry -- which is the main reason diets fail. All of this runs counter to the notion that people who are overweight are just eating too much food. Often those people are eating normal amounts of food for their size -- they are just choosing energy-dense foods that cause them to continue to gain weight. To really make an impact on weight, people need to consume far more "big" foods like fruits, vegetables, salads and soups. That can include, for instance, adding more vegetables to bulk up casseroles or other dishes to lower the overall energy density of favorite foods. Dieters should pay attention to basic nutrition and eat a balanced diet, but they should also work to ease high-energy-dense foods out of their diets. The problem is that our taste buds don't always like low-energy-dense foods as much as small convenience foods like snack chips and brownies. But new research shows there are ways to use low-energy-dense foods to help curb consumption of more fattening foods, without having to give them up altogether. In the study, diners were allowed to eat as much regular cheese tortellini as they wanted. One group was just given the tortellini, while other groups were told they had to eat a serving of salad first. The salads included both high-calorie and low-calorie dressings and cheeses, and the size varied from a 1½ cup to three cups. Researchers found that when diners pigged out on three cups of salad with low-fat dressing, they ate 107 calories less - - or about 12% fewer calories for the meal than when they didn't eat a first-course salad. The first course had such low energy density that it translated into fewer calories, despite the variety effect. But be warned, the energy density of the salad matters as well. Some diners were given a more energy-dense salad with full- fat dressing and cheese. They ended up eating 145 calories more -- or about 17% more calories for the whole meal -- than those who ate no salad at all. ADA 2003-10-20 Pearls for Practice: " The lesson for dieters is to binge on a healthy salad or other very low-energy- dense foods before a meal. ============================== Quote of the Week! “There is only one success... to be able to spend your life in your own way...” ------- Christopher Morley ============================ Your Friends in Diabetes Care Steve and Dave www.diabetesincontrol.com ================================ Have a question? Diabetes In Control Has Over 4000 Studies & Articles In Our Archives, Which Allows You To Do A Search On Any Topic! Just go to: http://www.diabetesincontrol.com/search.shtml ==================================== Advertisements Product Update: A1cNow is Now Over the Counter-No Prescription Needed! Now less than 10 dollars (for office use), the first and only NGSP A1c test that is instant and disposable. For more info on how you can now use it in your office practice click HERE! 75% of patients with diabetes are not getting the recommended A1c testing. To order or for more information, click here. http://www.a1cnow.net Get Your Copy of the new Book by Richard K. Bernstein, MD: Diabetes Solution “ New and Revised” Special pricing for Diabetes In Control Subscribers, 32% discount. www.diabetes-solution.net ==================================== If your patients are having a problem paying for their medications go to www.diabetesmeds.org and download the application that will allow them to get all of their medications for 10 dollars or less for a 90 day supply. To Enjoy low carb chocolates with no sugar and 1gm of carbohydrate: CLICK TO ENJOY! Diagnostic Tests for Home or Office: Total Cholesterol, Lipid Panel (Total Cholesterol, LDL, HDL & Triglycerides, PSA, Thyroid and A1c. More Info The Diabetes Education Society offers online accredited continuing education programs. Got an hour, take a course. Visit www.MedEdOps.org, take the free sample course and review the Course Catalog. Then update yourself and your staff to meet your Education Recognition requirements. For more information call (800) 659-5808.
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