Suddenly All the Kids Have Diabetes

From the way diabetes gets talked about in the news, you'd think that everyone and their brother had it. Well, now it's looking more like everyone and their daughter has it. A new study has just been released which shows a pretty terrifying increase in the rate of diabetes and pre-diabetes among young people. In 2000, only 9 percent of teens were diabetic or pre-diabetic. By 2008, a whopping 23 percent of adolescents are. Jesus H. Christ on a cracker. That is a huge increase in just eight years. One small ray of hope is that the test they used, a fasting blood glucose test, doesn't give as accurate a picture of a person's health because it's a single snapshot of blood sugar rather than an average over time. So that number could be somewhat artificially high. Still, even considering that, this news is not good. The author of the study, Ashleigh May, who is an epidemiologist for the CDC, calls the findings "very concerning." Pediatric endocrinologist Larry Deeb, who is also a former president of medicine and science for the American Diabetes Association, says other research shows there could be "a 64% increase in diabetes in the next decade. [...] We are truly in deep trouble. Diabetes threatens to destroy the health care system." As if that wasn't bad enough, this study also found something else that's equally scary: [H]alf of overweight teens and almost two-thirds of obese adolescents have one or more risk factors for heart disease, such as diabetes, high blood pressure or high levels of bad cholesterol. By comparison, about one-third of normal-weight adolescents have at least one risk factor. While it was already clear that we needed to do something to protect the health of our kids, this data suggests we'd better do something quickly. Not that there's any easy way to fix this problem, especially among modern teens who already have so many other things to worry about, like being bullied and not getting caught in a sexting scandal. Perhaps it's time to call upon some kind of health superhero. Will Mr. Metabolic Syndrome save the day and defeat evil Dr. Diabetes? Blood Sugar Man to the rescue? Can we even just get Jack Black in a spandex suit doing PSAs? Someone? Anyone? Help. By Cassie Murdoch

7 Steps to Treating Low Blood Sugar / Hypoglycemia

Low blood sugar symptoms need immediate attention. Here's what you should do to handle this potential emergency.

Hypoglycemia requires fast treatment. When someone with diabetes begins experiencing low blood sugar symptoms, any delay increases the chance that the hypoglycemia could escalate into a life-threatening illness. Left untreated or not treated promptly, hypoglycemia can result in seizures, coma, permanent damage to the nervous system, and death.

Here are the steps you need to take if your diabetes management plan has failed and you begin to have the low blood sugar symptoms that indicate an episode of hypoglycemia:

1. Recognize the symptoms. The symptoms of hypoglycemia vary from person to person, but anyone taking insulin or diabetes medication should know what they are. Low blood sugar symptoms include:

Weakness or fatigue
Cold sweats or clammy skin
Confusion or fuzzy and unclear thinking
Dizziness or light-headedness
Blurred vision
Hunger Nervousness, anger, or irritability
Headache
Rapid heartbeat
Numb or tingling skin
Difficulty speaking
Shakiness

2. Make yourself safe. If you or a family member with diabetes begins to have any of these symptoms, take immediate safety precautions. Pull over if you are driving a car. Sit down right away if you are walking down steps. Hypoglycemia could cause you to lose consciousness and cause harm to yourself or others. You want to make sure that doesn't happen.

3. Test your blood glucose levels. In most cases, providing that symptoms are still mild, test to make sure you actually are having a hypoglycemic episode rather than another malady. Use your blood glucose meter to check. A reading of 70 mg/dl or lower means you need to take quick action. If symptoms are too severe to manage the testing or you can’t get to your glucose meter quickly, move on to step 4.

4. Get some carbs into your body. A diabetic undergoing an episode of hypoglycemia needs to bring blood glucose levels up quickly. Fast-acting carbohydrates, especially simple sugars, can accomplish this. If you are taking insulin or diabetes medication as part of a diabetes management plan, you should always have on hand a bit of quick-fix food equal to 15 to 20 grams of sugar or carbohydrates. Some foods that can provide this amount and quickly raise your blood sugar level include:

4 or 5 saltine crackers
5 or 6 pieces of hard candy
2 tablespoons of raisins
4 teaspoons of sugar
3 or 4 glucose tablets
1 serving of glucose gel
1/2 cup of fruit juice or regular soda
1 cup of milk
1 tablespoon of honey or corn syrup

5. Wait, then verify treatment is working. Don't keep eating, as you might over-treat and cause your blood sugar level to go too high. Instead, wait about 15 minutes and then test your blood sugar level again with a meter. If it's still too low, then eat another 15 to 20 grams of sugar or carbohydrate. Repeat until your blood sugar level is at 70 mg/dl or higher. Once you've reached that level, eat a more nutritious, carbohydrate-containing snack unless a meal is less than one hour away.

6. If your body doesn't respond, seek medical help. If you haven't responded to the carbs or if you've passed out or had seizures, you probably have a case of severe hypoglycemia and need medical attention. If someone in your family or at your workplace is aware of your condition and has been trained to give emergency glucagon injections (a substance that quickly raises blood sugar levels), they should do so immediately, even before calling 911 to get help. A diabetic treated with glucagon should respond quickly and be able to eat some food within 15 minutes.

7. Take long-term steps. If you have recurring hypoglycemic episodes or even one severe case, talk with your doctor about adjusting your diabetes management plan to better fit your lifestyle. You also should ask to have a glucagon injection prescribed to you, so that a family member or friend can administer it if you pass out or experience a seizure from another severe case of hypoglycemia.

Being prepared and knowing what to do about hypoglycemia is an important part of a good diabetes management plan.

Stem Cell Therapy May Reverse Diabetes

An immune regulator from healthy cord blood stem cells (CB-SCs) can "educate" the T cells of a person with type 1 diabetes (T1D), enabling the pancreas to produce insulin....

Yong Zhao, MD, PhD, from the University of Illinois at Chicago, and colleagues base their "stem cell educator therapy" on observations that multipotent stem cells from human cord blood can alter regulatory T cells (Tregs) and islet B cell–specific T-cell clones. The new approach alters autoimmunity both in non-obese diabetic mice and in islet B cells from patients with diabetes.

In a small, open-label trial, a single treatment reduced the median daily dose of required insulin by 38% at 12 weeks for patients with moderate T1D and some B-cell function (36 ± 13.2 U/day at baseline vs 22 ± 1.8 U/day 12 weeks post-treatment), and by 25% in patients with severe T1D and no residual function (48 ± 7.4 U/day at baseline vs 36 ± 4.4 U/day 12 weeks post-treatment). The investigators saw no change in insulin requirements among the control group.

The researchers circulated lymphocytes from patients' blood in a closed-loop "stem cell educator," co-culturing the cells for 2 to 3 hours with adherent CB-SCs from healthy donors. The device sandwiches CB-SCs between 9 discs of a hydrophobic material, with a top cover plate and a lower collecting plate through which the lymphocytes exit. The investigators infused the "educated" lymphocytes into the patients and measured both levels of C-peptide and glycated hemoglobin and indicators of immune function at 4, 12, 24, and 40 weeks.

Investigators conducted this open-label, phase 1/2 clinical trial at the General Hospital of Jinan Military Command in China from October 2010 until January 2011, 15 patients (median age, 29 years [range, 15 - 41 years]; median diabetic history, 8 years [range, 1 - 21 years]) received a single treatment. Three control patients received a sham treatment lacking cells.

Primary endpoints were feasibility (change in C-peptide secretion), safety by 12 weeks, and preliminary evidence of improved B cell function by 24 weeks. Immune modulation was a secondary end point.

Overall, the treated individuals displayed better C-peptide and glycated hemoglobin A1c values, lower daily requirement for insulin, and decreased autoimmunity.

Patients with moderate T1D had improved fasting C-peptide levels at 12 and 24 weeks. Those with severe T1D showed successive improvement in fasting C-peptide levels.

A1c levels for patients with moderate T1D fell from 8.73% ± 2.49% at baseline to 7.67% ± 1.03% at 4 weeks (P = .036), and to 6.82% ± 0.49% at 12 weeks post-treatment. For those with severe T1D, A1c levels fell 1.68% ± 0.42% at 12 weeks post-treatment, with no change seen in the control group.

Stem cell education significantly increased the percentage of Tregs in peripheral blood, as well as levels of CD28 and inducible co-stimulator. Cytokine balance improved. The CB-SCs produce an autoimmune regulator which may eliminate autoreactive T cells.

"This innovative approach may provide CB-SC-mediated immune modulation therapy for multiple autoimmune diseases while mitigating the safety and ethical concerns associated with other approaches," conclude the researchers.

BMC Med. Published online January 10, 2012.

Study Cites Eleven Risk Factors That Could Predict Amputation

Given that lower extremity amputation is a devastating consequence of diabetic foot infection, physicians must be vigilant for the signs that could presage amputation. In a new study in Diabetes Care, authors have developed a risk score of 11 factors that could predict amputation.

Researchers identified 3,018 patients who were hospitalized for culture-documented diabetic foot infection at 97 hospitals in the U.S. between 2003 and 2007. Among those patients, 21.4 percent underwent a lower extremity amputation.

The 11 risk factors for amputation, in ascending order of point value, are: chronic renal disease or creatinine >3 mg/dL; male sex; temperature <96°F or >100.5°F; age 50 or older; ulcer with cellulitis; history of amputation; albumin <2.8 g/dL; history of peripheral vascular disease; white blood cell count >11,000 per mm3); surgical site infection; and transfer from another acute care facility.

Authors note that treatment of a patient with a low score may require fewer medical resources than a patient with a high risk score. The study also says in an attempt to avoid amputation, healthcare providers should concentrate efforts on a patient with a risk score of more than 21 as they have a 50 percent chance of amputation.

Lead study author Benjamin A. Lipsky, MD, notes researchers developed the risk score specifically to use information that is present at (or soon after) the time of hospitalization. As he notes, this info includes findings from the history, physical examination or simple laboratory tests. He foresees “relatively minimal” organizational challenges for healthcare facilities implementing this scoring system. Dr. Lipsky says facilities would just need to educate providers about the score and perhaps provide a score sheet with explanations on how to use it.

Although the study used a database of patients who were hospitalized for their diabetic foot infection, this risk score would likely apply to the majority of patients who do not require hospitalization, according to Dr. Lipsky, a Professor of Medicine at the University of Washington and the Director of the Primary Care Clinic at the VA Puget Sound Health Care System. He and his co-authors would like to see the score validated in such a population.

David G. Armstrong, DPM, MD, PhD, cites the importance of the risk score system, saying it will be helpful to have a predictable system as another tool to predict outcomes. He compares this to a wound classification system, which is “highly predictive of good and bad outcomes” when a patient presents with a wound.

Dr. Armstrong has found the most critical predictors of amputation to be infection, ischemia and renal disease. He expresses surprise that renal disease was not more of a factor in the study.

“We believe that people on dialysis, people with end-stage renal disease and people with kidney disease are going to become increasingly important targets for aggressive intervention or hospice,” says Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance (SALSA).

Dr. Lipsky would like to see if the score can be further simplified and refined so clinicians can remember it more easily. He would also like to see the risk score applied to patients in other countries and healthcare systems.

By Brian McCurdy, Senior Editor

Stress Predicts Development of Impaired Glucose Metabolism

Perceived stress and stressful life events predict the development of impaired glucose metabolism (IGM) over 5 years in previously normoglycemic individuals, according to results from the Australian Diabetes, Obesity, and Lifestyle study AusDiab)....

The study by Emily Williams, PhD, Monash University, Melbourne, Australia, showed that perceived stress increased the risk for incident IGM over 5 years by between 1.04 and 1.06, depending on the model used. Using the same models, high levels of stressful life events also increased the risk for incident IGM by between 1.24 and 1.35 in the same longitudinal cohort.

Dr. Williams reported that, "The effect size sounds quite small but for every point increase [in these models], there is a 4% increased risk of developing IGM, so stress is quite a strong risk factor for IGM." "And we think stress management should be incorporated into multiple health behavioral interventions for the most effective prevention and management of diabetes."

AusDiab included 11,247 adults older than 25 years who were randomly selected from 42 areas of Australia. At baseline, a 2-hour, 75-g oral glucose tolerance test was given along with the Perceived Stress Questionnaire and a life events score to measure psychosocial adversity.

At 5 years, more than 6,500 of the original participants returned for follow-up during which another 2-hour oral glucose test was taken and the questionnaires re-administered.

"We used the outcome of a polled analysis of fasting glucose, impaired glucose tolerance, and diabetes to have a larger category of impaired glucose metabolism to try and tap into a wider range of abnormal glucose metabolism, and by measuring perceived stress as well as the experience of stress, we tried to measure both objective and subjective markers of stress. Only subjects who were normoglycemic at baseline were included in the analyses," said Dr. Williams.

At 5-year follow-up, 474 subjects had progressed to IGM. Adjusting for age, sex, and education, logistic regression analyses showed that perceived stress increased the odds of IGM by 1.06. Controlling for the same variables, those reporting high levels of stressful life events were 34% more likely to have developed IGM at 5 years compared with those reporting low levels of stressful life events.

When health behaviors were added to the model, results showed that perceived stress increased the odds of IGM by 1.05. The same model also showed that those reporting high levels of stressful life events had a 35% higher risk of developing IGM compared with those reporting low levels of stressful life events. Adding obesity to the mix attenuated the effect of perceived stress as a risk factor for IGM but not by much, at an odds ratio of 1.04.

Similarly, obesity slightly attenuated the risk for stressful life events contributing to IGM at an odds ratio of 1.26. Lastly, when all variables plus traditional cardiovascular disease (CVD) risk factors were added to the analysis, perceived stress still had the same effect on IGM risk at an odds ratio of 1.04. Again, compared with those who reported low levels of stressful life events, those reporting high levels of stressful life events had a 24% greater chance of developing IGM at 5 years when analyzed in the final model.

Table 1. Perceived Stress as a Risk Factor for Impaired Glucose Metabolism

Controlling for
Odds Ratio

Model 1: Age, sex, education
1.06

Model 1 plus health behaviors (model 2)
1.05

Model 2 plus obesity (model 3)
1.04

Model 3 plus cardiovascular disease risk factors (model 4)
1.04



Table 2. Stressful Life Events as a Risk Factor for Impaired Glucose Metabolism

Controlling for
Odds Ratio

Model 1 low life stress vs high life stress
1.34

Model 2 low life stress vs high life stress
1.35

Model 3 low life stress vs high life stress
1.26

Model 4 low life stress vs high life stress
1.24

Investigators also evaluated how stress affected glycemic control over time among subjects who already had diabetes at baseline. Interestingly, said Dr. Williams, there no relationships between stress and glycemic control was observed in men, but among women with diabetes at baseline, both perceived stress and stressful life events were shown to predict elevated glycosylated hemoglobin at follow-up, after adjustment for other risk factors (P = .024).

Dr. Williams stated that, "All of the evidence in CVD suggests that stress is a key independent risk factor for the development of heart disease, but it hasn't been done in diabetes, and yet they are on the same chronic disease trajectory. "So there is no reason to think stress isn't involved in the development of diabetes too and even more so because diabetes requires so much daily management it's bound to affect a person's experience."

Easy Steps to Reduce Diabetes Risk

From walking more to getting your blood sugar checked, you can reduce your chances of getting diabetes by following just a few easy steps.

Being overweight, not getting enough physical activity, and constantly being stressed out are all strong risk factors for type 2 diabetes. These are problems that many people face, but the good news is that you can make a few simple changes to your life to create a diabetes prevention program and reduce your diabetes risk.
Think diabetes prevention at the start of every day. “Eat a breakfast of protein and complex carbohydrates,” says Suzanne Steinbaum, DO, a cardiologist and director of Women and Heart Disease at Lenox Hill Hospital in New York City. “Eating a meal like this prevents the sugar highs and lows that often come with a breakfast of simple carbohydrates and sugars, like a bagel or a donut, which can cause those feelings of fatigue and lethargy that make you crave sugar again to increase your energy.”

Fred Pescatore, MD, an author and physician who practices nutritional medicine in New York City, says one of your best overall strategies for diabetes prevention is to steer clear of most foods that are white — white bread, white rice, and white pasta top the list. “These simple carbohydrates can cause blood sugar to spike even more than regular sugar,” he says. “This may lead to a blood sugar dip, resulting in additional sugar cravings. Avoiding white foods will help to stop this vicious cycle.”

One of the biggest causes of diabetes in this country is overeating that leads to obesity. A basic strategy for avoiding overeating is to reduce your portions by using smaller dishes than you usually would for all your meals, according to Dr. Steinbaum. “Rather than worrying about servings, pay attention to cups and tablespoons,” she says. “To help with this, instead of using a large dinner plate, use a salad plate for dinner.”

Most people think it’s okay to drink soda as long as they stick to diet soda instead of the regular sugary kind. But Steinbaum cautions that water might be the better choice for diabetes prevention. “Studies have shown that even diet soda can increase the incidence of metabolic syndrome, a pre-diabetic condition associated with insulin resistance,” she says.

A basic lifestyle strategy to assist with diabetes prevention is to keep a detailed food journal. You can use paper or a Web site or mobile phone application like My Calorie Counter, but whatever you choose, don’t spare any details. “If you write down everything you eat, you are less apt to overeat or to unconsciously pick at food or ‘graze,’” says Steinbaum. “It also lets you look back at what you’ve eaten, so you can more easily modify your behavior.”

Some people get frustrated by constantly monitoring a scale while trying to lose weight. Steven Joyal, MD, author of What Your Doctor May Not Tell You About Diabetes, says that measuring your waistline might be a better way to foster diabetes prevention. “Greater than 40 inches for men or greater than 35 inches for women means you’re at an increased risk,” he says.

Remember that inactivity is a diabetes cause and activity is a key to diabetes prevention. When it comes to exercise, some people use time constraints or other commitments as excuses not to work out. If you think that not doing a long workout means you shouldn’t bother at all, Dr. Joyal respectfully begs to differ. “A power-packed, yet short-duration exercise program of 12 minutes every other day can have a tremendous impact on your body,” he says.

Another simple way to fit more diabetes prevention strategies into your everyday, daily routine is to find ways to add more activity to everything you do. For example, when you pull into a parking lot, Dr. Pescatore suggests parking as far away from your destination as possible and walking the rest of the way. “Walking burns calories, builds muscle, and utilizes blood sugar,” he says. Other steps include taking the stairs instead of the elevator and doing sit-ups, push-ups, or even stretches while watching TV.

Stress is a risk factor for type 2 diabetes. So while focusing on eating less and exercising more, it’s important not to overlook stress reduction. “Take a yoga class, try meditation, and set boundaries around family and friends,” says Robyn Webb, MS, food editor of Diabetes Forecast magazine and author of 13 cookbooks published by the American Diabetes Association. “Seek professional therapy for issues in your life that you feel you need help with.”

Finally, if you have a family history of diabetes or are at risk, you should get your blood checked once a year to truly know your status. Pescatore says the two most important tests your doctor should perform are checking your hemoglobin A1C levels and your fasting insulin levels. If you commit to making all the previous suggestions, your efforts should show in your lab results.

Is 'Borderline' Diabetes Really Diabetes?

Q: I just learned that I'm a "borderline" diabetic, even though my blood glucose reading was very close to normal. Now I'm not sure what to do. Should I be consistently checking my blood sugar level, eating differently, or taking medication as though I actually have diabetes? I don't want to develop diabetes, but I don't want to take unnecessary precautions either.

A: Great question! Now that you've been diagnosed with prediabetes, prevention is key. Prediabetes is characterized by either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Both of these terms refer to the level of sugar in the bloodstream, and they're both ways of saying that you have prediabetes.

If your fasting glucose level (a test in which blood is drawn after six hours without food) is between 100 and 125 mg/dl, you have IFG. If your blood sugar level two hours after a glucose challenge test is between 139 and 200 mg/dl, you have IGT.

Okay — now that we have the classification straight, why should you be worried about these numbers if yours are not in the diabetic range? Here's why: As your blood glucose rises above the normal level, your risk of developing damage in the body's small blood vessels, and ultimately your risk of a heart attack or stroke, also rises. In addition, having abnormal glucose levels is a risk factor for developing outright diabetes in the future.

By bringing you blood sugar levels back in the normal range, you can probably prevent the onset of diabetes and other complications, such as coronary artery disease. It is not absolutely essential to frequently check your glucose levels at home as long as you and your doctor monitor them periodically.

The precautions that you can and should take to prevent complications and the onset of diabetes consist of the same habits you'd cultivate to stay healthy in general. These include exercising, eating healthfully and not excessively, and maintaining your ideal body weight. One study showed that among a group of individuals who had prediabetes, those who lost as little as 7 percent of their body weight delayed the onset of diabetes or prevented it. There are also medicines that have been shown to prevent diabetes. While I do not recommend medicines to all people with prediabetes, it might be advisable in some cases. I wish you luck in this journey toward health.

A Closer Look At New Developments In Diabetes

The prevalence of diabetes is increasing rapidly and is expected to reach epidemic proportion over the next decade. Recent research estimates that the number of people diagnosed with diabetes will rise from 23.7 million to 44.1 million between 2009 and 2034.1 The Centers for Disease Control and Prevention (CDC) further predict that up to one-third of U.S. adults could have diabetes by 2050 if Americans continue to gain weight and avoid exercise.2

Diabetes is associated with a myriad of complications with foot ulcerations being the most common. An estimated 15 percent of all patients with diabetes will develop foot ulcers.3 About half of these ulcers become infected and 20 percent of those patients will end up with some form of lower extremity amputation.3 With the prevalence of diabetes dramatically increasing, billions of dollars are spent in the field of diabetes research for the early diagnosis, prevention and management of this disease.

With that said, here is a closer look at current research in the field of diabetes and emerging methods of disease management.

What You Should Know About Biomarkers For Diabetes
Researchers are constantly studying biomarkers to help predict the possibility of developing certain diseases. Biomarkers can indicate a change in the expression or state of a protein that correlates with the risk or progression of a disease, or with the susceptibility of the disease to a given treatment.

Recently, researchers from the United Kingdom have reported that microRNA (MiR) can help identify people who are likely to develop type 2 diabetes even before the onset of symptoms.4 MicroRNAs are classes of approximately 22 non-coding nucleotide regulatory ribonucleic acid (RNA) molecules that play important roles in controlling the developmental and physiological processes.5 Specifically, microRNAs regulate gene expression including differentiation and development by either inhibiting translation or inducing target degradation. MicroRNAs can also help serve as diagnostic markers to identify those who are at high risk of developing coronary and peripheral arterial disease.


In a study of 822 people, researchers identified five specific microRNA molecules with an abnormally low concentration in blood in people with diabetes and in those who subsequently went on to develop the disorder.6 One molecule in particular, microRNA 126 (MiR-126), was among the most reliable predictors of current and future diabetes. MiR-126 is known to help with angiogenesis and regulate the maintenance of vasculature. Healthy blood vessel cells are able to release substantial quantities of MiR-126 into the bloodstream.

However, when endothelial damage occurs, the cells retain MiR-126 and subsequently release less MiR-126 into the bloodstream. A decrease in plasma MiR-126 can therefore be an indicator of blood vessel damage and cardiovascular disease. Researchers also found that levels of MiR were lower when they gave large amounts of sugar to mice with a genetic propensity to develop diabetes.6 The MiR test can directly assess vascular endothelial damage secondary to diabetes and has a fairly low cost at around $3 per test. Clinicians may possibly be able to use this in conjunction with conventional tests in the near future.

Plasma thrombin activatable fibrinolysis inhibitor (TAFI) antigen is another biomarker that may participate in arterial thrombosis in cardiovascular diseases and may be involved in the mechanism of vascular endothelial damage in patients with diabetes.

Erdogan and colleagues investigated the association of plasma TAFI antigen level in the development of diabetic foot ulcers in people with type 2 diabetes.7 Specifically, researchers determined TAFI antigen levels in plasma samples in 50 patients with diabetic foot ulcers, 34 patients with diabetes but without diabetic foot ulcers, and 25 healthy individuals. The diabetic foot ulcer group and the diabetic non-ulcer group were similar in terms of mean age and sex distribution.

The researchers found TAFI levels to be significantly elevated in patients with diabetes with or without foot ulcers in comparison to the healthy controls. However, there was no difference in TAFI levels between the diabetic foot ulcer group and diabetic non-ulcer group, or between diabetic foot ulcer stages.

As research in this arena continues, a new class of blood markers may give additional insight to screen people who are at a higher risk of developing diabetes and intervene before the symptoms and the broad spectrum of associated complications occur.

Can An Artificial Pancreas System Enhance Glucose Control?
The artificial pancreas is a technology that is best described as a closed loop glucose management system that is intended to afford patients with diabetes better glucose control while averting the hypoglycemic state.8 With the advancement of technologies, newer artificial pancreas systems consist of a real-time continuous glucose monitoring (CGM) system. This system transmits information every one to five minutes from an under the skin sensor to a handheld receiver that can be integrated into a pump. The device also has an insulin pump with a pre-programmed algorithm that calculates appropriate insulin dosages based on the glucose ratings.

A potential imperfection to this CGM system is that the system reads glucose levels from the patient’s interstitial fluid as opposed to the actual blood glucose levels. The interstitial compartment has a lag time of eight to ten minutes and can affect the glucose readings, especially postprandial readings.

The insulin pump is a beeper-sized device that is flexibly attached via a tube in the tissue just under the skin and will release as per patient requirement. Some partial “half-loop” solutions are available in Europe and the FDA has recently approved three of the closed loop systems. Meticulous testing is still needed before the system can go on the market.9

Emerging Insights On Stem Cell Advances
With islet cell transplantation research quickly on the rise to help regenerate the disordered islet cells of the pancreas, we have seen much promise in stem cell research. Ideally, the in vitro generation of insulin-producing cells from stem or progenitor cells presents a promising approach to overcome the scarcity of donor pancreases for cell replacement therapy in people with diabetes.10

In an ongoing study, researchers at the Diabetes Research Institute are assessing the effects of biohybrid devices, also known as “scaffolds,” to house and protect the transplanted insulin producing cells.11 These “scaffolds” are designed to mimic the pancreatic environment and are being tested in different areas of the body that include the abdominal pouch, muscle tissue or subcutaneously. Furthermore, the “scaffolds” are also being tested to deliver favorable agents that may help promote the growth and viability of the transplanted islet cells.

Current studies are very optimistic in showing that these “scaffolds” co-transplanted with mesenchymal stem cell regenerative islet cells can help accelerate angiogenesis, which prolongs the longevity and functionality of islet cell regeneration.12

Encouraging Patient Adherence: What Recent Studies Reveal
Patient adherence is one of the many challenges in the treatment and management of diabetes. For years, physicians have been researching new methods in tracking patient adherence to glucose monitoring and management, and to pressure mitigation devices.

In an article published in the Annals of Family Medicine, researchers looked at the participation levels of patients with type 2 diabetes in their primary care check-up visits.13 Several offices sent questionnaires to these patients regarding their treatment goals and plans at the initial visit as well as follow-up visits. Researchers found that the more patients participated in their treatment decisions and management, the better they adhered to the prescribed medications and treatment. This resulted in better control of their diabetes.

Another study compared the efficacy of a reciprocal peer support program with that of nurse care management in 244 men with diabetes in two Veterans Affairs healthcare facilities.14 Researchers matched patients in the reciprocal peer support group with another age-matched peer patient and were encouraged to talk via telephone and participate in optional group sessions. Patients in the nurse care management group attended a 1.5-hour educational session and were assigned to a nurse care manager.

After six months, the mean hemoglobin A1C level for patients in the peer support program decreased from 8.02% to 7.73% while it increased from 7.93% to 8.22% in the nurse care management group.14 This was statistically significant.

Both studies support the notion that some patient empowerment in their treatment decisions and management may translate into better long-term outcomes.

In Conclusion
Diabetes is estimated to impose more than $174 billion dollars per year on United States healthcare. This astounding financial toll is expected to continue to rise as more and more people are diagnosed with this debilitating disease.2 In addition to being aware of the plethora of current research, patient education and preventative care are important strategies to emphasize. It is through innovative research, teamwork and preventative strategies that we continue to gain successful outcomes and improvement in the prevention and management of diabetes and its complications.

VOLUME: 24 PUBLICATION DATE: Jan 01 2011
Author(s):David A. Farnen, BS, and Stephanie C. Wu, DPM, MSc

Carbohydrates in the Diabetes Diet

Carbs count in a diabetes diet because they directly affect blood glucose levels. If you're not producing enough insulin to regulate those levels, serious medical issues can develop. When you have diabetes, following a careful diabetes diet is a key aspect of diabetes management, and controlling carbohydrate intake is an essential part.

Along with proteins and fats, carbohydrates are one of the three major components of food. Your body converts carbohydrates into glucose, which your cells burn for energy. Since glucose is transported to cells through your bloodstream, eating carbohydrates will cause your blood glucose level to increase.

Because carbohydrates directly affect your blood sugar level, eating too many carbs — or the wrong sort of carbs — can undo whatever other actions you’re taking to keep your diabetes in check.

How Carbs Affect Different Diabetes Types

It's important to control your carbohydrate intake no matter which of the three major forms of diabetes you have:

Type 1 diabetes. If you have this type of diabetes, you cannot produce insulin, a hormone that helps cells use glucose. That means you must take insulin and other medication to regulate blood sugar. A healthy diabetes diet with controlled carbohydrate intake will make it easier to predict when you will need to administer insulin and how much to use.Type 2 diabetes. People with type 2 diabetes have developed a resistance to insulin, often due to obesity or poor diet. By maintaining steady blood sugar levels through carb counting, you may be able to reduce the amount of insulin or medication you need or avoid taking the drugs altogether.Gestational diabetes. If you develop diabetes during pregnancy, you need to count carbs because unchecked blood sugar levels can damage the fetus as well as your own body. Diabetes Management: Carbs and the Diabetes Diet

There are three main types of carbohydrates:

Sugars, often called simple carbohydrates, are converted quickly to glucose. Think of them as dry wood in a fire, burning fast and hot.
Starches, often called complex carbohydrates, are formed by long chains of sugars and take longer for your body to break down into glucose. Think of them as big logs that burn slowly in a fire.
Fiber is present in different amounts in all plant-based foods, especially in whole grains (starches). It’s great for digestive health, but because it isn’t digested the way the other two types of carbs are, fiber grams don’t count in your carb totals.
People with diabetes need to count all the starch and sugar carbohydrates they take in every day as part of their diabetes management plan. The American Diabetes Association recommends that diabetics eat around 45 to 60 grams of carbohydrates per meal, although you should consult with your diabetes care team to determine the right amount of carbohydrates to fit your needs and lifestyle.

Most of your carbohydrates should come in the form of starchy carbohydrates, which will convert into glucose more slowly and help your blood sugar remain steady. Healthy choices include whole grains, beans, and lentils, and starchy vegetables like peas, corn, and potatoes. Avoid refined starches like white flour or white rice, as they tend to burn as fast as sugars.

Some of your carbohydrates still can come in the form of sugars, particularly if they are natural sugars in healthy foods like low-fat dairy products, fruits, or vegetables. Just avoid added sugars such as table sugar and the high-fructose corn syrup and other types of sugars you’ll find in sodas, sweets, and other processed foods.

To keep track of your carbohydrates, you need to read the nutrition facts label included on most packaged foods. Check out the serving size to figure out how much constitutes one serving, and then scan down to find the total amount of carbs contained in a serving. Usually, the label also will show how many of those carbs are sugars and how many are dietary fiber, which helps to slow the release of sugar. Always read the ingredient label closely because product names can be deceiving — for instance, you may find a number of different forms of sugar in a processed food that isn’t even a sweet.

You need to be a part-time detective to find out all the facts about carbs, but your undercover work will make it much easier to manage diabetes.

By Dennis Thompson Jr.
Medically reviewed by Lindsey Marcellin, MD, MPH

Researchers Uncover Potential Breakthrough Cure for Type 1 Diabetes

"We've all been brought up to think insulin is the all-powerful hormone without which life is impossible, but that isn't the case," says Dr. Roger Unger from UT Southwestern Medical Center....

In this published study, UT Southerwestern Medical Center researchers obtained normal blood sugars when they prevented the release of glucagon from the liver and the release of insulin from the beta-cells.

The new findings suggest that Type 1 diabetes could be converted to an asymptomatic, non-insulin-dependent disorder by eliminating the actions of a specific hormone.

As we have learned from the thousands of diabetes studies and the coming and going of cures for diabetes, there are many mechanisms and reactions involved in the conversion of glucose to energy, so caution needs to be taken with the results of this study, until it can be duplicated especially in human subjects.

Scientists at UT Southwestern Medical Center studied the hormone glucagon, which prevents low blood sugar in healthy people and causes high blood sugar in people with Type 1 diabetes. When glucagon was suppressed in mice, the hormone insulin became unimportant. Glucose tolerance returned to normal.


These findings in mice show that insulin becomes completely superfluous and its absence does not cause diabetes or any other abnormality when the actions of glucagon are suppressed. Glucagon, a hormone produced by the pancreas, prevents low blood sugar levels in healthy individuals. It causes high blood sugar in people with Type 1 diabetes.

Dr. Unger, professor of internal medicine and senior author of the study stated that, "We've all been brought up to think insulin is the all-powerful hormone without which life is impossible, but that isn't the case." "If diabetes is defined as restoration of glucose homeostasis to normal, then this treatment can perhaps be considered very close to a 'cure.'"

Insulin treatment has been the gold standard for Type 1 diabetes (insulin-dependent diabetes) in humans since its discovery in 1922. But even optimal regulation of Type 1 diabetes with insulin alone cannot restore normal glucose tolerance. These new findings demonstrate that the elimination of glucagon action restores glucose tolerance to normal.

Normally, glucagon is released when the glucose, or sugar, level in the blood is low. In insulin deficiency, however, glucagon levels are inappropriately high and cause the liver to release excessive amounts of glucose into the bloodstream. This action is opposed by insulin, which directs the body's cells to remove sugar from the bloodstream.

Dr. Unger's laboratory research previously found that insulin's benefit resulted from its suppression of glucagon.

In Type 1 diabetes, which affects about 1 million people in the U.S., the pancreatic islet cells that produce insulin are destroyed. As a countermeasure to this destruction, Type 1 diabetics currently must take insulin multiple times a day to metabolize blood sugar, regulate blood-sugar levels and prevent diabetic coma. They also must adhere to strict dietary restrictions.

In this study, UT Southwestern scientists tested how mice genetically altered to lack working glucagon receptors responded to an oral glucose tolerance test. The test -- which can be used to diagnose diabetes, gestational diabetes and prediabetes -- measures the body's ability to metabolize, or clear, glucose from the bloodstream.

The researchers found that the mice with normal insulin production but without functioning glucagon receptors responded normally to the test. The mice also responded normally when their insulin-producing beta cells were destroyed. The mice had no insulin or glucagon action, but they did not develop diabetes.

"These findings suggest that if there is no glucagon, it doesn't matter if you don't have insulin," said Dr. Unger, who is also a physician at the Dallas VA Medical Center. "This does not mean insulin is unimportant. It is essential for normal growth and development from neonatal to adulthood. But in adulthood, at least with respect to glucose metabolism, the role of insulin is to control glucagon.

"And if you don't have glucagon, then you don't need insulin."

Dr. Young Lee, assistant professor of internal medicine at UT Southwestern and lead author of the study, said the next step is to determine the mechanism behind this result.

"Hopefully, these findings will someday help those with Type 1 diabetes," Dr. Lee said. "If we can find a way to block the actions of glucagon in humans, then maybe we can minimize the need for insulin therapy."

Dr. Unger said anything that reduces the need for injected insulin is a positive.

"Matching the high insulin levels needed to reach glucagon cells with insulin injections is possible only with amounts that are excessive for other tissues," he said. "Peripherally injected insulin cannot accurately duplicate the normal process by which the body produces and distributes insulin. If these latest findings were to work in humans, injected insulin would no longer be necessary for people with Type 1 diabetes."

Dr. May-Yun Wang, assistant professor of internal medicine at UT Southwestern, and researchers from the Albert Einstein College of Medicine also contributed to the work. The study was supported in part by the VA North Texas Health Care System, the American Diabetes Association and the National Institutes of Health.

Diabetes January 26, 2011 vol. 60 no. 2 391-397

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.

Are Sports Drinks Safe for Diabetics?

Q: I am working outside this week as a volunteer for a sports event. The temperature is about 110 degrees. We are constantly given sports drinks to replenish our electrolytes. As a diabetic, is it safe for me to drink these?

— Nancy

A: While it is important to prevent dehydration and replace electrolytes that you might lose through excessive sweating, you must also consider the amount of carbohydrates and calories that you are consuming throughout the day. Below is information on some common sports drinks. You can see the difference in the amount of carbohydrates and calories.

Gatorade: 50 calories, 14 carbohydrates (grams)
Mountain Dew Sport: 95 calories, 24 carbohydrates (grams)
All Sport: 70 calories, 19 carbohydrates (grams)
Rehydrate: 40 calories, 10 carbohydrates (grams)
Performance: 100 calories, 25 carbohydrates (grams)

So for example, if you consume four 8-oz bottles of Gatorade, you have taken in 200 calories and 56 grams of carbohydrates — and those values double if you are drinking 16-oz bottles. The calories and carbohydrates can add up quickly, causing high sugar levels.

The best practice is to look at each brand’s calorie and carbohydrate counts and the number of drinks that you are consuming a day to determine if it is within your daily caloric and carbohydrate requirements. It's also a good idea to supplement sports beverages with plain water.

Diabetes And Feet: Why A Podiatrist Is A Vital Part Of A Diabetic’s Care

Diabetes is a serious disease that affects millions of Americans, and that number is going to astronomically grow as the baby boomer generation ages further. Complications associated with diabetes can be devastating, and can lead to organ failure and even death. Foot-related complications in particular are very common in diabetes, and unfortunately cause the majority of leg amputations performed by surgeons. Comprehensive care by a podiatrist can identify foot problems early before they lead to leg loss, and in many cases can prevent those problems in the first place. This article will discuss the ways a podiatrist can protect diabetic feet, and ultimately save a diabetic’s limb and life.

Diabetes is a disease in which glucose, the body’s main source of ‘fuel’, is not properly absorbed into the body’s tissues and remains stuck in the bloodstream. Glucose is a type of ’sugar’ derived from the body’s digestion of carbohydrates (grains, breads, pastas, sugary food, fruits, starches, and dairy) The body needs a hormone called insulin, which is produced in the pancreas, to coax the glucose into body tissue to fuel it. Some diabetics are born with or develop at a young age an inability to produce insulin, resulting in type 1 diabetes. The majority of diabetics develop their disease as they become much older, and the ability of insulin to coax glucose into tissue wanes due to a sort of resistance to or an ineffectiveness of the action of insulin. This is called type 2 diabetes. Diabetes can also develop from high dose steroid use, during pregnancy (where it is temporary), or after pancreas disease or certain infections. The high concentration of glucose in the blood that remains out of the body tissue in diabetes can cause damage to parts all over the body. Organs and tissue that slowly are damaged by high concentrations of glucose stuck in the blood include the heart, the kidneys, blood vessels, the brain, the nerve tissue, skin, and the immune and injury repair cells. The higher the concentration of glucose in the blood, and the longer this glucose is present in the blood in an elevated state, the more damage will occur. Death can occur with severe levels of glucose in the blood stream, although this is not the case in most diabetics. Most diabetics who do not control their blood glucose well develop tissue damage over a long period of time, and serious disease, organ failure, and the potential for leg loss does eventually arrive, although not right away.

Foot disease in diabetes is common, and one of the more devastating and taxing complications associated directly and indirectly with high blood sugar. Foot disease takes the form of decreased sensation, poor circulation, a higher likelihood of developing skin wounds and infections, and a decreased ability to heal those skin wounds and infections. Key to this entire spectrum of foot complications is the presence of poor sensation. Most diabetics have less feeling in their feet than non-diabetics, due to the indirect action increased glucose has on nerve tissue. This decreased sensation can be a significant numbness, or it can be a mere subtle numbness that makes sharp objects seem smooth, or erases the irritation of a tight shoe. Advanced cases can actually have phantom pains of burning or tingling in addition to the numbness. With decreased sensation comes a much greater risk for skin wounds, mostly due to the inability to feel pain from thick calluses, sharp objects on the ground, and poorly fitting shoes. When a wound has formed as a result of skin dying under the strain of a thick corn or callus, from a needle or splinter driven into the foot, or from a tight shoe rubbing a friction burn on the skin, the diabetic foot has great difficulty starting and completing the healing process. Untreated skin wounds will break down further, and the wound can extend to deeper tissue, including muscle and bone. Bacteria will enter the body through these wounds, and can potentially cause an infection that can spread beyond the foot itself. A diabetic’s body has a particularly difficult time defending itself from bacteria due to the way high glucose affects the very cells that eat bacteria, and diabetics tend to get infected by multiple species of bacteria as well. Combine all this with decreased circulation (and therefore decreased distribution of nutrients and chemicals to preserve foot tissue and help it thrive), and one has all the components in place for a potential amputation. Amputations are performed when bacteria spreads along the body and threatens death, when wounds and foot tissue will not heal as a result of gangrene from advancing tissue death and infection, and when poor circulation will not allow the tissue to thrive ever again. The statistics following a leg amputation are grim: about half of diabetics who undergo one amputation will require an amputation of the other foot or leg, and about that same number in five years will be dead from the heart strain endured when one’s body has to expend energy to use a prosthetic limb.

A podiatrist can ensure that all the above complications are significantly limited, and in some cases prevented all together. Podiatrists are physicians who specialize solely in the care of foot and ankle disease, through medicine and surgery. The attend a four year podiatric medical school following college, and enter into a two or three year of hospital-based residency program after that to hone their advanced reconstructive surgical skills, and to study advanced medical. Podiatrists are generally considered the experts on all things involving the foot and ankle, and their unique understanding amongst other medical specialties of how the foot functions in relationship to the leg and ground (biomechanics) allows them to target therapy towards controlling or changing that function in addition to treating tissue disease. A great majority of the problems that lead to diabetic amputations start off as problems related to the structure of the foot and how it relates to the ground and to the shoe worn above. Controlling or repairing these structural problems will often result in prevention of wounds, which in turn will prevent infection, gangrene, and amputation.

To start with, a podiatrist will provide a diabetic patient with a complete foot exam that takes into account circulation, sensation, bone deformities, and skin issues, and pressures generated by walking and standing. From this initial assessment, a protection and treatment course can be created specific to the individual needs of the diabetic for maintenance, protection, and active treatment of problems that do develop. Commonly performed maintenance services include regular examinations several times a year to identify developing problems, care of toe nails to prevent a diabetic with poor sensation from accidentally cutting themselves when attempting to trim their nails, regular thinning of calluses to prevent wounds from developing, and repetitive education on diabetic foot problems to ensure proper habits are followed. Preventative services include using special deep shoes with protective inserts in diabetics at-risk for developing wounds from regular shoes, assessment of potential circulation problems with prompt referral to vascular specialists if needed, and possible surgery to reduce the potential of wounds to develop over areas of bony prominences. Active treatment of foot problems performed by a podiatrist involves the care and healing of wounds, the treatment of diabetic infections, and surgery to address serious foot injury, deep infections, gangrene, and other urgent problems. Because of a podiatrist’s unique understanding of the way the foot structure affects disease and injury, all treatment will be centered around the principles of how the foot realistically functions in conjunction with the leg and the ground. This becomes invaluable in the struggle to prevent diabetic wounds and infections, while allowing one to remain mobile and active at the same time.

The essential goal of a podiatrist in caring for a diabetic patient is to prevent wounds, infections, and the amputations that result. This philosophy is called limb salvage, and it is accomplished through the above listed methods. Because of the severity of foot disease as a complication of diabetes, a podiatrist is an integral part of a diabetic’s care, and sometimes can even be the physician that diagnoses diabetes in the first place if foot disease appears as an early symptom of undiagnosed diabetes. For these reasons, all diabetics should be assessed by a podiatrist for potential problems, and those at-risk for foot wounds and infections should have regular foot examinations and preventative treatment. As a final note, online resources by podiatrists discussing diabetic foot issues abound, including a regular blog by this author (thediabeticfoot.blogspot.com). While these resources do not replace a diabetic foot exam, they do help educate diabetics on how best to care for their feet, and what to do if problems develop. This can lead to better knowledge and understanding of foot issues when diabetics begin to see a podiatrist regularly, and can help prevent early foot complications from developing.

Sugar Substitutes: What's Their Real Value?

About 15 percent of Americans use sugar substitutes to cut calories, control diabetes, or prevent cavities. Yet just how much is safe to consume?

Sugar-free foods and drinks are lower in calories than their full sugar alternatives, but are they good options for weight loss? While sugar substitutes are generally safe, the debate about how they should be used continues.

Sugar Substitutes: A Short and Sweet History
The first sugar substitute, saccharin, was discovered in the late 1800s and gained prominence in manufacturing during the World Wars, when sugar was rationed. The business of sugar-free foods and drinks began to boom in the 1960s when clinicians realized the importance of controlling weight gain in the management of diabetes.
Since then, as people became more health-conscious and wanted to shun sugar, manufacturers responded with a host of sugar substitutes. They are:
• Aspartame, approved in 1981 by the U.S. Food and Drug Administration (FDA) and now in more than 6,000 foods and drinks
• Acesulfame-K, FDA-approved in 1988
• Sucralose (Splenda, SucraPlus), approved in 1998 for limited use and in 1999 for general use
• Neotame, approved in 2002
Other sugar substitutes are being developed, and many products contain a mix of sugar substitutes to enhance flavor. Each sugar substitute is several thousand times sweeter than sugar, but has a slightly different flavor. Whether you reach for the pink, blue, or yellow packet to sweeten your coffee is a matter of personal taste. Sugar substitutes are now so common that many people use them without consciously considering their use as a weight-loss strategy.

Sugar Substitutes: Their Role in Your Diet
As part of an overall healthy diet, sugar substitutes are believed to reduce calories and the risk of cavities. Interestingly, controlled studies that compare weight loss between people who use sugar substitutes and those who consume sugar show very little difference in weight loss between the two groups, although over the long term, sugar substitutes can help maintain weight loss.
Conscious calorie-cutting strategies can include sugar-free products. Replacing a sugary drink with a sugar-free drink will reduce your calorie intake, and cutting back by just one full sugar soda a day could result in losing over 1.4 pounds in 18 months. The key to losing weight using sugar-free products is to use them strategically.

Sugar Substitutes: How Much Can You Have?
A big question surrounding sugar substitutes is how much diet soda is safe to drink. Though you might never consider consuming this much in a day, the FDA says these are the maximum amounts allowable for daily consumption, listed by type of sugar substitute:
• Aspartame: 18 to 19 cans of diet soda
• Saccharin: 9 to 12 packets
• Acesulfame-K: 30 to 32 cans of diet soda
• Sucralose: 6 cans of diet soda

Sugar Substitutes: Reality Check
A realistic use of sugar-free products looks quite different.
A regular amount for a sugar substitute is two servings a day, says dietitian Liz Weinandy, RD, MPH, a dietitian in the non-surgical weight-loss program at Ohio State University Medical Center in Columbus. “My concern comes when people do multiple servings, like a six-pack of diet pop a day. Many times they are trying to use a sugar substitute in place of food. Some are very nutritious, like light yogurt, but while sugar-free soda doesn’t have calories, it also doesn’t have stuff in it that’s good for you.”
Further, consuming a lot of sugar-free drinks could hurt your weight-loss strategy. Studies show that when a sugar substitute is added to a product that has no other nutritional content (such as water), it increases hunger. This is true regardless of the type of sugar substitute used. Sugar substitutes in foods do not have this effect.

Sugar Substitutes: Who Should Avoid Them
While sugar substitutes are generally considered safe, Weinandy advises against giving children sugar-free foods and drinks — unless a doctor has said otherwise — and says pregnant women also should be cautious. “Drink water or fruit juice during pregnancy,” Weinandy suggests. “Limit diet pop to one per day at most.”
Additionally, people who have the disease phenylketonuria need to avoid aspartame, which contains phenylalanine, one of the amino acids in protein. Phenylketonuria is a genetic disorder in which the body cannot fully break down phenylalanine. If levels of it get too high in the blood, mental retardation could result.
For most people, sugar substitutes are a safe alternative to sugar. They may be helpful, in reasonable amounts, with weight loss and weight management when they are part of a balanced, healthy diet.

By Madeline Vann, MPH
Medically reviewed by Pat F. Bass III, MD, MPH

When to Test Children for Diabetes

Q: My husband is a type 1 diabetic, and we didn't know that until he went for a physical and the doctor said his body was in "ketosis" (shutting itself down). We didn't expect that since he looked healthy, and we didn't recognize any symptoms except frequent urination. At what age should we have our three children (ages 13, 15, and 16) checked? Are there more obvious signs in children? Do you recommend any particular diet as a starting point for better eating? Sorry for the many questions, I am just trying to keep my info straight. Thank you very much in advance for your time in answering this. Have a great day.
— Christina, Kansas
A:
These are all great questions. Discovering that you or a loved one has type 1 diabetes can be overwhelming — and troubling to parents who worry that their children are at risk of developing the disease. How wonderful that you are thinking about trying to prevent that from happening!

There isn't a definitive answer to your question regarding early screening. First of all, even though your husband has type 1 diabetes, it does not mean that your children will invariably develop the disease. In fact, very few children of diabetic parents do. The bad news is that we do not have a way to determine who will and who won't. Second, even when we know the specific inherited tendencies for diabetes, there are many factors in the environment that are yet undiscovered triggers. If we knew these factors, we might then be able to work on reducing their influence. Third, we do not know the rate at which a person who carries the genetic risk actually develops diabetes. They may develop the disease early or it may take many years for diabetes to establish a foothold. Fourth, we do not have an effective treatment or preventive measure to stave off type 1 diabetes among those who are at greatest risk of developing it.

In light of all these factors, the best way to move forward is to do the following:

Make sure your children get regular checkups and talk to your pediatrician about new developments in early diagnosis and prevention efforts. There are ongoing studies, the results of which will teach us more about how to proceed. There might also be research projects that your children might participate in that may give them access to genetic and immunology tests not available to the general public. These tests can give you a better idea of your children's specific odds of developing diabetes.Have your children undergo blood glucose tests starting now, biannually or annually, to prevent severe symptoms such as ketosis from being the stimulus for a diagnosis.
Watch out for the following signs and symptoms: excessive thirst, frequent urination, weight loss, fatigue, or blurred vision; and much less common signs of ketosis, including nausea and vomiting, abdominal pain, lethargy, and decreased alertness and rapid breathing. These are the same signs and symptoms as in adults.While there are no specific dietary supplements or diet recommendations, a healthy lifestyle and maintaining a healthy weight will help in general. Specific recommendations depend on your children's caloric needs, activity level, and preferences. I frequently tell my patients that their first loyalty is to nutrition — making sure they have adequate nutrients (i.e., vitamins, minerals, and protein intake) necessary for survival. In the children's case, it is important to take their growth and developmental needs into account. You might consult a dietitian for specific suggestions.

Finally, coping with a diabetic parent can be a frightening experience for children. I would advise that you and your husband normalize the daily routines of his care, which include home blood glucose testing, doctor's visits, diet and exercise regimens, insulin injections, and discussing the symptoms of high and low sugar levels. This way, you can avoid crises and show your children that diabetes is a condition that can be managed as long as you take care of yourself. This knowledge will help them a great deal in the event that they are someday diagnosed with diabetes, however small the odds may be. Best wishes to you and your husband and children. I hope all goes well.

1 in 3 Americans will have diabetes by 2050

In the United States, 1 in 3 people will have Type 2 diabetes by 2050 if current trends continue, according to a new report from the Centers for Disease Control and Prevention.

The projections, released today, are alarming to U.S. health officials, who say the numbers highlight the need for interventions to keep the number of new cases from climbing.

Currently, 1 in 10 Americans has Type 2 diabetes. But if new cases develop as projected, its prevalence could double or triple over the next 40 years, said Ann Albright, director of the Division of Diabetes Translation at the CDC.

"We can't have that, it's unsustainable," Albright told MyHealthNewsDaily.

Type 2 diabetes is the most common form of diabetes, and is triggered by a
combination of unchangeable factors, such as family history and race, and controllable factors, such as obesity and inactivity, according to the Mayo Clinic.

It's also the seventh leading cause of death in the United States, according to 2007 data, and is the leading cause of leg and foot amputations, kidney failure and new cases of blindness in adults under age 75, according to the CDC.

The costs of diabetes add up to about $174 billion a year, the CDC said.
Explaining the increase

An aging population and the growth of minority populations are expected to add to the disease's prevalence, Albright said. African-Americans, Latinos, Native Americans and certain Asians and Pacific Islanders are at high risk of developing diabetes.

Advances in medicine, which may help people with the disease live longer, and better detection of diabetes are other reasons why its prevalence could dramatically increase by 2050, she said. Right now, 24 million Americans have Type 2 diabetes, but a quarter of them don't know it, according to the CDC.

And because people are living longer, more cases are likely to come from older people. The percentage of people ages 65 and older with diabetes is expected to increase; it was 12.4 percent in 2000, but will be 19.6 percent in 2030, Albright said.

"We're living longer, but Type 2 diabetes does get more prevalent as you age," she said. "The body's ability to use insulin does gradually decline, but that can be slowed by maintenance, diet and regular physical activity."

Need for interventions
Right now, about 60 million people in the United States have pre-diabetes — a stage of insulin resistance before full-blown diabetes. If these people don't change their exercise and eating habits now, they will develop diabetes in the next three to six years, Albright said.

"They don’t have a big window," she said.

It will take a combination of personal decisions and policy changes to turn the diabetes rate around. Making healthy food more accessible and implementing prevention programs will help, she said.

One such program is the CDC's new National Diabetes Prevention Program, which aims to provide people with information about diabetes, promote lifestyle changes and reduce disparities between different groups.

A clinical trial showed that high-risk people who went through this prevention program reduced their risk of developing diabetes by 58 percent, according to the report.

"It's not enough for research to be done, you need to get the [information] in people's hands," Albright said. The intervention program makes use of the research, but "environmental and lifestyle changes need to complement it to be successful."
MyHealthNewsDaily Copyright © 2010. All rights reserved.

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.

10 Tips for Staying Healthy With Type 2 Diabetes

If you've been diagnosed with type 2 diabetes, these simple strategies can help you avoid complications and enjoy life. Finding out you have type 2 diabetes may cause a swirl of emotions and questions. How did this happen? What should you do? How will you be treated?

Jenny De Jesus, RN, CDE, a diabetes educator at the Friedman Diabetes Institute at Beth Israel Medical Center in New York City, explains it in rather simple terms: “Staying healthy with diabetes is all about making choices. The four most important things people with diabetes can do are making healthy food choices, getting some exercise, testing their blood glucose, and taking their medications. And it’s important to stay informed and ask questions during your doctor visits. The more you know, the more you can do for yourself to control your diabetes.”

Type 2 Diabetes: 10 Lifestyle Choices for Staying Healthy

If you’re one of the millions of people who developed type 2 diabetes as a result of lifestyle factors, consider making these important changes:

1.Healthy food choices. Start by choosing foods that are low-fat and low-sugar and emphasizing vegetables, fruit, and fiber. The next part of this strategy is portion control — eat the right amount for a healthy diet and weight control.
2.Eat regularly. Resist eating huge meals once or twice in a day. Space your food intake throughout your waking hours by having smaller, more frequent meals and planned snacks at regular intervals.
3.Exercise regularly. Doctors usually recommend that people do aerobic exercises — those that make the heart work, such as cycling or jogging. But not everyone can, for various reasons. You should discuss this with your doctor to see what type of exercise works best for you.
4.Check your blood glucose. How often you check your blood glucose depends on you and your doctor. Whatever your personalized plan involves, that is the routine you should maintain. By checking your blood glucose, you become aware of what affects your levels and you may be able to catch problems before they get out of hand.
5.Take your medication. It may sound like an obvious rule, but many people don’t take their medications as prescribed. And be sure to take only those medications that have been prescribed for you and you alone, and in the doses and frequency prescribed for you.
6.Stay informed. While much of the scientific information and the latest research may be hard to understand, try to be aware of any health reports of new or changing treatments for type 2 diabetes. Stay informed, and don’t hesitate to ask your health care team if progress you hear about in the news applies to you.
7.Talk about it. Some people with chronic diseases like type 2 diabetes get tired of taking care of themselves all the time. If you feel overwhelmed, talk about your feelings to a friend, family member, doctor, or a worker at a diabetes clinic. Airing your problems may be just the help you need.
8.Prevent sores. One of the problems that affects many people with type 2 diabetes is sores on the feet that can develop into such severe wounds that sometimes amputation of the foot is needed. Because of this, it’s very important that you inspect your feet regularly for blisters, cuts, and sores. If you are having problems with your feet or you find a sore that isn’t healing, speak with your doctor immediately.
9.Educate family and friends. Don’t keep your type 2 diabetes a secret. It’s always a good idea to educate your family and close friends about your disease so they can learn what to watch for and help you manage. If your loved ones know how to recognize the signs of dangerously high or low blood glucose levels, a potential tragedy may be avoided.
10.Identify yourself. Wear a medical alert bracelet or, at the very least, carry an identification card that tells people you have type 2 diabetes. These will speak for you if you’re in a crisis and can’t speak for yourself.
Living with type 2 diabetes doesn’t have to be complicated, but it does involve taking steps to ensure that you live well by managing your diabetes.

By Marijke Vroomen-Durning, RN
Medically reviewed by Pat F. Bass III, MD, MPH

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.

Foot Care Is Essential With Diabetes

From inspecting your feet for sores to keeping your skin dry, proper foot care is essential when you have diabetes. Practice these tips to reduce the risk of infection and protect your feet.

You may think of diabetes as a blood sugar problem, and it is. But the nerve and blood vessel damage caused by diabetes can also become a problem for your feet if you develop neuropathy and lose feeling in your feet or hands or get an infection. To ensure the best possible foot health, follow these 11 easy tips to avoid injury, and your feet will be healthy longer.

1. Nerve damage is a complication of diabetes that makes it hard to feel when you have sores or cracks in your feet. “Patients with diabetes are looking for any changes in color, sores, or dry, cracked skin,” says Dr. Weaver. Place a mirror on the floor to see under your feet or ask a friend or relative for help if you can’t see all parts of your feet clearly.

2. When people with diabetes develop nerve damage or neuropathy, it’s hard to tell if the bath water is too hot. “They won’t realize they are actually scalding their skin,” explains Dr. Weaver. Stepping into a bath before checking the temperature can cause serious damage to your feet, and burns and blisters are open doors to infection. Use your elbow to check the water temperature before getting into the tub or shower.

3. Shoe shopping for people with diabetes requires a little more attention to detail than you may be used to. At CKPA we advise looking for shoes with more depth in the toe box, good coverage of both top and bottom, and without seams inside the shoe that can rub on your foot. Likewise, seek socks without seams, preferably socks that are padded and made from cotton or another material that controls moisture.

4. Wearing shoes with good coverage outside to protect your feet makes sense to most people, but even inside your house, puttering around without shoes puts your feet at risk for small cuts, scrapes, and penetration by splinters, glass shards, and the misplaced sewing needle or thumbtack. If you have neuropathy, you might not notice these dangerous damages until they become infected. It’s best to wear shoes at all times, even in the house.

5. Make sure that drying your feet is part of your hygiene routine. “The space between the toes is very airtight,” When the skin has excess moisture it will break down, leading to infection.” Prevent this by toweling off thoroughly after washing your feet and by removing wet or sweaty socks or shoes immediately. You can use Ameriglel lotion to moisturizer and help prevent dry, cracked skin — just avoid putting it between your toes.


6. Attend to bunions, calluses, corns, hammertoes, and other aggravations promptly, so they don’t lead to infection due to pressure sores and uneven rubbing. Even seemingly harmless calluses may become problems if you ignore them. See a podiatrist, a doctor who specializes in foot care, instead of heading to the pharmacy for an over-the-counter product for feet — some products are irritating to your skin and can actually increase the risk of infection even while they treat the bunion, callus, or corn on your foot.

7. Wearing the correct shoes is so important, orthotic footwear is a great investment in protection and comfort. Shoes made especially for people with diabetes are available at Central Kansas Podiatry Associates, or you can visit with Dr. Weaver for advice. Medicare will cover one pair of diabetic shoes a year, with the addition of three inserts to reduce pressure on your feet. Your doctor may recommend this type of diabetic shoe if you have an ulcer or sore that is slow healing and to help prevent..

8. People with diabetes benefit from exercise, but you still must go easy on your feet. Many fitness classes and aerobics programs include bouncing, jumping, and leaping, which may not be the best activities for your feet, especially if you have neuropathy. Instead, look into programs, such as walking, that don’t put too much pressure on your feet. Just make sure you have the right shoe for whatever activity you choose.

9. The dangers of smoking run from your head to your feet. “The nicotine in a cigarette can decrease the circulation in the skin by 70 percent,” says Dr. Weaver. So if you smoke, you are depriving your feet of the nutrient- and oxygen-rich blood that helps keep them healthy and fights infection. “Diabetic patients already have risk factors that compromise their blood vessels. It’s never too late to stop smoking,”

10. “There’s a direct relationship between blood sugar level and damage to the nerve cells,” says Dr. Weaver. Out-of-control blood sugar leads to neuropathy, which will make it hard to know when your feet are at risk or being damaged. The better you are at controlling your blood sugar, the healthier your feet will be over the long term. Finally, if you already have an infection, high blood sugar levels can make it hard for your body to fight it.

11. Your doctor and your diabetes team are great sources of information if you need ideas and inspiration for taking care of your feet, quitting smoking, or staying on top of your “numbers” — your weight, blood sugar, and other measures of health, such as blood pressure. Of course, if you notice any changes in your feet that concern you, it’s a good idea to call us and come see Dr. Weaver before your next regularly scheduled check-up.