Patients with newly diagnosed Type 2 diabetes were significantly more likely to show poor impulse control in psychological testing than healthy people....
In the standard Go/NoGo test of impulse control, newly diagnosed diabetics made about 50% more errors of commission than normal controls, regardless of whether they were overweight.
The differences were not attributable to cognitive impairment, the researchers concluded, because diabetic patients performed as well as controls on the Wisconsin Card Sorting Test of executive function.
"Our results showed that middle-aged, newly diagnosed, and medication-free patients with Type 2 diabetes have a particular neuropsychological deficit in inhibitory control of impulsive response, which is an independent effect of diabetes apart from being overweight," Yasuhiko Iwamoto, MD, of Tokyo Women's Medical University in Japan, and colleagues wrote.
They suggested the findings could help explain why diabetic patients find it difficult to make the recommended lifestyle adjustments such as avoiding high-fat foods and maintaining daily exercise.
The researchers explained that decision-making about daily activities relies on brain functions in different cerebral regions, mixing predictions of future rewards and punishments, inhibition of impulsive responses, and executive functions.
Overeating, they explained, occurs when the prospect of immediate reward overwhelms inhibitions that derive from awareness of negative consequences. "In such conditions, rapid reward prediction or impulsive response to environmental stimuli prevails over the preparations by executive function," Iwamoto and colleagues asserted.
Earlier studies had indicated that reward predictions by overweight individuals tend to be higher than those of normal weight people, and their impulse control was generally lower. Consequently, the Japanese researchers sought to test diabetic patients for performance on psychological tests that measure these functions.
The Go/NoGo test for impulse control involved showing participants one of two letters, N or H, with instructions to press a button when they saw the N but not H. Pressing the button in response to H was an error of commission, and failing to press it when shown the N was an error of omission. The test also measured reaction times, including slowed responses that sometimes followed errors.
Prediction of future rewards was evaluated with so-called reversal and extinction tasks.
In the former, participants won points for correctly switching images on a computer screen that randomly replaced each other. The extinction task was structured the same way, except that participants stopped winning points for executing the reversal after nine correct responses; at that point, they received points for not responding to the stimulus.
As on a TV game show, correct responses were signaled with a pleasant chime sound, whereas errors were announced with a buzzer. Participants were also assessed for clinical depression and for standard laboratory measures of glycemia and insulin resistance. A total of 27 newly diagnosed Type 2 diabetic patients and 27 non-diabetic controls participated. All participants in both groups were men, and none of the diabetic patients were taking medications for diabetes. The diabetic group included 16 who were overweight (mean BMI 29.8). There were 11 overweight controls (mean BMI 27.6).
Response inhibition in the Go/NoGo test was significantly decreased in the diabetic patients, the researchers reported. In a combined measure of commission and omission errors, labeled d', diabetic patients had a mean value of 2.55 compared with 3.22 for controls (P=0.001).
The difference was most pronounced for errors of commission, with a mean of 10 for patients versus about 6 for controls (P=0.002).
The researchers found a significant interaction between Go/NoGo performance and glycated hemoglobin levels, with an r2 value of 0.287 for d' versus HbA1c (P=0.024). Scores did not differ significantly by weight, although there was a trend toward reduced impulse control in overweight participants. Diabetes did not affect reaction times, overall or after errors, but weight did affect them, with faster reaction times in overweight participants.
Iwamoto and colleagues also found that diabetes status did not affect scores on the reversal and extinction tests. Overweight participants made about 40% more errors on the extinction test compared with normal-weight individuals (P=0.029) but not on the reversal test.
Achievement scores on the Wisconsin Card Sorting Test were similar in all patient groups stratified by weight and diabetes status.
So-called perseverative errors (involving continuous repetition of a response) appeared more common in normal-weight diabetic participants, but rates of these errors varied widely among individuals and the group difference was not statistically significant.
"Our study included only newly diagnosed patients with Type 2 diabetes, suggesting the possibility that the neuropsychological deficits in response inhibition may contribute to the behavioral problems leading to chronic lifestyle-related diseases, such as Type 2 diabetes," they wrote.
However, they acknowledged that the causal arrow could point in the other direction -- that "metabolic changes with diabetes affect brain functions and cause neuropsychological deficits."
Indeed, the researchers observed, some earlier studies have found that metabolic improvements in diabetic patients lead to improved cognitive performance.
"Further longitudinal studies will be useful to detect progression or improvement of neuropsychological deficits associated with metabolic change," Iwamoto and colleagues wrote.
They also recommended more studies into the potential causal role of impulsivity in development of Type 2 diabetes. If confirmed, psychobehavioral interventions aimed at improving impulse control could be beneficial in preventing or treating the disease
Showing posts with label insulin. Show all posts
Showing posts with label insulin. Show all posts
Thursday, April 7, 2011
Sunday, March 20, 2011
Insulin and Weight Gain?
Q: I take insulin and it's very hard for me to lose weight. I've read that this can happen — that insulin can contribute to weight gain. What can I do? I try to watch what I eat and have recently joined a fitness club, but I haven't had much success yet. Any advice?
— Susan
A:Insulin can, in fact, lead to weight gain. Here's how it works:
Insulin is a potent hormone that regulates glucose, fat, and protein metabolism. In many cases, people with type 2 diabetes start insulin therapy when oral medicines cannot or no longer control their glucose levels. This means that blood glucose levels in the body have been elevated for an extended period of time. In this state, the body does not metabolize glucose, fat, or protein in a well-regulated or efficient way. Cells that require glucose to function properly begin starving because of inadequate amounts of circulating insulin. Fat metabolism becomes abnormal, which can lead to high triglyceride levels. The body's metabolic rate then increases as it tries to convert this fat into a source of energy.
These abnormalities are usually corrected when you begin insulin therapy. The body begins using glucose better, and the metabolic rate declines by about five percent. Insulin also helps the body gain fat-free mass, but on the flip side, it also helps it store fat more efficiently. Therefore, efficient glucose and fat metabolism and the reduction in metabolic rate cause most people to gain four to six pounds during the first two to three years of insulin therapy. Individuals who had poor glucose control, or who lost significant amounts of weight before beginning insulin treatment, usually experience the most weight gain.
Losing weight in general requires persistent attention to energy balance — that is, the number of calories you take in versus the number you burn. During insulin therapy, the body does not need as much food to get the energy it requires, so reducing your caloric intake is quite important. This should be accompanied by an exercise regimen, as you have begun, to expend at least 200 to 300 calories a day.
In addition, you should consult with your doctor to consider other kinds of diabetes treatments that could mitigate the weight gain. These include metformin, an oral medication that prevents weight gain; an insulin analogue called detemir, which has been shown to cause less weight gain than NPH insulin; and exenatide, an antidiabetes injection that can lead to weight loss.
— Susan
A:Insulin can, in fact, lead to weight gain. Here's how it works:
Insulin is a potent hormone that regulates glucose, fat, and protein metabolism. In many cases, people with type 2 diabetes start insulin therapy when oral medicines cannot or no longer control their glucose levels. This means that blood glucose levels in the body have been elevated for an extended period of time. In this state, the body does not metabolize glucose, fat, or protein in a well-regulated or efficient way. Cells that require glucose to function properly begin starving because of inadequate amounts of circulating insulin. Fat metabolism becomes abnormal, which can lead to high triglyceride levels. The body's metabolic rate then increases as it tries to convert this fat into a source of energy.
These abnormalities are usually corrected when you begin insulin therapy. The body begins using glucose better, and the metabolic rate declines by about five percent. Insulin also helps the body gain fat-free mass, but on the flip side, it also helps it store fat more efficiently. Therefore, efficient glucose and fat metabolism and the reduction in metabolic rate cause most people to gain four to six pounds during the first two to three years of insulin therapy. Individuals who had poor glucose control, or who lost significant amounts of weight before beginning insulin treatment, usually experience the most weight gain.
Losing weight in general requires persistent attention to energy balance — that is, the number of calories you take in versus the number you burn. During insulin therapy, the body does not need as much food to get the energy it requires, so reducing your caloric intake is quite important. This should be accompanied by an exercise regimen, as you have begun, to expend at least 200 to 300 calories a day.
In addition, you should consult with your doctor to consider other kinds of diabetes treatments that could mitigate the weight gain. These include metformin, an oral medication that prevents weight gain; an insulin analogue called detemir, which has been shown to cause less weight gain than NPH insulin; and exenatide, an antidiabetes injection that can lead to weight loss.
Saturday, March 5, 2011
Can Diabetes Be Cured?
Q: I'm 47 years old and was recently diagnosed with diabetes. I'm about 25 pounds overweight and lead a sedentary lifestyle, but I'm starting a diet and an exercise program. Will my diabetes go away if I lose weight, watch my diet, and exercise regularly?
— Mary, Kansas City
A: It is wonderful that you are changing your lifestyle to become healthier! This will benefit you greatly, not only in controlling your blood sugar but also in improving your cholesterol levels, strengthening your bones, and improving your heart function. These changes come with a long list of health benefits, but whether they will allow you to stop taking medicines completely depends on several factors:
The primary cause of your diabetes
The length of time that you had undiscovered, or "hidden," diabetes
The length of time you've had diagnosed diabetes
How well your pancreas is functioning, including how much insulin it is producing, and the extent of insulin resistance associated with excess weight
As you probably know, the cause of diabetes among most adults is twofold. It's caused by insulin resistance resulting from excess weight, and inadequate insulin production in the pancreas. These two causes are also interrelated. Many people whose diabetes is primarily the result of excess weight and insulin resistance can potentially reduce their glucose levels by losing a significant amount of weight and controlling their sugar levels through diet and exercise alone. This assumes that their pancreas is still producing an adequate amount of insulin.
A good number of diabetics, however, have the illness but don't know it for at least five years before diagnosis. This is crucial because over time, the insulin-producing cells in the pancreas decline in function. Often, by the time a patient is diagnosed, a critical number of cells have stopped producing insulin entirely. There is no way to reverse this. If your diabetes is diagnosed early in the disease process, however, aggressive management may help you prevent further loss of function in those cells. This means maintaining your fasting glucose levels below 100mg/dl and your after-meal (two hours after) levels below 140 mg/dl. This is the same for morning and evening glucose levels.
It is also entirely possible for some people to control their blood glucose with diet alone. I have a few patients who have been able to do so. All are producing adequate insulin, have lost weight or are within their ideal body-weight range, and watch their diets.
— Mary, Kansas City
A: It is wonderful that you are changing your lifestyle to become healthier! This will benefit you greatly, not only in controlling your blood sugar but also in improving your cholesterol levels, strengthening your bones, and improving your heart function. These changes come with a long list of health benefits, but whether they will allow you to stop taking medicines completely depends on several factors:
The primary cause of your diabetes
The length of time that you had undiscovered, or "hidden," diabetes
The length of time you've had diagnosed diabetes
How well your pancreas is functioning, including how much insulin it is producing, and the extent of insulin resistance associated with excess weight
As you probably know, the cause of diabetes among most adults is twofold. It's caused by insulin resistance resulting from excess weight, and inadequate insulin production in the pancreas. These two causes are also interrelated. Many people whose diabetes is primarily the result of excess weight and insulin resistance can potentially reduce their glucose levels by losing a significant amount of weight and controlling their sugar levels through diet and exercise alone. This assumes that their pancreas is still producing an adequate amount of insulin.
A good number of diabetics, however, have the illness but don't know it for at least five years before diagnosis. This is crucial because over time, the insulin-producing cells in the pancreas decline in function. Often, by the time a patient is diagnosed, a critical number of cells have stopped producing insulin entirely. There is no way to reverse this. If your diabetes is diagnosed early in the disease process, however, aggressive management may help you prevent further loss of function in those cells. This means maintaining your fasting glucose levels below 100mg/dl and your after-meal (two hours after) levels below 140 mg/dl. This is the same for morning and evening glucose levels.
It is also entirely possible for some people to control their blood glucose with diet alone. I have a few patients who have been able to do so. All are producing adequate insulin, have lost weight or are within their ideal body-weight range, and watch their diets.
Saturday, February 5, 2011
Motivating a Teen With Type 1 Diabetes
Q: My 16-year-old son is having difficulty staying motivated to consistently take care of his diabetic needs like checking his blood sugar often and keeping a log book. His doctor hospitalized him at the start of school to establish better control — his first hospitalization since diagnosis with type 1 10 years ago. He is active in sports, likes to stay up late, eats only 15 to 30 carbs for breakfast, and is on a regimen of Lantus twice daily and Humalog for meals and highs (injections, no pump.) His last A1c was 10.3. Do you have suggestions for helping him be motivated to care for himself?
— Janelle
A:
That's a tough situation indeed. Many of my colleagues who care for teenaged patients have similar moments of exasperation. As you know so well, the teen years are filled with layers of complexities for kids themselves and their families. There are many issues that become priorities in any teenager's life, among them the challenges presented by their own growth and development. These issues become even more complicated for a teenager with diabetes.
Adolescence is a time of great change, and with physical growth come greater insulin requirements. And with rebellion, experimentation and the need for peer acceptance comes greater non-adherence. In addition, while trying to find and assert their own identity, teens become less reliant on mom and dad. The challenge for parents is equally great and the solutions, unfortunately, are usually time-consuming and labor-intensive.
Your son is doing certain things for which he should be congratulated, including getting involved in sports, carbohydrate counting and injecting his insulin several times a day. These are feats that many of my adult patients do not accomplish. Motivating your son further might require one or more of the following:
1.Understanding his attitude towards frequent glucose checks and his coping and problem-solving skills will help you in identifying specific ways to help him change his behavior.
2.Assessing his knowledge-base about the need to check his sugar levels and his knowledge of glucose and insulin balance during athletic engagements can identify gaps, which can be easily addressed.
3.Understanding his priorities and academic responsibilities and showing empathy to these daily challenges can help you provide a structure that is conducive to checking blood glucose levels and diabetes self-management.
4.Exploring the barriers of checking his sugar level at school, as well as the challenges he might face from his peers about having diabetes, doing frequent glucose checks and injecting insulin, might uncover issues that he finds difficult to discuss. Since you live in a small town, there might not be many other kids living with diabetes. Perhaps your son can connect with other kids with diabetes via the Internet for peer support. A good place to start is the American Diabetes Association.
5.More importantly, understanding your communication pattern with your son and assessing its effectiveness will help you find a happy medium between too much involvement and too little engagement. Empathy is important, but so is leaving him room to make his own decisions. In other words, asking him how he can meet the challenge of good glucose control might also be more effective than telling him to make a specific change in his behavior.
6.When exploring these areas, you should enlist the help of your son's doctor as well as a psychologist or diabetes educator in your area. In addition, if you find that there are barriers at school that prevent your son from checking glucose, you should involve the school and teachers. Some teens like taking leadership roles in teaching others about diabetes, advocating for students with diabetes and organizing groups. This gives them the motivation for also managing their diabetes better. Teachers can be recruited to stage such a forum for your son and perhaps other teens. Other possible venues you might explore include religious organizations, social clubs, and community fitness centers.
Finally, this might be time to consider the insulin pump, which many teens like because it allows them better control. I wish you much luck and hope you will write back with further questions or to tell us how you and your son are doing.
— Janelle
A:
That's a tough situation indeed. Many of my colleagues who care for teenaged patients have similar moments of exasperation. As you know so well, the teen years are filled with layers of complexities for kids themselves and their families. There are many issues that become priorities in any teenager's life, among them the challenges presented by their own growth and development. These issues become even more complicated for a teenager with diabetes.
Adolescence is a time of great change, and with physical growth come greater insulin requirements. And with rebellion, experimentation and the need for peer acceptance comes greater non-adherence. In addition, while trying to find and assert their own identity, teens become less reliant on mom and dad. The challenge for parents is equally great and the solutions, unfortunately, are usually time-consuming and labor-intensive.
Your son is doing certain things for which he should be congratulated, including getting involved in sports, carbohydrate counting and injecting his insulin several times a day. These are feats that many of my adult patients do not accomplish. Motivating your son further might require one or more of the following:
1.Understanding his attitude towards frequent glucose checks and his coping and problem-solving skills will help you in identifying specific ways to help him change his behavior.
2.Assessing his knowledge-base about the need to check his sugar levels and his knowledge of glucose and insulin balance during athletic engagements can identify gaps, which can be easily addressed.
3.Understanding his priorities and academic responsibilities and showing empathy to these daily challenges can help you provide a structure that is conducive to checking blood glucose levels and diabetes self-management.
4.Exploring the barriers of checking his sugar level at school, as well as the challenges he might face from his peers about having diabetes, doing frequent glucose checks and injecting insulin, might uncover issues that he finds difficult to discuss. Since you live in a small town, there might not be many other kids living with diabetes. Perhaps your son can connect with other kids with diabetes via the Internet for peer support. A good place to start is the American Diabetes Association.
5.More importantly, understanding your communication pattern with your son and assessing its effectiveness will help you find a happy medium between too much involvement and too little engagement. Empathy is important, but so is leaving him room to make his own decisions. In other words, asking him how he can meet the challenge of good glucose control might also be more effective than telling him to make a specific change in his behavior.
6.When exploring these areas, you should enlist the help of your son's doctor as well as a psychologist or diabetes educator in your area. In addition, if you find that there are barriers at school that prevent your son from checking glucose, you should involve the school and teachers. Some teens like taking leadership roles in teaching others about diabetes, advocating for students with diabetes and organizing groups. This gives them the motivation for also managing their diabetes better. Teachers can be recruited to stage such a forum for your son and perhaps other teens. Other possible venues you might explore include religious organizations, social clubs, and community fitness centers.
Finally, this might be time to consider the insulin pump, which many teens like because it allows them better control. I wish you much luck and hope you will write back with further questions or to tell us how you and your son are doing.
Thursday, December 23, 2010
Flaxseed and Diabetes
Q: Is flaxseed beneficial for people with type 2 diabetes? Does it help my prostate gland as well?
– Desiree, Kansas
A:
Yes, flaxseed may help lower your sugar levels, and it plays a role in the prevention of prostate cancer as well. However, the strength of the evidence is too weak to permit definitive recommendations. Nonetheless, flaxseed is rich in alpha-linolenic acid (ALA), an essential fatty acid that appears to be beneficial in preventing heart disease and related illnesses. Flaxseed contains the right ratio of omega-3 to omega-6 fatty acids, is high in fiber, and provides a phytoestrogen called lignan, which may have antioxidant properties that protect against certain cancers.
There is some evidence that eating flaxseed reduces blood sugar levels after a meal and increases insulin levels because of its high content of soluble fiber. (It is 28 percent fiber, of which two-thirds is soluble.) Indeed, flaxseed carbohydrate (what remains after the oil is removed) was used in a study that showed a beneficial effect. Although this result was not duplicated in other studies, flaxseed has been shown to improve insulin sensitivity. An interesting, yet unproven, potential benefit may be the prevention of type 1 and type 2 diabetes; in animal models, flaxseed has been shown to delay the onset of the disease.
Flaxseed might help your prostatic health as well. In fact, the American National Cancer Institute has singled out flaxseed as one of six foods that deserve extensive research. Why? Because flaxseed contains a large amount of phytonutrients that serve as antioxidants, as well as those omega-3 fatty acids, which seem to play a role in preventing the formation of abnormal cells in the body. In terms of your specific question, flaxseed may reduce the prostate-specific antigen (PSA), a protein produced by the cells of the prostate gland that is often used as a marker for cancer. Also, men whose prostatic fluids contain high levels of lignan (the phytoestrogen found in flaxseed) seem to have a low risk of prostate cancer, though study results of this were not conclusive.
One word of warning: Flaxseed is high in calories. Here's an idea of how much you might need to consume to obtain its beneficial effects — 1 tablespoon of flaxseed has 5 grams of fat and weighs 12 grams. You need to take 40 to 50 grams of flaxseed, which is equal to about 4 tablespoons and has a total of 20 grams of fat. Milled flax has 36 calories per tablespoon; flax oil has 124 calories per tablespoon. (Flaxseeds are more nutritious than their oil.) These caloric considerations are important in the control of your glucose level.
Stay tuned, as I am sure there will be more studies that will guide us better in using flaxseed to stay healthy.
– Desiree, Kansas
A:
Yes, flaxseed may help lower your sugar levels, and it plays a role in the prevention of prostate cancer as well. However, the strength of the evidence is too weak to permit definitive recommendations. Nonetheless, flaxseed is rich in alpha-linolenic acid (ALA), an essential fatty acid that appears to be beneficial in preventing heart disease and related illnesses. Flaxseed contains the right ratio of omega-3 to omega-6 fatty acids, is high in fiber, and provides a phytoestrogen called lignan, which may have antioxidant properties that protect against certain cancers.
There is some evidence that eating flaxseed reduces blood sugar levels after a meal and increases insulin levels because of its high content of soluble fiber. (It is 28 percent fiber, of which two-thirds is soluble.) Indeed, flaxseed carbohydrate (what remains after the oil is removed) was used in a study that showed a beneficial effect. Although this result was not duplicated in other studies, flaxseed has been shown to improve insulin sensitivity. An interesting, yet unproven, potential benefit may be the prevention of type 1 and type 2 diabetes; in animal models, flaxseed has been shown to delay the onset of the disease.
Flaxseed might help your prostatic health as well. In fact, the American National Cancer Institute has singled out flaxseed as one of six foods that deserve extensive research. Why? Because flaxseed contains a large amount of phytonutrients that serve as antioxidants, as well as those omega-3 fatty acids, which seem to play a role in preventing the formation of abnormal cells in the body. In terms of your specific question, flaxseed may reduce the prostate-specific antigen (PSA), a protein produced by the cells of the prostate gland that is often used as a marker for cancer. Also, men whose prostatic fluids contain high levels of lignan (the phytoestrogen found in flaxseed) seem to have a low risk of prostate cancer, though study results of this were not conclusive.
One word of warning: Flaxseed is high in calories. Here's an idea of how much you might need to consume to obtain its beneficial effects — 1 tablespoon of flaxseed has 5 grams of fat and weighs 12 grams. You need to take 40 to 50 grams of flaxseed, which is equal to about 4 tablespoons and has a total of 20 grams of fat. Milled flax has 36 calories per tablespoon; flax oil has 124 calories per tablespoon. (Flaxseeds are more nutritious than their oil.) These caloric considerations are important in the control of your glucose level.
Stay tuned, as I am sure there will be more studies that will guide us better in using flaxseed to stay healthy.
Saturday, December 11, 2010
Type 1 Diabetes Death Rate is Falling But….
Average rate is still 7 times higher in people with the disease vs. those without it....According to a new study, death rates have dropped significantly in people with Type 1 diabetes. Researchers also found that people diagnosed in the late 1970s have an even lower mortality rate compared with those diagnosed in the 1960s.
The study's senior author, Dr. Trevor J. Orchard, a professor of epidemiology, medicine and pediatrics in the Graduate School of Public Health at the University of Pittsburgh, Pennsylvania, stated that, "The encouraging thing is that, given good diabetes control, you can have a near-normal life expectancy."
But, the research also found that mortality rates for people with Type 1 still remain significantly higher than for the general population -- seven times higher, in fact. And some groups, such as women, continue to have disproportionately higher mortality rates: women with Type 1 diabetes are 13 times more likely to die than are their female counterparts without the disease.
Insulin replacement therapy isn't as effective as naturally-produced insulin. People with Type 1 diabetes often have blood sugar levels that are too high or too low, because it's difficult to predict exactly how much insulin you'll need. When blood sugar levels are too high due to too little insulin, it causes damage that can lead to long term complications, such as an increased risk of kidney failure and heart disease. On the other hand, if you have too much insulin, blood sugar levels can drop dangerously low, potentially leading to coma or death.
These factors are why Type 1 diabetes has long been associated with a significantly increased risk of death, and a shortened life expectancy.
However, numerous improvements have been made in Type 1 diabetes management during the past 30 years, including the advent of blood glucose monitors, insulin pumps, newer insulins, better medications to prevent complications and most recently continuous glucose monitors.
To assess whether or not these advances have had any effect on life expectancy, Orchard, along, with his colleagues, reviewed data from a Type 1 diabetes registry from Allegheny County, Pennsylvania. The registry contained information on almost 1,100 people under the age of 18 at the time they were diagnosed with Type 1 diabetes.
The children were sorted into three groups based on the year of their diagnosis: 1965 to 1969, 1970 to 1974 and 1975 to 1979. As of January 2008, 279 of the study participants had died, a death rate that is 7 times higher than would be expected in the general population.
When the researchers broke the mortality rate down by the time of diagnosis, they found that those diagnosed later had a much improved mortality rate. The group diagnosed in the 1960s had a 9.3 times higher mortality rate than the general population, while the early 1970s group had a 7.5 times higher mortality than the general population. For the late 1970s group, mortality had dropped to 5.6 times higher than the general population.
The mortality rate in women with Type 1 diabetes remained significantly higher, however, at 13 times the rate expected in women in the general population.
In addition, blacks with diabetes had a significantly lower 30-year survival rate than their white counterparts -- 57 percent versus 83 percent, according to the study.
Although Orchard said it isn't clear why women and blacks have higher-than-expected mortality, Barbara Araneo, director of complications therapies at the Juvenile Diabetes Research Foundation, said that both discrepancies have been found in other research, and that one theory is that blacks may have a greater genetic susceptibility to heart disease or high blood pressure. And, for women, she said previous research has shown that, "women with diabetes lose their innate protection against [heart disease], similar to the loss sustained in postmenopausal phases of life." But, she said, it's not clear how diabetes causes this loss.
The overall message of the study, however, is a positive one.
"The outcome of this study shows that diabetes care has improved in many ways over the last couple of decades, and as a result people with diabetes are living longer now," said Araneo, adding, "Managing and taking good care of your diabetes is the surest way to reduce the risk of developing complications later in life."
"What we're seeing now is incredibly encouraging, but it's not necessarily the full story yet," said Orchard, who noted that improvements in diabetes care should continue to lower mortality rates in people with Type 1 diabetes.
The study's senior author, Dr. Trevor J. Orchard, a professor of epidemiology, medicine and pediatrics in the Graduate School of Public Health at the University of Pittsburgh, Pennsylvania, stated that, "The encouraging thing is that, given good diabetes control, you can have a near-normal life expectancy."
But, the research also found that mortality rates for people with Type 1 still remain significantly higher than for the general population -- seven times higher, in fact. And some groups, such as women, continue to have disproportionately higher mortality rates: women with Type 1 diabetes are 13 times more likely to die than are their female counterparts without the disease.
Insulin replacement therapy isn't as effective as naturally-produced insulin. People with Type 1 diabetes often have blood sugar levels that are too high or too low, because it's difficult to predict exactly how much insulin you'll need. When blood sugar levels are too high due to too little insulin, it causes damage that can lead to long term complications, such as an increased risk of kidney failure and heart disease. On the other hand, if you have too much insulin, blood sugar levels can drop dangerously low, potentially leading to coma or death.
These factors are why Type 1 diabetes has long been associated with a significantly increased risk of death, and a shortened life expectancy.
However, numerous improvements have been made in Type 1 diabetes management during the past 30 years, including the advent of blood glucose monitors, insulin pumps, newer insulins, better medications to prevent complications and most recently continuous glucose monitors.
To assess whether or not these advances have had any effect on life expectancy, Orchard, along, with his colleagues, reviewed data from a Type 1 diabetes registry from Allegheny County, Pennsylvania. The registry contained information on almost 1,100 people under the age of 18 at the time they were diagnosed with Type 1 diabetes.
The children were sorted into three groups based on the year of their diagnosis: 1965 to 1969, 1970 to 1974 and 1975 to 1979. As of January 2008, 279 of the study participants had died, a death rate that is 7 times higher than would be expected in the general population.
When the researchers broke the mortality rate down by the time of diagnosis, they found that those diagnosed later had a much improved mortality rate. The group diagnosed in the 1960s had a 9.3 times higher mortality rate than the general population, while the early 1970s group had a 7.5 times higher mortality than the general population. For the late 1970s group, mortality had dropped to 5.6 times higher than the general population.
The mortality rate in women with Type 1 diabetes remained significantly higher, however, at 13 times the rate expected in women in the general population.
In addition, blacks with diabetes had a significantly lower 30-year survival rate than their white counterparts -- 57 percent versus 83 percent, according to the study.
Although Orchard said it isn't clear why women and blacks have higher-than-expected mortality, Barbara Araneo, director of complications therapies at the Juvenile Diabetes Research Foundation, said that both discrepancies have been found in other research, and that one theory is that blacks may have a greater genetic susceptibility to heart disease or high blood pressure. And, for women, she said previous research has shown that, "women with diabetes lose their innate protection against [heart disease], similar to the loss sustained in postmenopausal phases of life." But, she said, it's not clear how diabetes causes this loss.
The overall message of the study, however, is a positive one.
"The outcome of this study shows that diabetes care has improved in many ways over the last couple of decades, and as a result people with diabetes are living longer now," said Araneo, adding, "Managing and taking good care of your diabetes is the surest way to reduce the risk of developing complications later in life."
"What we're seeing now is incredibly encouraging, but it's not necessarily the full story yet," said Orchard, who noted that improvements in diabetes care should continue to lower mortality rates in people with Type 1 diabetes.
Saturday, September 25, 2010
Using Insulin with Type II Diabetes
Although most people with Type II diabetes are on oral medications, some may need insulin to control their blood sugar levels.
By Marijke Vroomen-Durning, RN
Medically reviewed by Pat F. Bass III, MD, MPH
Type II diabetes, previously known as adult-onset or non-insulin-dependent diabetes, is becoming more common in North America. As more people are diagnosed with type 2 diabetes, more research is being done into better ways to manage the disease.
Type II Diabetes: Medications
Type II diabetes is usually treated with oral medications that stimulate insulin production in the pancreas. Insulin, used in type 1 diabetes, was generally only given in Type II diabetes as a last resort if the oral medications weren’t working.
Gerald Bernstein, MD, associate professor of medicine at Albert Einstein College of Medicine in Bronx, N.Y., and a past president of the American Diabetes Association, says that the idea of going on to insulin is often seen as a threat: “If you don’t lose weight, you’ll wind up on insulin.” But, over time, researchers and doctors are learning that it may be in a patient’s best interest to begin insulin treatment earlier for type 2 diabetes, rather than later.
It’s important to understand the goal of treating diabetes. The treatment of diabetes is, of course, meant to lower blood sugar levels, but this is the short-term goal. The long-term goal of diabetes treatment is to slow the progression of the disease and, therefore, delay or prevent complications.
Vincent Woo, MD, chair of the clinical and scientific section of the Canadian Diabetes Association, says “this is a big topic,” and refers to the association’s guidelines, which say:
• If after two to three months of lifestyle changes, blood sugar control hasn't improved, it’s time to start medications. This could include insulin in combination with oral medications.
• If blood sugar levels aren’t under control after a trial period of oral medications alone, insulin may be added if appropriate. Insulin is normally administered under the skin several times per day, either by injection or via an insulin pump. Several years ago an inhaled insulin was marketed in the United States, but it was discontinued due to poor sales.
Dr. Bernstein agrees: “The reality is that all of the new data and the goals of glucose control suggest that insulin would actually be better used if it were started very early in type 2 diabetes.” New guidelines “suggest that insulin should be the earliest medication intervention after the patient is taught lifestyle changes and is placed on metformin,” he says.
Type 2 Diabetes: Using Insulin for a Short Period
Many people with type II diabetes do quite well with oral medications and just need to be vigilant. Unfortunately, diabetes is a complicated illness that gets worse when your body is stressed. The stresses aren’t necessarily things like a serious illness or surgery — they could include stress over an infection or a good stress, like pregnancy. Regardless of the cause, in these situations you may need insulin to get you over the hump.
The idea here is you’re given insulin while your body heals itself from the stress and, if all goes well; the insulin may be reduced or eliminated once the stressor is gone and your body returns to its pre-stress self.
These insulin’s will be either short-acting or longer-acting insulins, or both, depending on what your body needs at that point. But, you should remember that this is most likely a temporary measure and that the hope — and aim — of the treatment is to get you back onto your usual diabetes management plan.
Living with diabetes can be frustrating, especially if you are trying your best to keep your blood sugar levels under control. While using insulin may not have been in your plan or vision of diabetes management, you should keep in mind your long-term goal of slowing down the disease process. And, if insulin is part of that plan, learning how to manage and use the insulin may be exactly what you need.
By Marijke Vroomen-Durning, RN
Medically reviewed by Pat F. Bass III, MD, MPH
Type II diabetes, previously known as adult-onset or non-insulin-dependent diabetes, is becoming more common in North America. As more people are diagnosed with type 2 diabetes, more research is being done into better ways to manage the disease.
Type II Diabetes: Medications
Type II diabetes is usually treated with oral medications that stimulate insulin production in the pancreas. Insulin, used in type 1 diabetes, was generally only given in Type II diabetes as a last resort if the oral medications weren’t working.
Gerald Bernstein, MD, associate professor of medicine at Albert Einstein College of Medicine in Bronx, N.Y., and a past president of the American Diabetes Association, says that the idea of going on to insulin is often seen as a threat: “If you don’t lose weight, you’ll wind up on insulin.” But, over time, researchers and doctors are learning that it may be in a patient’s best interest to begin insulin treatment earlier for type 2 diabetes, rather than later.
It’s important to understand the goal of treating diabetes. The treatment of diabetes is, of course, meant to lower blood sugar levels, but this is the short-term goal. The long-term goal of diabetes treatment is to slow the progression of the disease and, therefore, delay or prevent complications.
Vincent Woo, MD, chair of the clinical and scientific section of the Canadian Diabetes Association, says “this is a big topic,” and refers to the association’s guidelines, which say:
• If after two to three months of lifestyle changes, blood sugar control hasn't improved, it’s time to start medications. This could include insulin in combination with oral medications.
• If blood sugar levels aren’t under control after a trial period of oral medications alone, insulin may be added if appropriate. Insulin is normally administered under the skin several times per day, either by injection or via an insulin pump. Several years ago an inhaled insulin was marketed in the United States, but it was discontinued due to poor sales.
Dr. Bernstein agrees: “The reality is that all of the new data and the goals of glucose control suggest that insulin would actually be better used if it were started very early in type 2 diabetes.” New guidelines “suggest that insulin should be the earliest medication intervention after the patient is taught lifestyle changes and is placed on metformin,” he says.
Type 2 Diabetes: Using Insulin for a Short Period
Many people with type II diabetes do quite well with oral medications and just need to be vigilant. Unfortunately, diabetes is a complicated illness that gets worse when your body is stressed. The stresses aren’t necessarily things like a serious illness or surgery — they could include stress over an infection or a good stress, like pregnancy. Regardless of the cause, in these situations you may need insulin to get you over the hump.
The idea here is you’re given insulin while your body heals itself from the stress and, if all goes well; the insulin may be reduced or eliminated once the stressor is gone and your body returns to its pre-stress self.
These insulin’s will be either short-acting or longer-acting insulins, or both, depending on what your body needs at that point. But, you should remember that this is most likely a temporary measure and that the hope — and aim — of the treatment is to get you back onto your usual diabetes management plan.
Living with diabetes can be frustrating, especially if you are trying your best to keep your blood sugar levels under control. While using insulin may not have been in your plan or vision of diabetes management, you should keep in mind your long-term goal of slowing down the disease process. And, if insulin is part of that plan, learning how to manage and use the insulin may be exactly what you need.
Sunday, September 19, 2010
Flaxseed and Diabetes
Q: Is flaxseed beneficial for people with type 2 diabetes? Does it help my prostate gland as well?
– Frank, Florida
A: Yes, flaxseed may help lower your sugar levels, and it plays a role in the prevention of prostate cancer as well. However, the strength of the evidence is too weak to permit definitive recommendations. Nonetheless, flaxseed is rich in alpha-linolenic acid (ALA), an essential fatty acid that appears to be beneficial in preventing heart disease and related illnesses. Flaxseed contains the right ratio of omega-3 to omega-6 fatty acids, is high in fiber, and provides a phytoestrogen called lignan, which may have antioxidant properties that protect against certain cancers.
There is some evidence that eating flaxseed reduces blood sugar levels after a meal and increases insulin levels because of its high content of soluble fiber. (It is 28 percent fiber, of which two-thirds is soluble.) Indeed, flaxseed carbohydrate (what remains after the oil is removed) was used in a study that showed a beneficial effect. Although this result was not duplicated in other studies, flaxseed has been shown to improve insulin sensitivity. An interesting, yet unproven, potential benefit may be the prevention of type 1 and type 2 diabetes; in animal models, flaxseed has been shown to delay the onset of the disease.
Flaxseed might help your prostatic health as well. In fact, the American National Cancer Institute has singled out flaxseed as one of six foods that deserve extensive research. Why? Because flaxseed contains a large amount of phytonutrients that serve as antioxidants, as well as those omega-3 fatty acids, which seem to play a role in preventing the formation of abnormal cells in the body. In terms of your specific question, flaxseed may reduce the prostate-specific antigen (PSA), a protein produced by the cells of the prostate gland that is often used as a marker for cancer. Also, men whose prostatic fluids contain high levels of lignan (the phytoestrogen found in flaxseed) seem to have a low risk of prostate cancer, though study results of this were not conclusive.
One word of warning: Flaxseed is high in calories. Here's an idea of how much you might need to consume to obtain its beneficial effects — 1 tablespoon of flaxseed has 5 grams of fat and weighs 12 grams. You need to take 40 to 50 grams of flaxseed, which is equal to about 4 tablespoons and has a total of 20 grams of fat. Milled flax has 36 calories per tablespoon; flax oil has 124 calories per tablespoon. (Flaxseeds are more nutritious than their oil.) These caloric considerations are important in the control of your glucose level.
Stay tuned, as I am sure there will be more studies that will guide us better in using flaxseed to stay healthy.
– Frank, Florida
A: Yes, flaxseed may help lower your sugar levels, and it plays a role in the prevention of prostate cancer as well. However, the strength of the evidence is too weak to permit definitive recommendations. Nonetheless, flaxseed is rich in alpha-linolenic acid (ALA), an essential fatty acid that appears to be beneficial in preventing heart disease and related illnesses. Flaxseed contains the right ratio of omega-3 to omega-6 fatty acids, is high in fiber, and provides a phytoestrogen called lignan, which may have antioxidant properties that protect against certain cancers.
There is some evidence that eating flaxseed reduces blood sugar levels after a meal and increases insulin levels because of its high content of soluble fiber. (It is 28 percent fiber, of which two-thirds is soluble.) Indeed, flaxseed carbohydrate (what remains after the oil is removed) was used in a study that showed a beneficial effect. Although this result was not duplicated in other studies, flaxseed has been shown to improve insulin sensitivity. An interesting, yet unproven, potential benefit may be the prevention of type 1 and type 2 diabetes; in animal models, flaxseed has been shown to delay the onset of the disease.
Flaxseed might help your prostatic health as well. In fact, the American National Cancer Institute has singled out flaxseed as one of six foods that deserve extensive research. Why? Because flaxseed contains a large amount of phytonutrients that serve as antioxidants, as well as those omega-3 fatty acids, which seem to play a role in preventing the formation of abnormal cells in the body. In terms of your specific question, flaxseed may reduce the prostate-specific antigen (PSA), a protein produced by the cells of the prostate gland that is often used as a marker for cancer. Also, men whose prostatic fluids contain high levels of lignan (the phytoestrogen found in flaxseed) seem to have a low risk of prostate cancer, though study results of this were not conclusive.
One word of warning: Flaxseed is high in calories. Here's an idea of how much you might need to consume to obtain its beneficial effects — 1 tablespoon of flaxseed has 5 grams of fat and weighs 12 grams. You need to take 40 to 50 grams of flaxseed, which is equal to about 4 tablespoons and has a total of 20 grams of fat. Milled flax has 36 calories per tablespoon; flax oil has 124 calories per tablespoon. (Flaxseeds are more nutritious than their oil.) These caloric considerations are important in the control of your glucose level.
Stay tuned, as I am sure there will be more studies that will guide us better in using flaxseed to stay healthy.
Tuesday, September 7, 2010
Teens with Type 2 Diabetes Have Brain Abnormalities
Obese adolescents with Type 2 diabetes have diminished cognitive performance and subtle abnormalities in the brain, researchers at NYU Langone Medical Center found…
Antonio Convit, MD, professor of Psychiatry and Medicine at NYU Langone Medical Center and the Nathan S. Kline Institute for Psychiatric Research, NY, explained that, "This is the first study that shows that children with Type 2 diabetes have more cognitive dysfunction and brain abnormalities than equally obese children who did not yet have marked metabolic dysregulation from their obesity."
"The findings are significant because they indicate that insulin resistance from obesity is lowering children's cognitive performance, which may be affecting their ability to perform well in school."
Researchers studied 18 obese adolescents with Type 2 diabetes and compared them to equally obese adolescents from the same socio-economic and ethnic background but without evidence of marked insulin resistance or pre-diabetes.
Investigators found that adolescents with Type 2 diabetes not only had significant reductions in performance on tests that measure overall intellectual functioning, memory, and spelling, which could affect their school performance, but also had clear abnormalities in the integrity of the white matter in their brains.
"Now we see that subtle changes in white matter of the brain in adolescents may be a result of the abnormal physiology that accompanies Type 2 diabetes. If we can improve insulin sensitivity and help children through exercise and weight loss , perhaps we can reverse these deficits."
Antonio Convit, MD, professor of Psychiatry and Medicine at NYU Langone Medical Center and the Nathan S. Kline Institute for Psychiatric Research, NY, explained that, "This is the first study that shows that children with Type 2 diabetes have more cognitive dysfunction and brain abnormalities than equally obese children who did not yet have marked metabolic dysregulation from their obesity."
"The findings are significant because they indicate that insulin resistance from obesity is lowering children's cognitive performance, which may be affecting their ability to perform well in school."
Researchers studied 18 obese adolescents with Type 2 diabetes and compared them to equally obese adolescents from the same socio-economic and ethnic background but without evidence of marked insulin resistance or pre-diabetes.
Investigators found that adolescents with Type 2 diabetes not only had significant reductions in performance on tests that measure overall intellectual functioning, memory, and spelling, which could affect their school performance, but also had clear abnormalities in the integrity of the white matter in their brains.
"Now we see that subtle changes in white matter of the brain in adolescents may be a result of the abnormal physiology that accompanies Type 2 diabetes. If we can improve insulin sensitivity and help children through exercise and weight loss , perhaps we can reverse these deficits."
Thursday, August 19, 2010
Diabetics need to take special care of their feet to avoid the possibility of amputation
More than 18 million American adults suffer from diabetes, a chronic disease in which the pancreas stops producing insulin, the hormone that enables people to turn food into energy.
The disease, over time, can cause poor blood circulation and nerve damage in the feet, making them vulnerable to ulcers, infections, deformities and brittle bones.
Dr. Jasen Langley, a podiatrist with Kimball Medical Center in Lakewood, is trying to create public awareness of this growing problem. In cooperation with the hospital, he heads diabetes education classes and a monthly support group, designed to help individuals manage their diabetes.
"People with diabetes are 10 times more likely to have a lower limb amputated than people without diabetes," said Langley, whose office is in Howell. "They must always be vigilant and should see a podiatrist at the first sign of trouble. Early treatment can keep diabetic foot problems from progressing and reduce the risk of amputations."
At a recent program, Langley talked about the key factors in preventing serious damage to the foot and ankle areas.
"The most important thing a diabetic can do is have good blood sugar control," Langley said. "Once the sugar is under control, the manifestations of problems will actually slow down. You won't see them as quickly as you do in an uncontrolled diabetic."
Good blood sugar control can be achieved by medications, a proper diet and exercise, doctors say.
Wear sneakers
Seventy-two-year-old Edie Berg knows all about fighting blood sugar. She has been battling diabetes for more than seven years and started using insulin in 2004 to better maintain control.
"I like the insulin because I was getting some high numbers and that can be scary," said Berg, who lives in Howell. "The insulin has given me better control of my blood sugar. If I get a high number, I just take a little bigger dose of insulin."
Berg has been taking steroids for many years to combat chronic obstructive pulmonary disease (COPD), a lung disease that makes it difficult to breathe. She was told by doctors that her blood sugar numbers would increase because of the steroids, but it wasn't until 2000 that diabetes set in.
Fortunately, Berg has not had any problems with her feet. She credits a healthy diet and regular trips to the doctor. "I go every two months to the doctor and my feet are always checked," Berg said. "Dr. Langley always wants me to make sure I wear sneakers. He says, "If one foot rubs against another and you can't feel it, that's the first sign of trouble.' When I rub my feet together, it tickles, so I know I am OK."
Diabetes costs more than $132 billion a year in the United States, including direct medical expenses as well as indirect costs such as lost work, disability and premature death, according to the Centers for Disease Control and Prevention in Atlanta.
Langley said many younger doctors are being more aggressive in their treatment of diabetics, which can help prevent surgery and reduce the financial toll.
"If a foot becomes bad enough that you need surgery, that can run in the neighborhood of $50,000, $60,000," Langley said. "That really takes a toll on the family and the insurance companies. That is why you are seeing the media and the Diabetes Association embarking on a more aggressive campaign to get the word out on the disease."
The disease, over time, can cause poor blood circulation and nerve damage in the feet, making them vulnerable to ulcers, infections, deformities and brittle bones.
Dr. Jasen Langley, a podiatrist with Kimball Medical Center in Lakewood, is trying to create public awareness of this growing problem. In cooperation with the hospital, he heads diabetes education classes and a monthly support group, designed to help individuals manage their diabetes.
"People with diabetes are 10 times more likely to have a lower limb amputated than people without diabetes," said Langley, whose office is in Howell. "They must always be vigilant and should see a podiatrist at the first sign of trouble. Early treatment can keep diabetic foot problems from progressing and reduce the risk of amputations."
At a recent program, Langley talked about the key factors in preventing serious damage to the foot and ankle areas.
"The most important thing a diabetic can do is have good blood sugar control," Langley said. "Once the sugar is under control, the manifestations of problems will actually slow down. You won't see them as quickly as you do in an uncontrolled diabetic."
Good blood sugar control can be achieved by medications, a proper diet and exercise, doctors say.
Wear sneakers
Seventy-two-year-old Edie Berg knows all about fighting blood sugar. She has been battling diabetes for more than seven years and started using insulin in 2004 to better maintain control.
"I like the insulin because I was getting some high numbers and that can be scary," said Berg, who lives in Howell. "The insulin has given me better control of my blood sugar. If I get a high number, I just take a little bigger dose of insulin."
Berg has been taking steroids for many years to combat chronic obstructive pulmonary disease (COPD), a lung disease that makes it difficult to breathe. She was told by doctors that her blood sugar numbers would increase because of the steroids, but it wasn't until 2000 that diabetes set in.
Fortunately, Berg has not had any problems with her feet. She credits a healthy diet and regular trips to the doctor. "I go every two months to the doctor and my feet are always checked," Berg said. "Dr. Langley always wants me to make sure I wear sneakers. He says, "If one foot rubs against another and you can't feel it, that's the first sign of trouble.' When I rub my feet together, it tickles, so I know I am OK."
Diabetes costs more than $132 billion a year in the United States, including direct medical expenses as well as indirect costs such as lost work, disability and premature death, according to the Centers for Disease Control and Prevention in Atlanta.
Langley said many younger doctors are being more aggressive in their treatment of diabetics, which can help prevent surgery and reduce the financial toll.
"If a foot becomes bad enough that you need surgery, that can run in the neighborhood of $50,000, $60,000," Langley said. "That really takes a toll on the family and the insurance companies. That is why you are seeing the media and the Diabetes Association embarking on a more aggressive campaign to get the word out on the disease."
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.
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