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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@...

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