Our abstracts this month look at the relationship of early infant feeding and type 1 diabetes, a research project that made every news program this past month; the relationship between exercise, hypertension and syndrome X; diabetes and silent cerebral infarcts in hypertensive patients; and counter-pulsation therapy's safety in diabetic patients with angina.
Our headlines this month touch many areas. Our first from Reuters Health News states that Sen. Ben Nelson, D-Neb., and Rep. Frank LoBiondo, R-N.J. have called on the Centers for Medicare and Medicaid to rewrite a regulation issued earlier this month limiting the conditions for which Medicare-recognized rehabilitation hospitals or units can provide services and qualify for special payments. As part of a law suit filed by the Medicare Rights Center, Easter Seals, and the American Parkinson's Diseases Association, Medicare officials agreed in July to delay implementation of the caps until Nov.1, and during that time to notify in writing at least 90% of Medicare beneficiaries. About 4 million Medicare beneficiaries use outpatient therapy services each year, and a study by the Urban Institute estimated that 12% of them would exceed the caps and be forced to pay out-of-pocket for further treatment. Now is the time for you to write, e-mail, or phone your Representatives and Senators if you want to keep your Medicare outpatient therapy.
There is a new low-calorie sweetener, tagatose, and it is making a debut in a frozen diet cola drink, but it may soon be available in many other sugar-free products. The commercial launch of tagatose which has 92 % of the sweetness of sugar came with the introduction of 7-11's Diet Pepsi Slurpee. Combined with two other sugar sweeteners, erthrritol and sucralose (Splenda), tagatose makes the frozen drink taste more like the sugar-sweetened drink. A naturally occurring sugar found in daily products and sold under the brand name Naturlose, tagatose is made from whey. It is a bulk sweetener like saccharin or Splenda, but those and other artificial sweeteners are hundreds of times sweeter than sugar and must be mixed with fillers. Tagatose spoons and measures just like sugar. It can be used for baking and, because it does not raise levels of blood sugar or insulin, diabetics can use it. Furthermore, it's a flavor enhancer that reduces the bitter aftertastes of other sugar substitutes.
You can think what you want about California and the recall there, but here's a headline you will be interested in: Still Gov. Gray Davis signed new laws to boost stem cell research. Last year the state approved a measure allowing stem cell research, including from human embryos donated at fertility clinics. Davis says that top researchers have since come to the state. The current legislation creates the nation's first statewide registry for researchers to locate such embryos. A second measure calls on state health officials to devise guidelines for stem cell research by 2005.
We receive many e-mails about diabetes in the work place. More than a few of you feel that you have been discriminated against, so you will be interested in the following information. In a press release dated Sept.9, 2003, the ADA reported that the 9th U.S. Circuit Court of Appeals revived a lawsuit by a diabetic woman who claimed that U.S. Bancorp illegally refused to let her eat at her desk to control her blood glucose levels. A previous judge in 2000 had dismissed this case. You can read more about this case on the internet. It's fascinating, but the original ruling was very frustrating for those of us with diabetes. Let's hopes this one stands.
The Archives of Internal Medicine 2003; 163:1735-1740 has an article that will be of interest to all of us with diabetes, since heart disease is a major risk factor for us. This article, written by Sunder Natarajan, MD, MSC et al, looks at Sex differences in risk for coronary heart disease mortality associated with diabetes and established heart disease. The sex-specific independent effect of diabetes and established coronary heart disease (CHD) on subsequent mortality is not known, and these researchers did an analysis of pooled data from the Framingham Heart Study and the Framingham Offspring Study with follow-up of 20 years. The results are noteworthy to take to your physician. For men, established CHD signifies a higher risk for CHD mortality than diabetes. The reverse was noted in women, with diabetes being associated with a greater risk for CHD mortality. Current recommendations for women with diabetes may need to be more aggressive to match CHD mortality risk, according to the researchers.
The American Heart Association 57th High Blood Pressure Research Conference reported that in a cohort of type 2 diabetics with hypertension, treatment with an ACE inhibitor did not prevent vascular remodeling or improve media to lumen ratio. This is according to Dr. Ernesto L. Schiffrin et al from the Clinical Research Institute of Montreal. This is controversial, so please ask your physician for more information.
Our final headline makes a great deal of sense; here are the findings from The Archives of Internal Medicine 2003;163:2058-2065 by John B. Dixon, MBBS, FRACGP et al in a article titled Depression in association with severe obesity. Using the Beck Depression Inventory for 487 subjects, the researchers found that severely obese subjects, especially younger women with poor body image, are at risk for depression. They found sustained improvement with weight loss. They hypothesize that severe obesity causes or aggravates depression.
Now for the abstracts. Our first article appeared in JAMA, 2003; 290:1721-1728 and is titled Early infant feeding and risk of developing type 1 diabetes-associated autoantibodies, by Annette-G .Ziegler, MD et al. The authors knowing that dietary factors have been named as risk factors for type 1 diabetes looked at if these factors trigger the islet autoimmunity that precedes clinical disease. Their study examined whether breast feeding duration, food supplementation or age at introduction of gluten-containing foods influences the risk of developing islet autoantibodies. This is a prospective natural history cohort study conducted from 1989 to 1003 in inpatient/outpatient clinics in Germany. The main outcome measurement was the development of islet autoantibodies in two consecutive blood samples. Life-table islet autoantibody frequency was 5.8% by age 5 years. Reduced exclusive breastfeeding duration did not significantly increase the risk of islet autoantibody risk. Food supplementation with gluten-containing foods before age 3 months, however, was associated significantly with increased islet autoantibody risk. Four of 17 children who received gluten foods before age 3 months developed islet autoantibodies. All 4 children had the high risk DRB1 genotype. When I heard about this research, I also heard about somewhat contradictory findings from a team of US researchers. So do go to the net and read more. Remember, these children did not develop diabetes; they just developed the autoantibodies.
Exercise plus weight loss reduces blood pressure in Syndrome X patients by Dr. Lana L. Watkins et al form Duke Medical Center appeared the Archives of Internal Medicine 2003;163:1889-1895. People with high blood pressure often exhibit an aggravation of abnormalities in carbohydrate and lipoprotein metabolism associated with increased risk of coronary heart disease. The researchers examined the effects of a 6-month program with either aerobic exercise training alone or a combination of exercise and structured weight loss. Fifty-three patients with hyperinsulinemia, dyslipidemia, and high blood pressure, characteristics of syndrome X, were included in the study. Twenty-one patients were randomly assigned to exercise only, 21 to exercise plus weight loss, and 11 to a control group. The team measured glucose tolerance, lipid levels, and blood pressure at baseline and after treatment. "Compared with pretreatment levels, the 2-hour insulin response to oral glucose was reduced by 27% in the exercise-only group and by 47% in the exercise plus weight loss group. Significant reduction in diastolic blood pressure was observed in the exercise plus weight loss group, but not in the exercise-only group. Neither intervention produced significant improvement in lipid profiles. The authors concluded that weight loss programs along with exercise can be a valuable therapy for syndrome X.
Diabetes is the main determinant of silent cerebral infarct in hypertensive patients, by Dr. Kazuo Eguchi et al from Japan, appeared in Stroke 2003;34. 2399-2403. The researchers studies 360 asymptomatic hypertensive patients who underwent 24-hour blood pressure monitoring and had a brain MRI performed. The subjects included 159 with diabetes mellitus, 201 without the disease. Although both groups had comparable blood pressures, 82% of the diabetics were found to have a silent cerebral infarct (SCI), compared with 58% of nondiabetics. Similarly, three or more SCIs were found in 62% of diabetics, but in only 35% of non-diabetics. Independent of age and 24-hour systolic blood pressure, diabetes was found to be strong predictor of any SCI and multiple SCIs. Among patients with sustained hypertension, the prevalence of any SCI and multiple SCIs was higher in those with diabetes. In contrast, among patients with white-coat hypertension, only multiple SCIs were more common in diabetes. The researchers concluded "There is increasing evidence that multiple SCIs are closely associated with cognitive problems, vascular dementia, and partly associated with Alzheimer's disease. If a patients is found to have multiple SCIs, aggressive blood pressure control is essential and the patient should be treated as if they have already had a clinical stroke."
The American Heart Journal 1003;146:453-458 has an article titled Counterpulsation therapy safe and effective for angina in diabetics, by Dr. Georgiann Linnemeier et al from HeartGen Center in Indianapolis. The current findings are based on a study of 1532 angina patients who were treated with EECP (enhanced external counterpulsation), including 665 with diabetes. Angina severity was assessed before EECP, immediately after EECP, and 1 year later. At baseline, the diabetic patients averaged 11 angina episodes per week. Eighty-six percent of the diabetic patients had a history of coronary revascularization, and most were considered unsuitable for a repeat procedure. Nearly 80% of the diabetics were able to complete the EECP regime. The mean treatment duration was 32.3 hours. When evaluated immediately after EECP, 69% of the diabetics had shown improvement by at least 1 in their Canadian Cardiovascular Society angina class. One year later, the improvement was still present in 72% of diabetics. Treatment with EECP was also tied to significant improvement in quality of life. The 1-year mortality rate for the current diabetic cohort-7.7%-was comparable to that seen for patients in coronary intervention registries. The results suggest that "EECP may be useful in select patients with diabetes with severe cardiovascular disease who are considered unsuitable for further coronary intervention."
BSP
