Discord or ACCORD? New Findings about Optimal Treatment for Type 2 Diabetes
March 18, 2010
Right after daylight savings time returned, new light was shed on the best ways to treat type 2 diabetes and its complications. The ACCORD (Action to Control Cardiovascular Risk in Diabetes) study and its various findings have shaken up the diabetes treatment world—at least a bit. The three papers relating to ACCORD that were published March 14, 2010 in the New England Journal of Medicine online at www.nejm.com are:
Here's a rundown of the content of each journal article from the ACCORD study, and what it means to you and your doctor as you work to establish your most effective and beneficial treatment regimen.
Combination Lipid Therapy: The goal was to determine the effectiveness of a combination therapy using a statin (in this case, simvastatin) and a fibrate (in this case fenofibrate, which is the generic name for medications designed to lower triglycerides) to reduce cardiovascular events such as stroke and heart attack, as compared to taking a statin alone.
More than 5,500 people participated and after almost 5 years, the researchers found that while there is a possible benefit for people who have a high triglyceride level and a low level of "good" HDL cholesterol, overall, "the combination of fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal stroke, as compared with simvastatin alone. These results do not support the routine use of combination therapy with fenofibrate and simvastatin to reduce cardiovascular risk in the majority of high-risk patients with type 2 diabetes."
If you are on a combination therapy, do not stop taking your medications until you discuss the potential benefits and the added risks of the treatment for your particular needs and goals.
Intensive Blood-Pressure Control: The goal of this part of the ACCORD study was to determine if people with high blood pressure who lowered it to a systolic pressure of 120 mm Hg had fewer nonfatal heart attacks, nonfatal strokes or fatal cardiovascular events than people who lowered their systolic blood pressure to 140 mm Hg. (Systolic blood pressure is the pressure exerted on the vascular system when the heart contracts; it is the top number in a blood pressure reading such as 120 over 90).
A total of 4,733 participants were followed for a little less than 5 years. Researchers found that lowering blood pressure to normal levels (that is 120)—below currently recommended level of less than 130 for people with diabetes—"did not significantly reduce the combined risk of fatal or nonfatal cardiovascular disease events in adults with type 2 diabetes who were at especially high risk for cardiovascular disease events." And as significant, the scientists found that among the group using intensive therapy to lower their blood pressure to 120, "serious adverse events that were attributed to blood-pressure medication were more frequent."
Risk-Factor Control: The ACCORD study is now over, and while its initial findings are significant, over time researchers will tease out more and more information from the data. Combined with the knowledge from two other large sale studies it can reshape our knowledge of how to best treat type 2 diabetes.
The bottom line, researchers propose, is the ACCORD shows that doctor and patients should establish flexible goals for controlling diabetes that take into account each persons individual health issues and strengths. They also addressed the confusion around the earlier-released ACCORD findings that indicated that aggressive treatment to lower A1Cs to 6% might increase fatal events. "A previous study by the ACCORD investigators," they wrote, "concluded that a strategy of intensified glycemic control was associated with an increased risk of death. However, a recent meta-analysis did not confirm such an increase in risk, and the role of intensified glycemic control has been a subject of debate. In this issue of the Journal, the joint publication of the ACCORD blood pressure trial (and the ACCORD lipid trial although not resolving this issue, makes the picture of diabetes management more complete."
That means it has never been more important to talk with your doctor about your treatment plan and to take the time to fully understand the medications you take and how they work.
Coffee and Diabetes: What Is the Connection?
March 9, 2010
To unravel the sometimes-confusing information that researchers have found on drinking coffee, tea and decaf, here's a look at some recent studies and what they may mean for your health.
Coffee: The Pros
Sharper Focus and Heart Health: You may think that coffee's benefits are limited to waking you up and sharpening your focus—at least that's what several studies have shown. But new research out of Germany, published in the American Journal of Clinical Nutrition, has found that caffeine intake can significantly improve your levels of HDL "good" cholesterol and improve the ratio of HDL to LDL "bad" cholesterol, both significant ways to improve cardiovascular health and reduce the possibility of heart disease or heart attacks—the number one killers of people with diabetes. (What they looked for and did not find was any indication that drinking coffee is helpful for controlling blood glucose levels.) The study, incidentally, was paid for by a consortium of European coffee companies.
Another study of more than 130,000 men and women conducted by Kaiser Permanente and presented at the American Heart Association's Conference on Cardiovascular Disease Epidemiology and Prevention, March 2, 2010, found that people who drank four or more cups of coffee a day had an 18% lower risk of being hospitalized for heart rhythm problems (arrhythmia) and those drinking one to three cups a day cut their risk by 7%. Lead author, Arthur Klatsky, M.D., senior consultant in cardiology at the Kaiser Permanente Medical Care Program said, "These data should be reassuring to people who drink moderate amounts of coffee that their habit is not likely to cause a rhythm disturbance." And, he pointed out, while the study does not mean that people should drink coffee to prevent rhythm problems, "it does support the idea that people who are at risk for rhythm problems or who have rhythm problems do not need to abstain from coffee."
Preventing Diabetes: Other research shows that coffee can significantly reduce the chance that you will develop diabetes, if you do not yet have prediabetes. The European Prospective Investigation into Cancer and Nutrition, which looked at more than 60,000 French women for more than a decade and was also published in the American Journal of Clinical Nutrition, found that drinking coffee with lunch correlated strongly with reducing the incidence of type 2 diabetes in study participants. This is on the heels of a University of Sydney report published in the Archives of Internal Medicine in December 2009 that found tea, coffee, and decaf coffee all reduced the risk of diabetes. In that study, each additional cup of coffee that a person drank reduced the risk of developing diabetes by 7%; and if you take in three to four cups a day, then the risk is slashed by an astounding 25%. Decaf coffee also proved even more beneficial: Three to four cups a day reduce the risk by 33%. For tea, drinking three to four cups a day reduced risk of type 2 diabetes by 20%.
Coffee: The Cons
Spiking Blood Sugar Levels: Among those with type 2 diabetes, a small study from Duke University from 2008, indicated that caffeine may cause blood sugar to spike a couple of hours after it is consumed. On days the study participants were given caffeine pills (250 mg, or the equivalent of about 2½ cups of regular coffee; decaf has less than 6 mg of caffeine per cup) their blood glucose levels went up 8% higher than on days when they had no caffeine. And after every meal their blood sugar spiked higher than it did on the days they had no caffeine. The lead researcher James D. Lane, Ph.D., described the results as clinically significant, and said caffeine seemed to raise glucose levels by as much as oral medications lowered it.
So what to do? It is confusing: For those without diabetes, coffee may prevent the development of the disease, and for those with diabetes, coffee may make it harder to control. But various researchers have speculated that it is not the caffeine that makes coffee protective for diabetes, but it is the substance that promotes insulin resistance. That's why decaf is more protective against diabetes than regular coffee and why researchers feel pretty sure that other substances in the coffee, yet to be identified, are what are healthful in various ways.
Are My Oral Type 2 Diabetes Medications Heart-Safe?
March 9, 2010
After a two year inquiry into the safety of the type 2 diabetes drug rosiglitazone to determine if it increased the risk of heart problems, the U.S. Senate Finance Committee issued their findings highlighting potential health risks. The report was developed over the last two years by committee investigators who reviewed more than 250,000 pages of documents provided by the drug's manufacturer, the FDA, and several research institutes. The report can be found at www.finance.senate.gov.
But what does that mean for you, the person dutifully taking what your doctor prescribes, and facing potential risks?
The American Heart Association issued the following guidelines after the Senate Committee's report.
- Consult with your physicians on any matters concerning risk factors you may have for heart disease and stroke, such as diabetes.
- In managing your diabetes, "focus on glycemic (blood sugar) control keeping your HbA1c levels below 7.0 to reduce the risk of the 'microvascular' complications of diabetes, such as kidney failure, painful nerve problems, and decreased vision or even blindness."
- The AHA states that any diabetes management program should be founded on a healthy diet and physical activity as well as healthful control of blood pressure and cholesterol and triglycerides. The AHA also adds: "An aspirin regimen should be used under the advice of a physician in patients who have known cardiovascular disease due to atherosclerosis."
- They then recommend that the type 2 oral medication metformin should "generally be the first choice, particularly in obese patients." Other medications should be used if a person cannot get their A1Cs down to satisfactory levels.
- They go on to add that, "if a thiazolidinediones (TZD), such as pioglitazone or rosiglitazone, is prescribed, it should not be used with an expectation of benefit in reducing the occurrence of heart attack or stroke, and the rationale for the choice of a TZD should be discussed with your physician. However, patients who have successfully achieved recommended HbA1c control on a TZD might consider remaining on their medication. If the treating physician and/or the patient are uncomfortable with using a TZD, another medication could be substituted. There is currently not enough data to support the choice of a specific TZD."
Type 2 Diabetes Drug Alert
February 24, 2010
A safety review notice was issued by the Food and Drug Administration (FDA) on February 23 about rosiglitazone, a drug used in several popular oral diabetes medications—Avandia®, Avandamet®, and Avandaryl®—to increase the body's sensitivity to insulin. But it has been suspected of triggering potentially fatal cardiovascular problems for several years. In 2007, Steve E. Nissen, M.D., chairman of the department of cardiovascular medicine at the Cleveland Clinic published a New England Journal of Medicine study that concluded "rosiglitazone was associated with a significant increase in the risk of myocardial infarction [heart attack]… patients and providers should consider the potential for serious adverse cardiovascular effects of treatment with rosiglitazone for type 2 diabetes." And the same year, the Food in Drug Administration issued a safety alert about a possible association between rosiglitazone and increased heart-related risk.
What was known then, according to the National Library of Medicine, was that the drug "may cause fluid retention that may lead to or worsen congestive heart failure (condition in which the heart is unable to pump enough blood to the other parts of the body)." They advise, in their Medline Plus online article, that "before you start to take rosiglitazone, tell your doctor if you have or have ever had congestive heart failure, especially if your heart failure is so severe that you must limit your activity and are only comfortable when you are at rest or you must remain in a chair or bed. Also tell your doctor if you were born with a heart defect, and if you have or have ever had swelling of the arms, hands, feet, ankles, or lower legs; heart disease, high blood pressure; coronary artery disease (narrowing of the blood vessels that lead to the heart); a heart attack; an irregular heartbeat; or high cholesterol or fats in the blood. Your doctor may tell you not to take rosiglitazone or may monitor you carefully during your treatment."
"If you develop congestive heart failure or other heart problems, you may experience certain symptoms. Tell your doctor immediately if you have any of the following symptoms, especially when you first start taking rosiglitazone or after your dose is increased: large weight gain in a short period of time; shortness of breath; swelling of the arms, hands, feet, ankles, or lower legs; swelling or pain in the stomach; waking up short of breath during the night; the need to sleep with extra pillows in order to breathe while lying down; frequent dry cough; or increased tiredness."
Now that the FDA has issued another notice of a safety review, people are feeling increased concern about taking rosiglitazone. This is what is current as of the last week of February 2010: The drug has not been pulled off the shelves. The FDA is currently reviewing scientific information that they received in August of 2009 from RECORD, a large, long-term study on the possible heart-attack related risks of rosiglitazone. The review will be completed in July of this year.
The FDA's current advice for anyone taking the drug is:
- Don't stop taking your medication without talking with your health care professional.
- Discuss any questions or concerns you have about rosiglitazone with your health care professional.
- Read the Medication Guide that comes with each rosiglitazone prescription to better understand the risks and benefits of your medication.
- Report any side effects with rosiglitazone to FDA's MedWatch program either online, by regular mail, by fax, or by phone.
- fda.gov/Safety/MedWatch/
- Regular Mail: Use postage-paid, pre-addressed FDA form 3500
- Fax: 1.800.FDA.0178
- Phone: 1.800.332.1088
Against the Grain
February 24, 2010
We have all been told that whole wheat is good for us—in fact, it is touted as the best choice when it comes to bread. Its high fiber content helps control blood sugar levels and is good for the digestive system, not to mention that it contains minerals and vitamins lost when grains are refined. But new research indicates that white rye flour, made from the inner, white part of the rye kernel, leads to better insulin and blood sugar levels compared to regular wheat flour and rye bran.
According to says Liza Rosén, a doctoral candidate in Applied Nutrition and Food Chemistry at Sweden's Lund University Faculty of Engineering who led the study, people who ate a breakfast of boiled rye kernels ate 16 percent fewer calories for lunch than those who ate breakfast bread made from white flour. "Since rye has been shown to yield low insulin responses, I started [my research] with that," says Rosén. "A high insulin response can lead to insulin resistance so that the body has a hard time responding to insulin. Insulin resistance can result in high blood sugar, high blood pressure, and bad blood fats, which in turn increase the risk of age-related diabetes and cardiovascular diseases."
Wheat prompts a higher insulin response than rye, Rosén says, because "rye contains more soluble fibers than wheat [and] they probably prevent the uptake of fat and other nutritional substances in the intestine."
Depression and Diabetes
February 12, 2010
If you suffer from type 2 diabetes and major depression, you are at seriously increased risk for life-threatening health problems. That's the conclusions of Washington state researchers in this month's issue of the journal Diabetes Care. Looking at more than 4,600 people, they found that those who had diabetes but were not depressed fared far better than those who suffered from both diabetes and depression. For that group, the danger of kidney failure and retinopathy leading to blindness increased 36% and the risk of a heart attack climbed 25%.
Why is diabetes and depression such a dangerous combination? It is true that diabetes patients with major depression tend to:
- be slightly younger and heavier,
- have more co-existing medical conditions,
- be more likely to be treated with insulin, and
- are more often women and more often smokers.
Even more significantly, people who have type 2 diabetes and are depressed also tend to have higher levels of a certain substance in the blood that is formed when blood sugar molecules attach to hemoglobin, an oxygen-carrying protein the red blood cells.
However, after taking these differences between depressed and non-depressed people with type 2 diabetes into account, the folks who suffer from depression are still at increased risk of kidney failure and heart attacks.
These findings come on the heels of a 2008 University of Washington study that found that among older people with diabetes who were on Medicare, depression was associated with a higher death rate from all causes during a two-year study period. Writing in the Journal of General Internal Medicine, lead author Wayne Katon, M.D., professor of psychiatry and behavioral sciences, noted that previous research indicates that depression and diabetes is a potentially lethal mix among young to middle-aged patients. Depression also puts patients at greater risk of complications from their diabetes.
The researchers found that people with both diabetes and depression had an increased risk of about 36% to 38% of dying from any cause during their two-year follow-up of all participants. A total of 12.1% of study participants who had both diabetes and depression died during that period. Among those without depression, 10.4% died.
One interesting change between this study group and those in the more recent survey: There was no difference in the rate of cardiovascular or cerebrovascular events (such as heart attack or stroke) between those people treated with antidepressants and those who had no indication of depression.
"Rates of mortality from vascular disease may be decreasing in recent years among patients with diabetes due to more aggressive treatment of high blood pressure, cholesterol, and glucose levels," the researchers surmised, "as well as widespread use of preventative medications such as aspirin and beta blockers."
Osteoporosis and Diabetes: Another One-Two Punch
February 12, 2010
Women with type 2 diabetes should talk to their doctor about their increased risk for bone fractures and osteoporosis—if they also take the much-prescribed oral diabetes medications known as TZDs (thiazolidinediones). TZDs include:
These drugs decrease insulin resistance and increase cells' insulin sensitivity. TZDs also cut down on the amount of glucose made by the liver in patients with type 2 diabetes.
A recent study published in The Journal of Clinical Endocrinology & Metabolism revealed the association between TZDs and bone loss: Women older than 65 were shown to have a 70% increased risk for developing fractures and younger women had a 50% increase in the risk.
The researchers from Detroit's Center for Health Services Research and Department of Internal Medicine at Henry Ford Hospital did not observe this association for men, "despite having nearly equal numbers of men and women in our study," says study co-author Zeina A. Habib, M.D.
To determine the relationship between TZD use and fracture risk in people with type 2 diabetes, the researchers followed 9,620 women and 9,450 men for seven years.
During the study period, 4,511 patients had at least one prescription fill for a TZD. The increased risk of bone fracture in women appeared after approximately one year of TZD use.
The bone breaks appeared in unusual locations: Typically, osteoporosis-related fractures involve the vertebra and hip. This study, however, found TZD use in women to be associated with fractures of the neck, thigh, leg and foot.
"Fractures are just one of a growing number of problems associated with these medications. Henry Ford and other researchers have previously found that this class of medications also can increase risk of congestive heart failure hospitalization," says study senior author L. Keoki Williams, M.D., MPH, who is affiliated with the Center for Health Services Research and Department of Internal Medicine at Henry Ford Hospital.
Dr. Williams notes that there are other medication options available to treat insulin resistance in patients with type 2 diabetes. "TZDs may put some patients at increased risk for other health issues, and I encourage patients to talk with their physician about other suitable options," says Dr. Williams. "If the physician feels the patient should be placed on a TZD, routine screening for bone loss and prophylactic therapy to prevent bone loss and fractures may also be needed."
On the Road—with Diabetes
January 27, 2010
Traveling with diabetes requires preplanning and careful management of medications and supplies—plus extra attention to your blood sugar levels, which can be affected by stress, changing sleep patterns, and erratic eating schedules. But there is no reason why an adult or child with type 1 or type 2 diabetes cannot enjoy a trip to grandma's, or around the world.
To help you get through the airport, adjust medication schedules, and feel your best, here are some tips.
Airport Security: Running the Gauntlet
- If you are going to be passing through airport security, obtain a signed letter from your doctor indicating that you have diabetes and that you need to carry insulin, syringes, pumps and/or lancets.
- All medication must have the original labels with the name on it that matches the passenger's ticket.
- You need a written prescription from your doctor for each item that you are transporting. You will have to obtain extra ones from your physician, since you will have surrendered the original to the pharmacist to have the prescription filled. You will also need prescriptions for continuous glucose monitors, standard glucose monitors, insulin pumps, glucagons shots, syringes, etc.
- Have syringes and vials of insulin in their original packaging and with a prescription. Even if you use an insulin pump, be sure to bring back-up insulin and syringes. Advise screeners that pumps cannot be removed because they are attached to a catheter under your skin. Manufacturers say that screening technologies do not harm the pump; but many people prefer visual inspections—be aware that it will increase your time in screening.
- Know what is and isn't allowed by TSA (Transportation Safety Administration) guidelines: Prescription medicine with a name that matches the passenger's ticket, up to 8 oz. of liquid (insulin) or low blood sugar treatment gel, and up to 4 oz. of non-prescription liquid medications are permitted. If you need to bring more than the allowed amount for carry-on, pack them in your checked luggage. Checked baggage may be subjected to cold temperatures, so be sure to carefully insulate any insulin bottles. Inspect the insulin after you arrive for crystallization or cloudiness. If you suspect that the insulin may be spoiled, discard the bottle and do not use it.
Adjusting Your Medication Schedule
- Before you head out for a car trip or an excursion by air, talk with your doctor about how travel may affect your diabetes management. Traveling can change your eating routine, your medication schedule, and your sleep patterns—all of which can raise or lower your blood sugar levels to an unhealthy point.
- Zoning out: Ask your doctor how changes in time zones may affect your medication schedule. On oral medications: With most pills, you gradually can change the time you take them. But if medications must be taken at a specific time—say, before meals—you have to adjust your schedule to the new clocks. On insulin: If you are on long-acting and short-acting insulin, test frequently and take short-acting insulin before every meal, whatever the time. Test and adjust insulin doses if your blood sugar is fluctuating.
- Pump it up: If you are on an insulin pump, you must work with the doctor to adjust the dosing schedule to suit your glucose control needs and the time zone. For short trips you may be able to stay with your routine, but much depends on your eating and sleeping patterns and how dramatically they change.
- Meal time: As you pass through time zones, or are shuttled around in airports without time to eat, you need to keep careful tables on your blood sugar levels and have plenty of emergency snacks and glucagon available. You also have to schedule time to get food in airports between flights: if that means you need to take longer to get to your destination, so be it.
A 2007 study in the journal Paediatric Child Health found that "insulin dosing may need to be adjusted if time zones are crossed during flight. When traveling east, the day is shortened and, if it is shortened by more than 2 hours, it may be necessary to decrease the amount of intermediate- or long-acting insulin [you take]. Conversely, if [traveling west and] the day is lengthened by more than 2 hours, more units of insulin may be needed." Once the flight is over, you then have to calculate a new pattern of medicating yourself so you don't overdose or underdose. Check blood sugar levels frequently.
High Blood Pressure & Diabetes: A Dangerous Duo
January 27, 2010
High blood pressure is a problem affecting up to 66% of adults with diabetes. But, unfortunately, hypertension rarely has symptoms. That's why the American Diabetes Association recommends that you have your blood pressure checked at the doctor's office two to four times a year. If your blood pressure is even slightly elevated, you increase your risk of eye, kidney and heart problems.
People with diabetes should aim for blood pressure readings of 130/80 or less. The first number is called systolic pressure and signifies the pressure as your heart pushes blood through the blood vessels. The second number, diastolic pressure, signifies the pressure when the vessels relax between heartbeats.
How Can You Control your Blood Pressure?
Medications and lifestyle changes can have a powerful effect on elevated blood pressure and reduce your risk of serious complications such as heart attack and stroke. Lifestyle remedies include modifying your diet, exercising more, quitting smoking, losing weight, reducing stress, and drinking alcohol moderately.
The wise food choices you can make are:
- Eat one or two servings of vegetables at lunch and at dinner. Eat fruit (take into account how it affects your glucose levels and pick the higher fiber, lower sugar fruits, such as blackberries, when possible).
- Switch to low-fat or fat-free dairy products (such as low-fat cheese and skim milk).
- Eat whole-grain breads (such as whole-wheat bread) and cereals.
- Choose lean meats and meat substitutes in place of red meat and prepared or sandwich meats.
- Bake, broil, roast or grill meats; steam vegetables. Avoid all fried foods.
- Add little or no salt to your food. Use spices and herbs for flavoring in place of fat. Avoid packaged foods with a high sodium content.
Exercise alternatives:
- Talk with your doctor about the kinds of physical activity that will be safe and good for you. Then aim for at least 30 minutes a day most days of the week. Walking is a great healthy routine as are cycling, yoga, and swimming.
Reduce your alcohol intake:
- Your blood pressure doesn’t appreciate your drinking! But if you do drink alcohol, limit yourself to one drink a day for women and two a day for men.
Quit smoking:
- Think heart. Elevated blood pressure puts a strain on it; smoking clogs up the blood vessels. The combination is lethal. Do we need to say more? Talk with your health care team about methods that can help.
Several types of blood pressure medications are available. Below the main ones recommended for people with diabetes. Other medications, such as thiazide diuretics, which may elevate blood sugar levels, and beta blockers, which can mask the symptoms of hypoglycemia, are not recommended for people with diabetes.
- ACE (angiotensin-converting enzyme) inhibitors are recommended for people with diabetes and high blood pressure because they seem to lower the pressure and protect against kidney disease and other diabetes-blood vessel-associated complications.
- ARBs (angiotensin II receptor blockers) also keep the blood vessels open and relaxed to help lower blood pressure. Like ACE inhibitors, ARBs protect your kidneys.
- Diuretics: so called "water pills," help rid your body of extra water and sodium through urine, which decreases blood volume and lowers pressure in the blood vessels.
Type 2 Diabetes Control Tricks and Tips
January 13, 2010
After 18 weeks of sticking with a low-glycemic diet—that is, substituting carbohydrates that digest slowly and have less of an effect on blood sugar for those that spike blood sugar—people with type 2 diabetes can see a significant improvement in their health and diabetes control.
That is what Ohio State researchers reported in the journal Public Health Nutrition. After 9 weeks of intervention, people with diabetes type 2 who were taught about the advantages of low-glycemic foods lost an average of about 5.1 pounds, decreased their waist circumference by 1.1 inches, reduced their body mass index (BMI; a ratio of weight to height) by almost a point, and lowered their after-meal blood glucose levels by 18 points.
What are the low-glycemic foods? Foods that slow the speed of digestion and prevent rapid increases in blood sugar, such as many vegetables, whole grains, dairy foods, nuts and seeds, beans and fruits, are called low-glycemic foods. On the glycemic-index, which ranks the relative impact of various carbohydrates on blood sugar, low-glycemic foods have a rating of 55 or less. Foods with a point value of 100 are the equivalent of pure glucose (sugar).
According to the American Diabetes Association, the following foods are "superfoods" that have a low-glycemic index and provide key nutrients that many of us do not get enough of through our food.
- Beans—They're very high in fiber and are good sources of magnesium and potassium. Although they are starchy, a 1⁄2 cup provides as much protein as an ounce of meat without the saturated fat.
- Dark green leafy vegetables—These greens, such as spinach, collards, and kale, are so low in calories and carbohydrates, you can't eat too much.
- Citrus fruits—Think of grapefruit, oranges, lemons and limes for soluble fiber and vitamin C.
- Sweet potatoes—These are a lower GI alternative to white potatoes and are packed with vitamin A and fiber.
- Pearled barley and oatmeal—They offer a high fiber breakfast with a low GI index and contain potassium.
- Nuts—An ounce of nuts can go a long way to supplying you with healthy fats. Other benefits are a dose of magnesium and fiber. Some nuts and seeds, such as walnuts and flax seeds, also contain omega-3 fatty acids.
Here's look at the glycemic index of some common foods:
Breads
- White bread 70
- Wholemeal bread 69
- Pumpernickel 41
- Dark rye 76
- Sourdough 57
- Heavy mixed grain 30–45
Legumes
- Lentils 28
- Soybeans 18
- Baked beans (canned) 48
Breakfast cereals
- Cornflakes 84
- Cheerios 83
- Puffed Wheat 80
- All Bran 42
- Porridge 46
Adding Insulin to the Mix
January 13, 2010
People with type 2 diabetes have traditionally taken oral medications such as metformin and sulfonylureas when lifestyle adjustments are not sufficient to control elevated glucose levels. Insulin has been considered the therapy of last resort; in fact, research shows that, on average, insulin isn't prescribed until 10 or 15 years after a person is initially diagnosed with type 2 diabetes. Sadly, that is often after complications, such as kidney or nerve damage, have developed and it is too late to institute strict glucose control that can reduce the risk of such health problems.
But now there is research to show that adding insulin to the oral medication regimen can improve glucose control and help reduce weight gain. And doing it sooner rather than later may be the best therapy. (A third of those with diabetes type 2 will eventually end up on insulin anyway as their body's cells become less and less responsive to insulin and the pancreas loses its ability to pump out sufficient supplies of the blood-sugar controlling hormone.)
A study in the New England Journal of Medicine examined 708 people with elevated glucose levels while taking while taking metformin and sulfonylurea therapy. Over the course of 3 years the participants were divided into three groups and given biphasic insulin aspart [a mixture of intermediate- and fast-acting insulin] twice daily, prandial insulin aspart [short acting insulin at meal times] three times daily, or basal insulin detemir [long acting] once daily (twice if required).
Basal insulin, which gives a well-controlled base line over a length of time, provided the best results. Participants on that type of insulin gained less weight and experienced fewer low blood sugar alarms than the others. The best blood sugar control, as measured by A1Cs, was achieved by those on the basal insulin and the prandial, mealtime, dosing.
Other studies have shown the same positive results from adding insulin to the type 2 diabetes management program. The United Kingdom Prospective Diabetes Study produced data that showed that 50% of those who took insulin plus a sulfonylurea had a desirable median HbA1c level of 6.7% after 6 years.
Nonetheless, many people are reluctant to begin taking insulin. They may feel the change represents failure or that it will make their diabetes worsen. These and other obstacles—such as the fear of hypoglycemia, weight gain, or pain caused by the needles—are surmountable.
According to Joseph Tibaldi, M.D., author of a 2008 study in the Americal Journal of Medicine that looks at initiating and intensifying insulin therapy in type 2 diabetes, "with modern treatment options, insulin therapy need no longer be feared by patients with type 2 diabetes or their carers. Many common concerns in this respect are unfounded, and today's insulin regimens are generally simple, effective, and well tolerated."The Coffee Cure?
December 15, 2009
Researchers at The George Institute for International Health in Sydney, Australia, may have found a way to stop or at least slow down the diabetes epidemic: Take a coffee or tea break, and do it often.
They looked at the findings from 18 studies, including 457,922 people, on the relationship between coffee and tea drinking and the diagnosis of type 2 diabetes. According to study author and public health expert Rachel Huxley, "In those individuals drinking more three to four cups a day, there was a 25 percent reduction in the risk of diabetes. And in those drinking six cups a day, there was a 40 percent reduction in risk day—compared to non-coffee drinkers."
Similar reductions in risk were observed for tea and decaffeinated beverages. "This," says Huxley, "suggests that any diabetes-sparing effect is not driven primarily through caffeine, as was previously thought."
For decaf, the same amount of brew slashed the risk by 33%; and tea drinkers saw a 20% reduction. Huxley and her colleagues think that compounds in coffee and tea—including magnesium and antioxidants known as lignans or chlorogenic acids—may be what may be at work to prevent type 2 diabetes.
In the study, the scientist explained that "the implications for the millions of individuals who have diabetes, or who are at future risk of developing it, [c]ould be substantial." They imagine a time when people who have the greatest risk for diabetes may be advised to "increase their consumption of tea and coffee in addition to increasing their levels of physical activity and weight loss."
Arthritis Drug May Slow Onset of Type 1 Diabetes
December 15, 2009
A monoclonal antibody called rituximab that is used to treat both rheumatoid arthritis and non-Hodgkin's lymphoma, may help people newly diagnosed with type 1 diabetes preserve their body's ability to produce insulin.
How does this biologic drug work? Well, when the body starts killing off healthy insulin-producing beta cells in the pancreas, it is immune system cells that wage the war. So-called T cells do the dirty work, but B cells are thought to urge them on. Rituximab directly attacks and destroys B cells. When there are fewer B cells, there are fewer triggers of the marauding T cells and more insulin-producing beta cells stay alive.
Philip Raskin, M.D., an author of the study published in the New England Journal of Medicine, explains, "Our findings in no way suggest that rituximab should be used as a treatment or that it will eliminate the need for daily insulin injections. [But] the results provide evidence that B cells play a significant role in type 1 diabetes and that selective suppression of these B cells may deter the destruction of the body's beta cells."
The study followed 81 people, ages eight to forty, who had been diagnosed with type 1 diabetes within the previous 100 days. In a randomized double-blind environment, they were given either infusions of rituximab or a placebo once a week for 4 weeks. The participants were then tracked for 2 years. After the first year, the people who had received the biologic drug needed to inject less insulin and had better blood sugar control than those who had been on the placebo. The next step, Dr. Raskin says, is to evaluate the potential effects of rituximab in diabetes.
Taking Control of Risk Factors for Diabetes and Heart Disease
December 2, 2009
You can control your risk for developing full-blown diabetes and improve your heart health without drugs, but it takes discipline.
The Diabetes Prevention Program (DPP) followed more than 3,200 people who were all overweight and had blood sugar levels higher than normal, but not high enough for a diagnosis of diabetes—a condition called prediabetes. The DPP revealed that participants who lost a modest amount of weight by eating a low-fat diet and increasing physical activity to at least 150 minutes of moderate exercise a week reduced their chances of developing diabetes by 58%. Taking metformin was less effective; it reduced the risk by 31%.
Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71%. About 5% of the lifestyle intervention group developed diabetes each year during the study period, compared with 11% of those in the placebo group. About 7.8% of the metformin group developed diabetes each year.
Further analysis of the data generated by the study revealed that the intensive lifestyle regimen can also sharply reduce the systemic inflammation associated with diabetes and obesity and may reduce the risk of heart disease.
According to Steve Haffner, M.D., M. PH., the chair of the DPP, and colleagues, the DPP was able to evaluate the effect of lifestyle changes and the oral diabetes drug metformin on moderate inflammation (as indicated by blood levels of a substance called C-reactive protein [CRP]) and on blood coagulation (as indicated by fibrogen levels). CRP and fibrogen levels are known indicators of cardiovascular disease.
Writing in the journal Diabetes, the DPP researchers stated that in men, metformin reduced CRP by 7% and lifestyle intervention reduced it by 33%. The placebo group saw in increase in CRP levels of 5%. Women taking metformin saw CRP levels fall 14%, while the lifestyle group cut them by 29%. There was no change in the placebo group.
"In conclusion," the study authors said, "intensive lifestyle intervention reduced levels of nontraditional cardiovascular risk factors [CRP and fibrogen] both relative to placebo and to a lesser degree relative to metformin. These significant reductions were achieved despite a relatively modest weight loss of around 6 to 7% over the first year with most participants still being obese at the end of the first year."
"The DPP study suggests that not only does intensive lifestyle intervention reduce the risk of developing type 2 diabetes, but it also has effects on markers that may eventually reduce the risk of cardiovascular disease."
Risks of Pre-Gestational Diabetes
December 2, 2009
Just as there is prediabetes, a condition in which blood sugar levels are elevated, but not enough to be diagnosed as diabetes, there is gestational glucose intolerance, a kind of pre-gestational diabetes. This is a condition in which blood sugar levels rise during pregnancy, but are not (yet) high enough to be diagnosed as gestational diabetes.
Researchers have found that pre-gestational diabetes poses serious health risks to the mother. According to a new study in The Endocrine Society’s Journal of Clinical Endocrinology & Metabolism, many women with the condition develop metabolic syndrome as soon as three months after giving birth.
Metabolic syndrome often leads to type 2 diabetes and heart disease. It is characterized a specific group of risk factors, such as having excess fat deposited around the waist, high triglyceride levels, high blood pressure, and high fasting blood glucose levels.
To control pre-gestational diabetes, work closely with your physician to determine the best nutritional and exercise plan for you and your baby.
Help your baby dodge the health issues your higher glucose levels create for a newborn such as problems breathing, excess body fat, low glucose levels right after birth, and an increased risk of developing type 2 diabetes later in life. (Your child's risk for type 2 diabetes may be lower if you breastfeed your baby and if your child maintains a healthy weight.)
Step to take include:
- Losing 5 to 7% of your body weight to sharply reduce the risk of developing type 2. Then reach and maintain your ideal weight.
- Becoming physically active for 30 minutes most days. Walk, swim, exercise, or go dancing.
- Following a healthy eating plan. Eat more grains, fruits, and vegetables. Cut down on fat and calories.
New Monotherapy Approved for Type 2 Diabetes
November 18, 2009
A study, published in Clinical Therapeutics, has demonstrated that a non-insulin, injectable drug therapy for type 2 diabetes, exenatide (Byetta), is an effective way for some patients to control their glucose levels and their weight. That's what led the Food and Drug Administration (FDA) to approve its use as a monotherapy, when lifestyle adjustments alone are not enough to avoid the ups and downs of type 2 diabetes.
Study participants treated with 5 mcg or 10 mcg of exenatide reduced their A1C by 0.7 percentage points and 0.9 percentage points, respectively. For every 1 percent reduction in A1C levels, there is a 10 percent reduction in risk of diabetic complications.
There are some potential negative side effects from the drug, however. Most common is nausea, affecting 3 percent of those taking a dose of 5mcg and 13 percent of those taking 10 mcg. More serious, but rarer side effects are kidney-related problems and acute pancreatitis. Talk to your doctor about these potential risks and the benefits.
Smile: Diabetes and Dental Health
November 18, 2009
Because gum disease, also called periodontal disease, can make it more difficult to control blood glucose levels and may raise the overall levels of inflammation in the body—already inflamed by high glucose levels and perhaps excess body fat—it is essential that everyone with diabetes take extra care of their teeth and gums. Inflammation is implicated in heart disease (the number one killer of folks with diabetes) and a whole roster of diabetes-related complications.
To help people with diabetes and their healthcare providers, the new International Diabetes Federation (IDF) guidelines encourage doctors, dentists and diabetes-care professionals to regularly ask their patients if they have symptoms of periodontal disease, such as swollen or red gums or bleeding during tooth brushing. The IDF also wants to encourage people with diabetes to learn about the risks of poor dental health and take steps to improve their dental hygiene—by scheduling regular cleanings, practicing twice daily brushing and flossing and establishing good control of blood glucose levels.
When It's Time to Add Insulin
November 7, 2009
If you have type 2 diabetes and find that oral medications and lifestyle adjustments are not doing enough to keep your blood sugar levels in line, you are a candidate for insulin injections. But how should you use insulin to obtain optimal blood sugar levels?
A three-year, randomized, controlled study (the highest quality type) of 708 people with type 2 diabetes compared the results of adding a once-a-day, basal insulin injection, three-a-day insulin injections—one at each mealtime, or insulin injections twice a day. The people who added insulin through once-a-day (basal) insulin injections and those who then added injections at mealtimes showed better control of their blood sugar levels than people who took insulin injections twice a day. Those who took basal insulin injections once a day also had fewer low blood sugar (hypoglycemic) episodes and gained less weight.
Jonathan Levy, lead clinician at the Oxford (UK) Centre for Diabetes, Endocrinology and Metabolism and co-principal investigator for the study explains: "Starting with a basal insulin and adding a mealtime insulin if required provided the best combination of effectiveness, safety and treatment satisfaction."
Does Your House Make You Fat?
November 7, 2009
A new study published in the Annals of Behavioral Medicine found that the number of TVs in a household, the presence or absence of exercise equipment in the home, and the amount of food that's left out on the kitchen counter have a huge influence on a person's weight management.
Researchers from California Polytechnic State University examined the health records of more than 167 people across the country who had managed to lose 10 percent—or more—of their body weight and keep it off for five years. They also looked at two groups who were overweight or obese but dieted frequently. The results surprised the researchers: "The home environment really came out as a stronger factor than we would have anticipated," said lead study author, professor Suzanne Phelan. "You have to pay attention to your home environment if you want to succeed. Do you have TVs in every room? When you walk into your kitchen, do you see high-fat food or healthy food?"
So what's the take-away for those looking to stick with more exercise, better food choices and a less sedentary lifestyle? The researchers concluded: Keep healthy things right at hand. If you want to choose better foods, keep better foods within reach. If you want to be more active, create opportunities for exercise in various rooms in the house. Lasting weight control, they advise, is about skill power, not just willpower.
Antioxidant Supplements: More Harm Than Good?
October 30, 2009
We've been told over and over again that we don't get enough antioxidants in our diet to fight the good fight against aging and cancer. That's why many of us take antioxidant supplements, such as beta carotene and vitamins E, A, and C. But we may be upsetting an important balance in the body that allows naturally occurring free radical (oxidized) molecules to do good as well as harm. That's the conclusion of a recent study published in the October issue of Cell Metabolism. The scientists found that antioxidants, commonly promoted as health-enhancing, may in fact speed up the early onset of type 2 diabetes by blocking free radical molecules' ability to enhance insulin action.
The problem is that while there is evidence that antioxidants in fruits and vegetables can protect us from cancer, cardiovascular disease, and type 2 diabetes, there is also scientific evidence that the targets of the antioxidants—oxidized free radical molecules or reactive oxygen species (ROS)—provide essential health benefits. In biology, it turns out, it is all about balance. And when we dose ourselves with antioxidant pills we upset the balance in ways we don't even know.
There are studies that suggest taking antioxidants may shorten lifespan. And recent research has found that taking antioxidant supplements while exercising may counteract the longer-term benefits of physical activity. "In a way," says the study's lead researcher Tony Tiganis, "we think there is a delicate balance and that too much of a good thing—surprise, surprise—might be bad."
So stick with the guidelines for 7 servings of fruits and vegetables a day—and you will let the ROS in the body promote insulin action and help protect yourself from premature aging and various diseases.
Diabetes May Affect a Woman's Heartbeat
October 30, 2009
Diabetes affects more than 23 million Americans and, according to a recent seven-year study of more than 17,000 people with the disease, nearly 4 percent, or 1 million, also have atrial fibrillation (AF)—an irregular heartbeat that can lead to stroke, heart attack, and chronic fatigue.
Women with diabetes are at a particularly increased risk of developing AF—something that was not fully appreciated until the study, published in Diabetes Care, found the connection. Sumeet Chugh, M.D., coauthor of the study and associate director of the Cedars-Sinai Heart Institute in Los Angeles says, "AF is the most common arrhythmia in the world, and diabetes is one of the most common and costly health conditions. Our study points out that there is a connection between these two epidemics—one we should pay closer attention to, especially among women. The gender differences need to be looked at more closely because they could have significant implications for how we treat diabetes in men and women."
At the start of the study, which also included around 17,000 people without diabetes as a control group, 3.6 percent of the patients with diabetes had AF while 2.5 percent of the non-diabetic patients had the condition—a difference of 44 percent. During the study period, people with diabetes were more likely than people without diabetes to develop AF. But the increased risk was only significant among women.
Diabetes and Diet's Secret Vice
October 7, 2009
Eating disorders and what is called disordered eating, which includes overeating and skipping meals, are a huge problem for people with type 1 diabetes and people with type 2 diabetes. Unfortunately, many people don't recognize that they have a distorted relationship to food. That's why it is so important to find out the signs and symptoms of eating disorders, such as anorexia nervosa, bulimia nervosa, and disordered eating and what you can do to adopt a healthy eating style.
Eating disorders are more common among people with type 1 diabetes than among those who have type 2 diabetes. On the other hand, people with diabetes type 2 are more apt to have disordered eating patterns, and may purge, binge, practice food restriction or use other ineffective methods to control or lose weight. These disordered eating habits are less severe than full-blown eating disorders but they still have profound impact on weight and overall health.
Unfortunately it is very difficult to get proper diagnosis and treatment for unhealthy eating habits unless you are frank with your health care providers. Writing in Diabetes Spectrum, researchers, Raquel Franzini Pereira, M.S., R.D., and Marle Alvarenga, M.S., Ph.D., point out that, "when behaviors such as eating in the car, eating with guilt, skipping meals, eating to cope with stress or emotional distress, binge eating, and frequent and strict dieting are not only socially accepted behaviors, but also tend to be considered common and therefore normal among people, including educators, they may not be perceived as deserving proper clinical attention." But they do. As do other behaviors including obsessive weighing, excessive calorie counting and over-exercising.
Type 1 Diabetes: The bottom line, say Franzizzi and Alvarenga, is that 27 percent of adolescents with type 1 diabetes binge and purge and 24 percent restrict their diets to try to lose weight. The results are devastating: there is a 15.7-fold increase in mortality of females with diabetes and anorexia when compared with females with diabetes alone. Another tactic: Skipping insulin doses or reducing the amount of insulin taken in order to lose weight may be common among somewhere between 15 and 37 percent of women and 34 percent of adolescents with type 1 diabetes. And this leads to lack of blood sugar control and eventually to serious complications—kidney disease, heart disease and nerve disease, eye problems, depression and more.
Type 2 Diabetes: Among people with type 2 diabetes, the study suggests that disordered eating or eating disorders often come before the diabetes diagnosis and may have a part in causing the obesity that usually proceeds diagnosis—some estimates say eating disorders may contribute to as many as 90 percent of cases of type 2 diabetes.
Treatment and Help
Eating disorders and disordered eating habits can cause serious health problems for people with diabetes and require astute medical intervention (particularly in the case of eating disorders), psychological support, and a health care team who can help reshape the patient's view of him- or herself and his or her relationship to food. (Although eating disorders affect women more often than men, adolescent and adult males also need to be aware of the part that these problems can play in that handling—or mishandling—of their diabetes.) If you think that you have a troubled relationship to food, talk to your diabetes educator, your primary care physician, a trusted teacher or friend…someone who can lend support and help you take steps to start a process of change. Healthy eating will help you will gain better control of your diabetes, and can help you avoid many health complications down the road.
The Hearty Heart
October 7, 2009
A new study has validated a simple and inexpensive way to reduce the risk of heart attack, stroke, and heart disease for people with diabetes. Many lives were saved by a program that bundled two generic, low-cost drugs—a cholesterol-lowering statin (lovastatin) and a blood pressure-lowering drug (lisinopril)—and gave daily doses to 68,560 people with diabetes or heart disease for two years. It is estimated that the protocol prevented 1,271 heart attacks and strokes in the first year following the study period, according to a paper published online in The American Journal of Managed Care.
Although previous research showed that statins and blood pressure medications separately can reduce the incidence of heart attacks and strokes, this study was the first to show that delivering this combination to a large group of people with diabetes and heart disease could save lives and reduce health care costs. The study results? The duo of drugs reduced the number of heart attacks and strokes among the many participants by an astounding 60 percent.
"Heart disease is the number one killer in the United States, and 23 million Americans have diabetes," says the study's lead author, R. James Dudl, M.D., the diabetes clinical lead at Kaiser Permanente’s Care Management Institute. "This is a proven program that can be applied in many settings to reduce heart attacks and strokes, and at the same time decrease the cost of care for those events."
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Original Date of Publication: 07 Oct 2009
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