June brings more news from medical journals and newspapers about diabetes. Each month we read and compile abstracts for you so that you too can keep up with the new research. We do this so that you can be knowledgeable of a disease that you live with 24/7. If we don't know about diabetes, how can we make the thousands of decisions we must make about how to care for ourselves, decide on interventions, and ward off both short and long term complications of diabetes? Yes, we know, that reading some research can be frightening because the subject may be very close to home, but without information you are at the mercy of the disease. We hope you use these abstracts to talk over your medical needs with your physician and health care team. Knowledge will help you feel more in control. People don't have to tell you how to live; you'll know the ramifications of how your behavior affects your life. So, dear readers, I lift my water glass to you and toast your fortitude and brain power.
Let's do our monthly overview of articles in a few sentences. These articles are on subjects that we tend to follow for all of you as you let us know that the subjects are of interest. The May issue of Diabetes Care has an article on the importance of intensive therapy for type 1 diabetes to combat mortality. The best way, according to authors, is to use the hemoglobin A1c test. The study that followed patients in Allegheny County, PA indicates that African Americans had a significantly higher mortality rate than Caucasians. It was felt that this was a reflection of increased mortality of African Americans in the general population and had to do with socioeconomic factors. The good news was that survival rates for type 1 diabetics is improving significantly. The second article is about stem cell research. April 26 the online edition of Science reports that NIH doctors have generated cells from embryonic stem cells that are capable of secreting insulin in response to glucose stimulation and that form pancreatic islet-like clusters. Dr. Ron McKay and his colleagues developed a five-step culturing technique that turns mouse embryonic stem cells into cell clusters that resemble pancreatic islets. The cells in the inner region of the clusters produced insulin, while those in the outer regions produced glucagon and somatostatin. Engineered cells for transplantation continues at the lab.
This month we begin with an article from JAMA on Fasting and postload glucose and the incidence of diabetes. Next we discuss the epidemic of diabetes in Australia. We spend a lot of time trying to convince those with diabetes to exercise and so when we see a journal article on heart disease, we tend to share it. This month we found one in the Archives of Internal Medicine titled Diabetes and all-cause and coronary heart disease mortality among US male physicians. We finish with an article showing that diabetics can incorporate sugar into their diets and then the gastrointestinal tract symptoms among person with diabetes mellitus. Let's begin.
JAMA, April 25,2001-Vol 285, No.16:21092113 has an article titled Relation of impaired fasting and postload glucose with incident type 2 diabetes in a Dutch population by Vegt, Femmie de, Ph.D. et al. The researchers were interested in examining the risk of developing diabetes mellitus in persons with impaired fasting glucose (IFG) knowing that there is a relationship between diabetes and impaired glucose tolerance (IGT). This is a population-based cohort study conducted from Oct 1989 to February 1992 among 1342 nondiabetic white residents of Hoorn, the Netherlands, aged 50 to 75 years at baseline, in whom fasting plasma glucose (FPG) levels and glucose levels 2 hours after a 75-g oral glucose tolerance test were measured at baseline and at follow-up in 1996-1998.
The cumulative incidence of diabetes, defined according to the diagnostic criteria of the World Health Organization (WHO-1985 and WHO-1999) and the American Diabetes Association (ADA-1997), during a mean follow-up of 6.4 years, was compared among participants with IFG, IGT, and normal glucose levels at baseline.
The cumulative incidence of diabetes was 6.1%, 8.3%, and 9.9% according to the WHO-1985, ADA, and WHO-1999 criteria, respectively. The cumulative incidence of diabetes for participants with both IFG and IGT was 64.5% compared with 4.5% for those with normal glucose levels at baselines. The researchers found that FPG and 2 hour postload glucose levels as well as waist-hip ratio are important risk factors in developing diabetes. They concluded that the cumulative incidence of diabetes was strongly related to both IFG and IGT at baseline and, in particular, to combined presence of IFG and IGT.
Harvard Medical School, Information Service had an article dated April 19, 2001 about Overweight Australians and a diabetic epidemic. Professor Robert Zimmet, director of the International Diabetes Institute, prepared the report about overeating, lack of exercise, and the mechanism of an aging society driving the epidemic, states, "This problem goes beyond medicine. Our whole way of life is moving us away from scenarios where we can maintain good health." Beyond becoming a major health problem, Zimmet said cost of treating diabetes could spark a crisis for the government-funded health system. One million Australians, about one in twenty have diabetes. This prevalence of diabetes matches or exceeds every Western nation except the US. The cost to the state of treating diabetes, now running at 200 million Australian dollars ($100 million), would hit 2 billion Australian dollars ($1 billion) within four years, this study says.
The report was based on a study of 11,000 people and found that 40 percent of Australians are overweight and a further 20 percent are obese. More than half of Australia's adults have high cholesterol and 30 percent have high blood pressure. We in the US know how this will play out. We all deal with rising health costs, HMOs which allocate spending, and an older and more sickly population as well as children who are sedentary and who are developing diseases not known in children and adolescents a very short time ago. (Please read our article on the epidemic of diabetes)
The Archives of Internal Medicine, Vol.161 No.2, Jan.22, 2001: 242-247 has an article titled Diabetes and all-cause and coronary heart disease mortality among US male physicians by Lotufo, Paulo A, MD et al. The researchers knowing that diabetes has long been associated with increased risk of coronary heart disease, wanted to determine the magnitude of this risk. They looked at the impact of diabetes and prior CHD (coronary heat disease) on all-cause and CHD mortality. This was done in a prospective cohort study of 91,285 US male physicians aged 40 to 84 who were divided into 4 groups: 1) A reference group of 82,247 men who were free of both diabetes and CHD (previous myocardial infarction and/or angina) at baseline, 2) 2,317 men with a history of diabetes but not CHD, 3) 5,906 men with a history of CHD but no diabetes, and, 4) 815 men with a history of both diabetes and CHD. Rates of all-cause and CHD mortality were compared in these groups.
Results indicated that over 5 years, 3627 deaths from all causes were documented, including 1242 deaths from CHD. Compared with men with no diabetes or CHD, the age-adjusted relative risk of death for men with no diabetes or CHD, the age-adjusted relative risk of death from any cause was 2.3 among men with diabetes and without CHD, 2.2 among men with CHD and without diabetes, and 4.7 among men with both diabetes and CHD. The relative risk for CHD, 5.6 among men with diabetes and without CHD, 5.6 among men with diabetes and without CHD, 5.6 among with CHD and without diabetes, and 12.0 among men with both diabetes and CHD. Multivariate adjustment for body mass index, smoking status, alcohol intake, and physical activity as well as stratification by these variables did not materially alter these associations.
The researchers concluded that diabetes is associated with substantial increase in all-cause and CHD mortality. For all-cause mortality, the magnitude of excess risk conferred by diabetes is similar to that conferred by a history of CHD; for mortality from CHD, a history of CHD is a more potent predictor of death. The presence of both diabetes and CHD, however, identifies a particularly high-risk group.
Diabetes Care 2001:24: 222-227 has an article titled With guidance diabetics can safely incorporate sugar into their diet, by Yale, Jean-Francois, MD et al from McGill University. This article pertains to type 2 diabetes and it examines how teaching these patients to include sugar does not adversely affect nutrition or metabolic control. The researchers randomized 48 type 2 diabetics to a conventional meal plan containing no concentrated sweets or to a meal plan permitting up to 10% of total calories from added sugars or sweets. The results indicated that the people in the "sugar" group had a tendency to consume fewer calories than the conventional group. The sugar group also ate significantly less carbohydrates and starch than the conventional group. Weight remained stable, and there was no evidence that consuming more sugar worsened metabolic profile or improved their perceived quality of life.
The researchers concluded that the study is strong evidence that teaching diabetic patients how to incorporate sugar into their diet may result in increased adherence to a healthy diet through better awareness of the carbohydrate content of food. They urge physicians to teach "sugar guidelines" to their diabetic patients. This does not mean that you who are reading this can go out and purchase all of the cookies and candy in a store. First, go to your physician and talk over your long and short term goals. Learn all you can about carbohydrate counting and how to eat a healthy diet, weighing the food you eat. Then, perhaps you too will feel confident with the help of your health care team to reincorporate refined sugar into your diet. Remember that 10% of a 1200 calorie a day diet is 120 and that's not a lot of sugar. Of course you know that means that the fat you find in these treats will have to be deleted from other foods you eat. With diabetes there are trade offs. Learn before you try.
We get many e-mails about gastrointestinal tract symptoms and diabetes so here is some information from Archives of Internal Medicine, 2000:160:2808-2816 by Maleki Dordaneh. MD et al. The researchers wanted to determine whether GI tract symptoms are more prevalent in unselected patients with DM from the general community compared with their age- and sex-matched counterparts without DM and to assess the association of GI tract symptoms in persons with DM with psychosomatic symptoms, medication use, and symptoms of autonomic neuropathy. The research was a population-based, cross-sectional study of type 1 DM, a random sample of residents with type 2 DM, and 2 age- and sex-stratified random samples of nondiabetic residents (total of 1262 persons for 4 groups) who were mailed a previously validated symptom questionnaire.
The results indicated that the prevalence of most GI tract symptoms is similar in persons with and without DM, except for a lower prevalence of constipation or laxative use in residents with type 1 DM, especially in men. This difference is associated with calcium channel blocker use rather than symptoms of autonomic neuropathy. They conclude that physicians should not associate GI tract symptoms with a complication of DM.
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