QD: News Every Day

Health care reform
Nothing good gets done until a committee has considered it. Now, the Senate Finance Committee put off voting on health care reform until the Congressional Budget Office chimes in with estimate of how much it will cost.

Flu vaccination
Health departments in three states began administering the first of the 7 million currently available H1N1 flu vaccine doses this week. Don't sweat it if your state wasn't one of them; 40 million doses will be available by mid-October and 10 million to 20 million will become available each week after that.

Globally, the World Health Organization has begun mass vaccination campaigns in China and Australia and will be starting soon in the U.S. and Europe. Worldwide, governments have ordered 440 million doses of GlaxoSmithKline's H1N1 vaccine Pandemrix.

In case you missed it ...
The U.S. fares worse than other industrialized countries in rates of preventable deaths--premature deaths caused by diabetes, epilepsy, stroke, influenza, ulcers and pneumonia--and has been falling further behind over the past decade, according to a Commonwealth Fund study published in the journal Health Affairs.

Labels: Diabetes, flu, H1N1, health care reform, QD, stroke

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posted by Ryan DuBosar at 12:30 PM   0 Comments

Saving health and money

Last month, I asked for some data on the cost-effectiveness of preventive care. The American Journal of Public Health has obliged. In a new study reported by HealthDay, researchers evaluated the cost and health benefits to be gained by preventing several chronic diseases. They found that preventing a patient's hypertension would save $13,702 in lifetime medical spending, while prevention of diabetes would save $34,483, and preventing obesity would save $7,168. Unfortunately, those cost arguments for tobacco cessation programs turn out to be wrong: quitting smoking would result in an increase of $15,959 in lifetime medical costs.

Since only the abstract of the study is free, I also didn't get to find out how one would successfully prevent all these conditions. The key to preventing obesity, especially, seems like a secret we would all like to know.

Labels: Diabetes, health care cost, hypertension, obesity, prevention, smoking cessation

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posted by Stacey Butterfield at 1:00 PM   0 Comments

Mediterranean diet trumps low-fat diet for diabetes management

Researchers compared the effects of a Mediterranean-style diet versus a typical low-fat diet for diabetes management in one of the longest-term randomized trials of its kind to assess their effectiveness, durability and safety on the need for diabetes medications in overweight patients with newly-diagnosed type 2 diabetes.

Researchers randomly assigned 215 patients to follow either a low carbohydrate, Mediterranean-style diet or a low-fat diet for four years. Nutritionists and dietitians counseled both groups in monthly sessions for the first year and bimonthly sessions for the next three years. Patients on the low-carbohydrate Mediterranean diet avoided medication, lost more weight, and decreased some coronary risk factors. Results were reported in Annals of Internal Medicine.

After four years, 44% of patients in the Mediterranean-style diet group required antihyperglycemic drug therapy compared to 70% in the low-fat diet group. Patients in the Mediterranean diet group also experienced greater weight loss and an improvement in some coronary risk factors.

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Labels: Diabetes, diet, obesity, weight loss

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posted by Ryan DuBosar at 7:00 AM   0 Comments

Getting poetic about it

An new article from JournalWatch uses a line of poetry to make the case that tight control for type 2 diabetes should be abandoned. The author convincingly points out how the evidence base shows more harm than benefit to be gained from driving A1cs down. But we wonder what's next: a haiku against drug-eluting stents? sonnets on sepsis?

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posted by Stacey Butterfield at 11:46 AM   0 Comments

A collection of diabetes tidbits

I spent today at an Internal Medicine 2009 precourse on diabetes and picked up a lot of miscellaneous interesting info, particularly during the session by Irl Hirsch, FACP, on monitoring in diabetes.

• Most common reason that patients' finger-sticks are inaccurate? They don't wash their hands beforehand. If you eat an orange, then test blood from one of your sticky fingers, the glucose from the fruit could make the result inaccurately high.
• But should your type 2 patients who aren't on insulin even be bothering to self-monitor? Given that there's no proof that home testing affects outcomes and test strips are expensive, Dr. Hirsch sees the main use being special occasions, like when a patient is eating something new and wants to see how her blood sugar responds.
• A1cs are good, but not perfect. Anemia, in particular, can make their results inaccurate. Also, did you know that half of an A1c result is determined by glucose levels over the previous 30 days?
• The newest big thing in diabetes monitoring--real-time continuous glucose monitors. They work great (i.e., significantly lower A1cs) if patients wear them all the time and pay attention to them, Dr. Hirsch said. Best used by patients and physicians who are tech-savvy and willing to devote some real time and attention.
• The next big thing, however, could turn out to be a very old thing--urine glucose testing. If a currently underway study proves that it's as effective as home blood testing, payers could push for a move back to the older, cheaper option.
• In the afternoon, David Kendall, MD, made a convincing case for incretin-based therapies. In addition to improving insulin secretion and response, the drugs reduce food intake and cause weight loss. So how to decide if exentide and the other on-their-way-to-market options in the class are right for your patients? That was a little fuzzier--you'll know 'em when you see 'em was the gist of his message.

Labels: Diabetes, internal medicine 2009

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posted by Stacey Butterfield at 3:11 PM   0 Comments

What's the big deal?

I'm mystified by the attention and press coverage that a new study in JAMA about dietary options for type 2 diabetics has attracted. The Canadian nutrition research found a very small difference in A1c levels resulting from two different diets (a .5% drop in patients who ate low-glycemic-index vs. a .18% decrease in those who ate a high-fiber diet). The results were less than overwhelming, but if these dietary changes are easy, maybe they're worth suggesting, right?

Good luck. The primary distinctions between the two diets are so miniscule that an obsessive-compulsive dieting teenager would have trouble keeping track, let alone your average overweight type 2 patient. To quote from the study, the first group was encouraged to eat "low-glycemic index breads (including pumpernickel, rye pita, and quinoa and flaxseed) and breakfast cereals (including Red River Cereal [hot cereal made of bulgur and flax], large flake oatmeal, oat bran, and Bran Buds [ready-to-eat cereal made of wheat bran and psyllium fiber])" while the other group ate "whole grain breads; whole grain breakfast cereals."

And what do both these dietary plans have in common? Carbs!

There are some potential significant differences hidden in the details of the diets (the low GI list included nuts, while the high-fiber people ate potatoes). Might that have been responsible for the differential in A1cs? We'll never know, because the effects were buried under the details of the cereal aisle.

It's a pet peeve of mine how little attention the relationship between carbs and blood sugar gets in diabetes care recommendations. It's one thing to suggest that obese patients cut the fat, but having people obsess over bread varieties instead of just eating their sandwiches open-faced? Frustrating.

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posted by Stacey Butterfield at 12:54 PM   0 Comments

Celebrating World Diabetes Day with a splash

Color-coding of disease awareness has become pretty standard--we all know about red dresses for heart disease and the ACP building was bathed in pink light last month to recognize breast cancer.

But the International Diabetes Foundation has taken things to a new level. Today is World Diabetes Day, and to recognize that, a famous Belgian statue of a small boy is peeing blue. (You know, because diabetes makes you pee, and well, blue wasn't taken by any high-profile disease yet.) They've also got some interesting fundraisers going on, like Desert Dingo Racing.

All in support of a good cause though--raising awareness of diabetes in children. We all know about the obesity-driven increase in type 2 diabetes among juveniles, but type 1 is also on the rise, according to the IDF, increasing 5% per year in pre-school children. Which seems like a lot, doesn't it?

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posted by Stacey Butterfield at 4:45 PM   0 Comments

A diabetes therapy from the future

Rather than putting patients with type 2 diabetes through the pain and risk of gastric bypass, physicians may soon be lining diabetic intestines to induce weight loss and control blood sugar. Researchers at the First World Congress on Interventional Therapies for Type 2 Diabetes reported on a cool new device (with a slightly less appealing name--the EndoBarrier Gastrointestinal Liner) which is inserted endoscopically and then alters the way food is absorbed by the digestive system.

As reported in the Washington Post, a trial of 18 patients (the device has been put into 118 people total) resulted in an average weight-loss of 27.5 pounds by 31 weeks, and improved glucose control as soon as a week after surgery. The studies were, of course, funded by the manufacturer and need more confirmation. And yes, having a plastic bag put down your gullet sounds gross, but it sure beats having your stomach stapled.

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posted by Stacey Butterfield at 9:15 AM   0 Comments

Some diabetic food for thought

In the course of reporting for an upcoming article on prediabetes (arriving online and in print in about a month), I interviewed endocrinologist Irl B. Hirsch, FACP, and he offered a few tidbits that didn't fit into the story but seemed worth sharing:

An increase in type 1 diabetes among adults. When asked what was the one thing he'd most like primary care docs to do to improve diabetes care, Dr. Hirsch suggested that they be alert to the fact that not all middle-aged new diabetics are type 2. "In my era we were all taught type 1 is kids, type 2 is adults. Often these people are misdiagnosed as type 2s. They are treated with pills, yet they need insulin," he said. Experts aren't sure why, but there's been a serious uptick in these cases in recent years, so if you see high glucose in a thin patient without a strong family history for example, keep type 1 in mind, Dr. Hirsch advised.

New ideas about screening methods. Citing a recent paper in the Journal of Clinical Endocrinology and Metabolism, Dr. Hirsch suggested that there may be a movement afoot to use A1cs as a diabetes screening tool. A1cs are reliable, don't require fasting and reflect longer-term glycemia, the consensus of experts who wrote the paper concluded. "What's interesting about that is that nobody recommends that we use A1c's for screening but about 50% of physicians already do," said Dr. Hirsch.

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posted by Stacey Butterfield at 11:00 AM   0 Comments

Booklet for pregnant patients with diabetes

On the heels of a study that found pre-pregnancy diabetes increases the risk for birth defects, the NIDDK is giving away a patient guide: "For Women with Diabetes: Your Guide to Pregnancy".

It's a 44-page booklet with info about checking and controlling blood glucose, maintaining a healthy diet, staying active and taking tests and diabetes medications during pregnancy. It also includes logs for recording daily blood glucose and ketone levels, food intake and physical activity.

The new booklet is available online in English, with a Spanish version coming soon.

You can also order a print copy via this site or by calling 1-800-860-8747.

Labels: Diabetes, patient education, pregnancy

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posted by Jessica Berthold at 3:10 PM   0 Comments

Guidelines aim to clarify treatment of pre-diabetes

The American College of Endocrinology last week issued its first guidelines on managing patients with pre-diabetes, suggesting aggressive lifestyle control as the first line of defense in warding off full-blown disease, followed by selective drug treatment and frequent monitoring of symptoms.

The guidelines recommend prescribing metformin or acarbose to high-risk patients, such as those with cardiovascular disease or worsening glycemia; statins to lower LDL cholesterol to 100 mg/dL; and ACE/ARB inhibitors to reach target blood pressure of 130/80 mmHg. Patients should undergo glucose and microalbuminuria testing annually and have fasting plasma glucose, hemoglobin A1C and lipids tests every six months, the guidelines state.

Physicians often have little success getting patients to embrace lifestyle changes, such as following a low-fat diet and exercising daily, as recommended in the guidelines. Will the new recommendations encourage more use of medications to control symptoms in patients at risk for diabetes? What are you doing in your practice?

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posted by Janet Colwell at 2:06 PM   4 Comments