ADA releases 2020 standards of medical care in diabetes

by University of North Carolina at Chapel Hill School of Medicine

John Buse, MD, Ph.D. Credit: University of North Carolina at Chapel Hill School of Medicine

A strong recurring message of individualizing patient care is echoed throughout the American Diabetes Association's Standards of Medical Care in Diabetes—2020 published recently. Based on the latest scientific diabetes research and clinical trials, the Standards of Care includes new and updated recommendations and guidelines for caring for people with diabetes, including individualized recommendations for treatment of cardiovascular disease based on patients' pre-existing conditions, special considerations for older adults with type 1 diabetes, and revised recommendations and additional supporting evidence for use of rapidly changing diabetes technology.

03 jan 2020--Also, the ADA released: 2019 Update to Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), which includes complimentary information on the treatment of type 2 diabetes based on important research findings from large cardiovascular outcomes trials published in 2019 and has been incorporated into the Standards of Care—2020.

John Buse, MD, Ph.D., the Verne S. Caviness Distinguished Professor of Medicine, Division Chief of Endocrinology and Metabolism, and Director of the NC Translational and Clinical Sciences (TraCS) Institute, led the writing of the update, which includes:

• The decision to treat high-risk individuals with a glucagon-like peptide 1 (GLP-1) receptor agonist or sodium–glucose cotransporter 2 (SGLT2) inhibitor to reduce major adverse cardiovascular events (MACE), hospitalization for heart failure (hHF), cardiovascular death, or chronic kidney disease (CKD) progression should be considered independently of baseline HbA1c or individualized HbA1c target;
• GLP-1 receptor agonists can also be considered in patients with type 2 diabetes without established cardiovascular disease (CVD) but with the presence of specific indicators of high risk; and
• SGLT2 inhibitors are recommended in patients with type 2 diabetes and heart failure, particularly those with heart failure with reduced ejection fraction, to reduce hHF, MACE, and CVD death, as well as in patients with type 2 diabetes with CKD to prevent the progression of CKD, hHF, MACE, and cardiovascular death.

The recommendations for treatment of cardiovascular disease, which is the leading cause of morbidity and mortality for individuals with diabetes, have now been individualized based on patients' risks, including the presence of atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk factors, diabetic kidney disease, or heart failure.

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More information: John B. Buse et al. 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), Diabetes Care (2019). DOI: 10.2337/dci19-0066

Journal information: Diabetes Care 

Provided by University of North Carolina at Chapel Hill School of Medicine 

Treating diabetes in older adults requires simpler medication regimens, looser glycemic targets

by The Endocrine Society

Simplifying medication regimens and tailoring glycemic targets in older adults with diabetes improves adherence and avoids treatment-related complications, according to a Clinical Practice Guideline issued today by the Endocrine Society. The Society debuted the guideline during a press conference on the opening day of ENDO 2019, its annual meeting in New Orleans, La.

24 mar 2019--The guideline, titled "Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline," was published online and will appear in the May 2019 print issue of The Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of the Endocrine Society. The guideline focuses on treatment strategies that take into consideration the overall health and quality of life of older adults with diabetes, defined as age 65 or older.

Aging plays a major role in the development of diabetes, which currently affects an estimated 33 percent of older adults in the U.S. Older adults with diabetes often have one or more co-existing conditions such as cognitive impairment, cardiovascular disease, impaired vision, and rheumatoid arthritis, which affect diabetes self-management.

"The guideline encourages clinicians to consider available evidence and a patient's overall health, likelihood to benefit from interventions and personal values when considering treatment goals such as glucose, blood pressure, and cholesterol," said Derek LeRoith, M.D., Ph.D., of Mount Sinai School of Medicine in New York, N.Y. LeRoith chaired the writing committee that developed the guideline. "Our framework prioritizes blood glucose targets over the hemoglobin A1c test when managing diabetes in older adults."

Recommendations from the guideline include:

• Simplifying medication regiments and tailoring glycemic targets in older adults with diabetes and cognitive impairment (e.g. dementia) to improve compliance and prevent treatment-related complications
• Designing outpatient diabetes regimens specifically to minimize hypoglycemia
• Targeting blood pressure levels of 140/90 mmHg to decrease the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease in older adults with diabetes aged 65 to 85 years
• Using an annual lipid profile to reduce the amount of "bad cholesterol" in the blood
• Administering annual comprehensive eye exams to detect retinal disease
• Establishing clear blood sugar targets for older adults with diabetes in hospitals or nursing homes at 100-140 mg/dL (5.55-7.77 mmol/L) fasting and 140-180 mg/dL (7.77-10 mmol/L) after meals while avoiding hypoglycemia

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Provided by The Endocrine Society

New guidance on treating diabetes in elderly and frail adults

New guidance has been published on managing diabetes in the elderly, including for the first time how to manage treatment for the particularly frail.

30 may 2018--The guidance was produced from a collaboration between experts in diabetes medicine, primary care and geriatric medicine, led by Dr. David Strain at the University of Exeter Medical School.
It will advise clinicians on helping elderly people with type 2 diabetes get the most out of treatment options, and for the first time contains guidance on how and when to stop diabetes treatments in particularly frail adults.
Dr. Strain said: "Older adults have been systematically excluded from clinical trials and have very different ambitions from their diabetes management. This guidance puts the older person with diabetes firmly back at the centre of target setting, ensuring that appropriate goals are agreed to achieve the best quality of life possible, without continuing treatments that would not provide any benefit and potentially cause harm."
The research was carried out in collaboration with NHS England and was published in Diabetic Medicine, the journal of Diabetes UK last month.
The report authors hope it will ultimately be incorporated into national guidance for GPs, to advise GPs on the management of type 2 diabetes in elderly adults, aiming to reduce complications and improve quality of life.
The guidance will be adopted across Devon immediately. The authors hope local health and care commissioners will adopt and implement these principles in their own areas.
Pav Kalsi, Senior Clinical Advisor at Diabetes UK, said: "People with diabetes rightly deserve to have access to the right care and support at every stage of their life, and that means the care they receive needs to be adapted and tailored to suit each individual's changing needs. For example, those who are elderly, and potentially frail, often have different priorities, such as safety and quality of life.
"We're really pleased that these new guidelines will, for the first time, help healthcare professionals give this tailored support and will help them review and decide whether to stop diabetes treatment for particularly frail adults.
"In the future, we hope these guidelines will have a positive impact on the lives of older people with diabetes."
The paper, 'Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative', is available online.

More information: W. D. Strain et al, Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative, Diabetic Medicine (2018). DOI: 10.1111/dme.13644


Provided by University of Exete

Weight loss over two years predicts reduced diabetes risk

23 july 2014—Weight loss over two years is associated with reduced diabetes incidence and improvement in cardiometabolic risk factors, according to a study published online July 14 in Diabetes Care.

Linda M. Delahanty, R.D., from Massachusetts General Hospital in Boston, and colleagues examined measures of weight loss in relation to incident diabetes and cardiometabolic risk factors. Data were collected for 1,000 participants in the Diabetes Prevention Program lifestyle intervention arm. They analyzed nine weight measures, characterizing baseline weight, short- versus long-term weight loss, short- versus long-term weight regain, and weight cycling. The authors sought to examine predictors of incident diabetes and improvement in cardiometabolic risk factors.

The researchers found that weight loss in the first six months was protective of diabetes (hazard ratio, 0.94 per kg; P < 0.01) and cardiometabolic risk factors (P < 0.01); however, long-term weight loss (from zero to two years) was the strongest predictor of decreased incidence of diabetes (hazard ratio, 0.90 per kg; P < 0.01) and cardiometabolic risk factor improvement (for example, fasting glucose; P < 0.01). Per participant, weight cycling ranged from zero to six times and correlated positively with incident diabetes (hazard ratio, 1.33; P < 0.01), fasting glucose (P = 0.02), homeostatic model assessment insulin resistance (P = 0.04), and systolic blood pressure (P = 0.01). The effect of weight cycling was significant for diabetes risk (hazard ratio, 1.22; P = 0.03), but not for cardiometabolic traits, after adjustment for baseline weight.

"Two-year weight loss was the strongest predictor of reduced diabetes risk and improvements in cardiometabolic traits," the authors write.

Pharmaceutical, nutrition, and exercise industries donated materials, equipment, or medicines and/or supported the study.

More information: Abstract 

Low number of taste buds linked to older age, higher fasting blood sugar

A study finds that the number of taste buds we have on our tongue decreases as we get older, and that the lower the number of taste buds, the more likely for fasting blood glucose (sugar) levels to be higher than normal. The results were presented Sunday at the joint meeting of the International Society of Endocrinology and the Endocrine Society: ICE/ENDO 2014 in Chicago.

24jun 2014--Because high fasting blood sugar level is a main characteristic of diabetes, the study findings suggest that the number of taste buds plays a role in glucose metabolism—how the body uses sugar—during aging, the authors proposed.

"The reduced number of taste buds with advancing age might be linked to the increased incidence of Type 2 diabetes among older adults," said the study's lead investigator, Chee Chia, MD, a medical officer at the National Institute of Aging (NIA) in Baltimore.

Diabetes affects more than 25 percent of Americans over age 65, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

Chia explained why she and a co-worker at the NIA, Josephine Egan, MD, thought there might be a connection between taste buds and diabetes. Taste buds at the tip of the tongue, whose medical term is "fungiform papillae," contain sweet taste receptors, and past studies show that people with Type 2 diabetes have impaired sweet taste. Furthermore, animal studies suggest that taste buds produce hormones that are important for glucose metabolism and that, in rodents, taste buds decrease in number with age.

To learn whether humans also have an age-related decline in the density of taste buds, Chia and Egan analyzed data from 353 adults who participated in the NIA's Baltimore Longitudinal Study of Aging between 2011 and 2014. This ongoing observational study of normal aging in community-dwelling volunteers included counts of the density, or number, of taste buds at the tip of the tongue after staining the subject's tongue with blue food dye.

The researchers found that older age was associated with fewer taste buds, a finding also seen in a larger clinical study published last October (Beaver Dam Offspring Study).

In addition, Chia reported that the fewer taste buds that subjects had, the higher their fasting blood sugar levels were and the less they had of a beneficial fat cell hormone called adiponectin. Prior studies found that obesity and Type 2 diabetes are associated with lower adiponectin levels.

"To my knowledge, this is the first association found between the number of taste buds and fasting glucose," Chia said. "It's very possible they could be unrelated, so we plan to do the study over a longer time, to confirm our findings."

"It's also possible," she added, "that having fewer taste buds means fewer hormones are secreted that may control glucose metabolism."

Provided by The Endocrine Society

Are the new ACC/AHA guidelines for lipids appropriate for people with diabetes?

New guidelines for the treatment of high cholesterol are not appropriate for people with type 2 diabetes – or are they? Two researchers will debate the topic at a symposium to be held on Tuesday, June 17, at the American Diabetes Association's 74th Scientific Sessions.

16 jun 2014--At issue are the newest guidelines issued jointly by the American College of Cardiology and American Heart Association in November 2013. Previous guidelines for treating people with high cholesterol were based upon cutpoints for low-density lipoprotein (LDL) cholesterol levels (the so-called "bad" cholesterol). People whose cholesterol levels hit those cutpoints were asked to initiate dietary changes, and, if that failed to lower levels sufficiently, statin therapy was recommended.

The new guidelines divide patients into four groups for whom statin treatment is recommended: individuals with cardiovascular disease; individuals with LDL cholesterol (LDL-C) levels higher than 190 mg/dL; individuals with diabetes, between the ages of 40-75, with LDL-C levels 70-189 mg/dL; and individuals without diabetes or cardiovascular disease, with LDL-C 70-189 mg/dL, and an estimated risk of cardiovascular disease greater than 7.5 percent. There are no specific target levels for lowering cholesterol, only the recommendation that statins be used to reduce it.

Under the new guidelines, the vast majority of people with type 2 diabetes would be recommended for statin therapy. But is that the right call?

Robert H. Eckel, MD, Professor of Medicine and Charles A. Boettcher Chair in Atherosclerosis at the University of Colorado, Anschutz Medical Campus, says, "Yes. Almost all people with diabetes should be on a statin. That's what the evidence tells us. You may not like the new guidelines, but these are evidence-based and this is what the evidence says."

Henry Ginsberg, MD, Irving Professor of Medicine and Director of the Irving Institute for Clinical and Translational Research at Columbia University, disagrees. "The guideline committee used the evidence-based construct much too narrowly," he said.

Ginsberg explained that he agreed with the recommendation to examine a person's risk for cardiovascular disease as well as their cholesterol level when determining whether to prescribe a statin. But he did not agree with the removal of target LDL cholesterol goals once a person is being treated with medication, or with the lack of recommendations for additional or alternative therapies.

"There are people who can't take a high dose of a statin, or who won't respond as well to a high dose," he said. "In that case, you should be adding another medication. The new guidelines try to make it too simple."

Ginsberg said the new guidelines actually ignore evidence that shows the lower a patient's LDL-C level, the better. "How do you get to those lower levels if statins alone aren't enough?" he asked. "You add a non-statin."

But Eckel said that exceptions, which often come up in patients with diabetes, are addressed in the new guidelines by suggesting that physicians make a judgment call. "It should be an educated judgment, though, based on an understanding of the increased risk of heart disease and stroke for people with diabetes."

The American Diabetes Association recommends that people with diabetes keep LDL-C levels at or below 100 mg/dL, or under 70 mg/dL if they also have cardiovascular disease. The Association recommends using high-dose statin therapy to reach those goals.

Ginsberg said he agrees with the Association's present guidelines, noting that they are based on a wealth of data that includes, but is not restricted to, randomized clinical trials.

Provided by American Diabetes Association

Severe hypoglycemia in diabetes tied to cardiac disease

For patients with type 1 and type 2 diabetes, severe hypoglycemia is associated with severe hypertension, hypokalemia, and QT prolongation, according to a study published online Aug. 12 in Diabetes Care.

For patients with type 1 and type 2 diabetes, severe hypoglycemia is associated with severe hypertension, hypokalemia, and QT prolongation, according to a study published online Aug. 12 in Diabetes Care.

19 aug 2013—For patients with type 1 and type 2 diabetes, severe hypoglycemia is associated with severe hypertension, hypokalemia, and QT prolongation, according to a study published online Aug. 12 in Diabetes Care.

Tetsuro Tsujimoto, M.D., from the National Center for Global Health and Medicine in Tokyo, and colleagues conducted a retrospective cohort study to assess vital signs, QT intervals, and newly diagnosed cardiovascular disease during severe hypoglycemia in patients with type 1 and type 2 diabetes. A total of 414 cases of severe hypoglycemia that could not be resolved by the patients themselves in a pre-hospital setting were included in analyses.

The researchers observed no significant difference in the median blood glucose levels between patients with type 1 (88 patients) and type 2 (326 patients) diabetes. In the type 1 diabetes group, the incidences of severe hypertension, hypokalemia, and QT prolongation were 19.8, 42.4, and 50.0 percent, respectively. For patients with type 2 diabetes, the corresponding proportions were 38.8, 36.3, and 59.9 percent, with a significant difference for the incidence of severe hypertension between the groups. Only in the type 2 diabetes group were newly-diagnosed cardiovascular disease during severe hypoglycemia (1.5 percent) and death (1.8 percent) observed. There was a significant difference in the type 2 diabetes group for blood glucose levels between the deceased and surviving patients.

"Type 1 and type 2 diabetic patients with severe hypoglycemia experienced many critical problems that could lead to cardiovascular disease, fatal arrhythmia, and death," the authors write.

More information: Abstract
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Diabetes guidelines linked to severe low blood sugar in frail elderly

When an independent senior health program implemented new recommended diabetes blood sugar guidelines, episodes of severe hypoglycemia (low blood sugar) tripled among frail elderly patients, according to a study led by Sei J. Lee, MD, a geriatrician at the San Francisco VA Medical Center.

23 may 2011--The study, which was published in the April 2011 issue of the Journal of the American Geriatrics Society, was the first to measure what happened when the guidelines, developed in 2003 by the American Geriatrics Society, were implemented among frail elders, said Lee. The study focused on outcomes at On Lok Senior Health, in San Francisco.

The guidelines call for a hemoglobin A1c level of less than 8 percent. The hemoglobin A1c test, which measures average blood sugar over the previous three months before the test, is considered an indicator of long-term blood sugar control for diabetics.

The long-term goal of such guidelines is the avoidance of vascular complications — including heart attack, stroke, and kidney disease — that are brought about by chronically high blood sugar, which damages circulation in small blood vessels. In order to accomplish this goal, blood sugar is monitored frequently during the day, and kept relatively low through diet, medications, and insulin injections — a regimen known as tight control.

When the frail elders were put on tight control, reported Lee, “there was good news and bad news.” The good news, he said, was that the incidence of hyperglycemia — blood sugar higher than 400 — decreased dramatically compared to pre-guideline levels.

At the same time, episodes of severe hypoglycemia — blood sugars of less than 50 that required trips to the emergency room — increased threefold. “These episodes were quite dangerous for these seniors,” said Lee. “When blood sugar gets too low, patients can become confused, they can fall, they can even become comatose. It can become life-threatening very quickly.”

Significantly, the increase in hypoglycemic episodes occurred during the first 18 months of the guidelines’ implementation; for the two years after that, the rate was similar to what it was before the guidelines were introduced. One possible explanation, according to the authors, is that a small number of patients are especially at risk of severe hypoglycemia in response to even a modest tightening of control. Once those patients have a severe hypoglycemic episode and are identified, the rest are treated successfully with the aggressive regimen.

“This says that the period when you are first implementing tighter control is the time of greatest risk,” said Lee. “That is the time to require closer follow-up of patients in order to make sure that these adverse effects are not occurring.”

Lee noted that the study took place under “ideal conditions” for implementing tight control with a minimum of bad outcomes: “This is a program where patients are seen several times a week, and where health care providers know exactly what medications they are taking, what and how much they’re eating, and how much physical activity they’re getting.”

If the occurrence of severe hypoglycemia increased even under these circumstances, said Lee, “then for the general population of the frail elderly, who are not monitored nearly as closely as our study population, the current guideline may be too aggressive.”

More information: http://onlinelibra … 03362.x/full

Provided by University of California, San Francisco

Raise A1C targets in elderly diabetics: study

NEW YORK 21 may 2011--- In older diabetics, the hemoglobin A1C level should be maintained below 8.0% but generally not below 6.0%, researchers advise.

In an April 19th online paper in Diabetes Care, Dr. Elbert S. Huang of the University of Chicago and colleagues cite evidence for a U-shaped relationship between mortality and A1C levels.

Medical organizations don't agree on suitable targets in the elderly, they say.

"For clinicians and older patients living with diabetes, I believe the study emphasizes the importance of working together to select the optimal glucose control target for the individual patient. We hope that the information contained within the study can serve as a basis for that discussion," Dr. Elbert S. Huang told Reuters Health by email.

Dr. Huang and his group retrospectively studied more than 71,000 patients over 60 years old with type 2 diabetes, using data from Kaiser Permanente Northern California for the years 2004- 2008.

The average age was 71 and the mean A1C level was 7.0%. The risk of non-fatal complications rose when A1C climbed above 6.0%. Adjusted hazard ratios were 1.09 for an A1C of 6.0 to 6.9%, and 1.86 for an A1C of 11.0% or more.

As recognized before, mortality had a U-shaped relationship with A1C. Compared to levels below 6.0%, levels between 5% and 9% were linked with lower rates of death.

After adjustment for other variables, the lower mortality risk with A1C levels between 8.0% and 8.9% was no longer significant. The hazard ratio for levels of 7.0 to 7.9% was 0.83, but 1.31 at levels of 11.0% and beyond.

Risks of complications or death became significantly higher at AICs of 8.0% or more. These patterns were generally similar across age groups ranging from 60 to more than 80 years.

Dr. Huang thinks the results will help to refine suitable targeting. Also, he said, "I think that the study findings on mortality call out for more research to understand why near normal blood sugars have a link to mortality."

SOURCE: http://bit.ly/jpDvnR

Diabetes Care 2011.

Look AHEAD Results Favor Intensive Lifestyle Intervention

At four years, this diabetes intervention beats education for CVD risk factor reduction

29 sept 2010 -- Intensive lifestyle intervention (ILI) for patients with type 2 diabetes can result in sustained improvements in cardiovascular risk factors and in fitness, according to a report published in the Sept. 27 issue of Archives of Internal Medicine.

Rena R. Wing, Ph.D., of Brown Medical School in Providence, R.I., and other members of The Look AHEAD Research Group reported four-year results of the ongoing trial, which was designed to obtain long-term data on the effects of ILI compared to diabetes support and education (DSE; the control group) on changes in weight, fitness, and cardiovascular disease risk factors.

Averaged across the four years, the researchers found that ILI patients had significantly greater improvements in weight, treadmill fitness, hemoglobin A1c level, high-density lipoprotein cholesterol, triglycerides, and blood pressure. Low-density lipoprotein cholesterol was more improved in the DSE group, a finding related to greater use of lipid-lowering medications in the DSE group.

"ILI can produce sustained weight loss and improvements in fitness, glycemic control, and cardiovascular disease risk factors in individuals with type 2 diabetes. Whether these differences in risk factors translate to reduction in cardiovascular disease events will ultimately be addressed by the Look AHEAD trial," the authors write.

One author disclosed serving on a scientific advisory committee for Free & Clear and financial relationships with BodyMedia Inc., UPMCHealth Plan, and Proctor & Gamble.

Abstract

Mental decline from diabetes can start in middle age

NEW YORK , 13 jun 2010– Diabetes can lead to a decline in memory, thinking speed, and mental flexibility in middle age, but controlling the blood sugar disorder might prevent some of these effects, new research from the Netherlands suggests.

While the mental decline may be invisible to the individual, the fact that the drop-off starts accumulating in middle age puts diabetics at greater risk later on because of reduced "brain reserves," Dr. David Knopman, of the Mayo Clinic in Rochester, Minnesota, told Reuters Health.

"Like a bicycle tire that's been partially deflated -- you'll be OK riding around but if you develop another little leak you'll be much closer to a flat tire much faster," said Knopman, who was not involved in the Dutch study.

Astrid Nooyens and colleagues at the National Institute for Public Health and the Environment in the Netherlands examined the health records and mental acuity scores of more than 2,600 men and women between the ages of 45 and 70 who enrolled in a large ongoing study into lifestyle effects on health.

At the five-year mark, of the 139 participants with type 2 diabetes, 61 were diabetics at the beginning of the study and 78 developed the chronic disease within the next five years.

The study confirmed the findings of earlier research, by Knopman and others, of an association between diabetes and declines in such mental functions as the ability to think quickly and recall words, but this is the first project to test memory and demonstrate how quickly the drop-off can occur.

Over a five-year period, decline in overall mental functioning in people with type 2 diabetes, while small, was nearly 3 times more pronounced than in non-diabetics.

But it didn't take many years for the impact to be felt. Even those who developed diabetes after beginning the study saw twice as much of a decline as their non-diabetic counterparts.

Compared to the "healthy" participants, participants who had long-term diabetes registered the largest declines in mental function. Those who developed diabetes during the trial saw less pronounced declines than their long-term counterparts in most areas except information processing, where they appeared to do a little better than the "healthy" people.

Type 2 diabetes is characterized by high blood sugar levels caused by the body's inability to process sugar properly. The illness can usually be controlled through diet and exercise but may also require drugs.

The Nooyens group found that while memory continues to decline for those with diabetes, the drop-off in thinking speed appears to occur in the first five years and then level off. That led the authors to suggest that early treatment and control of blood sugar levels could help thinking speed, but probably not memory, they note in the journal Diabetes Care.

The researchers found that for a small group of people who had lived with diabetes for nearly seven year, blood sugar levels did not explain the entire decline in mental function. In those people, they suspect other conditions related to diabetes such as high blood pressure and obesity.

The study did not look at whether patients with well-controlled diabetes experienced less mental decline compared to their poorly controlled counterparts, although the authors point out that there are other reasons, such as heart disease, to control sugar levels as well.

They also note that the random blood tests of both the long- and short-term diabetics suggested what treatment they were getting was "insufficient."

SOURCE: http://link.reuters.com/xyd69k Diabetes Care, online June 2, 2010

Analyses raise new questions about diabetes care

CHICAGO, 10 june 2009-- Strict lowering of blood sugar may not have been the cause of excess deaths in a major study of patients with type 2 diabetes, U.S. researchers said on Tuesday.

The trial, known as ACCORD, studied the effects of intensive strategies to help diabetics get near-normal blood sugar levels, but was stopped in February 2008 because there were 20 percent more deaths among people who got intensive treatment compared with those who got standard treatment.

One theory about the deaths is that they may have been caused by hypoglycemia or seriously low blood glucose levels.

But an analysis of deaths in the study suggests that was not the case. In fact, among those who had an episode of severe hypoglycemia, the risk of dying was lower among patients in an arm of the study who had been treated more aggressively.

"At this point we do not believe severe hypoglycemia ... is responsible for the increased risk of death seen among intensive arm participants," Dr. Denise Bonds, one of the ACCORD investigators, told reporters at the American Diabetes Association meeting in New Orleans.

Results of the ACCORD trial challenged conventional thinking that helping diabetics reach blood sugar levels considered normal for healthy people would help them avoid some of the more deadly complications of their disease.

Now, researchers are looking to other factors, such as drug combinations or age, as potential reasons for the deaths. Many patients in the ACCORD study were treated with GlaxoSmithKline's rosiglitazone or Avandia as well as older drugs such as metformin.

"We're going in the direction of trying to identify groups of patients for whom different strategies and different goals for treatment will be most appropriate," said Dr. Matthew Riddle of Oregon Health & Science University, who helped lead the ACCORD study.

TIMING OF TREATMENT A FACTOR

In a second trial of intensive glucose control called VADT, which studied older veterans with type 2 diabetes, timing of treatment appeared to play a role in determining which patients benefited.

Results of that study, published in December 2008 in the New England Journal of Medicine, found intensive treatment overall did not help, and even raised heart risks.

A new analysis of that study found that people who were started on an intensive treatment strategy to lower their blood sugar within the first 15 years of diagnosis did have fewer heart risks, including death from heart disease.

But those who went on intensive treatment 16 to 20 years after diagnosis had no benefit, Dr. William Duckworth of VA Medical Center in Phoenix and the University of Arizona told the briefing.

And for people who had had diabetes for more than 21 years, the risk of a major heart event such as a heart attack more than doubled. "The simple take-home message I believe we have for this is treat early, and treat carefully," Duckworth said.

Researchers are continuing to analyze both studies, but Duckworth said individualized treatment appears to be the best approach for helping diabetics reduce their heart risks.

At least 170 million people worldwide are estimated to have diabetes, a number that is predicted to at least double by 2030. Most have type 2 diabetes.

Fitter diabetic men live longer


By Megan Rauscher
NEW YORK,18 april 2009- Among middle-aged and older men with type 2 diabetes, their capacity for exercise is related to their likelihood of dying over a 7-year period, according to a new study.
Dr. Peter Kokkinos from the Veterans Affairs Medical Center, Washington, D.C., and colleagues say their findings show a strong association between increased exercise capacity and lower mortality risk.
Between 1986 and 2007, 1703 African American men and 1445 Caucasian men with type 2 diabetes completed a maximal exercise test. This classified them as "low-fit," "moderate-fit," or "high-fit."
During 7 years of follow-up, "a graded reduction in mortality risk was noted with increased exercise capacity for both races," the researchers report in the medical journal Diabetes Care.
Among African Americans, the death rate was 46 percent in the low-fit group, 27 percent in the moderate-fit group, and 15 percent in the high-fit group. Corresponding rates among Caucasians were 37 percent, 19 percent, and 9 percent.
The results suggest, the investigators say, that the exercise-related reduction in mortality may be stronger and more graded for Caucasians than for African-Americans.
It's important to note, the researchers say, that the men in their study for the most part came from a relatively low socioeconomic background, whereas most information on the benefit of fitness in diabetics has come from more privileged populations.
"Thus, our findings support the notion that higher exercise capacity is associated with lower all-cause mortality in men with type 2 diabetes, independent of socioeconomic status," Kokkinos and colleagues point out.
The findings, they add, "extend the public health message regarding the health benefits of cardiorespiratory fitness to men with diabetes ... and that health care professionals should encourage diabetic subjects to initiate and maintain a physically active lifestyle consisting of moderate-intensity activities."

Diabetics with previous foot ulcers may be able to participate in walking program

Scientist cautions that activities should be supervised closely by a medical professional

COLUMBIA, Mo., 15 jan 2009— More than 20 million Americans are living with diabetes, and that number is expected to increase by more than 5 million by 2010. One complication related to diabetes, Diabetic Peripheral Neuropathy, (DM+PN), can cause individuals to develop foot ulcers and, in extreme cases, amputation might be necessary. Previously, doctors and scientists have recommended that individuals with this complication stay off their feet. Now, a University of Missouri researcher has concluded that individuals with DM+PN might be able to engage in a graduated walking program under close supervision of a medical professional and thus prevent other life threatening illnesses.

Diabetic Peripheral Neuropathy is a nerve disorder that mostly affects the legs and feet by causing ulcerations, pain, tingling or even total loss of feeling. Ulcers might occur due to loss of muscle, which would expose the bones to greater pressure under the foot, or to loss of feeling in the foot.

"Physical activity is recommended for people with diabetes because it is proven to reduce the risk of mortality and development of cardiovascular disease," said Joseph LeMaster, an associate professor of family and community medicine at the University of Missouri. "Individuals with type 2 diabetes can increase their risk of cardiovascular disease by 34 percent and their risk of mortality by 39 percent if they do not participate regularly in some type of moderately intense exercise. People who have diabetes are already less active than most of the population and those with diabetic peripheral neuropathy tend to be even less active."

In the MU study, LeMaster examined the effects of lower-extremity exercise and walking intervention programs on foot ulcer occurrence in people with diabetic peripheral neuropathy. Participants with DM+PN were assigned to one of two groups: an intervention group, which was frequently monitored and assisted through leg strengthening exercises, a graduated walking program and motivational telephone calls every two weeks, and a control group. Both groups received diabetic and regular foot care education and eight sessions with a physical therapist.

During the first six months, LeMaster noted an increase in the total number of minor foot lesions and ulcers. However, at the end of the year, the number of lesions and ulcers in the intervention group had started to decrease compared to the control group, indicating a reduced risk.

"Because weight-bearing activity did not lead to a significant increase in foot ulcers, our study suggests that weight-bearing exercise might be appropriate for people with DM+PN if the patient currently has no foot ulcers, wears proper footwear, and is in a walking program that is well-supervised and safely monitored by a medical professional," LeMaster said.

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The study, "The Effect of Weight-Bearing Activity on Foot Ulcer Incidence in People with Diabetic Peripheral Neuropathy," was recently featured in the Physical Therapy Journal, in the Diabetes Special Issue.

Diabetes Epidemic Now Poses Challenges for Nursing Homes

By Serena Gordon

06 jan 2009-- More and more people with diabetes are living to older ages, thanks to medical advances. But the long-term facilities, such as nursing homes, that care for aging Americans may not be ready for the additional challenges that come with treating patients with diabetes.

"We need to spend appropriate time to think of a way to successfully provide care for people with diabetes as they enter their elder years, and we're just beginning to understand how to do that," said Dr. Paul Strumph, vice president and chief medical officer for the Juvenile Diabetes Research Foundation.

Although as many as one in four nursing home residents has diabetes, not all are getting care that meets the American Diabetes Association's goals for community-dwelling adults, according to a recent study.

The study, published in Diabetes Care, found that while 98 percent of nursing home residents with diabetes had their blood glucose levels monitored, only 38 percent met short-term glucose goals.

The better news from the study was that 67 percent of the nursing home residents with diabetes met their long-term glucose control goals, which meant they scored less than 7 percent on their A1C tests. A1C is a measure of long-term blood sugar control.

"One of the key differences in managing diabetes in a nursing home is that it's often not the condition of primary importance," said Helaine Resnick, director of research at the Institute for the Future of Aging Services for the American Association of Homes and Services for the Aging.

Resnick said one of the concerns she had with the study findings was that no one has yet to come up with specific guidelines for caring for elderly people with diabetes. Glucose control goals for someone who's 40 and living at home may well be different than for someone who's 85, cognitively impaired, and living in a long-term care facility, she said.

"Diabetes medications are designed to lower glucose levels, which can prevent complications from developing in diabetic people. But, when you take medicines to lower blood glucose, it can go too low, which can be extremely dangerous, especially for older adults," Resnick said, noting that it's difficult to find "the appropriate balance between keeping sugars low with the risk of keeping it too low."

Strumph pointed out that the needs of older people with diabetes may be different as well. People with type 1 diabetes and people with type 2 diabetes who need insulin often choose to use an insulin pump when they're younger, but pumps may not be the best choice for someone who's older and not as aware, he said.

"Someone in a nursing home could pull out a pump site and not know. In that case, you may want to be on a longer-acting insulin instead. We haven't yet defined what the ideal insulin [regimen] is for someone in a facility with a fairly predictable schedule," Strumph said.

Both Strumph and Resnick said it's important for family members, the nursing home resident, and the staff to come up with a realistic care plan.

"Families need to become more actively involved in working with care teams, and that's true for diabetes and for other conditions. Ensure that the facility understands the family's and the resident's preferences. Is your mother more interested in keeping her blood glucose control tight and risk [low blood sugar]? Or is it better for her to ease up on glucose control and work more on quality-of-life issues? Resnick said.

"Families have to be very involved, and the communication needs to be ongoing, because people's values can change," she added.

More information

For tips on selecting a nursing home, visit the AARP Web site.

Macular Edema Adds to Cost Burden for Elderly Diabetics

New onset of the disease adds almost one-third to medical costs

22 dec 2008-- New-onset diabetic macular edema in elderly patients increases medical costs by almost one-third, according to a report published in the December issue of the Archives of Ophthalmology.

Alisa M. Shea, of Duke University in Durham, N.C., and colleagues analyzed 2000 through 2004 data on Medicare beneficiaries, using a nationally representative 5 percent sample to determine the incidence of diabetic macular edema, and compared health care costs of patients with diabetic macular edema with a control cohort of patients with diabetes mellitus but no retinal disease history.

The impact of new-onset diabetic macular edema was significant; after controlling for confounding factors it added 31 percent to one-year medical costs and 29 percent to three-year medical costs, the researchers report. The use of tests and treatment also changed across the period under study, with 13 percent of patients receiving intravitreal injections in 2004 versus 1 percent in 2000, while optical coherence tomography use rose from 2.5 percent of patients in 2000 to over 40 percent in 2004, the report indicates.

"It has been estimated that approximately one-third of cases of diabetes mellitus in adults aged 20 years and older is undiagnosed," the authors write. "To the extent that this is true in the Medicare population, our findings may underestimate total costs associated with the disease."

Several study authors report financial relationships with the pharmaceutical industry.

Abstract

Low-Glycemic-Index Diet Improves Glycemic Control, HDL in Type 2 Diabetes

21 dec 2008--Patients with stable type 2 diabetes can improve their glycemic control and HDL level with a low-glycemic-index diet, according to a study published in JAMA.

Roughly 200 patients taking antihyperglycemic drugs underwent randomization to either a low-glycemic-index diet or a high-cereal-fiber diet for 6 months. (The low-glycemic-index diet emphasized foods like pumpernickel bread, bulgur-and-flax breakfast cereal, and peas, lentils, and nuts; the high-cereal-fiber diet emphasized whole-grain breads and breakfast cereals, brown rice, and avoidance of starchy foods.)

By the 6-month mark, hemoglobin A1c levels decreased and HDL levels rose, both significantly, in patients on the low-glycemic-index diet.

The authors say the low-glycemic-index diet may add further glycemic control in patients on antihyperglycemic drugs.

LINK(S):

JAMA article (Free)

Intensive Glucose Control Fails to Reduce Cardiovascular Events

21 dec 2008--Aggressive glucose control in hitherto poorly controlled type 2 diabetes does not lessen cardiovascular risk, according to a study released online by the New England Journal of Medicine.

Researchers randomized nearly 1800 military veterans with poorly controlled diabetes (hemoglobin A1c levels, 7.5% or greater) to either intensive or standard glucose control. Other cardiovascular risks were treated identically in both groups.

Although the median HbA1c level was 1.5 percentage points lower in the intensive-treatment group than in the standard group by 6 months, both groups showed similar rates of major cardiovascular events by a median follow-up of 5.6 years.

Writing in Journal Watch Cardiology, Harlan Krumholz observes that this is the third study failing to show a drop in cardiovascular risk after intensive glucose control. However, he adds, "critics might wonder if treatment earlier in the course of diabetes or longer follow-up would have altered this study's findings."

LINK(S):

NEJM article (Free)

Stress of Dealing with Diabetes Linked to Depression

By John Gever
BALTIMORE, 18 june 2008-- Type 2 diabetes and depression appear intertwined.
Patients with type 2 diabetes were more likely to develop depression and vice-versa, suggested a five-center study reported by Sherita Hill Golden, M.D., of Johns Hopkins, and colleagues in the June 18 issue of the Journal of the American Medical Association.
In parallel studies of participants in the Multi-Ethnic Study of Atherosclerosis, they found that patients under treatment for type 2 diabetes, but not those with untreated disease of comparable severity, were at a significantly increased risk for developing depressive symptoms over the next few years.
They suggested that the worries and burdens of managing their diabetes may lead to depression. "The psychological stress associated with diabetes management may lead to elevated depressive symptoms," they wrote.
At the same time, the investigators found a nonsignificant trend for depressed patients to develop type 2 diabetes, primarily because of lifestyle changes engendered by depression.
They concluded that the studies support a "bidirectional association" between depression and type 2 diabetes, in which each contributes to or exacerbates the other.
Patients with type 2 diabetes had an odds ratio of 1.54 (95% CI 1.13 to 2.09) of developing depressive symptoms during three to four years of follow-up, compared with participants with normal glucose, the researchers found.
However, among those with fasting plasma glucose levels indicative of type 2 diabetes but who were not under treatment, the odds ratio for developing depressive symptoms was 0.75 (95% CI 0.44 to 1.27).
They recommended that clinicians consider screening their patients with type 2 diabetes for depressive symptoms.
The Multi-Ethnic Study of Atherosclerosis was a longitudinal cohort study in which 6,814 people underwent a comprehensive health and lifestyle assessment from 2000 to 2002, and were then followed until 2004 and 2005. In the two parallel analyses, the numbers of participants add up to more than 6,814 because those without depressive symptoms or diabetes at baseline were included in both analyses.
In one analysis, the researchers selected 5,201 persons without diagnosed type 2 diabetes at baseline, and grouped them according to the presence or absence of depressive symptoms. The subsequent development of type 2 diabetes was determined for each group.
The other study, involving 4,847 participants, was structured similarly but focused on development of depression among patients without depressive symptoms at baseline, stratified by type 2 diabetes diagnosis.
The researchers grouped the patients without depression at baseline according to the presence or absence of type 2 diabetes. The subsequent development of depressive symptoms was determined for each group.
In the first study, the researchers found that only diagnosed and treated type 2 diabetes predicted development of depressive symptoms.
Elevated fasting plasma glucose at baseline actually appeared to be somewhat protective (HR 0.79, 95% CI 0.63 to 0.99), a finding Dr. Golden and colleagues could not explain. They called for more studies to confirm the relationship and identify likely mechanisms.
Adjusting for diabetes severity, comorbidities, and lifestyle factors including diet did not much influence the relationships between diabetes status and subsequent depression, the researchers said.
For example, the positive association between treated type 2 diabetes and subsequent depressive symptoms shrank only slightly in the fully adjusted model, to an odds ratio of 1.52 (95% CI 1.09 to 2.12).
Dr. Golden and colleagues found in the second study that for each five-point increase in scores on the Center for Epidemiologic Studies Depression Scale at baseline, the risk of developing diabetes increased by 10% (95% CI 2% to 19%) after adjusting for demographic factors and body mass index.
However, the relationship became statistically insignificant when the adjustment included lifestyle factors such as diet and smoking (HR 1.08 per five-point increase in depression scores, 95% CI 0.99 to 1.19).
The researchers said depression may still contribute to development of type 2 diabetes despite this lack of significance in the adjusted model.
"Depressed individuals are less likely to comply with dietary and weight loss recommendations and more likely to be physically inactive, contributing to obesity, a strong risk factor," Dr. Golden and colleagues pointed out.
"Future studies should determine whether interventions aimed at modifying behavioral factors associated with depression will complement current type 2 diabetes prevention strategies," the researchers said.
They noted that their data were scant in some respects. The depression scale they used was not designed to measure clinical depression, and the study had only one follow-up assessment of depressive symptoms. The study also did not collect detailed information on diabetic complications or disease severity.
The study was funded by the National Institutes of Health.
Study authors reported relationships with Merck, Novo Nordisk, Associated Jewish Federation of Baltimore, the Weinberg Foundation, Forest, GlaxoSmithKline, Eisai, Pfizer, AstraZeneca, Lilly, Ortho-McNeil, Bristol-Myers, Novartis, Supernus, Adlyfe, Takeda, Wyeth, Lundbeck, Merz, and Health Monitor.
Primary source: Journal of the American Medical AssociationSource reference:Golden S, et al "Examining a bidirectional association between depressive symptoms and diabetes" JAMA 2008; 299: 2751-59.

Racial Disparities in Diabetes Care Rooted in Physician Performance

By Todd Neale
BOSTON, 10 june 2008 -- Black patients treated for diabetes had worse outcomes than whites seen by the same clinicians at a large group practice in Massachusetts, researchers here found. The black patients were significantly less likely than whites to achieve control of hemoglobin A1c, LDL cholesterol, and blood pressure (P<0.001 for all), Thomas Sequist, M.D., M.P.H., of Brigham and Women's Hospital and Harvard, and colleagues reported in the June 9 issue of Archives of Internal Medicine. Controlling for sociodemographic factors attenuated some of the differences, but the bulk of the disparity was strongly driven by individual physician activity, the researchers concluded.
"In addition, the substantial physician-level variation in [diabetes] care was not related to overall performance or volume of black patients treated," the researchers said, "suggesting that system-wide interventions will be needed to improve care for minority patients across all physicians."
These interventions might include cultural competency training and the creation of race-stratified performance reports to raise awareness of disparities, Dr. Sequist said.
Racial disparities in diabetes care -- including poor attainment of intermediate treatment goals and worse long-term outcomes for blacks compared with whites -- have been well studied, the researchers said, but few studies have examined the role that factors at the physician level might play.
To help fill the gap, Dr. Sequist and colleagues evaluated care given to adults with diabetes at an integrated multispecialty group practice. They looked at records from 90 primary care physicians practicing in 13 ambulatory health centers who cared for at least five white patients and five black patients.
Of 6,814 patients, 4,556 were white and 2,258 were black. The black patients were significantly younger, less likely to be male, and more likely to live in communities with lower median household incomes than the whites (P<0.001 for all).
Patients of both races were equally likely to receive annual testing for hemoglobin A1c and LDL cholesterol, but blacks were less likely to have received a statin prescription in the previous year (54% versus 65%, P<0.001).
Blacks were significantly less likely to achieve ideal targets -- a hemoglobin A1c level of less than 7% (39% versus 47%), an LDL cholesterol level of less than 100 mg/dL (45% versus 57%), and a blood pressure of less than 130/80 mm Hg (24% versus 30%) (P<0.001 for all).
Blacks were also significantly less likely than whites to achieve even adequate control for these three measures (P<0.001 for all), the researchers said.
Controlling for clinical factors and between-physician effects had little impact on the disparities in care.
Sociodemographic factors, including age, sex, income, and insurance status, explained 13% to 38% of the observed differences, the researchers said.
Effects at the individual physician level, however, had a substantial influence on the differences, from 66% and 68% of the differences in hemoglobin A1c and LDL cholesterol control, respectively, to 75% of the disparity in blood pressure control.
There were no significant associations between the magnitude of the racial disparities and the number of black patients treated or the overall quality of diabetes care by individual physicians.
"Our data suggest that the problem of racial disparities is not characterized by only a few physicians providing markedly unequal care," the researchers said, "but that such differences in care are spread across the entire system, requiring the implementation of system-wide solutions."
The authors acknowledged several limitations, including the fact that studying just one practice might have reduced the ability to find between-physician effects on disparities in care.
The study was also limited by the inability to analyze differences in physician practice patterns, the use of zip code estimates of median income, the lack of information on outside social factors, and the exclusion of other racial or ethnic groups.
Despite these limitations, Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality in Rockville, Md., called the findings "important and provocative."
In an accompanying editorial, she proposed two explanations for the poorer outcomes in black patients in the study: First, aspects of care besides testing, such as teaching about medications and overall communication, might have been inferior. Second, she said, the disparities might have resulted from differences in the patients' level of engagement and support for long-term behavioral changes.
The findings illustrate the need to close the gap between ideal and actual care in diabetes, she said, noting that even in whites the level of control for intermediate outcomes fell short.
She said that public reporting of individual physicians' clinical performance might be one solution to eliminating disparities in care, although this remains controversial.
"Eliminating disparities in healthcare will require that all patients have access to care, as well as physician leadership to assure that the care provided is evidence-based, patient-centered, effective, consistent, and equitable," she concluded.
The study was funded by the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change national program.
Dr. Sequist serves as a consultant on the Aetna External Advisory Committee for Racial and Ethnic Equality. One of his co-authors serves as a consultant to RTI International and DxCG Inc. Dr. Clancy made no financial disclosures.

Primary source: Archives of Internal MedicineSource reference:Sequist T, et al "Physician performance and racial disparities in diabetes mellitus care" Arch Intern Med 2008; 168: 1145-1151. Additional source: Archives of Internal MedicineSource reference: Clancy C "Improving care quality and reducing disparities" Arch Intern Med 2008; 168: 1135-1136.