What all parents need to have in their medicine cabinet for handling minor and major mishaps.
Medically reviewed by Cynthia Haines, MD Print Email Lots of words can describe kids. "Naturally exuberant," "naturally active," and "naturally curious," are three phrases that Ken Haller, MD, associate professor of pediatrics at Saint Louis University School of Medicine, chooses to use.
Natural excitement and curiosity are normal and healthy parts of development, but they present special challenges for child safety. Children don't usually spend much time thinking about how to stay safe and healthy. That's mom and dad's job. While scrapes and bruises are also a normal part of childhood, there are more serious threats, such as poisoning and burns. Keeping key first-aid supplies handy for common injuries is a great first step in a child safety plan.
Child Safety: The Top 10 First-Aid Essentials
1. Your local poison control number. Almost 80 percent of reported poisoning cases involve children, and most of those are among children age 5 and under. Haller recommends placing the phone number for your local poison control center in your medicine cabinet and on your refrigerator, and programming it into your cell phone. "The centers are open 24 hours a day and have a nurse on call who can tell you exactly what to do after you describe the situation," Dr. Haller says. According to the Centers for Disease Control, in a life-threatening emergency situation, dial 911.
2. Pain relief medication. Child safety choices include acetaminophen (Tylenol) and non-steroid anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin) or naproxen (Aleve). Monitor children's dosages carefully. For instance, if they're sick with a cough and congestion and you've already given them a medicine with acetaminophen (like a cold remedy), you don't want to give them another dose of Tylenol at the same time.
3. An assortment of bandages. A two-inch-square sterile gauze pad can clean almost any wound, says Haller. In addition, have adhesive-free dressings, other sizes of sterile pads, or a roll of gauze for minor burns or kneecap scrapes. Tape and strip bandages in a variety of sizes work for cuts and blisters, and an elastic wrap like an Ace bandage is effective for sprains.
4. Soap for clean-up. "For most wounds, cleaning with soap and water is good enough," says Haller. Always wash a wound before dressing it. You might also want to have an antiseptic solution or towelettes handy, which Haller says makes a good disinfectant.
5. Antibiotic ointment. Choose today's gold standard, Polysporin, or the old standby, bacitracin. For a large open wound on a frightened young patient, you can put the ointment on the bandage pad, instead of directly on the injury.
6. Tweezers. Essential for the removal of splinters or dirt particles from a cut or puncture wound, tweezers should be wiped with alcohol before using. If possible, have both a pointed tip and a slanted tip pair.
7. Itch relief. Choose a few different formats to cover all itchy bases. Calamine lotion is still a soother for poison ivy and the like. Over-the-counter (OTC) hydrocortisone cream is great for dermatitis-type skin rashes and irritations, while an OTC antihistamine like Benadryl (a cold symptom and nasal allergy mainstay), is handy for an itchy initial reaction to a wasp or bee sting. If your child breaks out in hives and has any throat swelling, signs of a serious allergic reaction, call your doctor immediately.
8. "Instant" ice packs. These disposable packs don't need to be kept frozen and are literally a snap to use to reduce swelling after an injury.
9. A tooth-preserving storage device. Should one of your child's permanent teeth get knocked out by accident, a product like Save-A-Tooth will hold and protect it on your way to the dentist, improving the chances of it being replanting.
10. A sterile eye wash. This is handy to flush out any dirt or foreign particles that get into the eyes.
Child Safety: What to Toss
Here are a few medicine chest items that can be cleared out to make room for the top 10 child safety items:
• Ipecac (a poison treatment). "Ipecac is not recommended anymore," says Haller. Not only can ipecac cause a number of side effects, it can also make the damage of certain harsh poisons worse. Each poison affects the body differently and needs a different treatment approach.
• Neosporin. This antibacterial ointment may cause redness or inflammation and has been largely abandoned in favor of Polysporin or bacitracin.
• Aspirin is not recommended for children, unless specifically directed by your physician, because of the risk of a condition called Reye's syndrome.
• Expired products. Check your medicine cabinet every three months and get rid of products that have reached their expiration date. "It's not that they become toxic, but that the components break down, so they're simply no longer effective," Haller explains. "If you notice that your product is only past the date by a week or so and you need it right then, go ahead and use it. Just make a mental note to replace it soon." This advice goes for both over-the-counter and prescription items.
Taking time to ensure child safety is important. With a carefully thought-out shopping list and a trip to your favorite drugstore, you can easily outfit your medicine cabinet for most of life's little bumps along your child's road to discovery.
Tuesday, July 20, 2010
Monday, July 19, 2010
A revolutionary sneaker, or overhyped gimmick?
By Michael McCarthy, USA TODAY
They are, advertisements say, a game-changer in athletic footwear: sneakers that are supposed to tone muscles, promote healthy weight loss and improve the posture of those who walk, work or shop in them.
The makers of "toning shoes" say the shoes can help give wearers more shapely butts, legs and abs, often without the need for gym workouts. That's partly why toning shoes — which often have a rounded sole like a rocking chair, to stretch the wearer's leg muscles with each stride — represent the fastest-growing segment of the $17 billion-a-year athletic footwear industry. It's a market driven by a customer base that is 90% women, according to sneaker analyst Matt Powell of SportsOneSource.
YOUR HEALTH: 'Rocker' shoe put to the test
Busy moms and working women who spend much of the day on their feet — such as teachers, nurses, hairstylists and restaurant servers — are among the most devoted buyers of toning shoes, which typically sell for $100 to $250.
Skechers, the market leader, now has Pro Football Hall of Fame quarterback Joe Montana touting the shoes in an effort to attract men. Powell predicts that sales will explode 400% this year, to more than $1.5 billion.
"We've never seen a category grow this fast," he says.
But now a growing number of doctors are warning that toning shoes don't deliver on their marketing promises and could cause injuries by, among other things, changing a person's gait, or way of walking.
Claims that toning shoes can significantly contribute to a person's fitness are "utter nonsense," says Barbara de Lateur, distinguished service professor of physical medicine and rehabilitation at Johns Hopkins University's School of Medicine in Baltimore.
De Lateur and other doctors warn that toning shoes create their advertised benefit by destabilizing how a person walks and say that wearing the shoes can result in strained Achilles tendons. De Lateur also says the shoes can be a particular problem for older consumers or those who have difficulty keeping their balance.
Alison Drury of Louisville can attest to that.
She says she broke her right ankle after awkwardly rolling over the outside of her foot during her first mile-long walk in Skechers Shape-ups shoes.
"I'm afraid to ever put them on again," Drury says.
Montana said in an interview that his Shape-ups walking, cross-training and running shoes helped relieve pain in his knees and back and enabled him to start jogging for the first time in 15 years.
As for people getting hurt or doctors' warnings, the four-time Super Bowl champion says he can only talk from personal experience.
"I haven't fallen off one yet. And I've been jogging and walking for a long time in them," he says. "I can understand people's thoughts. But once you get in, and get yourself comfortable and used to the feel and the shape of the shoe, you don't even notice it."
A bright spot in the market
Toning shoes try to replicate the gentle, heel-to-toe motion of walking on a soft, sandy beach.
The instability built into them makes a wearer work harder to maintain his or her balance — effectively giving muscles a more rigorous workout, shoe companies say. This notion is explained in the instructional booklet and DVD that accompany Skechers Shape-ups.
The basic concept of shoes that result in the wearer's heels being lower than their toes is not new. Remember the Earth Shoe phenomenon in the 1970s?
But the sales and marketing by toning shoemakers such as Skechers, Reebok, MBT (Masai Barefoot Technology), Avia and New Balance are thoroughly 2010.
A growing number of companies, such as Skechers and Reebok, are moving beyond clunky-looking walking shoes and rolling out sleeker-looking toning sneakers for running, training and hiking that look more like athletic than orthopedic shoes.
Other companies, such as FitFlop, are rolling out toning sandals and clogs.
Toning shoes typically sell for more than basketball, running or cross-training shoes. That has made toning shoes a bright spot for manufacturers and retailers in the otherwise flat athletic footwear market, in which overall sales slid 1.4% in 2009, according to the NPD Group.
The only thing bigger than toning shoes' sales growth might be the claims their marketers make about them. The Skechers website says Shape-ups will help you "Shape Up While You Walk" by toning your butt, leg and abdominal muscles, burning calories, fighting cellulite, improving your posture and circulation and reducing knee joint stress.
"Get in Shape Without Setting Foot in a Gym," Skechers claims.
Reebok, on its website, says the balance-ball-inspired technology used in its EasyTone shoes generates 28% more muscle activity in the gluteus maximus muscles of test subjects and 11% more in their hamstrings and calves.
"EasyTone shoes help tone your butt and legs with every step," Reebok says.
MBT says its "Anti-Shoe" will "tone muscles your trainer never knew you had." In the movie The Joneses, Demi Moore plays a sexy suburban mom who makes the other housewives desperate for her MBTs.
'Sorry, I don't see it'
There are elements of truth to the ads, according to doctors who have questioned the effectiveness and safety of toning shoes. But many of the doctors want more independent studies on the shoes, rather than industry-financed research. Other doctors, such as de Lateur, say they have seen enough to conclude that the shoes mostly represent hype.
Her colleague at Johns Hopkins, Wendy Shore, says consumers would get the supposed health benefits of toning shoes and save money if they skipped buying the shoes, then "bought one less bagel a day — and walked an extra block."
David Davidson, national president of the American Academy of Podiatric Sports Medicine, says the shoes basically make adults learn to walk, or run, all over again by changing their gait. That's a "scary" prospect for someone with a "borderline problem" they might not know about.
Davidson says he's suspicious of any shoes that come with an instructional booklet and DVD.
"Nothing about these shoes has any redeeming value to me," he says. "Sorry, I don't see it."
Bryan Markinson, chief of podiatric medicine at Mount Sinai School of Medicine in New York, says some of his patients who are "not in the greatest of shape" have inflamed their Achilles tendons while wearing toning shoes. People thinking of buying them, he says, should begin an "active stretching program" or else risk injury.
Jonathan Deland, chief of foot and ankle service at the Hospital for Special Surgery in New York, warns the shoes can be "dangerous" for people with balance problems.
On the other hand, Deland acknowledges that he has worn Shape-ups and likes the way they make wearers use their muscles more to maintain balance.
"I don't want people to think these toning shoes are like going to the gym and feeling like you did a really great workout," Deland says.
"Can they help a bit? Yes."
Limits encouraged
Manufacturers point to thousands of unsolicited testimonials they say they've received from customers who report their shoes toned their legs and buttocks, reduced their waist or dress sizes and helped alleviate foot injuries such as heel spurs and plantar fasciitis.
Jennifer Weiderman, vice president of Skechers' Fitness Group, says she doesn't know of any customers who've injured themselves. To get used to them, people should wear them 25 to 45 minutes a day for the first couple of weeks, she says.
"It's like any new exercise program or eating plan," she says. "You don't want to go into it like gangbusters."
As for toning shoes' critics, she suggests they try a pair before making up their minds.
"We've had a lot of podiatrists, also chiropractors and medical professionals, who think they're great," she says. As with any new category, she adds, "There's always people who will have opinions."
Regarding Skechers' claim that consumers can get in shape without setting foot in the gym, she says that's meant more for people who don't have the time or money for often-pricey gym memberships.
"So if you can't get to the gym, you still can incorporate fitness into your lifestyle. I believe that's the premise behind that line," she says.
Robert Forster, a physical therapist in Santa Monica, Calif., was hired by Skechers to research the effect of Shape-ups. His conclusion: The shoes are a good way to "increase calorie burn and activate more muscles" while walking or doing daily errands.
All shoes change a person's gait, Forster says, adding that Shape-ups can improve a wearer's gait.
However, people with balance problems or tight Achilles tendons should take a "cautious approach," he says.
With air-filled pods on the bottom that sink into the shoes as the wearer walks, Reebok's EasyTone shoes look more like regular sneakers than the rounded-bottom Skechers Shape-ups.
Katrin Ley, Reebok's head of brand strategy, predicts the company will sell more than 5 million pairs in the USA this year — and a total of 10 million globally, because the brand is making strong inroads in Europe and Asia.
"It's something that is relevant around the world," Ley says.
Bill McInnis, head of Reebok's Advanced Innovation division, says the company sees EasyTones as "part of an active lifestyle," not a substitute for one. "We're not trying to say, 'Hey, this is a magic bullet. You don't have to work out again.' "
Not every athletic footwear maker is sold on toning shoes, however. Industry leader Nike has no plans to sell such shoes and is scornful of the products on the market.
"Our focus is on creating performance products that really work," Nike spokesman Derek Kent said in a statement.
"Unlike today's toning products, we won't ask the consumer to compromise on stability, flexibility or any other key performance characteristics as they train."
Mixed reactions
Such criticism might slow, but won't stop, toning shoes' popularity and sales growth, sneaker industry analyst Powell says.
Despite the reluctance of many men to buy a product that some see as "women's shoes," he expects sales of toning shoes to men to eventually become 25% of the market.
The reaction of consumers who've worn the shoes runs the gamut.
Lisa Nosseir of Monroe Township, N.J., loves the "support and comfort" she gets from Shape-ups, although she thinks the toning claims are "far-fetched."
Barb Likos of Denver says she considers her toning shoes a "cute gimmick."
Her Shape-ups help to strengthen her calf muscles, she says, but did nothing to tone her butt and thighs. Even though they are her "most comfortable pair of shoes," she says she regrets spending $120 on them.
As for Skechers trying to persuade men to buy them, well, good luck with that.
"My husband would not be caught dead in these things," Likos says.
If anyone's looking for a slightly used pair of Shape-ups, they can contact Drury in Louisville
They are, advertisements say, a game-changer in athletic footwear: sneakers that are supposed to tone muscles, promote healthy weight loss and improve the posture of those who walk, work or shop in them.
The makers of "toning shoes" say the shoes can help give wearers more shapely butts, legs and abs, often without the need for gym workouts. That's partly why toning shoes — which often have a rounded sole like a rocking chair, to stretch the wearer's leg muscles with each stride — represent the fastest-growing segment of the $17 billion-a-year athletic footwear industry. It's a market driven by a customer base that is 90% women, according to sneaker analyst Matt Powell of SportsOneSource.
YOUR HEALTH: 'Rocker' shoe put to the test
Busy moms and working women who spend much of the day on their feet — such as teachers, nurses, hairstylists and restaurant servers — are among the most devoted buyers of toning shoes, which typically sell for $100 to $250.
Skechers, the market leader, now has Pro Football Hall of Fame quarterback Joe Montana touting the shoes in an effort to attract men. Powell predicts that sales will explode 400% this year, to more than $1.5 billion.
"We've never seen a category grow this fast," he says.
But now a growing number of doctors are warning that toning shoes don't deliver on their marketing promises and could cause injuries by, among other things, changing a person's gait, or way of walking.
Claims that toning shoes can significantly contribute to a person's fitness are "utter nonsense," says Barbara de Lateur, distinguished service professor of physical medicine and rehabilitation at Johns Hopkins University's School of Medicine in Baltimore.
De Lateur and other doctors warn that toning shoes create their advertised benefit by destabilizing how a person walks and say that wearing the shoes can result in strained Achilles tendons. De Lateur also says the shoes can be a particular problem for older consumers or those who have difficulty keeping their balance.
Alison Drury of Louisville can attest to that.
She says she broke her right ankle after awkwardly rolling over the outside of her foot during her first mile-long walk in Skechers Shape-ups shoes.
"I'm afraid to ever put them on again," Drury says.
Montana said in an interview that his Shape-ups walking, cross-training and running shoes helped relieve pain in his knees and back and enabled him to start jogging for the first time in 15 years.
As for people getting hurt or doctors' warnings, the four-time Super Bowl champion says he can only talk from personal experience.
"I haven't fallen off one yet. And I've been jogging and walking for a long time in them," he says. "I can understand people's thoughts. But once you get in, and get yourself comfortable and used to the feel and the shape of the shoe, you don't even notice it."
A bright spot in the market
Toning shoes try to replicate the gentle, heel-to-toe motion of walking on a soft, sandy beach.
The instability built into them makes a wearer work harder to maintain his or her balance — effectively giving muscles a more rigorous workout, shoe companies say. This notion is explained in the instructional booklet and DVD that accompany Skechers Shape-ups.
The basic concept of shoes that result in the wearer's heels being lower than their toes is not new. Remember the Earth Shoe phenomenon in the 1970s?
But the sales and marketing by toning shoemakers such as Skechers, Reebok, MBT (Masai Barefoot Technology), Avia and New Balance are thoroughly 2010.
A growing number of companies, such as Skechers and Reebok, are moving beyond clunky-looking walking shoes and rolling out sleeker-looking toning sneakers for running, training and hiking that look more like athletic than orthopedic shoes.
Other companies, such as FitFlop, are rolling out toning sandals and clogs.
Toning shoes typically sell for more than basketball, running or cross-training shoes. That has made toning shoes a bright spot for manufacturers and retailers in the otherwise flat athletic footwear market, in which overall sales slid 1.4% in 2009, according to the NPD Group.
The only thing bigger than toning shoes' sales growth might be the claims their marketers make about them. The Skechers website says Shape-ups will help you "Shape Up While You Walk" by toning your butt, leg and abdominal muscles, burning calories, fighting cellulite, improving your posture and circulation and reducing knee joint stress.
"Get in Shape Without Setting Foot in a Gym," Skechers claims.
Reebok, on its website, says the balance-ball-inspired technology used in its EasyTone shoes generates 28% more muscle activity in the gluteus maximus muscles of test subjects and 11% more in their hamstrings and calves.
"EasyTone shoes help tone your butt and legs with every step," Reebok says.
MBT says its "Anti-Shoe" will "tone muscles your trainer never knew you had." In the movie The Joneses, Demi Moore plays a sexy suburban mom who makes the other housewives desperate for her MBTs.
'Sorry, I don't see it'
There are elements of truth to the ads, according to doctors who have questioned the effectiveness and safety of toning shoes. But many of the doctors want more independent studies on the shoes, rather than industry-financed research. Other doctors, such as de Lateur, say they have seen enough to conclude that the shoes mostly represent hype.
Her colleague at Johns Hopkins, Wendy Shore, says consumers would get the supposed health benefits of toning shoes and save money if they skipped buying the shoes, then "bought one less bagel a day — and walked an extra block."
David Davidson, national president of the American Academy of Podiatric Sports Medicine, says the shoes basically make adults learn to walk, or run, all over again by changing their gait. That's a "scary" prospect for someone with a "borderline problem" they might not know about.
Davidson says he's suspicious of any shoes that come with an instructional booklet and DVD.
"Nothing about these shoes has any redeeming value to me," he says. "Sorry, I don't see it."
Bryan Markinson, chief of podiatric medicine at Mount Sinai School of Medicine in New York, says some of his patients who are "not in the greatest of shape" have inflamed their Achilles tendons while wearing toning shoes. People thinking of buying them, he says, should begin an "active stretching program" or else risk injury.
Jonathan Deland, chief of foot and ankle service at the Hospital for Special Surgery in New York, warns the shoes can be "dangerous" for people with balance problems.
On the other hand, Deland acknowledges that he has worn Shape-ups and likes the way they make wearers use their muscles more to maintain balance.
"I don't want people to think these toning shoes are like going to the gym and feeling like you did a really great workout," Deland says.
"Can they help a bit? Yes."
Limits encouraged
Manufacturers point to thousands of unsolicited testimonials they say they've received from customers who report their shoes toned their legs and buttocks, reduced their waist or dress sizes and helped alleviate foot injuries such as heel spurs and plantar fasciitis.
Jennifer Weiderman, vice president of Skechers' Fitness Group, says she doesn't know of any customers who've injured themselves. To get used to them, people should wear them 25 to 45 minutes a day for the first couple of weeks, she says.
"It's like any new exercise program or eating plan," she says. "You don't want to go into it like gangbusters."
As for toning shoes' critics, she suggests they try a pair before making up their minds.
"We've had a lot of podiatrists, also chiropractors and medical professionals, who think they're great," she says. As with any new category, she adds, "There's always people who will have opinions."
Regarding Skechers' claim that consumers can get in shape without setting foot in the gym, she says that's meant more for people who don't have the time or money for often-pricey gym memberships.
"So if you can't get to the gym, you still can incorporate fitness into your lifestyle. I believe that's the premise behind that line," she says.
Robert Forster, a physical therapist in Santa Monica, Calif., was hired by Skechers to research the effect of Shape-ups. His conclusion: The shoes are a good way to "increase calorie burn and activate more muscles" while walking or doing daily errands.
All shoes change a person's gait, Forster says, adding that Shape-ups can improve a wearer's gait.
However, people with balance problems or tight Achilles tendons should take a "cautious approach," he says.
With air-filled pods on the bottom that sink into the shoes as the wearer walks, Reebok's EasyTone shoes look more like regular sneakers than the rounded-bottom Skechers Shape-ups.
Katrin Ley, Reebok's head of brand strategy, predicts the company will sell more than 5 million pairs in the USA this year — and a total of 10 million globally, because the brand is making strong inroads in Europe and Asia.
"It's something that is relevant around the world," Ley says.
Bill McInnis, head of Reebok's Advanced Innovation division, says the company sees EasyTones as "part of an active lifestyle," not a substitute for one. "We're not trying to say, 'Hey, this is a magic bullet. You don't have to work out again.' "
Not every athletic footwear maker is sold on toning shoes, however. Industry leader Nike has no plans to sell such shoes and is scornful of the products on the market.
"Our focus is on creating performance products that really work," Nike spokesman Derek Kent said in a statement.
"Unlike today's toning products, we won't ask the consumer to compromise on stability, flexibility or any other key performance characteristics as they train."
Mixed reactions
Such criticism might slow, but won't stop, toning shoes' popularity and sales growth, sneaker industry analyst Powell says.
Despite the reluctance of many men to buy a product that some see as "women's shoes," he expects sales of toning shoes to men to eventually become 25% of the market.
The reaction of consumers who've worn the shoes runs the gamut.
Lisa Nosseir of Monroe Township, N.J., loves the "support and comfort" she gets from Shape-ups, although she thinks the toning claims are "far-fetched."
Barb Likos of Denver says she considers her toning shoes a "cute gimmick."
Her Shape-ups help to strengthen her calf muscles, she says, but did nothing to tone her butt and thighs. Even though they are her "most comfortable pair of shoes," she says she regrets spending $120 on them.
As for Skechers trying to persuade men to buy them, well, good luck with that.
"My husband would not be caught dead in these things," Likos says.
If anyone's looking for a slightly used pair of Shape-ups, they can contact Drury in Louisville
Friday, July 16, 2010
Numb toes and diabetes warning sign
It is very important to realize that numb toes are a serious sign of diabetic neuropathy. This clearly means that the nerves of the feet are being damaged. This is a serious warning that must not be ignored. If this is not treated you can lose your feet. Many have had their feet cut off due to this problem. Numb toes are a warning that the diabetic or person with high blood glucose is losing the fight.
It is important to recognize that time is critical to the diabetic. Those who wait lose the body. The cause of the problem of numb toes is that the blood circulation is being cut off and this is something that you do not want. As the blood vessels and nerves become overtaken by the blood glucose poison the numbness in the feet come in. As the diabetic waits the vessels and nerves are overcome and lose.
Diabetes is a poison hign blood glucose that destroys the body. The typical diabetes diet of sugar free cannot stop the damage to the toes and fingers. Only a specialized diabetes foot diet can reverse the nerve damage. Diabetes is increasing worldwide with millions losing the battle to this illness.
A diabetic must realize that a common sugar free diet is not enough to reverse the problems of diabetic feet and toes. Never wait to find a reverse diabetes diet.
It is important to recognize that time is critical to the diabetic. Those who wait lose the body. The cause of the problem of numb toes is that the blood circulation is being cut off and this is something that you do not want. As the blood vessels and nerves become overtaken by the blood glucose poison the numbness in the feet come in. As the diabetic waits the vessels and nerves are overcome and lose.
Diabetes is a poison hign blood glucose that destroys the body. The typical diabetes diet of sugar free cannot stop the damage to the toes and fingers. Only a specialized diabetes foot diet can reverse the nerve damage. Diabetes is increasing worldwide with millions losing the battle to this illness.
A diabetic must realize that a common sugar free diet is not enough to reverse the problems of diabetic feet and toes. Never wait to find a reverse diabetes diet.
Surgical site infection risk in patients with diabetes
Surgical procedures are often unavoidable in patients with diabetes, and can even help reduce future risk of ulceration. But high postoperative infection rates in this patient population pose additional challenges to practitioners.
With 7.8% of the United States population (~23.6 million people) estimated to be diabetic, one can see how diabetes has become an increasing challenge for the medical community. It has been estimated that nearly a third of these patients are unaware of being diabetic. This prevalence will rise, as nearly 25% of adults over 60 are diabetic and there are increasing numbers being diagnosed in younger patients. Approximately 366 million people will have diabetes worldwide by the year 2030, most of these in developing countries. Foot disorders such as ulcers, infection, Charcot neuroarthropathy and peripheral arterial disease (PAD) are the most common causes of hospital admissions in diabetics. As diabetes mellitus is considered a lifelong condition, one can see the true impact on the healthcare system overall.
Peripheral neuropathy is one of the most common complications found in diabetics, prevalent in anywhere from 14-60% of the diabetic population. Peripheral neuropathy leads to sensory, motor and autonomic dysfunction, and this loss of protective sensation often causes these patients to fail to seek timely medical care for their conditions.
Foot surgery in patients with DM can be elective or preventative. Due to concerns with increased infection rates and slow healing of skin and bony structures in diabetics, elective surgery is performed with extreme caution. Prophylactic or preventative surgery is performed in those diabetics with pre-ulcerative areas, bony prominences and stable, non-infected ulcers. The purpose is to prevent ulcerations due to these bony prominences or to assist in healing of current ulcerations. Multiple types of surgeries can be performed based on the underlying bony deformity found, including hammertoe repair, bunion repair, metatarsal osteotomies, bone resections, Achilles tendon lengthenings for ulcers in the forefoot area and many more. Fracture repair is often required in diabetic patients. Those patients with Charcot foot deformity not treatable with bracing may require surgical intervention also.
It has been noted that diabetic patients without neuropathy can be treated with standard surgical technique and post-op care, but those who are neuropathic should have more fixation, be seen more often and remain non-weightbearing for approximately double the time period.
Peripheral arterial disease can also complicate the surgical site in diabetics, especially those with an insensate foot. Lack of blood flow to the surgical site not only affects the patient’s ability to heal the site quickly, but can also lead to an inability to fight off potential infection at the surgical site in the diabetic patient. Surgical site infections are infections that occur with 30 days of a surgical procedure, or within 1 year if an implant was inserted and is related to the surgery. One study found that by controlling factors such as hypothermia, blood glucose levels, removing hair from the surgical site and administering procedure-specific pre-operative antibiotics for an appropriate time frame, infection risk can be decreased.
One study showed a post-op infection rate of 6.7% in diabetic patients with neuropathy but no open wound undergoing forefoot surgery. A recent study was performed to examine wound infection rates involving 57,183 patients with ankle fractures undergoing repair. This study showed that non-diabetic patients had an infection rate of 1.4% after surgery. Diabetics without neuropathy or other comorbidities had a rate of 3.55% and diabetics with neuropathy or other comorbidities had an infection rate of 7.71%. Other reviews have found similar percentages, indicating that there is an obvious increased risk of infection in diabetics undergoing foot and ankle surgery. This implies that foot and ankle surgeons must have appropriate protocols in place to lessen these infection rates in their patients. First and foremost, comorbidities such as peripheral neuropathy and peripheral arterial disease must be diagnosed and managed prior to preventative surgery.
With 7.8% of the United States population (~23.6 million people) estimated to be diabetic, one can see how diabetes has become an increasing challenge for the medical community. It has been estimated that nearly a third of these patients are unaware of being diabetic. This prevalence will rise, as nearly 25% of adults over 60 are diabetic and there are increasing numbers being diagnosed in younger patients. Approximately 366 million people will have diabetes worldwide by the year 2030, most of these in developing countries. Foot disorders such as ulcers, infection, Charcot neuroarthropathy and peripheral arterial disease (PAD) are the most common causes of hospital admissions in diabetics. As diabetes mellitus is considered a lifelong condition, one can see the true impact on the healthcare system overall.
Peripheral neuropathy is one of the most common complications found in diabetics, prevalent in anywhere from 14-60% of the diabetic population. Peripheral neuropathy leads to sensory, motor and autonomic dysfunction, and this loss of protective sensation often causes these patients to fail to seek timely medical care for their conditions.
Foot surgery in patients with DM can be elective or preventative. Due to concerns with increased infection rates and slow healing of skin and bony structures in diabetics, elective surgery is performed with extreme caution. Prophylactic or preventative surgery is performed in those diabetics with pre-ulcerative areas, bony prominences and stable, non-infected ulcers. The purpose is to prevent ulcerations due to these bony prominences or to assist in healing of current ulcerations. Multiple types of surgeries can be performed based on the underlying bony deformity found, including hammertoe repair, bunion repair, metatarsal osteotomies, bone resections, Achilles tendon lengthenings for ulcers in the forefoot area and many more. Fracture repair is often required in diabetic patients. Those patients with Charcot foot deformity not treatable with bracing may require surgical intervention also.
It has been noted that diabetic patients without neuropathy can be treated with standard surgical technique and post-op care, but those who are neuropathic should have more fixation, be seen more often and remain non-weightbearing for approximately double the time period.
Peripheral arterial disease can also complicate the surgical site in diabetics, especially those with an insensate foot. Lack of blood flow to the surgical site not only affects the patient’s ability to heal the site quickly, but can also lead to an inability to fight off potential infection at the surgical site in the diabetic patient. Surgical site infections are infections that occur with 30 days of a surgical procedure, or within 1 year if an implant was inserted and is related to the surgery. One study found that by controlling factors such as hypothermia, blood glucose levels, removing hair from the surgical site and administering procedure-specific pre-operative antibiotics for an appropriate time frame, infection risk can be decreased.
One study showed a post-op infection rate of 6.7% in diabetic patients with neuropathy but no open wound undergoing forefoot surgery. A recent study was performed to examine wound infection rates involving 57,183 patients with ankle fractures undergoing repair. This study showed that non-diabetic patients had an infection rate of 1.4% after surgery. Diabetics without neuropathy or other comorbidities had a rate of 3.55% and diabetics with neuropathy or other comorbidities had an infection rate of 7.71%. Other reviews have found similar percentages, indicating that there is an obvious increased risk of infection in diabetics undergoing foot and ankle surgery. This implies that foot and ankle surgeons must have appropriate protocols in place to lessen these infection rates in their patients. First and foremost, comorbidities such as peripheral neuropathy and peripheral arterial disease must be diagnosed and managed prior to preventative surgery.
Friday, July 2, 2010
Liver at 50% Greater Risk in Diabetes
Although the liver is often overlooked in diabetes, even newly-diagnosed cases carry a substantial risk of serious hepatic damage, researchers found....
According to Gillian Booth, MD, MSc, of St. Michael's Hospital in Toronto, in a population-based study, newly-diagnosed diabetes was associated with a near doubling in the rate of liver cirrhosis, liver failure, or liver transplant compared with people in the general population who did not have diabetes.
After adjusting for important contributors to liver disease, the association remained significant with a 77% increased risk for newly-diagnosed diabetes patients (95% confidence interval 68% to 86%).
"The negative impact of diabetes on the retinal, renal, nervous, and cardiovascular systems is well recognized, yet little is known about its effect on the liver," they wrote.
According to Kenneth Cusi, MD, who has been studying this condition at the University of Texas Health Science Center in San Antonio, although much still remains to be discovered about the mechanisms and cause of the link between diabetes and liver disease, nonalcoholic steatohepatitis (NASH) is almost certainly involved.
"Steatosis is known to arise in relationship to insulin resistance in obesity, and most people with the condition do have some degree of glucose abnormality.... The two seem to 'feed on each other'."
Unlike with eye disease, cardiovascular disease, and kidney disease, guidelines for diabetes care don't recommend screening for liver disease.
"However, when the liver fails," Booth's group cautioned in the paper, "there is no equivalent form of management, such as hemodialysis or retinal photocoagulation."
They suggested that liver disease "may be appropriate for addition to the list of target-organ conditions related to diabetes," with annual screening by means of a blood test, such as for the liver enzyme alanine aminotransferase.
But the sensitivity of blood tests and even ultrasound aren't great for identifying fatty liver disease that is the precursor to more serious liver problems and liver biopsy is not a feasible screening method, Cusi noted.
Also, it would first have to be shown that preventive measures such as weight loss and glycemic and lipid control are effective in diabetes, as they are in isolated fatty liver without diabetes, the researchers said.
To expand evidence for the link, the researchers retrospectively examined the administrative databases of the universal healthcare system in the province of Ontario from 1994 through 2006.
They compared 438,069 adults with newly diagnosed diabetes and an age-, sex-, and regionally-matched control group of 2,059,708 individuals without known diabetes. Preexisting liver or alcohol-related disease were cause for exclusion.
During a median of 6.4 years of follow-up, serious liver disease -- liver cirrhosis, liver failure, or liver transplant -- developed in 2,463 newly-diagnosed diabetes cases and 5,902 controls.
Thus, unadjusted liver disease incidence was 92% higher with diabetes (8.19 per 10,000 person-years with diabetes and 4.17 without it).
This difference remained significant across mutually-adjusted patient subgroups by age, gender, urban versus rural residence, and income level.
Diabetes appeared to have the most pronounced link with liver and the least with liver transplantation.
Hypertension and obesity didn't appear to entirely account for the relationship with diabetes. The risk of serious liver disease in nondiabetic individuals with preexisting hypertension or obesity was elevated but less so than among those with diabetes.
But the researchers cautioned that it is difficult to separate out the effects of these related conditions.
"Although our findings and those of the U.S. study [which found elevated chronic NASH risk in veterans with diabetes] edge forward the idea that diabetes may be harmful to the liver, the question remains of whether this effect extends beyond the metabolic syndrome," they wrote.
Another question that remains to be answered is causality.
Booth's group pointed out that hepatic fat content rises in parallel with insulin resistance and glucose dysregulation and that diabetes as a complication of cirrhosis typically doesn't arise until cirrhosis reaches an advanced stage.
However, they noted, they couldn't rule out the pre-existence of subclinical liver disease before study entry.
According to Gillian Booth, MD, MSc, of St. Michael's Hospital in Toronto, in a population-based study, newly-diagnosed diabetes was associated with a near doubling in the rate of liver cirrhosis, liver failure, or liver transplant compared with people in the general population who did not have diabetes.
After adjusting for important contributors to liver disease, the association remained significant with a 77% increased risk for newly-diagnosed diabetes patients (95% confidence interval 68% to 86%).
"The negative impact of diabetes on the retinal, renal, nervous, and cardiovascular systems is well recognized, yet little is known about its effect on the liver," they wrote.
According to Kenneth Cusi, MD, who has been studying this condition at the University of Texas Health Science Center in San Antonio, although much still remains to be discovered about the mechanisms and cause of the link between diabetes and liver disease, nonalcoholic steatohepatitis (NASH) is almost certainly involved.
"Steatosis is known to arise in relationship to insulin resistance in obesity, and most people with the condition do have some degree of glucose abnormality.... The two seem to 'feed on each other'."
Unlike with eye disease, cardiovascular disease, and kidney disease, guidelines for diabetes care don't recommend screening for liver disease.
"However, when the liver fails," Booth's group cautioned in the paper, "there is no equivalent form of management, such as hemodialysis or retinal photocoagulation."
They suggested that liver disease "may be appropriate for addition to the list of target-organ conditions related to diabetes," with annual screening by means of a blood test, such as for the liver enzyme alanine aminotransferase.
But the sensitivity of blood tests and even ultrasound aren't great for identifying fatty liver disease that is the precursor to more serious liver problems and liver biopsy is not a feasible screening method, Cusi noted.
Also, it would first have to be shown that preventive measures such as weight loss and glycemic and lipid control are effective in diabetes, as they are in isolated fatty liver without diabetes, the researchers said.
To expand evidence for the link, the researchers retrospectively examined the administrative databases of the universal healthcare system in the province of Ontario from 1994 through 2006.
They compared 438,069 adults with newly diagnosed diabetes and an age-, sex-, and regionally-matched control group of 2,059,708 individuals without known diabetes. Preexisting liver or alcohol-related disease were cause for exclusion.
During a median of 6.4 years of follow-up, serious liver disease -- liver cirrhosis, liver failure, or liver transplant -- developed in 2,463 newly-diagnosed diabetes cases and 5,902 controls.
Thus, unadjusted liver disease incidence was 92% higher with diabetes (8.19 per 10,000 person-years with diabetes and 4.17 without it).
This difference remained significant across mutually-adjusted patient subgroups by age, gender, urban versus rural residence, and income level.
Diabetes appeared to have the most pronounced link with liver and the least with liver transplantation.
Hypertension and obesity didn't appear to entirely account for the relationship with diabetes. The risk of serious liver disease in nondiabetic individuals with preexisting hypertension or obesity was elevated but less so than among those with diabetes.
But the researchers cautioned that it is difficult to separate out the effects of these related conditions.
"Although our findings and those of the U.S. study [which found elevated chronic NASH risk in veterans with diabetes] edge forward the idea that diabetes may be harmful to the liver, the question remains of whether this effect extends beyond the metabolic syndrome," they wrote.
Another question that remains to be answered is causality.
Booth's group pointed out that hepatic fat content rises in parallel with insulin resistance and glucose dysregulation and that diabetes as a complication of cirrhosis typically doesn't arise until cirrhosis reaches an advanced stage.
However, they noted, they couldn't rule out the pre-existence of subclinical liver disease before study entry.
Body Fat Linked to Diabetes Risk in Older People
To avoid Type 2 diabetes, seniors may need to watch their weight just as closely as younger individuals do, a prospective cohort study showed....
Among individuals 65 and older, several measures of adiposity and weight gain were associated with a greater risk of developing Type 2 diabetes during follow-up, according to Mary Biggs, PhD, of the University of Washington School of Public Health and Community Medicine in Seattle, and colleagues.
The hazard ratios ranged from 1.9 to 6.0 when broken down by sex.
Self-reported body mass index at age 50 and weight gain from age 50 to study baseline were both also associated with risk of incident diabetes. "We found it surprising that the relationship between adiposity or body fat and diabetes was so strong among older adults," Biggs said.
"I think the results affirm the importance of weight control during middle age and suggest that weight control remains important into older ages in terms of reducing diabetes risks."
Although overweight and obesity are well-recognized risk factors for Type 2 diabetes among young and middle-age individuals, the relationship has not been well studied in older adults, according to the researchers.
So they turned to the Cardiovascular Health Study, which prospectively followed 4,193 men and women who were at least 65 and free of diabetes at baseline from 1989 to 2007. The participants came from four counties in North Carolina, Maryland, California, and Pennsylvania.
At baseline, mean age of participants was 72 and their mean BMI was 26 kg/m2 for both men and women; 45% had prediabetes (fasting glucose of 100 to 125 mg/dL).
Through a median follow-up of 12.4 years, there were 339 incident cases of Type 2 diabetes, defined as use of diabetes medication or a fasting glucose of at least 126 mg/dL.
With increasing quintiles of various measures of adiposity, there was a corresponding greater risk of developing diabetes, with no significant differences by sex or race.
All multivariate models were adjusted for age, sex, race, smoking, alcohol consumption, physical activity, and dietary factors.
The magnitude of the increased risk associated with various measures appeared to fade with age, with about half the risk in individuals 75 and older compared with those 65 to 74. However, the interaction with age was significant only for BMI at age 50 and at baseline and for fat mass.
There are several possible reasons risk might be increased to a lesser extent in older individuals, according to the researchers.
"Among older adults, standard anthropometric measures may not adequately quantify body fat due to age-related changes in body composition, including decreases in skeletal muscle mass and height," they wrote.
In addition, among older individuals, regional fat distribution may be more important in the etiology of diabetes than absolute fat mass, the pathophysiology of diabetes may differ, and selective survival may be involved. Changes in body weight were also associated with diabetes risk.
Compared with individuals who had a weight fluctuation of no more than about 4 pounds, those who gained 20 or more pounds from age 50 to baseline or 13 pounds or more from baseline to the third follow-up visit had a two- to threefold increased risk of developing diabetes.
"Results of this study affirm the importance of maintaining optimal weight during middle age for prevention of diabetes and, while requiring confirmation, suggest that weight control remains important in reducing diabetes risk among adults 65 years of age and older," the researchers wrote.
Among individuals 65 and older, several measures of adiposity and weight gain were associated with a greater risk of developing Type 2 diabetes during follow-up, according to Mary Biggs, PhD, of the University of Washington School of Public Health and Community Medicine in Seattle, and colleagues.
The hazard ratios ranged from 1.9 to 6.0 when broken down by sex.
Self-reported body mass index at age 50 and weight gain from age 50 to study baseline were both also associated with risk of incident diabetes. "We found it surprising that the relationship between adiposity or body fat and diabetes was so strong among older adults," Biggs said.
"I think the results affirm the importance of weight control during middle age and suggest that weight control remains important into older ages in terms of reducing diabetes risks."
Although overweight and obesity are well-recognized risk factors for Type 2 diabetes among young and middle-age individuals, the relationship has not been well studied in older adults, according to the researchers.
So they turned to the Cardiovascular Health Study, which prospectively followed 4,193 men and women who were at least 65 and free of diabetes at baseline from 1989 to 2007. The participants came from four counties in North Carolina, Maryland, California, and Pennsylvania.
At baseline, mean age of participants was 72 and their mean BMI was 26 kg/m2 for both men and women; 45% had prediabetes (fasting glucose of 100 to 125 mg/dL).
Through a median follow-up of 12.4 years, there were 339 incident cases of Type 2 diabetes, defined as use of diabetes medication or a fasting glucose of at least 126 mg/dL.
With increasing quintiles of various measures of adiposity, there was a corresponding greater risk of developing diabetes, with no significant differences by sex or race.
All multivariate models were adjusted for age, sex, race, smoking, alcohol consumption, physical activity, and dietary factors.
The magnitude of the increased risk associated with various measures appeared to fade with age, with about half the risk in individuals 75 and older compared with those 65 to 74. However, the interaction with age was significant only for BMI at age 50 and at baseline and for fat mass.
There are several possible reasons risk might be increased to a lesser extent in older individuals, according to the researchers.
"Among older adults, standard anthropometric measures may not adequately quantify body fat due to age-related changes in body composition, including decreases in skeletal muscle mass and height," they wrote.
In addition, among older individuals, regional fat distribution may be more important in the etiology of diabetes than absolute fat mass, the pathophysiology of diabetes may differ, and selective survival may be involved. Changes in body weight were also associated with diabetes risk.
Compared with individuals who had a weight fluctuation of no more than about 4 pounds, those who gained 20 or more pounds from age 50 to baseline or 13 pounds or more from baseline to the third follow-up visit had a two- to threefold increased risk of developing diabetes.
"Results of this study affirm the importance of maintaining optimal weight during middle age for prevention of diabetes and, while requiring confirmation, suggest that weight control remains important in reducing diabetes risk among adults 65 years of age and older," the researchers wrote.
Obesity, Other Risk Factors for Youth Diabetes Improved by Broad, School-based Intervention Program
One of the important announcements coming out of the American Diabetes Association's 70th Scientific Sessions were the results of a little known NIH study titled, "The Healthy Study: Interventions to reduce early diabetes risk." This may be a new model of how we can prevent our children from getting diabetes....
The NIH made a major investment in our children by modifying lifestyles in the grade schools to prevent a number of diseases. They also have a website that has all of the materials used in the program available at no cost: www.healthystudy.com.
A broad-based program to fight obesity and diabetes, aimed at US middle-school students and conducted directly by their teachers and other local school officials and designed to profoundly change not only diet, but also attitudes about food and fitness, appeared to improve measures of adiposity, insulin resistance, and other diabetes risk factors in a prospective randomized trial. The findings were presented here on June 28 at the 70th ADA Scientific Sessions and published online June 27, 2010, in the New England Journal of Medicine.
However, there wasn't a significant difference between students at schools that ran the three-year program and control schools, where the program wasn't instituted, in the study's primary end point: change in the prevalence of kids who were overweight or obese, defined as a body-mass index (BMI) in the >85th percentile. The prevalence fell similarly at schools with and without the intervention program.
By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1.
The program, which followed the students from the beginning of sixth grade to the end of eighth grade, also did not show a significant benefit in lowering the overall prevalence of kids who were obese at its conclusion -- that is, who finished the study in the >95th percentile for BMI. That prevalence fell by 19% at program compared with nonprogram schools, but the difference fell just short of significance at p=0.05.
However, the proportion of kids with waist circumference in the >90th percentile fell significantly more (p=0.04) at program schools. Students at those schools also had significantly (p=0.04) smaller increases in fasting insulin levels over the three years.
The program's benefits in the overall school populations were even more pronounced, and more solidly significant, among the approximately one-half of students in the >85th percentile for BMI at the beginning of sixth grade.
"This would suggest that, although the intervention did not meet its primary outcome of altering the combined prevalence of overweight or obesity, it did have effects on obesity and other important risk factors for Type 2 diabetes, Dr. Gary D. Foster (Temple University, Philadelphia, PA) said at a briefing for medical reporters. Foster chaired the HEALTHY study -- a name, not an acronym, chosen by students who participated in the comprehensive program.
He also said that the falling overweight/obesity rates at schools with and without the intervention program are consistent with national-level trends observed in other analyses that suggest that "rates of obesity in high-risk children in sixth to eighth grade appear not to be steady or increasing, but actually appear to be declining."
The HEALTHY study randomized 42 schools in seven regions of the US to follow or not follow the comprehensive intervention program. Schools qualified for participation if at least 50% of their students were members of a minority (primarily Hispanic or African American) or at least 50% qualified for government-subsidized meal programs; minority and low-income kids, the researchers note, are known to be at increased risk for both obesity and diabetes. Girls made up 53% of the 4,603 students tracked in the study, who had to be free of recognized diabetes at baseline.
At the press briefing, Dr. Griffin P. Rodgers (National Institutes of Health, Bethesda, MD), who is director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the HEALTHY study's primary underwriter, but who isn't one of its investigators, underscored the importance of targeting kids at increased risk for diabetes. "Earlier onset of diabetes may foreshadow earlier appearance of complications," he noted.
When the HEALTHY study and its six preceding pilot studies were initially in development, he continued, "obesity rates in American youth had been climbing steadily for two decades. Then, medical centers around the country began reporting a disturbing new trend, Type 2 diabetes was increasingly being diagnosed in youths, especially black, Hispanic, and American Indian adolescents. By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1. We needed to find ways to contain the rising rate of Type 2 diabetes in kids, and schools were a logical place to start."
Dr. Cynthia L. Ogden (Centers for Disease Control and Prevention, Atlanta, GA), also on hand at the briefing but not a HEALTHY study researcher, showed 2007/08 data from the National Health and Nutrition Examination Survey suggesting that 31.7% of US children aged two to 19 are overweight or obese, amounting to 23.4 million children. Among them, she said, are the 17% of US kids in that age group, a total of about 12.5 million, who qualify as obese.
Also, Rodgers said, the HEALTHY pilot trials suggested that up to 40% of eighth graders at schools with high-risk populations had elevated fasting glucose levels. "So the question became, can changes in schools -- namely, longer and more intense gym classes, healthier food choices, and classroom activities that promote healthy behavior -- lower risk factors for Type 2 diabetes in youth?"
The program consisted of interventions grouped in four domains. (Details and the materials used are available on the study's website.) The nutritional component called for healthy improvements in the quality and quantity of food and beverages available at the schools' cafeterias, snack bars, and vending machines, and even at fundraisers and classroom parties, according to Hirst. Available choices shifted to those lower in fat, higher in fiber, heavier on fruit and vegetables, and lower in added sugar.
The physical-activity component was aimed at increasing both participation and activity levels in physical education classes, emphasizing activities that raised the heart rate.
Dr. Kathryn Hirst (George Washington University School of Public Health, Washington, DC) provided more details of the intervention program, which consisted of "multiple components that were designed to change the school environment radically." Experts on the study's staff at its seven regional field offices provided "training, guidance, assistance, materials, and support" for instituting the program to the faculties and staff at each of the schools, "who were the ones who actually delivered the intervention," she noted.
Teachers received instruction on holding school-wide events that promoted physical activity. Minimum weekly durations of physical education classes were instituted.
The third component, focused on behavior, according to the report, promoted classroom and family-outreach activities to educate and sharpen self-awareness and decision-making, self-monitoring, and goal-setting skills consistent with the overall program.
The fourth component, communication, focused on the use of marketing techniques to promote the program's goals within the schools and establish a "brand" to characterize and identify the changes to menus and physical activities that were part of the program.
Healthy Study Group. A school-based intervention for diabetes risk reduction. New Engl J Med 2010; DOI:10.1056/NEJMoa1001933. Available at www.nejm.org.
The NIH made a major investment in our children by modifying lifestyles in the grade schools to prevent a number of diseases. They also have a website that has all of the materials used in the program available at no cost: www.healthystudy.com.
A broad-based program to fight obesity and diabetes, aimed at US middle-school students and conducted directly by their teachers and other local school officials and designed to profoundly change not only diet, but also attitudes about food and fitness, appeared to improve measures of adiposity, insulin resistance, and other diabetes risk factors in a prospective randomized trial. The findings were presented here on June 28 at the 70th ADA Scientific Sessions and published online June 27, 2010, in the New England Journal of Medicine.
However, there wasn't a significant difference between students at schools that ran the three-year program and control schools, where the program wasn't instituted, in the study's primary end point: change in the prevalence of kids who were overweight or obese, defined as a body-mass index (BMI) in the >85th percentile. The prevalence fell similarly at schools with and without the intervention program.
By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1.
The program, which followed the students from the beginning of sixth grade to the end of eighth grade, also did not show a significant benefit in lowering the overall prevalence of kids who were obese at its conclusion -- that is, who finished the study in the >95th percentile for BMI. That prevalence fell by 19% at program compared with nonprogram schools, but the difference fell just short of significance at p=0.05.
However, the proportion of kids with waist circumference in the >90th percentile fell significantly more (p=0.04) at program schools. Students at those schools also had significantly (p=0.04) smaller increases in fasting insulin levels over the three years.
The program's benefits in the overall school populations were even more pronounced, and more solidly significant, among the approximately one-half of students in the >85th percentile for BMI at the beginning of sixth grade.
"This would suggest that, although the intervention did not meet its primary outcome of altering the combined prevalence of overweight or obesity, it did have effects on obesity and other important risk factors for Type 2 diabetes, Dr. Gary D. Foster (Temple University, Philadelphia, PA) said at a briefing for medical reporters. Foster chaired the HEALTHY study -- a name, not an acronym, chosen by students who participated in the comprehensive program.
He also said that the falling overweight/obesity rates at schools with and without the intervention program are consistent with national-level trends observed in other analyses that suggest that "rates of obesity in high-risk children in sixth to eighth grade appear not to be steady or increasing, but actually appear to be declining."
The HEALTHY study randomized 42 schools in seven regions of the US to follow or not follow the comprehensive intervention program. Schools qualified for participation if at least 50% of their students were members of a minority (primarily Hispanic or African American) or at least 50% qualified for government-subsidized meal programs; minority and low-income kids, the researchers note, are known to be at increased risk for both obesity and diabetes. Girls made up 53% of the 4,603 students tracked in the study, who had to be free of recognized diabetes at baseline.
At the press briefing, Dr. Griffin P. Rodgers (National Institutes of Health, Bethesda, MD), who is director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the HEALTHY study's primary underwriter, but who isn't one of its investigators, underscored the importance of targeting kids at increased risk for diabetes. "Earlier onset of diabetes may foreshadow earlier appearance of complications," he noted.
When the HEALTHY study and its six preceding pilot studies were initially in development, he continued, "obesity rates in American youth had been climbing steadily for two decades. Then, medical centers around the country began reporting a disturbing new trend, Type 2 diabetes was increasingly being diagnosed in youths, especially black, Hispanic, and American Indian adolescents. By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1. We needed to find ways to contain the rising rate of Type 2 diabetes in kids, and schools were a logical place to start."
Dr. Cynthia L. Ogden (Centers for Disease Control and Prevention, Atlanta, GA), also on hand at the briefing but not a HEALTHY study researcher, showed 2007/08 data from the National Health and Nutrition Examination Survey suggesting that 31.7% of US children aged two to 19 are overweight or obese, amounting to 23.4 million children. Among them, she said, are the 17% of US kids in that age group, a total of about 12.5 million, who qualify as obese.
Also, Rodgers said, the HEALTHY pilot trials suggested that up to 40% of eighth graders at schools with high-risk populations had elevated fasting glucose levels. "So the question became, can changes in schools -- namely, longer and more intense gym classes, healthier food choices, and classroom activities that promote healthy behavior -- lower risk factors for Type 2 diabetes in youth?"
The program consisted of interventions grouped in four domains. (Details and the materials used are available on the study's website.) The nutritional component called for healthy improvements in the quality and quantity of food and beverages available at the schools' cafeterias, snack bars, and vending machines, and even at fundraisers and classroom parties, according to Hirst. Available choices shifted to those lower in fat, higher in fiber, heavier on fruit and vegetables, and lower in added sugar.
The physical-activity component was aimed at increasing both participation and activity levels in physical education classes, emphasizing activities that raised the heart rate.
Dr. Kathryn Hirst (George Washington University School of Public Health, Washington, DC) provided more details of the intervention program, which consisted of "multiple components that were designed to change the school environment radically." Experts on the study's staff at its seven regional field offices provided "training, guidance, assistance, materials, and support" for instituting the program to the faculties and staff at each of the schools, "who were the ones who actually delivered the intervention," she noted.
Teachers received instruction on holding school-wide events that promoted physical activity. Minimum weekly durations of physical education classes were instituted.
The third component, focused on behavior, according to the report, promoted classroom and family-outreach activities to educate and sharpen self-awareness and decision-making, self-monitoring, and goal-setting skills consistent with the overall program.
The fourth component, communication, focused on the use of marketing techniques to promote the program's goals within the schools and establish a "brand" to characterize and identify the changes to menus and physical activities that were part of the program.
Healthy Study Group. A school-based intervention for diabetes risk reduction. New Engl J Med 2010; DOI:10.1056/NEJMoa1001933. Available at www.nejm.org.
Thursday, July 1, 2010
HbA1clevels correlate strongly to future diabetes, cardiovascular risk
An ancillary study to the ARIC (Atherosclerosis Risk in Communities) study supports the most recent (2010) ADA risk categories of hemoglobin (Hb) A1c in identifying future risk of developing diabetes and macrovascular and microvascular disease. The data were presented by Elizabeth Selvin, PhD.
The ADA now recommends the use of HbA1c for the diagnosis of diabetes and identification of persons at increased risk for diabetes. The ADA defines an HbA1c of 5.7% to less than 6.5% as “high risk” for the future development of diabetes.
In this analysis, 11,092 participants from ARIC, a large community-based epidemiologic study, without cardiovascular disease or diabetes at baseline had HbA1c measured from stored whole blood samples obtained between 1990 and 1992. Participants were followed for 15 years.
“In individuals with an A1c of 5.7% to less than 6.5%, which is the group identified as high risk for the development of diabetes and other complications, we see a very high risk of the subsequent development of diabetes. We can also see that individuals in that range are at risk for kidney disease, CHD [coronary heart disease], and stroke,” said Selvin, assistant professor of epidemiology and medicine at Johns Hopkins in Baltimore.
Compared with the reference population with an HbA1c level of 5% to less than 5.7%, those in the high-risk category of 5.7% to less than 6.5% had more than triple the risk of diagnosed diabetes, a 60% increase in the risk of CHD, a 56% increase in the risk of stroke, a 62% increased risk of end-stage renal disease, and a 42% increase in all-cause mortality, all adjusted for age, sex, race, and other potential confounders.
These risks were even greater in the cohort with HbA1c levels of 6.5% or greater at baseline.
“The vast majority of individuals with HbA1c greater than 6.5% will subsequently be diagnosed with diabetes during follow-up, and they’re at very high risk of kidney disease and have almost 4 times the risk of developing end-stage renal disease compared to those people in the normal range, and a 2-fold increased risk of developing CHD or stroke or dying during follow-up,” she said.
More than 20% of the group with HbA1c values of 5.7% to less than 6.5% and almost 80% of those with values of 6.5% or greater developed diabetes within 10 years.
The ADA now recommends the use of HbA1c for the diagnosis of diabetes and identification of persons at increased risk for diabetes. The ADA defines an HbA1c of 5.7% to less than 6.5% as “high risk” for the future development of diabetes.
In this analysis, 11,092 participants from ARIC, a large community-based epidemiologic study, without cardiovascular disease or diabetes at baseline had HbA1c measured from stored whole blood samples obtained between 1990 and 1992. Participants were followed for 15 years.
“In individuals with an A1c of 5.7% to less than 6.5%, which is the group identified as high risk for the development of diabetes and other complications, we see a very high risk of the subsequent development of diabetes. We can also see that individuals in that range are at risk for kidney disease, CHD [coronary heart disease], and stroke,” said Selvin, assistant professor of epidemiology and medicine at Johns Hopkins in Baltimore.
Compared with the reference population with an HbA1c level of 5% to less than 5.7%, those in the high-risk category of 5.7% to less than 6.5% had more than triple the risk of diagnosed diabetes, a 60% increase in the risk of CHD, a 56% increase in the risk of stroke, a 62% increased risk of end-stage renal disease, and a 42% increase in all-cause mortality, all adjusted for age, sex, race, and other potential confounders.
These risks were even greater in the cohort with HbA1c levels of 6.5% or greater at baseline.
“The vast majority of individuals with HbA1c greater than 6.5% will subsequently be diagnosed with diabetes during follow-up, and they’re at very high risk of kidney disease and have almost 4 times the risk of developing end-stage renal disease compared to those people in the normal range, and a 2-fold increased risk of developing CHD or stroke or dying during follow-up,” she said.
More than 20% of the group with HbA1c values of 5.7% to less than 6.5% and almost 80% of those with values of 6.5% or greater developed diabetes within 10 years.
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