articles

[Guest guest]

I've been anemic for over 10 years, perhaps 15 years, running as low as 10.3 or

so. At times, I have hit 12, but rarely, and I am usually around 11, plus or

minus. Neither my general physician or nepthrologist are overly concerned, and

attribute it to kidney dysfunction, or as in the first article, ckd. I was kind

of surprised at how the doctors in this discussion seemed to be acting like low

enemia was something just being discovered (in relationship to diabetes and

ckd). Sometimes I really wonder about the medical field.

anyway, thanks for the articles Pat.

Dave

articles

1. Welcome to Medscape Nephrology and to this Spotlight entitled,

" Managing Anemia in Patients With Type 2 Diabetes and Chronic Kidney

Disease. " I am Dr.

Ajay Singh, Clinical Director at Brigham & Women's Hospital and

Associate Professor of Medicine at Harvard Medical School in Boston, MA,

and I will be

your moderator.

Slide 4. Prevalence of Diabetes and CKD Willa A. Hsueh, MD:

I think all of our audience knows that diabetes is the most common cause

of end stage renal disease in the US and there are about 30% to 40% of

patients

with type 1 DM who will go on to have chronic kidney disease and about

10% to 15%, maybe even as high as 20%, of patients with type 2 who will

go on to

have chronic kidney disease.

Aggressive Prevention of CKD Slide 5. Aggressive Prevention of CKD

I think we're all realizing, thanks to our nephrology colleagues, that

as patients develop albuminuria, not only is that an important sign of

kidney disease,

but I think it's a sign that there may be terrible problems with the

endothelium that could then lead to problems, of course, with coronary

heart disease

and stroke, so that should raise a red flag for all of us. In addition,

I think we also know that glycemic

control is very important for the microvascular complications, not just

the kidney but the eye and some of the neurologic complications. So with

that said,

I think as endocrinologists we're really focusing on tight control

early, tighter and tighter control. In fact, the recent ADA Guidelines

suggest that

we get our control to nearly normal in all of our patients with

hemoglobins around 5.5% or less. So there's an aggressive effort, I

think, to try to prevent

chronic kidney disease. Unfortunately, I think some patients will not

respond to some of

those or comply with some of those aggressive efforts, and we will still

have problems with the kidney.

Slide 6. Recognizing the Complications of CKD .. the question is how do

we recognize some of the complications early, that would include not

just the,

as we said, the coronary heart disease complications but also the

anemia, the changes in type 2 hyperparathyroidism or secondary

hyperparathyroidism, and

issues about early interventions for the anemia, and early interventions

with vitamin D therapy?

Dr. Singh: One of the really important issues, of course, is the burden

of cardiovascular disease in this population. Dr. Hsueh: Absolutely.

Dr. Singh: It seems like a number of observational studies have

indicated that at a very early stage in the syndrome of diabetic

nephropathy, patients

develop vascular disease and cardiovascular disease. Is it your sense

that the diabetologists are now increasingly

recognizing this and are becoming more aggresive in managing

cardiovascular disease in this population? Dr. Hsueh: Oh absolutely,

you cannot go to an

endocrine meeting without hearing about the marked increased incidence

of cardiovascular disease in patients with diabetes, and I think we've

known for

a long time that albuminuria is a key signal that heralds that, and I

think you all know well that as there is a progressive decrease in

glomerular filtration

rate, there's a progressive increase in cardiovascular disease.

%%Slide 8. Clinical Practice Guidelines for CKD and Diabetes

Mark E. Molitch, MD: several things came out of reviewing the

literature for those guidelines, certainly the glycemic control that

Willa had talked about

remains important, and even in the patient as they have advancing kidney

disease, we still need to get good glycemic control to try to reduce and

ameliorate

some of the other long-term complications of diabetes. But as far as the

cardiovascular

disease goes and the lipid management, these are patients at such high

risk that we recommend an LDL goal of less than 70 for those patients,

obviously

blood pressure treatment to get blood pressures less than 130/80 for

virtually all patients with diabetes, and perhaps even more stringent

goals for the

patient who's getting progressive

nephropathy. I think one of the things that brought home to me as we

were reviewing all this, is the knowledge that's relatively new, at how

early secondary

hyperparathyroidism and anemia start to be found.

%% Slide 9. Development of Anemia in Patients With Diabetes

Dr. Singh: one of the things that I have come across in the literature

is the idea that anemia tends to develop at an earlier stage in

diabetics than it

seems to in nondiabetics, so for any given level of GFR. What are your

thoughts on that, Willa ? Dr. Hsueh: Well we're recognizing more

patients, for

example, with stage 3 chronic kidney disease, and we are seeing evidence

that if patients have diabetes, the anemia for any level of chronic

kidney disease

seems to be worse than the nondiabetic patient, and of course there is

this anemia of chronic disease to begin with that our patients with

diabetes have,

and then when the kidney disease sets in, there are problems with

synthesis, as you know, of erythropoietin, and so that complicates the

issue, . Dr. Singh:

Mark, do you refer patients once they develop anemia or do you manage

the anemia yourself in your own practice?

Dr. Molitch: Well I think in our practice and probably in most

endocrine practices, by the time we find the patient whose hemoglobin is

getting less than

11 and we start thinking about erythropoietin [EPO], we have generally

been referring that patient to the nephrologist.Slide 10. TREAT Study

Design this

is a randomized prospective study looking at the effects of

erythropoietin supplementation, trying to get the hemoglobin levels up.

Slide 12. Diabetologists

and Nephrologists Working Together Dr. Singh:

In my own nephrology practice, I tend not to spend a lot of time

thinking about different types of insulin, so I would imagine that

Willa, you also don't

think about all the newer erythropoietins that are coming out since you

have such a strong nephrology division at UCLA. Dr. Hsueh: Well, like

Mark, with

erythropoietin, we're actually when we feel patients need that, we

actually call our nephrology colleagues and, as you said, they have a

very strong background.

What I'm amazed at is that our nephrology colleagues, once the

GFR is somewhere around 30 or less, they take over full management, so

they actually have to know about insulins and know about other issues.

%%Slide 15. Managing Patients With Diabetes and CKD

Dr. Singh: So what are your top 2 or 3 things that nowadays in 2007 you

think about in managing patients with diabetes who have chronic kidney

disease?

Do you, as Mark is alluding to, manage their lipids more aggressively,

their hypoparathyroidism, or do you feel that these areas still

represent controversial

issues? Dr. Hsueh: Well, as I said, we would see these patients more

in stage 2, stage 3, and maybe the beginning of stage 4, and I manage

their cardiovascular

risk, hypertension especially, very aggressively because I know that

whatever changes in blood pressure happen have great impact on the

kidney. The lipids

I'm concerned with, but I'm aware of the studies

you said, and then the question is the role of vitamin D because there's

very intriguing information that not only is it good for the

calcium-phosphorus

changes but also it may have anti-inflammatory effects; and there are a

number of studies at UCLA, then of course the whole issue of anemia, and

in patients

with heart disease, of course you want to provide oxygen but you don't

want to provide so many red cells that you get thrombosis formation.

Dr. Singh: So, Mark, do you think that diabetologists and nephrologists

can work together in managing these important conditions or is there

hope for

us to work together? Dr. Molitch:

Well absolutely I think it's almost a natural combination, but I think

one of the things we have to do is keep working together, and so it's

not a hand

off, it's a continued comanagement of the patients even once they get on

dialysis. I think the diabetologists can lend a hand in trying to help

manage

their diabetes even at that point. ..Dr. Singh:

So management of anemia and diabetes and kidney disease are

interrelated and now one can manage them in a diabetes center in a

collaborative fashion or

one can refer these patients but it seems like one of the key issues is

to certainly manage them, to recognize it early and manage them.

Slide 16. Management of Dialysis Patients With Diabetes

One quick question I have before we summarize is what about the dialysis

patient - do you tend to have them come back to your diabetes center or

diabetes

practice and continue to follow them or is it your observation that most

of these patients get managed wholly by the nephrologist when they reach

end-stage

renal disease?

Dr. Hsueh: Well I'm happy because there are more oral agents now on

board that we can use in dialysis patients, for example, in addition to

insulin,

. We now have sitagliptin or Januvia,.. you have to adjust the dose, but

it's a DPP-4 inhibitor that works on the incretin pathway. We have the

TZDs [thiazolidinediones]

which can be used all the

way through to end-stage kidney disease. And, of course, we have

acarbose, which mainly works on the gut and just slows, doesn't inhibit,

just slows carbohydrate

absorption. So you actually have 3 oral agents that you can mix and

match in patients with chronic kidney disease and then you have insulin,

so I think

we've broadened

the horizons for patients with CKD.

%% Slide 17. Summary and Closing Comments

Dr. Singh: So it sounds like nephrologists need to learn more about how

to manage diabetes with different types of insulins and oral agents and

diabetologists

need to learn to manage perhaps a little bit more about the

comorbidities of kidney disease such as hypoparathyroidism and lipid

abnormalities but also

anemia. And whether you refer these patients or you manage them in the

diabetes center, the key is to try to manage them together. Dr. Hsueh:

Well, we're

waiting for you to do the studies to tell us what level of hemoglobin

should we intervene, when should we intervene with vitamin D; of course,

both of

those studies are ongoing. Dr. Singh:

Right. Well, that was, I think, a very productive discussion, and I'd

like to thank Dr. Hsueh and Dr. Molitch for participating. I think we

achieved our

objectives of discussing the interrelatedness of anemia, diabetes, and

chronic kidney disease. I also believe that we really brought out the

notion that

diabetologists and nephrologists need to work together in both early

recognition and then subsequent management of these patients. Supported

by an independent

educational grant from Roche

2.%% Notice: The LightHouse for the Blind and Visually Impaired will be

hosting several informational survey interviews on talking glucose

meters and adaptive

insulin syringe devices. These interview sessions will be conducted in

conjunction with a doctorial student from UC Berkeley. The focus of the

interviews

is to collect data concerning talking glucose meters and adaptive

insulin syringe devices. The interview will take between 60 to 90

minutes in San Francisco

and there will be a $40 honorarium for those who participate. The

participants must be diabetic and have used or currently use a talking

glucose meter.

If you know of individuals who may qualify please contact Beth Berenson

at The LightHouse, Phone: or via email at:

3.%% Medscape - Metabolic Syndrome Linked to Chronic Kidney Disease

(Reuters Health) Jul 24 - A study of a Chinese population aged 40 years

and older found

an association between metabolic syndrome and chronic kidney disease.

(CKD) Metabolic syndrome " is a common disorder in developed countries, "

note the

researchers. " With its dramatic economic development and the consequent

changes in lifestyle and diet, China too has seen the metabolic syndrome

become

an important health care problem. " [2310 people;

cross-sectional study; mean age 60.7 years,] The overall prevalence of

metabolic syndrome was 34.1%, and the overall prevalence of CKD was

10.7%. The prevalence

of CKD was higher among subjects with metabolic syndrome than those

without metabolic syndrome (15.4% versus 8.3%, respectively. " Further

studies are needed

to determine if treatment of metabolic syndrome could substantially ease

the burden of CKD in China, " the team concludes. Mayo Clin Proc 2007;82

4.%% In Diabetes Today 23-JUL-2007 - Hepatitis C Strongly Linked to

Type 2 Diabetes (Reuters Health) - People infected with hepatitis C

virus have an

increased risk of developing type 2, or " adult-onset " diabetes, a

population-based study confirms. This risk is particularly high in

younger people who

are overweight, researchers have found.

Therefore, screening for and preventing diabetes in persons with HCV

infection could be started earlier than the suggested age of 45 or

older, which is

the recommendation for the general population, especially for patients

with are heavier or who have other diabetes risk factors for diabetes,

the team

writes. [4,958 people age 40 or older without diabetes, 3,486 tested

negative and 812 positive for HCV; 116 subjects were infected with both

HCV and HCV;

544 tested positive for hepatitis B; 7 year follow up] After adjusting

the data to account for established diabetes risk factors, the incidence

of DM was

70 percent higher in persons with HCV infection than in those without

it. " This finding is consistent with past studies showing that HCV

infection is highly

associated with diabetes. " the younger group with HCV infection was at

greater risk for the disease, they note. HCV infection plus being

overweight or

obese magnified the risk of diabetes by about three times compared with

uninfected persons of normal weight. American Journal of Epidemiology,

July 15,

2007.

5.%% TimesSelect F.D.A. Review Criticizes Diabetes Drug and Maker

July 26, 2007 Patients who take Avandia, a popular but controversial

diabetes medicine made by GlaxoKline, [GSK] are far more likely to

suffer and die from heart problems than those who take Actos, a similar

pill made

by Takeda, according to federal drug reviewers. Avandia is particularly

dangerous to patients who also take insulin. By contrast, Actos can be

taken safely

with insulin, according to the review. The findings likely spell the end

of Avandia's status as one of the nation's most popular drugs for

treating diabetics

who are not dependent on insulin. Last year, more than a million

patients in the US took Avandia, and a similar number took Actos.

Avandia's 2006 global sales were nearly $3.4 billion. The report and

charges that GSK sought to intimidate a doctor who publicly

warned about Avandia's risks in 1999 could lead to a cascade of lawsuits

against the company. Indeed, F.D.A. reviewers were sharply critical of

the quality

of the studies GSK has undertaken to test the safety of Avandia,

dismissing the present and future results of an ongoing 4,000-patient

trial as unreliable

and invalid. The report by medical and safety reviewers within the FDA

also provides ammunition to critics on Capitol Hill and elsewhere who

claim that

top F.D.A. officials have been far too slow to acknowledge Avandia's

risks. GlaxoKline suggested a year ago that the agency add a note

to the drug's

label about Avandia's growing heart risks, the report states. These

conclusions come in a 436-page compendium of reviews released in advance

of an advisory

committee hearing to be held on Monday to discuss Avandia's effects on

the heart. The F.D.A. intends to ask the committee of independent

experts whether

Avandia should continue to be sold. It is far from clear, F.D.A. safety

reviewers concluded in the report, whether taking Avandia, also known as

rosiglitazone,

is worth the risk. " A critical question to be resolved in determining

appropriate regulatory action is whether the anticipated therapeutic

benefit of rosiglitazone

outweighs the demonstrated

cardiovascular risk, " one F.D.A. reviewer concluded.

6.%% Medscape - Corneal Sensitivity Is Linked to Diabetic Neuropathy

(Reuters Health) Jul 26 - Results of a new study suggest that corneal

sensitivity is reduced in diabetic patients, and is related to the

severity of neuropathy.

" In diabetic patients, corneal sensitivity is reduced, due to a loss of

corneal nerve fibers, which leads to corneal keratopathy and a

susceptibility to

injury, with recurrent erosions and ulcers, " researchers write . Corneal

sensation, they add, can be evaluated using the Cochet-Bonnet

aesthesiometer (C-BA)

or the noncontact corneal aesthesiometer (NCCA). They examined corneal

sensitivity in 147 diabetic patients and 18 controls using these

approaches and

also assessed neuropathy deficit score. Neuropathy was classified as

being absent, mild, moderate or severe. No significant differences in

age, type of

diabetes, and A1C were observed among the groups. The duration of

diabetes increased with neuropathic severity. Corneal sensitivity was

significantly reduced

in patients with diabetes compared with controls. It was not reduced in

diabetic patients without neuropathy. However, a significant reduction

was observed

in those with any degree of neuropathy. A significant correlation was

observed between neuropathy

established by C-BA and NCCA. The findings, the investigators conclude

" have important clinical implications regarding the development of

corneal abnormalities

in diabetic patients and also raise the possibility that corneal

sensation could be used to screen for diabetic neuropathy. " Diabetes

Care 2007;30

7.%% Medical News Today - Improving Heart Health In Kids With Diabetes

Type 1: The More They Exercise, The Lower The Risk Of Early Death 28

Jul 2007

It's never too early to focus on how to maintain good cardiovascular

health, especially for people with type 1. A study published in the

August issue of

Diabetes Care underscores the need for regular physical activity among

youth, finding that the more active the child, the better the child's

cardiovascular

risk profile. Heart disease is the number one killer of people with

diabetes. Among type 1 patients

as young as 20-39 years, the risk of dying from cardio- and

cerebrovascular events is five times higher than it is for people who

don't have diabetes.

Previous studies have shown that the development of atherosclerotic

lesions begins in childhood and

that 69 percent of pediatric patients with type 1 diabetes exhibit one

or more cardiovascular risk factors.

A new study by researchers in Germany and Austria, which looked at the

physical activity levels and cardiovascular health of more than 23,000

young people

between the ages of 3 and 18, found that those who were most physically

active were the least likely to be at risk for heart disease. As

physical activity

levels rose, risk factors such as high lipid profiles, diastolic blood

pressure, and blood glucose

levels fell. Regular physical activity was defined as exercising for at

least 30 minutes at a time, not including school sports. The study found

that those

who were active at least once or twice per week were also less likely to

have high blood pressure than those who didn't exercise at all. And, it

showed

that the frequency of regular physical activity " was one of the most

important influencing factors for HbA1c. " The A1c test measures average

blood glucose

levels

over a period of 2-3 months and helps a person with diabetes determine

how well they are keeping blood glucose levels under control overall.

8.%% Medscape Medical News - The Choice of a Metabolic Syndrome

Generation: Soft Drink Consumption Associated With Increased Metabolic

Risk [for another

version of this see DRList 7-24-07]

July 25, 2007 - Drinking more than one soft drink daily is associated

with a higher risk of developing adverse metabolic traits, as well as

developing

the metabolic syndrome, a new study has shown. Interestingly, it doesn't

matter if the soda consumed is the diet variety, those with zero

calories, as

investigators showed these also

increased the burden of metabolic risk in middle-aged adults. " That was

one of the more striking aspects of this study, " lead investigator Dr R.

Vasan

(Boston University School of Medicine, MA) told

heartwire. . " It actually doesn't matter if the soft drink is regular or

diet. There was an association of increased risk of developing the

metabolic syndrome

with both types of drinks. " Vasan said that the consumption of soft

drinks has doubled to tripled between 1977 and 2001. During this same

time period,

soft-drink sizes have also increased to staggering proportions. With

evidence that soft-drink consumption is linked with weight gain and

obesity as well

as an increased risk of diabetes, the investigators questioned whether

soft-drink consumption in adults, in amounts that are seemingly

innocuous, like

one per day, posed any metabolic hazard. The team related the incidence

of metabolic syndrome and its components to soft-drink consumption in

more than

6000 individuals participating

in the Framingham Heart Study. In a cross-sectional analysis of the

data, investigators report that those consuming more than one soft drink

daily had

a 48% higher prevalence of metabolic syndrome

than those who drank less than one soft drink per day. In a longitudinal

analysis of more than 6000 subjects free from metabolic syndrome at

baseline,

drinking more than one soft drink daily was associated with a 44%

greater risk of developing metabolic syndrome and with developing 4 out

of 5 components

of metabolic syndrome. In a smaller sample of participants who had data

available regarding the type of soft drink consumed, researchers

observed that

that those who consumed one or more drinks of diet or regular soda per

day had a 50% to 60% increased risk of developing new-onset metabolic

syndrome.

Despite the fact that diet soda has zero calories, the findings are not

entirely surprising, said Vasan, as diet soft drinks have been

previously linked

with poor health outcomes in children, such as weight gain and high

blood pressure. In terms of theories explaining the association between

soft-drink

consumption and the metabolic syndrome risk, Vasan said there are no

definitive answers yet. .it might be a lifestyle/dietary background

thing driving

this. "

In addition, Vasan said diet soda might also induce a conditioning

response in which the soft drinks promote a dietary preference for

sweeter foods. Also,

because diet soda is liquid, this has the effect of individuals eating

more at the next meal, mainly because liquids are not as satiating. And

finally,

the brown caramel in soda has been linked with tissue damage and

inflammation, which might contribute to the increased risk. All of these

theories, however,

are debated in literature. " Clearly, these findings are sufficiently

intriguing that scientists now have to help us understand better why we

see this association, "

said Vasan. " We are not inferring causality from this analysis. It is

just an association, so we need to turn to the

scientists who are better positioned to help us understand the

association more. " Circulation. Published online July 23, 2007.

9.%% -FDA Advisory Panels Acknowledge Signal of Risk With Rosiglitazone,

but Stop Short of Recommending Its Withdrawal

Wood Heartwire 2007. C 2007 Medscape July 31, 2007 -

Rosiglitazone (Avandia, GlaxoKline [GSK]) is associated with a

clear signal of cardiac

ischemic risk in type 2 diabetics, the available data suggest, but this

signal is not enough to justify yanking the drug from the market. This

was the

near-unanimous conclusion of the FDA's joint Endocrinologic and

Metabolic Drugs/Drug Safety and Risk Management advisory committees at

Monday's hearing.

A long day of confusing, often conflicting data was capped by the

seemingly inconsistent conclusions of the committee members who agreed

20:3 with the

statement that available studies supported a signal of harm, but voted

22:1 to keep rosiglitazone on the market.

Dr Pickering who was one of the three members who did not

agree that there was a clear increased risk of ischemic events, pointed

to the apparent contradiction: " I'm puzzled as to how people can vote

yes for both

questions, " he mused. But the vast majority of voting members on the

panel seemed to agree with the sentiment

raised repeatedly by presenters, panelists, and open public-hearing

speakers, that it was important for physicians to have rosiglitazone in

their arsenal

of treatments for type 2. Indeed, some of the day's discussion revolved

around an emerging hypothesis that the other thiazolidinedione (TZD) on

the market,

pioglitazone [Actos], might

not carry the same safety concerns as rosiglitazone. Those data,

however, comes predominantly from an as-yet unpublished analysis

conducted by pioglitazone

manufacturer Takeda, and has not yet been reviewed by the FDA, nor was

it provided in full to panel members. A review of that data, was on

track to be

completed in time for the panel's review of the cardiovascular

ischemic/thrombotic risks of TZDs, which had originally been scheduled

for later in the

year. The hearing, however, was bumped up after the publication of a

controversial meta-analysis in the New England Journal of Medicine

(NEJM) [1]--pointing

to a significant 43% increase in myocardial infarction with

rosiglitazone.

During today's session, panel members heard from the sponsor and the

FDA, both of whom had conducted their own meta-analyses of the

randomized controlled

trial data and turned up findings that were surprisingly consistent with

the NEJM analysis--a 40% increased risk of serious ischemic events by

the FDA's

reckoning and a 31% increase in myocardial ischemic events in GSK's

meta-analysis.

All of the yes-votes reiterated the same concerns: that the evidence

linking rosiglitazone with increased risk of cardiovascular death or MI

was weak or

inconsistent, particularly in trials that had active control arms rather

than placebo comparators; that ischemic risk appeared higher in older

patients,

patients with heart failure, patients with

preexisting coronary disease, and patients taking insulin--and that this

should be reflected in the labeling. In fact, several panelists pointed

out that

current labeling lists rosiglitazone as being indicated for diabetics

taking insulin; they felt this should be removed and a black box should

be added

warning against its use in this group. Others emphasized that the

inconclusiveness of the existing studies and the fact that trials are

still ongoing should

also be mentioned in the packaging. But time and again, the experts on

the panel bemoaned the fact that, not for the first time, the FDA had

not had the

foresight to mandate appropriate trials, leaving the committees to try

to draw conclusions from meta-analyses and observational studies.

Even the ongoing RECORD, ACCORD, and BARI-2D trials, by the FDA's own

review, are underpowered or not designed to answer key questions about

whether ischemic

events will be higher than with other diabetes drugs, and if they are,

which patient subsets

will be affected. The mere fact that most of the studies included in the

meta-analyses were only six months in duration underscores the paucity

of solid

information. The sole no-vote on the key question of whether

rosiglitazone should remain on the market came from Dr Arthur Levin

(Center for Medical Consumers,

New York, NY).

" It seems to me that given the evidence of a strong safety signal, given

the fact that around this table and at the FDA there are doubts about

the ability

of ongoing clinical trials to definitively answer the question about the

CV safety of the drug, and given the enormity of the potential public

health risk

of allowing this drug to continue to be marketed and used by millions of

people for the rest of their lives,

I logically can't find any way to justify leaving this drug on the

market. " Levin's opinions have the support of at least two FDA insiders,

Dr Gerald Dal

Pan and Dr Graham , both in the FDA's Office of Surveillance and

Epidemiology, Center for Drug Evaluation

and Research. Graham presented a risk/benefit assessment of

rosiglitazone, pointing out that although his views were his own, his

findings had been reviewed

and were supported by others in his department, such that he was not

just speaking as " Graham the FDA Whistle-Blower. " Graham showed

projections

to back up his claim that ongoing studies " will not change our state of

knowledge... Graham's concerns about the quality of the existing

rosiglitazone

data, and the flawed studies in progress, struck a chord with panel

members, who called for stricter standards for pre-approval and

post-marketing studies.

" I would have to say, the FDA has to take some responsibility for the

dilemma in which we find ourselves, for approving less than optimally

designed trials

in the past, " Dr Arthur Moss observed. " I do think there is a problem

that needs to be rectified in the future. " Vindication for Nissen

Commenting on the

day's deliberations to heartwire, Dr Nissen (Cleveland Clinic,

OH), seemed satisfied that the FDA and sponsors' meta-analyses

had confirmed his own findings. . " One concern I have is that black-box

warnings do not always result in huge changes in prescribing practices,

so time

will tell, " he told heartwire

1. Nissen SE and Wolski K. Effect of rosiglitazone on the risk of

myocardial infarction and death from cardiovascular causes.

N Engl J Med 2007; 356:2457-2471.

10.%% Simultaneous Pancreas Kidney Transplantation From Old Donors

Medscape Transplantation. 2007; C2007 Medscape 07/24/2007 Patient and

Graft Survival

Implications of Simultaneous Pancreas Kidney Transplantation From Old

Donors Am J Transplant. 2007;7 Summary - The authors performed a

retrospective

analysis of the United Network for Organ Sharing database and identified

adult patients with type 1 DM who were placed on the waiting list for

simultaneous

pancreas-kidney (SPK) transplantation. 8850 patients (54%) received an

SPK transplant, of which 9% were from donors 45 years of age or older.

Survival

analyses were performed . .SPK transplantation from both young and old

donors independently predicted lower mortality compared with staying on

the waiting

list. An additional expected wait of 1.5 years for a young donor

equalized long-term survival expectations between young and old SPK

donors. On the basis

of these findings, the authors concluded that SPK transplantation offers

a substantial survival benefit independent of donor age and should be

considered

for patients with decreased access to organs from young donors.

Viewpoint - The critical shortage of donor organs challenges the

transplant community

to maximize and optimize the use of organs from all consenting deceased

donors. .the profile of acceptable older donors for SPK transplantation

may include

female sex, low body mass index, and noncerebrovascular etiology of

brain death. The patient population most likely to benefit from SPK

transplantation

from old donors includes either patients with limited access to timely

transplantation (eg, blood type O or B, highly sensitized) or those who

cannot afford

to wait for an extended period of time (unstable diabetes, prolonged

duration of dialysis, older age [> 50 years], known peripheral vascular

or cardiovascular

disease).

11.%% Medscape Medical News - Low GI Diets Better for Weight Loss, Lipid

Profiles, Finds Cochrane Review July 24, 2007 - A new Cochrane review

of six

randomized controlled trials comparing low glycemic index (GI) or

glycemic load (GL) diets with other diets has found that overweight or

obese people lost

more weight and had more improvement in lipid profiles with the low GI

eating plans.

Those on the low GI diets lost an average of 2.2 pounds (1 kg) more than

those given comparison diets, which included higher GI or GL diets and

conventional

weight loss diets. They also had significantly better decreases in total

and low-density lipoprotein (LDL) cholesterol, the researchers note. And

in the

two trials that evaluated only obese participants, weight loss was even

more apparent - the low GI dieters lost about 9.2 pounds, compared with

about 2.2

pounds shed by those on the other diets. However, the scientists caution

that enduring data are still needed. " Longer trials

with increased length of follow-up will determine whether the

improvements reported can be maintained and incorporated into lifestyle

long-term, " they

say. Two experts not connected with the review expressed mixed opinions.

One said this was a great review, while the other pointed out that the

difference

in weight loss

between the low and high GI diets was rather small. The team

included six trials in their review, including a total of 202 adults.

The diets lasted from 5 weeks to 6 months, and none of the studies

reported any adverseveffects

associated with consuming a low GI diet.vAs well as losing more weight,

those on the low GI diets also had significantly greatervloss of total

fat mass

and decrease in body mass index (BMI) than those on the comparison

diets. " Considering the brevity of the interventions, the results are

notable, " they

add.

Improvements in blood lipids were also significant. Cochrane Database

Syst Rev. Published online July 18, 2007.

Abbreviations: ADA - American Diabetes Association; DM - diabetes

Mellitus; FDA Federal Drug Administration; NIH - National Institutes of

Health; VA -

Veterans Administration. Definitions - Dorlands 31st Ed and Google

Disclaimer, I am a BSN RN but not a diabetic or diabetic educator.

Reports are excerpted unless otherwise noted. This project is done as a

courtesy to

the blind/visually impaired and diabetic communities.Dawn Wilcox

Coordinator The Health Library at Vista Center contact above e-mail or

thl@...

[Guest guest]

I thought it very interesting as that is what my endo and nephro are

doing with me!

Re: articles

A definite keeper. I believe I will read this one at least five times

from beginning to end. I will probably even take notes on it.

articles

1. Welcome to Medscape Nephrology and to this Spotlight entitled,

" Managing Anemia in Patients With Type 2 Diabetes and Chronic Kidney

Disease. " I am Dr.

Ajay Singh, Clinical Director at Brigham & Women's Hospital and

Associate Professor of Medicine at Harvard Medical School in Boston, MA,

and I will be

your moderator.

Slide 4. Prevalence of Diabetes and CKD Willa A. Hsueh, MD:

I think all of our audience knows that diabetes is the most common cause

of end stage renal disease in the US and there are about 30% to 40% of

patients

with type 1 DM who will go on to have chronic kidney disease and about

10% to 15%, maybe even as high as 20%, of patients with type 2 who will

go on to

have chronic kidney disease.

Aggressive Prevention of CKD Slide 5. Aggressive Prevention of CKD

I think we're all realizing, thanks to our nephrology colleagues, that

as patients develop albuminuria, not only is that an important sign of

kidney disease,

but I think it's a sign that there may be terrible problems with the

endothelium that could then lead to problems, of course, with coronary

heart disease

and stroke, so that should raise a red flag for all of us. In addition,

I think we also know that glycemic

control is very important for the microvascular complications, not just

the kidney but the eye and some of the neurologic complications. So with

that said,

I think as endocrinologists we're really focusing on tight control

early, tighter and tighter control. In fact, the recent ADA Guidelines

suggest that

we get our control to nearly normal in all of our patients with

hemoglobins around 5.5% or less. So there's an aggressive effort, I

think, to try to prevent

chronic kidney disease. Unfortunately, I think some patients will not

respond to some of

those or comply with some of those aggressive efforts, and we will still

have problems with the kidney.

Slide 6. Recognizing the Complications of CKD .. the question is how do

we recognize some of the complications early, that would include not

just the,

as we said, the coronary heart disease complications but also the

anemia, the changes in type 2 hyperparathyroidism or secondary

hyperparathyroidism, and

issues about early interventions for the anemia, and early interventions

with vitamin D therapy?

Dr. Singh: One of the really important issues, of course, is the burden

of cardiovascular disease in this population. Dr. Hsueh: Absolutely.

Dr. Singh: It seems like a number of observational studies have

indicated that at a very early stage in the syndrome of diabetic

nephropathy, patients

develop vascular disease and cardiovascular disease. Is it your sense

that the diabetologists are now increasingly

recognizing this and are becoming more aggresive in managing

cardiovascular disease in this population? Dr. Hsueh: Oh absolutely,

you cannot go to an

endocrine meeting without hearing about the marked increased incidence

of cardiovascular disease in patients with diabetes, and I think we've

known for

a long time that albuminuria is a key signal that heralds that, and I

think you all know well that as there is a progressive decrease in

glomerular filtration

rate, there's a progressive increase in cardiovascular disease.

%%Slide 8. Clinical Practice Guidelines for CKD and Diabetes

Mark E. Molitch, MD: several things came out of reviewing the

literature for those guidelines, certainly the glycemic control that

Willa had talked about

remains important, and even in the patient as they have advancing kidney

disease, we still need to get good glycemic control to try to reduce and

ameliorate

some of the other long-term complications of diabetes. But as far as the

cardiovascular

disease goes and the lipid management, these are patients at such high

risk that we recommend an LDL goal of less than 70 for those patients,

obviously

blood pressure treatment to get blood pressures less than 130/80 for

virtually all patients with diabetes, and perhaps even more stringent

goals for the

patient who's getting progressive

nephropathy. I think one of the things that brought home to me as we

were reviewing all this, is the knowledge that's relatively new, at how

early secondary

hyperparathyroidism and anemia start to be found.

%% Slide 9. Development of Anemia in Patients With Diabetes

Dr. Singh: one of the things that I have come across in the literature

is the idea that anemia tends to develop at an earlier stage in

diabetics than it

seems to in nondiabetics, so for any given level of GFR. What are your

thoughts on that, Willa ? Dr. Hsueh: Well we're recognizing more

patients, for

example, with stage 3 chronic kidney disease, and we are seeing evidence

that if patients have diabetes, the anemia for any level of chronic

kidney disease

seems to be worse than the nondiabetic patient, and of course there is

this anemia of chronic disease to begin with that our patients with

diabetes have,

and then when the kidney disease sets in, there are problems with

synthesis, as you know, of erythropoietin, and so that complicates the

issue, . Dr. Singh:

Mark, do you refer patients once they develop anemia or do you manage

the anemia yourself in your own practice?

Dr. Molitch: Well I think in our practice and probably in most

endocrine practices, by the time we find the patient whose hemoglobin is

getting less than

11 and we start thinking about erythropoietin [EPO], we have generally

been referring that patient to the nephrologist.Slide 10. TREAT Study

Design this

is a randomized prospective study looking at the effects of

erythropoietin supplementation, trying to get the hemoglobin levels up.

Slide 12. Diabetologists

and Nephrologists Working Together Dr. Singh:

In my own nephrology practice, I tend not to spend a lot of time

thinking about different types of insulin, so I would imagine that

Willa, you also don't

think about all the newer erythropoietins that are coming out since you

have such a strong nephrology division at UCLA. Dr. Hsueh: Well, like

Mark, with

erythropoietin, we're actually when we feel patients need that, we

actually call our nephrology colleagues and, as you said, they have a

very strong background.

What I'm amazed at is that our nephrology colleagues, once the

GFR is somewhere around 30 or less, they take over full management, so

they actually have to know about insulins and know about other issues.

%%Slide 15. Managing Patients With Diabetes and CKD

Dr. Singh: So what are your top 2 or 3 things that nowadays in 2007 you

think about in managing patients with diabetes who have chronic kidney

disease?

Do you, as Mark is alluding to, manage their lipids more aggressively,

their hypoparathyroidism, or do you feel that these areas still

represent controversial

issues? Dr. Hsueh: Well, as I said, we would see these patients more

in stage 2, stage 3, and maybe the beginning of stage 4, and I manage

their cardiovascular

risk, hypertension especially, very aggressively because I know that

whatever changes in blood pressure happen have great impact on the

kidney. The lipids

I'm concerned with, but I'm aware of the studies

you said, and then the question is the role of vitamin D because there's

very intriguing information that not only is it good for the

calcium-phosphorus

changes but also it may have anti-inflammatory effects; and there are a

number of studies at UCLA, then of course the whole issue of anemia, and

in patients

with heart disease, of course you want to provide oxygen but you don't

want to provide so many red cells that you get thrombosis formation.

Dr. Singh: So, Mark, do you think that diabetologists and nephrologists

can work together in managing these important conditions or is there

hope for

us to work together? Dr. Molitch:

Well absolutely I think it's almost a natural combination, but I think

one of the things we have to do is keep working together, and so it's

not a hand

off, it's a continued comanagement of the patients even once they get on

dialysis. I think the diabetologists can lend a hand in trying to help

manage

their diabetes even at that point. ..Dr. Singh:

So management of anemia and diabetes and kidney disease are

interrelated and now one can manage them in a diabetes center in a

collaborative fashion or

one can refer these patients but it seems like one of the key issues is

to certainly manage them, to recognize it early and manage them.

Slide 16. Management of Dialysis Patients With Diabetes

One quick question I have before we summarize is what about the dialysis

patient - do you tend to have them come back to your diabetes center or

diabetes

practice and continue to follow them or is it your observation that most

of these patients get managed wholly by the nephrologist when they reach

end-stage

renal disease?

Dr. Hsueh: Well I'm happy because there are more oral agents now on

board that we can use in dialysis patients, for example, in addition to

insulin,

.. We now have sitagliptin or Januvia,.. you have to adjust the dose, but

it's a DPP-4 inhibitor that works on the incretin pathway. We have the

TZDs [thiazolidinediones]

which can be used all the

way through to end-stage kidney disease. And, of course, we have

acarbose, which mainly works on the gut and just slows, doesn't inhibit,

just slows carbohydrate

absorption. So you actually have 3 oral agents that you can mix and

match in patients with chronic kidney disease and then you have insulin,

so I think

we've broadened

the horizons for patients with CKD.

%% Slide 17. Summary and Closing Comments

Dr. Singh: So it sounds like nephrologists need to learn more about how

to manage diabetes with different types of insulins and oral agents and

diabetologists

need to learn to manage perhaps a little bit more about the

comorbidities of kidney disease such as hypoparathyroidism and lipid

abnormalities but also

anemia. And whether you refer these patients or you manage them in the

diabetes center, the key is to try to manage them together. Dr. Hsueh:

Well, we're

waiting for you to do the studies to tell us what level of hemoglobin

should we intervene, when should we intervene with vitamin D; of course,

both of

those studies are ongoing. Dr. Singh:

Right. Well, that was, I think, a very productive discussion, and I'd

like to thank Dr. Hsueh and Dr. Molitch for participating. I think we

achieved our

objectives of discussing the interrelatedness of anemia, diabetes, and

chronic kidney disease. I also believe that we really brought out the

notion that

diabetologists and nephrologists need to work together in both early

recognition and then subsequent management of these patients. Supported

by an independent

educational grant from Roche

2.%% Notice: The LightHouse for the Blind and Visually Impaired will be

hosting several informational survey interviews on talking glucose

meters and adaptive

insulin syringe devices. These interview sessions will be conducted in

conjunction with a doctorial student from UC Berkeley. The focus of the

interviews

is to collect data concerning talking glucose meters and adaptive

insulin syringe devices. The interview will take between 60 to 90

minutes in San Francisco

and there will be a $40 honorarium for those who participate. The

participants must be diabetic and have used or currently use a talking

glucose meter.

If you know of individuals who may qualify please contact Beth Berenson

at The LightHouse, Phone: or via email at:

3.%% Medscape - Metabolic Syndrome Linked to Chronic Kidney Disease

(Reuters Health) Jul 24 - A study of a Chinese population aged 40 years

and older found

an association between metabolic syndrome and chronic kidney disease.

(CKD) Metabolic syndrome " is a common disorder in developed countries, "

note the

researchers. " With its dramatic economic development and the consequent

changes in lifestyle and diet, China too has seen the metabolic syndrome

become

an important health care problem. " [2310 people;

cross-sectional study; mean age 60.7 years,] The overall prevalence of

metabolic syndrome was 34.1%, and the overall prevalence of CKD was

10.7%. The prevalence

of CKD was higher among subjects with metabolic syndrome than those

without metabolic syndrome (15.4% versus 8.3%, respectively. " Further

studies are needed

to determine if treatment of metabolic syndrome could substantially ease

the burden of CKD in China, " the team concludes. Mayo Clin Proc 2007;82

4.%% In Diabetes Today 23-JUL-2007 - Hepatitis C Strongly Linked to

Type 2 Diabetes (Reuters Health) - People infected with hepatitis C

virus have an

increased risk of developing type 2, or " adult-onset " diabetes, a

population-based study confirms. This risk is particularly high in

younger people who

are overweight, researchers have found.

Therefore, screening for and preventing diabetes in persons with HCV

infection could be started earlier than the suggested age of 45 or

older, which is

the recommendation for the general population, especially for patients

with are heavier or who have other diabetes risk factors for diabetes,

the team

writes. [4,958 people age 40 or older without diabetes, 3,486 tested

negative and 812 positive for HCV; 116 subjects were infected with both

HCV and HCV;

544 tested positive for hepatitis B; 7 year follow up] After adjusting

the data to account for established diabetes risk factors, the incidence

of DM was

70 percent higher in persons with HCV infection than in those without

it. " This finding is consistent with past studies showing that HCV

infection is highly

associated with diabetes. " the younger group with HCV infection was at

greater risk for the disease, they note. HCV infection plus being

overweight or

obese magnified the risk of diabetes by about three times compared with

uninfected persons of normal weight. American Journal of Epidemiology,

July 15,

2007.

5.%% TimesSelect F.D.A. Review Criticizes Diabetes Drug and Maker

July 26, 2007 Patients who take Avandia, a popular but controversial

diabetes medicine made by GlaxoKline, [GSK] are far more likely to

suffer and die from heart problems than those who take Actos, a similar

pill made

by Takeda, according to federal drug reviewers. Avandia is particularly

dangerous to patients who also take insulin. By contrast, Actos can be

taken safely

with insulin, according to the review. The findings likely spell the end

of Avandia's status as one of the nation's most popular drugs for

treating diabetics

who are not dependent on insulin. Last year, more than a million

patients in the US took Avandia, and a similar number took Actos.

Avandia's 2006 global sales were nearly $3.4 billion. The report and

charges that GSK sought to intimidate a doctor who publicly

warned about Avandia's risks in 1999 could lead to a cascade of lawsuits

against the company. Indeed, F.D.A. reviewers were sharply critical of

the quality

of the studies GSK has undertaken to test the safety of Avandia,

dismissing the present and future results of an ongoing 4,000-patient

trial as unreliable

and invalid. The report by medical and safety reviewers within the FDA

also provides ammunition to critics on Capitol Hill and elsewhere who

claim that

top F.D.A. officials have been far too slow to acknowledge Avandia's

risks. GlaxoKline suggested a year ago that the agency add a note

to the drug's

label about Avandia's growing heart risks, the report states. These

conclusions come in a 436-page compendium of reviews released in advance

of an advisory

committee hearing to be held on Monday to discuss Avandia's effects on

the heart. The F.D.A. intends to ask the committee of independent

experts whether

Avandia should continue to be sold. It is far from clear, F.D.A. safety

reviewers concluded in the report, whether taking Avandia, also known as

rosiglitazone,

is worth the risk. " A critical question to be resolved in determining

appropriate regulatory action is whether the anticipated therapeutic

benefit of rosiglitazone

outweighs the demonstrated

cardiovascular risk, " one F.D.A. reviewer concluded.

6.%% Medscape - Corneal Sensitivity Is Linked to Diabetic Neuropathy

(Reuters Health) Jul 26 - Results of a new study suggest that corneal

sensitivity is reduced in diabetic patients, and is related to the

severity of neuropathy.

" In diabetic patients, corneal sensitivity is reduced, due to a loss of

corneal nerve fibers, which leads to corneal keratopathy and a

susceptibility to

injury, with recurrent erosions and ulcers, " researchers write . Corneal

sensation, they add, can be evaluated using the Cochet-Bonnet

aesthesiometer (C-BA)

or the noncontact corneal aesthesiometer (NCCA). They examined corneal

sensitivity in 147 diabetic patients and 18 controls using these

approaches and

also assessed neuropathy deficit score. Neuropathy was classified as

being absent, mild, moderate or severe. No significant differences in

age, type of

diabetes, and A1C were observed among the groups. The duration of

diabetes increased with neuropathic severity. Corneal sensitivity was

significantly reduced

in patients with diabetes compared with controls. It was not reduced in

diabetic patients without neuropathy. However, a significant reduction

was observed

in those with any degree of neuropathy. A significant correlation was

observed between neuropathy

established by C-BA and NCCA. The findings, the investigators conclude

" have important clinical implications regarding the development of

corneal abnormalities

in diabetic patients and also raise the possibility that corneal

sensation could be used to screen for diabetic neuropathy. " Diabetes

Care 2007;30

7.%% Medical News Today - Improving Heart Health In Kids With Diabetes

Type 1: The More They Exercise, The Lower The Risk Of Early Death 28

Jul 2007

It's never too early to focus on how to maintain good cardiovascular

health, especially for people with type 1. A study published in the

August issue of

Diabetes Care underscores the need for regular physical activity among

youth, finding that the more active the child, the better the child's

cardiovascular

risk profile. Heart disease is the number one killer of people with

diabetes. Among type 1 patients

as young as 20-39 years, the risk of dying from cardio- and

cerebrovascular events is five times higher than it is for people who

don't have diabetes.

Previous studies have shown that the development of atherosclerotic

lesions begins in childhood and

that 69 percent of pediatric patients with type 1 diabetes exhibit one

or more cardiovascular risk factors.

A new study by researchers in Germany and Austria, which looked at the

physical activity levels and cardiovascular health of more than 23,000

young people

between the ages of 3 and 18, found that those who were most physically

active were the least likely to be at risk for heart disease. As

physical activity

levels rose, risk factors such as high lipid profiles, diastolic blood

pressure, and blood glucose

levels fell. Regular physical activity was defined as exercising for at

least 30 minutes at a time, not including school sports. The study found

that those

who were active at least once or twice per week were also less likely to

have high blood pressure than those who didn't exercise at all. And, it

showed

that the frequency of regular physical activity " was one of the most

important influencing factors for HbA1c. " The A1c test measures average

blood glucose

levels

over a period of 2-3 months and helps a person with diabetes determine

how well they are keeping blood glucose levels under control overall.

8.%% Medscape Medical News - The Choice of a Metabolic Syndrome

Generation: Soft Drink Consumption Associated With Increased Metabolic

Risk [for another

version of this see DRList 7-24-07]

July 25, 2007 - Drinking more than one soft drink daily is associated

with a higher risk of developing adverse metabolic traits, as well as

developing

the metabolic syndrome, a new study has shown. Interestingly, it doesn't

matter if the soda consumed is the diet variety, those with zero

calories, as

investigators showed these also

increased the burden of metabolic risk in middle-aged adults. " That was

one of the more striking aspects of this study, " lead investigator Dr R.

Vasan

(Boston University School of Medicine, MA) told

heartwire. . " It actually doesn't matter if the soft drink is regular or

diet. There was an association of increased risk of developing the

metabolic syndrome

with both types of drinks. " Vasan said that the consumption of soft

drinks has doubled to tripled between 1977 and 2001. During this same

time period,

soft-drink sizes have also increased to staggering proportions. With

evidence that soft-drink consumption is linked with weight gain and

obesity as well

as an increased risk of diabetes, the investigators questioned whether

soft-drink consumption in adults, in amounts that are seemingly

innocuous, like

one per day, posed any metabolic hazard. The team related the incidence

of metabolic syndrome and its components to soft-drink consumption in

more than

6000 individuals participating

in the Framingham Heart Study. In a cross-sectional analysis of the

data, investigators report that those consuming more than one soft drink

daily had

a 48% higher prevalence of metabolic syndrome

than those who drank less than one soft drink per day. In a longitudinal

analysis of more than 6000 subjects free from metabolic syndrome at

baseline,

drinking more than one soft drink daily was associated with a 44%

greater risk of developing metabolic syndrome and with developing 4 out

of 5 components

of metabolic syndrome. In a smaller sample of participants who had data

available regarding the type of soft drink consumed, researchers

observed that

that those who consumed one or more drinks of diet or regular soda per

day had a 50% to 60% increased risk of developing new-onset metabolic

syndrome.

Despite the fact that diet soda has zero calories, the findings are not

entirely surprising, said Vasan, as diet soft drinks have been

previously linked

with poor health outcomes in children, such as weight gain and high

blood pressure. In terms of theories explaining the association between

soft-drink

consumption and the metabolic syndrome risk, Vasan said there are no

definitive answers yet. .it might be a lifestyle/dietary background

thing driving

this. "

In addition, Vasan said diet soda might also induce a conditioning

response in which the soft drinks promote a dietary preference for

sweeter foods. Also,

because diet soda is liquid, this has the effect of individuals eating

more at the next meal, mainly because liquids are not as satiating. And

finally,

the brown caramel in soda has been linked with tissue damage and

inflammation, which might contribute to the increased risk. All of these

theories, however,

are debated in literature. " Clearly, these findings are sufficiently

intriguing that scientists now have to help us understand better why we

see this association, "

said Vasan. " We are not inferring causality from this analysis. It is

just an association, so we need to turn to the

scientists who are better positioned to help us understand the

association more. " Circulation. Published online July 23, 2007.

9.%% -FDA Advisory Panels Acknowledge Signal of Risk With Rosiglitazone,

but Stop Short of Recommending Its Withdrawal

Wood Heartwire 2007. C 2007 Medscape July 31, 2007 -

Rosiglitazone (Avandia, GlaxoKline [GSK]) is associated with a

clear signal of cardiac

ischemic risk in type 2 diabetics, the available data suggest, but this

signal is not enough to justify yanking the drug from the market. This

was the

near-unanimous conclusion of the FDA's joint Endocrinologic and

Metabolic Drugs/Drug Safety and Risk Management advisory committees at

Monday's hearing.

A long day of confusing, often conflicting data was capped by the

seemingly inconsistent conclusions of the committee members who agreed

20:3 with the

statement that available studies supported a signal of harm, but voted

22:1 to keep rosiglitazone on the market.

Dr Pickering who was one of the three members who did not

agree that there was a clear increased risk of ischemic events, pointed

to the apparent contradiction: " I'm puzzled as to how people can vote

yes for both

questions, " he mused. But the vast majority of voting members on the

panel seemed to agree with the sentiment

raised repeatedly by presenters, panelists, and open public-hearing

speakers, that it was important for physicians to have rosiglitazone in

their arsenal

of treatments for type 2. Indeed, some of the day's discussion revolved

around an emerging hypothesis that the other thiazolidinedione (TZD) on

the market,

pioglitazone [Actos], might

not carry the same safety concerns as rosiglitazone. Those data,

however, comes predominantly from an as-yet unpublished analysis

conducted by pioglitazone

manufacturer Takeda, and has not yet been reviewed by the FDA, nor was

it provided in full to panel members. A review of that data, was on

track to be

completed in time for the panel's review of the cardiovascular

ischemic/thrombotic risks of TZDs, which had originally been scheduled

for later in the

year. The hearing, however, was bumped up after the publication of a

controversial meta-analysis in the New England Journal of Medicine

(NEJM) [1]--pointing

to a significant 43% increase in myocardial infarction with

rosiglitazone.

During today's session, panel members heard from the sponsor and the

FDA, both of whom had conducted their own meta-analyses of the

randomized controlled

trial data and turned up findings that were surprisingly consistent with

the NEJM analysis--a 40% increased risk of serious ischemic events by

the FDA's

reckoning and a 31% increase in myocardial ischemic events in GSK's

meta-analysis.

All of the yes-votes reiterated the same concerns: that the evidence

linking rosiglitazone with increased risk of cardiovascular death or MI

was weak or

inconsistent, particularly in trials that had active control arms rather

than placebo comparators; that ischemic risk appeared higher in older

patients,

patients with heart failure, patients with

preexisting coronary disease, and patients taking insulin--and that this

should be reflected in the labeling. In fact, several panelists pointed

out that

current labeling lists rosiglitazone as being indicated for diabetics

taking insulin; they felt this should be removed and a black box should

be added

warning against its use in this group. Others emphasized that the

inconclusiveness of the existing studies and the fact that trials are

still ongoing should

also be mentioned in the packaging. But time and again, the experts on

the panel bemoaned the fact that, not for the first time, the FDA had

not had the

foresight to mandate appropriate trials, leaving the committees to try

to draw conclusions from meta-analyses and observational studies.

Even the ongoing RECORD, ACCORD, and BARI-2D trials, by the FDA's own

review, are underpowered or not designed to answer key questions about

whether ischemic

events will be higher than with other diabetes drugs, and if they are,

which patient subsets

will be affected. The mere fact that most of the studies included in the

meta-analyses were only six months in duration underscores the paucity

of solid

information. The sole no-vote on the key question of whether

rosiglitazone should remain on the market came from Dr Arthur Levin

(Center for Medical Consumers,

New York, NY).

" It seems to me that given the evidence of a strong safety signal, given

the fact that around this table and at the FDA there are doubts about

the ability

of ongoing clinical trials to definitively answer the question about the

CV safety of the drug, and given the enormity of the potential public

health risk

of allowing this drug to continue to be marketed and used by millions of

people for the rest of their lives,

I logically can't find any way to justify leaving this drug on the

market. " Levin's opinions have the support of at least two FDA insiders,

Dr Gerald Dal

Pan and Dr Graham , both in the FDA's Office of Surveillance and

Epidemiology, Center for Drug Evaluation

and Research. Graham presented a risk/benefit assessment of

rosiglitazone, pointing out that although his views were his own, his

findings had been reviewed

and were supported by others in his department, such that he was not

just speaking as " Graham the FDA Whistle-Blower. " Graham showed

projections

to back up his claim that ongoing studies " will not change our state of

knowledge... Graham's concerns about the quality of the existing

rosiglitazone

data, and the flawed studies in progress, struck a chord with panel

members, who called for stricter standards for pre-approval and

post-marketing studies.

" I would have to say, the FDA has to take some responsibility for the

dilemma in which we find ourselves, for approving less than optimally

designed trials

in the past, " Dr Arthur Moss observed. " I do think there is a problem

that needs to be rectified in the future. " Vindication for Nissen

Commenting on the

day's deliberations to heartwire, Dr Nissen (Cleveland Clinic,

OH), seemed satisfied that the FDA and sponsors' meta-analyses

had confirmed his own findings. . " One concern I have is that black-box

warnings do not always result in huge changes in prescribing practices,

so time

will tell, " he told heartwire

1. Nissen SE and Wolski K. Effect of rosiglitazone on the risk of

myocardial infarction and death from cardiovascular causes.

N Engl J Med 2007; 356:2457-2471.

10.%% Simultaneous Pancreas Kidney Transplantation From Old Donors

Medscape Transplantation. 2007; C2007 Medscape 07/24/2007 Patient and

Graft Survival

Implications of Simultaneous Pancreas Kidney Transplantation From Old

Donors Am J Transplant. 2007;7 Summary - The authors performed a

retrospective

analysis of the United Network for Organ Sharing database and identified

adult patients with type 1 DM who were placed on the waiting list for

simultaneous

pancreas-kidney (SPK) transplantation. 8850 patients (54%) received an

SPK transplant, of which 9% were from donors 45 years of age or older.

Survival

analyses were performed . .SPK transplantation from both young and old

donors independently predicted lower mortality compared with staying on

the waiting

list. An additional expected wait of 1.5 years for a young donor

equalized long-term survival expectations between young and old SPK

donors. On the basis

of these findings, the authors concluded that SPK transplantation offers

a substantial survival benefit independent of donor age and should be

considered

for patients with decreased access to organs from young donors.

Viewpoint - The critical shortage of donor organs challenges the

transplant community

to maximize and optimize the use of organs from all consenting deceased

donors. .the profile of acceptable older donors for SPK transplantation

may include

female sex, low body mass index, and noncerebrovascular etiology of

brain death. The patient population most likely to benefit from SPK

transplantation

from old donors includes either patients with limited access to timely

transplantation (eg, blood type O or B, highly sensitized) or those who

cannot afford

to wait for an extended period of time (unstable diabetes, prolonged

duration of dialysis, older age [> 50 years], known peripheral vascular

or cardiovascular

disease).

11.%% Medscape Medical News - Low GI Diets Better for Weight Loss, Lipid

Profiles, Finds Cochrane Review July 24, 2007 - A new Cochrane review

of six

randomized controlled trials comparing low glycemic index (GI) or

glycemic load (GL) diets with other diets has found that overweight or

obese people lost

more weight and had more improvement in lipid profiles with the low GI

eating plans.

Those on the low GI diets lost an average of 2.2 pounds (1 kg) more than

those given comparison diets, which included higher GI or GL diets and

conventional

weight loss diets. They also had significantly better decreases in total

and low-density lipoprotein (LDL) cholesterol, the researchers note. And

in the

two trials that evaluated only obese participants, weight loss was even

more apparent - the low GI dieters lost about 9.2 pounds, compared with

about 2.2

pounds shed by those on the other diets. However, the scientists caution

that enduring data are still needed. " Longer trials

with increased length of follow-up will determine whether the

improvements reported can be maintained and incorporated into lifestyle

long-term, " they

say. Two experts not connected with the review expressed mixed opinions.

One said this was a great review, while the other pointed out that the

difference

in weight loss

between the low and high GI diets was rather small. The team

included six trials in their review, including a total of 202 adults.

The diets lasted from 5 weeks to 6 months, and none of the studies

reported any adverseveffects

associated with consuming a low GI diet.vAs well as losing more weight,

those on the low GI diets also had significantly greatervloss of total

fat mass

and decrease in body mass index (BMI) than those on the comparison

diets. " Considering the brevity of the interventions, the results are

notable, " they

add.

Improvements in blood lipids were also significant. Cochrane Database

Syst Rev. Published online July 18, 2007.

Abbreviations: ADA - American Diabetes Association; DM - diabetes

Mellitus; FDA Federal Drug Administration; NIH - National Institutes of

Health; VA -

Veterans Administration. Definitions - Dorlands 31st Ed and Google

Disclaimer, I am a BSN RN but not a diabetic or diabetic educator.

Reports are excerpted unless otherwise noted. This project is done as a

courtesy to

the blind/visually impaired and diabetic communities.Dawn Wilcox

Coordinator The Health Library at Vista Center contact above e-mail or

thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

[Guest guest]

My nephrologists handles my anemia. He does notwant my hemoglobin over

12, so depending on the blood count I have done about very 3 weeks, he

lets me know if I should take my Arreness injectin or not. The last one

I learned today was 11.9, so he does not want to take another shoot

until I have my next hemoglobin drawn. He says that too high a

hemoglobin can actually hurt the already poor kidneys.

Re: articles

I've been anemic for over 10 years, perhaps 15 years, running as low as

10.3 or so. At times, I have hit 12, but rarely, and I am usually around

11, plus or minus. Neither my general physician or nepthrologist are

overly concerned, and attribute it to kidney dysfunction, or as in the

first article, ckd. I was kind of surprised at how the doctors in this

discussion seemed to be acting like low enemia was something just being

discovered (in relationship to diabetes and ckd). Sometimes I really

wonder about the medical field.

anyway, thanks for the articles Pat.

Dave

articles

1. Welcome to Medscape Nephrology and to this Spotlight entitled,

" Managing Anemia in Patients With Type 2 Diabetes and Chronic Kidney

Disease. " I am Dr.

Ajay Singh, Clinical Director at Brigham & Women's Hospital and

Associate Professor of Medicine at Harvard Medical School in Boston, MA,

and I will be

your moderator.

Slide 4. Prevalence of Diabetes and CKD Willa A. Hsueh, MD:

I think all of our audience knows that diabetes is the most common cause

of end stage renal disease in the US and there are about 30% to 40% of

patients

with type 1 DM who will go on to have chronic kidney disease and about

10% to 15%, maybe even as high as 20%, of patients with type 2 who will

go on to

have chronic kidney disease.

Aggressive Prevention of CKD Slide 5. Aggressive Prevention of CKD

I think we're all realizing, thanks to our nephrology colleagues, that

as patients develop albuminuria, not only is that an important sign of

kidney disease,

but I think it's a sign that there may be terrible problems with the

endothelium that could then lead to problems, of course, with coronary

heart disease

and stroke, so that should raise a red flag for all of us. In addition,

I think we also know that glycemic

control is very important for the microvascular complications, not just

the kidney but the eye and some of the neurologic complications. So with

that said,

I think as endocrinologists we're really focusing on tight control

early, tighter and tighter control. In fact, the recent ADA Guidelines

suggest that

we get our control to nearly normal in all of our patients with

hemoglobins around 5.5% or less. So there's an aggressive effort, I

think, to try to prevent

chronic kidney disease. Unfortunately, I think some patients will not

respond to some of

those or comply with some of those aggressive efforts, and we will still

have problems with the kidney.

Slide 6. Recognizing the Complications of CKD .. the question is how do

we recognize some of the complications early, that would include not

just the,

as we said, the coronary heart disease complications but also the

anemia, the changes in type 2 hyperparathyroidism or secondary

hyperparathyroidism, and

issues about early interventions for the anemia, and early interventions

with vitamin D therapy?

Dr. Singh: One of the really important issues, of course, is the burden

of cardiovascular disease in this population. Dr. Hsueh: Absolutely.

Dr. Singh: It seems like a number of observational studies have

indicated that at a very early stage in the syndrome of diabetic

nephropathy, patients

develop vascular disease and cardiovascular disease. Is it your sense

that the diabetologists are now increasingly

recognizing this and are becoming more aggresive in managing

cardiovascular disease in this population? Dr. Hsueh: Oh absolutely,

you cannot go to an

endocrine meeting without hearing about the marked increased incidence

of cardiovascular disease in patients with diabetes, and I think we've

known for

a long time that albuminuria is a key signal that heralds that, and I

think you all know well that as there is a progressive decrease in

glomerular filtration

rate, there's a progressive increase in cardiovascular disease.

%%Slide 8. Clinical Practice Guidelines for CKD and Diabetes

Mark E. Molitch, MD: several things came out of reviewing the

literature for those guidelines, certainly the glycemic control that

Willa had talked about

remains important, and even in the patient as they have advancing kidney

disease, we still need to get good glycemic control to try to reduce and

ameliorate

some of the other long-term complications of diabetes. But as far as the

cardiovascular

disease goes and the lipid management, these are patients at such high

risk that we recommend an LDL goal of less than 70 for those patients,

obviously

blood pressure treatment to get blood pressures less than 130/80 for

virtually all patients with diabetes, and perhaps even more stringent

goals for the

patient who's getting progressive

nephropathy. I think one of the things that brought home to me as we

were reviewing all this, is the knowledge that's relatively new, at how

early secondary

hyperparathyroidism and anemia start to be found.

%% Slide 9. Development of Anemia in Patients With Diabetes

Dr. Singh: one of the things that I have come across in the literature

is the idea that anemia tends to develop at an earlier stage in

diabetics than it

seems to in nondiabetics, so for any given level of GFR. What are your

thoughts on that, Willa ? Dr. Hsueh: Well we're recognizing more

patients, for

example, with stage 3 chronic kidney disease, and we are seeing evidence

that if patients have diabetes, the anemia for any level of chronic

kidney disease

seems to be worse than the nondiabetic patient, and of course there is

this anemia of chronic disease to begin with that our patients with

diabetes have,

and then when the kidney disease sets in, there are problems with

synthesis, as you know, of erythropoietin, and so that complicates the

issue, . Dr. Singh:

Mark, do you refer patients once they develop anemia or do you manage

the anemia yourself in your own practice?

Dr. Molitch: Well I think in our practice and probably in most

endocrine practices, by the time we find the patient whose hemoglobin is

getting less than

11 and we start thinking about erythropoietin [EPO], we have generally

been referring that patient to the nephrologist.Slide 10. TREAT Study

Design this

is a randomized prospective study looking at the effects of

erythropoietin supplementation, trying to get the hemoglobin levels up.

Slide 12. Diabetologists

and Nephrologists Working Together Dr. Singh:

In my own nephrology practice, I tend not to spend a lot of time

thinking about different types of insulin, so I would imagine that

Willa, you also don't

think about all the newer erythropoietins that are coming out since you

have such a strong nephrology division at UCLA. Dr. Hsueh: Well, like

Mark, with

erythropoietin, we're actually when we feel patients need that, we

actually call our nephrology colleagues and, as you said, they have a

very strong background.

What I'm amazed at is that our nephrology colleagues, once the

GFR is somewhere around 30 or less, they take over full management, so

they actually have to know about insulins and know about other issues.

%%Slide 15. Managing Patients With Diabetes and CKD

Dr. Singh: So what are your top 2 or 3 things that nowadays in 2007 you

think about in managing patients with diabetes who have chronic kidney

disease?

Do you, as Mark is alluding to, manage their lipids more aggressively,

their hypoparathyroidism, or do you feel that these areas still

represent controversial

issues? Dr. Hsueh: Well, as I said, we would see these patients more

in stage 2, stage 3, and maybe the beginning of stage 4, and I manage

their cardiovascular

risk, hypertension especially, very aggressively because I know that

whatever changes in blood pressure happen have great impact on the

kidney. The lipids

I'm concerned with, but I'm aware of the studies

you said, and then the question is the role of vitamin D because there's

very intriguing information that not only is it good for the

calcium-phosphorus

changes but also it may have anti-inflammatory effects; and there are a

number of studies at UCLA, then of course the whole issue of anemia, and

in patients

with heart disease, of course you want to provide oxygen but you don't

want to provide so many red cells that you get thrombosis formation.

Dr. Singh: So, Mark, do you think that diabetologists and nephrologists

can work together in managing these important conditions or is there

hope for

us to work together? Dr. Molitch:

Well absolutely I think it's almost a natural combination, but I think

one of the things we have to do is keep working together, and so it's

not a hand

off, it's a continued comanagement of the patients even once they get on

dialysis. I think the diabetologists can lend a hand in trying to help

manage

their diabetes even at that point. ..Dr. Singh:

So management of anemia and diabetes and kidney disease are

interrelated and now one can manage them in a diabetes center in a

collaborative fashion or

one can refer these patients but it seems like one of the key issues is

to certainly manage them, to recognize it early and manage them.

Slide 16. Management of Dialysis Patients With Diabetes

One quick question I have before we summarize is what about the dialysis

patient - do you tend to have them come back to your diabetes center or

diabetes

practice and continue to follow them or is it your observation that most

of these patients get managed wholly by the nephrologist when they reach

end-stage

renal disease?

Dr. Hsueh: Well I'm happy because there are more oral agents now on

board that we can use in dialysis patients, for example, in addition to

insulin,

.. We now have sitagliptin or Januvia,.. you have to adjust the dose, but

it's a DPP-4 inhibitor that works on the incretin pathway. We have the

TZDs [thiazolidinediones]

which can be used all the

way through to end-stage kidney disease. And, of course, we have

acarbose, which mainly works on the gut and just slows, doesn't inhibit,

just slows carbohydrate

absorption. So you actually have 3 oral agents that you can mix and

match in patients with chronic kidney disease and then you have insulin,

so I think

we've broadened

the horizons for patients with CKD.

%% Slide 17. Summary and Closing Comments

Dr. Singh: So it sounds like nephrologists need to learn more about how

to manage diabetes with different types of insulins and oral agents and

diabetologists

need to learn to manage perhaps a little bit more about the

comorbidities of kidney disease such as hypoparathyroidism and lipid

abnormalities but also

anemia. And whether you refer these patients or you manage them in the

diabetes center, the key is to try to manage them together. Dr. Hsueh:

Well, we're

waiting for you to do the studies to tell us what level of hemoglobin

should we intervene, when should we intervene with vitamin D; of course,

both of

those studies are ongoing. Dr. Singh:

Right. Well, that was, I think, a very productive discussion, and I'd

like to thank Dr. Hsueh and Dr. Molitch for participating. I think we

achieved our

objectives of discussing the interrelatedness of anemia, diabetes, and

chronic kidney disease. I also believe that we really brought out the

notion that

diabetologists and nephrologists need to work together in both early

recognition and then subsequent management of these patients. Supported

by an independent

educational grant from Roche

2.%% Notice: The LightHouse for the Blind and Visually Impaired will be

hosting several informational survey interviews on talking glucose

meters and adaptive

insulin syringe devices. These interview sessions will be conducted in

conjunction with a doctorial student from UC Berkeley. The focus of the

interviews

is to collect data concerning talking glucose meters and adaptive

insulin syringe devices. The interview will take between 60 to 90

minutes in San Francisco

and there will be a $40 honorarium for those who participate. The

participants must be diabetic and have used or currently use a talking

glucose meter.

If you know of individuals who may qualify please contact Beth Berenson

at The LightHouse, Phone: or via email at:

3.%% Medscape - Metabolic Syndrome Linked to Chronic Kidney Disease

(Reuters Health) Jul 24 - A study of a Chinese population aged 40 years

and older found

an association between metabolic syndrome and chronic kidney disease.

(CKD) Metabolic syndrome " is a common disorder in developed countries, "

note the

researchers. " With its dramatic economic development and the consequent

changes in lifestyle and diet, China too has seen the metabolic syndrome

become

an important health care problem. " [2310 people;

cross-sectional study; mean age 60.7 years,] The overall prevalence of

metabolic syndrome was 34.1%, and the overall prevalence of CKD was

10.7%. The prevalence

of CKD was higher among subjects with metabolic syndrome than those

without metabolic syndrome (15.4% versus 8.3%, respectively. " Further

studies are needed

to determine if treatment of metabolic syndrome could substantially ease

the burden of CKD in China, " the team concludes. Mayo Clin Proc 2007;82

4.%% In Diabetes Today 23-JUL-2007 - Hepatitis C Strongly Linked to

Type 2 Diabetes (Reuters Health) - People infected with hepatitis C

virus have an

increased risk of developing type 2, or " adult-onset " diabetes, a

population-based study confirms. This risk is particularly high in

younger people who

are overweight, researchers have found.

Therefore, screening for and preventing diabetes in persons with HCV

infection could be started earlier than the suggested age of 45 or

older, which is

the recommendation for the general population, especially for patients

with are heavier or who have other diabetes risk factors for diabetes,

the team

writes. [4,958 people age 40 or older without diabetes, 3,486 tested

negative and 812 positive for HCV; 116 subjects were infected with both

HCV and HCV;

544 tested positive for hepatitis B; 7 year follow up] After adjusting

the data to account for established diabetes risk factors, the incidence

of DM was

70 percent higher in persons with HCV infection than in those without

it. " This finding is consistent with past studies showing that HCV

infection is highly

associated with diabetes. " the younger group with HCV infection was at

greater risk for the disease, they note. HCV infection plus being

overweight or

obese magnified the risk of diabetes by about three times compared with

uninfected persons of normal weight. American Journal of Epidemiology,

July 15,

2007.

5.%% TimesSelect F.D.A. Review Criticizes Diabetes Drug and Maker

July 26, 2007 Patients who take Avandia, a popular but controversial

diabetes medicine made by GlaxoKline, [GSK] are far more likely to

suffer and die from heart problems than those who take Actos, a similar

pill made

by Takeda, according to federal drug reviewers. Avandia is particularly

dangerous to patients who also take insulin. By contrast, Actos can be

taken safely

with insulin, according to the review. The findings likely spell the end

of Avandia's status as one of the nation's most popular drugs for

treating diabetics

who are not dependent on insulin. Last year, more than a million

patients in the US took Avandia, and a similar number took Actos.

Avandia's 2006 global sales were nearly $3.4 billion. The report and

charges that GSK sought to intimidate a doctor who publicly

warned about Avandia's risks in 1999 could lead to a cascade of lawsuits

against the company. Indeed, F.D.A. reviewers were sharply critical of

the quality

of the studies GSK has undertaken to test the safety of Avandia,

dismissing the present and future results of an ongoing 4,000-patient

trial as unreliable

and invalid. The report by medical and safety reviewers within the FDA

also provides ammunition to critics on Capitol Hill and elsewhere who

claim that

top F.D.A. officials have been far too slow to acknowledge Avandia's

risks. GlaxoKline suggested a year ago that the agency add a note

to the drug's

label about Avandia's growing heart risks, the report states. These

conclusions come in a 436-page compendium of reviews released in advance

of an advisory

committee hearing to be held on Monday to discuss Avandia's effects on

the heart. The F.D.A. intends to ask the committee of independent

experts whether

Avandia should continue to be sold. It is far from clear, F.D.A. safety

reviewers concluded in the report, whether taking Avandia, also known as

rosiglitazone,

is worth the risk. " A critical question to be resolved in determining

appropriate regulatory action is whether the anticipated therapeutic

benefit of rosiglitazone

outweighs the demonstrated

cardiovascular risk, " one F.D.A. reviewer concluded.

6.%% Medscape - Corneal Sensitivity Is Linked to Diabetic Neuropathy

(Reuters Health) Jul 26 - Results of a new study suggest that corneal

sensitivity is reduced in diabetic patients, and is related to the

severity of neuropathy.

" In diabetic patients, corneal sensitivity is reduced, due to a loss of

corneal nerve fibers, which leads to corneal keratopathy and a

susceptibility to

injury, with recurrent erosions and ulcers, " researchers write . Corneal

sensation, they add, can be evaluated using the Cochet-Bonnet

aesthesiometer (C-BA)

or the noncontact corneal aesthesiometer (NCCA). They examined corneal

sensitivity in 147 diabetic patients and 18 controls using these

approaches and

also assessed neuropathy deficit score. Neuropathy was classified as

being absent, mild, moderate or severe. No significant differences in

age, type of

diabetes, and A1C were observed among the groups. The duration of

diabetes increased with neuropathic severity. Corneal sensitivity was

significantly reduced

in patients with diabetes compared with controls. It was not reduced in

diabetic patients without neuropathy. However, a significant reduction

was observed

in those with any degree of neuropathy. A significant correlation was

observed between neuropathy

established by C-BA and NCCA. The findings, the investigators conclude

" have important clinical implications regarding the development of

corneal abnormalities

in diabetic patients and also raise the possibility that corneal

sensation could be used to screen for diabetic neuropathy. " Diabetes

Care 2007;30

7.%% Medical News Today - Improving Heart Health In Kids With Diabetes

Type 1: The More They Exercise, The Lower The Risk Of Early Death 28

Jul 2007

It's never too early to focus on how to maintain good cardiovascular

health, especially for people with type 1. A study published in the

August issue of

Diabetes Care underscores the need for regular physical activity among

youth, finding that the more active the child, the better the child's

cardiovascular

risk profile. Heart disease is the number one killer of people with

diabetes. Among type 1 patients

as young as 20-39 years, the risk of dying from cardio- and

cerebrovascular events is five times higher than it is for people who

don't have diabetes.

Previous studies have shown that the development of atherosclerotic

lesions begins in childhood and

that 69 percent of pediatric patients with type 1 diabetes exhibit one

or more cardiovascular risk factors.

A new study by researchers in Germany and Austria, which looked at the

physical activity levels and cardiovascular health of more than 23,000

young people

between the ages of 3 and 18, found that those who were most physically

active were the least likely to be at risk for heart disease. As

physical activity

levels rose, risk factors such as high lipid profiles, diastolic blood

pressure, and blood glucose

levels fell. Regular physical activity was defined as exercising for at

least 30 minutes at a time, not including school sports. The study found

that those

who were active at least once or twice per week were also less likely to

have high blood pressure than those who didn't exercise at all. And, it

showed

that the frequency of regular physical activity " was one of the most

important influencing factors for HbA1c. " The A1c test measures average

blood glucose

levels

over a period of 2-3 months and helps a person with diabetes determine

how well they are keeping blood glucose levels under control overall.

8.%% Medscape Medical News - The Choice of a Metabolic Syndrome

Generation: Soft Drink Consumption Associated With Increased Metabolic

Risk [for another

version of this see DRList 7-24-07]

July 25, 2007 - Drinking more than one soft drink daily is associated

with a higher risk of developing adverse metabolic traits, as well as

developing

the metabolic syndrome, a new study has shown. Interestingly, it doesn't

matter if the soda consumed is the diet variety, those with zero

calories, as

investigators showed these also

increased the burden of metabolic risk in middle-aged adults. " That was

one of the more striking aspects of this study, " lead investigator Dr R.

Vasan

(Boston University School of Medicine, MA) told

heartwire. . " It actually doesn't matter if the soft drink is regular or

diet. There was an association of increased risk of developing the

metabolic syndrome

with both types of drinks. " Vasan said that the consumption of soft

drinks has doubled to tripled between 1977 and 2001. During this same

time period,

soft-drink sizes have also increased to staggering proportions. With

evidence that soft-drink consumption is linked with weight gain and

obesity as well

as an increased risk of diabetes, the investigators questioned whether

soft-drink consumption in adults, in amounts that are seemingly

innocuous, like

one per day, posed any metabolic hazard. The team related the incidence

of metabolic syndrome and its components to soft-drink consumption in

more than

6000 individuals participating

in the Framingham Heart Study. In a cross-sectional analysis of the

data, investigators report that those consuming more than one soft drink

daily had

a 48% higher prevalence of metabolic syndrome

than those who drank less than one soft drink per day. In a longitudinal

analysis of more than 6000 subjects free from metabolic syndrome at

baseline,

drinking more than one soft drink daily was associated with a 44%

greater risk of developing metabolic syndrome and with developing 4 out

of 5 components

of metabolic syndrome. In a smaller sample of participants who had data

available regarding the type of soft drink consumed, researchers

observed that

that those who consumed one or more drinks of diet or regular soda per

day had a 50% to 60% increased risk of developing new-onset metabolic

syndrome.

Despite the fact that diet soda has zero calories, the findings are not

entirely surprising, said Vasan, as diet soft drinks have been

previously linked

with poor health outcomes in children, such as weight gain and high

blood pressure. In terms of theories explaining the association between

soft-drink

consumption and the metabolic syndrome risk, Vasan said there are no

definitive answers yet. .it might be a lifestyle/dietary background

thing driving

this. "

In addition, Vasan said diet soda might also induce a conditioning

response in which the soft drinks promote a dietary preference for

sweeter foods. Also,

because diet soda is liquid, this has the effect of individuals eating

more at the next meal, mainly because liquids are not as satiating. And

finally,

the brown caramel in soda has been linked with tissue damage and

inflammation, which might contribute to the increased risk. All of these

theories, however,

are debated in literature. " Clearly, these findings are sufficiently

intriguing that scientists now have to help us understand better why we

see this association, "

said Vasan. " We are not inferring causality from this analysis. It is

just an association, so we need to turn to the

scientists who are better positioned to help us understand the

association more. " Circulation. Published online July 23, 2007.

9.%% -FDA Advisory Panels Acknowledge Signal of Risk With Rosiglitazone,

but Stop Short of Recommending Its Withdrawal

Wood Heartwire 2007. C 2007 Medscape July 31, 2007 -

Rosiglitazone (Avandia, GlaxoKline [GSK]) is associated with a

clear signal of cardiac

ischemic risk in type 2 diabetics, the available data suggest, but this

signal is not enough to justify yanking the drug from the market. This

was the

near-unanimous conclusion of the FDA's joint Endocrinologic and

Metabolic Drugs/Drug Safety and Risk Management advisory committees at

Monday's hearing.

A long day of confusing, often conflicting data was capped by the

seemingly inconsistent conclusions of the committee members who agreed

20:3 with the

statement that available studies supported a signal of harm, but voted

22:1 to keep rosiglitazone on the market.

Dr Pickering who was one of the three members who did not

agree that there was a clear increased risk of ischemic events, pointed

to the apparent contradiction: " I'm puzzled as to how people can vote

yes for both

questions, " he mused. But the vast majority of voting members on the

panel seemed to agree with the sentiment

raised repeatedly by presenters, panelists, and open public-hearing

speakers, that it was important for physicians to have rosiglitazone in

their arsenal

of treatments for type 2. Indeed, some of the day's discussion revolved

around an emerging hypothesis that the other thiazolidinedione (TZD) on

the market,

pioglitazone [Actos], might

not carry the same safety concerns as rosiglitazone. Those data,

however, comes predominantly from an as-yet unpublished analysis

conducted by pioglitazone

manufacturer Takeda, and has not yet been reviewed by the FDA, nor was

it provided in full to panel members. A review of that data, was on

track to be

completed in time for the panel's review of the cardiovascular

ischemic/thrombotic risks of TZDs, which had originally been scheduled

for later in the

year. The hearing, however, was bumped up after the publication of a

controversial meta-analysis in the New England Journal of Medicine

(NEJM) [1]--pointing

to a significant 43% increase in myocardial infarction with

rosiglitazone.

During today's session, panel members heard from the sponsor and the

FDA, both of whom had conducted their own meta-analyses of the

randomized controlled

trial data and turned up findings that were surprisingly consistent with

the NEJM analysis--a 40% increased risk of serious ischemic events by

the FDA's

reckoning and a 31% increase in myocardial ischemic events in GSK's

meta-analysis.

All of the yes-votes reiterated the same concerns: that the evidence

linking rosiglitazone with increased risk of cardiovascular death or MI

was weak or

inconsistent, particularly in trials that had active control arms rather

than placebo comparators; that ischemic risk appeared higher in older

patients,

patients with heart failure, patients with

preexisting coronary disease, and patients taking insulin--and that this

should be reflected in the labeling. In fact, several panelists pointed

out that

current labeling lists rosiglitazone as being indicated for diabetics

taking insulin; they felt this should be removed and a black box should

be added

warning against its use in this group. Others emphasized that the

inconclusiveness of the existing studies and the fact that trials are

still ongoing should

also be mentioned in the packaging. But time and again, the experts on

the panel bemoaned the fact that, not for the first time, the FDA had

not had the

foresight to mandate appropriate trials, leaving the committees to try

to draw conclusions from meta-analyses and observational studies.

Even the ongoing RECORD, ACCORD, and BARI-2D trials, by the FDA's own

review, are underpowered or not designed to answer key questions about

whether ischemic

events will be higher than with other diabetes drugs, and if they are,

which patient subsets

will be affected. The mere fact that most of the studies included in the

meta-analyses were only six months in duration underscores the paucity

of solid

information. The sole no-vote on the key question of whether

rosiglitazone should remain on the market came from Dr Arthur Levin

(Center for Medical Consumers,

New York, NY).

" It seems to me that given the evidence of a strong safety signal, given

the fact that around this table and at the FDA there are doubts about

the ability

of ongoing clinical trials to definitively answer the question about the

CV safety of the drug, and given the enormity of the potential public

health risk

of allowing this drug to continue to be marketed and used by millions of

people for the rest of their lives,

I logically can't find any way to justify leaving this drug on the

market. " Levin's opinions have the support of at least two FDA insiders,

Dr Gerald Dal

Pan and Dr Graham , both in the FDA's Office of Surveillance and

Epidemiology, Center for Drug Evaluation

and Research. Graham presented a risk/benefit assessment of

rosiglitazone, pointing out that although his views were his own, his

findings had been reviewed

and were supported by others in his department, such that he was not

just speaking as " Graham the FDA Whistle-Blower. " Graham showed

projections

to back up his claim that ongoing studies " will not change our state of

knowledge... Graham's concerns about the quality of the existing

rosiglitazone

data, and the flawed studies in progress, struck a chord with panel

members, who called for stricter standards for pre-approval and

post-marketing studies.

" I would have to say, the FDA has to take some responsibility for the

dilemma in which we find ourselves, for approving less than optimally

designed trials

in the past, " Dr Arthur Moss observed. " I do think there is a problem

that needs to be rectified in the future. " Vindication for Nissen

Commenting on the

day's deliberations to heartwire, Dr Nissen (Cleveland Clinic,

OH), seemed satisfied that the FDA and sponsors' meta-analyses

had confirmed his own findings. . " One concern I have is that black-box

warnings do not always result in huge changes in prescribing practices,

so time

will tell, " he told heartwire

1. Nissen SE and Wolski K. Effect of rosiglitazone on the risk of

myocardial infarction and death from cardiovascular causes.

N Engl J Med 2007; 356:2457-2471.

10.%% Simultaneous Pancreas Kidney Transplantation From Old Donors

Medscape Transplantation. 2007; C2007 Medscape 07/24/2007 Patient and

Graft Survival

Implications of Simultaneous Pancreas Kidney Transplantation From Old

Donors Am J Transplant. 2007;7 Summary - The authors performed a

retrospective

analysis of the United Network for Organ Sharing database and identified

adult patients with type 1 DM who were placed on the waiting list for

simultaneous

pancreas-kidney (SPK) transplantation. 8850 patients (54%) received an

SPK transplant, of which 9% were from donors 45 years of age or older.

Survival

analyses were performed . .SPK transplantation from both young and old

donors independently predicted lower mortality compared with staying on

the waiting

list. An additional expected wait of 1.5 years for a young donor

equalized long-term survival expectations between young and old SPK

donors. On the basis

of these findings, the authors concluded that SPK transplantation offers

a substantial survival benefit independent of donor age and should be

considered

for patients with decreased access to organs from young donors.

Viewpoint - The critical shortage of donor organs challenges the

transplant community

to maximize and optimize the use of organs from all consenting deceased

donors. .the profile of acceptable older donors for SPK transplantation

may include

female sex, low body mass index, and noncerebrovascular etiology of

brain death. The patient population most likely to benefit from SPK

transplantation

from old donors includes either patients with limited access to timely

transplantation (eg, blood type O or B, highly sensitized) or those who

cannot afford

to wait for an extended period of time (unstable diabetes, prolonged

duration of dialysis, older age [> 50 years], known peripheral vascular

or cardiovascular

disease).

11.%% Medscape Medical News - Low GI Diets Better for Weight Loss, Lipid

Profiles, Finds Cochrane Review July 24, 2007 - A new Cochrane review

of six

randomized controlled trials comparing low glycemic index (GI) or

glycemic load (GL) diets with other diets has found that overweight or

obese people lost

more weight and had more improvement in lipid profiles with the low GI

eating plans.

Those on the low GI diets lost an average of 2.2 pounds (1 kg) more than

those given comparison diets, which included higher GI or GL diets and

conventional

weight loss diets. They also had significantly better decreases in total

and low-density lipoprotein (LDL) cholesterol, the researchers note. And

in the

two trials that evaluated only obese participants, weight loss was even

more apparent - the low GI dieters lost about 9.2 pounds, compared with

about 2.2

pounds shed by those on the other diets. However, the scientists caution

that enduring data are still needed. " Longer trials

with increased length of follow-up will determine whether the

improvements reported can be maintained and incorporated into lifestyle

long-term, " they

say. Two experts not connected with the review expressed mixed opinions.

One said this was a great review, while the other pointed out that the

difference

in weight loss

between the low and high GI diets was rather small. The team

included six trials in their review, including a total of 202 adults.

The diets lasted from 5 weeks to 6 months, and none of the studies

reported any adverseveffects

associated with consuming a low GI diet.vAs well as losing more weight,

those on the low GI diets also had significantly greatervloss of total

fat mass

and decrease in body mass index (BMI) than those on the comparison

diets. " Considering the brevity of the interventions, the results are

notable, " they

add.

Improvements in blood lipids were also significant. Cochrane Database

Syst Rev. Published online July 18, 2007.

Abbreviations: ADA - American Diabetes Association; DM - diabetes

Mellitus; FDA Federal Drug Administration; NIH - National Institutes of

Health; VA -

Veterans Administration. Definitions - Dorlands 31st Ed and Google

Disclaimer, I am a BSN RN but not a diabetic or diabetic educator.

Reports are excerpted unless otherwise noted. This project is done as a

courtesy to

the blind/visually impaired and diabetic communities.Dawn Wilcox

Coordinator The Health Library at Vista Center contact above e-mail or

thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

[Guest guest]

I was not aware that the hemoglobin being too high could be a problem. I'll

have to bring that up with my doc and my nepthrologist the next time I see them.

Thanks.

Dave

articles

1. Welcome to Medscape Nephrology and to this Spotlight entitled,

" Managing Anemia in Patients With Type 2 Diabetes and Chronic Kidney

Disease. " I am Dr.

Ajay Singh, Clinical Director at Brigham & Women's Hospital and

Associate Professor of Medicine at Harvard Medical School in Boston, MA,

and I will be

your moderator.

Slide 4. Prevalence of Diabetes and CKD Willa A. Hsueh, MD:

I think all of our audience knows that diabetes is the most common cause

of end stage renal disease in the US and there are about 30% to 40% of

patients

with type 1 DM who will go on to have chronic kidney disease and about

10% to 15%, maybe even as high as 20%, of patients with type 2 who will

go on to

have chronic kidney disease.

Aggressive Prevention of CKD Slide 5. Aggressive Prevention of CKD

I think we're all realizing, thanks to our nephrology colleagues, that

as patients develop albuminuria, not only is that an important sign of

kidney disease,

but I think it's a sign that there may be terrible problems with the

endothelium that could then lead to problems, of course, with coronary

heart disease

and stroke, so that should raise a red flag for all of us. In addition,

I think we also know that glycemic

control is very important for the microvascular complications, not just

the kidney but the eye and some of the neurologic complications. So with

that said,

I think as endocrinologists we're really focusing on tight control

early, tighter and tighter control. In fact, the recent ADA Guidelines

suggest that

we get our control to nearly normal in all of our patients with

hemoglobins around 5.5% or less. So there's an aggressive effort, I

think, to try to prevent

chronic kidney disease. Unfortunately, I think some patients will not

respond to some of

those or comply with some of those aggressive efforts, and we will still

have problems with the kidney.

Slide 6. Recognizing the Complications of CKD .. the question is how do

we recognize some of the complications early, that would include not

just the,

as we said, the coronary heart disease complications but also the

anemia, the changes in type 2 hyperparathyroidism or secondary

hyperparathyroidism, and

issues about early interventions for the anemia, and early interventions

with vitamin D therapy?

Dr. Singh: One of the really important issues, of course, is the burden

of cardiovascular disease in this population. Dr. Hsueh: Absolutely.

Dr. Singh: It seems like a number of observational studies have

indicated that at a very early stage in the syndrome of diabetic

nephropathy, patients

develop vascular disease and cardiovascular disease. Is it your sense

that the diabetologists are now increasingly

recognizing this and are becoming more aggresive in managing

cardiovascular disease in this population? Dr. Hsueh: Oh absolutely,

you cannot go to an

endocrine meeting without hearing about the marked increased incidence

of cardiovascular disease in patients with diabetes, and I think we've

known for

a long time that albuminuria is a key signal that heralds that, and I

think you all know well that as there is a progressive decrease in

glomerular filtration

rate, there's a progressive increase in cardiovascular disease.

%%Slide 8. Clinical Practice Guidelines for CKD and Diabetes

Mark E. Molitch, MD: several things came out of reviewing the

literature for those guidelines, certainly the glycemic control that

Willa had talked about

remains important, and even in the patient as they have advancing kidney

disease, we still need to get good glycemic control to try to reduce and

ameliorate

some of the other long-term complications of diabetes. But as far as the

cardiovascular

disease goes and the lipid management, these are patients at such high

risk that we recommend an LDL goal of less than 70 for those patients,

obviously

blood pressure treatment to get blood pressures less than 130/80 for

virtually all patients with diabetes, and perhaps even more stringent

goals for the

patient who's getting progressive

nephropathy. I think one of the things that brought home to me as we

were reviewing all this, is the knowledge that's relatively new, at how

early secondary

hyperparathyroidism and anemia start to be found.

%% Slide 9. Development of Anemia in Patients With Diabetes

Dr. Singh: one of the things that I have come across in the literature

is the idea that anemia tends to develop at an earlier stage in

diabetics than it

seems to in nondiabetics, so for any given level of GFR. What are your

thoughts on that, Willa ? Dr. Hsueh: Well we're recognizing more

patients, for

example, with stage 3 chronic kidney disease, and we are seeing evidence

that if patients have diabetes, the anemia for any level of chronic

kidney disease

seems to be worse than the nondiabetic patient, and of course there is

this anemia of chronic disease to begin with that our patients with

diabetes have,

and then when the kidney disease sets in, there are problems with

synthesis, as you know, of erythropoietin, and so that complicates the

issue, . Dr. Singh:

Mark, do you refer patients once they develop anemia or do you manage

the anemia yourself in your own practice?

Dr. Molitch: Well I think in our practice and probably in most

endocrine practices, by the time we find the patient whose hemoglobin is

getting less than

11 and we start thinking about erythropoietin [EPO], we have generally

been referring that patient to the nephrologist.Slide 10. TREAT Study

Design this

is a randomized prospective study looking at the effects of

erythropoietin supplementation, trying to get the hemoglobin levels up.

Slide 12. Diabetologists

and Nephrologists Working Together Dr. Singh:

In my own nephrology practice, I tend not to spend a lot of time

thinking about different types of insulin, so I would imagine that

Willa, you also don't

think about all the newer erythropoietins that are coming out since you

have such a strong nephrology division at UCLA. Dr. Hsueh: Well, like

Mark, with

erythropoietin, we're actually when we feel patients need that, we

actually call our nephrology colleagues and, as you said, they have a

very strong background.

What I'm amazed at is that our nephrology colleagues, once the

GFR is somewhere around 30 or less, they take over full management, so

they actually have to know about insulins and know about other issues.

%%Slide 15. Managing Patients With Diabetes and CKD

Dr. Singh: So what are your top 2 or 3 things that nowadays in 2007 you

think about in managing patients with diabetes who have chronic kidney

disease?

Do you, as Mark is alluding to, manage their lipids more aggressively,

their hypoparathyroidism, or do you feel that these areas still

represent controversial

issues? Dr. Hsueh: Well, as I said, we would see these patients more

in stage 2, stage 3, and maybe the beginning of stage 4, and I manage

their cardiovascular

risk, hypertension especially, very aggressively because I know that

whatever changes in blood pressure happen have great impact on the

kidney. The lipids

I'm concerned with, but I'm aware of the studies

you said, and then the question is the role of vitamin D because there's

very intriguing information that not only is it good for the

calcium-phosphorus

changes but also it may have anti-inflammatory effects; and there are a

number of studies at UCLA, then of course the whole issue of anemia, and

in patients

with heart disease, of course you want to provide oxygen but you don't

want to provide so many red cells that you get thrombosis formation.

Dr. Singh: So, Mark, do you think that diabetologists and nephrologists

can work together in managing these important conditions or is there

hope for

us to work together? Dr. Molitch:

Well absolutely I think it's almost a natural combination, but I think

one of the things we have to do is keep working together, and so it's

not a hand

off, it's a continued comanagement of the patients even once they get on

dialysis. I think the diabetologists can lend a hand in trying to help

manage

their diabetes even at that point. ..Dr. Singh:

So management of anemia and diabetes and kidney disease are

interrelated and now one can manage them in a diabetes center in a

collaborative fashion or

one can refer these patients but it seems like one of the key issues is

to certainly manage them, to recognize it early and manage them.

Slide 16. Management of Dialysis Patients With Diabetes

One quick question I have before we summarize is what about the dialysis

patient - do you tend to have them come back to your diabetes center or

diabetes

practice and continue to follow them or is it your observation that most

of these patients get managed wholly by the nephrologist when they reach

end-stage

renal disease?

Dr. Hsueh: Well I'm happy because there are more oral agents now on

board that we can use in dialysis patients, for example, in addition to

insulin,

. We now have sitagliptin or Januvia,.. you have to adjust the dose, but

it's a DPP-4 inhibitor that works on the incretin pathway. We have the

TZDs [thiazolidinediones]

which can be used all the

way through to end-stage kidney disease. And, of course, we have

acarbose, which mainly works on the gut and just slows, doesn't inhibit,

just slows carbohydrate

absorption. So you actually have 3 oral agents that you can mix and

match in patients with chronic kidney disease and then you have insulin,

so I think

we've broadened

the horizons for patients with CKD.

%% Slide 17. Summary and Closing Comments

Dr. Singh: So it sounds like nephrologists need to learn more about how

to manage diabetes with different types of insulins and oral agents and

diabetologists

need to learn to manage perhaps a little bit more about the

comorbidities of kidney disease such as hypoparathyroidism and lipid

abnormalities but also

anemia. And whether you refer these patients or you manage them in the

diabetes center, the key is to try to manage them together. Dr. Hsueh:

Well, we're

waiting for you to do the studies to tell us what level of hemoglobin

should we intervene, when should we intervene with vitamin D; of course,

both of

those studies are ongoing. Dr. Singh:

Right. Well, that was, I think, a very productive discussion, and I'd

like to thank Dr. Hsueh and Dr. Molitch for participating. I think we

achieved our

objectives of discussing the interrelatedness of anemia, diabetes, and

chronic kidney disease. I also believe that we really brought out the

notion that

diabetologists and nephrologists need to work together in both early

recognition and then subsequent management of these patients. Supported

by an independent

educational grant from Roche

2.%% Notice: The LightHouse for the Blind and Visually Impaired will be

hosting several informational survey interviews on talking glucose

meters and adaptive

insulin syringe devices. These interview sessions will be conducted in

conjunction with a doctorial student from UC Berkeley. The focus of the

interviews

is to collect data concerning talking glucose meters and adaptive

insulin syringe devices. The interview will take between 60 to 90

minutes in San Francisco

and there will be a $40 honorarium for those who participate. The

participants must be diabetic and have used or currently use a talking

glucose meter.

If you know of individuals who may qualify please contact Beth Berenson

at The LightHouse, Phone: or via email at:

3.%% Medscape - Metabolic Syndrome Linked to Chronic Kidney Disease

(Reuters Health) Jul 24 - A study of a Chinese population aged 40 years

and older found

an association between metabolic syndrome and chronic kidney disease.

(CKD) Metabolic syndrome " is a common disorder in developed countries, "

note the

researchers. " With its dramatic economic development and the consequent

changes in lifestyle and diet, China too has seen the metabolic syndrome

become

an important health care problem. " [2310 people;

cross-sectional study; mean age 60.7 years,] The overall prevalence of

metabolic syndrome was 34.1%, and the overall prevalence of CKD was

10.7%. The prevalence

of CKD was higher among subjects with metabolic syndrome than those

without metabolic syndrome (15.4% versus 8.3%, respectively. " Further

studies are needed

to determine if treatment of metabolic syndrome could substantially ease

the burden of CKD in China, " the team concludes. Mayo Clin Proc 2007;82

4.%% In Diabetes Today 23-JUL-2007 - Hepatitis C Strongly Linked to

Type 2 Diabetes (Reuters Health) - People infected with hepatitis C

virus have an

increased risk of developing type 2, or " adult-onset " diabetes, a

population-based study confirms. This risk is particularly high in

younger people who

are overweight, researchers have found.

Therefore, screening for and preventing diabetes in persons with HCV

infection could be started earlier than the suggested age of 45 or

older, which is

the recommendation for the general population, especially for patients

with are heavier or who have other diabetes risk factors for diabetes,

the team

writes. [4,958 people age 40 or older without diabetes, 3,486 tested

negative and 812 positive for HCV; 116 subjects were infected with both

HCV and HCV;

544 tested positive for hepatitis B; 7 year follow up] After adjusting

the data to account for established diabetes risk factors, the incidence

of DM was

70 percent higher in persons with HCV infection than in those without

it. " This finding is consistent with past studies showing that HCV

infection is highly

associated with diabetes. " the younger group with HCV infection was at

greater risk for the disease, they note. HCV infection plus being

overweight or

obese magnified the risk of diabetes by about three times compared with

uninfected persons of normal weight. American Journal of Epidemiology,

July 15,

2007.

5.%% TimesSelect F.D.A. Review Criticizes Diabetes Drug and Maker

July 26, 2007 Patients who take Avandia, a popular but controversial

diabetes medicine made by GlaxoKline, [GSK] are far more likely to

suffer and die from heart problems than those who take Actos, a similar

pill made

by Takeda, according to federal drug reviewers. Avandia is particularly

dangerous to patients who also take insulin. By contrast, Actos can be

taken safely

with insulin, according to the review. The findings likely spell the end

of Avandia's status as one of the nation's most popular drugs for

treating diabetics

who are not dependent on insulin. Last year, more than a million

patients in the US took Avandia, and a similar number took Actos.

Avandia's 2006 global sales were nearly $3.4 billion. The report and

charges that GSK sought to intimidate a doctor who publicly

warned about Avandia's risks in 1999 could lead to a cascade of lawsuits

against the company. Indeed, F.D.A. reviewers were sharply critical of

the quality

of the studies GSK has undertaken to test the safety of Avandia,

dismissing the present and future results of an ongoing 4,000-patient

trial as unreliable

and invalid. The report by medical and safety reviewers within the FDA

also provides ammunition to critics on Capitol Hill and elsewhere who

claim that

top F.D.A. officials have been far too slow to acknowledge Avandia's

risks. GlaxoKline suggested a year ago that the agency add a note

to the drug's

label about Avandia's growing heart risks, the report states. These

conclusions come in a 436-page compendium of reviews released in advance

of an advisory

committee hearing to be held on Monday to discuss Avandia's effects on

the heart. The F.D.A. intends to ask the committee of independent

experts whether

Avandia should continue to be sold. It is far from clear, F.D.A. safety

reviewers concluded in the report, whether taking Avandia, also known as

rosiglitazone,

is worth the risk. " A critical question to be resolved in determining

appropriate regulatory action is whether the anticipated therapeutic

benefit of rosiglitazone

outweighs the demonstrated

cardiovascular risk, " one F.D.A. reviewer concluded.

6.%% Medscape - Corneal Sensitivity Is Linked to Diabetic Neuropathy

(Reuters Health) Jul 26 - Results of a new study suggest that corneal

sensitivity is reduced in diabetic patients, and is related to the

severity of neuropathy.

" In diabetic patients, corneal sensitivity is reduced, due to a loss of

corneal nerve fibers, which leads to corneal keratopathy and a

susceptibility to

injury, with recurrent erosions and ulcers, " researchers write . Corneal

sensation, they add, can be evaluated using the Cochet-Bonnet

aesthesiometer (C-BA)

or the noncontact corneal aesthesiometer (NCCA). They examined corneal

sensitivity in 147 diabetic patients and 18 controls using these

approaches and

also assessed neuropathy deficit score. Neuropathy was classified as

being absent, mild, moderate or severe. No significant differences in

age, type of

diabetes, and A1C were observed among the groups. The duration of

diabetes increased with neuropathic severity. Corneal sensitivity was

significantly reduced

in patients with diabetes compared with controls. It was not reduced in

diabetic patients without neuropathy. However, a significant reduction

was observed

in those with any degree of neuropathy. A significant correlation was

observed between neuropathy

established by C-BA and NCCA. The findings, the investigators conclude

" have important clinical implications regarding the development of

corneal abnormalities

in diabetic patients and also raise the possibility that corneal

sensation could be used to screen for diabetic neuropathy. " Diabetes

Care 2007;30

7.%% Medical News Today - Improving Heart Health In Kids With Diabetes

Type 1: The More They Exercise, The Lower The Risk Of Early Death 28

Jul 2007

It's never too early to focus on how to maintain good cardiovascular

health, especially for people with type 1. A study published in the

August issue of

Diabetes Care underscores the need for regular physical activity among

youth, finding that the more active the child, the better the child's

cardiovascular

risk profile. Heart disease is the number one killer of people with

diabetes. Among type 1 patients

as young as 20-39 years, the risk of dying from cardio- and

cerebrovascular events is five times higher than it is for people who

don't have diabetes.

Previous studies have shown that the development of atherosclerotic

lesions begins in childhood and

that 69 percent of pediatric patients with type 1 diabetes exhibit one

or more cardiovascular risk factors.

A new study by researchers in Germany and Austria, which looked at the

physical activity levels and cardiovascular health of more than 23,000

young people

between the ages of 3 and 18, found that those who were most physically

active were the least likely to be at risk for heart disease. As

physical activity

levels rose, risk factors such as high lipid profiles, diastolic blood

pressure, and blood glucose

levels fell. Regular physical activity was defined as exercising for at

least 30 minutes at a time, not including school sports. The study found

that those

who were active at least once or twice per week were also less likely to

have high blood pressure than those who didn't exercise at all. And, it

showed

that the frequency of regular physical activity " was one of the most

important influencing factors for HbA1c. " The A1c test measures average

blood glucose

levels

over a period of 2-3 months and helps a person with diabetes determine

how well they are keeping blood glucose levels under control overall.

8.%% Medscape Medical News - The Choice of a Metabolic Syndrome

Generation: Soft Drink Consumption Associated With Increased Metabolic

Risk [for another

version of this see DRList 7-24-07]

July 25, 2007 - Drinking more than one soft drink daily is associated

with a higher risk of developing adverse metabolic traits, as well as

developing

the metabolic syndrome, a new study has shown. Interestingly, it doesn't

matter if the soda consumed is the diet variety, those with zero

calories, as

investigators showed these also

increased the burden of metabolic risk in middle-aged adults. " That was

one of the more striking aspects of this study, " lead investigator Dr R.

Vasan

(Boston University School of Medicine, MA) told

heartwire. . " It actually doesn't matter if the soft drink is regular or

diet. There was an association of increased risk of developing the

metabolic syndrome

with both types of drinks. " Vasan said that the consumption of soft

drinks has doubled to tripled between 1977 and 2001. During this same

time period,

soft-drink sizes have also increased to staggering proportions. With

evidence that soft-drink consumption is linked with weight gain and

obesity as well

as an increased risk of diabetes, the investigators questioned whether

soft-drink consumption in adults, in amounts that are seemingly

innocuous, like

one per day, posed any metabolic hazard. The team related the incidence

of metabolic syndrome and its components to soft-drink consumption in

more than

6000 individuals participating

in the Framingham Heart Study. In a cross-sectional analysis of the

data, investigators report that those consuming more than one soft drink

daily had

a 48% higher prevalence of metabolic syndrome

than those who drank less than one soft drink per day. In a longitudinal

analysis of more than 6000 subjects free from metabolic syndrome at

baseline,

drinking more than one soft drink daily was associated with a 44%

greater risk of developing metabolic syndrome and with developing 4 out

of 5 components

of metabolic syndrome. In a smaller sample of participants who had data

available regarding the type of soft drink consumed, researchers

observed that

that those who consumed one or more drinks of diet or regular soda per

day had a 50% to 60% increased risk of developing new-onset metabolic

syndrome.

Despite the fact that diet soda has zero calories, the findings are not

entirely surprising, said Vasan, as diet soft drinks have been

previously linked

with poor health outcomes in children, such as weight gain and high

blood pressure. In terms of theories explaining the association between

soft-drink

consumption and the metabolic syndrome risk, Vasan said there are no

definitive answers yet. .it might be a lifestyle/dietary background

thing driving

this. "

In addition, Vasan said diet soda might also induce a conditioning

response in which the soft drinks promote a dietary preference for

sweeter foods. Also,

because diet soda is liquid, this has the effect of individuals eating

more at the next meal, mainly because liquids are not as satiating. And

finally,

the brown caramel in soda has been linked with tissue damage and

inflammation, which might contribute to the increased risk. All of these

theories, however,

are debated in literature. " Clearly, these findings are sufficiently

intriguing that scientists now have to help us understand better why we

see this association, "

said Vasan. " We are not inferring causality from this analysis. It is

just an association, so we need to turn to the

scientists who are better positioned to help us understand the

association more. " Circulation. Published online July 23, 2007.

9.%% -FDA Advisory Panels Acknowledge Signal of Risk With Rosiglitazone,

but Stop Short of Recommending Its Withdrawal

Wood Heartwire 2007. C 2007 Medscape July 31, 2007 -

Rosiglitazone (Avandia, GlaxoKline [GSK]) is associated with a

clear signal of cardiac

ischemic risk in type 2 diabetics, the available data suggest, but this

signal is not enough to justify yanking the drug from the market. This

was the

near-unanimous conclusion of the FDA's joint Endocrinologic and

Metabolic Drugs/Drug Safety and Risk Management advisory committees at

Monday's hearing.

A long day of confusing, often conflicting data was capped by the

seemingly inconsistent conclusions of the committee members who agreed

20:3 with the

statement that available studies supported a signal of harm, but voted

22:1 to keep rosiglitazone on the market.

Dr Pickering who was one of the three members who did not

agree that there was a clear increased risk of ischemic events, pointed

to the apparent contradiction: " I'm puzzled as to how people can vote

yes for both

questions, " he mused. But the vast majority of voting members on the

panel seemed to agree with the sentiment

raised repeatedly by presenters, panelists, and open public-hearing

speakers, that it was important for physicians to have rosiglitazone in

their arsenal

of treatments for type 2. Indeed, some of the day's discussion revolved

around an emerging hypothesis that the other thiazolidinedione (TZD) on

the market,

pioglitazone [Actos], might

not carry the same safety concerns as rosiglitazone. Those data,

however, comes predominantly from an as-yet unpublished analysis

conducted by pioglitazone

manufacturer Takeda, and has not yet been reviewed by the FDA, nor was

it provided in full to panel members. A review of that data, was on

track to be

completed in time for the panel's review of the cardiovascular

ischemic/thrombotic risks of TZDs, which had originally been scheduled

for later in the

year. The hearing, however, was bumped up after the publication of a

controversial meta-analysis in the New England Journal of Medicine

(NEJM) [1]--pointing

to a significant 43% increase in myocardial infarction with

rosiglitazone.

During today's session, panel members heard from the sponsor and the

FDA, both of whom had conducted their own meta-analyses of the

randomized controlled

trial data and turned up findings that were surprisingly consistent with

the NEJM analysis--a 40% increased risk of serious ischemic events by

the FDA's

reckoning and a 31% increase in myocardial ischemic events in GSK's

meta-analysis.

All of the yes-votes reiterated the same concerns: that the evidence

linking rosiglitazone with increased risk of cardiovascular death or MI

was weak or

inconsistent, particularly in trials that had active control arms rather

than placebo comparators; that ischemic risk appeared higher in older

patients,

patients with heart failure, patients with

preexisting coronary disease, and patients taking insulin--and that this

should be reflected in the labeling. In fact, several panelists pointed

out that

current labeling lists rosiglitazone as being indicated for diabetics

taking insulin; they felt this should be removed and a black box should

be added

warning against its use in this group. Others emphasized that the

inconclusiveness of the existing studies and the fact that trials are

still ongoing should

also be mentioned in the packaging. But time and again, the experts on

the panel bemoaned the fact that, not for the first time, the FDA had

not had the

foresight to mandate appropriate trials, leaving the committees to try

to draw conclusions from meta-analyses and observational studies.

Even the ongoing RECORD, ACCORD, and BARI-2D trials, by the FDA's own

review, are underpowered or not designed to answer key questions about

whether ischemic

events will be higher than with other diabetes drugs, and if they are,

which patient subsets

will be affected. The mere fact that most of the studies included in the

meta-analyses were only six months in duration underscores the paucity

of solid

information. The sole no-vote on the key question of whether

rosiglitazone should remain on the market came from Dr Arthur Levin

(Center for Medical Consumers,

New York, NY).

" It seems to me that given the evidence of a strong safety signal, given

the fact that around this table and at the FDA there are doubts about

the ability

of ongoing clinical trials to definitively answer the question about the

CV safety of the drug, and given the enormity of the potential public

health risk

of allowing this drug to continue to be marketed and used by millions of

people for the rest of their lives,

I logically can't find any way to justify leaving this drug on the

market. " Levin's opinions have the support of at least two FDA insiders,

Dr Gerald Dal

Pan and Dr Graham , both in the FDA's Office of Surveillance and

Epidemiology, Center for Drug Evaluation

and Research. Graham presented a risk/benefit assessment of

rosiglitazone, pointing out that although his views were his own, his

findings had been reviewed

and were supported by others in his department, such that he was not

just speaking as " Graham the FDA Whistle-Blower. " Graham showed

projections

to back up his claim that ongoing studies " will not change our state of

knowledge... Graham's concerns about the quality of the existing

rosiglitazone

data, and the flawed studies in progress, struck a chord with panel

members, who called for stricter standards for pre-approval and

post-marketing studies.

" I would have to say, the FDA has to take some responsibility for the

dilemma in which we find ourselves, for approving less than optimally

designed trials

in the past, " Dr Arthur Moss observed. " I do think there is a problem

that needs to be rectified in the future. " Vindication for Nissen

Commenting on the

day's deliberations to heartwire, Dr Nissen (Cleveland Clinic,

OH), seemed satisfied that the FDA and sponsors' meta-analyses

had confirmed his own findings. . " One concern I have is that black-box

warnings do not always result in huge changes in prescribing practices,

so time

will tell, " he told heartwire

1. Nissen SE and Wolski K. Effect of rosiglitazone on the risk of

myocardial infarction and death from cardiovascular causes.

N Engl J Med 2007; 356:2457-2471.

10.%% Simultaneous Pancreas Kidney Transplantation From Old Donors

Medscape Transplantation. 2007; C2007 Medscape 07/24/2007 Patient and

Graft Survival

Implications of Simultaneous Pancreas Kidney Transplantation From Old

Donors Am J Transplant. 2007;7 Summary - The authors performed a

retrospective

analysis of the United Network for Organ Sharing database and identified

adult patients with type 1 DM who were placed on the waiting list for

simultaneous

pancreas-kidney (SPK) transplantation. 8850 patients (54%) received an

SPK transplant, of which 9% were from donors 45 years of age or older.

Survival

analyses were performed . .SPK transplantation from both young and old

donors independently predicted lower mortality compared with staying on

the waiting

list. An additional expected wait of 1.5 years for a young donor

equalized long-term survival expectations between young and old SPK

donors. On the basis

of these findings, the authors concluded that SPK transplantation offers

a substantial survival benefit independent of donor age and should be

considered

for patients with decreased access to organs from young donors.

Viewpoint - The critical shortage of donor organs challenges the

transplant community

to maximize and optimize the use of organs from all consenting deceased

donors. .the profile of acceptable older donors for SPK transplantation

may include

female sex, low body mass index, and noncerebrovascular etiology of

brain death. The patient population most likely to benefit from SPK

transplantation

from old donors includes either patients with limited access to timely

transplantation (eg, blood type O or B, highly sensitized) or those who

cannot afford

to wait for an extended period of time (unstable diabetes, prolonged

duration of dialysis, older age [> 50 years], known peripheral vascular

or cardiovascular

disease).

11.%% Medscape Medical News - Low GI Diets Better for Weight Loss, Lipid

Profiles, Finds Cochrane Review July 24, 2007 - A new Cochrane review

of six

randomized controlled trials comparing low glycemic index (GI) or

glycemic load (GL) diets with other diets has found that overweight or

obese people lost

more weight and had more improvement in lipid profiles with the low GI

eating plans.

Those on the low GI diets lost an average of 2.2 pounds (1 kg) more than

those given comparison diets, which included higher GI or GL diets and

conventional

weight loss diets. They also had significantly better decreases in total

and low-density lipoprotein (LDL) cholesterol, the researchers note. And

in the

two trials that evaluated only obese participants, weight loss was even

more apparent - the low GI dieters lost about 9.2 pounds, compared with

about 2.2

pounds shed by those on the other diets. However, the scientists caution

that enduring data are still needed. " Longer trials

with increased length of follow-up will determine whether the

improvements reported can be maintained and incorporated into lifestyle

long-term, " they

say. Two experts not connected with the review expressed mixed opinions.

One said this was a great review, while the other pointed out that the

difference

in weight loss

between the low and high GI diets was rather small. The team

included six trials in their review, including a total of 202 adults.

The diets lasted from 5 weeks to 6 months, and none of the studies

reported any adverseveffects

associated with consuming a low GI diet.vAs well as losing more weight,

those on the low GI diets also had significantly greatervloss of total

fat mass

and decrease in body mass index (BMI) than those on the comparison

diets. " Considering the brevity of the interventions, the results are

notable, " they

add.

Improvements in blood lipids were also significant. Cochrane Database

Syst Rev. Published online July 18, 2007.

Abbreviations: ADA - American Diabetes Association; DM - diabetes

Mellitus; FDA Federal Drug Administration; NIH - National Institutes of

Health; VA -

Veterans Administration. Definitions - Dorlands 31st Ed and Google

Disclaimer, I am a BSN RN but not a diabetic or diabetic educator.

Reports are excerpted unless otherwise noted. This project is done as a

courtesy to

the blind/visually impaired and diabetic communities.Dawn Wilcox

Coordinator The Health Library at Vista Center contact above e-mail or

thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

[Guest guest]

interesting, patricia. So let me ask something: is hypoglycemia present in

type 2 diabetics and if so, is there a certain way you know you have it?

Vicki

The LORD is good to those who depend on him, to those who search for him.

Lamentations 3:25, NLT

articles

1. ADA - Depression May Lead to Type 2 Diabetes Jan-2-2008

Researchers believe there is a link between chronic depression and the

development of T2DM in adults age 65 years and up. Using responses from

over 4,600

people without diabetes at the outset to the National Institutes of

Health's Center for Epidemiological Studies

Depression Scale, the researchers saw a 50% greater chance of developing

DM during the course of the 10-year study among those noting high

depressive symptoms--even

after accounting for weight and activity levels. They state that

depression has dramatic impacts on the autonomic nervous system, moving

from a resting

state to a responsive state under stress; insulin production is shut

down to handle potential threats when the body is in the responsive

state. Similar

research by Washington University School of Medicine determined that

when adults have both depression and T2, 90% of those experienced

depression first.

News summaries C2007 Information, Inc. Chicago Tribune (12/25/07)

2.%% MW - Habituation of Brain Responses Tied to Unawareness of

Hypoglycemia (Reuters Health) Dec 31 - Attenuation of amygdala and

frontal cortical responses

to low blood glucose concentration may lead to a lack of hypoglycemia

awareness in patients with T1DM. The lead researcher told Reuters Health

that the

studies are early

However, she said, " We think they may have important implications for

people with T1 who have lost their ability to recognize early

hypoglycemia ... and

are therefore at high risk for more severe

hypoglycemia with confusion and even coma. " The team used FDG-labeled

positron emission tomography to examine responses to euglycemia and

hypoglycemia

in 6 patients with hypoglycemia

awareness and 7 without such awareness. FDG uptake was increased in the

left amygdala in hypoglycemia awareness, but not in hypoglycemia

unawareness. The

team also found a " robust increase " bilaterally in the ventral striatum

during hypoglycemia unawareness.

Further analysis indicated bilateral attenuated activation of brain stem

regions and less deactivation in lateral orbitofrontal cortex in

hypoglycemia

unawareness. " The data suggest, that this group of people, perhaps 25%

of people who have had their DM for more than 15 years, have an altered

brain response

to a hypoglycemic episode in which they not only fail to feel that they

are hypoglycemic, but they also fail to generate the brain message that

the hypoglycemia

is unpleasant and dangerous. " In fact, " the message generated may even

be faintly rewarding, which would actually encourage experience of

further hypoglycemia, "

she added. " If this interpretation is correct, we will need to use

additional strategies, such as those currently successful in changing

other patterns

of repeated behavior that are damaging -- for example, smoking and

drinking alcohol -- to help people avoid hypoglycemia long-term, and

recover their awareness

of those occasional episodes that are inevitably part of today's insulin

therapies. " Diabetes 2007;56.

3.%% MW-Sirolimus Stents May Reduce Restenosis in Diabetics With

Coronary Disease (Reuters Health) Jan 04 - Compared with

paclitaxel-eluting stents (PES),

sirolimus-eluting stents (SES) appear to decrease the risk of in-stent

late luminal loss in diabetics with coronary artery disease, new

research shows.

Comparing PES with SES has been difficult since there are so many

individual variables

that contribute to neointimal hyperplasia. In the present study, the

researchers addressed this problem by comparing PES and SES directly in

the same diabetic

patient. [60 patients - 60 lesions were successfully treated with PES

and 60 with SES] On multivariate analysis, the type of drug-eluting

stent was the

only independent

predictor of in-stent late luminal loss. Specifically, in-stent late

luminal loss [loss of the open area in vessel] was 2.3-times more likely

when a PES

rather than a SES was used. Further research is needed to determine if

the better angiographic results achieved

with SES actually translate into long-term clinical benefits, the

authors conclude. Diabetes Care 2008;31.

4.%% MW - Retinopathy Linked to Subclinical Coronary Artery Disease

Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 03 - Retinal

microvascular

changes are associated with increased coronary artery calcification

(CAC), an indicator of subclinical coronary macrovascular disease,

findings from the

prospective Multi-Ethnic Study of Atherosclerosis (MESA) suggest. [6,000

subjects age 45 -84 years without a history of clinical cardiovascular

disease.

They underwent chest computed tomography to measure

coronary artery calcification and fundus photography to assess retinal

disease. Retinopathy was defined as the presence of microaneurysms,

hemorrhages,

cotton wool spots, intraretinal microvascular abnormalities, hard

exudates, venous beading or

new vessels. CAC was present in about half of the subjects. Retinopathy

was present in 14.3% of subjects with no CAC, 17.2% of subjects with

mild CAC,

and 20.8% of those with moderate to severe CAC. " The association between

retinopathy and moderate-to-severe CAC was present in all ethnic groups

and remained

significant in both men and women and in persons with and without

diabetes or hypertension, " the investigators found. They conclude that

" common pathophysiologic

processes may underlie both microvascular

and macrovascular disease. " Specifically, they suggest that " retinopathy

signs ...reflect generalized endothelial dysfunction, which in the

coronary circulation

may promote atherogenesis. "

" Inflammatory factors may also be involved " when patients without

hypertension or diabetes, and with generally low cardiovascular risk

profiles, present

with retinopathy and coronary artery calcification, h. " As yet, there

are no direct clinical implications from our study, " the ophthalmologist

researcher

said, " but physicians and patients should be aware that these conditions

are related. . patients with retinopathy may be at higher risk of both

subclinical

heart disease and clinical heart disease, such as heart failure. " On the

other hand, retinopathy is reversible..Reversal may occur in 3 years and

is associated

with lower BP and glucose levels, higher physical activity, and less

obesity, " he said. " It is possible, but not proven, that reversal is

associated with

lower risk of cardiovascular disease. " the team is

now evaluating the value of adding a retinal examination to a coronary

calcium CT scan for predicting cardiovascular disease.

Am J Epidemiol 2008;167:

5.%% MW - Alpha-Linolenic Acid May Lower Risk of Diabetic Peripheral

Neuropathy Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 07 -

Dietary intake

of alpha-linolenic acid was associated with reduced incidence of

diabetic peripheral neuropathy in a new analysis of data from the

National Health and

Nutrition Examination Survey (NHANES) 1999-2004. Alpha-linolenic acid is

an omega-3 fatty acid found in many vegetable oils, including flaxseed,

walnuts,

and canola oil. The researchers identified 1062 diabetics age 40 and

older for whom complete 24-hour dietary recall data were recorded.

Peripheral neuropathy

had been assessed using a nylon monofilament at three plantar sites on

each foot to test for sensation.

Dr. Eberhardt's group calculated the intake of total polyunsaturated

fatty acids and of seven specific fatty acids. In multivariate analyses,

they adjusted

for age, sex, race, education, height, weight, diabetes duration,

glycemic control, hypertension, smoking, and total

calorie intake. Relative to adults in the lowest quintile [fifth] of

alpha-linolenic acid intake the odds of having peripheral neuropathy was

0.54 for

subjects in the fourth quintile (1.35 - 2.10 g/day) of intake and 0.40

for adults in the fifth quintile (2.11 g/day or higher). High dietary

intake of

alpha-linolenic acid is associated with reduced risk of vascular disease

(coronary heart disease and hypertension), the team points out. " The

protective

effect of alpha-linolenic acid on macrovascular diseases and its

association with diabetic peripheral neuropathy may be due to a similar

biological mechanism. "

They recommend further study to verify a protective effect of

alpha-linolenic acid in patients with diabetes. Diabetes Care 2008;31.

6.%% MW-Fitness, Fatness, and Cardiovascular Risk Factors in Type 2

Diabetes: Look AHEAD Study Med Sci Sports Exerc. 2007;39(12) C2007

American College

of Sports Medicine 01/03/2008

Purpose: Most studies comparing the effects of fitness and fatness on

cardiovascular (CVD) risk have been done with young, healthy

participants with low

rates of obesity and high levels of fitness. The present study examined

the association of cardiorespiratory fitness and obesity with CVD risk

factors

in an ethnically diverse sample of overweight/obese individuals with

T2DM. [ Baseline data from Look AHEAD, 5145 overweight or obese

individuals with T2]..Among

the CVD risk factors, we examined continuous outcomes such as HbA1c,

HDL, LDL, triglycerides, SBP, diastolic blood pressure (DBP), ABI, and

1-yr CVD risk

estimate using the Framingham risk prediction equation. . At entry into

the study, participants averaged 58.7 and had a DM duration of 6.8. 60%

were women;

63.2% were white, 15.7% were African American, 13.2% Hispanic, 5.0%

Native American, and 1.0% Asian American. In conclusion, this study

shows that fitness

and fatness are highly associated; thus, it is unusual to find

individuals who are obese, yet very fit. Moreover, both fitness and

fatness are related

to CVD risk factors, although the strength of the associations for

fitness versus fatness differed for specific risk factors. Of particular

note is the

strong association of fitness with HbA1c, ABI, and Framingham risk score

in this population, and the relationships of BMI with SBP. Look AHEAD is

an ongoing

trial; it is expected to last through the year 2012. Half of the

participants are receiving intensive lifestyle intervention, and half

receive diabetes

education and support. Changes in weight, fitness, and CVD risk factors

are measured periodically throughout the study; the primary outcome

measure is

CVD morbidity and mortality.

7.%% MW - Imaging to Assess Effect of Medical Therapy in Patients With

Diabetes Mellitus Br J Diabetes Vasc Dis. 2007;7(4): 01/02/2008

Abstract - The incidence of T2DM is rapidly increasing throughout the

world. As an independent risk factor for cardiovascular disease both at

the microvascular

and macrovascular level, DM is a condition that deserves the most

aggressive medical management... invasive techniques have been

extensively used to assess

coronary atherosclerosis progression and drug efficacy in the general

population and smaller subsets of DM patients. While even minimal

luminal stenosis

reduction was associated with very significant reduction in event rates

in the general population, similar data are lacking in DM patients.

Although sensitive,

an obvious limitation of these techniques is their invasive nature and

the radiation exposure, besides a very considerable operational cost.

Hence, additional non-invasive imaging techniques have been adopted to

assess plaque progression or its haemodynamic effects in diabetic

patients. Carotid

Intima Media Thickness - Two decades ago investigators showed that the

thickness of the carotid wall (intima and media layer taken together)

measured ultrasonographically

was associated with the presence and extent of atherosclerosis of the

aorta..several randomised and epidemiological studies clearly proved the

value of

the cIMT as a marker of CV risk. An increased cIMT has been associated

with risk of MI and CVA in the elderly (> 65 years)

as well as younger age groups. cIMT is a marker of atherosclerosis

burden rather than a surrogate for obstructive CAD. Insulin resistance

alone in the

absence of clinical diabetes has been associated with an increased

cIMT.. Furthermore, cIMT appears to progress faster in diabetic patients

than in all

other patients.

Medical Interventions -Measurement of cIMT progression has been utilised

to assess efficacy of medical therapy in several studies in DM patients.

A short-

and a long-term follow-up study of 1,229 T1DM patients randomised to

either standard or intensive glucose-reducing therapy, compared cIMT

progression in

diabetes with that of age and sex-matched non-diabetic

individuals...cIMT progression was not different at the end of the first

year of follow-up between

controls and patients receiving intensive and standard therapy, but it

was significantly greater in the diabetic than control subjects at the

end of 6.5

years of follow-up. Coronary Artery Calcium - Coronary artery calcium is

deposited in the atherosclerotic milieu as the plaque develops via

active mechanisms

resembling bone formation. . it has been shown that there is an

excellent correlation(r=0.98) between CAC measured on CCT and

atherosclerotic plaque area.

Whether CAC imaging adds prognostic information in diabetes mellitus

remains unclear. Hypertension and several nontraditional CV risk

factors have been

associated with CAC progression in DM subjects. .. Additionally, a

greater proportion of DM than non-diabetic patients developed CAC during

follow-up if

no CAC was present at baseline (42% vs. 25%. Finally, as reported in

the general population, CAC progression was linked with adverse coronary

events during

follow-up. .DM patients who suffered a MI during follow-up demonstrated

a 4-fold and 2.5-fold greater CAC progression than non-diabetic subjects

receiving

and not receiving statins, respectively. CAC imaging appears to be a

reliable means to assess risk connected with subclinical atherosclerosis

in the general

population, although some debate remains in diabetic patients.

Functional Imaging - Various forms of nuclear myocardial perfusion

imaging have been utilised

in DM patients to assess the effect of glycaemic metabolism on vascular

function. Indeed, data suggest that coronary vasomotor abnormalities

accompany

glucose metabolism impairment and that vascular function deteriorates

with increasing severity of insulin-resistance and glucose intolerance.

Summary -

The existing evidence suggests that many modern imaging modalities may

be utilised to monitor the effectiveness of medical therapy for diabetes

on the

CV system. Indeed, almost all surrogate markers of atherosclerosis have

been studied in diabetic patients and have shown some validity for this

purpose.

However, many of the reported differences were very small, some were

obtained with invasive techniques and many implied exposure to

radiation. Finally,

very little evidence has so far linked the occurrence of events to the

progression of these markers of disease. Hence, future appropriately

powered studies

should focus on whether reducing plaque progression and restoring

vascular vasomotor activity translate into a significant improvement of

CV morbidity

and mortality in diabetes mellitus.

8.%% Type 2 Diabetes -- Insulin Therapy Initiating Insulin in the Type

2 Diabetes Patient Medscape Diabetes & Endocrinology. 2007; C2007

Medscape 12/28/2007

Introduction - T2DM is a progressive disease, and most patients will

eventually need insulin to achieve euglycemia.[normal blood sugar level]

Furthermore,

data have shown that early and aggressive

intervention to lower blood glucose reduces the risk of complications of

the disease. However, even with the ever-growing list of new medications

available,

it can be a daunting task for healthcare providers to decide which

treatment regimen is appropriate

to manage a particular patient. New guidelines and algorithms can help

determine which patients with type 2 diabetes should be started on

insulin and when

insulin should be initiated. The goals of insulin therapy are the same

as the goals of any therapy for the treatment

of diabetes: to achieve optimal glycemic control without causing undue

hypoglycemia or excessive weight gain and to minimize the impact on

lifestyle.

The Challenges of Insulin Therapy

Psychological insulin resistance is a real phenomenon. Individuals with

diabetes often feel that insulin is the beginning of the end. They fear

taking

the injection and feel that there is a stigma associated with insulin.

Insulin therapy can, in fact, be a real pain both literally and

figuratively. It

is intrusive, can limit spontaneity, and can interfere with daily

activities. As a consequence, adhering to an insulin regimen has been

difficult for many

patients. Because symptom severity is not indicative of disease

severity, many individuals do not understand the need for optimal

glycemic control or its

role in preventing complications. This lack of understanding can also

result in significant resistance as well as decreased adherence once

patients do

agree to begin insulin. That nonadherence will most likely carry over to

other parts of diabetes management, such as blood glucose testing. In

addition,

individuals fear that they will experience hypoglycemia and gain weight.

To top it off, there is the inconvenience and the disruption of daily

routines

and privacy.

Providers, on the other hand, also experience psychological resistance

to insulin therapy. They also may fear hypoglycemia and have concern for

their patients'

safety. In patients who already have a weight issue, the risk of gaining

weight adds to the complexity of the decision to initiate insulin. All

this, combined

with the time it takes to educate the patient and titrate the dose, adds

up to a lot of work. Teaming up with a diabetes educator who is

knowledgeable

in diabetes and insulin management can help alleviate this workload.

However, even if this resource is not available, simple algorithms and

titration schedules

make initiation and titration of insulin easier.

9.%% MW -Blood Pressure and Risk of Developing Type 2 Diabetes Mellitus:

The Women's Health Study Eur Heart J. 2007;28(23) C2007 Oxford

University Press

01/02/2008 Abstract Aims: To examine the relationship of blood

pressure (BP) and BP progression with the subsequent development of

T2DM. [ prospective

cohort study among 38 172 women free of DM and cardiovascular disease at

baseline. Women were classified into four categories according to

self-reported

baseline BP] During 10.2 years of follow-up, 1672 women developed

T2. Conclusion - Our study provides strong evidence that baseline BP and

BP progression are associated with an increased risk of incident T2.

Clinicians

should be aware of these relationships to optimize the management of

patients at increased risk for cardiovascular disease.

10.%% MW - New PPAR-Gamma Modulator Has Potent Antidiabetes and

Antiatherogenic Effects Reuters Health Information 2007. (Reuters

Health) Dec 28 - A new

specific peroxisome proliferator-activated receptor (PPAR) modulator

has demonstrated promise in a French in vitro and in vivo study of

mice.The researchers

note that the thiazolidinedione (TZD) class of drugs, although

effective and widely used to treat T2 tends to cause weight gain. This

study was undertaken

to evaluate S26948, a novel ligand for PPAR-gamma. The study found that

S26948 is a specific high-affinity agonist for PPAR-gamma, binding it

with the

same affinity as the TZD rosiglitazone does. Further, the results

suggest that S26948 promoted a PPAR-gamma conformation distinct from

that elicited by

rosiglitazone. In addition, [it] decreased blood glucose levels and

plasma insulin levels in male ob/ob mice, indicating that the drug

increased insulin

sensitivity, paralleling the effects of rosiglitazone treatment. Results

showed that the agent did not promote body- weight gain in the diabetic

mice.

Instead, the S26948-treated mice gained less weight than the controls,

indicating " a profoundly decreased food efficiency, " the authors write.

They concluded

that S26948's pattern of coactivator recruitment, which differs from

that of rosiglitazone, decreases its adipogenic capacity compared with

rosiglitazone. In a cohort of homozygous human apolipoprotein E2

knock-in mice, S26948 reduced atherosclerotic lesion surfaces by 46%

compared with controls.

Rosiglitazone had no effect on atherosclerotic lesion size. They add

that this line of research is ongoing with related compounds that are

considered even

more promising, not specifically with S26948. Diabetes 2007;56

11.%% MW - Depomed Says FDA Approves 1000 Mg Strength Tablets of

Glumetza (Reuters) Jan 02 - Depomed Inc said U.S. health regulators have

approved the

1000 mg strength tablets of Glumetza, an extended-release formulation of

metformin, for patients with T2.

The specialty pharmaceutical company said it acquired exclusive US

rights to the 1000 mg formulation of Glumetza in December 2005

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. Definitions -

Dorlands 31st Ed

and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic

educator. Reports are excerpted unless otherwise noted. This project is

done as a

courtesy to the blind/visually impaired and diabetic communities. Dawn

Wilcox Coordinator The Health Library at Vista Center contact above

e-mail or thl@...

__________ NOD32 2779 (20080109) Information __________

This message was checked by NOD32 antivirus system.

http://www.eset.com

[Guest guest]

interesting, patricia. So let me ask something: is hypoglycemia present in

type 2 diabetics and if so, is there a certain way you know you have it?

Vicki

The LORD is good to those who depend on him, to those who search for him.

Lamentations 3:25, NLT

articles

1. ADA - Depression May Lead to Type 2 Diabetes Jan-2-2008

Researchers believe there is a link between chronic depression and the

development of T2DM in adults age 65 years and up. Using responses from

over 4,600

people without diabetes at the outset to the National Institutes of

Health's Center for Epidemiological Studies

Depression Scale, the researchers saw a 50% greater chance of developing

DM during the course of the 10-year study among those noting high

depressive symptoms--even

after accounting for weight and activity levels. They state that

depression has dramatic impacts on the autonomic nervous system, moving

from a resting

state to a responsive state under stress; insulin production is shut

down to handle potential threats when the body is in the responsive

state. Similar

research by Washington University School of Medicine determined that

when adults have both depression and T2, 90% of those experienced

depression first.

News summaries C2007 Information, Inc. Chicago Tribune (12/25/07)

2.%% MW - Habituation of Brain Responses Tied to Unawareness of

Hypoglycemia (Reuters Health) Dec 31 - Attenuation of amygdala and

frontal cortical responses

to low blood glucose concentration may lead to a lack of hypoglycemia

awareness in patients with T1DM. The lead researcher told Reuters Health

that the

studies are early

However, she said, " We think they may have important implications for

people with T1 who have lost their ability to recognize early

hypoglycemia ... and

are therefore at high risk for more severe

hypoglycemia with confusion and even coma. " The team used FDG-labeled

positron emission tomography to examine responses to euglycemia and

hypoglycemia

in 6 patients with hypoglycemia

awareness and 7 without such awareness. FDG uptake was increased in the

left amygdala in hypoglycemia awareness, but not in hypoglycemia

unawareness. The

team also found a " robust increase " bilaterally in the ventral striatum

during hypoglycemia unawareness.

Further analysis indicated bilateral attenuated activation of brain stem

regions and less deactivation in lateral orbitofrontal cortex in

hypoglycemia

unawareness. " The data suggest, that this group of people, perhaps 25%

of people who have had their DM for more than 15 years, have an altered

brain response

to a hypoglycemic episode in which they not only fail to feel that they

are hypoglycemic, but they also fail to generate the brain message that

the hypoglycemia

is unpleasant and dangerous. " In fact, " the message generated may even

be faintly rewarding, which would actually encourage experience of

further hypoglycemia, "

she added. " If this interpretation is correct, we will need to use

additional strategies, such as those currently successful in changing

other patterns

of repeated behavior that are damaging -- for example, smoking and

drinking alcohol -- to help people avoid hypoglycemia long-term, and

recover their awareness

of those occasional episodes that are inevitably part of today's insulin

therapies. " Diabetes 2007;56.

3.%% MW-Sirolimus Stents May Reduce Restenosis in Diabetics With

Coronary Disease (Reuters Health) Jan 04 - Compared with

paclitaxel-eluting stents (PES),

sirolimus-eluting stents (SES) appear to decrease the risk of in-stent

late luminal loss in diabetics with coronary artery disease, new

research shows.

Comparing PES with SES has been difficult since there are so many

individual variables

that contribute to neointimal hyperplasia. In the present study, the

researchers addressed this problem by comparing PES and SES directly in

the same diabetic

patient. [60 patients - 60 lesions were successfully treated with PES

and 60 with SES] On multivariate analysis, the type of drug-eluting

stent was the

only independent

predictor of in-stent late luminal loss. Specifically, in-stent late

luminal loss [loss of the open area in vessel] was 2.3-times more likely

when a PES

rather than a SES was used. Further research is needed to determine if

the better angiographic results achieved

with SES actually translate into long-term clinical benefits, the

authors conclude. Diabetes Care 2008;31.

4.%% MW - Retinopathy Linked to Subclinical Coronary Artery Disease

Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 03 - Retinal

microvascular

changes are associated with increased coronary artery calcification

(CAC), an indicator of subclinical coronary macrovascular disease,

findings from the

prospective Multi-Ethnic Study of Atherosclerosis (MESA) suggest. [6,000

subjects age 45 -84 years without a history of clinical cardiovascular

disease.

They underwent chest computed tomography to measure

coronary artery calcification and fundus photography to assess retinal

disease. Retinopathy was defined as the presence of microaneurysms,

hemorrhages,

cotton wool spots, intraretinal microvascular abnormalities, hard

exudates, venous beading or

new vessels. CAC was present in about half of the subjects. Retinopathy

was present in 14.3% of subjects with no CAC, 17.2% of subjects with

mild CAC,

and 20.8% of those with moderate to severe CAC. " The association between

retinopathy and moderate-to-severe CAC was present in all ethnic groups

and remained

significant in both men and women and in persons with and without

diabetes or hypertension, " the investigators found. They conclude that

" common pathophysiologic

processes may underlie both microvascular

and macrovascular disease. " Specifically, they suggest that " retinopathy

signs ...reflect generalized endothelial dysfunction, which in the

coronary circulation

may promote atherogenesis. "

" Inflammatory factors may also be involved " when patients without

hypertension or diabetes, and with generally low cardiovascular risk

profiles, present

with retinopathy and coronary artery calcification, h. " As yet, there

are no direct clinical implications from our study, " the ophthalmologist

researcher

said, " but physicians and patients should be aware that these conditions

are related. . patients with retinopathy may be at higher risk of both

subclinical

heart disease and clinical heart disease, such as heart failure. " On the

other hand, retinopathy is reversible..Reversal may occur in 3 years and

is associated

with lower BP and glucose levels, higher physical activity, and less

obesity, " he said. " It is possible, but not proven, that reversal is

associated with

lower risk of cardiovascular disease. " the team is

now evaluating the value of adding a retinal examination to a coronary

calcium CT scan for predicting cardiovascular disease.

Am J Epidemiol 2008;167:

5.%% MW - Alpha-Linolenic Acid May Lower Risk of Diabetic Peripheral

Neuropathy Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 07 -

Dietary intake

of alpha-linolenic acid was associated with reduced incidence of

diabetic peripheral neuropathy in a new analysis of data from the

National Health and

Nutrition Examination Survey (NHANES) 1999-2004. Alpha-linolenic acid is

an omega-3 fatty acid found in many vegetable oils, including flaxseed,

walnuts,

and canola oil. The researchers identified 1062 diabetics age 40 and

older for whom complete 24-hour dietary recall data were recorded.

Peripheral neuropathy

had been assessed using a nylon monofilament at three plantar sites on

each foot to test for sensation.

Dr. Eberhardt's group calculated the intake of total polyunsaturated

fatty acids and of seven specific fatty acids. In multivariate analyses,

they adjusted

for age, sex, race, education, height, weight, diabetes duration,

glycemic control, hypertension, smoking, and total

calorie intake. Relative to adults in the lowest quintile [fifth] of

alpha-linolenic acid intake the odds of having peripheral neuropathy was

0.54 for

subjects in the fourth quintile (1.35 - 2.10 g/day) of intake and 0.40

for adults in the fifth quintile (2.11 g/day or higher). High dietary

intake of

alpha-linolenic acid is associated with reduced risk of vascular disease

(coronary heart disease and hypertension), the team points out. " The

protective

effect of alpha-linolenic acid on macrovascular diseases and its

association with diabetic peripheral neuropathy may be due to a similar

biological mechanism. "

They recommend further study to verify a protective effect of

alpha-linolenic acid in patients with diabetes. Diabetes Care 2008;31.

6.%% MW-Fitness, Fatness, and Cardiovascular Risk Factors in Type 2

Diabetes: Look AHEAD Study Med Sci Sports Exerc. 2007;39(12) C2007

American College

of Sports Medicine 01/03/2008

Purpose: Most studies comparing the effects of fitness and fatness on

cardiovascular (CVD) risk have been done with young, healthy

participants with low

rates of obesity and high levels of fitness. The present study examined

the association of cardiorespiratory fitness and obesity with CVD risk

factors

in an ethnically diverse sample of overweight/obese individuals with

T2DM. [ Baseline data from Look AHEAD, 5145 overweight or obese

individuals with T2]..Among

the CVD risk factors, we examined continuous outcomes such as HbA1c,

HDL, LDL, triglycerides, SBP, diastolic blood pressure (DBP), ABI, and

1-yr CVD risk

estimate using the Framingham risk prediction equation. . At entry into

the study, participants averaged 58.7 and had a DM duration of 6.8. 60%

were women;

63.2% were white, 15.7% were African American, 13.2% Hispanic, 5.0%

Native American, and 1.0% Asian American. In conclusion, this study

shows that fitness

and fatness are highly associated; thus, it is unusual to find

individuals who are obese, yet very fit. Moreover, both fitness and

fatness are related

to CVD risk factors, although the strength of the associations for

fitness versus fatness differed for specific risk factors. Of particular

note is the

strong association of fitness with HbA1c, ABI, and Framingham risk score

in this population, and the relationships of BMI with SBP. Look AHEAD is

an ongoing

trial; it is expected to last through the year 2012. Half of the

participants are receiving intensive lifestyle intervention, and half

receive diabetes

education and support. Changes in weight, fitness, and CVD risk factors

are measured periodically throughout the study; the primary outcome

measure is

CVD morbidity and mortality.

7.%% MW - Imaging to Assess Effect of Medical Therapy in Patients With

Diabetes Mellitus Br J Diabetes Vasc Dis. 2007;7(4): 01/02/2008

Abstract - The incidence of T2DM is rapidly increasing throughout the

world. As an independent risk factor for cardiovascular disease both at

the microvascular

and macrovascular level, DM is a condition that deserves the most

aggressive medical management... invasive techniques have been

extensively used to assess

coronary atherosclerosis progression and drug efficacy in the general

population and smaller subsets of DM patients. While even minimal

luminal stenosis

reduction was associated with very significant reduction in event rates

in the general population, similar data are lacking in DM patients.

Although sensitive,

an obvious limitation of these techniques is their invasive nature and

the radiation exposure, besides a very considerable operational cost.

Hence, additional non-invasive imaging techniques have been adopted to

assess plaque progression or its haemodynamic effects in diabetic

patients. Carotid

Intima Media Thickness - Two decades ago investigators showed that the

thickness of the carotid wall (intima and media layer taken together)

measured ultrasonographically

was associated with the presence and extent of atherosclerosis of the

aorta..several randomised and epidemiological studies clearly proved the

value of

the cIMT as a marker of CV risk. An increased cIMT has been associated

with risk of MI and CVA in the elderly (> 65 years)

as well as younger age groups. cIMT is a marker of atherosclerosis

burden rather than a surrogate for obstructive CAD. Insulin resistance

alone in the

absence of clinical diabetes has been associated with an increased

cIMT.. Furthermore, cIMT appears to progress faster in diabetic patients

than in all

other patients.

Medical Interventions -Measurement of cIMT progression has been utilised

to assess efficacy of medical therapy in several studies in DM patients.

A short-

and a long-term follow-up study of 1,229 T1DM patients randomised to

either standard or intensive glucose-reducing therapy, compared cIMT

progression in

diabetes with that of age and sex-matched non-diabetic

individuals...cIMT progression was not different at the end of the first

year of follow-up between

controls and patients receiving intensive and standard therapy, but it

was significantly greater in the diabetic than control subjects at the

end of 6.5

years of follow-up. Coronary Artery Calcium - Coronary artery calcium is

deposited in the atherosclerotic milieu as the plaque develops via

active mechanisms

resembling bone formation. . it has been shown that there is an

excellent correlation(r=0.98) between CAC measured on CCT and

atherosclerotic plaque area.

Whether CAC imaging adds prognostic information in diabetes mellitus

remains unclear. Hypertension and several nontraditional CV risk

factors have been

associated with CAC progression in DM subjects. .. Additionally, a

greater proportion of DM than non-diabetic patients developed CAC during

follow-up if

no CAC was present at baseline (42% vs. 25%. Finally, as reported in

the general population, CAC progression was linked with adverse coronary

events during

follow-up. .DM patients who suffered a MI during follow-up demonstrated

a 4-fold and 2.5-fold greater CAC progression than non-diabetic subjects

receiving

and not receiving statins, respectively. CAC imaging appears to be a

reliable means to assess risk connected with subclinical atherosclerosis

in the general

population, although some debate remains in diabetic patients.

Functional Imaging - Various forms of nuclear myocardial perfusion

imaging have been utilised

in DM patients to assess the effect of glycaemic metabolism on vascular

function. Indeed, data suggest that coronary vasomotor abnormalities

accompany

glucose metabolism impairment and that vascular function deteriorates

with increasing severity of insulin-resistance and glucose intolerance.

Summary -

The existing evidence suggests that many modern imaging modalities may

be utilised to monitor the effectiveness of medical therapy for diabetes

on the

CV system. Indeed, almost all surrogate markers of atherosclerosis have

been studied in diabetic patients and have shown some validity for this

purpose.

However, many of the reported differences were very small, some were

obtained with invasive techniques and many implied exposure to

radiation. Finally,

very little evidence has so far linked the occurrence of events to the

progression of these markers of disease. Hence, future appropriately

powered studies

should focus on whether reducing plaque progression and restoring

vascular vasomotor activity translate into a significant improvement of

CV morbidity

and mortality in diabetes mellitus.

8.%% Type 2 Diabetes -- Insulin Therapy Initiating Insulin in the Type

2 Diabetes Patient Medscape Diabetes & Endocrinology. 2007; C2007

Medscape 12/28/2007

Introduction - T2DM is a progressive disease, and most patients will

eventually need insulin to achieve euglycemia.[normal blood sugar level]

Furthermore,

data have shown that early and aggressive

intervention to lower blood glucose reduces the risk of complications of

the disease. However, even with the ever-growing list of new medications

available,

it can be a daunting task for healthcare providers to decide which

treatment regimen is appropriate

to manage a particular patient. New guidelines and algorithms can help

determine which patients with type 2 diabetes should be started on

insulin and when

insulin should be initiated. The goals of insulin therapy are the same

as the goals of any therapy for the treatment

of diabetes: to achieve optimal glycemic control without causing undue

hypoglycemia or excessive weight gain and to minimize the impact on

lifestyle.

The Challenges of Insulin Therapy

Psychological insulin resistance is a real phenomenon. Individuals with

diabetes often feel that insulin is the beginning of the end. They fear

taking

the injection and feel that there is a stigma associated with insulin.

Insulin therapy can, in fact, be a real pain both literally and

figuratively. It

is intrusive, can limit spontaneity, and can interfere with daily

activities. As a consequence, adhering to an insulin regimen has been

difficult for many

patients. Because symptom severity is not indicative of disease

severity, many individuals do not understand the need for optimal

glycemic control or its

role in preventing complications. This lack of understanding can also

result in significant resistance as well as decreased adherence once

patients do

agree to begin insulin. That nonadherence will most likely carry over to

other parts of diabetes management, such as blood glucose testing. In

addition,

individuals fear that they will experience hypoglycemia and gain weight.

To top it off, there is the inconvenience and the disruption of daily

routines

and privacy.

Providers, on the other hand, also experience psychological resistance

to insulin therapy. They also may fear hypoglycemia and have concern for

their patients'

safety. In patients who already have a weight issue, the risk of gaining

weight adds to the complexity of the decision to initiate insulin. All

this, combined

with the time it takes to educate the patient and titrate the dose, adds

up to a lot of work. Teaming up with a diabetes educator who is

knowledgeable

in diabetes and insulin management can help alleviate this workload.

However, even if this resource is not available, simple algorithms and

titration schedules

make initiation and titration of insulin easier.

9.%% MW -Blood Pressure and Risk of Developing Type 2 Diabetes Mellitus:

The Women's Health Study Eur Heart J. 2007;28(23) C2007 Oxford

University Press

01/02/2008 Abstract Aims: To examine the relationship of blood

pressure (BP) and BP progression with the subsequent development of

T2DM. [ prospective

cohort study among 38 172 women free of DM and cardiovascular disease at

baseline. Women were classified into four categories according to

self-reported

baseline BP] During 10.2 years of follow-up, 1672 women developed

T2. Conclusion - Our study provides strong evidence that baseline BP and

BP progression are associated with an increased risk of incident T2.

Clinicians

should be aware of these relationships to optimize the management of

patients at increased risk for cardiovascular disease.

10.%% MW - New PPAR-Gamma Modulator Has Potent Antidiabetes and

Antiatherogenic Effects Reuters Health Information 2007. (Reuters

Health) Dec 28 - A new

specific peroxisome proliferator-activated receptor (PPAR) modulator

has demonstrated promise in a French in vitro and in vivo study of

mice.The researchers

note that the thiazolidinedione (TZD) class of drugs, although

effective and widely used to treat T2 tends to cause weight gain. This

study was undertaken

to evaluate S26948, a novel ligand for PPAR-gamma. The study found that

S26948 is a specific high-affinity agonist for PPAR-gamma, binding it

with the

same affinity as the TZD rosiglitazone does. Further, the results

suggest that S26948 promoted a PPAR-gamma conformation distinct from

that elicited by

rosiglitazone. In addition, [it] decreased blood glucose levels and

plasma insulin levels in male ob/ob mice, indicating that the drug

increased insulin

sensitivity, paralleling the effects of rosiglitazone treatment. Results

showed that the agent did not promote body- weight gain in the diabetic

mice.

Instead, the S26948-treated mice gained less weight than the controls,

indicating " a profoundly decreased food efficiency, " the authors write.

They concluded

that S26948's pattern of coactivator recruitment, which differs from

that of rosiglitazone, decreases its adipogenic capacity compared with

rosiglitazone. In a cohort of homozygous human apolipoprotein E2

knock-in mice, S26948 reduced atherosclerotic lesion surfaces by 46%

compared with controls.

Rosiglitazone had no effect on atherosclerotic lesion size. They add

that this line of research is ongoing with related compounds that are

considered even

more promising, not specifically with S26948. Diabetes 2007;56

11.%% MW - Depomed Says FDA Approves 1000 Mg Strength Tablets of

Glumetza (Reuters) Jan 02 - Depomed Inc said U.S. health regulators have

approved the

1000 mg strength tablets of Glumetza, an extended-release formulation of

metformin, for patients with T2.

The specialty pharmaceutical company said it acquired exclusive US

rights to the 1000 mg formulation of Glumetza in December 2005

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. Definitions -

Dorlands 31st Ed

and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic

educator. Reports are excerpted unless otherwise noted. This project is

done as a

courtesy to the blind/visually impaired and diabetic communities. Dawn

Wilcox Coordinator The Health Library at Vista Center contact above

e-mail or thl@...

__________ NOD32 2779 (20080109) Information __________

This message was checked by NOD32 antivirus system.

http://www.eset.com

[Guest guest]

Vicky,

Type 2 diabetecs can become hypoglycemic if they are on meds that make

their pancreas produce insulin. Perhaps some type 2 diabetics on the

list can tell their experiences with this?

Re: articles

interesting, patricia. So let me ask something: is hypoglycemia present

in type 2 diabetics and if so, is there a certain way you know you have

it?

Vicki

The LORD is good to those who depend on him, to those who search for

him.

Lamentations 3:25, NLT

articles

1. ADA - Depression May Lead to Type 2 Diabetes Jan-2-2008

Researchers believe there is a link between chronic depression and the

development of T2DM in adults age 65 years and up. Using responses from

over 4,600

people without diabetes at the outset to the National Institutes of

Health's Center for Epidemiological Studies

Depression Scale, the researchers saw a 50% greater chance of developing

DM during the course of the 10-year study among those noting high

depressive symptoms--even

after accounting for weight and activity levels. They state that

depression has dramatic impacts on the autonomic nervous system, moving

from a resting

state to a responsive state under stress; insulin production is shut

down to handle potential threats when the body is in the responsive

state. Similar

research by Washington University School of Medicine determined that

when adults have both depression and T2, 90% of those experienced

depression first.

News summaries C2007 Information, Inc. Chicago Tribune (12/25/07)

2.%% MW - Habituation of Brain Responses Tied to Unawareness of

Hypoglycemia (Reuters Health) Dec 31 - Attenuation of amygdala and

frontal cortical responses

to low blood glucose concentration may lead to a lack of hypoglycemia

awareness in patients with T1DM. The lead researcher told Reuters Health

that the

studies are early

However, she said, " We think they may have important implications for

people with T1 who have lost their ability to recognize early

hypoglycemia ... and

are therefore at high risk for more severe

hypoglycemia with confusion and even coma. " The team used FDG-labeled

positron emission tomography to examine responses to euglycemia and

hypoglycemia

in 6 patients with hypoglycemia

awareness and 7 without such awareness. FDG uptake was increased in the

left amygdala in hypoglycemia awareness, but not in hypoglycemia

unawareness. The

team also found a " robust increase " bilaterally in the ventral striatum

during hypoglycemia unawareness.

Further analysis indicated bilateral attenuated activation of brain stem

regions and less deactivation in lateral orbitofrontal cortex in

hypoglycemia

unawareness. " The data suggest, that this group of people, perhaps 25%

of people who have had their DM for more than 15 years, have an altered

brain response

to a hypoglycemic episode in which they not only fail to feel that they

are hypoglycemic, but they also fail to generate the brain message that

the hypoglycemia

is unpleasant and dangerous. " In fact, " the message generated may even

be faintly rewarding, which would actually encourage experience of

further hypoglycemia, "

she added. " If this interpretation is correct, we will need to use

additional strategies, such as those currently successful in changing

other patterns

of repeated behavior that are damaging -- for example, smoking and

drinking alcohol -- to help people avoid hypoglycemia long-term, and

recover their awareness

of those occasional episodes that are inevitably part of today's insulin

therapies. " Diabetes 2007;56.

3.%% MW-Sirolimus Stents May Reduce Restenosis in Diabetics With

Coronary Disease (Reuters Health) Jan 04 - Compared with

paclitaxel-eluting stents (PES),

sirolimus-eluting stents (SES) appear to decrease the risk of in-stent

late luminal loss in diabetics with coronary artery disease, new

research shows.

Comparing PES with SES has been difficult since there are so many

individual variables

that contribute to neointimal hyperplasia. In the present study, the

researchers addressed this problem by comparing PES and SES directly in

the same diabetic

patient. [60 patients - 60 lesions were successfully treated with PES

and 60 with SES] On multivariate analysis, the type of drug-eluting

stent was the

only independent

predictor of in-stent late luminal loss. Specifically, in-stent late

luminal loss [loss of the open area in vessel] was 2.3-times more likely

when a PES

rather than a SES was used. Further research is needed to determine if

the better angiographic results achieved

with SES actually translate into long-term clinical benefits, the

authors conclude. Diabetes Care 2008;31.

4.%% MW - Retinopathy Linked to Subclinical Coronary Artery Disease

Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 03 - Retinal

microvascular

changes are associated with increased coronary artery calcification

(CAC), an indicator of subclinical coronary macrovascular disease,

findings from the

prospective Multi-Ethnic Study of Atherosclerosis (MESA) suggest. [6,000

subjects age 45 -84 years without a history of clinical cardiovascular

disease.

They underwent chest computed tomography to measure

coronary artery calcification and fundus photography to assess retinal

disease. Retinopathy was defined as the presence of microaneurysms,

hemorrhages,

cotton wool spots, intraretinal microvascular abnormalities, hard

exudates, venous beading or

new vessels. CAC was present in about half of the subjects. Retinopathy

was present in 14.3% of subjects with no CAC, 17.2% of subjects with

mild CAC,

and 20.8% of those with moderate to severe CAC. " The association between

retinopathy and moderate-to-severe CAC was present in all ethnic groups

and remained

significant in both men and women and in persons with and without

diabetes or hypertension, " the investigators found. They conclude that

" common pathophysiologic

processes may underlie both microvascular

and macrovascular disease. " Specifically, they suggest that " retinopathy

signs ...reflect generalized endothelial dysfunction, which in the

coronary circulation

may promote atherogenesis. "

" Inflammatory factors may also be involved " when patients without

hypertension or diabetes, and with generally low cardiovascular risk

profiles, present

with retinopathy and coronary artery calcification, h. " As yet, there

are no direct clinical implications from our study, " the ophthalmologist

researcher

said, " but physicians and patients should be aware that these conditions

are related. . patients with retinopathy may be at higher risk of both

subclinical

heart disease and clinical heart disease, such as heart failure. " On the

other hand, retinopathy is reversible..Reversal may occur in 3 years and

is associated

with lower BP and glucose levels, higher physical activity, and less

obesity, " he said. " It is possible, but not proven, that reversal is

associated with

lower risk of cardiovascular disease. " the team is

now evaluating the value of adding a retinal examination to a coronary

calcium CT scan for predicting cardiovascular disease.

Am J Epidemiol 2008;167:

5.%% MW - Alpha-Linolenic Acid May Lower Risk of Diabetic Peripheral

Neuropathy Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 07 -

Dietary intake

of alpha-linolenic acid was associated with reduced incidence of

diabetic peripheral neuropathy in a new analysis of data from the

National Health and

Nutrition Examination Survey (NHANES) 1999-2004. Alpha-linolenic acid is

an omega-3 fatty acid found in many vegetable oils, including flaxseed,

walnuts,

and canola oil. The researchers identified 1062 diabetics age 40 and

older for whom complete 24-hour dietary recall data were recorded.

Peripheral neuropathy

had been assessed using a nylon monofilament at three plantar sites on

each foot to test for sensation.

Dr. Eberhardt's group calculated the intake of total polyunsaturated

fatty acids and of seven specific fatty acids. In multivariate analyses,

they adjusted

for age, sex, race, education, height, weight, diabetes duration,

glycemic control, hypertension, smoking, and total

calorie intake. Relative to adults in the lowest quintile [fifth] of

alpha-linolenic acid intake the odds of having peripheral neuropathy was

0.54 for

subjects in the fourth quintile (1.35 - 2.10 g/day) of intake and 0.40

for adults in the fifth quintile (2.11 g/day or higher). High dietary

intake of

alpha-linolenic acid is associated with reduced risk of vascular disease

(coronary heart disease and hypertension), the team points out. " The

protective

effect of alpha-linolenic acid on macrovascular diseases and its

association with diabetic peripheral neuropathy may be due to a similar

biological mechanism. "

They recommend further study to verify a protective effect of

alpha-linolenic acid in patients with diabetes. Diabetes Care 2008;31.

6.%% MW-Fitness, Fatness, and Cardiovascular Risk Factors in Type 2

Diabetes: Look AHEAD Study Med Sci Sports Exerc. 2007;39(12) C2007

American College

of Sports Medicine 01/03/2008

Purpose: Most studies comparing the effects of fitness and fatness on

cardiovascular (CVD) risk have been done with young, healthy

participants with low

rates of obesity and high levels of fitness. The present study examined

the association of cardiorespiratory fitness and obesity with CVD risk

factors

in an ethnically diverse sample of overweight/obese individuals with

T2DM. [ Baseline data from Look AHEAD, 5145 overweight or obese

individuals with T2]..Among

the CVD risk factors, we examined continuous outcomes such as HbA1c,

HDL, LDL, triglycerides, SBP, diastolic blood pressure (DBP), ABI, and

1-yr CVD risk

estimate using the Framingham risk prediction equation. . At entry into

the study, participants averaged 58.7 and had a DM duration of 6.8. 60%

were women;

63.2% were white, 15.7% were African American, 13.2% Hispanic, 5.0%

Native American, and 1.0% Asian American. In conclusion, this study

shows that fitness

and fatness are highly associated; thus, it is unusual to find

individuals who are obese, yet very fit. Moreover, both fitness and

fatness are related

to CVD risk factors, although the strength of the associations for

fitness versus fatness differed for specific risk factors. Of particular

note is the

strong association of fitness with HbA1c, ABI, and Framingham risk score

in this population, and the relationships of BMI with SBP. Look AHEAD is

an ongoing

trial; it is expected to last through the year 2012. Half of the

participants are receiving intensive lifestyle intervention, and half

receive diabetes

education and support. Changes in weight, fitness, and CVD risk factors

are measured periodically throughout the study; the primary outcome

measure is

CVD morbidity and mortality.

7.%% MW - Imaging to Assess Effect of Medical Therapy in Patients With

Diabetes Mellitus Br J Diabetes Vasc Dis. 2007;7(4): 01/02/2008

Abstract - The incidence of T2DM is rapidly increasing throughout the

world. As an independent risk factor for cardiovascular disease both at

the microvascular

and macrovascular level, DM is a condition that deserves the most

aggressive medical management... invasive techniques have been

extensively used to assess

coronary atherosclerosis progression and drug efficacy in the general

population and smaller subsets of DM patients. While even minimal

luminal stenosis

reduction was associated with very significant reduction in event rates

in the general population, similar data are lacking in DM patients.

Although sensitive,

an obvious limitation of these techniques is their invasive nature and

the radiation exposure, besides a very considerable operational cost.

Hence, additional non-invasive imaging techniques have been adopted to

assess plaque progression or its haemodynamic effects in diabetic

patients. Carotid

Intima Media Thickness - Two decades ago investigators showed that the

thickness of the carotid wall (intima and media layer taken together)

measured ultrasonographically

was associated with the presence and extent of atherosclerosis of the

aorta..several randomised and epidemiological studies clearly proved the

value of

the cIMT as a marker of CV risk. An increased cIMT has been associated

with risk of MI and CVA in the elderly (> 65 years)

as well as younger age groups. cIMT is a marker of atherosclerosis

burden rather than a surrogate for obstructive CAD. Insulin resistance

alone in the

absence of clinical diabetes has been associated with an increased

cIMT.. Furthermore, cIMT appears to progress faster in diabetic patients

than in all

other patients.

Medical Interventions -Measurement of cIMT progression has been utilised

to assess efficacy of medical therapy in several studies in DM patients.

A short-

and a long-term follow-up study of 1,229 T1DM patients randomised to

either standard or intensive glucose-reducing therapy, compared cIMT

progression in

diabetes with that of age and sex-matched non-diabetic

individuals...cIMT progression was not different at the end of the first

year of follow-up between

controls and patients receiving intensive and standard therapy, but it

was significantly greater in the diabetic than control subjects at the

end of 6.5

years of follow-up. Coronary Artery Calcium - Coronary artery calcium is

deposited in the atherosclerotic milieu as the plaque develops via

active mechanisms

resembling bone formation. . it has been shown that there is an

excellent correlation(r=0.98) between CAC measured on CCT and

atherosclerotic plaque area.

Whether CAC imaging adds prognostic information in diabetes mellitus

remains unclear. Hypertension and several nontraditional CV risk

factors have been

associated with CAC progression in DM subjects. .. Additionally, a

greater proportion of DM than non-diabetic patients developed CAC during

follow-up if

no CAC was present at baseline (42% vs. 25%. Finally, as reported in

the general population, CAC progression was linked with adverse coronary

events during

follow-up. .DM patients who suffered a MI during follow-up demonstrated

a 4-fold and 2.5-fold greater CAC progression than non-diabetic subjects

receiving

and not receiving statins, respectively. CAC imaging appears to be a

reliable means to assess risk connected with subclinical atherosclerosis

in the general

population, although some debate remains in diabetic patients.

Functional Imaging - Various forms of nuclear myocardial perfusion

imaging have been utilised

in DM patients to assess the effect of glycaemic metabolism on vascular

function. Indeed, data suggest that coronary vasomotor abnormalities

accompany

glucose metabolism impairment and that vascular function deteriorates

with increasing severity of insulin-resistance and glucose intolerance.

Summary -

The existing evidence suggests that many modern imaging modalities may

be utilised to monitor the effectiveness of medical therapy for diabetes

on the

CV system. Indeed, almost all surrogate markers of atherosclerosis have

been studied in diabetic patients and have shown some validity for this

purpose.

However, many of the reported differences were very small, some were

obtained with invasive techniques and many implied exposure to

radiation. Finally,

very little evidence has so far linked the occurrence of events to the

progression of these markers of disease. Hence, future appropriately

powered studies

should focus on whether reducing plaque progression and restoring

vascular vasomotor activity translate into a significant improvement of

CV morbidity

and mortality in diabetes mellitus.

8.%% Type 2 Diabetes -- Insulin Therapy Initiating Insulin in the Type

2 Diabetes Patient Medscape Diabetes & Endocrinology. 2007; C2007

Medscape 12/28/2007

Introduction - T2DM is a progressive disease, and most patients will

eventually need insulin to achieve euglycemia.[normal blood sugar level]

Furthermore,

data have shown that early and aggressive

intervention to lower blood glucose reduces the risk of complications of

the disease. However, even with the ever-growing list of new medications

available,

it can be a daunting task for healthcare providers to decide which

treatment regimen is appropriate

to manage a particular patient. New guidelines and algorithms can help

determine which patients with type 2 diabetes should be started on

insulin and when

insulin should be initiated. The goals of insulin therapy are the same

as the goals of any therapy for the treatment

of diabetes: to achieve optimal glycemic control without causing undue

hypoglycemia or excessive weight gain and to minimize the impact on

lifestyle.

The Challenges of Insulin Therapy

Psychological insulin resistance is a real phenomenon. Individuals with

diabetes often feel that insulin is the beginning of the end. They fear

taking

the injection and feel that there is a stigma associated with insulin.

Insulin therapy can, in fact, be a real pain both literally and

figuratively. It

is intrusive, can limit spontaneity, and can interfere with daily

activities. As a consequence, adhering to an insulin regimen has been

difficult for many

patients. Because symptom severity is not indicative of disease

severity, many individuals do not understand the need for optimal

glycemic control or its

role in preventing complications. This lack of understanding can also

result in significant resistance as well as decreased adherence once

patients do

agree to begin insulin. That nonadherence will most likely carry over to

other parts of diabetes management, such as blood glucose testing. In

addition,

individuals fear that they will experience hypoglycemia and gain weight.

To top it off, there is the inconvenience and the disruption of daily

routines

and privacy.

Providers, on the other hand, also experience psychological resistance

to insulin therapy. They also may fear hypoglycemia and have concern for

their patients'

safety. In patients who already have a weight issue, the risk of gaining

weight adds to the complexity of the decision to initiate insulin. All

this, combined

with the time it takes to educate the patient and titrate the dose, adds

up to a lot of work. Teaming up with a diabetes educator who is

knowledgeable

in diabetes and insulin management can help alleviate this workload.

However, even if this resource is not available, simple algorithms and

titration schedules

make initiation and titration of insulin easier.

9.%% MW -Blood Pressure and Risk of Developing Type 2 Diabetes Mellitus:

The Women's Health Study Eur Heart J. 2007;28(23) C2007 Oxford

University Press

01/02/2008 Abstract Aims: To examine the relationship of blood

pressure (BP) and BP progression with the subsequent development of

T2DM. [ prospective

cohort study among 38 172 women free of DM and cardiovascular disease at

baseline. Women were classified into four categories according to

self-reported

baseline BP] During 10.2 years of follow-up, 1672 women developed

T2. Conclusion - Our study provides strong evidence that baseline BP and

BP progression are associated with an increased risk of incident T2.

Clinicians

should be aware of these relationships to optimize the management of

patients at increased risk for cardiovascular disease.

10.%% MW - New PPAR-Gamma Modulator Has Potent Antidiabetes and

Antiatherogenic Effects Reuters Health Information 2007. (Reuters

Health) Dec 28 - A new

specific peroxisome proliferator-activated receptor (PPAR) modulator

has demonstrated promise in a French in vitro and in vivo study of

mice.The researchers

note that the thiazolidinedione (TZD) class of drugs, although

effective and widely used to treat T2 tends to cause weight gain. This

study was undertaken

to evaluate S26948, a novel ligand for PPAR-gamma. The study found that

S26948 is a specific high-affinity agonist for PPAR-gamma, binding it

with the

same affinity as the TZD rosiglitazone does. Further, the results

suggest that S26948 promoted a PPAR-gamma conformation distinct from

that elicited by

rosiglitazone. In addition, [it] decreased blood glucose levels and

plasma insulin levels in male ob/ob mice, indicating that the drug

increased insulin

sensitivity, paralleling the effects of rosiglitazone treatment. Results

showed that the agent did not promote body- weight gain in the diabetic

mice.

Instead, the S26948-treated mice gained less weight than the controls,

indicating " a profoundly decreased food efficiency, " the authors write.

They concluded

that S26948's pattern of coactivator recruitment, which differs from

that of rosiglitazone, decreases its adipogenic capacity compared with

rosiglitazone. In a cohort of homozygous human apolipoprotein E2

knock-in mice, S26948 reduced atherosclerotic lesion surfaces by 46%

compared with controls.

Rosiglitazone had no effect on atherosclerotic lesion size. They add

that this line of research is ongoing with related compounds that are

considered even

more promising, not specifically with S26948. Diabetes 2007;56

11.%% MW - Depomed Says FDA Approves 1000 Mg Strength Tablets of

Glumetza (Reuters) Jan 02 - Depomed Inc said U.S. health regulators have

approved the

1000 mg strength tablets of Glumetza, an extended-release formulation of

metformin, for patients with T2.

The specialty pharmaceutical company said it acquired exclusive US

rights to the 1000 mg formulation of Glumetza in December 2005

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. Definitions -

Dorlands 31st Ed

and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic

educator. Reports are excerpted unless otherwise noted. This project is

done as a

courtesy to the blind/visually impaired and diabetic communities. Dawn

Wilcox Coordinator The Health Library at Vista Center contact above

e-mail or thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

__________ NOD32 2779 (20080109) Information __________

This message was checked by NOD32 antivirus system.

http://www.eset. <http://www.eset.com> com

[Guest guest]

My wife is t2, and a t2 can in fact have a hypoglycemic reaction. A t2 is not

constantly trying to find that balance between food intake and insulin dosages,

but when the affect of their medication causes insulin to react more than

expected, they can have low bg. Harry is t2 I believe, so perhaps he'll jump in

on this one.

Dave

articles

1. ADA - Depression May Lead to Type 2 Diabetes Jan-2-2008

Researchers believe there is a link between chronic depression and the

development of T2DM in adults age 65 years and up. Using responses from

over 4,600

people without diabetes at the outset to the National Institutes of

Health's Center for Epidemiological Studies

Depression Scale, the researchers saw a 50% greater chance of developing

DM during the course of the 10-year study among those noting high

depressive symptoms--even

after accounting for weight and activity levels. They state that

depression has dramatic impacts on the autonomic nervous system, moving

from a resting

state to a responsive state under stress; insulin production is shut

down to handle potential threats when the body is in the responsive

state. Similar

research by Washington University School of Medicine determined that

when adults have both depression and T2, 90% of those experienced

depression first.

News summaries C2007 Information, Inc. Chicago Tribune (12/25/07)

2.%% MW - Habituation of Brain Responses Tied to Unawareness of

Hypoglycemia (Reuters Health) Dec 31 - Attenuation of amygdala and

frontal cortical responses

to low blood glucose concentration may lead to a lack of hypoglycemia

awareness in patients with T1DM. The lead researcher told Reuters Health

that the

studies are early

However, she said, " We think they may have important implications for

people with T1 who have lost their ability to recognize early

hypoglycemia ... and

are therefore at high risk for more severe

hypoglycemia with confusion and even coma. " The team used FDG-labeled

positron emission tomography to examine responses to euglycemia and

hypoglycemia

in 6 patients with hypoglycemia

awareness and 7 without such awareness. FDG uptake was increased in the

left amygdala in hypoglycemia awareness, but not in hypoglycemia

unawareness. The

team also found a " robust increase " bilaterally in the ventral striatum

during hypoglycemia unawareness.

Further analysis indicated bilateral attenuated activation of brain stem

regions and less deactivation in lateral orbitofrontal cortex in

hypoglycemia

unawareness. " The data suggest, that this group of people, perhaps 25%

of people who have had their DM for more than 15 years, have an altered

brain response

to a hypoglycemic episode in which they not only fail to feel that they

are hypoglycemic, but they also fail to generate the brain message that

the hypoglycemia

is unpleasant and dangerous. " In fact, " the message generated may even

be faintly rewarding, which would actually encourage experience of

further hypoglycemia, "

she added. " If this interpretation is correct, we will need to use

additional strategies, such as those currently successful in changing

other patterns

of repeated behavior that are damaging -- for example, smoking and

drinking alcohol -- to help people avoid hypoglycemia long-term, and

recover their awareness

of those occasional episodes that are inevitably part of today's insulin

therapies. " Diabetes 2007;56.

3.%% MW-Sirolimus Stents May Reduce Restenosis in Diabetics With

Coronary Disease (Reuters Health) Jan 04 - Compared with

paclitaxel-eluting stents (PES),

sirolimus-eluting stents (SES) appear to decrease the risk of in-stent

late luminal loss in diabetics with coronary artery disease, new

research shows.

Comparing PES with SES has been difficult since there are so many

individual variables

that contribute to neointimal hyperplasia. In the present study, the

researchers addressed this problem by comparing PES and SES directly in

the same diabetic

patient. [60 patients - 60 lesions were successfully treated with PES

and 60 with SES] On multivariate analysis, the type of drug-eluting

stent was the

only independent

predictor of in-stent late luminal loss. Specifically, in-stent late

luminal loss [loss of the open area in vessel] was 2.3-times more likely

when a PES

rather than a SES was used. Further research is needed to determine if

the better angiographic results achieved

with SES actually translate into long-term clinical benefits, the

authors conclude. Diabetes Care 2008;31.

4.%% MW - Retinopathy Linked to Subclinical Coronary Artery Disease

Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 03 - Retinal

microvascular

changes are associated with increased coronary artery calcification

(CAC), an indicator of subclinical coronary macrovascular disease,

findings from the

prospective Multi-Ethnic Study of Atherosclerosis (MESA) suggest. [6,000

subjects age 45 -84 years without a history of clinical cardiovascular

disease.

They underwent chest computed tomography to measure

coronary artery calcification and fundus photography to assess retinal

disease. Retinopathy was defined as the presence of microaneurysms,

hemorrhages,

cotton wool spots, intraretinal microvascular abnormalities, hard

exudates, venous beading or

new vessels. CAC was present in about half of the subjects. Retinopathy

was present in 14.3% of subjects with no CAC, 17.2% of subjects with

mild CAC,

and 20.8% of those with moderate to severe CAC. " The association between

retinopathy and moderate-to-severe CAC was present in all ethnic groups

and remained

significant in both men and women and in persons with and without

diabetes or hypertension, " the investigators found. They conclude that

" common pathophysiologic

processes may underlie both microvascular

and macrovascular disease. " Specifically, they suggest that " retinopathy

signs ...reflect generalized endothelial dysfunction, which in the

coronary circulation

may promote atherogenesis. "

" Inflammatory factors may also be involved " when patients without

hypertension or diabetes, and with generally low cardiovascular risk

profiles, present

with retinopathy and coronary artery calcification, h. " As yet, there

are no direct clinical implications from our study, " the ophthalmologist

researcher

said, " but physicians and patients should be aware that these conditions

are related. . patients with retinopathy may be at higher risk of both

subclinical

heart disease and clinical heart disease, such as heart failure. " On the

other hand, retinopathy is reversible..Reversal may occur in 3 years and

is associated

with lower BP and glucose levels, higher physical activity, and less

obesity, " he said. " It is possible, but not proven, that reversal is

associated with

lower risk of cardiovascular disease. " the team is

now evaluating the value of adding a retinal examination to a coronary

calcium CT scan for predicting cardiovascular disease.

Am J Epidemiol 2008;167:

5.%% MW - Alpha-Linolenic Acid May Lower Risk of Diabetic Peripheral

Neuropathy Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 07 -

Dietary intake

of alpha-linolenic acid was associated with reduced incidence of

diabetic peripheral neuropathy in a new analysis of data from the

National Health and

Nutrition Examination Survey (NHANES) 1999-2004. Alpha-linolenic acid is

an omega-3 fatty acid found in many vegetable oils, including flaxseed,

walnuts,

and canola oil. The researchers identified 1062 diabetics age 40 and

older for whom complete 24-hour dietary recall data were recorded.

Peripheral neuropathy

had been assessed using a nylon monofilament at three plantar sites on

each foot to test for sensation.

Dr. Eberhardt's group calculated the intake of total polyunsaturated

fatty acids and of seven specific fatty acids. In multivariate analyses,

they adjusted

for age, sex, race, education, height, weight, diabetes duration,

glycemic control, hypertension, smoking, and total

calorie intake. Relative to adults in the lowest quintile [fifth] of

alpha-linolenic acid intake the odds of having peripheral neuropathy was

0.54 for

subjects in the fourth quintile (1.35 - 2.10 g/day) of intake and 0.40

for adults in the fifth quintile (2.11 g/day or higher). High dietary

intake of

alpha-linolenic acid is associated with reduced risk of vascular disease

(coronary heart disease and hypertension), the team points out. " The

protective

effect of alpha-linolenic acid on macrovascular diseases and its

association with diabetic peripheral neuropathy may be due to a similar

biological mechanism. "

They recommend further study to verify a protective effect of

alpha-linolenic acid in patients with diabetes. Diabetes Care 2008;31.

6.%% MW-Fitness, Fatness, and Cardiovascular Risk Factors in Type 2

Diabetes: Look AHEAD Study Med Sci Sports Exerc. 2007;39(12) C2007

American College

of Sports Medicine 01/03/2008

Purpose: Most studies comparing the effects of fitness and fatness on

cardiovascular (CVD) risk have been done with young, healthy

participants with low

rates of obesity and high levels of fitness. The present study examined

the association of cardiorespiratory fitness and obesity with CVD risk

factors

in an ethnically diverse sample of overweight/obese individuals with

T2DM. [ Baseline data from Look AHEAD, 5145 overweight or obese

individuals with T2]..Among

the CVD risk factors, we examined continuous outcomes such as HbA1c,

HDL, LDL, triglycerides, SBP, diastolic blood pressure (DBP), ABI, and

1-yr CVD risk

estimate using the Framingham risk prediction equation. . At entry into

the study, participants averaged 58.7 and had a DM duration of 6.8. 60%

were women;

63.2% were white, 15.7% were African American, 13.2% Hispanic, 5.0%

Native American, and 1.0% Asian American. In conclusion, this study

shows that fitness

and fatness are highly associated; thus, it is unusual to find

individuals who are obese, yet very fit. Moreover, both fitness and

fatness are related

to CVD risk factors, although the strength of the associations for

fitness versus fatness differed for specific risk factors. Of particular

note is the

strong association of fitness with HbA1c, ABI, and Framingham risk score

in this population, and the relationships of BMI with SBP. Look AHEAD is

an ongoing

trial; it is expected to last through the year 2012. Half of the

participants are receiving intensive lifestyle intervention, and half

receive diabetes

education and support. Changes in weight, fitness, and CVD risk factors

are measured periodically throughout the study; the primary outcome

measure is

CVD morbidity and mortality.

7.%% MW - Imaging to Assess Effect of Medical Therapy in Patients With

Diabetes Mellitus Br J Diabetes Vasc Dis. 2007;7(4): 01/02/2008

Abstract - The incidence of T2DM is rapidly increasing throughout the

world. As an independent risk factor for cardiovascular disease both at

the microvascular

and macrovascular level, DM is a condition that deserves the most

aggressive medical management... invasive techniques have been

extensively used to assess

coronary atherosclerosis progression and drug efficacy in the general

population and smaller subsets of DM patients. While even minimal

luminal stenosis

reduction was associated with very significant reduction in event rates

in the general population, similar data are lacking in DM patients.

Although sensitive,

an obvious limitation of these techniques is their invasive nature and

the radiation exposure, besides a very considerable operational cost.

Hence, additional non-invasive imaging techniques have been adopted to

assess plaque progression or its haemodynamic effects in diabetic

patients. Carotid

Intima Media Thickness - Two decades ago investigators showed that the

thickness of the carotid wall (intima and media layer taken together)

measured ultrasonographically

was associated with the presence and extent of atherosclerosis of the

aorta..several randomised and epidemiological studies clearly proved the

value of

the cIMT as a marker of CV risk. An increased cIMT has been associated

with risk of MI and CVA in the elderly (> 65 years)

as well as younger age groups. cIMT is a marker of atherosclerosis

burden rather than a surrogate for obstructive CAD. Insulin resistance

alone in the

absence of clinical diabetes has been associated with an increased

cIMT.. Furthermore, cIMT appears to progress faster in diabetic patients

than in all

other patients.

Medical Interventions -Measurement of cIMT progression has been utilised

to assess efficacy of medical therapy in several studies in DM patients.

A short-

and a long-term follow-up study of 1,229 T1DM patients randomised to

either standard or intensive glucose-reducing therapy, compared cIMT

progression in

diabetes with that of age and sex-matched non-diabetic

individuals...cIMT progression was not different at the end of the first

year of follow-up between

controls and patients receiving intensive and standard therapy, but it

was significantly greater in the diabetic than control subjects at the

end of 6.5

years of follow-up. Coronary Artery Calcium - Coronary artery calcium is

deposited in the atherosclerotic milieu as the plaque develops via

active mechanisms

resembling bone formation. . it has been shown that there is an

excellent correlation(r=0.98) between CAC measured on CCT and

atherosclerotic plaque area.

Whether CAC imaging adds prognostic information in diabetes mellitus

remains unclear. Hypertension and several nontraditional CV risk

factors have been

associated with CAC progression in DM subjects. .. Additionally, a

greater proportion of DM than non-diabetic patients developed CAC during

follow-up if

no CAC was present at baseline (42% vs. 25%. Finally, as reported in

the general population, CAC progression was linked with adverse coronary

events during

follow-up. .DM patients who suffered a MI during follow-up demonstrated

a 4-fold and 2.5-fold greater CAC progression than non-diabetic subjects

receiving

and not receiving statins, respectively. CAC imaging appears to be a

reliable means to assess risk connected with subclinical atherosclerosis

in the general

population, although some debate remains in diabetic patients.

Functional Imaging - Various forms of nuclear myocardial perfusion

imaging have been utilised

in DM patients to assess the effect of glycaemic metabolism on vascular

function. Indeed, data suggest that coronary vasomotor abnormalities

accompany

glucose metabolism impairment and that vascular function deteriorates

with increasing severity of insulin-resistance and glucose intolerance.

Summary -

The existing evidence suggests that many modern imaging modalities may

be utilised to monitor the effectiveness of medical therapy for diabetes

on the

CV system. Indeed, almost all surrogate markers of atherosclerosis have

been studied in diabetic patients and have shown some validity for this

purpose.

However, many of the reported differences were very small, some were

obtained with invasive techniques and many implied exposure to

radiation. Finally,

very little evidence has so far linked the occurrence of events to the

progression of these markers of disease. Hence, future appropriately

powered studies

should focus on whether reducing plaque progression and restoring

vascular vasomotor activity translate into a significant improvement of

CV morbidity

and mortality in diabetes mellitus.

8.%% Type 2 Diabetes -- Insulin Therapy Initiating Insulin in the Type

2 Diabetes Patient Medscape Diabetes & Endocrinology. 2007; C2007

Medscape 12/28/2007

Introduction - T2DM is a progressive disease, and most patients will

eventually need insulin to achieve euglycemia.[normal blood sugar level]

Furthermore,

data have shown that early and aggressive

intervention to lower blood glucose reduces the risk of complications of

the disease. However, even with the ever-growing list of new medications

available,

it can be a daunting task for healthcare providers to decide which

treatment regimen is appropriate

to manage a particular patient. New guidelines and algorithms can help

determine which patients with type 2 diabetes should be started on

insulin and when

insulin should be initiated. The goals of insulin therapy are the same

as the goals of any therapy for the treatment

of diabetes: to achieve optimal glycemic control without causing undue

hypoglycemia or excessive weight gain and to minimize the impact on

lifestyle.

The Challenges of Insulin Therapy

Psychological insulin resistance is a real phenomenon. Individuals with

diabetes often feel that insulin is the beginning of the end. They fear

taking

the injection and feel that there is a stigma associated with insulin.

Insulin therapy can, in fact, be a real pain both literally and

figuratively. It

is intrusive, can limit spontaneity, and can interfere with daily

activities. As a consequence, adhering to an insulin regimen has been

difficult for many

patients. Because symptom severity is not indicative of disease

severity, many individuals do not understand the need for optimal

glycemic control or its

role in preventing complications. This lack of understanding can also

result in significant resistance as well as decreased adherence once

patients do

agree to begin insulin. That nonadherence will most likely carry over to

other parts of diabetes management, such as blood glucose testing. In

addition,

individuals fear that they will experience hypoglycemia and gain weight.

To top it off, there is the inconvenience and the disruption of daily

routines

and privacy.

Providers, on the other hand, also experience psychological resistance

to insulin therapy. They also may fear hypoglycemia and have concern for

their patients'

safety. In patients who already have a weight issue, the risk of gaining

weight adds to the complexity of the decision to initiate insulin. All

this, combined

with the time it takes to educate the patient and titrate the dose, adds

up to a lot of work. Teaming up with a diabetes educator who is

knowledgeable

in diabetes and insulin management can help alleviate this workload.

However, even if this resource is not available, simple algorithms and

titration schedules

make initiation and titration of insulin easier.

9.%% MW -Blood Pressure and Risk of Developing Type 2 Diabetes Mellitus:

The Women's Health Study Eur Heart J. 2007;28(23) C2007 Oxford

University Press

01/02/2008 Abstract Aims: To examine the relationship of blood

pressure (BP) and BP progression with the subsequent development of

T2DM. [ prospective

cohort study among 38 172 women free of DM and cardiovascular disease at

baseline. Women were classified into four categories according to

self-reported

baseline BP] During 10.2 years of follow-up, 1672 women developed

T2. Conclusion - Our study provides strong evidence that baseline BP and

BP progression are associated with an increased risk of incident T2.

Clinicians

should be aware of these relationships to optimize the management of

patients at increased risk for cardiovascular disease.

10.%% MW - New PPAR-Gamma Modulator Has Potent Antidiabetes and

Antiatherogenic Effects Reuters Health Information 2007. (Reuters

Health) Dec 28 - A new

specific peroxisome proliferator-activated receptor (PPAR) modulator

has demonstrated promise in a French in vitro and in vivo study of

mice.The researchers

note that the thiazolidinedione (TZD) class of drugs, although

effective and widely used to treat T2 tends to cause weight gain. This

study was undertaken

to evaluate S26948, a novel ligand for PPAR-gamma. The study found that

S26948 is a specific high-affinity agonist for PPAR-gamma, binding it

with the

same affinity as the TZD rosiglitazone does. Further, the results

suggest that S26948 promoted a PPAR-gamma conformation distinct from

that elicited by

rosiglitazone. In addition, [it] decreased blood glucose levels and

plasma insulin levels in male ob/ob mice, indicating that the drug

increased insulin

sensitivity, paralleling the effects of rosiglitazone treatment. Results

showed that the agent did not promote body- weight gain in the diabetic

mice.

Instead, the S26948-treated mice gained less weight than the controls,

indicating " a profoundly decreased food efficiency, " the authors write.

They concluded

that S26948's pattern of coactivator recruitment, which differs from

that of rosiglitazone, decreases its adipogenic capacity compared with

rosiglitazone. In a cohort of homozygous human apolipoprotein E2

knock-in mice, S26948 reduced atherosclerotic lesion surfaces by 46%

compared with controls.

Rosiglitazone had no effect on atherosclerotic lesion size. They add

that this line of research is ongoing with related compounds that are

considered even

more promising, not specifically with S26948. Diabetes 2007;56

11.%% MW - Depomed Says FDA Approves 1000 Mg Strength Tablets of

Glumetza (Reuters) Jan 02 - Depomed Inc said U.S. health regulators have

approved the

1000 mg strength tablets of Glumetza, an extended-release formulation of

metformin, for patients with T2.

The specialty pharmaceutical company said it acquired exclusive US

rights to the 1000 mg formulation of Glumetza in December 2005

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. Definitions -

Dorlands 31st Ed

and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic

educator. Reports are excerpted unless otherwise noted. This project is

done as a

courtesy to the blind/visually impaired and diabetic communities. Dawn

Wilcox Coordinator The Health Library at Vista Center contact above

e-mail or thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

__________ NOD32 2779 (20080109) Information __________

This message was checked by NOD32 antivirus system.

http://www.eset. <http://www.eset.com> com

[Guest guest]

I am a type 2 diabetic, and if my sugar levels get to low, I find that I start

to shake and feel very weak. I am pleased to say, I don't get those feelings

very often.

Rowe

articles

1. ADA - Depression May Lead to Type 2 Diabetes Jan-2-2008

Researchers believe there is a link between chronic depression and the

development of T2DM in adults age 65 years and up. Using responses from

over 4,600

people without diabetes at the outset to the National Institutes of

Health's Center for Epidemiological Studies

Depression Scale, the researchers saw a 50% greater chance of developing

DM during the course of the 10-year study among those noting high

depressive symptoms--even

after accounting for weight and activity levels. They state that

depression has dramatic impacts on the autonomic nervous system, moving

from a resting

state to a responsive state under stress; insulin production is shut

down to handle potential threats when the body is in the responsive

state. Similar

research by Washington University School of Medicine determined that

when adults have both depression and T2, 90% of those experienced

depression first.

News summaries C2007 Information, Inc. Chicago Tribune (12/25/07)

2.%% MW - Habituation of Brain Responses Tied to Unawareness of

Hypoglycemia (Reuters Health) Dec 31 - Attenuation of amygdala and

frontal cortical responses

to low blood glucose concentration may lead to a lack of hypoglycemia

awareness in patients with T1DM. The lead researcher told Reuters Health

that the

studies are early

However, she said, " We think they may have important implications for

people with T1 who have lost their ability to recognize early

hypoglycemia ... and

are therefore at high risk for more severe

hypoglycemia with confusion and even coma. " The team used FDG-labeled

positron emission tomography to examine responses to euglycemia and

hypoglycemia

in 6 patients with hypoglycemia

awareness and 7 without such awareness. FDG uptake was increased in the

left amygdala in hypoglycemia awareness, but not in hypoglycemia

unawareness. The

team also found a " robust increase " bilaterally in the ventral striatum

during hypoglycemia unawareness.

Further analysis indicated bilateral attenuated activation of brain stem

regions and less deactivation in lateral orbitofrontal cortex in

hypoglycemia

unawareness. " The data suggest, that this group of people, perhaps 25%

of people who have had their DM for more than 15 years, have an altered

brain response

to a hypoglycemic episode in which they not only fail to feel that they

are hypoglycemic, but they also fail to generate the brain message that

the hypoglycemia

is unpleasant and dangerous. " In fact, " the message generated may even

be faintly rewarding, which would actually encourage experience of

further hypoglycemia, "

she added. " If this interpretation is correct, we will need to use

additional strategies, such as those currently successful in changing

other patterns

of repeated behavior that are damaging -- for example, smoking and

drinking alcohol -- to help people avoid hypoglycemia long-term, and

recover their awareness

of those occasional episodes that are inevitably part of today's insulin

therapies. " Diabetes 2007;56.

3.%% MW-Sirolimus Stents May Reduce Restenosis in Diabetics With

Coronary Disease (Reuters Health) Jan 04 - Compared with

paclitaxel-eluting stents (PES),

sirolimus-eluting stents (SES) appear to decrease the risk of in-stent

late luminal loss in diabetics with coronary artery disease, new

research shows.

Comparing PES with SES has been difficult since there are so many

individual variables

that contribute to neointimal hyperplasia. In the present study, the

researchers addressed this problem by comparing PES and SES directly in

the same diabetic

patient. [60 patients - 60 lesions were successfully treated with PES

and 60 with SES] On multivariate analysis, the type of drug-eluting

stent was the

only independent

predictor of in-stent late luminal loss. Specifically, in-stent late

luminal loss [loss of the open area in vessel] was 2.3-times more likely

when a PES

rather than a SES was used. Further research is needed to determine if

the better angiographic results achieved

with SES actually translate into long-term clinical benefits, the

authors conclude. Diabetes Care 2008;31.

4.%% MW - Retinopathy Linked to Subclinical Coronary Artery Disease

Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 03 - Retinal

microvascular

changes are associated with increased coronary artery calcification

(CAC), an indicator of subclinical coronary macrovascular disease,

findings from the

prospective Multi-Ethnic Study of Atherosclerosis (MESA) suggest. [6,000

subjects age 45 -84 years without a history of clinical cardiovascular

disease.

They underwent chest computed tomography to measure

coronary artery calcification and fundus photography to assess retinal

disease. Retinopathy was defined as the presence of microaneurysms,

hemorrhages,

cotton wool spots, intraretinal microvascular abnormalities, hard

exudates, venous beading or

new vessels. CAC was present in about half of the subjects. Retinopathy

was present in 14.3% of subjects with no CAC, 17.2% of subjects with

mild CAC,

and 20.8% of those with moderate to severe CAC. " The association between

retinopathy and moderate-to-severe CAC was present in all ethnic groups

and remained

significant in both men and women and in persons with and without

diabetes or hypertension, " the investigators found. They conclude that

" common pathophysiologic

processes may underlie both microvascular

and macrovascular disease. " Specifically, they suggest that " retinopathy

signs ...reflect generalized endothelial dysfunction, which in the

coronary circulation

may promote atherogenesis. "

" Inflammatory factors may also be involved " when patients without

hypertension or diabetes, and with generally low cardiovascular risk

profiles, present

with retinopathy and coronary artery calcification, h. " As yet, there

are no direct clinical implications from our study, " the ophthalmologist

researcher

said, " but physicians and patients should be aware that these conditions

are related. . patients with retinopathy may be at higher risk of both

subclinical

heart disease and clinical heart disease, such as heart failure. " On the

other hand, retinopathy is reversible..Reversal may occur in 3 years and

is associated

with lower BP and glucose levels, higher physical activity, and less

obesity, " he said. " It is possible, but not proven, that reversal is

associated with

lower risk of cardiovascular disease. " the team is

now evaluating the value of adding a retinal examination to a coronary

calcium CT scan for predicting cardiovascular disease.

Am J Epidemiol 2008;167:

5.%% MW - Alpha-Linolenic Acid May Lower Risk of Diabetic Peripheral

Neuropathy Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 07 -

Dietary intake

of alpha-linolenic acid was associated with reduced incidence of

diabetic peripheral neuropathy in a new analysis of data from the

National Health and

Nutrition Examination Survey (NHANES) 1999-2004. Alpha-linolenic acid is

an omega-3 fatty acid found in many vegetable oils, including flaxseed,

walnuts,

and canola oil. The researchers identified 1062 diabetics age 40 and

older for whom complete 24-hour dietary recall data were recorded.

Peripheral neuropathy

had been assessed using a nylon monofilament at three plantar sites on

each foot to test for sensation.

Dr. Eberhardt's group calculated the intake of total polyunsaturated

fatty acids and of seven specific fatty acids. In multivariate analyses,

they adjusted

for age, sex, race, education, height, weight, diabetes duration,

glycemic control, hypertension, smoking, and total

calorie intake. Relative to adults in the lowest quintile [fifth] of

alpha-linolenic acid intake the odds of having peripheral neuropathy was

0.54 for

subjects in the fourth quintile (1.35 - 2.10 g/day) of intake and 0.40

for adults in the fifth quintile (2.11 g/day or higher). High dietary

intake of

alpha-linolenic acid is associated with reduced risk of vascular disease

(coronary heart disease and hypertension), the team points out. " The

protective

effect of alpha-linolenic acid on macrovascular diseases and its

association with diabetic peripheral neuropathy may be due to a similar

biological mechanism. "

They recommend further study to verify a protective effect of

alpha-linolenic acid in patients with diabetes. Diabetes Care 2008;31.

6.%% MW-Fitness, Fatness, and Cardiovascular Risk Factors in Type 2

Diabetes: Look AHEAD Study Med Sci Sports Exerc. 2007;39(12) C2007

American College

of Sports Medicine 01/03/2008

Purpose: Most studies comparing the effects of fitness and fatness on

cardiovascular (CVD) risk have been done with young, healthy

participants with low

rates of obesity and high levels of fitness. The present study examined

the association of cardiorespiratory fitness and obesity with CVD risk

factors

in an ethnically diverse sample of overweight/obese individuals with

T2DM. [ Baseline data from Look AHEAD, 5145 overweight or obese

individuals with T2]..Among

the CVD risk factors, we examined continuous outcomes such as HbA1c,

HDL, LDL, triglycerides, SBP, diastolic blood pressure (DBP), ABI, and

1-yr CVD risk

estimate using the Framingham risk prediction equation. . At entry into

the study, participants averaged 58.7 and had a DM duration of 6.8. 60%

were women;

63.2% were white, 15.7% were African American, 13.2% Hispanic, 5.0%

Native American, and 1.0% Asian American. In conclusion, this study

shows that fitness

and fatness are highly associated; thus, it is unusual to find

individuals who are obese, yet very fit. Moreover, both fitness and

fatness are related

to CVD risk factors, although the strength of the associations for

fitness versus fatness differed for specific risk factors. Of particular

note is the

strong association of fitness with HbA1c, ABI, and Framingham risk score

in this population, and the relationships of BMI with SBP. Look AHEAD is

an ongoing

trial; it is expected to last through the year 2012. Half of the

participants are receiving intensive lifestyle intervention, and half

receive diabetes

education and support. Changes in weight, fitness, and CVD risk factors

are measured periodically throughout the study; the primary outcome

measure is

CVD morbidity and mortality.

7.%% MW - Imaging to Assess Effect of Medical Therapy in Patients With

Diabetes Mellitus Br J Diabetes Vasc Dis. 2007;7(4): 01/02/2008

Abstract - The incidence of T2DM is rapidly increasing throughout the

world. As an independent risk factor for cardiovascular disease both at

the microvascular

and macrovascular level, DM is a condition that deserves the most

aggressive medical management... invasive techniques have been

extensively used to assess

coronary atherosclerosis progression and drug efficacy in the general

population and smaller subsets of DM patients. While even minimal

luminal stenosis

reduction was associated with very significant reduction in event rates

in the general population, similar data are lacking in DM patients.

Although sensitive,

an obvious limitation of these techniques is their invasive nature and

the radiation exposure, besides a very considerable operational cost.

Hence, additional non-invasive imaging techniques have been adopted to

assess plaque progression or its haemodynamic effects in diabetic

patients. Carotid

Intima Media Thickness - Two decades ago investigators showed that the

thickness of the carotid wall (intima and media layer taken together)

measured ultrasonographically

was associated with the presence and extent of atherosclerosis of the

aorta..several randomised and epidemiological studies clearly proved the

value of

the cIMT as a marker of CV risk. An increased cIMT has been associated

with risk of MI and CVA in the elderly (> 65 years)

as well as younger age groups. cIMT is a marker of atherosclerosis

burden rather than a surrogate for obstructive CAD. Insulin resistance

alone in the

absence of clinical diabetes has been associated with an increased

cIMT.. Furthermore, cIMT appears to progress faster in diabetic patients

than in all

other patients.

Medical Interventions -Measurement of cIMT progression has been utilised

to assess efficacy of medical therapy in several studies in DM patients.

A short-

and a long-term follow-up study of 1,229 T1DM patients randomised to

either standard or intensive glucose-reducing therapy, compared cIMT

progression in

diabetes with that of age and sex-matched non-diabetic

individuals...cIMT progression was not different at the end of the first

year of follow-up between

controls and patients receiving intensive and standard therapy, but it

was significantly greater in the diabetic than control subjects at the

end of 6.5

years of follow-up. Coronary Artery Calcium - Coronary artery calcium is

deposited in the atherosclerotic milieu as the plaque develops via

active mechanisms

resembling bone formation. . it has been shown that there is an

excellent correlation(r=0.98) between CAC measured on CCT and

atherosclerotic plaque area.

Whether CAC imaging adds prognostic information in diabetes mellitus

remains unclear. Hypertension and several nontraditional CV risk

factors have been

associated with CAC progression in DM subjects. .. Additionally, a

greater proportion of DM than non-diabetic patients developed CAC during

follow-up if

no CAC was present at baseline (42% vs. 25%. Finally, as reported in

the general population, CAC progression was linked with adverse coronary

events during

follow-up. .DM patients who suffered a MI during follow-up demonstrated

a 4-fold and 2.5-fold greater CAC progression than non-diabetic subjects

receiving

and not receiving statins, respectively. CAC imaging appears to be a

reliable means to assess risk connected with subclinical atherosclerosis

in the general

population, although some debate remains in diabetic patients.

Functional Imaging - Various forms of nuclear myocardial perfusion

imaging have been utilised

in DM patients to assess the effect of glycaemic metabolism on vascular

function. Indeed, data suggest that coronary vasomotor abnormalities

accompany

glucose metabolism impairment and that vascular function deteriorates

with increasing severity of insulin-resistance and glucose intolerance.

Summary -

The existing evidence suggests that many modern imaging modalities may

be utilised to monitor the effectiveness of medical therapy for diabetes

on the

CV system. Indeed, almost all surrogate markers of atherosclerosis have

been studied in diabetic patients and have shown some validity for this

purpose.

However, many of the reported differences were very small, some were

obtained with invasive techniques and many implied exposure to

radiation. Finally,

very little evidence has so far linked the occurrence of events to the

progression of these markers of disease. Hence, future appropriately

powered studies

should focus on whether reducing plaque progression and restoring

vascular vasomotor activity translate into a significant improvement of

CV morbidity

and mortality in diabetes mellitus.

8.%% Type 2 Diabetes -- Insulin Therapy Initiating Insulin in the Type

2 Diabetes Patient Medscape Diabetes & Endocrinology. 2007; C2007

Medscape 12/28/2007

Introduction - T2DM is a progressive disease, and most patients will

eventually need insulin to achieve euglycemia.[normal blood sugar level]

Furthermore,

data have shown that early and aggressive

intervention to lower blood glucose reduces the risk of complications of

the disease. However, even with the ever-growing list of new medications

available,

it can be a daunting task for healthcare providers to decide which

treatment regimen is appropriate

to manage a particular patient. New guidelines and algorithms can help

determine which patients with type 2 diabetes should be started on

insulin and when

insulin should be initiated. The goals of insulin therapy are the same

as the goals of any therapy for the treatment

of diabetes: to achieve optimal glycemic control without causing undue

hypoglycemia or excessive weight gain and to minimize the impact on

lifestyle.

The Challenges of Insulin Therapy

Psychological insulin resistance is a real phenomenon. Individuals with

diabetes often feel that insulin is the beginning of the end. They fear

taking

the injection and feel that there is a stigma associated with insulin.

Insulin therapy can, in fact, be a real pain both literally and

figuratively. It

is intrusive, can limit spontaneity, and can interfere with daily

activities. As a consequence, adhering to an insulin regimen has been

difficult for many

patients. Because symptom severity is not indicative of disease

severity, many individuals do not understand the need for optimal

glycemic control or its

role in preventing complications. This lack of understanding can also

result in significant resistance as well as decreased adherence once

patients do

agree to begin insulin. That nonadherence will most likely carry over to

other parts of diabetes management, such as blood glucose testing. In

addition,

individuals fear that they will experience hypoglycemia and gain weight.

To top it off, there is the inconvenience and the disruption of daily

routines

and privacy.

Providers, on the other hand, also experience psychological resistance

to insulin therapy. They also may fear hypoglycemia and have concern for

their patients'

safety. In patients who already have a weight issue, the risk of gaining

weight adds to the complexity of the decision to initiate insulin. All

this, combined

with the time it takes to educate the patient and titrate the dose, adds

up to a lot of work. Teaming up with a diabetes educator who is

knowledgeable

in diabetes and insulin management can help alleviate this workload.

However, even if this resource is not available, simple algorithms and

titration schedules

make initiation and titration of insulin easier.

9.%% MW -Blood Pressure and Risk of Developing Type 2 Diabetes Mellitus:

The Women's Health Study Eur Heart J. 2007;28(23) C2007 Oxford

University Press

01/02/2008 Abstract Aims: To examine the relationship of blood

pressure (BP) and BP progression with the subsequent development of

T2DM. [ prospective

cohort study among 38 172 women free of DM and cardiovascular disease at

baseline. Women were classified into four categories according to

self-reported

baseline BP] During 10.2 years of follow-up, 1672 women developed

T2. Conclusion - Our study provides strong evidence that baseline BP and

BP progression are associated with an increased risk of incident T2.

Clinicians

should be aware of these relationships to optimize the management of

patients at increased risk for cardiovascular disease.

10.%% MW - New PPAR-Gamma Modulator Has Potent Antidiabetes and

Antiatherogenic Effects Reuters Health Information 2007. (Reuters

Health) Dec 28 - A new

specific peroxisome proliferator-activated receptor (PPAR) modulator

has demonstrated promise in a French in vitro and in vivo study of

mice.The researchers

note that the thiazolidinedione (TZD) class of drugs, although

effective and widely used to treat T2 tends to cause weight gain. This

study was undertaken

to evaluate S26948, a novel ligand for PPAR-gamma. The study found that

S26948 is a specific high-affinity agonist for PPAR-gamma, binding it

with the

same affinity as the TZD rosiglitazone does. Further, the results

suggest that S26948 promoted a PPAR-gamma conformation distinct from

that elicited by

rosiglitazone. In addition, [it] decreased blood glucose levels and

plasma insulin levels in male ob/ob mice, indicating that the drug

increased insulin

sensitivity, paralleling the effects of rosiglitazone treatment. Results

showed that the agent did not promote body- weight gain in the diabetic

mice.

Instead, the S26948-treated mice gained less weight than the controls,

indicating " a profoundly decreased food efficiency, " the authors write.

They concluded

that S26948's pattern of coactivator recruitment, which differs from

that of rosiglitazone, decreases its adipogenic capacity compared with

rosiglitazone. In a cohort of homozygous human apolipoprotein E2

knock-in mice, S26948 reduced atherosclerotic lesion surfaces by 46%

compared with controls.

Rosiglitazone had no effect on atherosclerotic lesion size. They add

that this line of research is ongoing with related compounds that are

considered even

more promising, not specifically with S26948. Diabetes 2007;56

11.%% MW - Depomed Says FDA Approves 1000 Mg Strength Tablets of

Glumetza (Reuters) Jan 02 - Depomed Inc said U.S. health regulators have

approved the

1000 mg strength tablets of Glumetza, an extended-release formulation of

metformin, for patients with T2.

The specialty pharmaceutical company said it acquired exclusive US

rights to the 1000 mg formulation of Glumetza in December 2005

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. Definitions -

Dorlands 31st Ed

and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic

educator. Reports are excerpted unless otherwise noted. This project is

done as a

courtesy to the blind/visually impaired and diabetic communities. Dawn

Wilcox Coordinator The Health Library at Vista Center contact above

e-mail or thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

__________ NOD32 2779 (20080109) Information __________

This message was checked by NOD32 antivirus system.

http://www.eset. <http://www.eset.com> com

[Guest guest]

From what I understand type 2s on medication can have lows, but they tend to not

be as severe as in those with type 1. Even type 2s on insulin seem to have less

of a problem with sudden, severe lows from what I have read, for some reason. I

could be wrong on this so I'd be interested to hear what those with type 2 on

the list have to say.

You would know you are experiencing lows if you have symptoms of hypoglycemia

(shakiness, sweatiness, dizziness, hunger, headache, concentration and

coordination difficulties, in severe cases loss of consciousness and seizures)

and if your blood sugar tested low at this time. I always test when I feel low

because sometimes I'm actually high, so never just assume you are low and treat

unless it is an emergency.

Jen

[Guest guest]

Way back when I was just on oral meds, I use to have low sugar reactions on my

glyburide 5mg. per day. I would especially get the shakes and sweats after

swimming a mile in the pool. I still get low sugar reactions now that I am

insulin dependent. Fortunately, I get the warnings of the low sugar reaction,

and doing a bs test usually confirms that a low sugar reaction is exactly what I

am having. My wife says I am having a low sugar reaction when I become

argumentative, irritable, and a bs test usually proves she is right.

When I have a low sugar reaction a four gram candy pepermint usually cures it or

a four or five gram chocolate bar will do the same. It is always wise to test

to see if this is the case in a low sugar reaction. Unfortunately, some Type

1's do not have a warning of the low sugar reaction. A niece of mine had a low

sugar reaction while driving her car, and she wound up driving the car into her

neighbor's house. Fortunately, she did not get injured. It only cost her

several thousands of dollars to get the house and the car repaired.

articles

1. ADA - Depression May Lead to Type 2 Diabetes Jan-2-2008

Researchers believe there is a link between chronic depression and the

development of T2DM in adults age 65 years and up. Using responses from

over 4,600

people without diabetes at the outset to the National Institutes of

Health's Center for Epidemiological Studies

Depression Scale, the researchers saw a 50% greater chance of developing

DM during the course of the 10-year study among those noting high

depressive symptoms--even

after accounting for weight and activity levels. They state that

depression has dramatic impacts on the autonomic nervous system, moving

from a resting

state to a responsive state under stress; insulin production is shut

down to handle potential threats when the body is in the responsive

state. Similar

research by Washington University School of Medicine determined that

when adults have both depression and T2, 90% of those experienced

depression first.

News summaries C2007 Information, Inc. Chicago Tribune (12/25/07)

2.%% MW - Habituation of Brain Responses Tied to Unawareness of

Hypoglycemia (Reuters Health) Dec 31 - Attenuation of amygdala and

frontal cortical responses

to low blood glucose concentration may lead to a lack of hypoglycemia

awareness in patients with T1DM. The lead researcher told Reuters Health

that the

studies are early

However, she said, " We think they may have important implications for

people with T1 who have lost their ability to recognize early

hypoglycemia ... and

are therefore at high risk for more severe

hypoglycemia with confusion and even coma. " The team used FDG-labeled

positron emission tomography to examine responses to euglycemia and

hypoglycemia

in 6 patients with hypoglycemia

awareness and 7 without such awareness. FDG uptake was increased in the

left amygdala in hypoglycemia awareness, but not in hypoglycemia

unawareness. The

team also found a " robust increase " bilaterally in the ventral striatum

during hypoglycemia unawareness.

Further analysis indicated bilateral attenuated activation of brain stem

regions and less deactivation in lateral orbitofrontal cortex in

hypoglycemia

unawareness. " The data suggest, that this group of people, perhaps 25%

of people who have had their DM for more than 15 years, have an altered

brain response

to a hypoglycemic episode in which they not only fail to feel that they

are hypoglycemic, but they also fail to generate the brain message that

the hypoglycemia

is unpleasant and dangerous. " In fact, " the message generated may even

be faintly rewarding, which would actually encourage experience of

further hypoglycemia, "

she added. " If this interpretation is correct, we will need to use

additional strategies, such as those currently successful in changing

other patterns

of repeated behavior that are damaging -- for example, smoking and

drinking alcohol -- to help people avoid hypoglycemia long-term, and

recover their awareness

of those occasional episodes that are inevitably part of today's insulin

therapies. " Diabetes 2007;56.

3.%% MW-Sirolimus Stents May Reduce Restenosis in Diabetics With

Coronary Disease (Reuters Health) Jan 04 - Compared with

paclitaxel-eluting stents (PES),

sirolimus-eluting stents (SES) appear to decrease the risk of in-stent

late luminal loss in diabetics with coronary artery disease, new

research shows.

Comparing PES with SES has been difficult since there are so many

individual variables

that contribute to neointimal hyperplasia. In the present study, the

researchers addressed this problem by comparing PES and SES directly in

the same diabetic

patient. [60 patients - 60 lesions were successfully treated with PES

and 60 with SES] On multivariate analysis, the type of drug-eluting

stent was the

only independent

predictor of in-stent late luminal loss. Specifically, in-stent late

luminal loss [loss of the open area in vessel] was 2.3-times more likely

when a PES

rather than a SES was used. Further research is needed to determine if

the better angiographic results achieved

with SES actually translate into long-term clinical benefits, the

authors conclude. Diabetes Care 2008;31.

4.%% MW - Retinopathy Linked to Subclinical Coronary Artery Disease

Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 03 - Retinal

microvascular

changes are associated with increased coronary artery calcification

(CAC), an indicator of subclinical coronary macrovascular disease,

findings from the

prospective Multi-Ethnic Study of Atherosclerosis (MESA) suggest. [6,000

subjects age 45 -84 years without a history of clinical cardiovascular

disease.

They underwent chest computed tomography to measure

coronary artery calcification and fundus photography to assess retinal

disease. Retinopathy was defined as the presence of microaneurysms,

hemorrhages,

cotton wool spots, intraretinal microvascular abnormalities, hard

exudates, venous beading or

new vessels. CAC was present in about half of the subjects. Retinopathy

was present in 14.3% of subjects with no CAC, 17.2% of subjects with

mild CAC,

and 20.8% of those with moderate to severe CAC. " The association between

retinopathy and moderate-to-severe CAC was present in all ethnic groups

and remained

significant in both men and women and in persons with and without

diabetes or hypertension, " the investigators found. They conclude that

" common pathophysiologic

processes may underlie both microvascular

and macrovascular disease. " Specifically, they suggest that " retinopathy

signs ...reflect generalized endothelial dysfunction, which in the

coronary circulation

may promote atherogenesis. "

" Inflammatory factors may also be involved " when patients without

hypertension or diabetes, and with generally low cardiovascular risk

profiles, present

with retinopathy and coronary artery calcification, h. " As yet, there

are no direct clinical implications from our study, " the ophthalmologist

researcher

said, " but physicians and patients should be aware that these conditions

are related. . patients with retinopathy may be at higher risk of both

subclinical

heart disease and clinical heart disease, such as heart failure. " On the

other hand, retinopathy is reversible..Reversal may occur in 3 years and

is associated

with lower BP and glucose levels, higher physical activity, and less

obesity, " he said. " It is possible, but not proven, that reversal is

associated with

lower risk of cardiovascular disease. " the team is

now evaluating the value of adding a retinal examination to a coronary

calcium CT scan for predicting cardiovascular disease.

Am J Epidemiol 2008;167:

5.%% MW - Alpha-Linolenic Acid May Lower Risk of Diabetic Peripheral

Neuropathy Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 07 -

Dietary intake

of alpha-linolenic acid was associated with reduced incidence of

diabetic peripheral neuropathy in a new analysis of data from the

National Health and

Nutrition Examination Survey (NHANES) 1999-2004. Alpha-linolenic acid is

an omega-3 fatty acid found in many vegetable oils, including flaxseed,

walnuts,

and canola oil. The researchers identified 1062 diabetics age 40 and

older for whom complete 24-hour dietary recall data were recorded.

Peripheral neuropathy

had been assessed using a nylon monofilament at three plantar sites on

each foot to test for sensation.

Dr. Eberhardt's group calculated the intake of total polyunsaturated

fatty acids and of seven specific fatty acids. In multivariate analyses,

they adjusted

for age, sex, race, education, height, weight, diabetes duration,

glycemic control, hypertension, smoking, and total

calorie intake. Relative to adults in the lowest quintile [fifth] of

alpha-linolenic acid intake the odds of having peripheral neuropathy was

0.54 for

subjects in the fourth quintile (1.35 - 2.10 g/day) of intake and 0.40

for adults in the fifth quintile (2.11 g/day or higher). High dietary

intake of

alpha-linolenic acid is associated with reduced risk of vascular disease

(coronary heart disease and hypertension), the team points out. " The

protective

effect of alpha-linolenic acid on macrovascular diseases and its

association with diabetic peripheral neuropathy may be due to a similar

biological mechanism. "

They recommend further study to verify a protective effect of

alpha-linolenic acid in patients with diabetes. Diabetes Care 2008;31.

6.%% MW-Fitness, Fatness, and Cardiovascular Risk Factors in Type 2

Diabetes: Look AHEAD Study Med Sci Sports Exerc. 2007;39(12) C2007

American College

of Sports Medicine 01/03/2008

Purpose: Most studies comparing the effects of fitness and fatness on

cardiovascular (CVD) risk have been done with young, healthy

participants with low

rates of obesity and high levels of fitness. The present study examined

the association of cardiorespiratory fitness and obesity with CVD risk

factors

in an ethnically diverse sample of overweight/obese individuals with

T2DM. [ Baseline data from Look AHEAD, 5145 overweight or obese

individuals with T2]..Among

the CVD risk factors, we examined continuous outcomes such as HbA1c,

HDL, LDL, triglycerides, SBP, diastolic blood pressure (DBP), ABI, and

1-yr CVD risk

estimate using the Framingham risk prediction equation. . At entry into

the study, participants averaged 58.7 and had a DM duration of 6.8. 60%

were women;

63.2% were white, 15.7% were African American, 13.2% Hispanic, 5.0%

Native American, and 1.0% Asian American. In conclusion, this study

shows that fitness

and fatness are highly associated; thus, it is unusual to find

individuals who are obese, yet very fit. Moreover, both fitness and

fatness are related

to CVD risk factors, although the strength of the associations for

fitness versus fatness differed for specific risk factors. Of particular

note is the

strong association of fitness with HbA1c, ABI, and Framingham risk score

in this population, and the relationships of BMI with SBP. Look AHEAD is

an ongoing

trial; it is expected to last through the year 2012. Half of the

participants are receiving intensive lifestyle intervention, and half

receive diabetes

education and support. Changes in weight, fitness, and CVD risk factors

are measured periodically throughout the study; the primary outcome

measure is

CVD morbidity and mortality.

7.%% MW - Imaging to Assess Effect of Medical Therapy in Patients With

Diabetes Mellitus Br J Diabetes Vasc Dis. 2007;7(4): 01/02/2008

Abstract - The incidence of T2DM is rapidly increasing throughout the

world. As an independent risk factor for cardiovascular disease both at

the microvascular

and macrovascular level, DM is a condition that deserves the most

aggressive medical management... invasive techniques have been

extensively used to assess

coronary atherosclerosis progression and drug efficacy in the general

population and smaller subsets of DM patients. While even minimal

luminal stenosis

reduction was associated with very significant reduction in event rates

in the general population, similar data are lacking in DM patients.

Although sensitive,

an obvious limitation of these techniques is their invasive nature and

the radiation exposure, besides a very considerable operational cost.

Hence, additional non-invasive imaging techniques have been adopted to

assess plaque progression or its haemodynamic effects in diabetic

patients. Carotid

Intima Media Thickness - Two decades ago investigators showed that the

thickness of the carotid wall (intima and media layer taken together)

measured ultrasonographically

was associated with the presence and extent of atherosclerosis of the

aorta..several randomised and epidemiological studies clearly proved the

value of

the cIMT as a marker of CV risk. An increased cIMT has been associated

with risk of MI and CVA in the elderly (> 65 years)

as well as younger age groups. cIMT is a marker of atherosclerosis

burden rather than a surrogate for obstructive CAD. Insulin resistance

alone in the

absence of clinical diabetes has been associated with an increased

cIMT.. Furthermore, cIMT appears to progress faster in diabetic patients

than in all

other patients.

Medical Interventions -Measurement of cIMT progression has been utilised

to assess efficacy of medical therapy in several studies in DM patients.

A short-

and a long-term follow-up study of 1,229 T1DM patients randomised to

either standard or intensive glucose-reducing therapy, compared cIMT

progression in

diabetes with that of age and sex-matched non-diabetic

individuals...cIMT progression was not different at the end of the first

year of follow-up between

controls and patients receiving intensive and standard therapy, but it

was significantly greater in the diabetic than control subjects at the

end of 6.5

years of follow-up. Coronary Artery Calcium - Coronary artery calcium is

deposited in the atherosclerotic milieu as the plaque develops via

active mechanisms

resembling bone formation. . it has been shown that there is an

excellent correlation(r=0.98) between CAC measured on CCT and

atherosclerotic plaque area.

Whether CAC imaging adds prognostic information in diabetes mellitus

remains unclear. Hypertension and several nontraditional CV risk

factors have been

associated with CAC progression in DM subjects. .. Additionally, a

greater proportion of DM than non-diabetic patients developed CAC during

follow-up if

no CAC was present at baseline (42% vs. 25%. Finally, as reported in

the general population, CAC progression was linked with adverse coronary

events during

follow-up. .DM patients who suffered a MI during follow-up demonstrated

a 4-fold and 2.5-fold greater CAC progression than non-diabetic subjects

receiving

and not receiving statins, respectively. CAC imaging appears to be a

reliable means to assess risk connected with subclinical atherosclerosis

in the general

population, although some debate remains in diabetic patients.

Functional Imaging - Various forms of nuclear myocardial perfusion

imaging have been utilised

in DM patients to assess the effect of glycaemic metabolism on vascular

function. Indeed, data suggest that coronary vasomotor abnormalities

accompany

glucose metabolism impairment and that vascular function deteriorates

with increasing severity of insulin-resistance and glucose intolerance.

Summary -

The existing evidence suggests that many modern imaging modalities may

be utilised to monitor the effectiveness of medical therapy for diabetes

on the

CV system. Indeed, almost all surrogate markers of atherosclerosis have

been studied in diabetic patients and have shown some validity for this

purpose.

However, many of the reported differences were very small, some were

obtained with invasive techniques and many implied exposure to

radiation. Finally,

very little evidence has so far linked the occurrence of events to the

progression of these markers of disease. Hence, future appropriately

powered studies

should focus on whether reducing plaque progression and restoring

vascular vasomotor activity translate into a significant improvement of

CV morbidity

and mortality in diabetes mellitus.

8.%% Type 2 Diabetes -- Insulin Therapy Initiating Insulin in the Type

2 Diabetes Patient Medscape Diabetes & Endocrinology. 2007; C2007

Medscape 12/28/2007

Introduction - T2DM is a progressive disease, and most patients will

eventually need insulin to achieve euglycemia.[normal blood sugar level]

Furthermore,

data have shown that early and aggressive

intervention to lower blood glucose reduces the risk of complications of

the disease. However, even with the ever-growing list of new medications

available,

it can be a daunting task for healthcare providers to decide which

treatment regimen is appropriate

to manage a particular patient. New guidelines and algorithms can help

determine which patients with type 2 diabetes should be started on

insulin and when

insulin should be initiated. The goals of insulin therapy are the same

as the goals of any therapy for the treatment

of diabetes: to achieve optimal glycemic control without causing undue

hypoglycemia or excessive weight gain and to minimize the impact on

lifestyle.

The Challenges of Insulin Therapy

Psychological insulin resistance is a real phenomenon. Individuals with

diabetes often feel that insulin is the beginning of the end. They fear

taking

the injection and feel that there is a stigma associated with insulin.

Insulin therapy can, in fact, be a real pain both literally and

figuratively. It

is intrusive, can limit spontaneity, and can interfere with daily

activities. As a consequence, adhering to an insulin regimen has been

difficult for many

patients. Because symptom severity is not indicative of disease

severity, many individuals do not understand the need for optimal

glycemic control or its

role in preventing complications. This lack of understanding can also

result in significant resistance as well as decreased adherence once

patients do

agree to begin insulin. That nonadherence will most likely carry over to

other parts of diabetes management, such as blood glucose testing. In

addition,

individuals fear that they will experience hypoglycemia and gain weight.

To top it off, there is the inconvenience and the disruption of daily

routines

and privacy.

Providers, on the other hand, also experience psychological resistance

to insulin therapy. They also may fear hypoglycemia and have concern for

their patients'

safety. In patients who already have a weight issue, the risk of gaining

weight adds to the complexity of the decision to initiate insulin. All

this, combined

with the time it takes to educate the patient and titrate the dose, adds

up to a lot of work. Teaming up with a diabetes educator who is

knowledgeable

in diabetes and insulin management can help alleviate this workload.

However, even if this resource is not available, simple algorithms and

titration schedules

make initiation and titration of insulin easier.

9.%% MW -Blood Pressure and Risk of Developing Type 2 Diabetes Mellitus:

The Women's Health Study Eur Heart J. 2007;28(23) C2007 Oxford

University Press

01/02/2008 Abstract Aims: To examine the relationship of blood

pressure (BP) and BP progression with the subsequent development of

T2DM. [ prospective

cohort study among 38 172 women free of DM and cardiovascular disease at

baseline. Women were classified into four categories according to

self-reported

baseline BP] During 10.2 years of follow-up, 1672 women developed

T2. Conclusion - Our study provides strong evidence that baseline BP and

BP progression are associated with an increased risk of incident T2.

Clinicians

should be aware of these relationships to optimize the management of

patients at increased risk for cardiovascular disease.

10.%% MW - New PPAR-Gamma Modulator Has Potent Antidiabetes and

Antiatherogenic Effects Reuters Health Information 2007. (Reuters

Health) Dec 28 - A new

specific peroxisome proliferator-activated receptor (PPAR) modulator

has demonstrated promise in a French in vitro and in vivo study of

mice.The researchers

note that the thiazolidinedione (TZD) class of drugs, although

effective and widely used to treat T2 tends to cause weight gain. This

study was undertaken

to evaluate S26948, a novel ligand for PPAR-gamma. The study found that

S26948 is a specific high-affinity agonist for PPAR-gamma, binding it

with the

same affinity as the TZD rosiglitazone does. Further, the results

suggest that S26948 promoted a PPAR-gamma conformation distinct from

that elicited by

rosiglitazone. In addition, [it] decreased blood glucose levels and

plasma insulin levels in male ob/ob mice, indicating that the drug

increased insulin

sensitivity, paralleling the effects of rosiglitazone treatment. Results

showed that the agent did not promote body- weight gain in the diabetic

mice.

Instead, the S26948-treated mice gained less weight than the controls,

indicating " a profoundly decreased food efficiency, " the authors write.

They concluded

that S26948's pattern of coactivator recruitment, which differs from

that of rosiglitazone, decreases its adipogenic capacity compared with

rosiglitazone. In a cohort of homozygous human apolipoprotein E2

knock-in mice, S26948 reduced atherosclerotic lesion surfaces by 46%

compared with controls.

Rosiglitazone had no effect on atherosclerotic lesion size. They add

that this line of research is ongoing with related compounds that are

considered even

more promising, not specifically with S26948. Diabetes 2007;56

11.%% MW - Depomed Says FDA Approves 1000 Mg Strength Tablets of

Glumetza (Reuters) Jan 02 - Depomed Inc said U.S. health regulators have

approved the

1000 mg strength tablets of Glumetza, an extended-release formulation of

metformin, for patients with T2.

The specialty pharmaceutical company said it acquired exclusive US

rights to the 1000 mg formulation of Glumetza in December 2005

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. Definitions -

Dorlands 31st Ed

and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic

educator. Reports are excerpted unless otherwise noted. This project is

done as a

courtesy to the blind/visually impaired and diabetic communities. Dawn

Wilcox Coordinator The Health Library at Vista Center contact above

e-mail or thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

__________ NOD32 2779 (20080109) Information __________

This message was checked by NOD32 antivirus system.

http://www.eset. <http://www.eset.com> com

[Guest guest]

I only had hypoglycemia a couple of times since being diagnosed with type 2.

As soon as I was out of the hospital the first time and my first foot ulcers

healed, I started exercising by riding a stationary bike and sometimes using

the Sansone " walk away the pounds " videos. Not long after losing

some weight I started having hypoglecemic incidents. I started cutting my

dosages of diabetes meds in half and eventually stopped taking them

altogether. I was able to keep the weight I had lost off and no longer

needed the meds for about a year. Then, I did something stupid. I got lazy

again and stopped exercising and put some of the weight back on.

I didn't go back to the doctor right away to get more prescriptions because

I thought I could handle things myself. Then, of course, I started getting

foot ulcers again and ended up back in the hospital. My problem now is that

even with keeping my BS under better control, I still get foot ulcers and

now have this Charcot condition to worry about. But basically, yes you can

get hypoglecemia as a type 2 diabetic.

Becky

_____

From: blind-diabetics

[mailto:blind-diabetics ] On Behalf Of LaFrance-Wolf

Sent: Friday, January 11, 2008 11:10 AM

To: blind-diabetics

Subject: RE: articles

Vicky,

Type 2 diabetecs can become hypoglycemic if they are on meds that make

their pancreas produce insulin. Perhaps some type 2 diabetics on the

list can tell their experiences with this?

Re: articles

interesting, patricia. So let me ask something: is hypoglycemia present

in type 2 diabetics and if so, is there a certain way you know you have

it?

Vicki

The LORD is good to those who depend on him, to those who search for

him.

Lamentations 3:25, NLT

articles

1. ADA - Depression May Lead to Type 2 Diabetes Jan-2-2008

Researchers believe there is a link between chronic depression and the

development of T2DM in adults age 65 years and up. Using responses from

over 4,600

people without diabetes at the outset to the National Institutes of

Health's Center for Epidemiological Studies

Depression Scale, the researchers saw a 50% greater chance of developing

DM during the course of the 10-year study among those noting high

depressive symptoms--even

after accounting for weight and activity levels. They state that

depression has dramatic impacts on the autonomic nervous system, moving

from a resting

state to a responsive state under stress; insulin production is shut

down to handle potential threats when the body is in the responsive

state. Similar

research by Washington University School of Medicine determined that

when adults have both depression and T2, 90% of those experienced

depression first.

News summaries C2007 Information, Inc. Chicago Tribune (12/25/07)

2.%% MW - Habituation of Brain Responses Tied to Unawareness of

Hypoglycemia (Reuters Health) Dec 31 - Attenuation of amygdala and

frontal cortical responses

to low blood glucose concentration may lead to a lack of hypoglycemia

awareness in patients with T1DM. The lead researcher told Reuters Health

that the

studies are early

However, she said, " We think they may have important implications for

people with T1 who have lost their ability to recognize early

hypoglycemia ... and

are therefore at high risk for more severe

hypoglycemia with confusion and even coma. " The team used FDG-labeled

positron emission tomography to examine responses to euglycemia and

hypoglycemia

in 6 patients with hypoglycemia

awareness and 7 without such awareness. FDG uptake was increased in the

left amygdala in hypoglycemia awareness, but not in hypoglycemia

unawareness. The

team also found a " robust increase " bilaterally in the ventral striatum

during hypoglycemia unawareness.

Further analysis indicated bilateral attenuated activation of brain stem

regions and less deactivation in lateral orbitofrontal cortex in

hypoglycemia

unawareness. " The data suggest, that this group of people, perhaps 25%

of people who have had their DM for more than 15 years, have an altered

brain response

to a hypoglycemic episode in which they not only fail to feel that they

are hypoglycemic, but they also fail to generate the brain message that

the hypoglycemia

is unpleasant and dangerous. " In fact, " the message generated may even

be faintly rewarding, which would actually encourage experience of

further hypoglycemia, "

she added. " If this interpretation is correct, we will need to use

additional strategies, such as those currently successful in changing

other patterns

of repeated behavior that are damaging -- for example, smoking and

drinking alcohol -- to help people avoid hypoglycemia long-term, and

recover their awareness

of those occasional episodes that are inevitably part of today's insulin

therapies. " Diabetes 2007;56.

3.%% MW-Sirolimus Stents May Reduce Restenosis in Diabetics With

Coronary Disease (Reuters Health) Jan 04 - Compared with

paclitaxel-eluting stents (PES),

sirolimus-eluting stents (SES) appear to decrease the risk of in-stent

late luminal loss in diabetics with coronary artery disease, new

research shows.

Comparing PES with SES has been difficult since there are so many

individual variables

that contribute to neointimal hyperplasia. In the present study, the

researchers addressed this problem by comparing PES and SES directly in

the same diabetic

patient. [60 patients - 60 lesions were successfully treated with PES

and 60 with SES] On multivariate analysis, the type of drug-eluting

stent was the

only independent

predictor of in-stent late luminal loss. Specifically, in-stent late

luminal loss [loss of the open area in vessel] was 2.3-times more likely

when a PES

rather than a SES was used. Further research is needed to determine if

the better angiographic results achieved

with SES actually translate into long-term clinical benefits, the

authors conclude. Diabetes Care 2008;31.

4.%% MW - Retinopathy Linked to Subclinical Coronary Artery Disease

Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 03 - Retinal

microvascular

changes are associated with increased coronary artery calcification

(CAC), an indicator of subclinical coronary macrovascular disease,

findings from the

prospective Multi-Ethnic Study of Atherosclerosis (MESA) suggest. [6,000

subjects age 45 -84 years without a history of clinical cardiovascular

disease.

They underwent chest computed tomography to measure

coronary artery calcification and fundus photography to assess retinal

disease. Retinopathy was defined as the presence of microaneurysms,

hemorrhages,

cotton wool spots, intraretinal microvascular abnormalities, hard

exudates, venous beading or

new vessels. CAC was present in about half of the subjects. Retinopathy

was present in 14.3% of subjects with no CAC, 17.2% of subjects with

mild CAC,

and 20.8% of those with moderate to severe CAC. " The association between

retinopathy and moderate-to-severe CAC was present in all ethnic groups

and remained

significant in both men and women and in persons with and without

diabetes or hypertension, " the investigators found. They conclude that

" common pathophysiologic

processes may underlie both microvascular

and macrovascular disease. " Specifically, they suggest that " retinopathy

signs ...reflect generalized endothelial dysfunction, which in the

coronary circulation

may promote atherogenesis. "

" Inflammatory factors may also be involved " when patients without

hypertension or diabetes, and with generally low cardiovascular risk

profiles, present

with retinopathy and coronary artery calcification, h. " As yet, there

are no direct clinical implications from our study, " the ophthalmologist

researcher

said, " but physicians and patients should be aware that these conditions

are related. . patients with retinopathy may be at higher risk of both

subclinical

heart disease and clinical heart disease, such as heart failure. " On the

other hand, retinopathy is reversible..Reversal may occur in 3 years and

is associated

with lower BP and glucose levels, higher physical activity, and less

obesity, " he said. " It is possible, but not proven, that reversal is

associated with

lower risk of cardiovascular disease. " the team is

now evaluating the value of adding a retinal examination to a coronary

calcium CT scan for predicting cardiovascular disease.

Am J Epidemiol 2008;167:

5.%% MW - Alpha-Linolenic Acid May Lower Risk of Diabetic Peripheral

Neuropathy Reuters Health Information 2008. C 2008 Reuters Ltd. Jan 07 -

Dietary intake

of alpha-linolenic acid was associated with reduced incidence of

diabetic peripheral neuropathy in a new analysis of data from the

National Health and

Nutrition Examination Survey (NHANES) 1999-2004. Alpha-linolenic acid is

an omega-3 fatty acid found in many vegetable oils, including flaxseed,

walnuts,

and canola oil. The researchers identified 1062 diabetics age 40 and

older for whom complete 24-hour dietary recall data were recorded.

Peripheral neuropathy

had been assessed using a nylon monofilament at three plantar sites on

each foot to test for sensation.

Dr. Eberhardt's group calculated the intake of total polyunsaturated

fatty acids and of seven specific fatty acids. In multivariate analyses,

they adjusted

for age, sex, race, education, height, weight, diabetes duration,

glycemic control, hypertension, smoking, and total

calorie intake. Relative to adults in the lowest quintile [fifth] of

alpha-linolenic acid intake the odds of having peripheral neuropathy was

0.54 for

subjects in the fourth quintile (1.35 - 2.10 g/day) of intake and 0.40

for adults in the fifth quintile (2.11 g/day or higher). High dietary

intake of

alpha-linolenic acid is associated with reduced risk of vascular disease

(coronary heart disease and hypertension), the team points out. " The

protective

effect of alpha-linolenic acid on macrovascular diseases and its

association with diabetic peripheral neuropathy may be due to a similar

biological mechanism. "

They recommend further study to verify a protective effect of

alpha-linolenic acid in patients with diabetes. Diabetes Care 2008;31.

6.%% MW-Fitness, Fatness, and Cardiovascular Risk Factors in Type 2

Diabetes: Look AHEAD Study Med Sci Sports Exerc. 2007;39(12) C2007

American College

of Sports Medicine 01/03/2008

Purpose: Most studies comparing the effects of fitness and fatness on

cardiovascular (CVD) risk have been done with young, healthy

participants with low

rates of obesity and high levels of fitness. The present study examined

the association of cardiorespiratory fitness and obesity with CVD risk

factors

in an ethnically diverse sample of overweight/obese individuals with

T2DM. [ Baseline data from Look AHEAD, 5145 overweight or obese

individuals with T2]..Among

the CVD risk factors, we examined continuous outcomes such as HbA1c,

HDL, LDL, triglycerides, SBP, diastolic blood pressure (DBP), ABI, and

1-yr CVD risk

estimate using the Framingham risk prediction equation. . At entry into

the study, participants averaged 58.7 and had a DM duration of 6.8. 60%

were women;

63.2% were white, 15.7% were African American, 13.2% Hispanic, 5.0%

Native American, and 1.0% Asian American. In conclusion, this study

shows that fitness

and fatness are highly associated; thus, it is unusual to find

individuals who are obese, yet very fit. Moreover, both fitness and

fatness are related

to CVD risk factors, although the strength of the associations for

fitness versus fatness differed for specific risk factors. Of particular

note is the

strong association of fitness with HbA1c, ABI, and Framingham risk score

in this population, and the relationships of BMI with SBP. Look AHEAD is

an ongoing

trial; it is expected to last through the year 2012. Half of the

participants are receiving intensive lifestyle intervention, and half

receive diabetes

education and support. Changes in weight, fitness, and CVD risk factors

are measured periodically throughout the study; the primary outcome

measure is

CVD morbidity and mortality.

7.%% MW - Imaging to Assess Effect of Medical Therapy in Patients With

Diabetes Mellitus Br J Diabetes Vasc Dis. 2007;7(4): 01/02/2008

Abstract - The incidence of T2DM is rapidly increasing throughout the

world. As an independent risk factor for cardiovascular disease both at

the microvascular

and macrovascular level, DM is a condition that deserves the most

aggressive medical management... invasive techniques have been

extensively used to assess

coronary atherosclerosis progression and drug efficacy in the general

population and smaller subsets of DM patients. While even minimal

luminal stenosis

reduction was associated with very significant reduction in event rates

in the general population, similar data are lacking in DM patients.

Although sensitive,

an obvious limitation of these techniques is their invasive nature and

the radiation exposure, besides a very considerable operational cost.

Hence, additional non-invasive imaging techniques have been adopted to

assess plaque progression or its haemodynamic effects in diabetic

patients. Carotid

Intima Media Thickness - Two decades ago investigators showed that the

thickness of the carotid wall (intima and media layer taken together)

measured ultrasonographically

was associated with the presence and extent of atherosclerosis of the

aorta..several randomised and epidemiological studies clearly proved the

value of

the cIMT as a marker of CV risk. An increased cIMT has been associated

with risk of MI and CVA in the elderly (> 65 years)

as well as younger age groups. cIMT is a marker of atherosclerosis

burden rather than a surrogate for obstructive CAD. Insulin resistance

alone in the

absence of clinical diabetes has been associated with an increased

cIMT.. Furthermore, cIMT appears to progress faster in diabetic patients

than in all

other patients.

Medical Interventions -Measurement of cIMT progression has been utilised

to assess efficacy of medical therapy in several studies in DM patients.

A short-

and a long-term follow-up study of 1,229 T1DM patients randomised to

either standard or intensive glucose-reducing therapy, compared cIMT

progression in

diabetes with that of age and sex-matched non-diabetic

individuals...cIMT progression was not different at the end of the first

year of follow-up between

controls and patients receiving intensive and standard therapy, but it

was significantly greater in the diabetic than control subjects at the

end of 6.5

years of follow-up. Coronary Artery Calcium - Coronary artery calcium is

deposited in the atherosclerotic milieu as the plaque develops via

active mechanisms

resembling bone formation. . it has been shown that there is an

excellent correlation(r=0.98) between CAC measured on CCT and

atherosclerotic plaque area.

Whether CAC imaging adds prognostic information in diabetes mellitus

remains unclear. Hypertension and several nontraditional CV risk

factors have been

associated with CAC progression in DM subjects. .. Additionally, a

greater proportion of DM than non-diabetic patients developed CAC during

follow-up if

no CAC was present at baseline (42% vs. 25%. Finally, as reported in

the general population, CAC progression was linked with adverse coronary

events during

follow-up. .DM patients who suffered a MI during follow-up demonstrated

a 4-fold and 2.5-fold greater CAC progression than non-diabetic subjects

receiving

and not receiving statins, respectively. CAC imaging appears to be a

reliable means to assess risk connected with subclinical atherosclerosis

in the general

population, although some debate remains in diabetic patients.

Functional Imaging - Various forms of nuclear myocardial perfusion

imaging have been utilised

in DM patients to assess the effect of glycaemic metabolism on vascular

function. Indeed, data suggest that coronary vasomotor abnormalities

accompany

glucose metabolism impairment and that vascular function deteriorates

with increasing severity of insulin-resistance and glucose intolerance.

Summary -

The existing evidence suggests that many modern imaging modalities may

be utilised to monitor the effectiveness of medical therapy for diabetes

on the

CV system. Indeed, almost all surrogate markers of atherosclerosis have

been studied in diabetic patients and have shown some validity for this

purpose.

However, many of the reported differences were very small, some were

obtained with invasive techniques and many implied exposure to

radiation. Finally,

very little evidence has so far linked the occurrence of events to the

progression of these markers of disease. Hence, future appropriately

powered studies

should focus on whether reducing plaque progression and restoring

vascular vasomotor activity translate into a significant improvement of

CV morbidity

and mortality in diabetes mellitus.

8.%% Type 2 Diabetes -- Insulin Therapy Initiating Insulin in the Type

2 Diabetes Patient Medscape Diabetes & Endocrinology. 2007; C2007

Medscape 12/28/2007

Introduction - T2DM is a progressive disease, and most patients will

eventually need insulin to achieve euglycemia.[normal blood sugar level]

Furthermore,

data have shown that early and aggressive

intervention to lower blood glucose reduces the risk of complications of

the disease. However, even with the ever-growing list of new medications

available,

it can be a daunting task for healthcare providers to decide which

treatment regimen is appropriate

to manage a particular patient. New guidelines and algorithms can help

determine which patients with type 2 diabetes should be started on

insulin and when

insulin should be initiated. The goals of insulin therapy are the same

as the goals of any therapy for the treatment

of diabetes: to achieve optimal glycemic control without causing undue

hypoglycemia or excessive weight gain and to minimize the impact on

lifestyle.

The Challenges of Insulin Therapy

Psychological insulin resistance is a real phenomenon. Individuals with

diabetes often feel that insulin is the beginning of the end. They fear

taking

the injection and feel that there is a stigma associated with insulin.

Insulin therapy can, in fact, be a real pain both literally and

figuratively. It

is intrusive, can limit spontaneity, and can interfere with daily

activities. As a consequence, adhering to an insulin regimen has been

difficult for many

patients. Because symptom severity is not indicative of disease

severity, many individuals do not understand the need for optimal

glycemic control or its

role in preventing complications. This lack of understanding can also

result in significant resistance as well as decreased adherence once

patients do

agree to begin insulin. That nonadherence will most likely carry over to

other parts of diabetes management, such as blood glucose testing. In

addition,

individuals fear that they will experience hypoglycemia and gain weight.

To top it off, there is the inconvenience and the disruption of daily

routines

and privacy.

Providers, on the other hand, also experience psychological resistance

to insulin therapy. They also may fear hypoglycemia and have concern for

their patients'

safety. In patients who already have a weight issue, the risk of gaining

weight adds to the complexity of the decision to initiate insulin. All

this, combined

with the time it takes to educate the patient and titrate the dose, adds

up to a lot of work. Teaming up with a diabetes educator who is

knowledgeable

in diabetes and insulin management can help alleviate this workload.

However, even if this resource is not available, simple algorithms and

titration schedules

make initiation and titration of insulin easier.

9.%% MW -Blood Pressure and Risk of Developing Type 2 Diabetes Mellitus:

The Women's Health Study Eur Heart J. 2007;28(23) C2007 Oxford

University Press

01/02/2008 Abstract Aims: To examine the relationship of blood

pressure (BP) and BP progression with the subsequent development of

T2DM. [ prospective

cohort study among 38 172 women free of DM and cardiovascular disease at

baseline. Women were classified into four categories according to

self-reported

baseline BP] During 10.2 years of follow-up, 1672 women developed

T2. Conclusion - Our study provides strong evidence that baseline BP and

BP progression are associated with an increased risk of incident T2.

Clinicians

should be aware of these relationships to optimize the management of

patients at increased risk for cardiovascular disease.

10.%% MW - New PPAR-Gamma Modulator Has Potent Antidiabetes and

Antiatherogenic Effects Reuters Health Information 2007. (Reuters

Health) Dec 28 - A new

specific peroxisome proliferator-activated receptor (PPAR) modulator

has demonstrated promise in a French in vitro and in vivo study of

mice.The researchers

note that the thiazolidinedione (TZD) class of drugs, although

effective and widely used to treat T2 tends to cause weight gain. This

study was undertaken

to evaluate S26948, a novel ligand for PPAR-gamma. The study found that

S26948 is a specific high-affinity agonist for PPAR-gamma, binding it

with the

same affinity as the TZD rosiglitazone does. Further, the results

suggest that S26948 promoted a PPAR-gamma conformation distinct from

that elicited by

rosiglitazone. In addition, [it] decreased blood glucose levels and

plasma insulin levels in male ob/ob mice, indicating that the drug

increased insulin

sensitivity, paralleling the effects of rosiglitazone treatment. Results

showed that the agent did not promote body- weight gain in the diabetic

mice.

Instead, the S26948-treated mice gained less weight than the controls,

indicating " a profoundly decreased food efficiency, " the authors write.

They concluded

that S26948's pattern of coactivator recruitment, which differs from

that of rosiglitazone, decreases its adipogenic capacity compared with

rosiglitazone. In a cohort of homozygous human apolipoprotein E2

knock-in mice, S26948 reduced atherosclerotic lesion surfaces by 46%

compared with controls.

Rosiglitazone had no effect on atherosclerotic lesion size. They add

that this line of research is ongoing with related compounds that are

considered even

more promising, not specifically with S26948. Diabetes 2007;56

11.%% MW - Depomed Says FDA Approves 1000 Mg Strength Tablets of

Glumetza (Reuters) Jan 02 - Depomed Inc said U.S. health regulators have

approved the

1000 mg strength tablets of Glumetza, an extended-release formulation of

metformin, for patients with T2.

The specialty pharmaceutical company said it acquired exclusive US

rights to the 1000 mg formulation of Glumetza in December 2005

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. Definitions -

Dorlands 31st Ed

and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic

educator. Reports are excerpted unless otherwise noted. This project is

done as a

courtesy to the blind/visually impaired and diabetic communities. Dawn

Wilcox Coordinator The Health Library at Vista Center contact above

e-mail or thlvistacenter (DOT) <mailto:thl%40vistacenter.org> org

__________ NOD32 2779 (20080109) Information __________

This message was checked by NOD32 antivirus system.

http://www.eset. <http://www.eset. <http://www.eset.com> com> com

[Guest guest]

I had an interesting experience during my last hospital stay. For some

reason, instead of letting me take my oral meds, the nurses preferred giving

me insulin injections. It particularly bugged me when they would give me an

injection about 9:00 at night. The first night they did this, I woke up in

the middle of the night and had to go to the bathroom. Anyone who has been

in a hospital knows how tiny the bathrooms are. I got in there and then

became confused and couldn't find the door or figure out how to get out. It

dawned on me that not only was I confused, but I was feeling shaky and was

perspiring. I knew my BS was too low. Before I pulled the emergency string

in the bathroom, I remembered that the door was sliding and not a push/pull

door so managed to get out. As soon as I got back to bed I pushed the

button to summons a nurse. I asked for a snack, and soon felt better. From

that night on, I made sure they brought me a snack, and as soon as I got the

injection of insulin (it did no good to argue with them and tell them not to

give me one) I would eat a few gram crackers and would make it through the

night without any problems.

Becky

_____

From: blind-diabetics

[mailto:blind-diabetics ] On Behalf Of Jesso

Sent: Friday, January 11, 2008 12:25 PM

To: blind-diabetics

Subject: Re: articles

From what I understand type 2s on medication can have lows, but they tend to

not be as severe as in those with type 1. Even type 2s on insulin seem to

have less of a problem with sudden, severe lows from what I have read, for

some reason. I could be wrong on this so I'd be interested to hear what

those with type 2 on the list have to say.

You would know you are experiencing lows if you have symptoms of

hypoglycemia (shakiness, sweatiness, dizziness, hunger, headache,

concentration and coordination difficulties, in severe cases loss of

consciousness and seizures) and if your blood sugar tested low at this time.

I always test when I feel low because sometimes I'm actually high, so never

just assume you are low and treat unless it is an emergency.

Jen

[Guest guest]

1.NIHPRESS Digest-15 Feb 2008 to19 Feb 2008 (#2008-21) Stress Hormone

Impacts Memory, Learning in Diabetic Rodents - Diabetes is known to

impair the cognitive

health of people, but now scientists have identified one potential

mechanism underlying these learning and memory problems. A new National

Institute on

Aging (NIA) study in diabetic, T1 & T2 rodents finds that increased levels

of a stress hormone produced by the adrenal gland disrupt the healthy

functioning

of the hippocampus, the region of the brain responsible for learning and

short-term memory. Moreover, when levels of the adrenal glucocorticoid

hormone

corticosterone (also known as cortisol in humans) are returned to

normal, the hippocampus recovers its ability to build new cells and

regains the " plasticity "

needed to compensate for injury and disease and adjust to change.

" This research in animal models is intriguing, suggesting the

possibility of novel

approaches in preventing and treating cognitive impairment by

maintaining normal levels of glucocorticoid, " said the NIA director.

" Further study will

provide a better understanding of the often complex interplay between

the nervous system, hormones and cognitive health. " Cortisol production

is controlled

by the hypothalamic - pituitary axis (HPA), a hormone-producing system

involving the hypothalamus and pituitary gland in the brain and the

adrenal gland

located near the kidney. People with poorly controlled DM often have an

overactive HPA axis and excessive cortisol produced by the adrenal

gland. " This

advance in our understanding of the physiological changes caused by

excessive production of cortisol may eventually play a role in

preventing and treating

cognitive decline in diabetes,.. these findings may also help explain

the connection between stress-related mood disorders and diabetes found

in human

population studies.

2.%% MW -Human Embryonic Stem Cells Generate Insulin-Secreting Cells in

Vivo Reuters Health Information 2008. © 2008 Reuters Ltd.

Feb 20 - The findings of a new study, according to the researchers,

provide " definitive evidence " that human embryonic stem cells can be

used to create glucose-responsive, insulin-secreting cells. " Development

of a cell therapy for diabetes would be greatly aided by a renewable

supply of

human beta-cells, " The team from Novocell Inc. in San Diego, comment.

They show that pancreatic endoderm, derived from human embryonic stems

cells, can

generate endocrine cells that are " morphologically and functionally

similar " to beta-cells after being implanted into mice. In addition, the

team goes

on to show that implantation of the stem cell-derived endoderm protects

against streptozotocin-induced hyperglycemia. These findings suggest

that human

embryonic stem cells could, in fact, represent a renewable supply of

islet-like cells for treating diabetes, the researchers conclude. Nat

Biotechnol 2008.

Feb 20th online issue

3.%% 21 Feb 2008 s Hopkins Health Alerts - Diabetes

Using a Continuous Glucose Monitor - Self-testing of blood glucose with

a blood glucose meter is the backbone of DM management. Results from the

Diabetes

Control and Complications Trial (DCCT) indicate that people with DM

should be more aggressive in their daily monitoring of blood glucose

levels if they

want to reduce their risk of diabetes complications. This means not only

more frequent blood glucose testing but also adjusting your diet,

exercise, and

doses of insulin or oral medications according to the results of your

tests. Frequent blood testing takes time and requires lots of finger

pricks. But

what if you could test your glucose 288 times a day without turning into

a human pincushion? You might be able to with a continuous glucose

monitor, according

to a recent study of people with diabetes who used insulin. A continuous

glucose monitor consists of a small sensor wire inserted beneath the

skin of the

abdomen and held in place with an adhesive patch. Every five minutes,

the sensor measures blood glucose and transmits the information to a

pager-sized

receiver with a digital readout that attaches to your clothing. In the

study, 91 people wore a continuous glucose monitor. Half of them saw

their blood

glucose levels displayed on the readout, were informed if their blood

glucose levels were too high or too low, and heard an alarm when their

blood glucose

fell below 55 mg/dL. The remaining participants did not see their

glucose levels on the readout or receive any warnings. Over a 3-day

period, volunteers

who received feedback on their blood glucose levels spent 26% more time

with their glucose under control and 23% less time with their glucose at

hypoglycemia

levels than those who didn’t receive the feedback. Diabetes Care Vol

29, .

4.%% ADA -Increased Arterial Stiffness in Normoglycemic Normotensive

[normal blood sugar and normal BP] Offspring of Type 2 (Diabetes)

Parents 2/20/08

Although there is a correlation between the occurrence of reduced

arterial distensibility and DM, there is scant research on this

association. To determine

the development of arterial distensibility in offspring of parents with

T2DM, 55 individuals were evaluated according to BP, blood glucose,

glycohemoglobin,

and insulin sensitivity. Subjects' carotid diastolic diameter, measured

by echo tracking, exhibited similar carotid diameters at diastole and

statistically

significant reduced increases of carotid diameter at systole; reduced

carotid artery distensibility; and an increased pulse pressure. The

team concluded

that in patients with a predisposition to DM, carotid artery stiffening

is a potential condition that can occur in the absence of blood pressure

alterations.

Hypertension 2/08# 51

5.%% ADA -New data on the role of the accumulation of cardiovascular

risk factors in the development of endothelial dysfunction in type 2

diabetes Feb-18-2008

The effects of the accumulation of cardiovascular risk factors and

insulin resistance

on endothelial function in diabetic patients [101] and 9 controls was

evaluated ..As compared to controls and DM patients, patients with

diabetes and

3 other cardiovascular risk factors (i.e., dyslipidemia, obesity.

hypertension) showed lower vasodilation values [FMD]. In addition,

insulin resistance

and high blood pressure significantly correlated with impaired FMD, thus

suggesting a relevant role in the pathogenesis of endothelial

dysfunction J Atheroscler

Thromb 2007, 14(6)

6.%%ADA -Insulin glargine plus glimepiride reported safe and effective

in type 2 diabetes 2/18/08 The safety and efficacy of combined insulin

glargine

and glimepiride was evaluated, for the first time, in a multicenter,

open-label trial enrolling a total of 100 ethnic

Japanese men and women with inadequately controlled T2DM on oral

antidiabetic drugs;24weeks of morning glimepiride (3 mg) plus

bedtime insulin glargine was well-tolerated and effective in reducing

mean HbA1c (1.5%), fasting plasma glucose (88.3 mg/dl), and postprandial

plasma glucose

(112.0 mg/dl), These findings indicate that insulin glargine plus

glimepiride could be used in patients with T2 and poor glycemic control

Diabetes Res

Clin Practice 2008, 79(1):

7.%%ADA - ADT increases the incidence of diabetes in patients with

prostate cancer 2-14-2008 A retrospective study using data from 8,481

individuals determined

the association between androgen- deprivation therapy (ADT) and the

incidence of DM in patients with prostate cancer. Multivariate analysis

revealed that

age, demographic characteristics, comorbidities and use of statins

played a significant role in increasing the relative risk of DM among

these patients.

Within 12 months, patients receiving ADT showed a 1.36 higher relative

risk of developing DM when compared to patients not treated with ADT.

The authors

conclude that ADT is associated with an increase in metabolic syndrome

and diabetes in patients with prostate cancer . Urology 2007,

70(6):1104).

8.%% Resting Heart Rate May Be Tied to Diabetes Mortality (Reuters

Health) Feb 22 - A higher resting heart rate in middle age is among

factors associated

with diabetes claims and mortality from DM in older age, researchers

report. " Heart rate, " as lead researcher Dr. M. Carnethon told Reuters

Health, " is

a simple-to-measure clinical tool that provides potentially useful

information about an individual's metabolic health. " Her team note that

given the apparent

association between heart rate and life expectancy, they sought to

determine

whether heart rate might also have a connection with DM and mortality

from the disease. [15,000 people;35-64years old; free of DM. After

adjusting for

demographics and factors such as smoking, the odds of having a

DM-related claim was about 10% higher for each 12 BPM increase in

baseline resting heart

rate. In subjects aged 35 to 49 at baseline, however, a higher heart

rate was associated with an increased risk of diabetes mortality even

after adjustment

for BMI. They conclude, " Our findings provide further evidence that

higher heart rate is associated with adverse morbidity and mortality

from a number

of causes including DM. " Diabetes Care 2008;31.

9.%% MW- (Reuters Health) Feb 15 - A drug approved for the treatment of

arthritis may have a role in reducing diabetic and cardiovascular risk

in young

obese individuals, Harvard researchers report. The anti-inflammatory

drug salsalate reduced fasting glucose, C-peptide levels and C-reactive

protein levels

in a placebo-controlled trial.[20 non-DM adults;younger than 30

years;(BMI)at least 30; 4 wk Compared with placebo, salsalate

significantly reduced fasting

glucose by 13%, glycemic response after an oral glucose challenge by

20%, glycated albumin by 17% and circulating levels of C-reactive

protein by 34%.

In addition, salsalate decreased fasting and oral glucose tolerance test

C-peptide levels, improved insulin sensitivity and inhibited insulin

clearance,

and increased adiponectin levels by 57% compared with placebo. Insulin

levels were unchanged. " This proof-of-principle study demonstrates that

salsalate

reduces glycemia and may improve inflammatory cardiovascular risk

indexes in overweight individuals, " .. " These data support the

hypothesis that subacute-

chronic inflammation contributes to the pathogenesis of obesity- related

dysglycemia [abnormal blood sugar] and that targeting inflammation may

provide

a therapeutic route for DM prevention. " " Salsalate is marketed in the US

for the treatment of arthritic pain. It is not approved for use in

obesity, " " We

are conducting additional clinical research studies to evaluate

targeting inflammation using salsalate in patients with DM to determine

safety and efficacy

to reduce blood sugars. A second ongoing study is in patients with

impaired glucose tolerance, also at high risk for development of T2. "

Diabetes Care

2008;31

10.%% Nature Clinical Practice Endocrinology & Metabolism (2008) 4,

Increased liver fat content in patients with type 2 diabetes is

independent of obesity no abstract so we have provided the first

paragraph. Many patients

with T2DM have increased liver fat content, giving a high prevalence of

nonalcoholic fatty liver disease; whether this increase is independent

of obesity

has not been confirmed. Kotronen and colleagues assessed liver fat

content in patients with T2 compared with that in nondiabetic

individuals matched for

age, sex and BMI. Since a simple measure of liver fat content in

patients with T2 would also be useful for directing therapy, the authors

also measured

glycemic markers, lipids, and liver enzyme concentrations in serum.

[Full text 1. Personal subscription2. 7 day single article pass for

US$18 © 2008 Nature

Publishing Group

11.%% Nature Clinical Practice Endocrinology & Metabolism (2008) 4,

Serum uric acid levels predict mortality in patients with type 2

diabetes The team

using the(Preventive Cardiology Information System) database, performed

a retrospective cohort analysis of 535 consecutive patients with T2DM to

examine

the association of serum uric acid levels with all-cause mortality and

glycemic control. [Full text see #10]

12.%%Nature Clinical Practice Endocrinology & Metabolism (2008) 4, Does

treatment with 17alpha-hydroxyprogesterone caproate increase the risk of

gestational

diabetes mellitus? Preterm birth is a leading cause of perinatal

mortality and morbidity, is responsible for 75% of all neonatal deaths,

and remains

an expensive health-care problem. Although preterm labor can be caused

by infection or weakness of the cervix, the etiology in most cases

remains unexplained.

As the onset of labor is associated with a physiological withdrawal of

progesterone, it is thought that administration of pharmacological doses

of progesterone

might prevent initiation of the pathway leading to labor. In addition,

progesterone is an anti-inflammatory agent. The results of two studies

suggest that

progesterone reduces the incidence of preterm delivery. additional

evidence is needed before this therapy becomes widely adopted. [Full

text-see #10]

13.%% Amer Journ Ophthalmology Volume 145,Issue 3 (March 2008)

Serum and Tear Levels of Nerve Growth Factor in Diabetic Retinopathy

Patients Purpose- To measure serum and tear nerve growth factor (NGF)

concentrations

in diabetic retinopathy (DR) patients to determine whether the NGF

correlated with parameters associated with DR. [254 DR patients and 71

nondiabetic controls;

nt demographic characteristics and DM parameters, including blood sugar

levels, HbA1c, liver and renal function, evaluated. Serum and

tear NGF concentrations and the ratio of NGF to total protein (TP) in

serum and tear fluid were determined. Results- Serum and tear NGF

levels were found

to be higher in proliferative diabetic retinopathy

(PDR) patients than in nondiabetic controls and nonproliferative

diabetic retinopathy (NPDR) patients. Similarly, NGF levels were higher

in PDR patients than in controls and NPDR patients after adjusting for

possible

confounding factors such as age, gender, serum blood urea nitrogen,

creatinine, and diabetic parameters. In addition, the NGF-to-TP ratio

for both serum

and tear fluid was higher

in the PDR group compared with the control and NPDR groups. NGF levels

correlated well with diabetes duration, HbA1c, and blood sugar levels

and diabetic

nephropathy. Conclusions NGF concentration may be a good parameter for

evaluating DR status. In addition, serum and tear NGF concentrations

correlated

strongly, indicating that tear fluid

assays may offer an effective, accurate, and noninvasive option for NGF

measurement. The content on this site is intended for health

professionals.

14.%% MW - Vitamin E May Help Limit Cardiac Events in Some Diabetics

(Reuters Health) Feb 22 - Vit E supplementation reduces cardiovascular

events in middle-aged

patients with T2DM and the haptoglobin (Hp) 2-2 genotype, Israeli

researchers report. They note that Hp is a determinant of cardiovascular

events in patients

with DM. The common alleles are Hp 1 and Hp 2.The Hp2 allele protein

product, provides inferior antioxidant protection. They say 2-3% of the

general population

are diabetics who carry the Hp 2-2 genotype. [a randomized trial in

1,434 such individuals aged 55 +] Subjects received vitamin E, 400 U per

day, or placebo.

At 18 months, 2.2% of vit-E treated patients had experienced the

composite endpoint of MI, stroke and cardiovascular death, compared to

4.7% of subjects

in the placebo group. This finding led to early termination of the

study, the authors report. In comments to Reuters Health, Dr. Levy lead

author stressed,

" It is critically important that this study be repeated before any

treatment recommendations can be made. " If their findings are confirmed,

he concluded,

" Hp genotyping to determine if you should get vitamin E could become

part of the routine management of the individual with diabetes. "

Arterioscler Thromb

Vasc Biol 2008;28.

15.%% NY Times Feb 26, 2008 Screening: Dialysis Can Lower Blood Sugar

Readings A common test to see how well diabetics control blood-sugar

levels tends

to give misleadingly good news when the patients are on hemodialysis,

researchers say...

MW - Glycated Albumin Test Needed to Assess Glucose in Hemodialysis

Patients (Reuters Health) Feb 20 - New research indicates that a

glycated albumin assay

is more accurate than standard HbA1c testing in assessing glycemic

control in diabetic hemodialysis patients. " These results suggest that

the nearly 200,000

diabetic hemodialysis patients in the US who use (HbA1c) may not be

receiving optimal care for their blood sugar, " senior author said in a

statement. Glycated

albumin testing was hypothesized to be more accurate than HbA1c in

assessing glycemic control because it does not rely on red blood cell

survival, which

is typically reduced in hemodialysis patients. The team performed HbA1c

and glycated albumin testing on blood samples obtained from 307

Caucasian

and African-American diabetics, including 258 who were on hemodialysis

for end-stage renal disease. The findings indicated that HbA1c testing

underestimated

glycemic control compared with glycated albumin testing. Moreover, HbA1c

was influenced by the hemoglobin concentration and by the erythropoietin

dose,

whereas glycated albumin was not. " This study supports the glycated

albumin test as a more accurate measure of long-term blood sugar control

among diabetic

patients who are on hemodialysis, " he said. The study confirms a report

by Japanese investigators and is the " first to demonstrate the

inaccuracy of the

HbA1c in black and white dialysis patients. " The glycated albumin test

is not available in the US yet08. February 20th issue of Kidney

International

16.%%MNTD - Link Found Between Excessive Nutrient Levels And Insulin

Resistance 22 Feb 2008 For quite some time now, scientists suspected

the so-called

hexosamine pathway -a small side business of the main sugar processing

enterprise inside a cell - to be involved in the development of insulin

resistance.

But they could never quite

put their finger on the underlying mechanism. Now, researchers at the

Salk Institute for Biological Studies have uncovered the long- missing

molecular

link: the enzyme OGT (short for O-linked ß-– acetylglucosamine

transferase), the last in a line of enzymes that shuttle sugars through

the hexosamine pathway.

Their study revealed that OGT slams the brake on insulin signaling soon

after insulin fires up the machinery that pulls glucose from the blood

stream and

squirrels it away inside liver or stashes the surplus energy in fatpads.

" For the first time we have a real understanding of how the insulin

signaling system is turned on and off, " says the lead researcher. He

hopes that " this

could lead to a new class of insulin-sensitizing drugs that loosen the

brake and let insulin work a little bit longer. " When insulin binds its

receptor

on the cell surface it sets off a cascade of intracellular signals

resulting in the production of PIP3, a specialized lipid molecule that

masterminds a

whole army of molecules that work together to synthesize and store

carbohydrates, lipids and proteins. " But turning on a physiological

process is only

half the story. You also need instructions that tell the cell to get off

the accelerator

and put on the brake. " ..Since the amount of O-GlcNAc is directly tied

to availability of glucose, lipids and other nutrients in the

bloodstream the team

believes that the hexosamine pathway acts as fuel gauge, protecting the

body's cells against the toxic effects of too much glucose and other

high-energy

molecules. Excessive quantities of nutrients - the result of a lifestyle

where food is plentiful and exercise is optional - drive O-GlcNAc levels

up, which

in turn dampen the insulin response, paving the way for a relentless

progression of insulin resistance. .Most people with insulin resistance

go on to develop

T2DM within 10 years. adapted by Medical News Today from original press

release.

17.%% MND - Hypoglycemia Alert Dogs Offer Assistance To People With

Diabetes 20 Feb 2008 Glucose monitors, test strips, and lancets:

people with diabetes

are all too familiar with the equipment used to test their blood glucose

(sugar) levels. Now some people

are adding a different kind of aid to their diabetes management regimen.

The March 2008 issue of Diabetes Forecast, features an article about

assistance

dogs that are trained to sense episodes of human hypoglycemia, or low

blood glucose, and sound a life-saving alert. According to the article,

these dogs

seem to sense a dangerous drop in blood glucose before it begins,

allowing the people they work with to prevent an episode altogether.

Some dogs seem to

sense high blood glucose, too. Mark Ruefenacht is a forensic scientist

with T1DM who started a hypoglycemia alert dog training center in

California

and has been placing trained dogs with people who need them for 3 years.

Scientists remain unsure about how the dogs are able to sense changes in

their

human companions. It is believed that the dogs are reacting to scents

created by chemical changes related to glucose imbalance, but no one

knows exactly

which chemicals cause the scent. Despite this scientific uncertainty,

hypoglycemia alert dogs have provided a great sense of relief to people

with DM and

their families, including parents of young children with DM and adults

whose history of hypoglycemic episodes made it difficult or even

dangerous to live

alone. Currently, there are only a few groups in the US training

assistance dogs to sense hypoglycemia. The training requires years of

expensive work,

which severely limits the number of people who can be paired with dogs.

For those who do get the chance, however, the benefit can be remarkable.

" The

first time that dog gets you up in the middle of the night because your

child is dropping into a serious low, rapidly you realize it's worth

every penny

you spent, and every minute you had to wait, " says Donna Cope, whose

child has diabetes.

18.%% MND - Hispanics Have Higher Levels On Test That Measures Blood

Sugar Control, Study Finds 20 Feb 2008

Among those with DM Hispanics had higher levels than non-Hispanic whites

on a test that indicates how well patients are controlling their blood

sugar [A1C]

which measures hemoglobin levels that are linked with glucose; higher

A1C values indicate that patients have difficulty controlling their

blood sugar.

Researchers looked at 11 studies containing results of A1C tests for

Hispanics and non-Hispanics 18+ The study also found that " the largest

difference

for A1C was among [people enrolled in] nonmanaged care insurance groups

the lead author said.” We found a similar trend in the African-American

population

with DM a year ago. " communication issues and a lack of trust in the

health system might prevent some Hispanics from adequately controlling

their DM.

She said that the study could lead to early treatment and awareness of

how diabetes affects Hispanics. February issue of Diabetes Care, via

Winston Salem

Journal 2/16

19.%% MW - Relationship Between Low Birth Weight and Disorders of

Glucose Regulation 02/15/2008 Disorders of Glucose Regulation in Adults

and Birth Weight:

Results From the Australian Diabetes, Obesity and Lifestyle (AusDiab)

Study Diabetes Care. 2008;31

[11,000 participants that collected fasting and postchallenge glucose

values; 1999-2000. During a 2004-2005 follow-up survey, participants

were asked about their birth weight. The population-attributable risk

for low birth weight for DM was 13.5% in women and 4.8% in men.

Viewpoint - Low birth weight has previously been associated with

increased risk for T2DM but no population-based studies have reported an

association until

now. It has been hypothesized that inadequate nutrition during gestation

results in later-life resistance

to insulin-stimulated glucose uptake but does not affect insulin

secretion. Although the current study can neither confirm nor refute

that hypothesis,

it does support it -- given that the results were strongest in women,

who tend to be more intrinsically insulin resistant. .. birth weights

overall are

relatively high in western societies, but survival of very low birth

weights is higher than ever. it is fascinating to consider that prenatal

care may

have implications

not just for child health, but for long-term adult health as well.

20.%% MW -Effect of Cinnamon on Glucose Control and Lipid Parameters

Diabetes Care. 2008;31(1) Conclusions - In this meta-analysis of 5

randomized placebo-

controlled trials, patients with T1 or T2 receiving cinnamon did not

demonstrate statistically or clinically significant changes in A1C,

FBG,[fasting blood

glucose] or lipid parameters in comparison with subjects receiving

placebo. The median duration of patient treatment and follow-up in all

included trials

was 12 weeks. This duration of treatment is appropriate to observe

clinically significant changes in FBG and lipids. However, it is likely

too short to

see the full effect of treatment on A1C. Still, we would have expected

a trend or tendency toward beneficial changes in A1C..Instead, A1C

levels increased

to a greater extent with cinnamon than with placebo in our

meta-analysis. Cinnamon's ability to prevent diabetes in patients with

pre-diabetes and those

at high risk is unknown.

21.%% MW - Have the Risks of Rosiglitazone Been Exaggerated?

Future Cardiol. 2008;4(1):9-13. ©2008 Future Medicine Ltd.

Conclusions & Implications - The risk for adverse cardiovascular

outcomes for diabetic patients taking rosiglitazone [avandia] is

uncertain: neither increased

nor decreased risk is established. These uncertainties were reflected in

the vote of the Advisory Panel who voted 20:3 in favor of a suggestion

of increased

risk for ischemic cardiac events, but voted 22:1 against pulling it off

the market. The FDA's recent decision to allow rosiglitazone to stay on

the market

with increased black-box warnings about the risk of IHD events also

accurately reflects these uncertainties. In our opinion, reasoned

analysis of additional

data, derived primarily from prospective clinical trials designed

specifically for establishing the cardiovascular benefit

or risk of rosiglitazone, will be required to adjudicate these

inconclusive results and resolve the uncertainties regarding the safety

of rosiglitazone.

It is reassuring that GSK has agreed to conduct a new long-term study to

evaluate the potential cardiovascular risk of rosiglitazone as requested

by the

FDA. Meanwhile, in the face of uncertainty, the best advice for the

practicing clinician is a 'don't stop, don't start' strategy. No need to

stop rosiglitazone

in patients who have tolerated it long term without

any adverse events and whose blood sugars are under good control. No

need to start patients on rosiglitazone before exhausting alternative

treatment options.

22.%% MW -Current Management of Gestational Diabetes Mellitus

Expert Rev of Obstet Gynecol. 2008;3(1) ©2008 Future Drugs Ltd.

2/18/2008 Abstract - Diabetes mellitus is one of the most common medical

complications of pregnancy; gestational DM (GDM) accounts for

approximately 90-95%

of all cases. GDM is defined as carbohydrate intolerance of variable

severity with onset or first recognition during pregnancy. It has been

demonstrated

that good metabolic control maintained throughout pregnancy can reduce

maternal and fetal complications in diabetes. Diet is the mainstay of

treatment

in GDM, but physical activity is a helpful adjunctive

therapy when euglycemia is not achieved by diet alone. When diet and

exercise fail to maintain euglycemia, exogenous insulin is used.

Traditionally, insulin

therapy has been considered the gold

standard for management. The American College of Obstetricians and

Gynecologists and ADA do not currently recommend oral hypoglycemic

agents as a treatment

for GDM. Concerns regarding safety demand further well-designed studies.

23.%% MW-Autonomic Regulation of the Association Between Exercise and

Diabetes Exerc Sport Sci Rev. 2008;36(1) 2/19/2008

Summary - The autonomic nervous system is an attractive mechanism to

evaluate in the association between physical activity and diabetes

incidence. One

of the most compelling reasons is the responsiveness of the autonomic

nervous system to lifestyle changes. Increasing physical activity levels

has numerous

primary and secondary benefits that are realized independent of the

challenging goal of weight loss. The positive impact of physical

activity on autonomic nervous system functioning may prove to be a key

benefit in diabetes prevention.

24.%% MW- Early Detection and Significance of Structural Cardiovascular

Abnormalities in Patients With Type 2 Diabetes Mellitus Expert Rev

Cardiovasc

Ther. 2008;6(1) 2/15/2008

Abstract - Cardiovascular disease is the leading cause of death among

patients with T2DM. The main forms of structural heart disease

associated with diabetes

are coronary heart disease and diabetic cardiomyopathy, which is

characterized by left ventricular hypertrophy, left ventricular

diastolic and systolic

dysfunction. Asymptomatic structural heart disease is common and

associated with a poor prognosis in patients with DM. Contemporary

practice guidelines

do not recommend screening of asymptomatic individuals for structural

heart disease. Potential screening modalities, such as echocardiography,

are costly

and inaccessible. A simple, inexpensive blood test for brain natriuretic

peptide is a useful marker of structural heart disease and is a prime

candidate

for screening patients with T2 and prioritizing referral for

echocardiography...A simple blood test, brain natriuretic peptide (BNP),

is emerging as a

potential screening tool. The cardiac ventricles secrete BNP in response

to an increase in wall stress. BNP, which has multiple actions including

diuresis,

has emerged as an important cardiac neurohormone with multiple potential

roles in the management of patients with cardiac dysfunction...

25.%% MW -Vildagliptin Improves Control of Type 2 Diabetes With Mild

Hyperglycemia (Reuters Health) Feb 18 - Vildagliptin, [galvus] a potent

and selective

dipeptidyl peptidase-IV (DPP-4) inhibitor, produces long-term

improvement in beta-cell function and glycemic control in patients with

T2DM and mild hyperglycemia,

according to a new report. " Improvement of glucose control, which was a

known fact for vildagliptin, is paralleled, and likely caused, by an

improvement

of beta-cell function, " Dr. A. Mari told Reuters Health. [ effects of 1

year of treatment with vildagliptin versus placebo on beta-cell function

in 306

patients with T2 and only mild hyperglycemia (HbA1c of 6.2%-7.5%).

Vildagliptin significantly increased insulin secretion rate (by 17%),

and glucose sensitivity

(by 40%), compared to placebo. " Because none of the effects of

vildagliptin were maintained after a 4-week washout period, we conclude

that longer term

studies would be necessary to determine whether DPP-4 inhibition

modifies disease progression, " the authors add. J Clin Endocrinol Metab

2008;93

26.%% MW - Does Waist Circumference Predict Diabetes and Cardiovascular

Disease Beyond Commonly Evaluated Cardiometabolic Risk Factors? Diabetes

Care.

2007;30(12) Posted 02/22/2008 Objective: While the measurement of

waist circumference (WC) is recommended in current clinical guidelines,

its clinical

utility was questioned in a recent consensus statement. In response, we

sought to determine whether WC predicts DM and cardiovascular

disease (CVD) beyond that explained by BMI and commonly obtained

cardiometabolic risk factors including BP, lipoproteins, and glucose.

[5,882 adults from the 1999-2004 National Health and Nutrition

Conclusions: WC predicted DM, but not CVD, beyond that explained by

traditional cardiometabolic risk factors and BMI. The findings lend

critical support

for the recommendation that WC be a routine measure for identification

of the high-risk, abdominally obese patient.

AFB - Amer Foundation for the Blind

Abbreviations: T1DM - type 1 diabetes mellitus T2DM - type 2; ADA -

American Diabetes Association; BP - blood pressure; DM - diabetes

Mellitus;HTN - hypertension;

MW Medscape Web MD; FDA Federal Drug Administration; NIH - National

Institutes of Health; VA - Veterans Administration. MND- Medical News

Today Definitions

- Dorlands 31st Ed and Google. Disclaimer, I am a BSN RN but not a

diabetic or diabetic educator. Reports are excerpted unless otherwise

noted. This project

is done as a courtesy to the blind/visually impaired and diabetic

communities. Dawn Wilcox Coordinator The Health Library at Vista Center

contact above

e-mail or thl@...