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
Thursday, February 24, 2005
Wednesday, February 23, 2005
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%.
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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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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Sunday, February 20, 2005
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...............................
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...............................
Friday, February 04, 2005
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
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
Thursday, February 03, 2005
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.
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.
Friday, January 07, 2005
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
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 Problems and Treatments
Thursday, January 06, 2005
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.
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.
Monday, December 27, 2004
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.
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.
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
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
Wednesday, December 15, 2004
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."
Saturday, December 11, 2004
Diabetic Gourmet Magazine - Dedicated to Diabetic Dining and Healthy Living
Diabetic Gourmet Magazine: free newsletter, daily tidbits, menus and forum.
Diabetic Gourmet Magazine: free newsletter, daily tidbits, menus and forum.
Diabetes.com: "
Sponsored by GlaxoSmithKline
Welcome to Diabetes.comYou Can Be Stronger Than Diabetes"
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."
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."
Monday, December 06, 2004
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.
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.
Sunday, December 05, 2004
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."
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."
Friday, December 03, 2004
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
"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
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