Monday, 30 November 2009
Size and Related Costs for the U.S.
In an article published in Diabetes Care, December 2009 Issue, the authors, none of whom are clinicians but number crunchers..concluded:
Between 2009 and 2034, the number of people with diagnosed and undiagnosed
diabetes will increase from 23.7 million to 44.1 million. The obesity distribution in the
population without diabetes will remain stable over time with 65% of individuals of the
population being overweight or obese.
Two things are very clear from these conclusions: eventhough the authors may not think it politically correct to mention it.
1. the current strategies of prevention and treatment have FAILED. not only the care of diabetes any better in preventing complications, the current group of professionals are not very good at preventing Diabetes.
2. as it has been shown year after year, no strategy is proven successful to turn around the rising tide of overweight and obesity. The current strategies most of them are thought at ivory towers of the universities and implemented at grass roots level, are not working. Some of the strategies born at the grass root levels are working, such as the Mo Po Tsyo in Phnom Penh in Cambodia.
But we are repeatedely bombarded with newer and more powerful medications for Type 2 DM.. if you are in the field long enough you would know that much of the newer mediations dont work as people had hoped for.
What is missing is the input from the people affected, whether they are individuals or communities and listening to them. Prescribing medications to people who cannot afford them, talking nutrition to patients who have no access to good food is at the bottom of a big pyramid of barriers.
Instead of telling patients or even ordering them: you should do it.. perhaps we might ask them, what can you do ?
if diabetes and obesity is increasing at this rate, despite all the money poured into its prevention and treatment, the situation may seem hopeless so perhaps a change in the personnel involved or the type of personnel involved need to be changed. Perhaps to scrutinize the roles of the professionals a little bit more, especially those licenced to practice and prescribe without much understanding of the society and environment and give power to people who are suffering from this disease, to communities affected globally and left powerless to do any thing about it..
I will never forget a meeting at a remote corner of south Dakota in the USA at an Indian Reservation, at a community meeting to tackle Diabetes, the epidemiologists and other beauracrats of the Indian Health Service were astounded to hear the elders expressing their solution to this Diabetes Epidemic:
Give us all jobs and you will see how quickly Diabetes is taken care of..
Someone ought to listen to the wisdom of the Elderly Lakotas!
Thursday, 19 November 2009
It was so touching for me to see this patient
A 35 year old mother of four, the oldest being 15 and the youngest being 5, living with her brother and sister, separated from her spouse.
Two months ago she had come for a physical examination, and that time was found to have very high blood sugars. On 30th September 2009, A1C was found to be 12.7.
She was begun on 70/30 insulin twice daily.
More importantly the Diabetes team had entered into discussion with her regarding her eating and other life habits.
The two immediate actions she took were stopping completely the drinking of Pop and secondly toe decrease frying of her food.
I saw her today November 19, 2009 at the clinic.
Her fasting Blood sugar was 120 and HgA1c was 9.2 %. A reduction of average blood sugar of more than 100 mg/dl.
What does take someone like her to do this, in this short period of time, in seven weeks time. ?
Let us dissect it using the Indian Paradigm.. Medical/Social/Spiritual resolution of this problem.
Indians who become Diabetic (almost always Type 2) at a younger age, I strongly believe, has a defect in the metabolism whereas those persons, Indians and non Indians alike who become diabetic (type 2) at a later age, which is much more physiologic. After taking into consideration of any precipitating factor such as excessive use of Alcohol, the treatment should be directed towards the aetiology in this group of people.
The cultural relevance here is that, most of our patients who become diabetic at this age, are overweight with truncal obesity, and could trace their glucose dysfunction to many years, with Gestational Diabetes or Acanthosis Nigricans. As such they have built a history of Insulin Resistance.
Clinical experience show that they respond much less to oral agents than to Insulin. No need for fancy insulin analogues, but like in this lady 70/30 for the ease of use, and then the providers can further tailor the dosge or medication.
She was not given the choice and insisted on going on Insulin as the first method of treatment.
The social aspect: she is unemployed, has four children, aged 15 to five years of age, lives with her brother and sister. Subsists on Unemployment compensation and Food Stamp Programme. He husband had left her and provides no financial support. She recognized the need to be healthy so that she can look after her children, she listened to the advice of the Diabetes Team and made two changes: to avoid frying of the food and secondly not to drink Pop.
The diabetes team patiently and sympathetically listens to her regarding her problems, whether or not they are medical or medically related to her condition. Encourages her efforts through her difficult financial situation. This is the time I feel immensely grateful to the Indian Health Service where a patient with Diabetes can obtain, without any cost, visits to the Health Care Provider, Optometrist, Podiatrist, Pharmacist among others.
And patients like her, pays us the dividend, by looking after themselves.
One important way of thinking among the Indians that is different is: they respond to shown care and not being told that others care for them. One Meskwakia patient told me, if you don’t care for me, why should I care for myself? An entirely different world view…
Our collective care of this patient has paid off, her feeling better and being better is also good for her tribe and her family and her people.
I would like to talk to her more, and learn about her circumstances and how she is achieving life style changes and habits.. and the motivation behind them.
Sunday, 8 November 2009
Usually I like to put on this blog much more medically oriented articles, but re reading this i had written some time earlier, I wanted to put it here as well. My other blog is www.medicoanthropologist.blogspot.com
The Culture of Poverty
Today, I am in the richest country. (By their own reckoning and calculations.) But I am amidst a very disadvantaged part of that population. This is not Japan... you would know why if you are to read the just published book,
The Spirit Level: Why More Equal Societies Almost Do Better by Richard Wilkinson and Kate Pickett. Allen Lane, 297 pages. In a review, it was written: Within the rich world, where destitution is rare, countries where incomes are more evenly distributed have longer lived citizens and lower rates of obesity, delinquency, depression and teenage pregnancy than richer countries where wealth is more concentrated.
So I am in a rich country, with a distribution of wealth similar to many Latin American countries, but without much destitution...Poverty yes, but not destitution, the kind one would see in SlumDog Millionaire!
I met a 35 year old from the Culture of Poverty today.
What is Culture of Poverty? Anthropologists would immediately recognize this sociological moniker of Oscar Lewis.
The culture of poverty concept is a social theory explaining the cycle of poverty. Based on the concept that the poor have a unique value system, the culture of poverty theory suggests the poor remain in poverty because of their adaptations to the burdens of poverty. (From Wikipedia)
The culture of Poverty is not just about MONEY and income but as many thinkers have pointed out, it is about values which are upheld by the society and also by individuals in that society. Those of us who are travelers would agree with my Meskwaki teacher, who told me... We may be poor, but we have our culture; we don’t mind poverty, we can deal with it, but it is misery that we don’t like. Recent excellent literature in English from India, (Vikas Swarup: Six Suspects; Arvind Adiga: The White Tiger) mould the characters with the motto: it is not just about poverty but Suffering…
Let me tell you about this representative of the culture of poverty. He had a nonchalant way of talking, the friendly way of talking of his people. He is 35 years old. He was happy to see me, having come to get some medications from the Pharmacy. He has not taken any medications (which he receives free of charge) since he left the job because he did not like the rules and regulations and the control the supervisor had over his work habits. (He was the janitor at a Clinic). He had been to the Casino, and had won some money, 1500 USD and has been in a splurging mood, and he and his wife has been out drinking each night and also visiting popular all you can eat restaurants in the vicinity. He looked at his watch and said, can’t wait to leave to go back to the city for some drinks and food.
The nurse opens the door and slips me the result of his blood sugar, it was over 525 mg/dl, a level at which any “normal” person would be suffering enough to be admitted to a hospital. Are you OK, yes, I feel fine…
He then began ranting and raving about his wife’s 18 year old son, who has dropped out of school, and thus depriving himself of a chance to learn a skill, ability to exercise his body by playing football...Now, I am told, he stays in bed during the day, at night gallivants around, with other in his age group..
Where is his father? I asked. His father lives nearby with his new wife and a daughter who is 16 years old. This boy used to live with them, but the father had kicked him out of his house after the boy made the girl (who is the daughter of the wife of his father) pregnant and before he turned 18, he was already a father. Now with no education, no skills, depending upon his mother for his daily expenses, this young boy stare into a future of darkness.
When I was his age, I was working, I was responsible, did the chores around the house, my new friend continued. This kid does not lift a finger, sleeps most of the day, does not prepare food for himself, throws something into the microwave oven and waits for his mother to prepare him something to eat in the evening and give him some money to go out and have fun with his friends.
My friend, to whom I had just administered 10 units of Insulin to bring his high blood sugar down, said... Soon after my sixteenth birthday, my girlfriend who was 16 at that time gave birth to my daughter... I worked hard and always provided for the girl who is now 19...
Words of a soldier of the culture of poverty, who at 35 is already a grandfather (his stepson has a one year old daughter!)...Unemployed and very soon unemployable, with no great skill to offer the society, and his health failing. (Even though he has type 2 Diabetes which affects adults, he has had this diabetes since he was 19 years old and is already beginning to show signs of complications such as early blindness!)…he has already created directly or indirectly another generation to carry on this legacy of poverty... Money, Job will not carry him out of the hole he has dug in the society, the very same society which discriminated against him and he is paying it back by becoming a burden and creating another generation of burden... and he will have the greatest revenge… by dying early... to hit this competitive society where the material production is most valued, he dies and deprives the society of its investment on him, whatever little it was. He will not pay them back and even in his death, he will continue to demand payments for those he had created…
I felt immensely sad. A life without hope. A darkness. And this in the richest country, he has become the measurement of the crimes the society has committed: dropping out of school, teenage pregnancy, alcoholism, early death.
“Society prepares the crime, wrote Adolphe Quetelet, a Belgian statistician, in 1835, and the guilty person is only the instrument.”
So I present to you, the instrument of the Culture of Poverty.
Saturday, 7 November 2009
STORY HIGHLIGHTS (published on November 4th at 5 pm)
· People with type 2 diabetes taking drug Byetta may be at risk for kidney problems
· Byetta was linked to higher risk of acute pancreatitis, which is potentially life-threatening
· Kidney symptoms can include changes in urine color, swelling in feet and legs, fatigue, nausea
People with type 2 diabetes who are taking the blood-sugar-lowering drug Byetta may be at increased risk for kidney problems, including kidney failure, the U.S. Food and Drug Administration reported this week.
The drug's label will be updated to warn doctors and patients about this possible side effect.
Byetta (exenatide) is a relatively new drug and was approved to treat type 2 diabetes in 2005. It's known as an incretin mimetic and is a synthetic version of a compound found in the venom of a Gila monster, a lizard in the southwestern United States.
Doctors wrote almost 7 million Byetta prescriptions between 2005 and 2008. The drug is injected, and patients and doctors tend to like it because it's easier to inject than insulin and can promote weight loss in some people.
When Exenatide (Byetta) came out, there was a rush to prescribe it among the Family Practitioners (the effect of Drug Reps?), as you can see nearly 2 million prescriptions per year! How many of us know the cost of Byetta for one month?
CVS Pharmacy: $226.99
Kroger (supermarket) pharmacy: $163.95
Publix (supermarket) pharmacy: $196.96
In the clinics for the Indians where I work, I have not started a single patient on Byetta. There is just one patient under my care who was prescribed Byetta by someone else and he is fighting the workers compensation board regarding some injury so I have not changed his medications.
I am very reluctant to jump into the bandwagon about prescribing new medications since in my field of Endocrinology, new medications come and very quickly are shown to have serious side effects and we always fall back on the time and proven medications. Glyburide/Metformin/Non Modified Insulins were the only medications on the market few years ago and the major increase in expenses for Diabetes Care in America is due to the increase in the price of newer medications. The newer insulins are three to four times as expensive as the older ones. I would like to hear how much improvement in “numbers” these newer insulins have made on a community wide basis..
It is well accepted that the kidney metabolism of American Indians along with many other indigenous peoples of the world is very delicate and very prone to damage. So it is another reason not to prescribe Exanetide to Indian patients..
Wednesday, 4 November 2009
Indians are hyperinsulinaemic, have greater hyperinsulinaemic responses to food and keep their blood sugars in constant range even while they are becoming obese. So it is not uncommon to see, obese Indians with hyperinsulinemia and absolutely normal blood sugars.
Palm oil makes this condition worse by increasing hyperinsulinaemia, and keep the blood glucose levels in the normal range, while increasing obesity in the average person (laboratory studies)
We are looking for a reason why a group of people who were all thin, have all become overweight. There has to be something in their metabolism that didn’t agree with the environmental changes that made them all overweight. The finger points to ingredients in the food( palm oil, high fructose corn syrup, hydrogenation of fat etc) rather than the composition of food ( Carbs/fat/protein).
When my Meskwakia teacer said to me, it is the free food that the govt gave us that brought us sickness, I didn’t understand what she meant. Now many years later, as majority of the Americans are also fed fabricated and false foods and becoming obese and diabetic, I hear the prophetic voice of my Indian teacher..
These thoughts occurred to me while I was reading the following:
High-fat diet-induced hyperglycemia and obesity in mice: differential effects of dietary oils.
Ikemoto S, Takahashi M, Tsunoda N, Maruyama K, Itakura H, Ezaki O.
Division of Clinical Nutrition, National Institute of Health and Nutrition, Tokyo, Japan.
These data indicate that (1) fasting blood insulin levels vary among fat subtypes, and a higher fasting blood insulin level in palm oil-fed mice may explain their better glycemic control irrespective of their marked obesity; (2) a favorable glucose response induced by fish oil feeding may be mediated by a decrease of body weight; and (3) obesity and a higher intake of linoleic acid are independent risk factors for dysregulation of glucose tolerance.
Tuesday, 3 November 2009
Aspirin 'only for heart patients'
The use of aspirin to ward off heart attacks and strokes in those who do not have obvious cardiovascular disease should be abandoned, researchers say.
The Drugs and Therapeutics Bulletin (DTB) study says aspirin can cause serious internal bleeding and does not prevent cardiovascular disease deaths.
It says doctors should review all patients currently taking the drug for prevention of heart disease.
The Royal College of GPs says it supports the DTB's recommendations.
Low-dose aspirin is widely used to prevent further episodes of cardiovascular disease in people who have already had problems such as a heart attack or stroke.
This approach - known as secondary prevention - is well-established and has confirmed benefits.
But many thousands of people in the UK are believed to be taking aspirin as a protective measure before they have any heart symptoms.
Between 2005 and 2008, the DTB said four sets of guidelines were published recommending aspirin for the "primary prevention" of cardiovascular disease - in patients who had shown no sign of the disease.
These included people aged 50 and older with type 2 diabetes and those with high blood pressure.
But the DTB said a recent analysis of six controlled trials involving a total of 95,000 patients published in the journal the Lancet does not back up the routine use of aspirin in these patients because of the risk of serious gastrointestinal bleeds and the negligible impact it has on curbing death rates.
Dr Ike Ikeanacho, editor of the DTB, said: "Current evidence for primary prevention suggests the benefits and harms of aspirin in this setting may be more finely balanced than previously thought, even in individuals estimated to be at high risk of experiencing cardiovascular events, including those with diabetes or elevated blood pressure."
Professor Steve Field, chairman of the Royal College of General Practitioners, said the DTB was an excellent source of independent advice for medical professionals.
He said: "Given the evidence, the DTB's statement on aspirin prescription is a sensible one.
"The Royal College of General Practitioners would support their call for existing guidelines on aspirin prescription to be amended, and for a review of patients currently taking aspirin for prevention."
June Davison, senior cardiac nurse at the British Heart Foundation said: "It is well established that aspirin can help prevent heart attacks and strokes among people with heart and circulatory disease - so this group of people should continue to take aspirin as prescribed by their doctor.
"However, for those who do not have heart and circulatory disease the risk of serious bleeding outweighs the potential preventative benefits of taking aspirin.
"We advise people not to take aspirin daily, unless they check with their doctor.
"The best way to reduce your risk of developing this disease is to avoid smoking, eat a diet low in saturated fat and rich in fruit and vegetables and take regular physical activity."
Monday, 2 November 2009
Pesticides and PCBs in Blood Stream Correlate with Incidence of DiabetesA study conducted among members of New York State's Mohawk tribe found that the odds of being diagnosed with diabetes in this population was almost 4 times higher in members who had high concentrations of PCBs in their blood serum. It was even higher for those with high concentrations of pesticides in their blood.
Diabetes in Relation to Serum Levels of Polychlorinated Biphenyls and Chlorinated Pesticides in Adult Native Americans Neculai Codru, Maria J. Schymura,Serban Negoita,Robert Rej,and David O. Carpenter.Environ Health Perspect. 2007 October; 115(10): 1442-1447.Published online 2007 July 17. doi: 10.1289/ehp.10315.
It is very important to note that there is no reason to believe this phenomenon is limited to people of Native American heritage. Upstate NY has a well-known and very serious PCB problem--remember Love Canal? And the entire population of the U.S. has been overexposed to powerful pesticides for a generation.
More evidence that obesity may be caused by exposure to toxic pollutants which damage genes comes in a study published January of 2009. This study tracked the exposure of a group of pregnant Belgian woman to several common pollutants: hexachlorobenzene, dichlorodiphenyldichloroethylene (DDE) , dioxin-like compounds, and polychlorinated biphenyls (PCBs). It found a correlation between exposure to PCBs and DDE and obesity by age 3, especially in children of mothers who smoked.
Intrauterine Exposure to Environmental Pollutants and Body Mass Index during the First 3 Years of LifeStijn L. Verhulst et al., Environmental Health Perspectives. Volume 117, Number 1, January 2009
These studies, which garnered no press attention at all, probably have more to tell us about the reason for the so-called "diabetes epidemic" than any other published over the last decade.
Use of Herbicide Atrazine Maps to Obesity, Causes Insulin ResistanceA study published in April of 2009 mentions that "There is an apparent overlap between areas in the USA where the herbicide, atrazine (ATZ), is heavily used and obesity-prevalence maps of people with a BMI over 30."
It found that when rats were given low doses of this pesticide in thier water, "Chronic administration of ATZ decreased basal metabolic rate, and increased body weight, intra-abdominal fat and insulin resistance without changing food intake or physical activity level." In short the animals got fat even without changing their food intake. When the animals were fed a high fat, high carb diet, the weight gain was even greater.
Insulin resistance was increased too, which if it happens in people, means that people who have genetically-caused borderline capacity to secrete insulin are more likely to become diabetic when they are exposed to this chemical via food or their drinking water.
Chronic Exposure to the Herbicide, Atrazine, Causes Mitochondrial Dysfunction and Insulin ResistancePLoS ONE Published 13 Apr 2009
Trace Amounts of Arsenic in Urine Correlate with Dramatic Rise in DiabetesA study published in JAMA in August of 2008 found of 788 adults who had participated in the 2003-2004 National Health and Nutrition Examination Survey (NHANES) found those who had the most arsenic in their urine, were nearly four times more likely to have diabetes than those who had the least amount.
The study is reported here:
Arsenic Exposure and Prevalence of Type 2 Diabetes in US Adults. Ana Navas-Acien et al. JAMA. 2008;300(7):814-822.
The New York Times report about this study (no longer online) added this illuminating bit of information to the story:
Arsenic can get into drinking water naturally when minerals dissolve. It is also an industrial pollutant from coal burning and copper smelting. Utilities use filtration systems to get it out of drinking water.
Seafood also contains nontoxic organic arsenic. The researchers adjusted their analysis for signs of seafood intake and found that people with Type 2 Diabetes had 26 percent higher inorganic arsenic levels than people without Type 2 Diabetes.
How arsenic could contribute to diabetes is unknown, but prior studies have found impaired insulin secretion in pancreas cells treated with an arsenic compound.
Prescription Drugs, Especially SSRI Antidepressants Cause Obesity and Possibly DiabetesAnother important environmental factor is this: Type 2 Diabetes can be caused by some commonly prescribed drugs. Beta blockers and atypical antipsychotics like Zyprexa have been shown to cause diabetes in people who would not otherwise get it. This is discussed here.
There is some research that suggests that SSRI antidepressants may also promote diabetes. It is well known that antidepressants cause weight gain.
Spin doctors in the employ of the drug companies who sell these high-profit antidepressants have long tried to attribute the relationship between depression and obesity to depression, rather than the drugs used to treat the condition.
However, a new study published in June 2009 used data from the Canadian National Population Health Survey (NPHS), a longitudinal study of a representative cohort of household residents in Canada and tracked the incidence of obesity over ten years.
The study found that, "MDE [Major Depressive Episode] does not appear to increase the risk of obesity. ...Pharmacologic treatment with antidepressants may be associated with an increased risk of obesity. [emphasis mine]. The study concludesed,
Unexpectedly, significant effects were seen for serotonin-reuptake-inhibiting antidepressants [Prozac,Celexa, Lovox, Paxil, Zoloft] and venlafaxine [Effexor], but neither for tricyclic antidepressants nor antipsychotic medications.
Scott B. Patten et al. Psychother Psychosom 2009;78:182-186 (DOI: 10.1159/000209349)
Here is an article posted by the Mayo Clinic that includes the statement "weight gain is a reported side effect of nearly all antidepressant medications currently available.
Antidepressants and weight gain - Mayoclinic.com
Here is a report about a paper presented at the 2006 ADA Conference that analyzed the Antidepressant-Diabetes connection in a major Diabetes prevention study:
Medscape: Antidepressant use associated with increased type 2 diabetes risk.
Eating a diet high in processed food increases the risk of depression, research suggests.
What is more, people who ate plenty of vegetables, fruit and fish actually had a lower risk of depression, the University College London team found.
Data on diet among 3,500 middle-aged civil servants was compared with depression five years later, the British Journal of Psychiatry reported.
The team said the study was the first to look at the UK diet and depression.
The UK population is consuming less nutritious, fresh produce and more saturated fats and sugars
Dr Andrew McCulloch, Mental Health Foundation
They split the participants into two types of diet - those who ate a diet largely based on whole foods, which includes lots of fruit, vegetables and fish, and those who ate a mainly processed food diet, such as sweetened desserts, fried food, processed meat, refined grains and high-fat dairy products.
After accounting for factors such as gender, age, education, physical activity, smoking habits and chronic diseases, they found a significant difference in future depression risk with the different diets.
Those who ate the most whole foods had a 26% lower risk of future depression than those who at the least whole foods.
By contrast people with a diet high in processed food had a 58% higher risk of depression than those who ate very few processed foods.
Although the researchers cannot totally rule out the possibility that people with depression may eat a less healthy diet they believe it is unlikely to be the reason for the findings because there was no association with diet and previous diagnosis of depression.
Study author Dr Archana Singh-Manoux pointed out there is a chance the finding could be explained by a lifestyle factor they had not accounted for.
"There was a paper showing a Mediterranean diet was associated with a lower risk of depression but the problem with that is if you live in Britain the likelihood of you eating a Mediterranean diet is not very high.
"So we wanted to look at bit differently at the link between diet and mental health."
It is not yet clear why some foods may protect against or increase the risk of depression but scientists think there may be a link with inflammation as with conditions such as heart disease.
Dr Andrew McCulloch, chief executive of the Mental Health Foundation, said: "This study adds to an existing body of solid research that shows the strong links between what we eat and our mental health.
"Major studies like this are crucial because they hold the key to us better understanding mental illness."
He added people's diets were becoming increasingly unhealthy.
"The UK population is consuming less nutritious, fresh produce and more saturated fats and sugars.
"We are particularly concerned about those who cannot access fresh produce easily or live in areas where there are a high number of fast food restaurants and takeaways."
Margaret Edwards, head of strategy at the mental health charity SANE, said: "Physical and mental health are closely related, so we should not be too surprised by these results, but we hope there will be further research which may help us to understand more fully the relationship between diet and mental health."