Diabetes Research - Diabetic Atherosclerosis for Health...

Diabetes Research

Diabetes Research

Diabetic-Lifestyle.
publishers@diabetic-lifestyle.com
september 2002

Diabetic-Lifestyle Health Updates brings the latest in medical treatment and research results on diabetes and its complications. Diabetic-Lifestyle offers recipes, menus, medical updates, entertaining, travel - practical information to enhance life while managing diabetes on a daily basis.

This is the section of www.diabetic-lifestyle.com that shares the newest research and headlines that you need to live the healthiest life possible. Each month we read all of the medical journals and review articles and bring you abstracts on subjects that you, our readers, have told us are of interest. So, if you have a topic we haven't covered for a while, just e-mail and let us know. We certainly will look for you and print them here in this section of our monthly magazine.

Once again, we begin with headlines-a line or two about some news of interest. Our journal articles this month are about hyperglycemic effects on stroke outcomes, the need for diabetic children to be screened for microvascular disease, diabetes and liver disease, silent ischemia and microalbuminuria as predictors of coronary event in diabetes, light drinking and atherosclerosis risk in type 2 diabetes, and finally low health literacy and glycemic control.
First let's look at those headlines.

FYI--We have presented information here on the incidence of eating disorders and diabetes in adolescents with diabetes. This month we noted that there are now Internet sites to help adolescents who are anorexic or bulimic. Diabetes Care 25:1289-1296, 2002 examined eating disorders in an article titled Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes, by Dianne Neumark-Sztainer, PhD et al. It's an important read if you have concerns about your child.

Diabetes 2002;2148-2153 reports in an article titled Long-term glycemic control can be achieved with islet transplantation by Edmond A. Ryan, MD et al the results of 53 islet transplantation procedures in 30 patients. Of 15 with at least one year of follow-up, 12 were insulin independent. The number has subsequently dropped to 9. Of the 6 patients who were post-transplant, 4 remain off insulin. There were some therapy-related complications noted including hypercholesterolemia in two/thirds of the patients and increased protein levels in 4 who already had proteinuria. In addition antihypertensive therapy was started or increased in more than half of the patients and 3 required retinal laser photocoagulation. Given these findings, the authors concluded that islet transplantation is a reasonable option for those with severe problems with glycemic lability or hypoglycemia.

Each month we have an article about exercise because we know the value of including it in your regime. This morning's newspaper (Aug.1,2002) had an article from the Associated Press written by Stephanie Nano which abstracted an article from the New England Journal of Medicine about a study which corroborates what many doctors have known for some time and that is being even modestly overweight increases the chances of developing heart failure. The study based on 5,881 men and women showed that heart failure is double in obese people and 34 percent higher in those who are overweight compared to those of normal weight. Diabetes Care 2002; 25:1123-1128 has an article which fits in well with this information. Orlistat, a useful adjunct to metformin in overweight diabetics, by Dr. John Miles et al at Mayo Clinic found that "Orlistat produced significant decreases in body weight, hemoglobin A1c, total and LDL cholesterol, and systolic blood pressure compared to placebo. One last headline on the same subject of overweight comes from Diabetes Care 2002;25:1142-1148. It is titled Obesity, weight gain before diagnosis of diabetes ups risk of CHD, by Dr. Eunyoung Cho et all at Harvard. The information and data were gleamed from the Nurses' Health Study. They found 418 cases of coronary heart disease during follow-up. After adjusting for age, smoking and other confounding variables, current BMI was significantly associated with increased risk of CHD among diabetic women.

Let's look at this month's journal articles. The Annals of Neurology (Ann Neurol 2002;52:20-18) has an article by Dr. Steven M. Davis et al from the Royal Melbourne Hospital, Australia about Acute hyperglycemia influences stroke outcomes. The group investigated the link between blood glucose levels and stroke outcomes in 63 acute stroke patients. A subset of 33 patients underwent magnetic resonance spectroscopy, and the relationship between blood glucose levels and lactate production in the ischemic region was evaluated. Based on MRI findings, 40 patients had hypoperfused at-risk tissue and 23 patients did not. Acute hyperglycemia was associated with reduced tissue salvage, greater final infarct size, and worse functional outcomes, but only in patients with hypoperfused at-risk tissue. Furthermore, in these patients higher glucose levels were associated with greater lactate production and smaller tissue salvage. The researchers conclude that "Elevated blood glucose levels are associated with an increased progression of hypoperfused at-risk tissue progressing to infarction and poor stroke outcome." They suggest that further studies are needed to determine if aggressive blood glucose control can improve the outcomes of acute stroke.

The Archives of Disease in Childhood 2002;87:10-12 has an article by Dr. David B. Dunger et al from Addenbrooke's Hospital in Cambridge, UK, about Diabetic children should be screened annually for early microvascular disease. The group noted that this screening should start around the age of 10 years in children with type 1 diabetes and it should include retinal funduscopy, monitoring of arterial blood pressure, and measurement of urinary albumin excretion. The reason for these screening programs is so that appropriate interventions could be given to the patients at the highest risk. They explained that the influence of puberty on the risk for microvascular disease has led to the recommendation of screening at such a young age. "Microalbuminuria (MA) is not rare and may progress within the first 5 years after diagnosis of type 1 diabetes mellitus in pubertal subjects". They add that it is unclear whether transient MA during puberty may also result from an increased genetic risk for future complications. While patients with transient MA may be protected during puberty by lower HbA1c levels, they still have an increased genetic risk of future nephropathy. Dr. Dunger and his colleagues write that 20% of these patients may develop persistent microalbuminuria within 3 years.

Gastroenterology 2002; 122:1822-1828 has an article written by dr. El-Serag of the Dept. of Veterans Affairs Medical Center and Dr. James Everhart from the National Institute of Diabetes and Digestive and Kidney Disease, about Diabetes increases the risk of acute liver failure. The two doctors identified all the patients in the VA database who were discharged with a diagnosis of diabetes from 1985 to 1990. They compared these patients to a randomly selected cohort of nondiabetic patients. The final study cohort included 173,643 diabetic patients and 650,620 nondiabetic patients who were followed through 2000. Among diabetic patients, the cumulative risk of acute liver failure was significantly higher compared with nondiabetic patients (incidence rate 2.31 per 10,000 person years verses 1.44 per 10,000 person years). Analysis that controlled for comorbidity, age, sex, ethnicity, and period of military service found that diabetes was associated with a relative risk of 1.44 for developing acute liver failure. The association remained after excluding patients who developed viral hepatitis during follow-up and those with acute liver failure after troglitazone was introduced. The authors advise "periodic monitoring of liver enzymes and caution in the use of potentially hepatoxic drugs may be warranted in patients with diabetes."

The Journal of the American College of Cardiology 2002;40:56-61 has an article on Silent ischema and microalbuminuria may predict coronary events in diabetes by Dr. Martin K. Rutter form the Lahey Clinic in Mass. Coronary heart disease is the number one cause of death in patients with type 2 diabetes. In this population, heart disease often presents without warning as myocardial infarction, heart failure, or even sudden death. Therefore, to allow therapeutic intervention, tests are needed that that can predict which patients are at increased risk for coronary events. The authors looked at the predictive value in asymptomatic type 2 patients of SMI and MA in 86 patients with type 2 diabetes and no history of coronary heart disease. The group included 43 patients with MA individually matched to 43 patients without MA. The patients were followed for nearly 3 years. Treadmill testing at baseline revealed that 45 patients had SMI. During the study period, 15 patients experienced a total of 23 coronary events. SMI was the most sensitive predictors of events, the researchers found. Still, combining SMI and MA results allowed the researchers to identify patients at particularly high and low risk for coronary events. The findings suggest that "SMI, MA and ankle brachial index could be of practical value in risk stratification. Future studies should aim to determine risk thresholds for initial anti-ischemia therapy and for CHD screening to identify those who are likely to benefit from revascularization".

We receive many e-mails about alcohol safety and diabetes. Light drinking may curb atherosclerotic risk in type 2 diabetes in Diabetes Care 2002;25:1223-1228 by Dr. Ichrico Wakabayashi et al of Yamagata University may help answer some of these questions. The investigators evaluated the consumption on aortic pulse wave velocity "which reflects aortic stiffness and is increased with atherosclerotic progression" They also looked at established atherosclerotic risk factors in the subjects. The 194 participants had a mean age of 63.4 years of age and already had some degree of atherosclerosis. Their data supported the hypothesis that the general concept that light-to-moderate drinking prevents atherosclerosis can also be applied to diabetic subjects. The mechanisms responsible for the preventive effects of drinking alcohol on atherosclerotic progression in diabetes remain uncertain, according to the team. From the current study, it does appear that changes in serum HDL cholesterol and plasma fibrinogen are involved. For example, there were no significant differences in systolic blood pressure, HDL cholesterol and triglycerides among nondrinkers and light drinkers, although these levels were significantly higher in heavy drinkers. There were also no significant between-group differences in mean BMI, uric acid, and fibrinogen levels. The authors also say that the lack of between-group differences in HbA1c levels supports prior research indicating that habitual drinking does not affect glucose tolerance in diabetics.

Our final call to action is a journal (JAMA 2002; 288: 475-482) article by Dr. Dean Schillinger et al at the University of California at San Francisco about Low health literacy linked to poor glycemic control in type 2 diabetics. Dr. Schillinger reports that 20% of patients with adequate health literacy had poor glycemic control and 30% of those with inadequate health literacy had poor glycemic control. Of those with adequate health literacy, 33% exhibited tight glycemic control, while 20% of those with inadequate health literacy had tight glycemic control. Retinopathy was reported by 36% of patients with low health literacy and by 19% of patients with adequate health literacy. The authors write that 'the prevalence of poor health literacy, and the strength and consistency of the association between health literacy and diabetes outcomes that we observed should serve as a call to action" for health professionals. Dr. Schillinger and team stress the need for more research on office-based strategies to improve communication. There also needs to be a "deeper understanding of the needs and competencies of patients of patients with poor health literacy." He feels that this population may have alternative health beliefs, and healthcare providers need to "draw out those beliefs and creatively incorporate them...into educational efforts."


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