Toe Pulse Oximetry May Help Detect Lower Extremity Arterial Disease in Type 2 Diabetics

March 2, 2005 — Pulse oximetry of the toes may be as accurate as ankle-brachial index (ABI) for the screening of lower extremity arterial disease (LEAD) in patients with type 2 diabetes, according to the results of a study published in the Feb. 28 issue of the Archives of Internal Medicine.

"LEAD is common and underdiagnosed in patients with diabetes mellitus and is associated with higher total mortality," write G. Iyer Parameswaran, MD, and colleagues from Unity Health System in Rochester, New York. "Early detection of LEAD, before the onset of symptoms in patients with diabetes mellitus, is desirable and can lead to tighter, better control of risk factors for arterial disease."

The investigators compared the accuracy of pulse oximetry, ABI, and both tests combined to diagnose LEAD in 57 consecutive outpatients with type 2 diabetes but with no symptoms of LEAD. Patients younger than 40 years and those with known LEAD or typical symptoms of LEAD were excluded. All patients underwent ABI measurement, which was considered abnormal if it was less than 0.9; pulse oximetry to measure SaO2 of the index fingers and big toes in the supine position and at 12-inch elevation; and Doppler waveform analysis of lower extremity arteries.

Pulse oximetry of the toes was classified as abnormal if the SaO2 was more than 2% lower than in the finger or when the foot was elevated 12 inches. The combination of both tests was classified as positive if either test was positive for LEAD, and negative if both tests were negative.

LEAD, defined as monophasic waveforms on Doppler waveform analysis, was present in 31% of patients. For pulse oximetry, sensitivity was 77% (95% confidence interval [CI], 61% - 88%) and specificity was 97% (95% CI, 91% - 99%). For ABI, sensitivity was 63% (95% CI, 46% - 77%) and specificity was 97% (95% CI, 91% - 99%). Positive likelihood ratios were 30 (95% CI, 7.6 - 121) for pulse oximetry and 24.8 (95% CI, 6.2 - 99.8) for ABI. Negative likelihood ratios were 0.23 (95% CI, 0.12 - 0.43) for pulse oximetry and 0.38 (95% CI, 0.25 - 0.59) for ABI. For both tests combined, sensitivity was 86% (95% CI, 71% - 94%) and specificity was 92% (95% CI, 84% - 96%).

"Pulse oximetry of the toes seems as accurate as ABI to screen for LEAD in patients with type 2 diabetes," the authors write. "Combination of the two tests increases sensitivity."

Study limitations include the small number of patients; performance of the tests by one investigator, precluding measurement of interobserver variability; and the possibility that the sequence of measurements, pulse oximetry followed by ABI, may have influenced the measurements and results.

"These results suggest that pulse oximetry may be a useful additional tool to screen for LEAD in patients with diabetes mellitus," the authors conclude. "Assessment of change in clinical outcomes owing to modification of risk factors for atherosclerosis in asymptomatic patients identified by screening as having LEAD is an area that needs further research."

The authors report no financial conflicts of interest.

Arch Intern Med. 2005;165:442-446

Exercise Inception, Even Late in Life, Cuts Cardiovascular Risks

NEW YORK (Reuters Health) Mar 11 - Adopting a regular exercise routine for the first time later in life, reduces the development of metabolic risk factors for cardiovascular disease, Canadian researchers report in the March issue of Diabetes Care.

"Our next step," lead investigator, Dr. Robert John Petrella, said in an interview with Reuters Health, "is to expand the impact into the broader community."

In particular, Dr Petrella and colleagues at the University of Western Ontario, London examined the effect of chronic exercise training on the development of metabolic markers of cardiovascular disease. Two cohorts of previously sedentary healthy adults between the ages of 55 and 75 years were studied.

One group initiated regular supervised physical exercise training and the other acted as a sedentary control group. Baseline fitness levels were similar between groups.

At 10 years, complete data were available for 161 active and 136 sedentary subjects. Withdrawal was mostly due to failure to adhere to the exercise program in the active group and poor physical health in the sedentary group.

Sedentary patients exhibited significantly more metabolic abnormalities than active patients. Active subjects demonstrated a 3.5% increase in fitness levels versus a 13.8% decrease in sedentary patients.

Sedentary patients were also more likely to have a positive exercise electrocardiogram or symptom (32%) than were active subjects (10%). They also had more comorbidities.

Overall, 11% of active group patients and 28% of sedentary group patients had the metabolic syndrome at 10 years. In the active group, those who moved from low to moderate to high fitness showed significantly fewer metabolic markers compared to those who remained at a low fitness levels or moved to a lower level.

In light of these findings and "since primary care physicians have greatest contact with most of the population at risk for cardiovascular disease," Dr. Petrella concluded, giving such lifestyle intervention to patients "could have the best impact if it were delivered by primary care physicians."

Diabetes Care 2005;28:694-701.

Glucose Tolerance Test, B12 Levels Best to Diagnose Sensory Neuropathy

May 11, 2004 — Patients with sensory neuropathy should be evaluated with a glucose tolerance test and vitamin B12 levels, while other studies should be based on clinical findings, according to the results of a study published in the May 10 issue of the Archives of Internal Medicine.

"Peripheral neuropathy is a common problem that often prompts a lengthy and expensive diagnostic evaluation," write A. Gordon Smith, MD, and J. Robinson Singleton, MD, from the University of Utah School of Medicine in Salt Lake City. "A rational, evidence-based diagnostic approach to peripheral neuropathy is desirable.... The goal was to develop a focused diagnostic algorithm that can be easily applied in a general medical setting."

Using a standard diagnostic approach, the authors evaluated 138 patients referred with predominantly sensory symptoms and no previously defined etiology for neuropathy.

Family history was positive in 25% of patients, with at least one first-degree relative with symptoms suggesting neuropathy. The two-hour oral glucose tolerance test (OGTT) had the highest diagnostic yield (61%) of all laboratory tests and was more sensitive than other measures of glucose metabolism. Two patients were diagnosed with vitamin B12 deficiency.

Less than 5% of patients had abnormal results of serum protein electrophoresis, immunofixation, or antinuclear antibody testing, which is comparable to rates found in the general population.

Based on these findings, the authors suggest that patients with sensory-predominant neuropathy should be tested for glucose tolerance and vitamin B12 level, that abnormalities of serum protein electrophoresis and antinuclear antibodies are of uncertain significance, and that other tests should be performed only when the clinical scenario is suggestive.

"Using this approach, only 31% of patients completing the recommended evaluation were found to have an idiopathic neuropathy," the authors write. "Patients with atypical features may benefit from referral to a peripheral neuropathy center."

Study limitations include the tertiary care setting, in which the prevalence of laboratory abnormalities could be biased against common disorders, and the fact that not every patient had every recommended test.

Since the manuscript was accepted for publication, the American Diabetes Association (ADA) revised its criterion for impaired fasting glucose (IFG) as ranging from 100 to 125 mg/dL (5.6 - 6.9 mmol/L). Of an additional 12 patients with IFG using the new criterion, seven had impaired glucose tolerance (IGT) and two had diabetes on the basis of the two-hour plasma glucose test during an OGTT.

"The revised criterion has not substantially altered the diagnostic yield of the fasting plasma glucose test (either alone or as part of the OGTT) in this patient population," the authors write.

The authors report no relevant financial interest in this article.

Arch Intern Med. 2004;164:1021-1025

U.S. Group Says Crestor Risk Higher Than Other Statins

WASHINGTON (Reuters) Mar 10 - The rate of serious muscle damage reported in patients who took AstraZeneca Plc's Crestor (rosuvastatin) was six times higher than with other statins, a consumer group said on Thursday.

The findings by consumer group Public Citizen contradicted a statement by the U.S. Food and Drug Administration last week that the risks of muscle injury from Crestor were similar to those of related drugs.

Public Citizen renewed its call for the FDA to immediately ban Crestor.

The group said it had reviewed reports of cases of rhabdomyolysis and compared them with the number of prescriptions filled for each drug. The reports were submitted to the FDA between Oct. 1, 2003, and Sept. 30, 2004.

For Crestor, there were about 13 reports of rhabdomyolysis for every million prescriptions filled, Public Citizen estimated. That rate was 6.2 times higher than the rates for all other statins combined.

The lowest rate among other statins was 0.6 reports per million prescriptions of Bristol-Myers Squibb's Pravachol (pravastatin).

"These data affirm the pre-approval findings from clinical trials of increased muscle damage/rhabdomyolysis for Crestor compared with other statins and refute the FDA statement that the rates are 'similar'," Public Citizen said in a letter to FDA Commissioner Lester Crawford.

Last week, the FDA said it had completed a review of Crestor's safety and concluded risks of muscle injury were similar to those of other statins. To reduce the risk, doctors were advised to consider the lowest possible dose for certain patients.

AstraZeneca has repeatedly defended Crestor as safe and effective when used according to directions.

Public Citizen first petitioned the FDA to ban Crestor in March 2004.

Impact on Medication Use and Adherence of Australian Pharmacists' Diabetes Care Services

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Abstract and Introduction
Abstract

Objective: To assess the effect of a specialized service implemented in community pharmacies for patients with type 2 diabetes on medication use and medication-related problems.
Design: Parallel group, multisite, control versus intervention, repeated measures design, with three different regions in New South Wales, Australia, used as intervention regions, then matched with control regions as much as possible.
Intervention: After initial training, pharmacists followed a clinical protocol for more than 9 months, with patient contact approximately monthly. Each patient received an adherence assessment at the beginning and end of the study, adherence support, and a medication review as part of the intervention.
Main Outcome Measures: Risk of nonadherence using Brief Medication Questionnaire (BMQ) scores and changes to medication regimen.
Results: Compared with 82 control patients, 106 intervention patients with similar demographic and clinical characteristics had significantly improved self-reported nonadherence as reflected in total BMQ scores after 9 months. The mean (± SD) number of medications prescribed at follow-up in intervention participants decreased significantly, from 8.2 ± 3.0 to 7.7 ± 2.7. No reduction was observed among the control patients (7.6 ± 2.4 and 7.3 ± 2.4). The overall prevalence of changes to the regimen was also significantly higher in the intervention group (51%) compared with controls (40%).
Conclusion: Community pharmacists trained in medication review and using protocols in collaboration with providers improved adherence in patients with type 2 diabetes, reduced problems patients had in accessing their medications, and recommended medication regimen changes that improved outcomes.
Introduction

Diabetes mellitus (DM) is a chronic incurable disease whose prevalence is growing worldwide.[1] Approximately 7.5% of Australians older than 25 years have diabetes, and more than one half of them are undiagnosed. In Australia, the direct annual health care costs for treating diabetes and its associated complications were estimated to be AU$1.4 billion in 1995 and may reach AU$2.3 billion by 2010.[2]

Since the publication of evidence......Cont online

Should All Diabetic Patients Receive a Statin? Results From Recent Trials

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Abstract

Diabetes is associated with the development of premature cardiovascular disease. In the three early trials of statin therapy for patients with established coronary heart disease there were many patients with diabetes; subgroup analysis has confirmed the benefits of cholesterol lowering with statin therapy in these patients. In the two early primary prevention trials, however, there were few patients with diabetes and so, initially, there was little evidence supporting the use of statins in diabetic patients without cardiovascular disease. The Heart Protection Study (HPS) and Collaborative AtoRvastatin Diabetes Study (CARDS) have now provided this evidence and firmly established that cholesterol lowering is of benefit in reducing cardiovascular events in patients with type 2 diabetes, regardless of the level of baseline cholesterol, or the presence or absence of cardiovascular disease. A few recent studies have failed to find benefit in diabetic patients but there are explanations for these negative findings. Ideally all patients with diabetes, especially the middle-aged and elderly, should be treated with statins but it remains uncertain at what age therapy should start and how low to reduce the cholesterol for maximum benefit.
Introduction..Cont............

Diabetes Triples Risk of Liver Cancer

NEW YORK (Reuters Health) Mar 07 - It appears that diabetes is an independent risk factor for hepatocellular carcinoma (HCC), raising the risk two- to three-fold, investigators report in the April issue of Gut.

While previous studies have revealed a relationship between diabetes and HCC (see Reuters Health reports, February 25 and September 7, 2004), results were based on referral samples and selection bias may have occurred.

The current study, using data from the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database, is the first population-based case-control study in the US that adjusted for other major risk factors related to HCC, senior author Dr. Hashem El-Serag, at Baylor College of Medicine in Houston, and colleagues maintain.

The study included 2161 patients aged 65 and older with diagnostic confirmation of HCC between 1994 and 1999. The control group included 6183 randomly selected individuals.

The authors found that 43.3% of HCC patients and 19.4% of control subjects had diabetes diagnosed during the 3 years preceding the date of HCC diagnosis (to exclude the possibility that HCC was the cause of the diabetes).

After adjusting for demographic factors, the odds ratio of HCC associated with diabetes was 3.08 (p < 0.0001). After excluding patients with hepatitis B or C virus, alcoholic liver disease or hemochromatosis, the odds ratio remained 2.87 to 3.11.

Hepatitis C virus alone was associated with an odds ratio of 24.42. In the presence of diabetes, it was increased to 36.88, suggesting a synergistic interaction between the two diseases.

"Diabetes may account for a significant proportion of patients with idiopathic HCC," Dr. El-Serag's group concludes.

Gut 2005;54:533-539.



Reuters Health Information 2005. © 2005 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

Lifestyle and metformin interventions cost-effective for preventing diabetes

Last Updated: 2005-02-28 17:00:10 -0400 (Reuters Health)

NEW YORK (Reuters Health) - The Diabetes Prevention Program (DPP), which involves lifestyle or metformin interventions, has been shown to delay or prevent the development of type 2 diabetes. Now, new research indicates that the DPP approach is cost-effective.

Meanwhile, in a similar study, lifestyle modifications were found to decrease the risk of diabetes in nonsmokers without impaired glucose tolerance, echoing what was seen previously in patients with impaired tolerance.

Both reports appear in the Annals of Internal Medicine for March 1.

In the first study, Dr. William H. Herman, from the University of Michigan in Ann Arbor, and colleagues used a Markov simulation model to assess the cost-effectiveness of the DPP interventions among subjects 25 years of age or older with impaired glucose tolerance.

The lifestyle intervention of the DPP involved a healthy, low-calorie/low-fat diet and moderate physical activity reinforced on a one-to-one basis and in group sessions. The metformin intervention involved a twice-daily dose of 850 mg with adherence support by a case manager.

The lifestyle and metformin interventions delayed the onset of diabetes by 11 and 3 years, respectively, compared with placebo, the authors note. The corresponding reductions in the absolute incidence of diabetes were 20% and 8%. In addition, both interventions reduced the occurrence of diabetic complications and improved survival.

Compared with placebo, the cost per quality-adjusted life-years (QALYs) for the lifestyle and metformin interventions was $1100 and $31,300, respectively, the researchers found. The corresponding costs per QALY, from a societal perspective, were $8800 and $29,900. In both analyses, the metformin intervention was dominated by the lifestyle intervention.

In the second study, Dr. George Davey Smith, from the University of Bristol in the UK, and colleagues assessed the incidence of diabetes among 11,827 men without impaired glucose tolerance who participated in the Multiple Risk Factor Intervention Trial (MRFIT). As part of the trial, the subjects were randomized to receive a lifestyle intervention, similar to that used in the DPP, or usual care.

In the overall analysis, the rate of diabetes in the intervention group -- 11.5% -- was actually slightly higher than the rate in the usual care group -- 10.8%. Further analysis revealed that the lifestyle intervention raised the risk of diabetes among smokers by 26%, but lowered the risk among nonsmokers by 18% (p = 0.0003).

As to why this occurred, the authors believe that the smoking cessation encouraged by the intervention may have resulted in weight gain among smokers that counterbalanced the beneficial effects seen. By contrast, this would not have occurred in patients who were nonsmokers at baseline.

In a related editorial, Dr. Jaakko Tuomilehto, from the National Public Health Institute in Helsinki, Finland, comments that while these reports show that lifestyle interventions can delay or prevent diabetes and are cost effective, the question remains of "what should be done with smokers?" It is possible that switching from diuretics and beta-blockers to drugs that interfere with the renin-angiotensin system may help cut the risk of diabetes in smokers with hypertension.

Ann Intern Med 2005;142:313-332,381-383.

Angiotensin receptor blockade improves renal blood flow in diabetics

Last Updated: 2005-02-22 12:25:13 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Chronic angiotensin II receptor blockade with olmesartan improves renal vascular perfusion despite significant blood pressure reductions in patients with type 2 diabetes, according to a report by German researchers in the April issue of the Journal of the American Society of Nephrology.

"Angiotensin II subtype 1 receptor antagonists (AT1-RA) not only lower blood pressure, but at the same time lower intraglomerular pressure and increase renal perfusion," Dr. Danilo Fliser from Medical School Hannover told Reuters Health. "Thus, their use offers a complete prevention of hemodynamically mediated damage to the diabetic kidney."

Dr. Fliser and colleagues examined the effect of 12 weeks of treatment with the AT1-RA olmesartan on renal hemodynamics in 35 patients with type 2 diabetes.

Blood pressure fell significantly with olmesartan treatment, the authors report, but did not change significantly in patients that received placebo.

Olmesartan treatment was associated with a significant increase in effective renal plasma flow and decreases in filtration fraction and renal vascular resistance, but glomerular filtration rate did not change with AT1-RA blockade. In contrast, patients that received placebo experienced a significant increase in filtration fraction and a nonsignificant increase in renal vascular resistance.

Reductions in isoprostane generation in the patients treated with olmesartan suggest that chronic AT1-RA blockade may prevent renal vascular damage not only by direct hemodynamic effects but also by reducing inflammation and/or reactive oxygen species generation, the investigators explain.

"Our results document that the favorable renal hemodynamic action of AT1-RA observed in acute experiments in individuals with type 2 diabetes persists even after prolonged AT1-receptor blockade," the authors conclude. "This effect may contribute to the renoprotective effect of AT1-RA documented in large prospective trials on prevention of progression of diabetic nephropathy."

Dr. Fliser added that "our findings support the routine use of AT1-RA, at least in diabetic patients with hypertension and/or presence of renal involvement."

J Am Soc Nephrol 2005.

Finding type 2 diabetics in primary care

A concern about the obesity epidemic is the increased numbers of people with adult-onset diabetes. Chance finding of frank diabetes or pre-diabetic hyperglycaemia is often a major trigger for lifestyle changes of less but better food, more exercise, and lost weight. Early detection and better control could ameliorate problems associated with diabetes.

This smacks of screening. Screening is a word fraught with danger, because in any set of circumstances there are three camps: the small numbers of enthusiasts who are either for it or against it, and the great mass of normal professionals whose main reaction is profound cynicism about another target. A study that shows that real-world targeted screening can work and might make sense [1] is a welcome relief.

Study

The study was conducted in 16 practices in Somerset and Devon, randomly selected from 42 volunteer practices. They had to have over 3,500 patients and have good (>60%) recording of BMI. Each practice was asked to sample 100 patients, 25 from each of four groups with different entry criteria (Table 1) relating to age and BMI. Selection of patients within the practices was done randomly. Patients could be selected for more than one group. Those with previously diagnosed diabetes were excluded, and only Caucasians were screened.

Trained practice nurses ran the screening clinics. Patients were sent a provisional clinic appointment, followed up by telephone reminder. Weight, height and age were recorded, and a fasting venous blood sample taken for plasma glucose measurement. Those with fasting plasma glucose over 6 mmol/L were invited for repeat testing. Diabetes was defined as plasma glucose of 7 mmol/L or more on both occasions. Impaired fasting glycaemia was defined as levels of 6.1-6.9 mmol/L on both tests.

Results

The response rate to invitation to attend the screening clinic was 61%. That meant 1,287 people attended, and, as some were in more than one group, there were 1,644 data points for analysis. BMI information was available for 77% of the over-50 population, and 20% of these were out of date or inaccurate compared with clinic measured BMI. Self-reported age differed from practice computer in 27/1,287 cases by more than one year. Of the 1,287 who attended for screening:

* 199 (15%) had an abnormal first test
* All of these attended a second time
* 148 (12%) had an abnormal second test
* 55 (4.3%) had type 2 diabetes
* 93 (7.2%) had impaired fasting glycaemia

The numbers of patients needed to be screened to detect one case of type 2 diabetes or impaired fasting glycaemia was low (7-13, Table 1), and reasonably flat across the groups.



Comment

These screening strategies discovered substantial numbers of people with previously undiagnosed type 2 diabetes. Undiagnosed diabetes rates were about 20% of those already diagnosed. For those with impaired fasting glycaemia, a glucose tolerance test might have been appropriate. Better recording of BMI and an expert computer system (they do exist!) could identify people at risk relatively simply. Practices could choose what criteria they might wish to adopt based on perceived workload, and on resources available. Lower age and BMI criteria should identify people early enough for lifestyle changes to be effective, especially in those with impaired glycaemia.

Reference:

1. CJ Greaves et al. A simple pragmatic system for detecting new cases of type 2 diabetes and impaired fasting glycaemia in primary care. Family Practice 2004 21: 57-62.

Internet diabetes monitoring

The setting for this trial was Korean patients with type 2 diabetes and Internet access. Severe concomitant disease was an exclusion criterion, or previous participation in any similar programme. Participants underwent examination and laboratory tests before and after 12 weeks in the study.

Patients consenting to participate were randomised to usual or Internet care. Usual care involved monthly visits with two or three visits with senior staff during a 12 week period. The Internet intervention consisted of a portal in which patients could enter pre- and postprandial blood glucose results, with information on type and dose of glucose lowering drugs, weight, exercise, and any other important changes. There was also an opportunity to ask questions.

Internet diabetes monitoring

The setting for this trial was Korean patients with type 2 diabetes and Internet access. Severe concomitant disease was an exclusion criterion, or previous participation in any similar programme. Participants underwent examination and laboratory tests before and after 12 weeks in the study.

Patients consenting to participate were randomised to usual or Internet care. Usual care involved monthly visits with two or three visits with senior staff during a 12 week period. The Internet intervention consisted of a portal in which patients could enter pre- and postprandial blood glucose results, with information on type and dose of glucose lowering drugs, weight, exercise, and any other important changes. There was also an opportunity to ask questions.

Genetics of type 2 diabetes mellitus: status and perspectives.

Hansen L, Pedersen O.

Steno Diabetes Center, Copenhagen, Denmark.

Throughout the last decade, molecular genetic studies of non-autoimmune diabetes mellitus have contributed significantly to our present understanding of this disease's complex aetiopathogenesis. Monogenic forms of diabetes (maturity-onset diabetes of the young, MODY) have been identified and classified into MODY1-6 according to the mutated genes that by being expressed in the pancreatic beta-cells confirm at the molecular level the clinical presentation of MODY as a predominantly insulin secretory deficient form of diabetes mellitus. Genomewide linkage studies of presumed polygenic type 2 diabetic populations indicate that loci on chromosomes 1q, 5q, 8p, 10q, 12q and 20q contain susceptibility genes. Yet, so far, the only susceptibility gene, calpain-10 (CAPN10), which has been identified using genomewide linkage studies, is located on chromosome 2q37. Mutation analyses of selected 'candidate' susceptibility genes in various populations have also identified the widespread Pro12Ala variant of the peroxisome proliferator-activated receptor-gamma and the common Glu23Lys variant of the ATP-sensitive potassium channel, Kir6.2 (KCNJ11). These variants may contribute significantly to the risk type 2 diabetes conferring insulin resistance of liver, muscle and fat (Pro12Ala) and a relative insulin secretory deficiency (Glu23Lys). It is likely that, in the near future, the recent more detailed knowledge of the human genome and insights into its haploblocks together with the developments of high-throughput and cheap genotyping will facilitate the discovery of many more type 2 diabetes gene variants in study materials, which are statistically powered and phenotypically well characterized. The results of these efforts are likely to be the platform for major progress in the development of personalized antidiabetic drugs with higher efficacy and few side effects.

PMID: 15715885 [PubMed - in process]

Many Type 2 Diabetics Should Take Statins

April 22, 2004 — Controlling cholesterol is as important as controlling blood sugar for patients with type 2 diabetes, according to new guidelines of the American College of Physicians (ACP) published in the April 20 issue of the Annals of Internal Medicine.

In April 2003, the ACP recommended tight blood pressure control in type 2 diabetes. The new ACP guidelines are the second set of guidelines recommending aggressive management of cardiovascular risk factors in this patient population. Specifically, the guidelines recommend statins for individuals with type 2 diabetes mellitus and coronary artery disease (CAD), and for all people with diabetes and any other risk factor for cardiovascular disease.

"We want both physicians and patients to know that when treating diabetes, controlling cardiovascular risk factors, particularly cholesterol levels and high blood pressure, is as important as controlling blood sugar," lead author Vincenza Snow, MD, FACP, a senior medical associate of scientific policy at the American College of Physicians, says in a news release. "This is life-saving information. In addition to controlling blood sugar levels, people with diabetes may be surprised to know that they must also be vigilant about controlling their blood pressure and cholesterol levels."

According to the American Diabetes Association, approximately 80% of people with type 2 diabetes will develop or die of complications of heart and vascular disease, and approximately 65% of deaths in diabetes are caused by heart disease and stroke. Furthermore, the increase in prevalence of type 2 diabetes has been labeled an epidemic. About 6% of the U.S. population, or 16 million Americans, have type 2 diabetes, and an additional 800,000 Americans older than 20 years are diagnosed with the disease each year.

The ACP evidence-based guidelines offer practical suggestions on all aspects of diabetes treatment for primary care physicians. For patients, the ACP is issuing a video news release to educate those with type 2 diabetes and their families about the importance of controlling cholesterol.

To control cholesterol in individuals with diabetes, specific recommendations are that all adults with type 2 diabetes and known CAD should take statins, regardless of their cholesterol levels. All adults, including premenopausal women, with type 2 diabetes and another CAD risk factor, such as hypertension, hypercholesterolemia, smoking, sedentary lifestyle or obesity, should take statins or the nonstatin drug gemfibrozil, regardless of cholesterol levels.

Having started cholesterol-lowering therapy, patients with type 2 diabetes should remain on at least moderate doses of a statin. Physicians should not delay starting statin treatment until cholesterol exceeds a critical level, nor should they treat only until a target level of cholesterol is reached and then abandon therapy. Except for patients with hepatic dysfunction, muscle pain, or concomitant use of drugs that interact with statins, routine monitoring of liver function or muscle enzymes is probably not necessary.

"Women with diabetes who have not reached menopause may think their female hormones protect them from CAD," Dr. Snow says. "But statistics show that premenopausal women with type 2 diabetes and at least one other cardiovascular risk factor are as likely as men to develop CAD. So ACP says that women with diabetes and other risk factors for CAD should take a statin."

The evidence base for these guidelines is summarized in an accompanying paper by Sandeep Vijan, MD, MS, and Rodney A. Hayward, MD, from Veterans Affairs in Ann Arbor, Michigan. It includes a systematic review of research on cholesterol-lowering drug therapy in people with type 2 diabetes who have CAD or cardiovascular risk factors. Specific issues reviewed include the benefits of tight lipid control in primary prevention, for patients without known CAD, and in secondary prevention, for patients with documented CAD; and the benefit of lowering cholesterol to a target level of low-density lipoprotein (LDL).

The authors concluded that statins are extremely safe, except for patients with hepatic dysfunction or with use of medications interacting with statins. Lipid-lowering medications appear to reduce risk of major cardiovascular events in diabetes by 22% to 24%.

"In patients with type 2 diabetes, treatment with lipid-lowering agents reduces cardiovascular risk," the authors write. "Most patients, including those whose baseline LDL cholesterol levels are below 2.97 mmol/L (< 115 mg/dL), and possibly below 2.59 mmol/L (< 100 mg/dL), benefit from statins. Moderate doses of these drugs suffice in most patients with diabetes."

The authors report no potential financial conflicts of interest.

Ann Intern Med. 2004;140:644-649, 650-658

A Pro-Active Call Center May Improve Glycemic Control in Type 2 Diabetes

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Feb. 4, 2005 — A Pro-Active Call Center Treatment Support (PACCTS) intervention can improve glycemic control in type 2 diabetes, according to the results of a randomized trial published in the February issue of Diabetes Care. A second article in the same issue established that this intervention, using trained nonmedical telephone operators supported by specially designed software and a diabetes nurse, was well received by the patients.

"Diabetes educator-led PACCTS for diabetes care is well established as a health care delivery vehicle in the US," write Robert J. Young, MD, from Hope Hospital in Salford, U.K., and colleagues. "It seems to offer service delivery characteristics that might enhance effectiveness, such as continuity, convenience, and risk-stratified intervention. However, it has not been subject to rigorous or large-scale clinical trial assessment of its effectiveness or efficiency."

Of 591 randomly selected individuals with type 2 diabetes in Salford, U.K., 197 individuals were randomized to the usual care (control) group and 394 to the PACCTS (intervention) group. Both groups received lifestyle advice and drug treatment according to local guidelines, but only PACCTS patients were telephoned according to a protocol in which the frequency of calls was proportional to the patients' last glycated hemoglobin (HbA1c) level. The primary outcome measure was absolute reduction in HbA1c level, and the secondary outcome was the proportion of patients in whom HbA1c level decreased by at least 1%.

The one-year study was completed by 332 patients (84%) in the PACCTS group and 176 patients (89%) in the control group, and final HbA1c values were available in 374 patients (95%) in the PACCTS group and 180 patients (92%) in the usual care group.

Compared with the usual care group, HbA1c level improved by 0.31% overall (95% confidence interval [CI], 0.11-0.52; P = .003) in the PACCTS group. However, for patients with baseline HbA1c level less than 7%, there was no change, and for patients with baseline HbA1c level of more than 7%, improvement increased to 0.49% (95% CI, 0.21-0.77; P < .001). The difference in the proportions of patients achieving at least a 1% reduction in HbA1c level was 10% overall (95% CI, 4-16; P < .001) and 15% (95% CI, 7-24; P < .001) for patients with baseline HbA1c level of more than 7%, favoring the PACCTS intervention.

"In an urban Caucasian trial population with blood glucose HbA1c > 7%, PACCTS facilitated significant improvement in glycemic control," the authors write. "Further research should extend the validity of findings to rural communities and other ethnic groups, as well as to smoking and lipid and blood pressure control."

GlaxoSmithKline funded the staff, data management, and analysis costs of this study. British Telecom acted as technology partners funding call center equipment, development, and maintenance costs. One of the authors was indirectly funded by GlaxoSmithKline.

An accompanying article by Andrew F. Long, MSc, MPhil, and colleagues from the PACCTS Team describes the results of a questionnaire survey designed to examine patients' views of the acceptability of and satisfaction with PACCTS.

Using the Diabetes Satisfaction and Treatment Questionnaire (DTSQ), the investigators determined satisfaction with care in all 591 patients at baseline and at the end of the study. In addition, 394 intervention patients received an acceptability questionnaire after at least three proactive calls from the call center and at the end of the trial, and a sample of 25 patients participated in in-depth, semistructured interviews.

Response rates were 79% for the DTSQ and 65% for the acceptability questionnaire. Individuals receiving the PACCTS intervention continued to report high levels of satisfaction with their treatment (95% CI, 32.3-33.2 at one year), and more than 90% strongly agreed or agreed that the telecarer approach was acceptable.

Based on qualitative comments, the patients expressed satisfaction with having a personalized service; improved feelings of well-being, such as confidence and self-control; assistance with problem solving; and developing rapport and a strong bond with the telecarers.

"A personalized PACCTS approach is acceptable to patients," the authors conclude. "A service giving priority to the interpersonal dimension leads to increased commitment from patients to improve long-term glycemic control."

Study limitations include potential bias in the measurement of satisfaction; a possible "expectation" effect with behavior change arising from the expectation of a call and the monitoring of glucose control; differences between PACCTS and other telecare systems; and limited one-year follow-up.

"These results suggest that several processes can contribute to a successful patient-centered telephone-supported disease management, [including] listening to and focusing on the concerns of patients, individualized problem solving, and continuity of care over time," the authors conclude. "It may not be the information provision per se that is important (raising awareness and knowledge), but its provision in a context of enablement and support aimed at self-efficacy."

GlaxoSmithKline and British Telecom funded this study, and GlaxoSmithKline indirectly funded some of its authors.

Diabetes Care. 2005;28:278-289
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:

* Describe the PACCTS intervention for diabetes care.
* Evaluate the impact of PACCTS with usual care vs usual care only on diabetic outcomes at one year.

Clinical Context

The U.K. Prospective Diabetes Study demonstrated the effort required to obtain and maintain improved glucose control, and the importance of tight control in preventing long-term adverse outcomes of diabetes. Telephone diabetes education has been advocated and delivered by nurses and dieticians as part of a patient education strategy in chronic disease management. PACCTS was developed as a health care model in the U.S. and offers continuity, convenience, and access to patients as a risk-stratified intervention. However, according to the current authors, the strategy has not been tested for its efficacy in diabetes management in large, rigorous clinical trials.

The current authors conducted a randomized, open controlled trial to compare the outcomes of diabetes control at one year for an unselected group of patients with diabetes who were offered either usual care or usual care with PACCTS intervention modified for that community. The patients were from among 22 group practices in one U.K. community.
Study Highlights

* Patients were from an inner city, and 95% were white. More than 80% were in the lowest 2 socioeconomic strata. 22 practices with 591 patients agreed to participate.
* Exclusion criteria were diabetes duration less than one year, terminal illness, and inability to use the telephone.
* Patients were randomized to receive either usual care (n = 176, control) or usual care and PACCTS (n = 332, PACCTS) stratified by baseline HbA1c level (< 7, good; 7-9, moderate; and > 9%, poor).
* Usual care consisted of following the English National Guidelines for managing glucose control in type 2 diabetes, using a standard stepped-care protocol for patients, continuing medical education to primary care providers, and annual review. The guidelines are available at: http://www.NICE.org.UK.
* PACCTS was delivered by call center operators (telecarers) trained for 3 months by a diabetes specialist nurse with a focus on listening skills, motivational interviewing, and database methodology.
* The PACCTS application consisted of four main domains: knowledge, readiness to change (lifestyle intervention), medication adherence, and blood glucose control (self-testing and clinic follow-up reminders).
* Telecarers (working part-time) made calls once every 3 months if HbA1c level was 7% or less, every 7 weeks if HbA1c level was 7.1% to 9.0%, and monthly if HbA1c level was more than 9%. Each call lasted 20 minutes. If supplemental counseling was required, a referral was made to the specialist nurse.
* Primary outcome was HbA1c level at one year.
* Secondary outcome was proportion of patients reducing HbA1c level by at least 1% at one year.
* The study was powered at 90% to detect a reduction of 1% in HbA1c level in the PACCTS group at a significance level of 5%. Analysis was by intent-to-treat, using last observation carried forward for missing data.
* Mean age was 67 years, 58% were male, mean body mass index was 30.3 kg/m2, and mean duration of diabetes was 6 years. At baseline, a quarter of patients used lifestyle intervention only for control, 30% used one oral hypoglycemic agent (OHA), 25% used two OHAs, and 20% used insulin with or without OHA.
* There were more than 4,000 telephone consultations, with 90% outbound and 10% inbound.
* 10.7% of the control and 15.7% of the PACCTS group withdrew.
* Medication use in the control group increased overall, with no change in 91% and step-up in 9%.
* In the PACCTS group, medication decreased in 3%, did not change in 75%, and increased in 22%.
* Medication use increased more in the PACCTS than in the control group (P = .002).
* Mean HbA1c level improved by 0.3% in the PACCTS vs the control group (P < .003). The improvement was greater for patients with HbA1c level of 7% or more at 0.49% (P < .001), and there was no change in patients with baseline HbA1c level less than 7%.
* Significantly more patients in the PACCTS group had improvement of at least 1% in HbA1c level (overall 10%; P < .001). For patients with baseline HbA1c level of more than 7%, the proportion with improvement of at least 1% in HbA1c level was 15% (P < .001).
* The results were independent of age, sex, or practice (group vs single handed).
* In a separate article, patient surveys with 79% response rate for the PACCTS and 65% response rate for the control group indicated that PACCTS was well accepted by patients and offered increased feelings of well-being, confidence, and self-control.

Pearls for Practice

* The PACCTS intervention for diabetes management consists primarily of trained telecarer-initiated calls to patients focusing on the domains of knowledge, readiness to change (lifestyle intervention), medication adherence, and blood glucose control.
* Compared with usual care, patients with diabetes with a baseline HbA1c level of more than 7% who were offered PACCTS for one year had improved HbA1c control, with a higher proportion showing improvement of at least 1%.

Vitamin B12 Status of Patients Treated With Metformin: A Cross-Sectional Cohort Study

Introduction

Following the results of the United Kingdom Prospective Diabetes Study (UKPDS)[1] metformin is increasingly used in the treatment of type 2 diabetes. Metformin has an excellent safety profile,[2] but malabsorption of vitamin B12 may occur during long-term metformin treatment.[3,4] However, the prevalence and clinical significance of this potential adverse drug reaction is unknown. The recommendation to check serum cobalamin during therapy, e.g. once a year, is not followed strictly in clinical practice. Moreover, serum cobalamin may be insufficient as a marker of vitamin B12 status. Reduced serum cobalamin concentrations have been observed in controlled clinical studies with metformin alone and added to glibenclamide,[5] and with metformin added to insulin.[6] Vitamin B12 deficiency is associated with raised serum HCy and MMA levels. Whereas marginal elevations of HCy have been observed after metformin in diabetic[6] as well as non-diabetic[7] subjects, MMA has not been measured in this context. HCy is an independent cardiovascular risk factor.[8] Vitamin B12 deficiency may have serious consequences such as megaloblastic anaemia, myelopathy and neuropathy, and subnormal cobalamin concentrations have been associated with dementia. Megaloblastic anaemia due to metformin-associated vitamin B12 deficiency has been reported,[9,10] but it can be treated successfully with cyanocobalamin.[11] Symptoms of B12-related neuropathy can be misinterpreted as diabetes neuropathy.

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Statin Drugs and Coenzyme Q10

Statin drugs are one of the most used pharmaceutical classes of products throughout the world. Lipitor® (atorvastatin) and Zocor® (simvastatin) have been ranked among the top 10 prescription drugs since 1999, with $9.2 billion in sales generated.

Clinical research has documented the benefit of these drugs for the prevention and treatment of heart disease. Other possible indications include reduction of Alzheimer disease, risk of stroke, and osteoporosis. Millions of Americans use these drugs on a daily basis, and are expected to take them for many years in order to manage elevated cholesterol levels...............................

Diabetes Appears to Increase Risk of Sepsis

"Diabetes Appears to Increase Risk of Sepsis"


ALEXANDRIA, VA -- January 27, 2005 -- A new study adds potentially fatal blood infections to the list of health risks from diabetes, a condition that is on the rise in the United States as obesity rates climb, according to the Feb. 15 issue of Clinical Infectious Diseases, now available online. Researchers have known for years that obesity and diabetes are linked. Most diabetics have type 2 diabetes--and most people with type 2 diabetes are obese. Diabetes can cause a host of health troubles, including kidney problems, damage to nerves and blood vessels and blindness. A heightened risk of infections in diabetic people has also been suggested. The condition known as sepsis can be brought on by bloodstream infection, and may lead to fever and septic shock, a potentially fatal drop in blood pressure. Diabetic people are more vulnerable to bacterial blood infections called bacteremia, particularly if they develop other bacterial infections, such as urinary tract infections (UTIs). Danish researchers studied more than 1,300 patients with bacteremia caused by E. coli and related bacteria and found that about 17 percent had diabetes, compared with only 6 percent among the controls, who were matched for age and sex from the general population. Compared with non-diabetics, diabetic patients were more likely to have bacteremia caused by urinary tract infection, rather than abdominal infection. Death after bacteremia also occurred more often in diabetics than in non-diabetics. So, with type 2 diabetes becoming increasingly common as Americans gain weight, the risk for serious infectious complications is a real one, according to Reimar Thomsen, M.D., Ph.D., lead author of the study. "Bacteremia...is a life-threatening infection," he says, "and bacteremia with sepsis is the 10th most common cause of death in the United States." Dr. Thomsen of Aalborg Hospital and Aarhus University Hospital (currently with Vanderbilt University) added that urinary tract infections seem to be a common problem in diabetics, and that the researchers "believe that urinary tract infections are the most important link between diabetes and an increased risk of bacteremias caused by E. coli and related bacteria." To reduce the risk of potentially fatal infection, Dr. Thomsen suggested that diabetics--particularly women, who are more prone to UTIs--try to avoid known risk factors, such as unnecessary catheterization. "Diabetic persons with signs and symptoms of urinary tract infection or bacteremia/sepsis should always seek medical care promptly, and doctors should keep a high level of suspicion for these infections if the patient has got diabetes," Dr. Thomsen added. SOURCE: Infectious Diseases Society of America

Diabetic Neuropathies: The Nerve Damage of Diabetes: "Diabetic Neuropathies: The Nerve Damage of Diabetes"
Diabetic neuropathies are a family of nerve disorders caused by diabetes. People with diabetes can, over time, have damage to nerves throughout the body. Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may also occur in every organ system, including the digestive tract, heart, and sex organs. People with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the greater the risk.

Does Someone in Your Household Have Diabetes?

An estimated 18.2 million Americans have diabetes, according to the American Diabetes Association. The effects of this disease can cause severe foot problems. November is American Diabetes Month – a good time to remind family members with this disease that good foot care must be a part of their overall treatment regimen. Circulatory and nerve damage problems caused by diabetes can leave patients with serious foot ulcers and other conditions that, if left untreated, can result in amputation. In fact, about 82,000 lower-limb amputations are performed each year on people with diabetes.

Help keep your family members on their feet! Anyone with diabetes should inspect their feet daily and have them checked by a foot and ankle surgeon at least once a year; more often if poor blood flow to the foot or nerve damage is present.
>Diabetic Foot Care Guidelines.
Diabetic Foot Problems and Treatments

Australian Prescriber: "The management of type 2 diabetes"
SYNOPSIS
Control of blood glucose in type 2 diabetes involves a stepped approach to therapy ideally by a multidisciplinary team. Therapy begins with education, then a reduction in dietary fat and an increase in exercise. If control remains inadequate, the usual next steps are the addition of metformin, and later a sulfonylurea. In those who do not respond to maximal doses of these drugs, insulin therapy may be needed. Initially, intermediate-acting insulin injected at bedtime can be added. This can be increased to twice daily insulin without tablets if control is not adequate. In addition to the control of blood glucose, it is imperative to manage hypertension and dyslipidaemia and to screen for macro- and microvascular complications.

Depression May Raise Women's Diabetes Risk

Depression May Raise Women's Diabetes Risk
Symptoms of Depression Linked to Insulin Resistance

By Jennifer Warner
Reviewed By Brunilda Nazario, MD
on Wednesday, December 22, 2004
WebMD Medical News



Dec. 22, 2004 -- Feeling blue may raise women's risk of developing type 2 diabetes, according to new research.

The study shows that symptoms of depression in middle-aged women are associated with higher levels of insulin resistance, which is a precursor to diabetes.

Researchers say the findings may help explain why depression is twice as common among people with diabetes compared with the general population. Depression is also associated with poor diabetes management.

Depression and Diabetes Linked

In the study, which appears in the December issue of Diabetes Care, researchers looked at the association between symptoms of depression and diabetes among a group of 2,662 middle-aged women who took part in the Study of Women's Health Across the Nation. All of the women were free of diabetes when the study began.

Three years later, 97 cases of diabetes were diagnosed among the women.

Researchers found that depression predicted a 66% greater risk of diabetes in the women, but this association disappeared after they adjusted for other risk factors associated with the development of diabetes, such as excess fat around the midsection (a heart disease and type 2 diabetes risk factor known as central adiposity).

However, symptoms of depression were linked to greater levels of insulin resistance among the women.

In addition, depressed African-American women were more than 2.5 times more likely to develop diabetes, even after adjusting for other risk factors.

Researchers say the results show that depressive symptoms can increase the risk of diabetes and are related to higher levels of insulin resistance -- another risk factor for diabetes.

They add that depression can alter hormones relating to how the body handles stress. This in turn can affect body fat distribution and how it handles blood sugar metabolism.

They say people should be encouraged to seek treatment for depression and maintain and adopt active lifestyles, healthy diets, and weight loss, if needed, to reduce their risk of diabetes.

SOURCE: Everson-Rose, S. Diabetes Care, December 2004; vol 27: pp 2856-2862.

A Nutty Way to Improve Cholesterol in Diabetes

A Nutty Way to Improve Cholesterol in Diabetes
Eating a Healthy Diet Including Walnuts May Reduce Type 2 Diabetes Risks

By Jennifer Warner
Reviewed By Brunilda Nazario, MD
on Friday, December 03, 2004
WebMD Medical News



Dec. 3, 2004 -- Incorporating a handful of walnuts into a healthy diet may help people with type 2 diabetes improve their cholesterol levels and reduce their risk of heart disease, a new study suggests.

Researchers found including walnuts as part of a balanced, low-fat diet helped people with diabetes increase their "good" HDL cholesterol levels while lowering their "bad" LDL cholesterol levels.

But don't reach for the nut bowl just yet. Experts say merely adding walnuts to an already unhealthy diet won't necessarily undo the damage. Instead, they say it's important to substitute walnuts for other sources of fat in the diet in order to achieve the best results.

Walnuts contain an omega-3 fatty acid called alpha-linolenic acid or ALA, which is similar to the omega-3 fatty acids found in fatty fish, such as salmon. Previous studies have shown that alpha-linolenic acid has a number of heart-healthy effects, including improving cholesterol levels.

Researchers say this is one of the first studies to look at the effects of the fatty acids found in walnuts in people with type 2 diabetes.

Walnuts May Aid in Diabetes Management

In the study, which appears in the December issue of Diabetes Care, researchers looked at the effects of three different diets on cholesterol levels in older adults with type 2 diabetes.

Nearly 60 men and women were divided into three groups that followed three different diet plans: a low-fat diet, a modified-fat diet, or a modified-fat diet that included eight to 10 walnuts per day (30 grams). All of the diets were based on eating a variety of whole foods, such as cereals and breads, fruits and vegetables, lean meat, fish, and low-fat dairy products with no more than 30% of total calories from fat.

After six months of the diet, the results showed that the people who ate the modified-fat diet including walnuts experienced a bigger increase in "good" HDL cholesterol levels than those in the other two diets. People who ate walnuts as part of a balanced diet also experienced an average 10% reduction in "bad" LDL cholesterol levels.

Researchers say the study suggests that incorporating walnuts into a healthy diet may be an easy way for people with type 2 diabetes to get the right kinds of fats and fatty acids into their diet.

"Walnuts are an easy and convenient way of getting polyunsaturated omega-3 fatty acids into the diet. And they're particularly important for people with diabetes because they're a simple snack food, which is an integral component of managing the diet in diabetes," says researcher Linda Tapsell, PhD, of the University of Wollongong in Australia, in a news release.

Although the walnut diet appeared to help improve cholesterol levels in people with type 2 diabetes, no significant differences were found between the groups in terms of body weight or body fat.

Funding for the study was provided by the California Walnut Commission.

Hyperglycemia Slows Mental Functions in People with Diabetes

ALEXANDRIA, VA -- December 22, 2004 -- A temporary rise in blood glucose (sugar) levels in people with both types of diabetes can interfere with their ability to think quickly and solve problems, according to a study in the January issue of Diabetes Care.

Researchers at the University of Virginia Health System (UVHS) found that people who had both type 1 and type 2 diabetes performed poorly on math and verbal tests when they became hyperglycemic, a condition in which blood glucose levels are higher than normal. Symptoms of hyperglycemia include high blood glucose, high levels of sugar in the urine, frequent urination, and increased thirst. Roughly 55 percent of the people in the study showed signs of cognitive slowing or increased errors while hyperglycemic, suggesting that the consequences of hyperglycemia vary among individuals. However, among those whose cognitive performance deteriorated when blood sugar levels rose, the negative effects consistently appeared once levels reached or exceeded a threshold of 15 mmol/l or 270 mg/dl.

Because hypoglycemia (when blood glucose levels are too low) can cause dizziness and an inability to focus, many people consume large amounts of carbohydrates to avoid this state prior to school exams and other cognitive- sensitive tasks. But this study suggests that carbohydrate-loading could be counterproductive, the researchers conclude, because hyperglycemia often occurs after overeating.

"The best way to minimize any negative effects on cognitive functioning is to keep blood glucose levels tightly controlled," said lead researcher Dr. Daniel J. Cox, of the Center for Behavioral Medicine Research at UVHS. "People who have diabetes should pay careful attention to the warning signs of hyperglycemia so that they can quickly take action to treat it."

Treatment for hyperglycemia can include increasing insulin or reducing food intake.


SOURCE: American Diabetes Association

BioMed Central | Full text | Update on Charcot Neuroarthropathy: "Charcot neuroarthropathy is not uncommon in diabetic patients with peripheral neuropathy. Often, the condition is misdiagnosed for cellulitis or osteomyelitis and treatment is delayed. A high index of suspicion is required in these patients to initiate appropriate treatment early. This article covers the pathogeneses of this condition and briefly describes the recent studies performed to understand the underlying etiopathogenetic factors of this devastating condition. Lastly, it mentions the recently completed multicenter trial using bisphosphonates in diabetic Charcot neuroarthropathy."

Diabetic Gourmet Magazine - Dedicated to Diabetic Dining and Healthy Living
Diabetic Gourmet Magazine: free newsletter, daily tidbits, menus and forum.

Diabetes.com: "
Sponsored by GlaxoSmithKline

Welcome to Diabetes.comYou Can Be Stronger Than Diabetes"

David Mendosa: A Writer on the Web: "Diabetes is a disease that perhaps more than any other depends much more on the patient than on the doctor. If you are newly diagnosed with diabetes, please start with Advice for Newbies. I have written hundreds of magazine and on-line articles, columns, and Web pages about diabetes, most of which are listed and linked in my Diabetes Directory. This includes the 15 pages of my On-Line Diabetes Resources,"

Diabetes Resource Center: "Welcome to the Diabetes Resource Center! This site was developed by Eli Lilly and Company. The purpose of this resource center is to provide easy steps for healthy foot care. By increasing the importance of daily foot exams, most diabetic foot ulcers and amputations can be prevented"

Sarahealth.com | Diabetes: "Diabetes | Links
You are visiting Sarahealth, the site dedicated to achieving optimal physical and emotional wellness. This page discusses Type 2 diabetes with a focus on self-education and self-management."

The Brownsville Herald � Study on diabetes surpasses anticipated figures
Dec. 6, 2004 — Elida Ortiz blames a poor diet and sedentary lifestyle for her diabetes, but the odds may have been stacked against her.

“You are what you eat,” said Ortiz who was diagnosed with Type II diabetes four years ago.

“I used to eat three of four flour tortillas or six corn tortilla tacos (per meal),” said 59-year-old Ortiz, “I needed to change that.”

Lifestyle choices, such as a high-fat, high-sugar diet and lack of exercise, can trigger diabetes in individuals that carry the disease.

Vitamin E Helps Some Diabetes Patients - Trustworthy, Physician-Reviewed Information from WebMD: "Nov. 23, 2004 -- Some people with diabetes may benefit from taking vitamin E, according to an international team of scientists.

Vitamin E's possible heart benefits are described in a letter published in the November issue of the journal Diabetes Care. The letter was written by researchers, including Andrew Levy, MD, PhD, of Technion-Israel Institute of Technology in Haifa, Israel."

Title: Testosterone Deficiency Found in One-Third of Diabetic Men
"Testosterone Deficiency Found in One-Third of Diabetic Men"


Study is first to reveal hypogonadism as common complication of diabetes BUFFALO, NY -- November 29, 2004 -- Low testosterone production appears to be a common complication of type 2 diabetes in men, affecting 1 out of 3 diabetic patients, a new study has shown. Moreover, results of the investigation show that this condition, known clinically as hypogonadism, is caused not by a defect in the testes, where testosterone is produced, but by improper functioning of the pituitary gland, which controls production of testosterone, or of the hypothalamus, the region of the brain that controls the pituitary. "This starts a whole new story on the crucial complications of type 2 diabetes," said Paresh Dandona, M.D., senior author on the study and director of the Division of Endocrinology, Diabetes and Metabolism at the University at Buffalo and Kaleida Health, where the study was conducted. Results of the study appear in the November issue of Journal of Clinical Endocrinology and Metabolism. Sandeep Dhindsa, M.D., UB assistant professor of medicine and first author on the study, said the findings are important because hypogonadism has not been recognized as a complication of type 2 diabetes, and the high prevalence of 30 percent was unexpected. "The surprisingly high prevalence of low testosterone levels was associated with lower levels of pituitary hormones called gonadotrophins, suggesting that the primary defect in these patients was either in the pituitary or higher up in the hypothalamus," he said. "Since gonadotrophins drive the testes to produce testosterone, this finding gives us an insight into the pathogenesis of this complication of type 2 diabetes." Earlier studies, including those conducted by this research group, found that diabetic subjects with erectile dysfunction and low testosterone levels often have low levels of pituitary hormones. However, conclusions from prior studies have been fraught with problems with testosterone assays, Dhindsa noted. "A large portion of testosterone in the blood is bound to proteins, but a small portion is unbound and largely determines the amount of testosterone that is available to the tissues," said Dhindsa. "This active portion is called free testosterone. Assays to accurately determine it are delicate, tedious and time-consuming. "This investigation set out to determine, in a prospective fashion, the prevalence of low total testosterone, accurately measure free testosterone in male patients with type 2 diabetes and to attempt to determine the seat of the problem in those with low free testosterone." The study involved 103 consecutive males with type 2 diabetes who were referred to the Diabetes-Endocrinology of Western New York for treatment. None of the men had been diagnosed previously with low testosterone levels. The researchers collected fasting blood samples from the participants and analyzed them for testosterone levels and for hormones associated with testosterone production. They also measured cholesterol and glucose levels, and a blood marker for how well glucose was controlled during previous months, called hemoglobin A1c. Data on height, weight and diabetic complications, including erectile dysfunction, neuropathy, retinopathy and coronary artery disease, were recorded. Results showed that nearly one-third of the men had hypogonadism. Although obesity is associated with hypogonadism and is prevalent among type 2 diabetics, only 10-15 percent of the variation in low free testosterone levels could be attributable to body mass index, Dhindsa said. More than 30 percent of lean patients also were hypogonadal. "Equally important, most of the men who had low testosterone levels also had lower levels of gonadotrophins, as compared to men with normal testosterone levels," he noted. "Furthermore, the gonadotrophin concentration in the blood correlated positively with free testosterone levels, supporting the notion that the cause of the defect is in the pituitary or hypothalamus." The high prevalence of low testosterone in diabetic men is concerning, said Dhindsa, because in addition to lowered libido and erectile dysfunction, the condition is associated with loss of muscle tone, increase in abdominal fat, loss of bone density, and can affect mood and cognition. "Further studies will help us determine why type 2 diabetic patients are more prone to developing hypogonadism," he said. "While obesity may explain part of the high prevalence of hypogonadism, it is likely that other factors associated with type 2 diabetes also contribute significantly. This area is clearly ripe for further investigation." Additional researchers on the study were Sathyavani Prabhakar, M.D., UB clinical assistant instructor of medicine, Manak Sethi, M.D., research assistant, Arindam Bandyopadhyay, M.D., UB clinical assistant professor of medicine, and Ajay Chaudhuri, M.D., UB assistant professor of medicine. SOURCE: University at Buffalo

Prevention of type 2 diabetes mellitus through inhibition of the Renin-Angiotensin system

Healthspan Vitamin supplements. Buy tax-free vitamins online with Healthspan: "As always, Healthspan brings you the most 'advanced Glucosamine supplements' in the UK! Wherever and whenever there have been valuable advances in the science of nutrition, Healthspan have incorporated them into their 'advanced' range of products. We now offer liquid and vegetarian forms of Glucosamine. "

Letters to the Editor - January 15, 2004 - American Family Physician: "Use of Metformin Is a Cause of Vitamin B12 Deficiency"
Small studies and case reports have shown that 10 to 30 percent of patients who are prescribed metformin show signs of reduced vitamin B12 absorption leading to clinically significant abnormalities in about 30 percent of cases.

: "Title: AHA: Statins May Lower Blood Pressure
'AHA: Statins May Lower Blood Pressure'


By Charlene Laino NEW ORLEANS, LA -- November 10, 2004 -- Statin therapy leads to a significant reduction in diastolic and systolic blood pressure, a randomized, double-blind, placebo-controlled comparative trial shows. Beatrice A. Golomb, MD, PhD, associate professor of medicine, University of California, San Diego (UCSD), La Jolla, California, presented the results here on November 9[th at the American Heart Association Scientific Sessions 2004."

Close Control Of Blood Pressure Associated With Fewer Eye Problems In Patients With Type 2 Diabetes

Cookin' With Google -- ResearchBuzz, September 13, 2003: "Judy Hourihan came up with the idea of searching Google to figure out what you're going to have for dinner and I turned it into a Google Hack. one of the most popular ones out there.
"To use the recipe search, all you have to do is type a couple of ingredients in, and select the kind of recipe that you want. The service then searches Google to find recipes that match your specific criteria. You can even narrow things down to recipes for vegetarians, diabetics, and people on the Atkins Diet. When you only have a certain number of ingredients on hand, use Cookin’ With Google to figure out what’s for dinner.

Healthy Diabetic Recipes - a database of recipes suitable for diabetics
This is a GREAT site for any Diabetic (Including YOU Cath in Limassol)

BestTreatments :: Conditions :: Diabetes :: What treatments work?: "The different tablets used to treat diabetes can be divided into five groups. We have listed these below with some names of individual drugs (and brand names). Click on the links to find out more about:"

Diabetes, Foot Care and Foot Ulcers
PRODIGY PILS L541; (Version=23): "About 1 in 10 people with diabetes develop a foot ulcer at some stage. A foot ulcer is prone to infection, which may become severe. This leaflet aims to explain why foot ulcers sometimes develop, what you can do to help prevent them, and typical treatments if one does occur."

Type 2 Diabetes
PRODIGY PILS L49; (Version=24): "Type 2 diabetes occurs mainly in people aged over 40. The 'first-line' treatment is diet and exercise. If the blood glucose level remains high despite a trial of diet and exercise, then tablets to reduce the blood glucose level are usually advised. Insulin injections are needed in some cases. Other treatments include reducing blood pressure if it is high, and other measures to reduce the risk of complications."

Foot Care For People With Diabetes
PRODIGY PILS L540; (Version=23): "About 1 in 10 people with diabetes develop a foot ulcer at some stage. A foot ulcer does not heal very easily, is difficult to treat, and is prone to serious infection. Another leaflet called 'Diabetes, Foot Care and Foot Ulcers' gives more details. This leaflet gives a summary on how you can help to prevent foot ulcers."

Diabetic Retinopathy
And Other Eye Complications of Diabetes
PRODIGY PILS L584; (Version=23): "What is diabetic retinopathy?

What is diabetes?
Diabetes mellitus (just called diabetes from now on) occurs when the level of glucose (sugar) in the blood becomes higher than normal. There are two main types of diabetes - Type 1 and Type 2. See separate leaflets called 'Type 1 Diabetes' and 'Type 2 Diabetes' for more general information about diabetes."

Diabetes and High Blood Pressure
PRODIGY PILS L543; (Version=23): "Diabetes and High Blood Pressure"
What is high blood pressure?

High blood pressure (hypertension) means that the pressure of the blood in your arteries is too high. Blood pressure is recorded as two figures. For example, 140/80 mmHg. This is said as '140 over 80'. Blood pressure is measured in millimetres of mercury (mmHg).

Treatments for Type 2 Diabetes
PRODIGY PILS L583; (Version=23): "This leaflet mainly discuses treatments which can lower the blood glucose level. It briefly mentions other treatments which may also be advised if you have Type 2 diabetes. See a separate leaflet called 'Type 2 Diabetes' for more general information about this condition."

BBC NEWS | Health | Diabetics 'must test blood more': "Diabetics should be checking their blood sugar levels more regularly to reduce the risk of heart disease and strokes, US research shows."

BBC NEWS | Health | Herbal remedies 'do work': "cientific tests on a range of traditional remedies have shown they have 'real benefits', researchers say.

Experts from King's College London said the treatments from around the world had properties which may help treat conditions such as diabetes and cancer.

The remedies included India's curry leaf tree, reputed to treat diabetes."

RedNova - Deadly Threat of Diabetes: "EDDIE Cusack fears for the future when he looks around at the other people at his regular diabetes clinic. At 70, Eddie is pretty philosophical about developing type two diabetes, a condition which has traditionally been associated with getting older. As long as he is sensible about his diet and takes regular exercise, he should be able to control a serious illness which is potentially life- threatening."

Coenzyme Q10:

"High Cholesterol

Levels of CoQ10 tend to be lower in people with high cholesterol compared to healthy individuals of the same age. In addition, certain cholesterol-lowering drugs called statins (such as atorvastatin, cerivastatin, lovastatin, pravastatin, simvastatin) appear to deplete natural levels of CoQ10 in the body. Taking CoQ10 supplements can correct the deficiency caused by statin medications without affecting the medication's positive effects on cholesterol levels.

Diabetes

CoQ10 supplements may improve heart health and blood sugar and help manage high cholesterol and high blood pressure in individuals with diabetes. (High blood pressure, high cholesterol, and heart disease are all common problems associated with diabetes). Despite some concern that CoQ10 may cause a sudden and dramatic drop in blood sugar (called hypoglycemia), two recent studies of people with diabetes given CoQ10 two times per day showed no hypoglycemic response. The safest bet if you have diabetes is to talk to your doctor or registered dietitian about the possible use of CoQ10."

Coenzyme Q10: Questions and Answers, Cancer Facts 9.16
# What is Coenzyme Q10?

Coenzyme Q10 (also known as CoQ10, Q10, vitamin Q10, ubiquinone, or ubidecarenone) is a compound that is made naturally in the body. A coenzyme is a substance needed for the proper functioning of an enzyme, a protein that speeds up the rate at which chemical reactions take place in the body. The Q and the 10 in coenzyme Q10 refer to parts of the compound’s chemical structure.

Coenzyme Q10: "Heart disease. Cancer. AIDS. As unbelievable as it might sound, each of these deadly diseases often responds to a coenzyme Q10, a little known nutrient that can make a big difference in your health.

Granted, such 'cure all' statements leave people wondering whether CoQ10 is just the latest panacea of the month. Rest assured: the benefits of this nutrient are well documented in the medical journals. It's one of the most frequently prescribed heart 'drugs' in Japan and widely used in Europe-and one company even owns the patent for the CoQ10 treatment of AIDS.

Ask your doctor about CoQ10, though, and he'll probably say he's never heard of it. Part of the problem is CoQ10's name. 'Most doctors don't know what a coenzyme is,' said Karl Folkers, Ph.D., one of the researchers who pioneered CoQ10. Most biochemists know it as ubiquinone, an equally arcane name."

Exercise helps to overcome endothelial dysfunction
in patients with type 2 diabetes>:

Pharmacists' Diabetes Services in Australia: "Objective: To implement and evaluate a specialized service for type 2 diabetes mellitus in the community pharmacy."

Advances in Diabetes for the Millennium: Insulin Treatment and Glucose Monitoring: "Newer insulins and easier blood glucose monitoring have greatly improved the ability to obtain excellent control of blood glucose levels with less risk of hypoglycemia. In type 1 diabetes, insulin pump therapy remains the optimal approach with the most flexibility, especially with the ultra-fast-acting analogs lispro or aspart. Otherwise, once- or twice-daily dosing with the long-acting analog glargine provides excellent basal coverage, and lispro or aspart at meals provides bolus coverage, all in the attempt to mimic physiological insulin secretion. For type 2 diabetes, although oral agents continue to be a mainstay of therapy, it is clear that many patients require insulin to attain the goal A1c of < 6.5%. Once-daily glargine is now used more commonly after 1-2 oral agents have failed, and it typically takes the place of sulfonylureas. The future will likely have better systems for continuous glucose monitoring and novel therapies to control glucose through agents that affect gut hormones."

Diabetics Exposed to Telmisartan and Enalapril
: "The first long-term study to compare an angiotensin receptor blocker (ARB) and an angiotensin-converting enzyme (ACE) inhibitor in patients with hypertension and early-stage type 2 diabetic nephropathy has shown that the ARB telmisartan and the ACE inhibitor enalapril have comparable long-term renoprotective effects.[1] The Diabetics Exposed to Telmisartan And Enalapril (DETAIL) trial is thus the first to show that an ARB offers renoprotection that is clinically equivalent to that of an ACE inhibitor."

: "There are many new orally administered agents to treat type 2 diabetes. Sulfonylureas and meglitinides stimulate insulin secretion. Metformin has been joined by thiazolidinediones to reduce insulin resistance. Disaccharidase inhibitors slow glucose uptake after a meal. Beta-3 agonists and agents that augment glucagon-like peptide activity are promising new agents in the effort to not only control glucose levels but also restrain weight gain. The future treatment of diabetes will require multiple drugs working in concert to normalize blood glucose."

Red Meat Increases Type 2 Diabetes Risk in Older Women: "NEW YORK (Reuters Health) Sept 09 - Middle age and elderly women with high levels of red meat in their diet appear to have an increased risk of developing type 2 diabetes, according to a study published in the September issue of Diabetes Care"

Low Glycemic Index Diet Helpful in Men With Type 2 Diabetes
August 2, 2004 — A low glycemic index (LGI) diet improves glycemic control, some lipid profiles, and fibrinolysis in men with type 2 diabetes, according to the results of a randomized trial published in the August issue of Diabetes Care

Twenty Percent of Patients With Asymptomatic Diabetes Have...
July 30, 2004 — Twenty percent of patients with asymptomatic diabetes have silent myocardial ischemia, according to the results of the Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects (DIAD) study published in the August issue of Diabetes Care. These findings support the American Diabetes Association (ADA) guidelines recommending routine screening.

American Diabetes Association 64th Annual Scientific Sessions

Splenda

The Struggle for Mastery in Insulin Action:
ype 2 diabetes arises from a combination of impaired insulin action and defective pancreatic β-cell function. Classically, the two abnormalities have been viewed as distinct yet mutually detrimental processes. The combination of impaired insulin-dependent glucose metabolism in skeletal muscle and impaired β-cell function causes an increase of hepatic glucose production, leading to a constellation of tissue abnormalities that has been referred to as the diabetes "ruling triumvirate." Targeted mutagenesis in mice has led to a critical reappraisal of the integrated physiology of insulin action

Dual Blockade of Renin-Angiotensin System Renoprotective...: "Aug. 1, 2003 � Dual blockade of the renin-angiotensin system (RAS) is renoprotective in type 2 diabetes, according to the results of a double-blind, randomized trial published in the August issue of Diabetes Care. Adding an angiotensin II receptor blocker (ARB) to treatment with maximal recommended doses of an angiotensin-converting enzyme (ACE) inhibitor provided superior short-term renoprotection independent of systemic blood pressure changes."

Adding Thiazolidinedione to Metformin Plus Insulin Improves...: "July 1, 2004 � Adding thiazolidinedione to metformin (MET) plus insulin (INS) improved glycemic control and reduced INS dose without increasing weight gain, according to the results of a randomized trial published in the July issue of Diabetes Care. The editorialist suggests that treating to target is all that matters, regardless of what combination of medications is used. Cost and lifestyle should be considered in choosing optimal triple therapy."

News - Metformin Shows Promise for Diabetes Prevention, but Further Studies Needed
Metformin may help prevent type 2 diabetes in individuals at high risk of developing the disease, but new studies must evaluate its long-term safety, efficacy, cost-effectiveness, according to Donald L. Sullivan, PhD, RPh, and Aleda M. Hess, Pharm D, both of Ohio Northern University, Ada, United States.

News - Rosiglitazone Could Have Antiinflammatory Effects: "Thiazolidinedione rosiglitazone, a selective agonist of peroxisome proliferator-activated receptor gamma has demonstrated antiinflammatory effects, according to a new American study.

Troglitazone, a thiazolidinedione agonist of peroxisome proliferator-activated receptor gamma (PPAR�) and a partial agonist of PPAR�, was previously shown to have a significant antiinflammatory activity in a trial of diabetic obese patients and nondiabetic obese subjects, writes P. Mohanty, MD, and colleagues, Division of Endocrinology, Diabetes and Metabolism, State University of New York, New York."

Webcast/CME - Evolution of Type 2 Diabetes: The Time for Insulin is Now
This multi-media webcast reviews the goals of type 2 diabetes management, the benefits of intensive therapy, guidelines for measurement of glycaemic control, and practical strategies for helping achieve and maintain glycaemic control via intensive therapy methodologies

Adding Thiazolidinedione to Metformin Plus Insulin Improves...
July 1, 2004 — Adding thiazolidinedione to metformin (MET) plus insulin (INS) improved glycemic control and reduced INS dose without increasing weight gain, according to the results of a randomized trial published in the July issue of Diabetes Care. The editorialist suggests that treating to target is all that matters, regardless of what combination of medications is used. Cost and lifestyle should be considered in choosing optimal triple therapy.

MayoClinic.com - Diabetes Center

Rosuvastatin Label Change in EU Indicates Risk of Myopathy

June 10, 2004 — The U.S. Food and Drug Administration (FDA) issued a public health advisory yesterday, notifying healthcare professionals of labeling changes for rosuvastatin (Crestor, made by AstraZeneca) in the 22 member states of the European Union (EU). These changes, which are already in effect in FDA-approved labeling in the U.S., reflect the increased risk of myopathy associated with high levels of rosuvastatin.

Glucagon-like Peptide 1: Part II
The central role of GLP-1 in glucose tolerance has raised questions about the possible involvement of this peptide in the pathogenesis of diabetes. In addition, the wide range of coordinated actions by which GLP-1 lowers blood glucose has launched a new wave of drug development centered on this peptide hormone.

Incretin Hormones in Diabetes and Metabolism
Introduction
The Incretin Effect
The Incretin Hormones: GIP and GLP-1
Incretin Physiology and Type 2 Diabetes Mellitus
Current Status of Drugs in Development
Concluding Remarks
References

The Glycemic Index: "What is the Glycemic Index?
The glycemic index is a ranking of carbohydrates based on their immediate effect on blood glucose (blood sugar) levels. It compares foods gram for gram of carbohydrate. Carbohydrates that breakdown quickly during digestion have the highest glycemic indexes. The blood glucose response is fast and high. Carbohydrates that breakdown slowly, releasing glucose gradually into the blood stream, have low glycemic indexes."

ACE Inhibitors Improve Survival in Type 2 Diabetes: "May 27, 2004 � Angiotensin-converting enzyme (ACE) inhibitors significantly reduce all-cause mortality in patients with type 2 diabetes who do not have a history of cardiovascular disease, according to the results of a cohort study published in the June issue of Diabetes Care.
'ACE inhibitor therapy is widely used in lower-risk patients with type 2 diabetes to reduce mortality, despite limited evidence to support this clinical strategy,' write Dean T. Eurich, BSP, MSC, from the Institute of Health Economics in Edmonton, Alberta, Canada, and colleagues."

ACE Inhibitors Improve Survival in Type 2 Diabetes

May 27, 2004 — Angiotensin-converting enzyme (ACE) inhibitors significantly reduce all-cause mortality in patients with type 2 diabetes who do not have a history of cardiovascular disease, according to the results of a cohort study published in the June issue of Diabetes Care.

Aspirin-Like Treatment May Be Safe, Effective for Type 2 Diabetes
May 3, 2004 (Boston) — Salsalate, an aspirin-like anti-inflammatory agent, has shown promise as a type 2 diabetes treatment in a small pilot study at the Joslin Clinic.

Robert J. Silver, MD, a fellow in endocrinology and diabetes at the Boston-based diabetes center, reported that 3.0 g taken orally for two weeks was enough to reduce blood fasting glucose by 9% in nine patients. Other benefits included reductions of 12% in triglyceride and 15% in free fatty acid levels.

More Coffee, Less Diabetes - Diabetes Mellitus, Type 2, Type 1, and Metabolic Disorders treatment and medications
More Coffee, Less Diabetes
Authors' Conclusion: "Coffee drinking has a graded inverse association with the risk of type 2 DM; however, the reasons for this risk reduction associated with coffee remain unclear." (J. Tuomilehto and coauthors, JAMA. 2004;291:1213)

Our Translation: More coffee, less type 2 diabetes. We really have no idea why this is so.

Grapefruit Consumption Implicated in Case of Statin-Related Rhabdomyolysis: "Grapefruit Consumption Implicated in Case of Statin-Related Rhabdomyolysis



NEW YORK (Reuters Health) Mar 01 - A recent case of statin-associated rhabdomyolysis appears to have been triggered by grapefruit consumption, according to a report published in the February 24th issue of Neurology. Although the case involved simvastatin, the authors note that other statins could also be influenced by grapefruit consumption."

GLUCOPHAGE (metformin hydrochloride tablets)
GLUCOPHAGE XR (metformin hydrochloride
extended-release tablets)

Oral Antidiabetes Medications (FDA Consumer magazine, January-February 2002)

Diabetic Neuropathy: An Intensive Review

Diabetes and Macrovascular Disease: Risk Factor Management
The Impact of Cardiovascular Disease
What We Know About the Endothelium
Vasculoprotection With Nitric Oxide
The Role of Oxidative Stress in Endothelial Dysfunction and Vascular Disease
The Renin-Angiotensin System: A Major Role in Endothelial Function
Putting It All Together: The Path to Coronary Artery Disease
Endothelial Dysfunction: Causes and Treatment Strategies
Plaque Pathology: An Inside View
Diabetes: A Source of Endothelial Insult
Reducing Macrovascular Complications: Evidence From the Statin Trials
More on the Vasculoprotective Effects of Lipid Lowering With Statins
Reducing Macrovascular Complications: Evidence From the Angiotensin-Converting Enzyme Inhibitor Trials
Findings From the Heart Outcomes Prevention Evaluation
Vasculoprotection With Angiotensin-Converting Enzyme Inhibitors
The Current Views on Risk Reduction Therapy

Cross-Talk Between Iron Metabolism and Diabetes
Emerging scientific evidence has disclosed unsuspected influences between iron metabolism and type 2 diabetes. The relationship is bi-directional—iron affects glucose metabolism, and glucose metabolism impinges on several iron metabolic pathways. Oxidative stress and inflammatory cytokines influence these relationships, amplifying and potentiating the initiated events. The clinical impact of these interactions depends on both the genetic predisposition and the time frame in which this network of closely related signals acts

Iron Stores in Healthy Women Linked to Diabetes Risk

Feb. 10, 2004 — Higher amounts of iron stores in the blood are associated with an increased risk of type 2 diabetes in healthy women with no known diabetes risk factors, according to the results of a nested case-control trial published in the Feb. 11 issue of The Journal of the American Medical Association.

Daily Multivitamin/Mineral Supplement Reduces Infection in Type 2 Diabetes

Chromium Supplements Appear to Improve Glucose Sensitivity in Diabetics

Sweet Potato Extract Improves Glycemic Control in Type 2 Diabetes

Diabetes Care: Small-Bowel Bacterial Overgrowth in Diabetic Subjects Is Associated With Cardiovascular Autonomic Neuropathy.: "Gastrointestinal symptoms are present in 50-70% of patients with diabetes. Delayed gastric emptying, and disturbance of intestinal motility are frequent findings [1,2]. Impaired intestinal motility is often followed by small-bowel bacterial overgrowth (SBBO), which can possibly lead to deconjugation of bile acids, diarrhea, "

Medscape Resource Center - Diabetic Microvascular Complications: "Diabetes is, of course, a disease of complications. But landmark studies such as the Diabetes Control and Complication Trial have shown that achieving tight glycemic control can directly reduce the risk of diabetic complications, especially diabetic microvascular complications. New screening tools and potential new treatments also hold promise for making diabetic microvascular complications such as retinopathy and neuropathy more manageable and less inevitable."

Laxity in Diabetic Care in the US - MedicineNet.com Medical References for Patients

Quote: "If you're a diabetic over 55, you should be on an aspirin a day, a lipid-lowering agent [to lower cholesterol], and a medication to prevent heart attacks, like an ACE inhibitor. Heart attacks kill 80% of diabetics, and you can drop that by 70% by taking those three medications. You should therefore see your provider and discuss getting on them. Simple three pills, very safe and very simple, with almost no side effects. It could add years to your life." (Dr. R. James Dudi, Kaiser Permanente Health Plan, San Diego)

BBC NEWS | Health | Back pain drug 'may aid diabetics'

A drug used to treat backpain may also prevent patients with diabetes from going blind or having limbs amputated, a study suggests.
Scientists in the United States have found evidence to indicate that benfotiamine may be able to keep blood vessels healthy.

The Five Absolute Worst Foods You Can Eat 10/18/03

By Dr. Joseph Mercola
with Rachael Droege


There are no “bad” foods, right? Only food you should eat in moderation? Well, not really. The following foods are so bad for your body that I really can’t see any reason to eat them. Not only do they have zero nutritional value, but they also give your body a healthy dose of toxins, which should make the idea of eating them really hard to swallow.