health updates

may 2006

May is that glorious month that brings us out into our gardens to glory in the growth of all of those seedlings and plants we toiled over in April. The barbecue has been used nightly for at least a month and we have a pile of recipes to try. Family and friends arrive early for an evening in the garden, and for those of us who live in condos, on the balcony. As the school year winds down, we make sure that the children and grandchildren are enrolled in the best camp for them or that we have a family together time while those wonderful children are out of school. While we’re doing all of this we also plan to escape the heat of the summer at home for cooler climates, but with all of this going on, we continue to be involved in our health care and on a daily basis, we continue to learn, read, and share information about how to live the fullest lives with diabetes. Do look at the web site in the What’s Hot articles for information about selecting a camp for your diabetic child or his/her rights when attending school next year. It is important that you know all of these rights before attending an IEP planning session at school or before you sign anything. There are also in depth articles on nutrition guidelines, travel with diabetes, and much more. We look forward to hearing from you with your questions which we try to answer quickly and concisely. Thanks.

Let’s start with our headlines and then we’ll go on to the abstracts which this month concern how to improve diabetes control in the primary setting, sex differences of endogenous sex hormones and risk of type 2 diabetes, and finally type 2 diabetes in midlife estimated from the Cambridge risk score and BMI. The first headline comes from the JDF and brings exciting news to all of us who have been waiting to live a more normal life. Since I was diagnosed with type 1 diabetes more than 20 years ago, I have been waiting for an artificial pancreas and on March 27, 2006 the JDF announced that the federal government approved another device that continuously monitors glucose, an important step in the development of an artificial pancreas. Those of us who wear an insulin pump know what a boon they are, but finger pricks all day long are still mandatory. Having this new device would greatly improve glycemic control by allowing us all to monitor our blood glucose levels and more precisely dose our insulin based on real-time information. Even better, this type of improved control would lead to reduced short and long term medical complications. This new device is called the STS Continuous Glucose Monitoring System which was developed by DexCom, Inc. Diabetes Care 29:818-822, 2006 has an article titled Attributions of Adolescents with Type 1 Diabetes in Social Situations by Anthony A. Hains, PHD et al. The authors examined the relationships among negative attributions of friend reactions (NAFRs) within a social context, anticipated adherence difficulties, diabetes stress, and metabolic control. The sample was made up of 104 adolescents with type 1 diabetes who completed instruments measuring demographics, attribution of friend reactions, anticipated adherence, and diabetes stress. Metabolic control was measured by HbA1c. The researchers concluded that adolescents who made NAFRs were more likely to find adherence difficult in social situations. They have increased feelings of stress, with the latter associated with poorer metabolic control. They concluded that intervention efforts to address negative attributions may impact adherence behavior and feelings of stress, especially if specific contexts of self-care behavior are taken into account. Diabetes Care 29:798-804,2006 has an article titles High Risk of Cardiovascular Disease in patients with Type 1 Diabetes in the U.K. by Sabita S. Soedamah-Muthu,PHD et al. The researchers looked at the absolute and relative risk of cardiovascular disease (CVD) in patients with type 1 diabetes in the U.K. The subjects were sex-matched and age-matched were selected from the General Practice Research Database (GPRD), a large primary care database representative of the U.K. Incident major CVD events, compromising myocardial infarction, acute coronary heart disease death, coronary revascularizations, or stroke, were captured for a period from 1992-1999. The hazard ratio (HR) for major CVD was 3.6 in type 1 diabetic men compared with those without diabetes and 7.7 in women. Increased HRs were found for acute coronary events, coronary revascularizations, and stroke. Type 1 men aged 45-55 had an absolute CVD risk similar to that of men 10-15 years older, with an even greater difference in women. They concluded that despite advanced in care, the absolute and relative risks of CVD remains extremely high in patients with type 1 diabetes. Women with type 1 continue to experience relative risks of CVD thab men compared with those without diabetes. It’s time to look at our abstracts. First we present an article from the Archives of Internal Medicine 2006;166:507-513 titled An Intervention to Overcome Clinical Inertia and Improve Diabetes Mellitus Control in a Primary Care Setting by David C. Ziemer, M.D. et al. The researchers looked at whether interventions aimed at health care providers’ behavior could overcome the rise in levels of HbA1c in the country. Although treatment guidelines are widespread, HbA1c levels continue to rise. In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 8.33 mmol/L during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations). At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback reminders groups than for reminders alone and control groups. After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback plus reminders groups was sustained: 52% did anything, and 30% did enough. Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c. The researchers concluded that feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings. JAMA, 2006;296:1288-1299 has an article titled Sex Differences of Endogenous Sex Hormones and Risk of Type 2 Diabetes by Eric L. Ding, BA et al. Inconsistent data suggest that endogenous sex hormones may have a role in sex-dependent etiologies of type 2 diabetes, such that hyperandrogenism may increase risk in women while decreasing risk in men. The researchers systematically assessed studies evaluating the association of plasma levels of testosterone, sex hormone-binding globulin (SHBG), and estradiol with the risk of type 2 diabetes. Systematic search of EMBASE and MEDLINE (1966-2005) for English-language articles using the keywords diabetes, testosterone, sex-binding-globulin, and estradiol; references of retrieved articles; and direct author contact were examined. From 80 retrieved articles, 43 prospective and cross-sectional studies were identified, comprising 6974 women and 6427 men and presenting relative risks (RRs) or hormone levels for cases and controls. Results were pooled using random effects and meta-regressions. Cross-sectional studies indicated that testosterone level was significantly lower in men with type 2 diabetes and higher in women with type 2 diabetes compared with controls. Similarly, prospective studies showed that men with higher testosterone levels had a 42% lower risk of type 2 diabetes, while there was a suggestion that testosterone increased risk in women. Cross-sectional and prospective studies indicated that women with higher SHBG levels had an 80% lower risk of type 2 diabetes, while men with higher SHBG levels had a 52% lower risk. Estradiol levels were elevated among men and postmenopausal women with diabetes compared to controls. The researchers concluded that endogenous sex hormones may differently modulate glycemic status and risk of type 2 diabetes in men and women. High testosterone levels are associated with higher risk of type 2 diabetes in women but lower risk in men; the inverse association of SHBG with risk was stronger in women than men. Finally there is an article in the Archives of Internal Medicine 2006;166:682-688 titles Type 2 Diabetes Mellitus in Midlife Estimated From the Cambridge Risk Score and Body Mass Index by Claudia Thomas, PhD et al. The Cambridge Risk Score (CRS) was developed to screen for type 2 diabetes risk. The researchers assessed the ability of the CPS to predict HbA1c levels and compared that to body mass index (BMI) at predicting HbA1c levels in midlife. They included 7452 participants without known diabetes in a biomedical survey of 1958 British Cohort at 45 years of age. Receiver operator characteristic curves were used to compare the ability of the CRS and BMI to identify people with elevated HbA1c levels using a threshold of 7.0% or more, 6.9% or more, and 5.5% ore more. Of the total sample, 0.9% had an HbA1c level of 7% or more, 3.8%, 6% or more; and 24.4%, 5.5% or more. The CRS detected individuals with elevated HbA1c levels with reasonable accuracy for the first two levels of HbA1c. Similar results were seen with the BMI alone. When testing the lower HbA1c threshold of 5.5% or more, t he CRS and BMI did not perform well. Owing to the low performance of diabetes at 45 years of age, only 2% to 3% of those considered at risk had elevated HbA1c levels. The researchers concluded that for a population n mid-life, the CRS identified individuals with elevated HbA1c levels reasonably well. However, the CRS had no advantage compared with BMI alone in identifying diabetes risk. BSP