MEDICAL TERMS USED IN SOUTH TEXAS, USA

PANCREATIC REST FOR NEWLY DIAGNOSED TYPE 2 DIABETES

Early and intensive therapy preserved beta-cell function long term in type 2 diabetes

• June 13, 2012

AllPHILADELPHIA — Initiating intensive therapy in treatment-naïve, newly-diagnosed patients with type 2 diabetes preserved beta-cell function for 3.5 years, according to data presented at the American Diabetes Association’s 72nd Scientific Sessions.

“Everybody knows that type 2 diabetes is a progressive disease and this progression is determined by a progressive decline in beta-cell function over time,” Ildiko Lingvay, MD, assistant professor of internal medicine at University of Texas Southwestern Medical Center, said during her presentation. “Our ideal goal as physicians when we treat our patients is to preserve beta-cell function, either by decreasing the slope of decline or, ideally, by stabilizing beta-cell function over time — a disease-modifying effect.”

In light of data from the UKPDS and ADOPT studies, Lingvay and colleagues developed a treatment strategy that they hoped would preserve beta-cell function in treatment-naïve patients who were newly diagnosed with type 2 diabetes. They randomly assigned patients to insulin-based treatment or triple oral therapy preceded by a short, 3-month course of insulin-based therapy.

patients were treated with insulin and metformin during the 3-month run-in, after which they were randomly assigned to treatment continuation or triple oral therapy. The goal of the run-in period, according to Lingvay was to remove the transient stunning of beta-cell function due to glucotoxicity.

All patients were treated with Novolog 70/30 at 0.2 U/kg or metformin at 500 mg daily, which was titrated weekly to 1,000 mg twice daily. Triple oral therapy included glyburide 1.25 mg twice daily, which was titrated throughout the study; metformin 1,000 mg twice daily and pioglitazone (Actos, Takeda) 15 mg titrated during 3 months to 45 mg.

Treatment failure was defined as HbA1c ≥8%. If patients in the triple oral arm achieved this target, they were switched to the insulin group. Similarly, if patients in the insulin group achieved this target, they remained on insulin with the option to change the frequency or type of treatment.

Lingvay and colleagues screened 67 patients; 63 enrolled and 58 finished the 3-month run-in and were randomized in a 1:1 fashion with continued insulin or were switched to triple oral therapy.

At the time of diagnosis, the average HbA1c was 10.6%; after the 3 months of the run-in period, HbA1c was reduced to 5.9% and 100% of participants achieved the ADA-recommended goal of HbA1c ≤7%.

At the time of randomization, age was about 45 years, 80% were minorities, average BMI was 36 and the insulin dose was 0.6 U/kg, which was three times the initial dose patients.

There was a rapid improvement in glycemic control within the first 3 months, with normalization of glucose then sustained glycemic control through 3.5 years, regardless of treatment assignment. 

Treatment failure occurred in three patients in the insulin group and five in the triple oral therapy group.

In regards to the main outcome of beta-cell function, C-peptide AUC/glucose AUC did not show the expected decline, Lingvay said. Stabilization of beta-cell function occurred in both treatment groups.

Weight increased in both groups, but there was no statistically significant difference. Mild hypoglycemia was defined conservatively (any home glucose measurement of <70 mg/dl associated with any symptoms suggestive of hypoglycemia) and occurred at a rate of one per month during the first 4 months. According to Lingvay, the rate decreased to less than 0.5 events per month and remained low during the course of the study.

“This is a very important finding, in light of a very low HbA1c achieved and maintained throughout the study; and the fact that; all patients were treated with insulin or sulfonylurea.”

Lingvay said follow-up continues and 6-year results will be available soon.

Before concluding, however, she shared some lessons learned while conducting this study.

“I suggest we try to achieve glycemic normalization as quickly as possible after diagnosis. Additionally, I recommend we maintain glycemic control long-term. Because diabetes is such a multifactorial disease with so many underlying pathophysiological components, I don’t personally think monotherapy is the answer to change the course of the disease. I recommend combination treatment with complimentary mechanisms of action. Also, [we should] anticipate disease progression. Treatment intensification should be done while the patient’s glycemic control is still within the target range; I would not recommend waiting until HbA1c go above target before intensifying treatment.” – by Stacey L. Fisher

For more information:

Lingvay I. CT-SY26. Presented at: the American Diabetes Association’s Scientific Sessions; June 8-12; Philadelphia.

Disclosure: Dr. Lingvay serves on medical advisory board for NovoNordisk, and the study was sponsored through and investigator-initiated trial grant from NovoNordisk.

Run for your life! Study finds joggers live an average of six years longer

Need a solid excuse to dust off your running shoes? Joggers have been found to live an average of six years longer than those who don't jog.

However, you’ll have to run for at least one hour a week for benefit, according to a new study in Denmark.

Researchers found that jogging was associated with a 44 per cent reduction in the relative risk of death for those over 35 years compared with deaths among those who did not run.

The same benefit applied to both men and women.

The 44 per cent reduction translates to an ‘age-adjusted survival benefit’ of 6.2 years in men and 5.6 years in women, according to Dr. Peter Schnohr, chief cardiologist from the Copenhagen City Heart study.

Furthermore, the jogger’s lives are not only longer but happier too as those who ran reported an overall sense of well-being, said Schnohr. 

'The results of our research allow us to definitively answer the question of whether jogging is good for your health,' Schnohr said in a statement.

'We can say with certainty that regular jogging increases longevity. The good news is that you don't actually need to do that much to reap the benefits,' he continued. 

Fighting fit: The study also found that joggers led happier lives

The study also found that the optimum benefit of jogging was for those who jogged at a slow-to-average pace for between an hour and two and a half hours spread over two or three weekly sessions.

The revelations are the latest to come out of the Copenhagen City Heart Study which began in 1976. At the beginning of the programme the study’s 19,329 participants’ age ranged from 20 to 79.

The 1,878 participants in the most recent study were asked how often and how quickly they ran.

Researchers then compared deaths among the joggers among the non-joggers in the main study pool of almost 20,000.

Over 35 years, 122 joggers died compared with 10,158 non-joggers.

DIABETES CARE WITHOUT BORDERS

Dear Friends:
The Endocrine Society is objecting the fact that some of the anti diabetic medications would be sold over the counter, insisting that the diabetes care has to be under SUPERVISION of a medical doctor who would coordinate the other activities. Ever since I have begun working with the Indians, I have known that model to be faulty, the only way we can improve the health of the Indians, is work together, not in a hierarchical fashion but in a circular fashion and make the patient feel and understand that it is possible to take care of their health. I have always joked to Michele, My aim is to make my self Unemployed! Indian Health Services and the Tribal Programmes are leading the way and showing the light on how to better look after an indian patient with Diabetes: cooperation and consensus. I am becoming more and more an ornament, I happily admit!
Best wishes
I am enlosing a letter I wrote to Maurits Van Pelt who runs a diabetes are programme in Cambodia (mopotsyo.org) in which people from the community are taught to take care of people with diabetes , the so called Peer to Peer Education Programme. I know you have thousands of emails to read, but read my letter to him if you have a minute to spare.
Dear Maurits,
Recently I heard a comment, I am not sure where in Asia, that the doctor said: I am against medications being freely made available to the patient. Current studies show that up to 80 per cent of the patients (abstract presented at ADA last year) do not follow the regimen prescribed. Among my own patients I can be sure that they take the morning dosage and often do not take the afternoon dosage because of their social life balanced towards evenings and nights.
FDA in the USA, not always a user friendly organization seems to have decided to make available without prescription commonly used drugs. But Endocrine Society vehemently protests that Diabetes medications be excluded from this benevolence.
Just look at the tone of the letter from Endo Society, a little bit condescending and arrogant. We in the field recognize that the days of Doctor directed or supervised Diabetes Care is going to be history and that innovation is coming in from empowerment is given to the patient and not provide more authority to the Doctor.
My role in the team in our clinic, is to see the patient last, rather than first and organize their therapeutic regimen, but after they have been seen by: optometrist, podiatrist, diabetes nutritionist and diabetes educator, I am given time to counsel and talk about spiritual matters (this being possible among the Native American Indians). The Diabetes Educators would have already begun the change in treatment regimen if they thought so, I agree with them almost always. I do keep an eye on prevention factors on complications,especially nephropathy, again following very local criteria, such as
our patients normal BP is around 110-120/60-70.
There is unexplained haematuria with or without diabetes, possibility of IgA nephropathy.
Protein is always measured in the urine and followed. (this is also being automated without my participation) and i check that.
So the time given to me, which is about 45 min to 1 hour per patient: 25 % on medically related matters and 75% on non medical non pharmaceutical matters.
Our patients have easy access to medications and strips to measure blood sugars.
So our system is much closer to MOPOTSYO model than the model espoused by Endocrine society and here is their note:
Society Recommends Exclusion of Diabetes Medications from Nonprescription Drug Expansion

Endocrine Insider
April 4, 2012

To increase patients’ access to safe treatments for certain conditions, the U.S. Food and Drug Administration (FDA) is considering making some commonly used prescription drugs available without a prescription. FDA held a hearing on March 22-23 to receive public feedback on the expansion, which is proposed to provide more ready access for medications for highly prevalent diseases that can be self-diagnosed and treated. As examples of such diseases, FDA listed hyperlipidemia, hypertension, migraine headaches, and asthma in a February 28 request for comments. The Society is concerned that FDA might also include medications for diabetes under this expansion due to the high prevalence of the disease.

As a result of its concerns, the Society submitted a comment letterurging the FDA to exclude diabetes medications from this expansion due to the complexity of treating and managing diabetes. The Society recommends that diabetes medications continue to be prescribed by a physician and that allied health professionals should continue to provide education and assistance to patients in coordination with a supervising physician. The FDA is currently considering comments on the proposed expansion and the Society will inform its members once a determination has been made. Additional information can be accessed here.



as an anthropologist I have to question the motive of the society, which is primarily to protect the endocrinologists rather than the welfare of the patient? Medications are freely available in most parts of the world and in many countries patients never get to see a doctor but a pharmacist is the one that gives the advice.



Quantitatively speaking, the results of National Studies in the USA, does not show that the measurements are any better than poor, developing countries of the world. and of course if you compare, the results among the Mexican Americans in Texas or Blacks in Georgia or American Indians in South Dakota, most of the developing countries have similar or better quantitative profiles . In Basra, Iraq a war zone the average A1C is very similar to the above groups mentioned.



What Endocrine Society need to understand is that Diabetes as we see it (excluding type 1) is a social disease and the answers are going to be social in nature, with a good contribution from medications. In a study published in the last couple of days they wanted to show that injectable Exanetide was better than Metformin, but it turned out to be not superior to any of the medications we commonly use except Sitagliptin, another newer medication.



Today I will start reading about Outcome Measurements and also i was happy to see that the World Diabetes Foundation has taken an interest in the Diabetes among Indigenous peoples of the world! I will be in touch with you regarding how to approach them.



Enjoy your holidays. You deserve it. It is a beautiful day in Paris. I will be leaving for the Indians (Nebraska and South Dakota) on April 16th.



Yehuda

LIFESTYLE COUNSELING ON A REGULAR BASIS WILL GET YOU THE WANTED RESULTS IN DIABETES HYPERTENSION AND HIGH CHOLESTEROL

Lifestyle Counseling in Routine Care and Long-Term Glucose, Blood Pressure, and Cholesterol Control in Patients With Diabetes
Fritha Morrison, MPH1, Maria Shubina, SCD1 and Alexander Turchin, MD, MS1,2,3⇓
+ Author Affiliations

1Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
2Harvard Medical School, Boston, Massachusetts
3Clinical Performance Measurement, Partners HealthCare System, Boston, Massachusetts
Corresponding author: Alexander Turchin, aturchin@partners.org.
Abstract

OBJECTIVE In clinical trials, diet, exercise, and weight counseling led to short-term improvements in blood glucose, blood pressure, and cholesterol levels in patients with diabetes. However, little is known about the long-term effects of lifestyle counseling on patients with diabetes in routine clinical settings.

RESEARCH DESIGN AND METHODS This retrospective cohort study of 30,897 patients with diabetes aimed to determine whether lifestyle counseling is associated with time to A1C, blood pressure, and LDL cholesterol control in patients with diabetes. Patients were included if they had at least 2 years of follow-up with primary care practices affiliated with two teaching hospitals in eastern Massachusetts between 1 January 2000 and 1 January 2010.

RESULTS Comparing patients with face-to-face counseling rates of once or more per month versus less than once per 6 months, median time to A1C <7.0% was 3.5 versus 22.7 months, time to blood pressure <130/85 mmHg was 3.7 weeks versus 5.6 months, and time to LDL cholesterol <100 mg/dL was 3.5 versus 24.7 months, respectively (P < 0.0001 for all). In multivariable analysis, one additional monthly face-to-face lifestyle counseling episode was associated with hazard ratios of 1.7 for A1C control (P < 0.0001), 1.3 for blood pressure control (P < 0.0001), and 1.4 for LDL cholesterol control (P = 0.0013).

CONCLUSIONS Lifestyle counseling in the primary care setting is strongly associated with faster achievement of A1C, blood pressure, and LDL cholesterol control. These results confirm that the findings of controlled clinical trials are applicable to the routine care setting and provide evidence to support current treatment guidelines.

IF THE VEGETARIAN DIET CAN MAKE YOU HAPPIER, WHY ARE THE INDIANS SO MOROSE?

iTHE POINT OF THIS ARTICLE IS NOT ABOUT VEGETARIAN DIET ELSEWHERE THAN USA BECAUSE THE MEAT PRODUCTS ARE SO TAINTED THAT GOING VEGETARIAN IS LIKE DETOXIFYING YOURSELF AND THE SENSE OF WELL BEING COMES FROM THE DE TOXIFICATION..

Vegetarian Diet Could Make You Happier And Less Stressed, Study Shows

Posted: 03/11/2012 10:59 am
By Elizabeth Nolan Brown, for Blisstree.com
Omnivores, take note: Embracing a vegetarian diet could make you happier and less stressed, according to new research published in Nutrition Journal.
The reason comes down to fatty acids: Diets that include meat and fish are higher in arachidonic acid (AA), an animal source of omega-6 fatty acids. Much of the meat Americans eat today is quite high in AA: The average omega-6 to omega-3 fatty acid profile of modern grain-fed meat is 5 times higher than grass-fed meat, like our ancestors ate. And previous research has shown high levels of AA can cause mood-disturbing brain changes.

High-fish diets also mean higher levels of long-chain, or omega-3 fatty acids, like eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Both EPA and DHA combat the negative effects of AA. High dietary levels of omega-3 fatty acids are linked to better brain health, better mood and a host of other health benefits. Most health experts recommend an omega-6/omega-3 ratio of about 4:1.

In theory, then, frequent fish eaters should have be protected against the damaging effects of AA because of their higher intake of omega-3 acids. But an earlier study found omnivores reported significantly worse moods than vegetarians, despite higher intakes of EPA and DHA.
In this follow-up study, 39 meat-eating participants were assigned to one of three diets. A control group ate meat, fish or poultry daily; a second group ate fish 3-4 times weekly but no meat; and a third group ate strictly vegetarian. After two weeks, mood scores were unchanged for the fish- and meat-eating groups, but vegetarians reported significantly better moods and less stress.
“Restricting meat, fish, and poultry improved … short-term mood state in modern omnivores,” the researchers concluded.
After two weeks on a vegetarian diet, participants had “negligible amounts” of EPA, DHA and AA in their bodies. Fatty acid levels in the control group were unchanged. Participants in the fish eating group showed 95 to 100% higher levels of EPA and DHA fatty acids—but their omega-6 to omega-3 ratios were still heavily skewed toward omega-6′s.
To work plant sources of omega-3 fatty acids (called ALA) into your diet, try chia seeds, hemp seed, cauliflower and purslane.

Red meat increases death, cancer and heart risk, says study

A diet high in red meat can shorten life expectancy, according to researchers at Harvard Medical School.

The study of more than 120,000 people suggested red meat increased the risk of death from cancer and heart problems.

Substituting red meat with fish, chicken or nuts lowered the risks, the authors said.

The British Heart Foundation said red meat could still be eaten as part of a balanced diet.

The researchers analysed data from 37,698 men between 1986 and 2008 and 83,644 women between 1980 and 2008.

They said adding an extra portion of unprocessed red meat to someone's daily diet would increase the risk of death by 13%, of fatal cardiovascular disease by 18% and of cancer mortality by 10%. The figures for processed meat were higher, 20% for overall mortality, 21% for death from heart problems and 16% for cancer mortality.

The study said: "We found that a higher intake of red meat was associated with a significantly elevated risk of total, cardiovascular disease, and cancer mortality.

"This association was observed for unprocessed and processed red meat with a relatively greater risk for processed red meat."

The researchers suggested that saturated fat from red meat may be behind the increased heart risk and the sodium used in processed meats may "increase cardiovascular disease risk through its effect on blood pressure".

Victoria Taylor, a dietitian at the British Heart Foundation, said: "Red meat can still be eaten as part of a balanced diet, but go for the leaner cuts and use healthier cooking methods such as grilling.

"If you eat processed meats like bacon, ham, sausages or burgers several times a week, add variation to your diet by substituting these for other protein sources such as fish, poultry, beans or lentils."