Researcher Martin Gibala

It found that a total of 30 minutes of high-intensity intermittent exercise per week, involving a total time commitment of 75 minutes, lowered 24-hour blood sugar concentrations, reduced blood sugar spikes after meals, and increased skeletal muscle mitochondrial capacity, a marker of metabolic health.

“These findings are intriguing because they suggest that exercising very strenuously for short periods of time, may provide many of the same health benefits as traditional exercise training,” says Martin Gibala, professor in the Department of Kinesiology at McMaster and supervising author of the study. “This is the first study to show that intense interval training may be a potent, time-efficient strategy to improve glycemic regulation in people with type 2 diabetes.”

Current guidelines from the Canadian Diabetes Association call for 150 minutes of moderate to vigorous exercise per week—twice the training time commitment of study participants—which can be tough to manage for many people including those with diabetes, adds Gibala.

He is quick to point out that larger studies are needed to comprehensively examine the potential benefits of this type of training, especially compared to traditional exercise guidelines.

For the study, researchers gave each volunteer a baseline exam to test blood sugar over a 24-hour period, assess fitness levels and take biopsies of thigh muscle to measure proteins linked to health status. Each workout involved riding a stationary bike for 10 bouts of 60 seconds at roughly 90 percent of maximal heart rate, with one minute between each burst of exercise. The routine also included a warm up and cool down such that each training session lasted 25 minutes in total.

Participants showed improved blood sugar levels even though they did not lose weight during the short two-week study.

“The improved glycemic control may be linked to changes in the subjects’ muscles, such as an improved ability to clear glucose from the blood after meals”, says Gibala. “We need to conduct further research to identify the mechanisms behind these results.”

The research was funded by the Natural Sciences and Engineering Council of Canada and the Canadian Diabetes Association.

Material adapted from McMaster University.

High rates of vitamin D deficiency have been found in obese populations and past studies have linked low vitamin D levels to cardiovascular disease and type 2 diabetes. The mechanisms by which obesity and its comorbidities are related to vitamin D deficiency are not fully known. This new study examined associations between vitamin D levels and dietary habits in obese children, and tested whether there were correlations between vitamin D levels and markers of abnormal glucose metabolism and blood pressure.

“Our study found that obese children with lower vitamin D levels had higher degrees of insulin resistance,” said Micah Olson, MD, of The University of Texas Southwestern Medical Center in Dallas and lead author of the study. “Although our study cannot prove causation, it does suggest that low vitamin D levels may play a role in the development of type 2 diabetes.”

In this study, researchers measured vitamin D levels, blood sugar levels, serum insulin, BMI and blood pressure in 411 obese subjects and 87 control non-overweight subjects. Study participants were also asked to provide dietary information including daily intake of soda, juice and milk, average daily fruit and vegetable intake, and whether or not they routinely skipped breakfast.

“Poor dietary habits such as skipping breakfast and increased soda and juice intake were associated with the lower vitamin D levels seen in obese children,” said Olson. “Future studies are needed to determine the clinical significance of lower vitamin D levels in obese children, the amount and duration of treatment necessary to replenish vitamin D levels in these children and whether treatment with vitamin D can improve primary clinical endpoints such as insulin resistance.”

Other researchers working on the study include Naim Maalouf, Jon Oden, Perrin White and Michele Hutchison of The University of Texas Southwestern Medical Center.

Material adapted from Material adapted from Endocrine Society.

Reference
The article, “Vitamin D Deficiency in Obese Children and Its Relationship to Glucose Homeostasis,” appears in the January 2012 issue of JCEM.

Researcher Michael Stern

“It appears that both Type 2 diabetes and autism have a common underlying mechanism – impaired glucose tolerance and hyperinsulinemia,” said Rice University biochemist Michael Stern, author of the opinion paper, which appears online in this month’s issue of Frontiers in Cellular Endocrinology.

Hyperinsulinemia, often a precursor to insulin resistance, is a condition characterized by excess levels of insulin in the bloodstream. Insulin resistance is often associated with both obesity and Type 2 diabetes.

“It will be very easy for clinicians to test my hypothesis,” said Stern, professor of biochemistry and cell biology at Rice. “They could do this by putting autistic children on low-carbohydrate diets that minimize insulin secretion and see if their symptoms improve.”

Stern said the new finding also suggests that glucose tolerance in pregnant women may need to be addressed more seriously than it is now. Stern said he first realized there could be a common link between Type 2 diabetes and autism a few years ago, but he assumed someone else had already thought of the idea.

Stern’s lab, which is located at Rice’s BioScience Research Collaborative, specializes in investigating the genetic interactions associated with genetic diseases like neurofibromatosis, a disorder in which patients are several times more likely to be afflicted with autism and autism spectrum disorders (ASD) like Asperger’s syndrome.

Autism and ASD are neurological disorders that have a strong but poorly understood genetic basis. The U.S. Centers for Disease Control and Prevention estimates that about nine out of 1,000 U.S. children are diagnosed with ASD.

Stern said at least four genes associated with increased frequency in autism are known to produce proteins that play key roles in a biochemical pathway known as PI3K/Tor. Stern said he had been studying a form of abnormal function in the synapses of fruit flies that was remarkably similar to abnormalities observed in rats and mice with defects in a different pathway known as mGluR-mediated long-term depression.

“I had also spent a lot of time thinking about insulin signaling because another project in my lab is an endocrinology project in which we’re studying how key proteins involved in insulin signaling affect the timing of metamorphosis in fruit flies,” Stern said.

From his studies in both areas, Stern knew two things: PI3K/Tor was the major pathway for insulin signals within cells, and insulin could affect synapses in a remarkably similar way to the mGluR defects associated with autism.

“When I read that the incidence of autism was increasing, and combined that with the fact that the incidence of Type 2 diabetes is also increasing, it seemed reasonable that each increase could have the same ultimate cause — the increase in hyperinsulinemia in the general population,” Stern said. “I didn’t do anything with this notion for a few years because it seemed so obvious that I figured everyone already knew this hypothesis, or had tested it and found it was not true.”

Stern said he changed his mind a few months ago when a health care consulting firm asked him to provide input about autism.

“In preparing for this interview, I discovered that gestational diabetes was the most important identified maternal risk factor for autism, but that ‘no known mechanism could account for this,’” Stern recalled. “When I read this, I was speechless. That’s when I realized that this was not obvious to others in the field, so I decided to write this up with the hope that clinicians might become aware of this and treat their patients accordingly.”

In writing the article, Stern said he learned that the role of insulin in cognitive function is becoming more widely accepted.

“I was checking to see if insulin was known to affect synaptic function, and I learned that the nasal application of insulin is already being tested to see if it is beneficial for both Alzheimer’s and schizophrenia.”

Stern said he also found preliminary studies that indicated that low-carb diets were therapeutic for some individuals with autism and ASD.

“Based on what’s already in the literature, insulin needs to be taken seriously as a causative element in autism,” Stern said. “I hope that clinicians will take the next step and put this to a rigorous test and determine how to best use this information to benefit patients.”

Material adapted from Rice University.

In one report, Katie Weinger, Ed.D., of the Joslin Diabetes Center, Boston, and colleagues, evaluated the efficacy of a behavioral intervention for improving glycemic control among patients with long-duration poorly controlled diabetes. The trial randomized 222 adults with diabetes to three treatment groups: structured behavioral treatment (included a five-session manual-based, educator-led structural intervention with cognitive behavioral strategies), group attention control (educator-led attention control group education program) and individual control (unlimited individual nurse and dietitian education sessions for six months).

The authors found that all participants, regardless of treatment group, showed glycemic improvement, however the structured behavioral group showed greater improvements compared to the other two treatment groups. Additionally, participants with type 2 diabetes showed greater improvement than patients with type 1 diabetes. Quality of life, number of daily glucose meter checks and frequency of diabetes self-care did not differ by type of intervention over time; however, patients with type 2 diabetes showed higher quality of life scores than patients with type 1. The authors concluded that, “a structured, cognitive behavioral program is more effective than two control interventions in improving glycemia in adults with long-duration diabetes.”

In a second report, JoAnn Sperl-Hillen, M.D., of HealthPartners Research Foundation and HealthPartners Medical Group, Minneapolis, and colleagues evaluated a total of 623 adults from Minnesota and New Mexico with type 2 diabetes and glycosylated hemoglobin (HbA1c) concentrations of 7 percent or higher. Participants were randomized to receive either group education, individual education or usual care (no assigned education; control group).

The authors found that individual education resulted in better glucose control in patients with established suboptimally controlled diabetes than did group education. Although mean (average) HbA1c concentrations decreased across all treatment groups, levels decreased significantly more in the individual education group (-0.51 percent) when compared with the group education (-0.27 percent) and the usual care (-0.24 percent) groups. Participants in the individual education group also were more likely to have HbA1c levels at or below 7 percent than participants in either the group education or usual care treatments. “In conclusion, among patients with type 2 diabetes of relatively long duration and HbA1c levels of 7 percent or higher, short-term glucose control improved more in those receiving individual diabetes education than in those receiving group diabetes education or assigned to no education,” the authors write.

A third study, conducted by Dominick L. Frosch, Ph.D., of the Palo Alto Medical Foundation Research Institute, Palo Alto, Calif., and colleagues examined the effectiveness of disease management programs among socially and economically disadvantaged patients with poorly controlled diabetes. The study included 201 patients (72 percent African American or Latino; 74 percent with annual incomes of less than or equal to $15,000) with poorly controlled diabetes. Participants were randomized to receive either an intervention package consisting of a 24-minute video behavior support intervention with a workbook and five sessions of telephone coaching by a trained diabetes nurse (treatment group), or a 20-page brochure developed by the National Diabetes Education Program (control group).

The authors found that most participants in both the treatment group (94.3 percent) and control group (93.5 percent) had received the assigned treatment materials and the majority (88.5 percent in the treatment group and 89.8 percent in the control group) rated the clarity of the information presented as good, very good, or excellent at the one-month follow-up. Across treatment groups there was a significant overall reduction in mean (average) HbA1c levels from study initiation to six-month follow-up; however differences between the groups were not significant. The authors also found that differences in other clinical measures (including blood lipid levels and blood pressure) and measures of diabetes knowledge and self-care behaviors were also non-significant.

“More intensive and therefore more expensive interventions may be a worthwhile investment to lower the high costs associated with poorly managed diabetes in the long term; however, larger structural interventions also may be necessary to overcome the many challenges faced by these severely disadvantaged patients,” the authors conclude.

Material adapted from JAMA.

References
Arch Intern Med. Published online October 10, 2011. doi:10.1001/archinternmed.2011.502; doi:10.1001/archinternmed.2011.507; doi:10.1001/archinternmed.2011.497.

Diabetes has become increasingly common in the United States and the world, according to background information in the article. Elevated levels of hemoglobin A1c (a measure of blood glucose levels and control over two to three months), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) are associated with an increase in the risk of complications. Reducing the levels decreases those risks, but the article notes that most patients with diabetes do not have these levels under control. Currently, treatment guidelines do not include recommendations for how frequently physicians should see patients with diabetes, although recommended intervals for testing and adjustments to medication may range from every two to three days for insulin to every three months for hemoglobin A1c. “However,” the authors write, “benefits of more frequent provider encounters may not be limited to treatment intensification and testing.”

Fritha Morrison, M.P.H., from Brigham and Women’s Hospital, Boston, and colleagues conducted a retrospective cohort study to determine whether more frequent encounters with a physician help patients improve control of diabetes. The authors analyzed data from 26,496 adult patients with diabetes and elevated hemoglobin A1c, BP and/or LDL-C levels who visited primary care physicians affiliated with two Boston hospitals for at least two years between January 2000 and January 2009. Treatment goals at the beginning of the study were hemoglobin A1c of less than 7 percent, BP of less than 130/85 mm Hg (millimeters of mercury) and LDL-C of less than 100 mg/dL (milligrams per deciliter). The researchers assessed the relationship between the frequency of clinician encounters (defined as notes in the medical record) and time to control of hemoglobin A1c, BP and LDL-C.

Among patients who had encounters with their physicians every one to two weeks, the median (midpoint) time to reaching the treatment goals was 4.4 months (without insulin) and 10.1 months (with insulin) for hemoglobin A1c, 1.3 months for BP and 5.1 months for LDL-C. Among patients who had physician encounters every three to six months, the median time to goal achievement was 24.9 months (without insulin) and 52.8 months (with insulin), 13.9 months and 32.8 months, respectively. When, after analysis, the time between physician encounters was doubled, the median time to reaching hemoglobin A1c goal increased 35 percent without insulin and 17 percent with insulin; for BP and LDL-C, these median times to goal increased 87 percent and 27 percent, respectively. As the physician encounter frequency increased up to once every two weeks for most goals, the time to control decreased progressively, consistent with the pharmacodynamics (the time course and effects of medications) for the respective classes of medication.

“The present findings provide evidence that for many patients with elevated hemoglobin A1c, BP, or LDL-C, more frequent patient-provider encounters were associated with a shorter time to treatment target, and control was fastest at two-week intervals,” report the authors. They suggest that this interval may be appropriate for the most severely uncontrolled patients, but recognize that innovative approaches to achieve this frequency may be necessary because of the increasing demand on health care resources. The authors add, “The retrospective nature of this study prevents us from establishing a causal relationship between encounter frequency and patient outcomes,” and call for further research.

Material adapted from JAMA.

Reference
Arch Intern Med. 2011;171[17]:1542-1550.

“Our study controlled for obesity, smoking, sedentary lifestyle and HbA1c levels, and still found that depression was associated with an increased risk of retinopathy,” said co-author Wayne Katon, M.D. HbA1c is a blood test that measures a person’s average blood sugar levels over several months.

Katon is the director of health services and psychiatric epidemiology at the University of Washington Medical School, in Seattle. He and his colleagues studied 2,359 patients with diabetes enrolled in the Pathways Epidemiologic Study and assessed their level of depression using the Patient Health Questionnaire-9 (PHQ-9), a self-reported survey of depression symptoms.

Over the five-year follow-up period, 22.9 percent of the patients who had PHQ-9 scores that ranked as “major depression” developed diabetic retinopathy compared with 19.7 percent of the patients without depression. With a five-point increase on the PHQ-9 score, patients’ risk of having diabetic retinopathy increased by up to 15 percent.

“Our findings suggested that psychobiologic changes associated with depression such as increased cortisol levels and activity of blood-clotting factors may be linked to the development of retinopathy,” Katon said.

“There is no question that the burden of depression among patients with diabetes is very high and that depression is a risk factor for worse outcomes in patients with diabetes, as was seen in this study,” said Todd Brown, M.D., an assistant professor of medicine at the division of endocrinology and metabolism at Johns Hopkins University.

He added that multiple explanations might account for these findings — some related to biological changes and some due to behavioral social issues, such as decreased physical activity and poorer utilization of health care.

“The big question with all of this is whether identifying and treating depression in patients with diabetes will change clinical outcomes,” Brown said. “And currently, there are no universal recommendations for depression screening among patients with diabetes.”

Material adapted from Health Behavior News Service, part of the Center for Advancing Health.

Reference
General Hospital Psychiatry is a peer-reviewed research journal published bimonthly by Elsevier Inc. For information about the journal, contact Wayne Katon, M.D., at (206) 543-7177.

The report explains that fisetin, a naturally-occurring flavonoid found most abundantly in strawberries and to a lesser extent in other fruits and vegetables, lessens complications of diabetes. Previously, the lab showed that fisetin promoted survival of neurons grown in culture and enhanced memory in healthy mice. That fisetin can target multiple organs strongly suggests that a single drug could be used to mitigate numerous medical complications.

“This manuscript describes for the first time a drug that prevents both kidney and brain complications in a type 1 diabetes mouse model,” says David Schubert, Ph.D., professor and head of the Cellular Neurobiology Laboratory and one of the manuscript’s co-authors. “Moreover, it demonstrates the probable molecular basis of how the therapeutic is working.”

Pam Maher, Ph.D., a senior staff scientist in the CNL, is the study’s corresponding author. Maher initially identified fisetin as a neuroprotective flavonoid ten years ago. “In plants, flavonoids act as sunscreens and protect leaves and fruit from insects,” she explains. “As foods they are implicated in the protective effect of the ‘Mediterranean Diet.’”

Other celebrity flavonoids include polyphenolic compounds in blueberries and red wine.

Although her group’s focus is neurobiology, Maher and colleagues reasoned that, like other flavonoids, fisetin might ameliorate a spectrum of disorders seen in diabetic patients. To test this, they evaluated effects of fisetin supplementation in Akita mice, a very robust model of type 1 diabetes, also called childhood onset diabetes.

Akita mice exhibit increased blood sugar typical of type 1 diabetes and display pathologies seen in serious human complications of both type 1 and 2 diabetes. Those include diabetic nephropathy or kidney disease, retinopathy, and neuropathies in which patients lose touch or heat sensations.

Mice fed a fisetin-enriched diet remained diabetic, but acute kidney enlargement-or hypertrophy-seen in untreated mice was reversed, and high urine protein levels, a sure sign of kidney disease, fell. Moreover, fisetin ingestion ameliorated anxiety-related behaviors seen in diabetic mice.

“Most mice put in a large area become exploratory,” says Maher. “But anxious mice tend not to move around. Akita mice showed enhanced anxiety behavior, but fisetin feeding restored their locomotion to more normal levels.”

The study also defines a likely molecular mechanism underlying these effects. Researchers observed that blood and brain levels of sugars affixed to proteins known as advanced glycation end-products-or AGEs-were reduced in fisetin-treated compared to untreated Akita mice. These decreases were accompanied by increased activity of the enzyme glyoxalase 1, which promotes removal of toxic AGE precursors.

The discovery of an AGE-antagonizing enzyme upregulated by fisetin is very intriguing because substantial evidence implicates high blood AGE levels with many if not most diabetic complications. “We know that fisetin increases activity of the glyoxalase enzyme and may increase its expression,” says Maher. “But what is important is that ours is the first report that any compound can enhance glyoxalase 1 activity.”

Interestingly, excessively high AGE levels also correlate with inflammatory activity thought to promote some cancers. In fact, studies published by others confirm that fisetin decreases tumorigenicity of prostate cancer cells both in culture and in animal models, which if supported would represent a major added incentive to eat your strawberries.

To ingest fisetin levels equivalent to those fed Akita mice, Maher estimates that humans would have to eat 37 strawberries a day, assuming that strawberry fisetin is as readily metabolizable by humans as fisetin-spiked lab chow is by mice. Rather than through diet, Maher envisions that fisetin-like drugs could be taken as a supplement.

Schubert notes that fisetin is also effective in mouse models of Alzheimer’s disease. “We and others have shown that diabetes may be a risk factor for Alzheimer’s disease, making identification of a safe prophylactic like fisetin highly significant,” he says.

Maher acknowledges that the public may be suffering from flavonoid-fatigue given media coverage of the promises of these compounds. “Polyphenolics like fisetin and those in blueberry extracts are found in fruits and vegetables and are related to each other chemically,” she says. “There is increasing evidence that they all work in multiple diseases. Hopefully some combination of these compounds will eventually get to the clinic.”

Schubert concurs that their findings only reinforce what common sense and our mothers told us was a healthy lifestyle. “Eat a balanced diet and as much freshly prepared organic food as possible, get some exercise, keep socially and mentally active and avoid sodas with sugar and highly processed foods since they can contain high levels of AGEs,” he advises.

But he also worries that hoops that must be jumped through to bring a natural product like fisetin, as opposed to a totally synthetic drug, to clinical trials are daunting because it is difficult to protect patents on natural products. “We will never know if a compound like fisetin works in humans until someone is willing to support a clinical trial.”

Also contributing to this study were Richard Dargusch and Jennifer L. Ehren, Ph.D.,of the Cellular Neurobiology Laboratory, and Kumar Sharma, M.D., and Shinichi Okada, M.D., Ph.D., of the Department of Medicine at University of California, San Diego.

Material adapted from Salk Institute for Biological Studies.

Professor Majid Ezzati

Diabetes occurs when the cells of the body are not able to take up sugar in the form of glucose. As a consequence, the amount of glucose in the blood is higher than normal. Over time, this raises the risk of heart disease and stroke, and can also cause damage to the kidneys, nerves, and retinas. High blood glucose and diabetes are responsible for over three million deaths worldwide each year.

The new study found that between 1980 and 2008, the number of adults with diabetes rose from 153 million to 347 million. Seventy per cent of the rise was due to population growth and ageing with the other 30 per cent due to higher prevalence. The proportion of adults with diabetes rose to 9.8 per cent of men and 9.2 per cent of women in 2008, compared with 8.3 per cent of men and 7.5 per cent of women in 1980.

The estimated number of diabetics was considerably higher than a previous study in 2009 which put the number worldwide at 285 million.

The study, the largest of its kind for diabetes, was carried out by an international collaboration of researchers, led by Professor Majid Ezzati from Imperial College London and co-led by Dr. Goodarz Danaei from the Harvard School of Public Health, in collaboration with The World Health Organization and a number of other institutions.

Professor Majid Ezzati, from the School of Public Health at Imperial College London, said “Diabetes is one of the biggest causes of morbidity and mortality worldwide. Our study has shown that diabetes is becoming more common almost everywhere in the world. This is in contrast to blood pressure and cholesterol, which have both fallen in many regions. Diabetes is much harder to prevent and treat than these other conditions.”

Dr. Goodarz Danaei, from the Harvard School of Public Health, added “Unless we develop better programmes for detecting people with elevated blood sugar and helping them to improve their diet and physical activity and control their weight, diabetes will inevitably continue to impose a major burden on health systems around the world.”

To test whether or not someone has diabetes, doctors measure the levels of glucose in a patient’s blood after they have not eaten for 12 to 14 hours, since blood sugar rises after a meal. A “fasting plasma glucose” (FPG) below 5.6 millimoles per litre (mmol/L) is considered normal, above 7 mmol/L is diagnostic of diabetes and an FPG level between 5.6 and 7 is considered pre-diabetes.

The study included blood sugar measurements from 2.7 million participants aged 25 years or more across the world and used advanced statistical methods for analyzing data. According to the results, average fasting sugar rose from 5.3 mmol/L in men and 5.2 mmol/L in women in 1980 to 5.5 mmol/L in men and 5.4 mmol/L in women in 2008, even after accounting for age differences over time.

The study also found that:

• Diabetes has taken off most dramatically in Pacific Island nations, which now have the highest diabetes levels in the world. In the Marshall Islands, one in three women and one in four men have diabetes. Glucose and diabetes were also particularly high in south Asia, Latin America, the Caribbean, Central Asia, North Africa, and the Middle East.
• Among high-income countries, the rise in diabetes was relatively small in Western Europe and highest in North America. Diabetes and glucose levels were highest in USA, Greenland, Malta, New Zealand, and Spain, and lowest in the Netherlands, Austria, and France.
• Of the 347 million people with diabetes, 138 million live in China and India and another 36 million in the USA and Russia.
• The region with the lowest glucose levels was sub-Saharan Africa, followed by east and southeast Asia.

Funding for the study came from the Bill and Melinda Gates Foundation and the World Health Organisation.

Material adapted from Imperial College London.

Reference
‘National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants.’ The Lancet, published online 25 June 2011. DOI:10.1016/S0140-6736(11)60679-X

“Over time, the prevalence of DKD may increase due to the expanding size of the diabetes population or decrease due to the implementation of diabetes therapies,” according to background information in the article the authors write.

Ian H. de Boer, M.D., M.S., of the University of Washington, Seattle, and colleagues examined trends in the prevalence of DKD in the United States and changes in disease manifestations among persons with diabetes over the past 2 decades. The study included data from the Third National Health and Nutrition Examination Survey (NHANES III) from 1988-1994 (n = 15,073), NHANES 1999-2004 (n = 13,045), and NHANES 2005-2008 (n = 9,588). Participants with diabetes were defined by levels of hemoglobin A 1c of 6.5 percent or greater, use of glucose-lowering medications, or both (n = 1,431 in NHANES III; n = 1,443 in NHANES 1999-2004; n=1,280 in NHANES 2005-2008). Diabetic kidney disease was defined as diabetes with albuminuria (ratio of urine albumin to creatinine 30 mg/g or greater), impaired glomerular filtration rate (less than 60 mL/min/1.73 m 2 estimated using the Chronic Kidney Disease Epidemiology Collaboration formula), or both.

The researchers found that the prevalence of DKD in the U.S. population was 2.2 percent in 1988-1994, 2.8 percent in 1999-2004, and 3.3 percent in 2005-2008, with the demographically adjusted increase in DKD prevalence being 18 percent from 1988-1994 to 1999-2004 and 34 percent from 1988-1994 to 2005-2008. The estimated numbers of persons with DKD in the U.S. at any given point in time increased from 3.9 million during 1988-1994 to 5.5 million during 1999-2004 to 6.9 million during 2005-2008.

The proportion of persons with diabetes taking glucose-lowering medications increased from 56.2 percent to 74.2 percent and the use of renin-angiotensin-aldosterone system inhibitors increased from 11.2 percent to 40.6 percent. The prevalence of impaired GFR increased from 14.9 percent in 1988-1994 to 17.7 percent in 2005-2008. The prevalence of impaired albuminuria decreased from 27.3 percent to 23.7 percent during these time periods, but this was not statistically significant.

“In conclusion, DKD has become more prevalent in the U.S. population over the last 2 decades and will likely contribute increasingly to health care costs and mortality. Among persons with diabetes, clinical manifestations of DKD shifted to include more impaired GFR but the prevalence of any DKD did not change despite increased use of diabetes-related medications,” the authors write.

Material adapted from JAMA.

Reference
JAMA. 2011;305[24]2532-2539.

“Type 2 diabetes mellitus is associated with increased risks of both stroke and coronary heart disease (CHD),” the authors write. “Metabolic syndrome (MetS) or insulin resistance identifies individuals at higher risk for developing type 2 diabetes and is also associated with an increase in stroke and cardiovascular morbidity.”

Alfred Callahan, M.D., from Vanderbilt University, Nashville, and colleagues evaluated these risks as part of a secondary analysis of the Stroke Prevention by Aggressive Reduction of Cholesterol Levels (SPARCL) Trial. The primary goal of that study was to evaluate the effect of a cholesterol-lowering statin drug (atorvastatin) on reducing the incidence of stroke in patients with a prior stroke or TIA. For this study, the authors performed a secondary analysis on the data to determine the risk of recurrent stroke or cardiovascular events in patients with type 2 diabetes or MetS, and whether atorvastatin affected those risks.

In total, the study included 4,731 participants who had experienced an ischemic stroke or TIA. When enrollment began, researchers classified 794 individuals as having type 2 diabetes, 642 as having MetS and the remaining 3,295 as having neither condition. The endpoints used for this analysis were recurrence of stroke, major coronary or cardiovascular events, any CHD event, and any revascularization procedure (a procedure, such as angioplasty, to open a blocked artery).

Patients with type 2 diabetes were more likely than those in the control group to experience another stroke, major cardiovascular incident, or revascularization procedure. Those in the MetS group were not at increased risk of stroke or major cardiovascular events, but were more likely than those in the control group to undergo revascularization procedures. Treatment with the statin medication did not significantly reduce the risk of these events in participants with type 2 diabetes or MetS.

The authors note that their results are similar to other studies of stroke and cardiovascular events in individuals with MetS or type 2 diabetes. In particular, they cite the differences in risks between the two conditions. They also point out that statin use did not seem to be protective for participants: “Although the possibility of variation in the benefit of statin treatment in subjects with or without type 2 diabetes or MetS cannot be excluded by this analysis, there was no evidence of a difference in treatment effect.”

Material adapted from JAMA.

Reference
Arch Neurol. 2011;doi:10.1001/archneurol.2011.146.

“Previous studies have shown that children of mothers who gain too much weight during pregnancy are more likely to be overweight for their age. However, not all these studies accounted for the mother’s diabetes status during pregnancy, which is a known risk factor for offspring obesity,” Josefson said.

The new study evaluated only pregnant women without gestational diabetes, therefore ruling out the chance that this disorder could account for their findings.

Josefson and her colleagues wanted to learn whether pregnant women who gain more than the recommended amount of weight have over-weight infants. Doctors, however, do not typically measure a newborn’s body fat, she said. Many past studies that measured newborn body fat used an imprecise method, such as skin fold thickness, according to the authors’ abstract.

This study used a new infant body composition system (Pea Pod) that employs an air-displacement technique, which Josefson said accurately and safely measures newborn body fat. This technique requires the infant to simply lie in a machine for two minutes, she said. Newborns in the study underwent measurements of length, weight and fat within 48 hours of birth.

Of the 56 mothers the researchers studied, 31 women were within guidelines for pregnancy weight gain, and 25 exceeded the guidelines. The Institute of Medicine recommends that women at a healthy weight before pregnancy gain 25 to 35 pounds while expecting a single baby; overweight women, 15 to 25 pounds; and obese women, 11 to 20 pounds.

Study subjects who were obese before pregnancy were more likely than healthy-weight women to exceed the weight-gain guidelines (70 percent versus 31 percent, respectively), the authors reported. Yet regardless of pre-pregnancy weight, women who put on more than the recommended weight gave birth to significantly fatter babies. Their newborns had 490 grams, or 17.5 ounces, of body fat, whereas newborns of women who stayed within the guidelines had 390 grams (13.9 ounces) of fat. This higher obesity risk existed even when birth weight was normal.

“Excessive weight gain during pregnancy, regardless of pre-pregnancy weight, is an important risk factor for newborn obesity,” Josefson said. “More research is needed to determine if high amounts of fat at birth are associated with high amounts of fat in childhood.”

Material adapted from Endocrine Society.

“At eight weeks, the group on the lower fat diet had significantly higher insulin secretion and better glucose tolerance and tended to have higher insulin sensitivity,” said Barbara Gower, Ph.D., professor in the Department of Nutrition Sciences at UAB and lead author of the study. “These improvements indicate a decreased risk for diabetes.”

Gower says the unique aspect of this study is that the results were independent of weight loss.

The study participants were fed exactly the amount of food required to maintain their body weight, and the researchers took into account any minor fluctuations in body weight during analyses. Thus, results from this study suggest that those trying to minimize risk for diabetes over the long term might consider limiting their daily consumption of fat at around 27 percent of their diet.

“People find it hard to lose weight,” said Gower. “What is important about our study is that the results suggest that attention to diet quality, not quantity, can make a difference in risk for type 2 diabetes.”

The findings were even stronger in African-Americans, a population with an elevated risk for diabetes. Gower says African-Americans on the lower fat diet showed a stronger difference in insulin secretion compared to the lower carb group, indicating that diet might be an important variable for controlling diabetes risk in that population.

Study participants in the lower fat group received a diet comprising 27 percent fat and 55 percent carbohydrate. The lower carb group’s diet was 39 percent fat and 43 percent carbohydrate. All food for the eight-week trial was provided by the study.

“The diets used in this study were actually fairly moderate,” said UAB dietitian Laura Lee Goree, R.D., L.D., a study co-author. “Individuals at risk for diabetes easily could adopt the lower fat diet we employed. Our findings indicate that the lower-fat diet might reduce the risk of diabetes or slow the progression of the disease.”

A typical dinner meal on the lower fat diet would include sesame chicken with rice, snow peas and carrots, frozen broccoli, fat-free cheese, oranges and a dinner roll.
According to the American Diabetes Association, Type 2 diabetes is the most common form of diabetes; millions of Americans have been diagnosed with it, and many more are unaware they are at high risk. Some groups have a higher risk for developing Type 2 diabetes, particularly African-Americans, Latinos, Native Americans and the elderly.

In Type 2 diabetes, the body either does not produce enough insulin or the cells ignore it. Insulin is necessary for the body to be able to use glucose for energy. When you eat food, the body breaks down the sugars and starches into glucose, which is the basic fuel for the cells in the body. Insulin takes the sugar from the blood into the cells. When glucose builds up in the blood instead of going into cells, it can lead to diabetes complications.

Gower says further research is needed to determine if the difference between diets in carbohydrate or fat was responsible for the differences in the measures of glucose metabolism and probe the potential cause-and-effect relationship between insulin and glucose responses to the diets.

Material adapted from University of Alabama at Birmingham.

“Exercise is a cornerstone of diabetes management, along with dietary and pharmacological interventions. Current guidelines recommend that patients with type 2 diabetes should perform at least 150 minutes per week of moderate-intensity aerobic exercise and should perform resistance exercise 3 times per week,” according to background information in the article. “Regular exercise improves glucose control in diabetes, but the association of different exercise training interventions on glucose control is unclear.”

Daniel Umpierre, M.Sc., of the Hospital de Clinicas de Porto Alegre, Brazil, and colleagues performed a systematic review and meta-analysis of previously conducted randomized controlled clinical trials (RCTs) of at least 12 weeks’ duration that evaluated the ability of structured exercise training or physical activity advice to lower hemoglobin A1c (HbA1c) levels as compared with a control group in patients with type 2 diabetes. The researchers identified 47 RCTs (8,538 patients) that met criteria for inclusion.

The researchers found that overall, structured exercise training (23 studies) was associated with a decline in HbA1c level (-0.67 percent) compared with control participants. In addition, structured aerobic exercise (-0.73 percent), structured resistance training (-0.57 percent), and both combined (-0.51 percent) were each associated with declines in HbA1c levels compared with control participants.

“Structured exercise durations of more than 150 minutes per week were associated with HbA1c reductions of 0.89 percent, while structured exercise durations of 150 minutes or less per week were associated with HbA1c reductions of 0.36 percent. Overall, interventions of physical activity advice (24 studies) were associated with lower HbA1c levels (-0.43 percent) compared with control participants. Combined physical activity advice and dietary advice was associated with decreased HbA1c (-0.58 percent) as compared with control participants. Physical activity advice alone was not associated with HbA1c changes,” the authors write.

“This systematic review and meta-analysis of RCTs demonstrates important findings regarding the prescription of structured exercise training. First, aerobic, resistance, and combined training are each associated with HbA1c decreases, and the magnitude of this reduction is similar across the 3 exercise modalities. Second, our findings demonstrate that structured exercise of more than 150 minutes per week is associated with greater declines in HbA1c than structured exercise of 150 minutes or less per week in patients with type 2 diabetes. This finding is important because the current guideline-recommended exercise duration is at least 150 minutes per week. Although high-intensity exercise has been previously shown to have an association with HbA1c reduction, our findings did not demonstrate that more intensive exercise was associated with greater declines in HbA1c.”

The researchers add that the finding that physical activity advice is only associated with HbA1c reduction when accompanied by a dietary cointervention highlights the need for a combined recommendation of these lifestyle interventions.

Material adapted from JAMA.

Reference
JAMA. 2011;305[17]1790-1799.

“Poor sleep quality in people with diabetes was associated with worse control of their blood glucose levels,” said Kristen Knutson, PhD, assistant professor of medicine and lead author of the study. “People who have a hard time controlling their blood glucose levels have a greater risk of complications. They have a reduced quality of life. And, they have a reduced life expectancy.”

People with diabetes generally have poorer sleep than the general population, and poor sleep has been proposed as a risk factor for developing the disease. Sleep disorders, such as obstructive sleep apnea, are more prevalent in people with type 2 diabetes, Knutson said.

For the study, researchers monitored the sleep of 40 people with diabetes for six nights. The subjects also reported if they generally suffered from symptoms of sleep disturbances like insomnia, snoring or sleep apnea. At clinical examinations, they gave blood samples to allow researchers to measure insulin and glucose levels.

The subjects wore activity monitors on their wrists at night, which measure their wrist movements throughout the night. Poor sleep, or insomnia, was determined by both poor sleep quality based on the activity monitors and the subject telling the researchers that they often had a hard time falling asleep or woke up during the night.

Among the diabetics, poor sleepers had 23% higher blood glucose levels in the morning and 48% higher blood insulin levels. Using these numbers to estimate a person’s insulin resistance, the researchers found that poor sleepers with diabetes had 82% higher insulin resistance than normal sleepers with diabetes.

Knutson said the next step for researchers is to see if treating poor sleep can improve long-term outcomes and quality of life for diabetics. “For someone who already has diabetes, adding a sleep treatment intervention, whether it’s treating sleep apnea or treating insomnia, may be an additional help for them to control their disease,” Knutson said.

In fact, restoring a healthy amount of sleep may be as powerful an intervention as the drugs currently used to treat type 2 diabetes. “This suggests that improving sleep quality in diabetics would have a similar beneficial effect as the most commonly used anti-diabetes drugs,” said Eve Van Cauter, PhD, professor of medicine and co-author of the study.

Further investigation into which leads to the other – the chronic poor sleep or chronic insulin resistance – could improve the quality of life for people with type 2 diabetes.

“Anything that we can do to help people improve their ability to control their glucose will help their lives in the long run,” Knutson said.

The data was collected as part of the CARDIA study, an ongoing longitudinal study of the heart health. It has tracked thousands of people for over 20 years.

In addition to Drs. Knutson and Van Cauter, authors include Phyllis Zee and Kiang Liu at Northwestern University, and Diane Lauderdale at the University of Chicago Department of Health Studies.

Material adapted from University of Chicago Medical Center.

Download / Abstract
The study, “Cross-sectional associations between measure of sleep and markers of glucose metabolism among persons with and without diabetes” was published online March 16, 2011, in the journal Diabetes Care.

Charles Mobbs, PhD, Professor of Neuroscience and Geriatrics and Palliative Care Medicine at Mount Sinai School of Medicine, and his research team evaluated mice that were genetically predisposed to have Type 1 or 2 diabetes. The mice were allowed to develop diabetic nephropathy, or kidney failure. Half of the mice were put on the ketogenic diet, while the control group maintained a standard high carbohydrate diet. The researcher founds that after eight weeks, kidney failure was reversed in the mice on the ketogenic diet.

“Our study is the first to show that a dietary intervention alone is enough to reverse this serious complication of diabetes,” said Dr. Mobbs. “This finding has significant implications for the tens of thousands of Americans diagnosed with diabetic kidney failure, and possibly other complications, each year.”

The ketogenic diet is a low-carbohydrate, moderate protein, and high-fat diet typically used to control seizures in children with epilepsy. Many cells can get their energy from ketones, which are molecules produced when the blood glucose levels are low and blood fat levels are high. When cells use ketones instead of glucose for fuel, glucose is not metabolized. Since high glucose metabolism causes kidney failure in diabetes, researchers hypothesized that the ketogenic diet would block those toxic effects of glucose.

Considering the extreme requirements of the diet, it is not a long-term solution in adults. However, Dr. Mobbs’ research indicates that exposure to the diet for as little as a month may be sufficient to “reset” the gene expression and pathological process leading to kidney failure.

The researchers also identified a large array of genes expressed during diabetic nephropathy not previously known to play a role in the development of this complication. These genes are associated with kidney failure as a result of the stress on cellular function. The team found that the expression of these genes was also reversed in the mice on the ketogenic diet.

Dr. Mobbs and his team plan to continue to research the impact of the ketogenic diet and the mechanism by which it reverses kidney failure in people with diabetes, and in age-related kidney failure. He believes the ketogenic diet could help treat other neurological diseases and retinopathy, a disease that results in vision loss.

“Knowing how the ketogenic diet reverses nephropathy will help us identify a drug target and subsequent pharmacological interventions that mimic the effect of the diet,” said Dr. Mobbs. “We look forward to studying this promising development further.”

Material adapted from Mount Sinai Medical Center.

Their findings, published online ahead of print in Medical Care, showed the intervention was successful in lowering patients’ blood pressure, increasing their physical activity by about four miles of walking per week, and easing their depressive symptoms.

“Depression is a common, treatable issue for many people who have diabetes,” says study lead author John Piette, Ph.D., a senior research scientist at the VA and professor of internal medicine at the U-M Medical School. “Unfortunately, most busy clinics cannot provide the level of intensive care these patients need. This study shows that telephone-delivered counseling can improve patients’ access to effective depression care, improve their cardiovascular health, and get them moving again.”

The cognitive behavior therapy helped the study participants address negative thought processes and behaviors that made it difficult for them to manage their diabetes and make healthy lifestyle choices, Piette says.

The physical activity component of the program used pedometers to help patients set walking goals and monitor their progress. Along with physical benefits, exercise also helps boost one’s mood.

Most patients entered the study with relatively good blood glucose control. So while the intervention did not lead to a drop in A1C, a common measurement of blood glucose levels, patients did see more than a 4-point improvement in their systolic blood pressure, walked about half a mile more per day, and reported an improvement in their general quality of life.

At the end of the year, 58 percent of patients who received the intervention had depression symptoms that were in remission, compared to only 39 percent of the patients who did not receive counseling.

“Health systems should consider routinely offering structured telephone psychotherapy to their patients with diabetes and depression,” says senior study author Marcia Valenstein, M.D., M.S., an associate professor of psychiatry at the U-M Medical School and VA research scientist. “Patients with depression and additional chronic medical conditions do better if their depression is addressed first, if it is addressed systematically, and if exercise is also encouraged. Delivering therapy by telephone makes it feasible to reach large numbers of patients who may not attend traditional in-person appointments.”

Methods: 291 patients with type 2 diabetes and significant depressive symptoms completed the study; 145 received the intervention, which consisted of 12 weeks of cognitive behavioral therapy over the phone, followed by nine monthly “booster” sessions. After six weeks, a pedometer-based walking program was introduced. Depression, coping, and quality-of-life measurements were taken using standardized scales.

Funding: The research was funded by grants from the National Institutes of Health, Michigan Diabetes Research and Training Center and the Michigan Institute for Clinical and Health Research.

Additional authors were: Caroline Richardson, M.D., of U-M and VA; Sonia Duffy, Ph.D., of U-M and VA; Joseph Himle, Ph.D., of U-M; and Trissa Torres, M.D.; Mark Vogel, Ph.D.; and Kimberly Barber, Ph.D., all of Genesys Health System, Flint, Mich.

Material adapted from University of Michigan Health System.

Reference
“A Randomized Trial of Telephonic Counseling Plus Walking for Depressed Diabetes Patients,” Medical Care. doi: 10.1097/MLR.0b013e318215d0c9

Previous epidemiologic studies have shown an association between diabetes and an increased risk for cancers including colorectal, liver and pancreas, according to Gabriel Lai, Ph.D., a cancer prevention fellow at the National Cancer Institute.

“Our results provide further evidence that abnormal insulin and glucose signaling may contribute to cancer initiation and development,” he said. “There are myriad benefits from avoiding diabetes through exercise, diet, and maintaining a healthy body weight. Our study confirms additional benefits in the form of reduced morbidity and mortality from certain cancers.”

Lai and colleagues conducted a prospective study using data from more than 500,000 predominantly white, non-Hispanic men and women aged 50 to 71 years. From 1995 to 1996, the participants completed questionnaires about diet, lifestyle, and whether or not they had diabetes. Researchers followed the patients for 11 years.

Results showed that diabetes was associated with an 8 percent increased risk for cancer among women and a 4 percent decreased risk for men. In previous research, a decreased risk for prostate cancer was associated with diabetes, which researchers believe might be due to the lower testosterone levels associated with diabetes. After excluding prostate cancer from their evaluation, Lai and colleagues found that diabetes was associated with a 9 percent increased risk for cancer in men.

As for mortality, diabetes was associated with an 11 percent increased risk in women and a 17 percent increased risk in men.

“These risks appeared independent from other cancer risk factors, such as obesity and cigarette smoking,” Lai said.

After evaluating by cancer site, the researchers found diabetes was associated with a significant increase in risk for colon, rectal and liver cancers among men and women. In men, diabetes was associated with an increased risk for pancreatic and bladder cancers; in women, it was associated with an increased risk for stomach, anal and endometrial cancers. No association was found between diabetes and lung, skin, or other cancers.

“Follow-up studies to identify the biologic mechanisms involved should be performed to build upon confirmed findings,” Lai said.

Material adapted from American Association for Cancer Research (AACR).

“Our results show clearly that insulin has the potential to be developed as a therapeutic agent for Alzheimer’s for which no satisfactory treatment is currently available,” says Paresh Dandona, MD, PhD, UB distinguished professor of medicine in the School of Medicine and Biomedical Sciences and senior author on the study.

One of the four proteins shown in the study to be suppressed by insulin is a precursor to beta amyloid, the main component of plaques considered the hallmark of Alzheimer’s disease.

The findings also demonstrate for the first time that the four precursor proteins studied are expressed in peripheral mononuclear cells, white blood cells that are an important component of the immune system.

The paper builds on the UB researchers’ earlier work showing that insulin has a potent and rapid anti-inflammatory effect on peripheral mononuclear cells. It also builds on the well-known association between obesity, type 2 diabetes and chronic low-grade inflammation, as well as insulin resistance, all conditions that manifest a significantly increased prevalence of Alzheimer’s disease.

In the study, 10 obese, patients with type 2 diabetic were infused with two 100 ml units of insulin per hour over a period of four hours. The patients were all taking oral drugs to treat their diabetes; none of them were taking insulin or any antioxidant or nonsteroidal anti-inflammatory drugs. The control group received 5 percent dextrose per hour or normal saline solution.

The low-dose insulin was found to suppress the expression of amyloid precursor protein, from which beta amyloid is derived. It also suppressed presenilin-1 and presenilin-2 – the two subunits of an enzyme that converts amyloid precursor protein into beta amyloid, which goes on to form the amyloid plaques. Insulin also suppressed glycogen synthase kinase, which phosphorylates, or adds on another phosphate group, to another neuronal protein, tau, to form the neurofibrillary tangles, the other important component of Alzheimer’s disease in the brain.

“Our data show, for the first time that the peripheral mononuclear cells express some of the key proteins involved in the pathogenesis of Alzheimer’s disease,” says Dandona. “They demonstrate that these cells can be used for investigating the effect of potential Alzheimer’s disease therapies on key proteins involved in the disease.

“Even more importantly, it is likely that insulin has a direct cellular effect on these precursor proteins while also exerting its other anti-inflammatory actions,” he continues. “If this effect of insulin proves in larger studies to be systemic, then insulin may well be a potential therapeutic agent in treating Alzheimer’s disease. The challenge is to deliver insulin directly into the brain, thus avoiding its hypoglycemic effect.”

Fortunately, Dandona says, a previous preliminary study has shown that intranasal delivery of insulin can lead to its entry into the brain along the olfactory nerves and that its administration may improve cognitive function in patients with Alzheimer’s disease. However, he cautions, the mode of action is not known.

“Our study provides a potential rational mechanism,” he says.

Additional contributors to the study, all from Dandona’s lab, are Islam Mohamed; Husam Ghanim, PhD, research assistant professor of medicine; Chang Ling Sia; Sandeep Dhindsa, assistant professor of medicine; Sonny Dandona; Antoine Makdissi, assistant professor of medicine; and Ajay Chaudhuri, MD, associate professor of medicine.

Material adapted from University at Buffalo.

Adults between 51 and 70 with diabetes developed age-related ailments like cognitive impairment, incontinence, falls, dizziness, vision impairment, and pain at a faster rate than those without diabetes, the study found.

“Our findings suggest that middle age adults with diabetes start to accumulate these age-related problems,” says lead author Christine Cigolle, M.D., M.P.H., an assistant professor of family medicine and internal medicine at the U-M Medical School and research scientist at the VA. “Because diabetes affects multiple organ systems, it has the potential to contribute significantly to the development of a number of issues that we associate with aging.”

For adults aged 51-60 with diabetes, the odds of developing new geriatric conditions were nearly double those of their counterparts who did not have diabetes, the researchers found. By the time people with and without diabetes reach 80, the overall effects of aging and impact of other diseases start to reduce the disparities between the two groups.

“The findings suggest that adults with diabetes should be monitored for the development of these conditions beginning at a younger age than we previously thought,” says Cigolle, also a research assistant professor at the U-M Institute of Gerontology.

“If we know to start looking for these conditions earlier, we can manage and treat them more effectively,” she adds.

Additional authors who contributed were Pearl G. Lee, M.D.; Kenneth M. Langa, M.D., Ph.D.; Yuo-Yu Lee, M.S.; Zhiyi Tian, M.S.; and Caroline S. Blaum, M.D., M.S., all of U-M. Lee, Langa and Blaum also have VA appointments.

Material adapted from University of Michigan Health System.

Reference / Abstract
“Geriatric Conditions Develop in Middle-Aged Adults with Diabetes,” Journal of General Internal Medicine, March, 2011.

Today, an estimated 285 million people around the globe suffer from Type 2 diabetes, and the number is expected to double by 2030, notes Dr. Rubino, who also serves as associate professor of surgery at Weill Cornell Medical College. “The need for effective, potentially curative therapies is urgent.”

According to an analysis presented today at the Congress by an Australian researcher, bariatric surgery to treat Type 2 diabetes has been demonstrated to be very cost effective in the countries in which this research has been done – the United States, United Kingdom, Australia, and in some European settings.

The review also found that several studies have determined that bariatric surgery was not only cost effective, but cost saving, says Catherine Keating, a senior research fellow from the Health Economics Unit at Deakin University in Melbourne, who made the presentation. For obese patients diagnosed with Type 2 diabetes during the two years prior to bariatric surgery, one study found that the upfront costs of surgery would be fully recouped through the prevention of future health care costs to treat Type 2 diabetes. This study was undertaken alongside a clinical trial that found that remission of Type 2 diabetes was five times greater in surgically treated patients, relative to those receiving conventional therapies, she says.

“For this patient group bariatric surgery generates both cost savings and health benefits,” Ms. Keating says. “This provides the strongest rationale yet for implementation of this treatment on economic grounds.”

Treatment studies have shown that bariatric surgery, initially developed for the treatment of morbid obesity, can improve or normalize blood sugar levels, reduce or even eliminate the need for medication, and lower the risk of diabetes-related death.

A number of new cost-effectiveness studies have been discussed at the meeting, says Dr. David Reed Flum, who co-chairs the Congress’s policy track. “As health care costs soar, the obligation of all those involved in this issue is to understand the way resources are currently being applied to the treatment and prevention of diabetes and to explore what the future impact on health care resources might be if surgery becomes a meaningful part of the public health response to the diabetes epidemic,” says Dr. Flum, professor of surgery and health services at the University of Washington School of Medicine.

“Health ministers, economists, payers, and politicians have a critical role in determining the future of this issue, and we expected a robust dialog during this track of the Congress” he says.

The studies looked at whether the costs of the surgery – estimated at between $15,000 and $24,000 in the United States – are justified by its effectiveness and its potential to save future health care treatment for obesity-related diseases such as Type 2 diabetes.

“The effectiveness credentials for bariatric surgery are now very strong. It has been proven to reduce disease, extend life expectancy, and improve quality of life,” says Ms. Keating. “However, in the context of limited health care budgets, authorities around the world state that health care funding should be informed by an assessment of both treatment costs and effectiveness.”

To perform her analysis, Ms. Keating examined 16 published studies that looked at the cost-effectiveness of bariatric surgery, including gastric bypass and gastric banding. Ten of those studies examined the procedures in severely obese patients (those whose body mass index, or BMI, is greater than 35) who did not have Type 2 diabetes, and six looked at patients with Type 2 diabetes whose BMI was 30 to 40 (moderately to severely obese).

Each country establishes its own measure of cost effectiveness. In the United States, the threshold for benefit is $50,000 per quality-adjusted life year (QALY), which is defined as a year of human life with some adjustments for disease or disability.

Ms. Keating’s review found that bariatric surgery was very cost effective in both populations she studied (patients without diabetes and a BMI over 35, and patients with diabetes and a BMI 30 to 40), but that it was twice as cost effective in the latter category – the patients with Type 2 diabetes.

“This is likely because patients with diabetes have greater ill heath and therefore more benefits can be achieved through surgery in terms of quality of life, life expectancy, and prevention of future health care costs,” she says. “Without treatment, patients with Type 2 diabetes would endure lifelong disease and escalating health care costs.”

Among the costs associated with medical management of Type 2 diabetes are treatment for complications that affect the eyes, heart, kidneys, and extremities. Long-term costs include outpatient care, prescription medications and diabetes-related hospitalizations and surgeries, including amputations.

The analysis further demonstrated that using surgery to treat patients with newly diagnosed Type 2 diabetes (diagnosed less than five years before surgery) is more cost effective than using the surgery with patients whose diabetes has been established for longer than five years. For example, a 2009 U.S. study found that bypass surgery had cost-effectiveness ratios of $7,000/QALY and $12,000/QALY for severely obese patients with newly diagnosed and established diabetes, respectively.

“Targeting recently diagnosed diabetes is likely to be more cost effective because diabetes remission rates achieved are higher in this group than in those with established Type 2 diabetes,” Ms. Keating says. “Some of the studies I analyzed, particularly those targeting therapy for patients with recently diagnosed Type 2 diabetes, have found that the costs of surgery may be fully recouped through prevention of future health care costs. This excellent result is fairly rare.”

Material adapted from NewYork-Presbyterian Hospital/Columbia University Medical Center and NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

The scientists studied 351 participants in the Joslin 50-Year Medalist study, which examines people who have lived with type 1 diabetes for 50 years or more. Among this population, 43% are free from advanced diabetic eye complications, 87% from kidney disease, 39% from nerve disease, and 52% from cardiovascular disease.

The surprising number of Medalists without complications “is strong evidence that there are protective molecular, physiologic, or genetic mechanisms that in these fortunate individuals fight against the toxic effects of high blood sugars over many decades,” says Jennifer Sun, M.D., first author on the paper published in Diabetes Care.

As a group, the Joslin Medalists are very careful about controlling their blood glucose levels. However, within a reasonable range of glucose control, the study found that freedom from complications does not appear to correlate with how well these people controlled the blood sugar levels that go awry in diabetes. This conclusion differs from results shown in every other major recent study of diabetes management.

Clues to this protection may be found in analyses of a family of proteins called advanced glycation end products (AGEs), which are increased by high blood sugar levels. In the study, subjects who exhibited two specific AGEs were more than seven times as likely to have any complication. But this study also demonstrated for the first time that a combination of two other AGEs is associated with protection against eye disease.

Additionally, the researchers found a group of Medalists, followed at Joslin’s Beetham Eye Institute, whose diabetic eye complications stabilized after 17 years at a mild stage rather than continuing to worsen as expected. This finding again indicated that protective factors are present in this group.

The Joslin Medalist study has gathered data on more than 600 people and is running a broad series of investigations into what guards so many of them from complications.

Moreover, these diabetes veterans can provide other important lessons, as Dr. Sun points out.

“Insights from the Medalist Study are great motivators for patients who have just been diagnosed with diabetes or are early in the disease, particularly younger kids and adolescents,” she says. “We can tell these patients that we encourage them to control their blood sugars and get their recommended diabetes care, because they can live many decades with excellent vision and the chance to avoid other severe complications.”

Senior author on the paper is George King, M.D., Joslin’s chief scientific officer and head of the Dianne Nunnally Hoppes laboratory. Other contributors include Hillary Keenan, Jerry Cavallerano, Alessandro Doria and Lloyd Paul Aiello of Joslin; Bela Asztalos and Ernst Schaefer of Tufts University; and David Sell, Christopher Strauch and Vincent Monnier of Case Western Reserve University. Lead funders include the Juvenile Diabetes Research Foundation, the National Institutes of Health, the Massachusetts Lions Foundation, the Brehm Foundation, the Thomas J. Beatson, Jr. Foundation and Eli Lilly.

Material adapted from Joslin Diabetes Center.

“This is an important study,” said Xiao-Chuan Liu, Ph.D., who presented the results. “It is the first study to establish a strong link between nicotine and diabetes complications. If you’re a smoker and have diabetes, you should be concerned and make every effort to quit smoking.”

Nearly 26 million people in the United States and 260 million more worldwide have diabetes. Those complications — which include heart attacks, stroke, kidney failure, and nerve damage — are why diabetes is the sixth leading cause of death in the United States, and the third leading cause in some minority groups, according to the National Institutes of Health. Treating those complications takes $1 out of every $10 spent on health care each year.

Liu cited past research showing that good control of blood sugar levels is the key to preventing complications. The gold standard for monitoring long-term blood sugar levels in people with diabetes is the hemoglobin A1c (HbA1c) blood test. Used in conjunction with daily home blood sugar monitoring, the HbA1c test reveals the average amount of sugar in the blood during the last several weeks. High test results mean that diabetes is not well controlled and there is an increased risk of complications.

Doctors have known for years that smoking increases the risk of developing complications. Studies also show that smokers with diabetes have higher levels of HbA1c than nonsmokers with diabetes. However, nobody knew the exact substance in cigarette smoke responsible for the elevation in HbA1c. Liu and colleagues suspected it may be nicotine and set out to check nicotine’s effects on HbA1c. Using human blood samples, they showed that concentrations of nicotine similar to those found in the blood of smokers did, indeed, raise levels of HbA1c.

“Nicotine caused levels of HbA1c to rise by as much as 34 percent,” said Liu, who is with California State Polytechnic University in Pomona, Calif. “No one knew this before. The higher the nicotine levels, the more HbA1c is produced.”

Doctors could use data from this study as a new basis for encouraging patients with diabetes to quit smoking, Liu said. What about nicotine patches, electronic cigarettes, and other stop-smoking products? Liu pointed out that people tend to use those products for only brief periods, and that the benefits of permanently stopping smoking may outweigh any risk from temporary elevations in HbA1c. However, the study may raise concern over the long term use of such products, he added.

Material adapted from American Chemical Society (ACS).

Researchers found that patients who take statin drugs to control cholesterol levels for their diabetes could realize $832 in savings over three years if they increased their medication adherence by 10 percent. The same increase in medication adherence from patients taking ACE-inhibitors, a class of antihypertensive drug, was associated with $285 lower Medicare costs over a three-year period. A 10 percentage-point increase is equal to taking three more pills a month if a patient were prescribed one a day for a 30-day month.

“This is a commonsensical notion that better adherence to drugs that are recommended should have impacts that could plausibly save money,” Stuart said. “Our conclusion is, yeah, it’s there, but it’s a pretty modest saving.”

Stuart and colleagues followed about 4,000 Medicare patients who had diabetes diagnoses. Researchers asked the patients to track their pill counts and derived estimated spending costs from Medicare data. Their findings conflict with some published data on the correlation between medication adherence and medical savings.

“There is literature out there that suggests that you could cut the total health spending by a third or more if you just made people more adherent with the drugs that they should be taking,” Stuart said.

Studies have a difficult time linking medication adherence with cost savings. “It may be the people who take their pills regularly also regularly exercise and watch their diet and conform to all the requirements, so it’s hard to separate them,” said Robert Henry, president of medicine and science for the American Diabetes Association.

Because factors other than medication adherence influence a patient’s health, other outcomes such as overall quality of life are also tough to measure. “I think a general statement can be made that the more compliant one is, the better their quality of life, the lower their complication rate and probably a greater longevity,” Henry said.

Material adapted from Health Behavior News Service, part of the Center for Advancing Health.

“Responsibilities and anxieties can differ for patients with diabetes and their spouses, but each may experience stress, frustration, and sadness at times related to the demands of living with this disease,” said Melissa M. Franks, an assistant professor of child development and family studies. “We know spouses often support their partners, but in our work we want to know what form their involvement takes and how the disease and its management affect both the patient and spouse.”

Franks and her team found that the distress spouses feel is similar to what patients feel, and this could contribute to their own depressive symptoms, such as irritability or sadness. These depressive symptoms come from their own anxieties about living with the disease or caring for someone with the disease and not necessarily because the other person is struggling.

Researchers also found that when male patients were concerned about the management of their diabetes, their depressive symptoms were elevated more than those for female patients with similar levels of concerns.

“This gender difference is consistent with prior work showing that male patients who are not managing their disease well tend to experience greater depressive symptoms,” Franks said. “And while we saw this difference between male and female patients, we did not see the same pattern of distress between their respective spouses. This is surprising, because one might assume that the spouse would be as worried, or, according to family roles, that wives might worry more. However, more research, especially long-term observations, is needed.”

The findings were based on statistical models with 185 couples older than 50. The patients and spouses completed individual surveys that measured distress related to diabetes, such as adherence to treatment recommendations, as well as depressive symptoms. The gender effects were measured by comparing the couples’ responses. There were 67 female patients and 118 male patients, and each couple was screened to make sure only one person had diabetes.

“Because spouses’ distress is not always directly linked to feelings of their partner, it tells us that we need to pay more attention to the spouse as well as the patient,” she said. “Understanding the triggers for depressive symptoms can help practitioners and experts better care for patients and spouses as individuals and as a unit.

“We also found that many people reported some depressive symptoms, and some reported levels indicative of risk for clinical depression. It’s important to consider depressive symptoms because they may signal concerns and problems that could be alleviated with treatment.”

Diabetes affects about one in five Americans over the age of 60, and the majority of those people have Type 2 diabetes, which is a disease of the endocrine system. Type 2 diabetes, also referred to as adult-onset diabetes, is caused by insufficient secretion of insulin and resistance to insulin, which is problematic because it lessens the ability of cells to absorb glucose from the bloodstream. The incidence of the disease, which is considered a leading cause of death, is increasing as more people are overweight and sedentary.

The disease is managed daily through diet, exercise, and medications. Complications, such as poor blood circulation, vision impairment, heart disease and stroke, are possible if the disease is not managed. In this study, spouses often reported that the disease’s daily management as well as the fear of their loved one’s living with diabetes were common concerns.

Material adapted from Purdue University.

Reference / Abstract
Melissa M. Franks, Todd Lucas, Mary Ann Parris Stephens, Karen S. Rook, & Richard Gonzalez. Diabetes Distress and Depressive Symptoms: A Dyadic Investigation of Older Patients and Their Spouses. Family Relations, Volume 59, Issue 5, pages 599–610, December 2010.

Reporting with colleagues in the current edition of the journal Diabetes, first author Atsushi Goto, a UCLA doctoral student in epidemiology, and Dr. Simin Liu, a professor of epidemiology and medicine with joint appointments at the UCLA School of Public Health and the David Geffen School of Medicine at UCLA, show that women who drink at least four cups of coffee a day are less than half as likely to develop diabetes as non-coffee drinkers.

When the findings were adjusted for levels of SHBG that protective effect disappeared, the researchers said.

The American Diabetes Association estimates that nearly 24 million children and adults in the U.S. – nearly 8 percent of the population – have diabetes. Type 2 diabetes is the most common form of the disease and accounts for about 90 to 95 percent of these cases.

Early studies have consistently shown that an “inverse association” exists between coffee consumption and risk for type 2 diabetes, Liu said. That is, the greater the consumption of coffee, the lesser the risk of diabetes. It was thought that coffee may improve the body’s tolerance to glucose by increasing metabolism or improving its tolerance to insulin.

“But exactly how is elusive,” said Liu, “although we now know that this protein, SHBG, is critical as an early target for assessing the risk and prevention of the onset of diabetes.”

Earlier work by Liu and his colleagues published in the New England Journal of Medicine had identified two mutations in the gene coding for SHBG and their effect on the risk of developing type 2 diabetes; one increases risk while the other decreases it, depending on the levels of SHBG in the blood.

A large body of clinical studies has implicated the important role of sex hormones in the development of type 2 diabetes, and it’s known that SHBG not only regulates the sex hormones that are biologically active but may also bind to receptors in a variety of cells, directly mediating the signaling of sex hormones.

“That genetic evidence significantly advanced the field,” said Goto, “because it indicated that SHBG may indeed play a causal role in affecting risk for type 2 diabetes.”

“It seems that SHBG in the blood does reflect a genetic susceptibility to developing type 2 diabetes,” Liu said. “But we now further show that this protein can be influenced by dietary factors such as coffee intake in affecting diabetes risk – the lower the levels of SHBG, the greater the risk beyond any known diabetes risk factors.”

For the study, the researchers identified 359 new diabetes cases matched by age and race with 359 apparently healthy controls selected from among nearly 40,000 women enrolled in the Women’s Health Study – a large-scale cardiovascular trial originally designed to evaluate the benefits and risks of low-dose aspirin and vitamin E in the primary prevention of cardiovascular disease and cancer.

They found that women who drank four cups of caffeinated coffee each day had significantly higher levels of SHBG than did non-drinkers and were 56 percent less likely to develop diabetes than were non-drinkers. And those who also carried the protective copy of the SHBG gene appeared to benefit the most from coffee consumption.

When the investigators controlled for blood SHBG levels, the decrease in risk associated with coffee consumption was not significant. This suggests that it is SHBG that mediates the decrease in risk of developing type 2 diabetes, Liu said.

And there is bad news for decaf lovers. “Consumption of decaffeinated coffee was not significantly associated with SHBG levels, nor diabetes risk,” Goto said. “So you probably have to go for the octane!”

Other authors of the study included Brian Chen, of UCLA, and Julie Buring, JoAnn Manson and Yiqing Song, of Brigham and Women’s Hospital and Harvard Medical School. Funding was provided by the National Institutes of Health. No conflicts of interest were reported by the authors.

Material adapted from The UCLA School of Public Health.

Depression affects close to 15 million U.S. adults each year and more than 23.5 million U.S. adults have diabetes according to background information in the article. Symptoms of depression affect between one-fifth and one-fourth of patients with diabetes, nearly twice as many as individuals without diabetes. Diabetes and its complications are leading causes of death around the world.

An Pan, Ph.D., of the Harvard School of Public Health, Boston, and colleagues studied 78,282 women aged 54 to 79 in 2000 who were participating in the Nurses’ Health Study. The women were classified as having depression if they reported being diagnosed with the condition, were treated with antidepressant medications, or scored high on an index measuring depressive symptoms. Reports of type 2 diabetes were confirmed using a supplementary questionnaire.

During six years of follow-up, 4,654 of the women died, including 979 who died from cardiovascular disease. Compared with women who did not have either condition, those with depression had a 44 percent increased risk of death, those with diabetes had a 35 percent increased risk of death, and those with both conditions had approximately twice the risk of death.

When considering only deaths from cardiovascular disease, women with diabetes had a 67 percent increased risk, women with depression had a 37 percent increased risk, and women with both had a 2.7-fold increased risk.

“The underlying mechanisms of the increased mortality risk associated with depression in patients with diabetes remains to be elucidated,” the authors write. “It is generally suggested that depression is associated with poor glycemic control, an increased risk of diabetes complications, poor adherence to diabetes management by patients, and isolation from the social network.” In addition, diabetes and depression are both linked to unhealthy behaviors such as smoking, poor diet, and a sedentary lifestyle, and depression could trigger changes in the nervous system that adversely affect the heart.

“Considering the size of the population that could be affected by these two prevalent disorders, further consideration is required to design strategies aimed to provide adequate psychological management and support among those with longstanding chronic conditions, such as diabetes,” the authors conclude.

Material adapted from JAMA and Archives Journals.

Reference / Abstract
An Pan, PhD; Michel Lucas, PhD; Qi Sun, MD, ScD; Rob M. van Dam, PhD; Oscar H. Franco, MD, ScD, PhD; Walter C. Willett, MD, DrPH; JoAnn E. Manson, MD, DrPH; Kathryn M. Rexrode, MD; Alberto Ascherio, MD, DrPH; Frank B. Hu, MD, PhD. Increased Mortality Risk in Women With Depression and Diabetes Mellitus. Arch Gen Psychiatry. 2011;68(1):42-50. doi:10.1001/archgenpsychiatry.2010.176.

Children and young adults with diabetes are already at high risk for heart disease before they take up smoking, but few studies have examined the association between cigarette smoking and heart disease risk factors in youth with diabetes.

Funded by the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive Kidney Diseases, the study examined tobacco use and heart disease risk factors in a racially and ethnically diverse group of 3,466 children and young adults with diabetes aged 10 to 22 years old across the United States.

Researchers found that 10 percent of youth with type 1 diabetes and 16 percent of youth with type 2 diabetes were currently using some form of tobacco products: cigarettes, cigars, or smokeless tobacco. Less than half of the youth reported that they had been counseled by their health care provider to not smoke or stop smoking.

“We found a substantial proportion of youth with diabetes are current cigarette smokers, which greatly adds to their already elevated risk for heart disease,” said study lead author Kristi Reynolds, PhD, MPH, a research scientist and epidemiologist at the Kaiser Permanente Southern California Department of Research & Evaluation. “Smoking is preventable, so aggressive smoking prevention and cessation programs are needed to prevent or delay heart disease in youth with diabetes.”

These findings were based on analysis of data from the SEARCH for Diabetes in Youth Study, a large multi-center study of youth diagnosed with diabetes before the age of 20 years who were enrolled by six clinical centers in California, Colorado, Hawaii, Ohio, South Carolina and Washington.

The study found the prevalence of current cigarette smoking in youth with type 1 diabetes to be 1.3 percent of 10- to 14-year-olds, 14.9 percent of 15- to 19-year-olds, and 27 percent of those 20 years and older. Among youth with type 2 diabetes, 4.4 percent of 10- to 14-year-olds were currently cigarette smokers, 12.9 percent of 15- to 19-year-olds were cigarette smokers, and 37.3 percent in youth 20 years and older were cigarette smokers.

The study also found early signs of heart disease among those using cigarette products. Youth who were past and current smokers had a higher prevalence of high triglyceride levels, high LDL cholesterol levels, low HDL cholesterol levels and more physical inactivity than non-smokers.

“Cigarette smoking is a completely preventable risk factor for cardiovascular and other diseases. While this is true for all children, it is especially true for children with diabetes because of the increased risk of cardiovascular disease in that population,” said study co-author Stephen R. Daniels, MD, PhD, professor and chairman of the Department of Pediatrics at the University of Colorado School of Medicine and Pediatrician-in-Chief at The Children’s Hospital in Denver.

In adults with diabetes, the risk of heart disease is greatly increased compared with adults without diabetes, and smoking may increase that risk. About 90 percent of adult smokers started smoking before age 18. Because of the already increased risk of cardiovascular disease in individuals with diabetes mellitus, the American Diabetes Association emphasizes the importance of smoking cessation for those individuals.

Material adapted from Kaiser Permanente.

“Avoiding aggressive impulses takes self control, and self control takes a lot of energy. Glucose provides that energy in the brain,” said Brad Bushman, co-author of the study and professor of communication and psychology at Ohio State University.

“Drinking sweetened lemonade helped provide the short-term energy needed to avoid lashing out at others.”

The finding is more than just a medical curiosity, Bushman said. In two published papers, he and his colleagues did several studies showing that people who have trouble metabolizing, or using, glucose in their bodies show more evidence of aggression and less willingness to forgive others.

The problem is that the number of people who have trouble metabolizing glucose – mainly those with diabetes – is rising rapidly. From 1980 through 2008, the number of Americans with diabetes has more than tripled (from 5.6 million to 18.1 million).

“Diabetes may not only harm yourself – it is bad for society,” Bushman said. “The healthy metabolism of glucose may contribute to a more peaceful society by providing people with a higher level of energy for self-control.”

Bushman conducted the lemonade study with C. Nathan DeWall and Timothy Deckman of the University of Kentucky and Matthew Gailllot of SUNY-Albany. It appears online in the journal Aggressive Behavior and will be published in a future print edition.

In the study, 62 college students fasted for three hours to reduce glucose instability. They were told they were going to participate in a taste-test study, and then have their reaction times evaluated in a computerized test against an opponent.

Half of the participants were given lemonade sweetened with sugar, while the others were given lemonade with a sugar substitute.

After waiting eight minutes to allow the glucose to be absorbed in their bloodstream, the participants took part in the reaction test.

The reaction test has been used and verified in other studies as a way to measure aggression. Participants were told they and an unseen partner would press a button as fast as possible in 25 trials, and whoever was slower would receive a blast of white noise through their headphones.

At the beginning of each trial, participants set the level of noise their partner would receive if they were slower. The noise was rated on a scale of 1 to 10 – from 60 decibels to 105 decibels (about the same volume as a smoke alarm). In actuality, each participant won 12 of the 25 trials (randomly determined).

Aggression was measured by the noise intensity participants chose on the first trial – before they were provoked by their partner.

Results showed that participants who drank the lemonade sweetened with sugar behaved less aggressively than those who drank lemonade with a sugar substitute. Those who drank the sugar-sweetened beverage chose a noise level averaging 4.8 out of 10, while those with the sugar substitute averaged 6.06.

“To our knowledge, this is the first study to find that boosting glucose levels can reduce actual aggressive behavior,” Bushman said.

“To be sure, consuming sugar should not be considered a panacea for curbing aggression. But the results do suggest that people who reportedly “snap” with aggression may need some way to boost their mental energy, so they can override their aggressive impulses.”

In two other studies in the same paper, the researchers showed how problems metabolizing glucose may translate to problems on a societal level. Using 2001 data, the researchers found that the diabetes rates for each of the 50 states were linked to violent crime rates. Those states with higher diabetes rates also tended to have higher rates of murder, assault, rape and robbery, even after controlling for poverty rates in each state.

“This suggests that diabetes did not predict violent crime simply because poverty contributes to both diabetes and violent crime,” he said. “There is a real correlation between diabetes and violence.”

In a separate analysis, the researchers tested whether another medical problem related to glucose metabolism was linked to violence worldwide.

They examined the prevalence, in the populations of 122 countries around the world, of a deficiency in an enzyme called glucose-6-phosphate dehydrogenase. This enzyme is related to glucose metabolism. It is the most common enzyme deficiency in the world, afflicting more than 400 million people.

Countries with higher levels of the disorder also had more violent killings, even outside of war.

“Taken together, these studies offer different types of evidence linking low glucose and other problems metabolizing glucose with aggression and violence,” Bushman said.

The findings were further corroborated in another series of studies, published recently in the journal Personality and Individual Differences.

In that paper, Bushman and DeWall, along with University of Kentucky researcher Richard Pond, had participants complete a commonly used and well-accepted checklist that measures the number and severity of Type 2 diabetes symptoms, such as numbness in the feet, shortness of breath at night, and overall sense of fatigue. In three separate studies, the same participants completed different measures of their willingness to forgive others.

On all three measures, people with higher levels of diabetic symptoms were less likely to forgive others for their transgressions.

In a fourth study, participants took part in a prisoner’s dilemma game, which is often used to understand how people deal with conflict. In this version, participants had to choose whether to cooperate or compete against an unseen partner in a computer game.

“We were especially interested in how participants responded when their partner behaved in an uncooperative, antagonizing manner when the game began,” Bushman said. “Would they forgive their partner or would they refuse to cooperate?”

Results showed that those who scored higher on diabetic symptoms were less likely to forgive an initially uncooperative partner, when compared to those who scored lower on diabetic symptoms.

“These studies are more evidence that diabetic symptoms may cause difficulty in how people relate to each other on a day-to-day basis,” Bushman said.

“It’s not an excuse – diabetes does not mean people have to act aggressively, but it may shed some light on why these behaviors occur.”

“With the rate of diabetes increasing worldwide, it is something that should concern all of us.”

Material adapted from Ohio State University.

According to Marion J Franz, MS, RD, lead author and noted nutrition consultant, “This publication has reviewed the process for developing the guidelines, identified major and contributing factors for diabetes nutrition therapy, reviewed and summarized research, and stated the nutrition practice recommendations that are to be integrated into the nutrition care process. The nutrition practice guidelines provide recommendations for assessing client/patient needs and for selecting interventions, monitoring and evaluating outcomes. The evidence is strong that medical nutrition therapy provided by RDs is an effective and essential therapy in the management of diabetes. RDs are uniquely skilled in this process.”

The authors conducted a thorough review of the research literature to distill evidence-based nutrition recommendations and practice guidelines regarding the major nutrition therapy factors – carbohydrates (intake, sucrose, non-nutritive sweeteners, glycemic index, fiber), protein intake, cardiovascular disease, and weight management. Armed with information regarding what works and why, RDs can encourage lifestyle changes and select appropriate interventions based on key recommendations that include consistency in day-to-day carbohydrate intake, adjusting insulin doses to match carbohydrate intake, substitution of sucrose-containing foods, usual protein intake, cardioprotective nutrition interventions, weight management strategies, regular physical activity, and use of self-monitored blood glucose data.

Key recommendations:

• Consistency in day-to-day carbohydrate intake for persons with type 2 diabetes
• Adjusting insulin dose to match carbohydrate intake for persons with type 1 diabetes
• Focusing on total carbohydrate intake rather than the type of carbohydrate
• Cardio protective nutrition interventions
• Weight management strategies
• Regular physical activity
• Use of self glucose monitoring data to determine if goals are being met

Material adapted from Elsevier.

Reference
The article is “The Evidence for Medical Nutrition Therapy for Type 1 and Type 2 Diabetes in Adults” by Marion J Franz, MS, RD; Margaret A Powers, PhD, RD; Carolyn Leontos, MS, RD; Lea Ann Holzmeister, RD; Karmeen Kulkarni, MS, RD; Arlene Monk, RD; Naomi Wedel, MS, RD; and Erica Gradwell, MS, RD. It appears in the Journal of the American Dietetic Association, Volume 110, Issue 12 (December 2010), published by Elsevier.

An estimated 23.5 million U.S. adults – more than 10 percent – have diabetes, including 23 percent of those ages 60 and older, according to background information in the article. Major depressive disorder affects about 14.8 million U.S. adults each year. “Although it has been hypothesized that the diabetes-depression relation is bidirectional, few studies have addressed this hypothesis in a prospective setting,” the authors write.

An Pan, Ph.D., of the Harvard School of Public Health, Boston, and colleagues assessed the relationship between the two diseases among 65,381 women who were age 50 to 75 in 1996. Participants completed an initial questionnaire about their medical history and health practices, and then follow-up questionnaires every two years through 2006. They were classified as having depression if they reported symptoms of depression, using antidepressant medication or being given a diagnosis of depression by a physician. Women who reported a new diagnosis of diabetes completed a supplementary questionnaire about symptoms, diagnostic tests and treatments.

During the 10-year follow-up, 2,844 women were diagnosed with type 2 diabetes and 7,415 developed depression. Women with depression were about 17 percent more likely to develop diabetes after controlling for other risk factors, such as physical activity and body mass index (BMI). Those who were taking antidepressants had a 25 percent higher risk of developing diabetes than those who did not have depression.

After controlling for other risk factors for mood disorders, women with diabetes were 29 percent more likely to develop depression. Women who took insulin for diabetes had a further increased risk – 53 percent higher than women without diabetes.

“The findings from this well-characterized cohort of more than 55,000 U.S. women with 10 years’ follow-up add to the growing evidence that depression and diabetes are closely related to each other, and this reciprocal association also depends on the severity or treatment of each condition,” the authors write. “All the associations were independent of sociodemographic, diet and lifestyle factors.”

The results indicate that lifestyle factors such as physical activity and BMI may partially mediate the association between depression and new cases of diabetes, but since the association remained significant after adjusting for these factors, depression may have an effect on risk for diabetes beyond weight and inactivity. In addition, the findings reinforce the idea that diabetes is related to stress, the authors note. “A diagnosis of diabetes may lead to the symptoms of depression for the following reasons: depression may result from the biochemical changes directly caused by diabetes or its treatment, or from the stresses and strains associated with living with diabetes and its often debilitating consequences,” they write.

“Future studies are needed to confirm our findings in different populations and to investigate the potential mechanisms underlying this association,” the authors conclude. “Furthermore, depression and diabetes are highly prevalent in the middle-aged and elderly population, particularly in women. Thus, proper lifestyle interventions including adequate weight management and regular physical activity are recommended to lower the risk of both conditions.”

Material adapted from JAMA and Archives Journals.

Dr. Penckofer added, “This article further substantiates the role of this nutrient in the prevention and management of glucose intolerance and diabetes.”

Sue Penckofer, PhD, RN, a professor at the Marcella Niehoff School of Nursing, shows some foods that have been fortified with vitamin D.

One study examined for this review article evaluated 3,000 people with type 1 diabetes and found a decreased risk in disease for people who took vitamin D supplements.  Observational studies of people with type 2 diabetes also revealed that supplements may be important in preventing this disease.

“Management of vitamin D deficiency may be a simple and cost-effective method to improve blood-sugar control and prevent the serious complications associated with diabetes,” said Joanne Kouba, PhD, RD, LDN, study co-author and clinical assistant professor of dietetics at the Marcella Niehoff School of Nursing.  The study findings appeared in Diabetes Educator.

Diet alone may not be sufficient to manage vitamin D levels.  A combination of adequate dietary intake of vitamin D, exposure to sunlight, and treatment with vitamin D2 or D3 supplements can decrease the risk of diabetes and related health concerns.  The preferred range in the body is 30-60 ng/mL of 25(OH) vitamin D.

“People at risk for diabetes should be screened for low vitamin D levels,” said Mary Ann Emanuele, MD, FACP, study co-author and professor of medicine, division of endocrinology and metabolism, Loyola University Health System.  “This will allow health-care professionals to identify a nutrient deficiency early on and intervene to improve the long-term health of these individuals.”

Vitamin D deficiency also may be associated with hyperglycemia, insulin resistance, hypertension and heart disease.  In fact, Penckofer recently published another study inCirculation that reported on the role of chronic vitamin D deficiency in heart disease.  TheCirculation study authors included Glen W. Sizemore, MD, emeritus professor of Medicine, Division of Endocrinology and Metabolism, Loyola University Chicago Stritch School of Medicine, and Diane E. Wallis, MD, Midwest Heart Specialists, Downers Grove, Ill.

Material adapted from Loyola University Health System.

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Research funded by the Biotechnology and Biological Sciences Research Council (BBSRC), the Medical Research Council (MRC) and the European Union Sixth Framework Programme, shows that a protein called secreted frizzled-related protein 1 (SFRP1) is produced by fat cells and may be involved in changes to our metabolism that could increase the risk of diabetes and cardiovascular disease.

Professor Antonio Vidal-Puig from the Institute of Metabolic Science, University of Cambridge said “We have known for some time that many obese individuals are at greater risk of developing diabetes, cardiovascular disease and also cancer. But this is not true for all obese people.”

Dr Jaswinder Sethi, also from the Institute of Metabolic Sciences, University of Cambridge added “What we still do not fully understand, is how the expansion of fat tissue is regulated in healthy people and how this process of regulation might be different in those obese people who have health problems such as the metabolic syndrome.”

One hypothesis is that storing surplus fat in itself may not lead to metabolic syndrome but there may be a maximum limit of how much fat a person can store safely before the body’s natural responses lead to the debilitating chronic health problems often associated with obesity.

Dr Sethi continued “To investigate this we have been using a combination of molecular cell biology, human gene profiling and mouse genetics as tools to understand what is happening as fat cells and tissues develop and then, in some very obese people, lose their normal process of regulation.”

The researchers have found that the level of SFRP1 increases as fat cells and tissues increase in volume until it peaks at about the point of mild obesity. There is evidence that SFRP1 is involved in recruiting new fat cells, thereby facilitating the expansion of fat tissue up until this point where it peaks.

“SFRP1 seems to be very closely linked to some sort of tipping point, after which the way in which our fat tissue is regulated changes significantly and there are knock-on consequences to our wider metabolism. We think that in very obese people this may be an early event that triggers metabolic syndrome and the chronic health problems associated with it, such as diabetes and cardiovascular disease,” said Dr Sethi.

The fat tissue of people who are obese and also have diabetes shows signs of not being regulated as it usually would be. In this tissue, the researchers also see the levels of SFRP1 begin to fall so as to prevent further expansion of the tissue. It is this fall in SFRP1 that has knock-on effects on metabolism that may in part explain the link between morbid obesity and metabolic syndrome.

The researchers believe that SFRP1 works in concert with other molecules to respond to the availability, or not, of energy. Together these molecules also determine to what extent our fat tissue can continue to expand as we consume more calories than we burn.

Professor Douglas Kell, BBSRC Chief Executive said: “Research such as this leads to better understanding of the biochemistry that drives normal human physiology. In particular we can see how we usually respond to extremes brought on by the various onslaughts of our lifestyles and environments. Increasing our understanding of the fundamentals of metabolic signalling is an important part of working towards an increase in health span to match our increasing life spans.”

Material adapted from Biotechnology and Biological Sciences Research Council (BBSRC).

The participants were randomized into two groups; the infants in the intervention group were weaned to a highly hydrolyzed casein-based formula (Nutramigen, Mead Johnson Nutrition), while those in the control group were weaned to a regular cow’s milk-based formula supplemented with 20% Nutramigen to make the two formulas comparable in terms of smell and taste. The intention was that the participants should be exposed to their study formula for at least 2 months by the age of 6 months, or if exclusively breast-fed up to that age by the age of 8 months.

The study participants were observed up to the age of 10 years for the appearance of diabetes-predictive autoantibodies and progression to type 1 diabetes. Twenty-five children (12%) developed at least two diabetes-predictive autoantibodies out of the five tested for, which marks a high risk of presenting with clinical diabetes. Seventeen children tested positive for two or more autoantibodies had been randomized to the control group (16%), whereas seven belonged to the intervention (casein hydrolysate) group (7%). Nine children (8%) in the control group presented with clinical diabetes by the age of 10 years, while four of those (4%) who had been exposed to the casein hydrolysate progressed to clinical disease

Professor Mikael Knip of the Hospital for Children and Adolescents, and University of Helsinki, who has been responsible for the analyses of diabetes-predictive autoantibodies states: ”The study showed that the safe and simple dietary intervention applied in this pilot trial was capable of reducing the emergence of diabetes-predictive autoantibodies by about 50% by age 10 in the participants carrying increased disease risk. The current study population does not provide sufficient statistical power to definitely conclude whether an intervention of this type will reduce the frequency of clinical type 1 diabetes, although the preliminary data are promising.”

A full-scale trial – TRIGR (Trial to Reduce IDDM in the Genetically at Risk) – was initiated in 2002 and is currently running in 77 study centers in 15 countries to provide a conclusive answer to the question of whether weaning to a highly hydrolyzed formula will reduce the cumulative incidence of clinical type 1 diabetes. A total of 2160 children have been randomized for TRIGR. The first end-point in TRIGR, i.e. positivity for at least two diabetes-associated autoantibodies and/or clinical type 1 diabetes by age 6, will be reached in 2013 and the final endpoint, clinical diabetes by the age of 10 in the year 2017.

The current pilot trial and the full-scale TRIGR aim at primary prevention of type 1 diabetes, i.e. to stop the initiation of the disease process which lasts for months and years before clinical disease manifestation. Dr. Knip emphasizes that the results indicate that it is possible to reduce the initiation of the disease process substantially by early dietary intervention in high-risk individuals. “On the other hand we have to keep in mind that this pilot trial has been performed in children with predisposing genes and a family member affected by type 1 diabetes. At this point it remains open whether this type of intervention will work in children from the general population,” cautions Dr. Knip.

The researchers have not determined the decisive difference is between the casein hydrolysate and regular cow’s milk-based formulas. An experimental study recently showed that a highly hydrolyzed formula reduces gut permeability and has a beneficial effect on gut microflora. Studies have been initiated to identify the mechanism(s) by which the highly hydrolyzed formula protects against beta-cell autoimmunity represented by diabetes-predictive autoantibodies. Another Finnish trial is currently testing the hypothesis whether an insulin-free formula decreases the initiation of the diabetic disease process in children at risk given the central role of insulin as an early autoantigen in type 1 diabetes.

Professor Hans K. Åkerblom was the Principal Investigator for the current pilot trial, which was performed at the University of Helsinki, Helsinki University Central Hospital, the University of Kuopio, the University of Oulu, the University of Tampere, the University of Turku, Tampere University Hospital, the National Institute for Health and Welfare and nine central hospitals, all in Finland. In addition, the University of Toronto, Ontario, Canada, was involved in the study.

The study was supported by the European Union, the Juvenile Diabetes Research Foundation, the Academy of Finland, Helsinki University Central Hospital, the University of Helsinki, the Finnish Diabetes Research Foundation, the Novo Nordisk Foundation, the Medical Research Foundation of Tampere University Hospital, the Dorothea Olivia, Karl Walter, and Jarl Walter Perklén Foundation, and the Liv och Hälsa Fund.

Material adapted from Helsingin yliopisto (University of Helsinki).

“The good thing about insulin sensitivity is that it’s very modifiable through diet and exercise,” says psychology graduate student Mitzi Gonzales, who co-authored the paper published in the journal Obesity with Assistant Professor Andreana Haley and other colleagues.

To better understand why midlife obesity is linked to higher risk of cognitive decline and dementia in old age, the researchers had middle-aged adults between 40 and 60 years of age complete a challenging cognitive task while undergoing functional magnetic resonance imaging (fMRI).

While obese, overweight and normal-weight participants performed equally well on the task, obese individuals displayed lower functional brain response in one brain region, the inferior parietal lobe.

Obese participants also had lower insulin sensitivity than their normal weight and overweight peers, meaning that their bodies break down glucose less efficiently. Poor insulin sensitivity may ultimately lead to diabetes mellitus if the pancreas is unable to secrete enough insulin to compensate for reduced glucose use.

The study shows that impaired insulin sensitivity, which generally accompanies obesity, may serve as a mediator between midlife obesity and cognitive decline later on. Researchers chose to examine insulin sensitivity because insulin helps regulate people’s metabolism and also affects cognitive functions.

The study exemplifies the aim of Haley’s lab, which is to use neuroimaging in middle-aged individuals to provide early identification of risk for cognitive decline later in life.

“Generally, very few people study the middle-aged segment of the population, but that’s when many chronic diseases are first identified and neurodegenerative processes are triggered,” says Haley. “We found that while behavioral performance of obese middle-aged individuals may be the same — they can complete the same cognitive tasks as normal weight individuals — their brain is already doing something different to produce that outcome.”

Haley and Gonzales are planning a follow up study to determine if a 12-week exercise intervention can reverse the observed differences in brain response.

Dr. Alon Chen of the Weizmann Institute’s Neurobiology Department and his research team have now discovered that changes in the activity of a single gene in the brain not only cause mice to exhibit anxious behavior, but also lead to metabolic changes that cause the mice to develop symptoms associated with type 2 diabetes. These findings were published online this week in the Proceedings of the National Academy of Sciences (PNAS).

All of the body’s systems are involved in the stress response, which evolved to deal with threats and danger. Behavioral changes tied to stress include heightened anxiety and concentration, while other changes in the body include heat-generation, changes the metabolism of various substances and even changes in food preferences. What ties all of these things together? The Weizmann team suspected that a protein known as Urocortin-3 (Ucn3) was involved. This protein is produced in certain brain cells — especially in times of stress — and it’s known to play a role in regulating the body’s stress response. These nerve cells have extensions that act as ‘highways’ that speed Ucn3 on to two other sites in the brain: One, in the hypothalamus – the brain’s center for hormonal regulation of basic bodily functions — oversees, among other things, substance exchange and feelings of hunger and satiety; the other is involved in regulating behavior, including levels of anxiety. Nerve cells in both these areas have special receptors for Ucn3 on their surfaces, and the protein binds to these receptors to initiate the stress response.

The researchers developed a new, finely-tuned method for influencing the activity of a single gene in one area in the brain, using it to increase the amounts of Ucn3 produced in just that location. They found that heightened levels of the protein produced two different effects: The mice’s anxiety-related behavior increased, and their bodies underwent metabolic changes, as well. With excess Ucn3, their bodies burned more sugar and fewer fatty acids, and their metabolic rate sped up. These mice began to show signs of the first stages of type 2 diabetes: A drop in muscle sensitivity to insulin delayed sugar uptake by the cells, resulting in raised sugar levels in the blood. Their pancreas then produced extra insulin to make up for the perceived ‘deficit.’

‘We showed that the actions of single gene in just one part of the brain can have profound effects on the metabolism of the whole body,’ says Chen. This mechanism, which appears to be a ‘smoking gun’ tying stress levels to metabolic disease, might, in the future, point the way toward the treatment or prevention of a number of stress-related diseases.

Material adapted from Weizmann Institute of Science by CFisher.

“The findings suggest that if we could improve the quality of the parent-adolescent relationship and increase parents’ monitoring of adolescents’ diabetes management, we could improve adolescents’ adherence to the type 1 diabetes regimen and, subsequently, their long-term health,” says the study’s first author, Pamela King, a postdoctoral researcher in psychology.

King says proper management of type 1 diabetes – also known as juvenile diabetes – requires adherence to a complicated, demanding treatment regimen, including multiple daily blood-glucose tests, multiple insulin injections or use of an insulin pump, regular meals, limited fat and carbohydrate intake, regular exercise, and adjustments to insulin dosage based on diet and exercise. Type 1 diabetics produce no insulin of their own.

The Juvenile Diabetes Research Foundation estimates that type 1 diabetes shortens life expectancy by seven to 10 years. “Of course, life expectancy will be influenced by how well people manage their diabetes over their lifetime,” says King.

Despite the fact that poor adherence has life-threatening consequences for health, previous research suggests that adherence declines significantly during adolescence. But most of the earlier studies were “cross-sectional,” meaning they only looked at a snapshot in time.

The Challenge of Teenagers with a Chronic Illness
The Utah psychologists conducted a “longitudinal” study, in which they analyzed the behavior of 252 adolescent type 1 diabetics and their parents over a two-year period, conducting interviews every six months about the youths’ adherence to their treatment regimen and different aspects of parental involvement.

The adolescent diabetics were recruited from the University of Utah’s Utah Diabetes Center and from Mountain Vista Medicine in South Jordan, Utah. Most of the diabetics live in Utah and Idaho, with a couple from Wyoming and Nevada.

When the study began, their ages ranged from 10 to 14; by the time it ended, some of the patients were turning 17.

The study revealed a decline in three markers of parental involvement as the adolescent diabetic grows older: a decline in mothers’ and fathers’ monitoring of adolescents’ diabetes care behaviors (for example, knowing what the adolescent eats), a decline in parents’ acceptance of the teen in general (an indicator of parent-adolescent relationship quality), and a decline in their assistance with diabetes management tasks (such as getting the adolescent diabetes supplies).

But only some of those declining indicators of involvement actually related significantly to declines in the youths’ adherence to their treatment regimen. In other words, teens and “tweens” who had more trouble following their treatment plan were those whose mothers became less accepting of them, and whose mothers and fathers had grown more lax about monitoring their offspring’s diabetes treatment and care.

“Adolescence is a challenging time for those with a chronic illness,” says King. “Adolescents experience a variety of biological, psychological and social changes before they reach adulthood. Adolescents with a chronic illness have to cope with these normal developmental challenges while trying to manage the demands of their chronic illness.”

Material adapted from University of Utah by CFisher.

“Diabetes alone has shown to be a risk factor for dementia, as has major depression by itself,” noted the lead author of the study, Dr. Wayne Katon, University of Washington (UW) professor of psychiatry and behavioral sciences. Also on the study team were researchers from the Group Health Research Institute in Seattle and the Veterans Affairs (VA) Puget Sound Health Care System, as well as UW researchers in medicine and in epidemiology.

Various other population studies, Katon and the other authors noted, have shown that the risk of Alzheimer’s disease, vascular dementia, and other types of dementia is from 40 percent to 100 percent higher in people with diabetes, compared to people without diabetes. A history of depression more than doubles the subsequent risk of Alzheimer’s disease and other forms of dementia in the general population.

“We wanted to determine the effects of both conditions – diabetes and major depression – occurring together,” Katon said. “Our analysis suggests that major depression more than doubles the risk of dementia in adults with diabetes.”

The research team on this project, which is part of the Pathways Epidemiological Follow-Up Study, tracked the outcomes of adults from the Group Health Cooperative’s diabetes registry who agreed to participate. They were patients from nine Puget Sound area primary-care clinics in western Washington state. The clinics were chosen for their socioeconomic and racial/ethnic diversity and were demographically similar to the area’s population. Initial enrollment of patients took place between 2000 and 2002, and the patients were studied for five years. Patients already diagnosed with dementia were excluded from the study.

Over the five-year period, 36 of 455, or 7.9 percent, of the diabetes patients with major depression were diagnosed with dementia. Among the 3,382 patients with diabetes alone, 163 or 4.8 percent developed dementia.

The researchers calculated that major depression with diabetes was associated with a 2.7-fold increase of dementia, compared to diabetes alone. Because the onset of dementia can sometimes be marked by depression, the researchers also adjusted their hazard model to exclude patients who developed dementia in the first two years after their depression diagnosis.

The team’s previous findings from earlier studies showed that depression increases the mortality rate among people with diabetes, as well as the rate of complications such as heart, blood vessel, kidney and vision problems.

The exact manner in which diabetes and depression interact to result in poorer outcomes is not certain. Some studies suggest that a genetic marker for dementia is associated with a faster cognitive decline. Depression may also raise the risk of dementia, the authors noted, because of biological abnormalities linked to this affective illness, including high levels of the stress hormone cortisol, poor regulation in the hypothalamus-pituitary system, or autonomic nervous system problems that can affect heart rate, blood clotting, and inflammatory responses.

Depression, they added, might also raise the risk of dementia because of behaviors common in the condition, such as smoking, over-eating, lack of exercise, and difficulty in adhering to medication and treatment regimens. In the current study, patients with both diabetes and major depression were more likely to be female, single, smokers, physically inactive, and treated with insulin. They also had more diabetes complications and a higher body mass index, a ratio calculated from height and weight. However, these differences were controlled for in the analysis and depression remained an important risk factor.

Diabetes, the authors noted, is a risk factor for dementia because of blood vessel problems and also may accelerate the decline of Alzheimer’s disease. Many factors linked to diabetes might also increase the odds of developing dementia, including tissue damage from high blood sugar levels, episodes of low blood sugar and insulin resistance.

Depression is common among people who have diabetes. Until more research is available on the exact mechanisms behind the links between depression, diabetes, and dementia, the researchers say, “It seems prudent for clinicians to add effective screening and treatment for depression to other preventive measures such as exercise, weight control, and blood sugar control to protect against the development of cognitive deficits in patients with diabetes.”

Material adapted from University of Washington by CFisher.

The prevalence of pediatric obesity has tripled in the past three decades and inner-city minority children have been disproportionally affected. In the South Bronx, nearly one in three children enrolled in the Head Start program, which provides educational services for three- to five-year-olds from low-income households, is obese. Almost half are overweight or obese[1].

“After 20 years of medical practice in the South Bronx, I have come to appreciate the enormity, complexity and morbidity of the epidemic,” said Philip Ozuah, M.D., Ph.D., chair of pediatrics at Einstein and Montefiore and principal investigator of the study. “The impact of obesity on children and their health is devastating and demands to be addressed.”

Physical inactivity is one of the contributing factors to this widespread problem. Although the World Health Organization has identified physical activity in schools as an essential strategy to prevent childhood obesity, many schools – especially in low-income areas – lack facilities to implement the recommendation.

To address this reality, Dr. Ozuah and his team created a series of 10-minute audio CDs designed to encourage aerobic activity. Developed in conjunction with the New York City Department of Education and local schools, the education-based CDs coincide with the curriculum of each grade level. The activities are led by a teacher in a standard classroom setting and are meant to be a supplement to physical education classes and recess.

Through his innovative approach to confronting childhood obesity, Dr. Ozuah offers the type of leadership we need to fight the epidemic and its consequences, including the appearance of type 2 diabetes among children and adolescents,” said Allen M. Spiegel, M.D., the Marilyn and Stanley M. Katz Dean at Einstein and former director of the National Institute of Diabetes and Digestive and Kidney Diseases. “Type 2 diabetes is no longer a disease diagnosed only in adults. Children are now facing the dire complications associated with lifelong exposure to type 2 diabetes, including heart disease, kidney disease, blindness and lower-limb amputations. We face enormous human and economic costs if we do nothing.”

“This novel strategy to increasing physical activity in children is the outgrowth of Montefiore’s school-health program,” said Steven M. Safyer, M.D., president and CEO of Montefiore Medical Center. “As one of the largest programs in the country, Montefiore’s school-health program has a legacy of success in developing novel ways of improving the health and well-being of urban school-aged children.”

The series of CDs, called CHAM JAM (Children’s Hospital at Montefiore Joining Academics in Movement), contain educational material and music that encourage dance, movement and exercise. To keep the activities fresh and to offer variety, new versions are regularly developed and distributed.

Building upon this promising pilot program, Einstein-Montefiore researchers will use this new grant to quadruple the reach of the CD series, from 4,000 to 16,000 students enrolled in kindergarten through third grade in Bronx schools. Through this new randomized group, researchers will evaluate the frequency of CD use, physical activity level during playback, and overall physical fitness of the students over the course of two years.

“We have received consistently positive feedback from the schools we’re working with and our preliminary results are very promising,” said Dr. Ozuah. “We believe that this program, if validated by further research, has the potential to transform school-based health policies across the country in terms of increasing physical activity in inner-city children, particularly in resource-poor neighborhoods.”

Researchers have already begun to identify additional schools to participate in the program and will begin distributing the new CDs in the coming weeks. This new phase of the study will run through August 2011.

Material adapted from Albert Einstein College of Medicine by CFisher.

Reference:
[1] Matte T, et al. “Obesity in the South Bronx: A Look Across Generations.” New York City Department of Health and Mental Hygiene, 2007.

Ciechanowski also directs the training institute at the Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP) at Harborview Medical Center, which is part of UW Medicine.

The report was published in this month’s Diabetes Care, a professional journal of the American Diabetes Association.

This is the first known study, the research team believes, to examine the association between relationship styles and mortality.

The researchers examined 3,535 adult patients with type 1 and type 2 diabetes enrolled as Group Health Cooperative patients in the Puget Sound area of Washington state. Because depression has been linked to premature death from diabetes, patients with depression were not included to avoid confounding the study results.

The patients completed a relationship questionnaire, developed in 1994 by Griffin and Bartholomew. Based on the results of this survey, patients were divided into two groups: those with an interactive style and those with an independent style in relating to people.

Individuals with an interactive style find it easy to get close to others and rely on them, and in turn are dependable for others. Those with an independent style tend to be either dismissive or fearful of close relationships. Some people with this style would like emotional closeness, but find it hard to trust or depend on others. Others can be indifferent to close relationships, preferring instead to be free and self-reliant.

“These ways of relating often extend to their relationships with health-care providers,” the researchers said.

Regardless of their style, most patients Ciechanowski and his colleagues have studied over several projects perceive health care as rushed, impersonal and fragmented. Those with an independent style also reported feeling threatened by the power health-care providers had. Some were highly attuned to signs of rejection; others were sensitive to being controlled, and at the same time worried that help would not be available for them. Those with an independent style in relationships often felt a wall existed between patients and providers.

Interactive patients tended to understand the pressures health professionals were under, and overlooked minor shortcomings, previous research by Ciechanowski and his team has found. Such patients were more likely to value ongoing relationships with their providers, even when circumstances weren’t ideal, and respected their training and knowledge.

During the course of the most recent study, diabetes patients who were mistrustful of people, including health-care providers, had a 33 percent higher mortality rate than those who interacted easily with others and sought comfort and support. The researchers found the significantly higher risk of death among diabetes patients who were less likely to seek support still held after controlling for other potential risk factors for mortality such as age, marital status, other medical conditions, complications of diabetes and body mass index.

The exact mechanisms behind the link between an independent relationship style and a higher mortality rate are not yet known, the researchers said, and further research is needed to delineate the reasons and to develop effective interventions.

“Prior studies have shown that lower support seeking is associated with poorer adherence to treatment,” Ciechanowski noted. An independent relationship style, he explained, is often played out in missed appointments, higher glucose readings, lower satisfaction with health-care, and poorer home treatment of diabetes in such areas as foot care, exercise, diet, oral and injectible medication use, blood sugar monitoring, and smoking cessation.

“Many self-management behaviors related to diabetes are optimally carried out in collaboration with others — family, peers and health-care providers,” Ciechanowski noted. Planning and cooking diabetic-friendly meals, exercising, and quitting smoking are best undertaken, he added, with motivational support. Also, as diabetes gets more severe or complications arise, a self-reliant attitude that worked in the past may become a liability.

There are approaches, according to Ciechanowski, that health-care providers can try to improve collaboration with diabetes patients who have an independent relationship style, such as directly and non-judgmentally talking about this style. Also, providers might coach patients and help them set simple goals in seeking support in managing their diabetes. However, the effectiveness of such approaches in reducing the higher death rates among such patients has not yet been tested.

“Our research is based on a developmental theory known as attachment theory where earlier experiences often shape an individual’s ability to trust later in life,” Ciechanowski explains. “As clinicians, we have to keep in mind that what we say and how we say it can make a big difference in trust between clinician and patient — which has implications for treatment adherence and health outcomes. Bedside manner matters. Also, as stewards of health care, we have to be mindful about what our fast-paced health-care system says to patients to engender trust or not. Long waits, less face-to-face time with providers, rashly delivered health information, and lack of continuous care can reduce trust — particularly in those with an independent relationship style.”

Material adapted from University of Washington by CFisher.

Background (continued)
Elizabeth Lin M.D., MPH, Michael Von Korff, Sc.D., and colleagues from Group Health Research Institute in Seattle, WA, and Wayne Katon M.D., and colleagues from the University of Washington, examined the association between type 2 diabetes and depression among 4,623 patients enrolled in Group Health, a health plan serving residents of Washington state. They first interviewed the participants between 2000 and 2002, and then conducted follow-up interviews between 2005 and 2007. They tracked the participants’ rates of microvascular complications (e.g., blindness, end-stage kidney disease, amputations, and kidney failure deaths) and macrovascular complications (e.g., heart attack, stroke, cardiovascular procedures and deaths).

Results of the Study
At the follow-up interview, 14 percent of the participants had developed a clinically advanced microvascular complication, and 24 percent had developed a severe macrovascular complication. Over the five-year follow-up period, those with major depression had a 36 percent higher risk of developing microvascular complications and a 25 percent higher risk of developing macrovascular complications compared with patients without major depression.

Significance
Those with type 2 diabetes and coexisting major depression are more likely to experience life-threatening complications than those without coexisting major depression. To reduce the risk of diabetes complications, better interventions are needed that not only treat the diabetes but address any accompanying depression as well.

What’s Next
More research is needed to identify the underlying mechanisms for the association between depression and diabetes complications, and to develop interventions that treat both diabetes and accompanying major depression. In addition, better screening is needed to help identify those patients with diabetes who are at higher risk for developing major depression and other life-threatening complications.

More information about diabetes is available from the National Diabetes Education Program.

Material adapted from the National Institute of Mental Health by CFisher.

Reference
Lin EHB, Rutter CM, Katon W, Heckbert SR, Ciechanowski P, Oliver MM, Ludman EJ, Young BA, Williams LH, McCulloch DK, Von Korff M. Depression and advanced complications of diabetes. Diabetes Care. 2010 Feb. 33(2): 264-269.

The study was conducted by scientists from the Group Health Research Institute, Seattle; the University of Washington (UW) School of Medicine and School of Public Health, and the Veterans Affairs Puget Sound Health Care System. The lead author is Dr. Elizabeth Lin of the Group Health Research Institute.

Among their research volunteers with type 2 diabetes followed over 5 years, major depression was associated with a 36 percent higher risk of developing advanced micro-vascular complications, such as end-stage kidney disease or blindness, and a 25 percent higher risk of developing advanced macrovascular complications, such as stroke or myocardial infarction (heart attack from a blood clot), compared with diabetes patients without depression. The clinically significant risks remained even after the researchers adjusted for diabetes severity and self-care activities.

Between 2000 and 2002, the Pathways Epidemiological Follow-up Study enrolled 4,632 primary-care Group Health Cooperative patients with diabetes. These patients were tracked through 2005-2007. The final sample size was 3,723. The researchers reviewed medical records, diagnostic and procedural codes, lists of prescribed medications, and death certificates to determine what happened to each patient over nearly five years. The researchers used proportional hazard models to calculate the association between depression and the risk of advanced complications. Even among patients with diabetes who had no prior indication of microvascular or macrovascular problems, depression increased the chances that these problems would develop.

As in earlier reports, the diabetes patients with major depression tended to be slightly younger, heavier, have more co-existing medical conditions, and were more likely to be treated with insulin than were diabetes patients without depression. They also had higher levels of a substance in the blood formed when the sugar glucose attaches to hemoglobin, an oxygen-carrying protein. The major depression group had a higher proportion of women and smokers. However, after controlling for these differences between depressed and non-depressed patients with diabetes, the increased risk of complications associated with depression remained.

Several previous studies suggest the negative relationship between depression and diabetes cuts both ways. People with depression are prone to diabetes, and vice versa. Impairment from diabetes, such as blindness or kidney failure requiring long-term dialysis, interferes with a person’s daily life and can be overwhelming. The person may become depressed or an existing depression may worsen.

As the incidence of type 2 diabetes soars, the clinical and public health significance of these findings increases, the authors noted. Further research is needed, the authors added, to clarify the underlying biological mechanism for the association between depression and complications of diabetes, and to test interventions which might be effective in lowering the risk of complications among patients who have both diabetes and depression.

Materiel adapted from University of Washington by CFisher.

Hiroaki Kumano, from Waseda University, Japan, worked with a team of researchers to assess response inhibition, a measure of self-control, in 27 patients with type-2 diabetes and 27 healthy controls. He said, “Patients with type 2 diabetes are required to make strict daily decisions; for example, they should resist the temptation of high-fat, high-calorie food, which is frequently cued by specific people, places and events. Appropriate behavior modification thus depends on the patient’s ability to inhibit impulsive thoughts and actions cued by these environmental stimuli”.

In order to gauge the patients’ ability to resist such impulsive behavior, the researchers used a test in which participants had to quickly press a button in response to the correct signal on a computer screen, while pressing the button in response to the wrong symbol counted against their score. They found that patients with diabetes performed significantly worse at the test, suggesting that they struggled to control the impulse to press the button. Other results showed that the inhibitory failure observed in diabetic patients was mainly explained by cognitive impairment of impulsivity control, rather than by deficits in motor performance, error monitoring and adjustment. According to Kumano, “This suggests the possibility that the neuropsychological deficits in response inhibition may contribute to the behavioral problems leading to chronic lifestyle-related diseases, such as type 2 diabetes.”

Download
Download Decreased response inhibition in middle-aged male patients with type 2 diabetes by Kaya T Ishizawa, Hiroaki Kumano, Atsushi Sato, Hiroshi Sakura and Yasuhiko Iwamoto. BioPsychoSocial Medicine (in press).

Material adapted from BioMed Central by CFisher.

The researchers speculate that initial weight loss may also lead to decreased diabetes related heart disease, blindness, nerve and kidney damage, and even death.  The conclusions in this study were based on 2,500 diabetic adults tracked over 4 years.

The researchers emphasized that to realize the benefits similar to those in this study, weight loss efforts must start immediately following diagnosis. Participants that achieved weight loss goals within 18 months doubled their chances of improved blood pressure and blood sugar measures four years later, even if they put the weight back on by the four year check up – in fact, many participants with initial weight loss that realized blood pressure/glucose improvements at the end of 4 years had similar weights to those without weight loss following diagnosis (i.e., the weight returned by the end of the study).  The researchers do not know why blood pressure/glucose gains persist despite the weight return, but we do not need to understand the “why” to benefit from this research!

Remember to always talk to your physician before making any healthcare changes. Please review an important warning about using sources other than your qualified healthcare provider to make health-related decisions.

CFisher

*Feldstein, A., Nichols, G., Smith, D., Stevens, V., Rosales, A., Perrin, N., & Bachman, K. (2008, August 12). Losing Weight After Diabetes Diagnosis Can Prevent Diabetes-Related Disease, Kaiser Permanente Study Finds. Retrieved August 17, 2008, from xnet.kp.org/newscenter/pressreleases/nat/nat_080812_diabetesandweightloss.html