Surgical procedures are often unavoidable in patients with diabetes, and can even help reduce future risk of ulceration. But high postoperative infection rates in this patient population pose additional challenges to practitioners.
With 7.8% of the United States population (~23.6 million people) estimated to be diabetic, one can see how diabetes has become an increasing challenge for the medical community. It has been estimated that nearly a third of these patients are unaware of being diabetic. This prevalence will rise, as nearly 25% of adults over 60 are diabetic and there are increasing numbers being diagnosed in younger patients. Approximately 366 million people will have diabetes worldwide by the year 2030, most of these in developing countries. Foot disorders such as ulcers, infection, Charcot neuroarthropathy and peripheral arterial disease (PAD) are the most common causes of hospital admissions in diabetics. As diabetes mellitus is considered a lifelong condition, one can see the true impact on the healthcare system overall.
Peripheral neuropathy is one of the most common complications found in diabetics, prevalent in anywhere from 14-60% of the diabetic population. Peripheral neuropathy leads to sensory, motor and autonomic dysfunction, and this loss of protective sensation often causes these patients to fail to seek timely medical care for their conditions.
Foot surgery in patients with DM can be elective or preventative. Due to concerns with increased infection rates and slow healing of skin and bony structures in diabetics, elective surgery is performed with extreme caution. Prophylactic or preventative surgery is performed in those diabetics with pre-ulcerative areas, bony prominences and stable, non-infected ulcers. The purpose is to prevent ulcerations due to these bony prominences or to assist in healing of current ulcerations. Multiple types of surgeries can be performed based on the underlying bony deformity found, including hammertoe repair, bunion repair, metatarsal osteotomies, bone resections, Achilles tendon lengthenings for ulcers in the forefoot area and many more. Fracture repair is often required in diabetic patients. Those patients with Charcot foot deformity not treatable with bracing may require surgical intervention also.
It has been noted that diabetic patients without neuropathy can be treated with standard surgical technique and post-op care, but those who are neuropathic should have more fixation, be seen more often and remain non-weightbearing for approximately double the time period.
Peripheral arterial disease can also complicate the surgical site in diabetics, especially those with an insensate foot. Lack of blood flow to the surgical site not only affects the patient’s ability to heal the site quickly, but can also lead to an inability to fight off potential infection at the surgical site in the diabetic patient. Surgical site infections are infections that occur with 30 days of a surgical procedure, or within 1 year if an implant was inserted and is related to the surgery. One study found that by controlling factors such as hypothermia, blood glucose levels, removing hair from the surgical site and administering procedure-specific pre-operative antibiotics for an appropriate time frame, infection risk can be decreased.
One study showed a post-op infection rate of 6.7% in diabetic patients with neuropathy but no open wound undergoing forefoot surgery. A recent study was performed to examine wound infection rates involving 57,183 patients with ankle fractures undergoing repair. This study showed that non-diabetic patients had an infection rate of 1.4% after surgery. Diabetics without neuropathy or other comorbidities had a rate of 3.55% and diabetics with neuropathy or other comorbidities had an infection rate of 7.71%. Other reviews have found similar percentages, indicating that there is an obvious increased risk of infection in diabetics undergoing foot and ankle surgery. This implies that foot and ankle surgeons must have appropriate protocols in place to lessen these infection rates in their patients. First and foremost, comorbidities such as peripheral neuropathy and peripheral arterial disease must be diagnosed and managed prior to preventative surgery.
Friday, July 16, 2010
Friday, July 2, 2010
Liver at 50% Greater Risk in Diabetes
Although the liver is often overlooked in diabetes, even newly-diagnosed cases carry a substantial risk of serious hepatic damage, researchers found....
According to Gillian Booth, MD, MSc, of St. Michael's Hospital in Toronto, in a population-based study, newly-diagnosed diabetes was associated with a near doubling in the rate of liver cirrhosis, liver failure, or liver transplant compared with people in the general population who did not have diabetes.
After adjusting for important contributors to liver disease, the association remained significant with a 77% increased risk for newly-diagnosed diabetes patients (95% confidence interval 68% to 86%).
"The negative impact of diabetes on the retinal, renal, nervous, and cardiovascular systems is well recognized, yet little is known about its effect on the liver," they wrote.
According to Kenneth Cusi, MD, who has been studying this condition at the University of Texas Health Science Center in San Antonio, although much still remains to be discovered about the mechanisms and cause of the link between diabetes and liver disease, nonalcoholic steatohepatitis (NASH) is almost certainly involved.
"Steatosis is known to arise in relationship to insulin resistance in obesity, and most people with the condition do have some degree of glucose abnormality.... The two seem to 'feed on each other'."
Unlike with eye disease, cardiovascular disease, and kidney disease, guidelines for diabetes care don't recommend screening for liver disease.
"However, when the liver fails," Booth's group cautioned in the paper, "there is no equivalent form of management, such as hemodialysis or retinal photocoagulation."
They suggested that liver disease "may be appropriate for addition to the list of target-organ conditions related to diabetes," with annual screening by means of a blood test, such as for the liver enzyme alanine aminotransferase.
But the sensitivity of blood tests and even ultrasound aren't great for identifying fatty liver disease that is the precursor to more serious liver problems and liver biopsy is not a feasible screening method, Cusi noted.
Also, it would first have to be shown that preventive measures such as weight loss and glycemic and lipid control are effective in diabetes, as they are in isolated fatty liver without diabetes, the researchers said.
To expand evidence for the link, the researchers retrospectively examined the administrative databases of the universal healthcare system in the province of Ontario from 1994 through 2006.
They compared 438,069 adults with newly diagnosed diabetes and an age-, sex-, and regionally-matched control group of 2,059,708 individuals without known diabetes. Preexisting liver or alcohol-related disease were cause for exclusion.
During a median of 6.4 years of follow-up, serious liver disease -- liver cirrhosis, liver failure, or liver transplant -- developed in 2,463 newly-diagnosed diabetes cases and 5,902 controls.
Thus, unadjusted liver disease incidence was 92% higher with diabetes (8.19 per 10,000 person-years with diabetes and 4.17 without it).
This difference remained significant across mutually-adjusted patient subgroups by age, gender, urban versus rural residence, and income level.
Diabetes appeared to have the most pronounced link with liver and the least with liver transplantation.
Hypertension and obesity didn't appear to entirely account for the relationship with diabetes. The risk of serious liver disease in nondiabetic individuals with preexisting hypertension or obesity was elevated but less so than among those with diabetes.
But the researchers cautioned that it is difficult to separate out the effects of these related conditions.
"Although our findings and those of the U.S. study [which found elevated chronic NASH risk in veterans with diabetes] edge forward the idea that diabetes may be harmful to the liver, the question remains of whether this effect extends beyond the metabolic syndrome," they wrote.
Another question that remains to be answered is causality.
Booth's group pointed out that hepatic fat content rises in parallel with insulin resistance and glucose dysregulation and that diabetes as a complication of cirrhosis typically doesn't arise until cirrhosis reaches an advanced stage.
However, they noted, they couldn't rule out the pre-existence of subclinical liver disease before study entry.
According to Gillian Booth, MD, MSc, of St. Michael's Hospital in Toronto, in a population-based study, newly-diagnosed diabetes was associated with a near doubling in the rate of liver cirrhosis, liver failure, or liver transplant compared with people in the general population who did not have diabetes.
After adjusting for important contributors to liver disease, the association remained significant with a 77% increased risk for newly-diagnosed diabetes patients (95% confidence interval 68% to 86%).
"The negative impact of diabetes on the retinal, renal, nervous, and cardiovascular systems is well recognized, yet little is known about its effect on the liver," they wrote.
According to Kenneth Cusi, MD, who has been studying this condition at the University of Texas Health Science Center in San Antonio, although much still remains to be discovered about the mechanisms and cause of the link between diabetes and liver disease, nonalcoholic steatohepatitis (NASH) is almost certainly involved.
"Steatosis is known to arise in relationship to insulin resistance in obesity, and most people with the condition do have some degree of glucose abnormality.... The two seem to 'feed on each other'."
Unlike with eye disease, cardiovascular disease, and kidney disease, guidelines for diabetes care don't recommend screening for liver disease.
"However, when the liver fails," Booth's group cautioned in the paper, "there is no equivalent form of management, such as hemodialysis or retinal photocoagulation."
They suggested that liver disease "may be appropriate for addition to the list of target-organ conditions related to diabetes," with annual screening by means of a blood test, such as for the liver enzyme alanine aminotransferase.
But the sensitivity of blood tests and even ultrasound aren't great for identifying fatty liver disease that is the precursor to more serious liver problems and liver biopsy is not a feasible screening method, Cusi noted.
Also, it would first have to be shown that preventive measures such as weight loss and glycemic and lipid control are effective in diabetes, as they are in isolated fatty liver without diabetes, the researchers said.
To expand evidence for the link, the researchers retrospectively examined the administrative databases of the universal healthcare system in the province of Ontario from 1994 through 2006.
They compared 438,069 adults with newly diagnosed diabetes and an age-, sex-, and regionally-matched control group of 2,059,708 individuals without known diabetes. Preexisting liver or alcohol-related disease were cause for exclusion.
During a median of 6.4 years of follow-up, serious liver disease -- liver cirrhosis, liver failure, or liver transplant -- developed in 2,463 newly-diagnosed diabetes cases and 5,902 controls.
Thus, unadjusted liver disease incidence was 92% higher with diabetes (8.19 per 10,000 person-years with diabetes and 4.17 without it).
This difference remained significant across mutually-adjusted patient subgroups by age, gender, urban versus rural residence, and income level.
Diabetes appeared to have the most pronounced link with liver and the least with liver transplantation.
Hypertension and obesity didn't appear to entirely account for the relationship with diabetes. The risk of serious liver disease in nondiabetic individuals with preexisting hypertension or obesity was elevated but less so than among those with diabetes.
But the researchers cautioned that it is difficult to separate out the effects of these related conditions.
"Although our findings and those of the U.S. study [which found elevated chronic NASH risk in veterans with diabetes] edge forward the idea that diabetes may be harmful to the liver, the question remains of whether this effect extends beyond the metabolic syndrome," they wrote.
Another question that remains to be answered is causality.
Booth's group pointed out that hepatic fat content rises in parallel with insulin resistance and glucose dysregulation and that diabetes as a complication of cirrhosis typically doesn't arise until cirrhosis reaches an advanced stage.
However, they noted, they couldn't rule out the pre-existence of subclinical liver disease before study entry.
Body Fat Linked to Diabetes Risk in Older People
To avoid Type 2 diabetes, seniors may need to watch their weight just as closely as younger individuals do, a prospective cohort study showed....
Among individuals 65 and older, several measures of adiposity and weight gain were associated with a greater risk of developing Type 2 diabetes during follow-up, according to Mary Biggs, PhD, of the University of Washington School of Public Health and Community Medicine in Seattle, and colleagues.
The hazard ratios ranged from 1.9 to 6.0 when broken down by sex.
Self-reported body mass index at age 50 and weight gain from age 50 to study baseline were both also associated with risk of incident diabetes. "We found it surprising that the relationship between adiposity or body fat and diabetes was so strong among older adults," Biggs said.
"I think the results affirm the importance of weight control during middle age and suggest that weight control remains important into older ages in terms of reducing diabetes risks."
Although overweight and obesity are well-recognized risk factors for Type 2 diabetes among young and middle-age individuals, the relationship has not been well studied in older adults, according to the researchers.
So they turned to the Cardiovascular Health Study, which prospectively followed 4,193 men and women who were at least 65 and free of diabetes at baseline from 1989 to 2007. The participants came from four counties in North Carolina, Maryland, California, and Pennsylvania.
At baseline, mean age of participants was 72 and their mean BMI was 26 kg/m2 for both men and women; 45% had prediabetes (fasting glucose of 100 to 125 mg/dL).
Through a median follow-up of 12.4 years, there were 339 incident cases of Type 2 diabetes, defined as use of diabetes medication or a fasting glucose of at least 126 mg/dL.
With increasing quintiles of various measures of adiposity, there was a corresponding greater risk of developing diabetes, with no significant differences by sex or race.
All multivariate models were adjusted for age, sex, race, smoking, alcohol consumption, physical activity, and dietary factors.
The magnitude of the increased risk associated with various measures appeared to fade with age, with about half the risk in individuals 75 and older compared with those 65 to 74. However, the interaction with age was significant only for BMI at age 50 and at baseline and for fat mass.
There are several possible reasons risk might be increased to a lesser extent in older individuals, according to the researchers.
"Among older adults, standard anthropometric measures may not adequately quantify body fat due to age-related changes in body composition, including decreases in skeletal muscle mass and height," they wrote.
In addition, among older individuals, regional fat distribution may be more important in the etiology of diabetes than absolute fat mass, the pathophysiology of diabetes may differ, and selective survival may be involved. Changes in body weight were also associated with diabetes risk.
Compared with individuals who had a weight fluctuation of no more than about 4 pounds, those who gained 20 or more pounds from age 50 to baseline or 13 pounds or more from baseline to the third follow-up visit had a two- to threefold increased risk of developing diabetes.
"Results of this study affirm the importance of maintaining optimal weight during middle age for prevention of diabetes and, while requiring confirmation, suggest that weight control remains important in reducing diabetes risk among adults 65 years of age and older," the researchers wrote.
Among individuals 65 and older, several measures of adiposity and weight gain were associated with a greater risk of developing Type 2 diabetes during follow-up, according to Mary Biggs, PhD, of the University of Washington School of Public Health and Community Medicine in Seattle, and colleagues.
The hazard ratios ranged from 1.9 to 6.0 when broken down by sex.
Self-reported body mass index at age 50 and weight gain from age 50 to study baseline were both also associated with risk of incident diabetes. "We found it surprising that the relationship between adiposity or body fat and diabetes was so strong among older adults," Biggs said.
"I think the results affirm the importance of weight control during middle age and suggest that weight control remains important into older ages in terms of reducing diabetes risks."
Although overweight and obesity are well-recognized risk factors for Type 2 diabetes among young and middle-age individuals, the relationship has not been well studied in older adults, according to the researchers.
So they turned to the Cardiovascular Health Study, which prospectively followed 4,193 men and women who were at least 65 and free of diabetes at baseline from 1989 to 2007. The participants came from four counties in North Carolina, Maryland, California, and Pennsylvania.
At baseline, mean age of participants was 72 and their mean BMI was 26 kg/m2 for both men and women; 45% had prediabetes (fasting glucose of 100 to 125 mg/dL).
Through a median follow-up of 12.4 years, there were 339 incident cases of Type 2 diabetes, defined as use of diabetes medication or a fasting glucose of at least 126 mg/dL.
With increasing quintiles of various measures of adiposity, there was a corresponding greater risk of developing diabetes, with no significant differences by sex or race.
All multivariate models were adjusted for age, sex, race, smoking, alcohol consumption, physical activity, and dietary factors.
The magnitude of the increased risk associated with various measures appeared to fade with age, with about half the risk in individuals 75 and older compared with those 65 to 74. However, the interaction with age was significant only for BMI at age 50 and at baseline and for fat mass.
There are several possible reasons risk might be increased to a lesser extent in older individuals, according to the researchers.
"Among older adults, standard anthropometric measures may not adequately quantify body fat due to age-related changes in body composition, including decreases in skeletal muscle mass and height," they wrote.
In addition, among older individuals, regional fat distribution may be more important in the etiology of diabetes than absolute fat mass, the pathophysiology of diabetes may differ, and selective survival may be involved. Changes in body weight were also associated with diabetes risk.
Compared with individuals who had a weight fluctuation of no more than about 4 pounds, those who gained 20 or more pounds from age 50 to baseline or 13 pounds or more from baseline to the third follow-up visit had a two- to threefold increased risk of developing diabetes.
"Results of this study affirm the importance of maintaining optimal weight during middle age for prevention of diabetes and, while requiring confirmation, suggest that weight control remains important in reducing diabetes risk among adults 65 years of age and older," the researchers wrote.
Obesity, Other Risk Factors for Youth Diabetes Improved by Broad, School-based Intervention Program
One of the important announcements coming out of the American Diabetes Association's 70th Scientific Sessions were the results of a little known NIH study titled, "The Healthy Study: Interventions to reduce early diabetes risk." This may be a new model of how we can prevent our children from getting diabetes....
The NIH made a major investment in our children by modifying lifestyles in the grade schools to prevent a number of diseases. They also have a website that has all of the materials used in the program available at no cost: www.healthystudy.com.
A broad-based program to fight obesity and diabetes, aimed at US middle-school students and conducted directly by their teachers and other local school officials and designed to profoundly change not only diet, but also attitudes about food and fitness, appeared to improve measures of adiposity, insulin resistance, and other diabetes risk factors in a prospective randomized trial. The findings were presented here on June 28 at the 70th ADA Scientific Sessions and published online June 27, 2010, in the New England Journal of Medicine.
However, there wasn't a significant difference between students at schools that ran the three-year program and control schools, where the program wasn't instituted, in the study's primary end point: change in the prevalence of kids who were overweight or obese, defined as a body-mass index (BMI) in the >85th percentile. The prevalence fell similarly at schools with and without the intervention program.
By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1.
The program, which followed the students from the beginning of sixth grade to the end of eighth grade, also did not show a significant benefit in lowering the overall prevalence of kids who were obese at its conclusion -- that is, who finished the study in the >95th percentile for BMI. That prevalence fell by 19% at program compared with nonprogram schools, but the difference fell just short of significance at p=0.05.
However, the proportion of kids with waist circumference in the >90th percentile fell significantly more (p=0.04) at program schools. Students at those schools also had significantly (p=0.04) smaller increases in fasting insulin levels over the three years.
The program's benefits in the overall school populations were even more pronounced, and more solidly significant, among the approximately one-half of students in the >85th percentile for BMI at the beginning of sixth grade.
"This would suggest that, although the intervention did not meet its primary outcome of altering the combined prevalence of overweight or obesity, it did have effects on obesity and other important risk factors for Type 2 diabetes, Dr. Gary D. Foster (Temple University, Philadelphia, PA) said at a briefing for medical reporters. Foster chaired the HEALTHY study -- a name, not an acronym, chosen by students who participated in the comprehensive program.
He also said that the falling overweight/obesity rates at schools with and without the intervention program are consistent with national-level trends observed in other analyses that suggest that "rates of obesity in high-risk children in sixth to eighth grade appear not to be steady or increasing, but actually appear to be declining."
The HEALTHY study randomized 42 schools in seven regions of the US to follow or not follow the comprehensive intervention program. Schools qualified for participation if at least 50% of their students were members of a minority (primarily Hispanic or African American) or at least 50% qualified for government-subsidized meal programs; minority and low-income kids, the researchers note, are known to be at increased risk for both obesity and diabetes. Girls made up 53% of the 4,603 students tracked in the study, who had to be free of recognized diabetes at baseline.
At the press briefing, Dr. Griffin P. Rodgers (National Institutes of Health, Bethesda, MD), who is director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the HEALTHY study's primary underwriter, but who isn't one of its investigators, underscored the importance of targeting kids at increased risk for diabetes. "Earlier onset of diabetes may foreshadow earlier appearance of complications," he noted.
When the HEALTHY study and its six preceding pilot studies were initially in development, he continued, "obesity rates in American youth had been climbing steadily for two decades. Then, medical centers around the country began reporting a disturbing new trend, Type 2 diabetes was increasingly being diagnosed in youths, especially black, Hispanic, and American Indian adolescents. By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1. We needed to find ways to contain the rising rate of Type 2 diabetes in kids, and schools were a logical place to start."
Dr. Cynthia L. Ogden (Centers for Disease Control and Prevention, Atlanta, GA), also on hand at the briefing but not a HEALTHY study researcher, showed 2007/08 data from the National Health and Nutrition Examination Survey suggesting that 31.7% of US children aged two to 19 are overweight or obese, amounting to 23.4 million children. Among them, she said, are the 17% of US kids in that age group, a total of about 12.5 million, who qualify as obese.
Also, Rodgers said, the HEALTHY pilot trials suggested that up to 40% of eighth graders at schools with high-risk populations had elevated fasting glucose levels. "So the question became, can changes in schools -- namely, longer and more intense gym classes, healthier food choices, and classroom activities that promote healthy behavior -- lower risk factors for Type 2 diabetes in youth?"
The program consisted of interventions grouped in four domains. (Details and the materials used are available on the study's website.) The nutritional component called for healthy improvements in the quality and quantity of food and beverages available at the schools' cafeterias, snack bars, and vending machines, and even at fundraisers and classroom parties, according to Hirst. Available choices shifted to those lower in fat, higher in fiber, heavier on fruit and vegetables, and lower in added sugar.
The physical-activity component was aimed at increasing both participation and activity levels in physical education classes, emphasizing activities that raised the heart rate.
Dr. Kathryn Hirst (George Washington University School of Public Health, Washington, DC) provided more details of the intervention program, which consisted of "multiple components that were designed to change the school environment radically." Experts on the study's staff at its seven regional field offices provided "training, guidance, assistance, materials, and support" for instituting the program to the faculties and staff at each of the schools, "who were the ones who actually delivered the intervention," she noted.
Teachers received instruction on holding school-wide events that promoted physical activity. Minimum weekly durations of physical education classes were instituted.
The third component, focused on behavior, according to the report, promoted classroom and family-outreach activities to educate and sharpen self-awareness and decision-making, self-monitoring, and goal-setting skills consistent with the overall program.
The fourth component, communication, focused on the use of marketing techniques to promote the program's goals within the schools and establish a "brand" to characterize and identify the changes to menus and physical activities that were part of the program.
Healthy Study Group. A school-based intervention for diabetes risk reduction. New Engl J Med 2010; DOI:10.1056/NEJMoa1001933. Available at www.nejm.org.
The NIH made a major investment in our children by modifying lifestyles in the grade schools to prevent a number of diseases. They also have a website that has all of the materials used in the program available at no cost: www.healthystudy.com.
A broad-based program to fight obesity and diabetes, aimed at US middle-school students and conducted directly by their teachers and other local school officials and designed to profoundly change not only diet, but also attitudes about food and fitness, appeared to improve measures of adiposity, insulin resistance, and other diabetes risk factors in a prospective randomized trial. The findings were presented here on June 28 at the 70th ADA Scientific Sessions and published online June 27, 2010, in the New England Journal of Medicine.
However, there wasn't a significant difference between students at schools that ran the three-year program and control schools, where the program wasn't instituted, in the study's primary end point: change in the prevalence of kids who were overweight or obese, defined as a body-mass index (BMI) in the >85th percentile. The prevalence fell similarly at schools with and without the intervention program.
By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1.
The program, which followed the students from the beginning of sixth grade to the end of eighth grade, also did not show a significant benefit in lowering the overall prevalence of kids who were obese at its conclusion -- that is, who finished the study in the >95th percentile for BMI. That prevalence fell by 19% at program compared with nonprogram schools, but the difference fell just short of significance at p=0.05.
However, the proportion of kids with waist circumference in the >90th percentile fell significantly more (p=0.04) at program schools. Students at those schools also had significantly (p=0.04) smaller increases in fasting insulin levels over the three years.
The program's benefits in the overall school populations were even more pronounced, and more solidly significant, among the approximately one-half of students in the >85th percentile for BMI at the beginning of sixth grade.
"This would suggest that, although the intervention did not meet its primary outcome of altering the combined prevalence of overweight or obesity, it did have effects on obesity and other important risk factors for Type 2 diabetes, Dr. Gary D. Foster (Temple University, Philadelphia, PA) said at a briefing for medical reporters. Foster chaired the HEALTHY study -- a name, not an acronym, chosen by students who participated in the comprehensive program.
He also said that the falling overweight/obesity rates at schools with and without the intervention program are consistent with national-level trends observed in other analyses that suggest that "rates of obesity in high-risk children in sixth to eighth grade appear not to be steady or increasing, but actually appear to be declining."
The HEALTHY study randomized 42 schools in seven regions of the US to follow or not follow the comprehensive intervention program. Schools qualified for participation if at least 50% of their students were members of a minority (primarily Hispanic or African American) or at least 50% qualified for government-subsidized meal programs; minority and low-income kids, the researchers note, are known to be at increased risk for both obesity and diabetes. Girls made up 53% of the 4,603 students tracked in the study, who had to be free of recognized diabetes at baseline.
At the press briefing, Dr. Griffin P. Rodgers (National Institutes of Health, Bethesda, MD), who is director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the HEALTHY study's primary underwriter, but who isn't one of its investigators, underscored the importance of targeting kids at increased risk for diabetes. "Earlier onset of diabetes may foreshadow earlier appearance of complications," he noted.
When the HEALTHY study and its six preceding pilot studies were initially in development, he continued, "obesity rates in American youth had been climbing steadily for two decades. Then, medical centers around the country began reporting a disturbing new trend, Type 2 diabetes was increasingly being diagnosed in youths, especially black, Hispanic, and American Indian adolescents. By 1999, some pediatric centers, especially those in inner cities, were seeing more new cases of Type 2 diabetes than Type 1. We needed to find ways to contain the rising rate of Type 2 diabetes in kids, and schools were a logical place to start."
Dr. Cynthia L. Ogden (Centers for Disease Control and Prevention, Atlanta, GA), also on hand at the briefing but not a HEALTHY study researcher, showed 2007/08 data from the National Health and Nutrition Examination Survey suggesting that 31.7% of US children aged two to 19 are overweight or obese, amounting to 23.4 million children. Among them, she said, are the 17% of US kids in that age group, a total of about 12.5 million, who qualify as obese.
Also, Rodgers said, the HEALTHY pilot trials suggested that up to 40% of eighth graders at schools with high-risk populations had elevated fasting glucose levels. "So the question became, can changes in schools -- namely, longer and more intense gym classes, healthier food choices, and classroom activities that promote healthy behavior -- lower risk factors for Type 2 diabetes in youth?"
The program consisted of interventions grouped in four domains. (Details and the materials used are available on the study's website.) The nutritional component called for healthy improvements in the quality and quantity of food and beverages available at the schools' cafeterias, snack bars, and vending machines, and even at fundraisers and classroom parties, according to Hirst. Available choices shifted to those lower in fat, higher in fiber, heavier on fruit and vegetables, and lower in added sugar.
The physical-activity component was aimed at increasing both participation and activity levels in physical education classes, emphasizing activities that raised the heart rate.
Dr. Kathryn Hirst (George Washington University School of Public Health, Washington, DC) provided more details of the intervention program, which consisted of "multiple components that were designed to change the school environment radically." Experts on the study's staff at its seven regional field offices provided "training, guidance, assistance, materials, and support" for instituting the program to the faculties and staff at each of the schools, "who were the ones who actually delivered the intervention," she noted.
Teachers received instruction on holding school-wide events that promoted physical activity. Minimum weekly durations of physical education classes were instituted.
The third component, focused on behavior, according to the report, promoted classroom and family-outreach activities to educate and sharpen self-awareness and decision-making, self-monitoring, and goal-setting skills consistent with the overall program.
The fourth component, communication, focused on the use of marketing techniques to promote the program's goals within the schools and establish a "brand" to characterize and identify the changes to menus and physical activities that were part of the program.
Healthy Study Group. A school-based intervention for diabetes risk reduction. New Engl J Med 2010; DOI:10.1056/NEJMoa1001933. Available at www.nejm.org.
Thursday, July 1, 2010
HbA1clevels correlate strongly to future diabetes, cardiovascular risk
An ancillary study to the ARIC (Atherosclerosis Risk in Communities) study supports the most recent (2010) ADA risk categories of hemoglobin (Hb) A1c in identifying future risk of developing diabetes and macrovascular and microvascular disease. The data were presented by Elizabeth Selvin, PhD.
The ADA now recommends the use of HbA1c for the diagnosis of diabetes and identification of persons at increased risk for diabetes. The ADA defines an HbA1c of 5.7% to less than 6.5% as “high risk” for the future development of diabetes.
In this analysis, 11,092 participants from ARIC, a large community-based epidemiologic study, without cardiovascular disease or diabetes at baseline had HbA1c measured from stored whole blood samples obtained between 1990 and 1992. Participants were followed for 15 years.
“In individuals with an A1c of 5.7% to less than 6.5%, which is the group identified as high risk for the development of diabetes and other complications, we see a very high risk of the subsequent development of diabetes. We can also see that individuals in that range are at risk for kidney disease, CHD [coronary heart disease], and stroke,” said Selvin, assistant professor of epidemiology and medicine at Johns Hopkins in Baltimore.
Compared with the reference population with an HbA1c level of 5% to less than 5.7%, those in the high-risk category of 5.7% to less than 6.5% had more than triple the risk of diagnosed diabetes, a 60% increase in the risk of CHD, a 56% increase in the risk of stroke, a 62% increased risk of end-stage renal disease, and a 42% increase in all-cause mortality, all adjusted for age, sex, race, and other potential confounders.
These risks were even greater in the cohort with HbA1c levels of 6.5% or greater at baseline.
“The vast majority of individuals with HbA1c greater than 6.5% will subsequently be diagnosed with diabetes during follow-up, and they’re at very high risk of kidney disease and have almost 4 times the risk of developing end-stage renal disease compared to those people in the normal range, and a 2-fold increased risk of developing CHD or stroke or dying during follow-up,” she said.
More than 20% of the group with HbA1c values of 5.7% to less than 6.5% and almost 80% of those with values of 6.5% or greater developed diabetes within 10 years.
The ADA now recommends the use of HbA1c for the diagnosis of diabetes and identification of persons at increased risk for diabetes. The ADA defines an HbA1c of 5.7% to less than 6.5% as “high risk” for the future development of diabetes.
In this analysis, 11,092 participants from ARIC, a large community-based epidemiologic study, without cardiovascular disease or diabetes at baseline had HbA1c measured from stored whole blood samples obtained between 1990 and 1992. Participants were followed for 15 years.
“In individuals with an A1c of 5.7% to less than 6.5%, which is the group identified as high risk for the development of diabetes and other complications, we see a very high risk of the subsequent development of diabetes. We can also see that individuals in that range are at risk for kidney disease, CHD [coronary heart disease], and stroke,” said Selvin, assistant professor of epidemiology and medicine at Johns Hopkins in Baltimore.
Compared with the reference population with an HbA1c level of 5% to less than 5.7%, those in the high-risk category of 5.7% to less than 6.5% had more than triple the risk of diagnosed diabetes, a 60% increase in the risk of CHD, a 56% increase in the risk of stroke, a 62% increased risk of end-stage renal disease, and a 42% increase in all-cause mortality, all adjusted for age, sex, race, and other potential confounders.
These risks were even greater in the cohort with HbA1c levels of 6.5% or greater at baseline.
“The vast majority of individuals with HbA1c greater than 6.5% will subsequently be diagnosed with diabetes during follow-up, and they’re at very high risk of kidney disease and have almost 4 times the risk of developing end-stage renal disease compared to those people in the normal range, and a 2-fold increased risk of developing CHD or stroke or dying during follow-up,” she said.
More than 20% of the group with HbA1c values of 5.7% to less than 6.5% and almost 80% of those with values of 6.5% or greater developed diabetes within 10 years.
Tuesday, June 29, 2010
New Study Demonstrates Dramatic Impact of Podiatric Care
Patients with diabetes who receive medical and surgical care provided by a podiatrist are less likely to suffer hospitalization or amputation than patients who do not receive care from a podiatrist, according to a new study from Thomson Reuters. Thomson Reuters is an internationally respected research firm with expertise in the health-care market.
The study, sponsored by APMA, examined records for more than 32,000 patients with diabetes under 65 and matched health and risk factors for those who had podiatry visits to those who did not. Care by a podiatric physician, defined as at least one pre-ulcer visit, was associated with lower risk of hospitalization and amputation. James Wrobel, DPM, presented the results at the American Diabetes Association Scientific Sessions this weekend in Orlando, Florida.
"The dramatic results of the study demonstrate the important role of today's podiatrist," said APMA President Kathleen Stone, DPM. "As a profession, we make a significant impact on patient outcomes and health-care costs. As more diabetic patients receive high-quality medical care by podiatrists prior to developing ulcers, we will see even greater reductions in cost and improvements in patients' quality of life. The next step is to confirm these findings with prospective pilot programs that identify high-risk patients and provide preventive foot care services by podiatrists."
The study, sponsored by APMA, examined records for more than 32,000 patients with diabetes under 65 and matched health and risk factors for those who had podiatry visits to those who did not. Care by a podiatric physician, defined as at least one pre-ulcer visit, was associated with lower risk of hospitalization and amputation. James Wrobel, DPM, presented the results at the American Diabetes Association Scientific Sessions this weekend in Orlando, Florida.
"The dramatic results of the study demonstrate the important role of today's podiatrist," said APMA President Kathleen Stone, DPM. "As a profession, we make a significant impact on patient outcomes and health-care costs. As more diabetic patients receive high-quality medical care by podiatrists prior to developing ulcers, we will see even greater reductions in cost and improvements in patients' quality of life. The next step is to confirm these findings with prospective pilot programs that identify high-risk patients and provide preventive foot care services by podiatrists."
Wednesday, June 16, 2010
Join CKPA for 2nd Annual Rip’s B.A.D. Ride
Alefs Harley-Davidson
July 31st, 2010
The American Diabetes Association’s Bikers Against Diabetes (B.A.D.) Ride is an event for EVERYONE! It is a family festival with good entertainment, good friends, prizes, auctions, raffles, games all for a great cause!
Bikers will make a minimum donation of $30 and receive a patch to commemorate the ride. T-shirts, bandanas, and more prizes will be available for riders, depending on levels of money they raise. Riders will enjoy a ride around the beautiful plains of Kansas and have the option of participating in a poker run. B.A.D. Ride is sure to be a great time for the whole family! Help us on the road to a CURE!
The ADA- We make a difference everyday for the 23.6 million adults and children affected by diabetes in the United States
July 31st, 2010
The American Diabetes Association’s Bikers Against Diabetes (B.A.D.) Ride is an event for EVERYONE! It is a family festival with good entertainment, good friends, prizes, auctions, raffles, games all for a great cause!
Bikers will make a minimum donation of $30 and receive a patch to commemorate the ride. T-shirts, bandanas, and more prizes will be available for riders, depending on levels of money they raise. Riders will enjoy a ride around the beautiful plains of Kansas and have the option of participating in a poker run. B.A.D. Ride is sure to be a great time for the whole family! Help us on the road to a CURE!
The ADA- We make a difference everyday for the 23.6 million adults and children affected by diabetes in the United States
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