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, Nebraska
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.
Monday, September 13, 2010
Weight Loss with Low-Carb or Low-Fat Diets
Obese patients lost similar amounts of weight over two years with either a low-fat or low-carbohydrate diet, but the latter had a more favorable effect on HDL cholesterol, data from a randomized trial showed....
Weight loss averaged 24 lbs. (11 kg) at one year and 15 lbs (7 kg) at two years with no significant differences between groups, according to Gary D. Foster, PhD, of Temple University in Philadelphia, PA, and co-authors. However, patients assigned to the low-carbohydrate diet had more rapid early declines in blood pressure, triglycerides, and VLDL cholesterol and greater increases in HDL throughout the study, they reported.
"This two-year multicenter study of more than 300 participants revealed that neither dietary fat nor carbohydrate intake influenced weight loss when combined with a comprehensive lifestyle intervention," they wrote. "Both diet groups achieved clinically significant and nearly identical weight loss… These long-term data suggest that a low-carbohydrate approach is a viable option for obesity treatment for obese adults."
Several randomized trials have shown that people on low-carbohydrate diets achieve greater short-term weight loss than those on low-fat, calorie-restricted diets, but long-term results have been mixed.
Nor have low-carbohydrate and low-fat diets been examined closely to determine whether they differ with respect to outcomes other than weight loss.
Foster and colleagues sought to inform on some of those issues by conducting a randomized, multicenter clinical trial that had weight loss as its primary outcome but also assessed cardiovascular risk factors, bone mineral density, and general symptoms. They hypothesized that a low-carbohydrate diet would result in greater weight loss at two years compared with a low-calorie, low-fat diet.
The study involved 307 patients with a mean age of 45, mean body mass index of 36, and mean weight of 103 kg (227 lbs). Two-thirds of the participants were women, and 70% were white. Investigators excluded patients with dyslipidemia or diabetes.
The low-carbohydrate diet limited carbohydrate intake to 20 g/d for 12 weeks and then increased by 5 g/d per week. Participants in this group could consume as much fat and protein as they wanted. Limiting carbohydrate intake was the primary behavioral focus for this group.
The low-fat diet was also calorie-restricted: 1,200-1,500 kcal/d for women and 1,500-1,800 kcal/d for men. Carbohydrates accounted for about 55% of calories, fat for 30%, and protein for 15%. Limiting total energy intake (kcal/d) was the primary behavioral target for the group.
Both groups reached maximum weight loss (11 to 12 kg) after six months. They did not differ significantly with respect to absolute weight loss at one year (about 11 kg) or at two years (7.37 kg in the low-fat group versus 6.34 kg in the low-carbohydrate group, P=0.41).
The only significant difference in weight loss occurred at three months, when the low-carbohydrate group averaged 9.49 kg versus 8.37 kg in the low-fat group (P=0.019). The trend over the entire 24 months of the trial did not differ significantly (P=0.30). The groups did differ with respect to several secondary endpoints, however.
The low-carbohydrate diet was associated with more rapid reductions in triglycerides and VLDL cholesterol, which differed significantly between groups after three months. The groups did not differ at 24 months, but the overall trend in VLDL favored the low-carbohydrate diet (P=0.027).
The low-fat diet led to greater reductions in LDL at all time points. Mean LDL increased in the low-carbohydrate group during the first six months before declining at one year. The overall trend favored the low-fat diet (P=0.0009).
HDL increased more rapidly with the low-carbohydrate diet and remained significantly different from the low-fat group at all four time points (P=0.008 to P<0.001) and in the overall analysis (P=0.0058).
The low-carbohydrate diet led to small but statistically greater reductions in total cholesterol (P=0.030 for trend).
Systolic blood pressure did not differ significantly between groups at any point in time. The low-carbohydrate diet resulted in significantly greater reductions in diastolic blood pressure at three of four intervals, but the overall trend was not significant (P=0.36).
The authors noted hypothetical concerns that a low-carbohydrate diet might lead to greater loss in bone mineral density, but the two groups did not differ with respect to changes in BMD at any time during the study, and the declines in BMD were within expected ranges.
Participants in the low-carbohydrate group reported significantly more adverse effects, particularly during the first six to 12 months of the study. The low-carbohydrate diet was associated with more reports of bad breath, hair loss, constipation, and dry mouth. However, trends over the entire trial did not differ significantly for any of these.
Weight loss averaged 24 lbs. (11 kg) at one year and 15 lbs (7 kg) at two years with no significant differences between groups, according to Gary D. Foster, PhD, of Temple University in Philadelphia, PA, and co-authors. However, patients assigned to the low-carbohydrate diet had more rapid early declines in blood pressure, triglycerides, and VLDL cholesterol and greater increases in HDL throughout the study, they reported.
"This two-year multicenter study of more than 300 participants revealed that neither dietary fat nor carbohydrate intake influenced weight loss when combined with a comprehensive lifestyle intervention," they wrote. "Both diet groups achieved clinically significant and nearly identical weight loss… These long-term data suggest that a low-carbohydrate approach is a viable option for obesity treatment for obese adults."
Several randomized trials have shown that people on low-carbohydrate diets achieve greater short-term weight loss than those on low-fat, calorie-restricted diets, but long-term results have been mixed.
Nor have low-carbohydrate and low-fat diets been examined closely to determine whether they differ with respect to outcomes other than weight loss.
Foster and colleagues sought to inform on some of those issues by conducting a randomized, multicenter clinical trial that had weight loss as its primary outcome but also assessed cardiovascular risk factors, bone mineral density, and general symptoms. They hypothesized that a low-carbohydrate diet would result in greater weight loss at two years compared with a low-calorie, low-fat diet.
The study involved 307 patients with a mean age of 45, mean body mass index of 36, and mean weight of 103 kg (227 lbs). Two-thirds of the participants were women, and 70% were white. Investigators excluded patients with dyslipidemia or diabetes.
The low-carbohydrate diet limited carbohydrate intake to 20 g/d for 12 weeks and then increased by 5 g/d per week. Participants in this group could consume as much fat and protein as they wanted. Limiting carbohydrate intake was the primary behavioral focus for this group.
The low-fat diet was also calorie-restricted: 1,200-1,500 kcal/d for women and 1,500-1,800 kcal/d for men. Carbohydrates accounted for about 55% of calories, fat for 30%, and protein for 15%. Limiting total energy intake (kcal/d) was the primary behavioral target for the group.
Both groups reached maximum weight loss (11 to 12 kg) after six months. They did not differ significantly with respect to absolute weight loss at one year (about 11 kg) or at two years (7.37 kg in the low-fat group versus 6.34 kg in the low-carbohydrate group, P=0.41).
The only significant difference in weight loss occurred at three months, when the low-carbohydrate group averaged 9.49 kg versus 8.37 kg in the low-fat group (P=0.019). The trend over the entire 24 months of the trial did not differ significantly (P=0.30). The groups did differ with respect to several secondary endpoints, however.
The low-carbohydrate diet was associated with more rapid reductions in triglycerides and VLDL cholesterol, which differed significantly between groups after three months. The groups did not differ at 24 months, but the overall trend in VLDL favored the low-carbohydrate diet (P=0.027).
The low-fat diet led to greater reductions in LDL at all time points. Mean LDL increased in the low-carbohydrate group during the first six months before declining at one year. The overall trend favored the low-fat diet (P=0.0009).
HDL increased more rapidly with the low-carbohydrate diet and remained significantly different from the low-fat group at all four time points (P=0.008 to P<0.001) and in the overall analysis (P=0.0058).
The low-carbohydrate diet led to small but statistically greater reductions in total cholesterol (P=0.030 for trend).
Systolic blood pressure did not differ significantly between groups at any point in time. The low-carbohydrate diet resulted in significantly greater reductions in diastolic blood pressure at three of four intervals, but the overall trend was not significant (P=0.36).
The authors noted hypothetical concerns that a low-carbohydrate diet might lead to greater loss in bone mineral density, but the two groups did not differ with respect to changes in BMD at any time during the study, and the declines in BMD were within expected ranges.
Participants in the low-carbohydrate group reported significantly more adverse effects, particularly during the first six to 12 months of the study. The low-carbohydrate diet was associated with more reports of bad breath, hair loss, constipation, and dry mouth. However, trends over the entire trial did not differ significantly for any of these.
Friday, September 10, 2010
Long Distance Runners Have More Coronary Plaque?
A group of elite long-distance runners had less body fat, better lipid profiles, and better heart rates than people being tested for cardiac disease, but, paradoxically, the runners had more calcified plaque in their heart arteries, according to a new study…
Investigators performed computed tomography angiography on 25 people who had run at least one marathon a year since 1985, according to senior author Robert Schwartz, MD, of the Minneapolis Heart Institute and Foundation. They compared the athletes with 23 control patients who were undergoing the same scan for symptomatic or suspected heart abnormalities.
In controls, the calcium plaque volume was 169 mm3 compared with 274 mm3 for the elite runners (P=0.028), the researchers reported at the American College of Cardiology meeting. The runners also had a higher calcium score and higher non-calcified plaque volume, although those differences did not reach statistical significance.
Lead author Jonathan Schwartz, MD, of the University of Colorado Health Science Center in Denver stated that the reasons for the high calcified plaque readings among hard-core athletes are elusive, "but the [runners'] favorable factors may be counterbalanced by metabolic and mechanical factors that enhance coronary plaque growth."
"You have to consider that these runners may be in a constant state of inflammation, and that may be why we are seeing more plaque," added Schwartz.
He said the researchers, who originally set out to compare their results with European studies using electron beam CT, sent letters to elite runners identified as having completed at least one marathon race in each of the last 25 years. "All the runners we contacted agreed to be in the study," he noted.
The investigators also identified a control group of 23 men who were undergoing coronary CT angiography for clinical reasons, typically for elevated risk factors or abnormal or/inconclusive stress tests.
The participants underwent 64-slice computed tomography angiography and were compared for blood pressure, heart rate, and serum lipids. The scan data were analyzed using commercial plaque characterization software for calcified and non-calcified plaque and calcium score.
No one is sure exactly what the plaque findings mean.
"I'm not sure you can make much from these data," added Maria Rosa Costanzo, MD, a spokesperson for the American Heart Association and medical director of the Edward Hospital Center for Advanced Heart Failure in Naperville, Ill. "We don't have any idea of the outcomes of these patients."
She also noted that the number of patients in the study was small.
But the investigators aren't finished. "More subjects are under study for clarification of these results," said the younger Schwartz.
Investigators performed computed tomography angiography on 25 people who had run at least one marathon a year since 1985, according to senior author Robert Schwartz, MD, of the Minneapolis Heart Institute and Foundation. They compared the athletes with 23 control patients who were undergoing the same scan for symptomatic or suspected heart abnormalities.
In controls, the calcium plaque volume was 169 mm3 compared with 274 mm3 for the elite runners (P=0.028), the researchers reported at the American College of Cardiology meeting. The runners also had a higher calcium score and higher non-calcified plaque volume, although those differences did not reach statistical significance.
Lead author Jonathan Schwartz, MD, of the University of Colorado Health Science Center in Denver stated that the reasons for the high calcified plaque readings among hard-core athletes are elusive, "but the [runners'] favorable factors may be counterbalanced by metabolic and mechanical factors that enhance coronary plaque growth."
"You have to consider that these runners may be in a constant state of inflammation, and that may be why we are seeing more plaque," added Schwartz.
He said the researchers, who originally set out to compare their results with European studies using electron beam CT, sent letters to elite runners identified as having completed at least one marathon race in each of the last 25 years. "All the runners we contacted agreed to be in the study," he noted.
The investigators also identified a control group of 23 men who were undergoing coronary CT angiography for clinical reasons, typically for elevated risk factors or abnormal or/inconclusive stress tests.
The participants underwent 64-slice computed tomography angiography and were compared for blood pressure, heart rate, and serum lipids. The scan data were analyzed using commercial plaque characterization software for calcified and non-calcified plaque and calcium score.
No one is sure exactly what the plaque findings mean.
"I'm not sure you can make much from these data," added Maria Rosa Costanzo, MD, a spokesperson for the American Heart Association and medical director of the Edward Hospital Center for Advanced Heart Failure in Naperville, Ill. "We don't have any idea of the outcomes of these patients."
She also noted that the number of patients in the study was small.
But the investigators aren't finished. "More subjects are under study for clarification of these results," said the younger Schwartz.
Tuesday, September 7, 2010
Teens with Type 2 Diabetes Have Brain Abnormalities
Obese adolescents with Type 2 diabetes have diminished cognitive performance and subtle abnormalities in the brain, researchers at NYU Langone Medical Center found…
Antonio Convit, MD, professor of Psychiatry and Medicine at NYU Langone Medical Center and the Nathan S. Kline Institute for Psychiatric Research, NY, explained that, "This is the first study that shows that children with Type 2 diabetes have more cognitive dysfunction and brain abnormalities than equally obese children who did not yet have marked metabolic dysregulation from their obesity."
"The findings are significant because they indicate that insulin resistance from obesity is lowering children's cognitive performance, which may be affecting their ability to perform well in school."
Researchers studied 18 obese adolescents with Type 2 diabetes and compared them to equally obese adolescents from the same socio-economic and ethnic background but without evidence of marked insulin resistance or pre-diabetes.
Investigators found that adolescents with Type 2 diabetes not only had significant reductions in performance on tests that measure overall intellectual functioning, memory, and spelling, which could affect their school performance, but also had clear abnormalities in the integrity of the white matter in their brains.
"Now we see that subtle changes in white matter of the brain in adolescents may be a result of the abnormal physiology that accompanies Type 2 diabetes. If we can improve insulin sensitivity and help children through exercise and weight loss , perhaps we can reverse these deficits."
Antonio Convit, MD, professor of Psychiatry and Medicine at NYU Langone Medical Center and the Nathan S. Kline Institute for Psychiatric Research, NY, explained that, "This is the first study that shows that children with Type 2 diabetes have more cognitive dysfunction and brain abnormalities than equally obese children who did not yet have marked metabolic dysregulation from their obesity."
"The findings are significant because they indicate that insulin resistance from obesity is lowering children's cognitive performance, which may be affecting their ability to perform well in school."
Researchers studied 18 obese adolescents with Type 2 diabetes and compared them to equally obese adolescents from the same socio-economic and ethnic background but without evidence of marked insulin resistance or pre-diabetes.
Investigators found that adolescents with Type 2 diabetes not only had significant reductions in performance on tests that measure overall intellectual functioning, memory, and spelling, which could affect their school performance, but also had clear abnormalities in the integrity of the white matter in their brains.
"Now we see that subtle changes in white matter of the brain in adolescents may be a result of the abnormal physiology that accompanies Type 2 diabetes. If we can improve insulin sensitivity and help children through exercise and weight loss , perhaps we can reverse these deficits."
Beyond Bunionectomy: The Role of Physical Therapy
More and more surgeons are embracing the idea that physical therapy after bunion surgery can improve range of motion and other functional outcomes. But some practitioners still aren’t sure it’s right for everyone.
Most surgeons will tell you outcomes of hallux valgus surgery are very good, often quoting a 90% to 100% percent success rate. A survey-based study published in the December 2001 issue of Foot and Ankle International is typically cited as evidence.
But consensus is harder to come by in determining to what degree post-operative physical therapy contributes to functional outcomes. Some doctors send patients home with a self-administered exercise and self-massage routine and nothing more. Others prescribe an extensive, twice-weekly supervised physical therapy protocol that lasts from four to eight weeks on top of home-based exercises. To complicate matters, patients start PT at various times after surgery, depending on the rate of healing and the type of procedure.
Not all practitioners are ready to accept the idea that physical therapy, and not just surgical technique, can have a substantial impact on the success of hallux valgus procedures.
“Some physicians may think if they send a patient for physical therapy after surgery, it reflects poorly on their surgical procedure,” said Juan J. Rivera, DPM, a private practice podiatrist with the Ankle + Foot Center of Tampa Bay, who views physical therapy as complementary. “In actuality, you are helping your patient optimize their ultimate results and overall post-surgical experience.”
In the last year, two studies, one published and one presented at the American College of Foot and Ankle Surgeons’ annual meeting, have revived the debate. They suggest that post-operative physical therapy can significantly improve range of motion and weight bearing outcomes.
Enter new evidence
In the September 2009 issue of Physical Therapy, investigators from the Foot and Ankle Center in Vienna, Austria, analyzed 30 patients who underwent surgical correction of mild to moderate hallux valgus deformity, including 20 Austin osteotomies and 10 Scarf osteotomies. Prior to initiating the study, the researchers had observed that despite favorable clinical results, including pain relief, the ability to wear a wider variety of shoes, and the ability to participate in recreational activities, gait patterns did not spontaneously alter after surgery.
“We noticed that patients who underwent hallux valgus surgery didn’t use their great toe for push off, even though the deformity was corrected sufficiently,” said Reinhard Schuh, MD, a first-year resident in the department of orthopaedic surgery at Innsbruck Medical University and lead author of the study.
“To achieve bony union of the osteotomy, we had to avoid loading for four weeks,” Schuh said. “But we instructed patients to perform passive ROM exercises starting two days after surgery.”
At four weeks, patients began a comprehensive, 45-minute rehabilitation program once a week for four to six weeks. The standard protocol included elevation of the leg, lymphatic drainage, and activation of the muscle pump, and cryotherapy in the first session to reduce swelling. Other modalities, such as scar tissue massage, mobilization, manual therapy, soft tissue techniques, proprioceptive training for the lower leg, strengthening exercises, and gait training, were added progressively over the next four weeks.
Although the researchers did not use a control group, they found that at six months after surgery patients experienced significant improvements in first metatarsophalangeal joint range of motion and function. Weight bearing at the great toe and first metatarsal head, specifically related to maximum force levels and force-time integral, also improved significantly. Participants’ mean functional score on the American Orthopaedic Foot & Ankle Society forefoot scale improved from 60.7 out of 100 before surgery to 94.5 out of 100 at six months. By comparison, previous plantar pressure studies have documented a lack of weight bearing in the medial forefoot and first ray after hallux valgus surgery not followed by physical therapy.
Believe it or not
In the second study, which has been submitted for publication, researchers studied 55 patients who had undergone Scarf procedures at the Weil Foot and Ankle Institute in Des Plaines, IL. The large, 16-office practice in the Chicago area handles 500 bunion surgeries a year. According to Lowell Weil, Jr., DPM, MBA, senior investigator of the study, surgeons in his practice fall into two camps.
“The advent of screws and proper screw fixation eliminated the need for complete immobilization. Patients are able to return to activities and start physical therapy earlier, which has tremendous benefits. We developed physical therapy protocols for patients undergoing these types of procedures,” he said. “Despite that, some doctors in our practice weren’t prescribing physical therapy; they didn’t believe it made a difference.”
So Weil and a few colleagues set out to investigate. Their nonbelieving colleagues’ patients, who did not receive PT, served as a control group.
They studied 44 patients (65 feet) who underwent Scarf osteotomy procedures between 2006 and 2008, followed by a program of once- or twice-weekly physical therapy sessions. The 30 to 45 minute sessions continued for one to six weeks. Another group of 11 patients (14 feet) received no post-operative therapy.
Follow up occurred between November 2009 and January 2010. The physical therapy group significantly outperformed the control group on the Foot Function Index (FFI) and the ACFAS Universal Foot and Ankle Scoring System (see table).
Opinions about post-operative physical therapy in hallux valgus cases are as varied as surgical procedures. For PT proponents, like Michael Loshigian, DPM, a podiatric foot and ankle surgeon in private practice with the Metropolitan Foot Group in New York City, the benefits are indisputable.
“My own experience is fairly clear. Patients who have some sort of formal or informal physical therapy after hallux valgus surgery have better overall results and the progression of healing is more consistent and reliable,” Loshigian said.
Getting a head start
Loshigian, who performs these surgeries at least weekly, says the physical therapy protocol often begins shortly after surgery.
“In a joint fusion case, there should not be any attempt to move the joint, obviously. But in the majority of cases, we’re reorienting the MTP joint, restoring normal range of motion and alignment and function of that joint. In those cases, I have patients start their own range of motion exercises the day after surgery,” he said.
A primary objective is to prevent the soft tissue contracture and joint stiffening that can result from cutting and repositioning of bone.
“It’s easier to maintain good range of motion from the beginning than to attempt to restore it after it has been lost,” he said. “If we give those soft tissues an opportunity to tighten up, movement becomes difficult.”
Loshigian usually starts patients on formal twice-weekly physical therapy two to three weeks after surgery, once he removes the stitches. For most patients, the complete course of therapy lasts six to eight weeks.
At three or four weeks after surgery, patients can start weight bearing without the protection of a post-op shoe; at that point, Loshigian recommends strengthening the muscles and tendons that control the great toe along with continuing ROM exercises and techniques to reduce swelling. The final stage involves strengthening the lower legs and improving patterns of gait, agility, and balance.
Contributing factors
Rivera says many factors influence his decisions about the timing and course of therapy.
“Surgical procedures —MTP joint fusion, arthroplasty, chevron, opening base wedge, closing base wedge, first metatarsal-cuneiform joint fusion—all have various timeframes to stay offloaded, which can lead to disuse atrophy,” he said. “Many patients have such low pain tolerance, they need gait retraining to overcome post-operative pain and swelling and regain joint flexibility. Older patients need more help with loss of balance and proprioception.”
Another issue is the amount of time a patient with an operable deformity has postponed surgery; long delays can lead to compensatory gait patterns that are difficult to unlearn without additional physical therapy.
“A common example for me is the patient who undergoes hallux limitus correction surgery,” he said. “The biomechanical compensation for a painful arthritic great toe joint is to ambulate with the foot in an inverted position. Post surgery, the patient continues to ambulate in that position out of habit, delaying the healing of the foot.”
Not for everyone
Donald R. Bohay, MD, a professor of orthopedic surgery at Michigan State University who is also in private practice at Orthopaedic Associates of Michigan in Grand Rapids, views hallux valgus surgery and its aftermath from a slightly different perspective.
“I’m a believer in physical therapy that can help your patient get better faster,” Bohay said. “But I don’t think we know for sure that the patient who gets physical therapy versus the patient who doesn’t is necessarily better after a year.”
Bohay, who favors tarsometatarsal arthrodesis with a modified McBride procedure, says that his patients wear a post-op splint for two weeks. They then wear a short leg cast with heel weight bearing for six weeks, followed by a weight bearing boot for two to four weeks.
Most of the surgeons interviewed for this article would prescribe supervised physical therapy for a procedure requiring so much healing time and immobilization. However, Bohay instructs most of his patients to do home-based range-of-motion exercises and soft self-massage with vitamin E oil to desensitize the foot. When he considers it necessary, he does prescribe formal physical therapy.
“You get a sense that some patients aren’t going to do the program. Those patients do well by going to PT,” he said. “Then there are patients who have a lot more done, who are very swollen, very stiff. For them, physical therapy helps reestablish control, range of motion, and desensitization.”
The therapist’s perspective
Despite the general consensus among surgeons that PT is a useful tool after bunion correction, at least in certain cases, physical therapists express frustration that surgeons don’t take full advantage of their expertise.
“It’s a misconception that physical therapy is cookie cutter,” said Clarke Brown, PT, DPT, OCS, ATC, who is in private practice in Rochester, NY, and president of the American Physical Therapy Association’s foot and ankle special interest group. “We study these procedures. We develop separate protocols for them, and adapt them for each patient.”
Physical therapy following bunion surgery, Brown said, should extend well above the ankle.
“The most challenging thing about feet is that they radically change what happens all the way up the kinetic chain. The good practitioner looks at the whole system, all the way up to the knee, the hip, and the back. We look at the range of motion in all the joints and the strength of the entire leg,” he said. “Most chronic bunion patients can’t effectively lift the bunion leg in side-lying. The hip muscles atrophy.”
Brown notes that the foot and ankle subspecialty in physical therapy is just developing. Even though it’s not something surgeons have clamored for, those who witness the benefits of specialized therapy are sold, he said.
“We found that the faster we started to move the patient’s foot and toes, the more quickly the swelling went down,” he said. “One podiatrist used to take his sutures out after two weeks. But when we moved aggressively, the incisions would sometimes open up. Now he takes the stitches out at 21 days, saying ‘I’ll leave these in longer so you guys can do more.’ The more we communicate with each other, the better.”
A proactive approach
Stephen Paulseth, PT, DPT, SCS, ATC, who runs a private practice in West Los Angeles, often sees patients who have complications or problems that he believes could have been avoided by introducing physical therapy earlier.
“If doctors would send their patients for prehab, they would be doing so much better,” said Paulseth, who preceded Brown as president of the foot and ankle SIG. “I sometimes see patients six weeks in who haven’t really done much. They’ve been told to ice, strengthen, and do some gentle motion, but they just can’t tolerate it.”
He believes proper therapy and patient training can reduce the progression of bunion surgeries.
“Calf length is number one. Inadequate dorsiflexion of the ankle leads to all kinds of distal forefoot issues, including hallux valgus. Patients should begin calf stretching as soon as possible, and they have to continue calf stretching after they’ve healed,” Paulseth said.
Surgeons contend that most patients who undergo hallux valgus surgeries are happy with the results.
“From my experience, the vast majority of patients who have gone through this procedure are very satisfied with the results and in retrospect would choose to undergo the same procedure again,” Loshigian said. “As for their initial post-op experience, the feedback I get from most patients is that it is less stressful and painful than they anticipated.”
In Brown’s estimation, that already good patient experience could be even better if the relationship between patient, doctor, and physical therapist were more collaborative.
“When patients do better quicker, the word of mouth is more positive for the doctor,” he said. “Everybody wins.”
August 2010 by Linda Weber
Most surgeons will tell you outcomes of hallux valgus surgery are very good, often quoting a 90% to 100% percent success rate. A survey-based study published in the December 2001 issue of Foot and Ankle International is typically cited as evidence.
But consensus is harder to come by in determining to what degree post-operative physical therapy contributes to functional outcomes. Some doctors send patients home with a self-administered exercise and self-massage routine and nothing more. Others prescribe an extensive, twice-weekly supervised physical therapy protocol that lasts from four to eight weeks on top of home-based exercises. To complicate matters, patients start PT at various times after surgery, depending on the rate of healing and the type of procedure.
Not all practitioners are ready to accept the idea that physical therapy, and not just surgical technique, can have a substantial impact on the success of hallux valgus procedures.
“Some physicians may think if they send a patient for physical therapy after surgery, it reflects poorly on their surgical procedure,” said Juan J. Rivera, DPM, a private practice podiatrist with the Ankle + Foot Center of Tampa Bay, who views physical therapy as complementary. “In actuality, you are helping your patient optimize their ultimate results and overall post-surgical experience.”
In the last year, two studies, one published and one presented at the American College of Foot and Ankle Surgeons’ annual meeting, have revived the debate. They suggest that post-operative physical therapy can significantly improve range of motion and weight bearing outcomes.
Enter new evidence
In the September 2009 issue of Physical Therapy, investigators from the Foot and Ankle Center in Vienna, Austria, analyzed 30 patients who underwent surgical correction of mild to moderate hallux valgus deformity, including 20 Austin osteotomies and 10 Scarf osteotomies. Prior to initiating the study, the researchers had observed that despite favorable clinical results, including pain relief, the ability to wear a wider variety of shoes, and the ability to participate in recreational activities, gait patterns did not spontaneously alter after surgery.
“We noticed that patients who underwent hallux valgus surgery didn’t use their great toe for push off, even though the deformity was corrected sufficiently,” said Reinhard Schuh, MD, a first-year resident in the department of orthopaedic surgery at Innsbruck Medical University and lead author of the study.
“To achieve bony union of the osteotomy, we had to avoid loading for four weeks,” Schuh said. “But we instructed patients to perform passive ROM exercises starting two days after surgery.”
At four weeks, patients began a comprehensive, 45-minute rehabilitation program once a week for four to six weeks. The standard protocol included elevation of the leg, lymphatic drainage, and activation of the muscle pump, and cryotherapy in the first session to reduce swelling. Other modalities, such as scar tissue massage, mobilization, manual therapy, soft tissue techniques, proprioceptive training for the lower leg, strengthening exercises, and gait training, were added progressively over the next four weeks.
Although the researchers did not use a control group, they found that at six months after surgery patients experienced significant improvements in first metatarsophalangeal joint range of motion and function. Weight bearing at the great toe and first metatarsal head, specifically related to maximum force levels and force-time integral, also improved significantly. Participants’ mean functional score on the American Orthopaedic Foot & Ankle Society forefoot scale improved from 60.7 out of 100 before surgery to 94.5 out of 100 at six months. By comparison, previous plantar pressure studies have documented a lack of weight bearing in the medial forefoot and first ray after hallux valgus surgery not followed by physical therapy.
Believe it or not
In the second study, which has been submitted for publication, researchers studied 55 patients who had undergone Scarf procedures at the Weil Foot and Ankle Institute in Des Plaines, IL. The large, 16-office practice in the Chicago area handles 500 bunion surgeries a year. According to Lowell Weil, Jr., DPM, MBA, senior investigator of the study, surgeons in his practice fall into two camps.
“The advent of screws and proper screw fixation eliminated the need for complete immobilization. Patients are able to return to activities and start physical therapy earlier, which has tremendous benefits. We developed physical therapy protocols for patients undergoing these types of procedures,” he said. “Despite that, some doctors in our practice weren’t prescribing physical therapy; they didn’t believe it made a difference.”
So Weil and a few colleagues set out to investigate. Their nonbelieving colleagues’ patients, who did not receive PT, served as a control group.
They studied 44 patients (65 feet) who underwent Scarf osteotomy procedures between 2006 and 2008, followed by a program of once- or twice-weekly physical therapy sessions. The 30 to 45 minute sessions continued for one to six weeks. Another group of 11 patients (14 feet) received no post-operative therapy.
Follow up occurred between November 2009 and January 2010. The physical therapy group significantly outperformed the control group on the Foot Function Index (FFI) and the ACFAS Universal Foot and Ankle Scoring System (see table).
Opinions about post-operative physical therapy in hallux valgus cases are as varied as surgical procedures. For PT proponents, like Michael Loshigian, DPM, a podiatric foot and ankle surgeon in private practice with the Metropolitan Foot Group in New York City, the benefits are indisputable.
“My own experience is fairly clear. Patients who have some sort of formal or informal physical therapy after hallux valgus surgery have better overall results and the progression of healing is more consistent and reliable,” Loshigian said.
Getting a head start
Loshigian, who performs these surgeries at least weekly, says the physical therapy protocol often begins shortly after surgery.
“In a joint fusion case, there should not be any attempt to move the joint, obviously. But in the majority of cases, we’re reorienting the MTP joint, restoring normal range of motion and alignment and function of that joint. In those cases, I have patients start their own range of motion exercises the day after surgery,” he said.
A primary objective is to prevent the soft tissue contracture and joint stiffening that can result from cutting and repositioning of bone.
“It’s easier to maintain good range of motion from the beginning than to attempt to restore it after it has been lost,” he said. “If we give those soft tissues an opportunity to tighten up, movement becomes difficult.”
Loshigian usually starts patients on formal twice-weekly physical therapy two to three weeks after surgery, once he removes the stitches. For most patients, the complete course of therapy lasts six to eight weeks.
At three or four weeks after surgery, patients can start weight bearing without the protection of a post-op shoe; at that point, Loshigian recommends strengthening the muscles and tendons that control the great toe along with continuing ROM exercises and techniques to reduce swelling. The final stage involves strengthening the lower legs and improving patterns of gait, agility, and balance.
Contributing factors
Rivera says many factors influence his decisions about the timing and course of therapy.
“Surgical procedures —MTP joint fusion, arthroplasty, chevron, opening base wedge, closing base wedge, first metatarsal-cuneiform joint fusion—all have various timeframes to stay offloaded, which can lead to disuse atrophy,” he said. “Many patients have such low pain tolerance, they need gait retraining to overcome post-operative pain and swelling and regain joint flexibility. Older patients need more help with loss of balance and proprioception.”
Another issue is the amount of time a patient with an operable deformity has postponed surgery; long delays can lead to compensatory gait patterns that are difficult to unlearn without additional physical therapy.
“A common example for me is the patient who undergoes hallux limitus correction surgery,” he said. “The biomechanical compensation for a painful arthritic great toe joint is to ambulate with the foot in an inverted position. Post surgery, the patient continues to ambulate in that position out of habit, delaying the healing of the foot.”
Not for everyone
Donald R. Bohay, MD, a professor of orthopedic surgery at Michigan State University who is also in private practice at Orthopaedic Associates of Michigan in Grand Rapids, views hallux valgus surgery and its aftermath from a slightly different perspective.
“I’m a believer in physical therapy that can help your patient get better faster,” Bohay said. “But I don’t think we know for sure that the patient who gets physical therapy versus the patient who doesn’t is necessarily better after a year.”
Bohay, who favors tarsometatarsal arthrodesis with a modified McBride procedure, says that his patients wear a post-op splint for two weeks. They then wear a short leg cast with heel weight bearing for six weeks, followed by a weight bearing boot for two to four weeks.
Most of the surgeons interviewed for this article would prescribe supervised physical therapy for a procedure requiring so much healing time and immobilization. However, Bohay instructs most of his patients to do home-based range-of-motion exercises and soft self-massage with vitamin E oil to desensitize the foot. When he considers it necessary, he does prescribe formal physical therapy.
“You get a sense that some patients aren’t going to do the program. Those patients do well by going to PT,” he said. “Then there are patients who have a lot more done, who are very swollen, very stiff. For them, physical therapy helps reestablish control, range of motion, and desensitization.”
The therapist’s perspective
Despite the general consensus among surgeons that PT is a useful tool after bunion correction, at least in certain cases, physical therapists express frustration that surgeons don’t take full advantage of their expertise.
“It’s a misconception that physical therapy is cookie cutter,” said Clarke Brown, PT, DPT, OCS, ATC, who is in private practice in Rochester, NY, and president of the American Physical Therapy Association’s foot and ankle special interest group. “We study these procedures. We develop separate protocols for them, and adapt them for each patient.”
Physical therapy following bunion surgery, Brown said, should extend well above the ankle.
“The most challenging thing about feet is that they radically change what happens all the way up the kinetic chain. The good practitioner looks at the whole system, all the way up to the knee, the hip, and the back. We look at the range of motion in all the joints and the strength of the entire leg,” he said. “Most chronic bunion patients can’t effectively lift the bunion leg in side-lying. The hip muscles atrophy.”
Brown notes that the foot and ankle subspecialty in physical therapy is just developing. Even though it’s not something surgeons have clamored for, those who witness the benefits of specialized therapy are sold, he said.
“We found that the faster we started to move the patient’s foot and toes, the more quickly the swelling went down,” he said. “One podiatrist used to take his sutures out after two weeks. But when we moved aggressively, the incisions would sometimes open up. Now he takes the stitches out at 21 days, saying ‘I’ll leave these in longer so you guys can do more.’ The more we communicate with each other, the better.”
A proactive approach
Stephen Paulseth, PT, DPT, SCS, ATC, who runs a private practice in West Los Angeles, often sees patients who have complications or problems that he believes could have been avoided by introducing physical therapy earlier.
“If doctors would send their patients for prehab, they would be doing so much better,” said Paulseth, who preceded Brown as president of the foot and ankle SIG. “I sometimes see patients six weeks in who haven’t really done much. They’ve been told to ice, strengthen, and do some gentle motion, but they just can’t tolerate it.”
He believes proper therapy and patient training can reduce the progression of bunion surgeries.
“Calf length is number one. Inadequate dorsiflexion of the ankle leads to all kinds of distal forefoot issues, including hallux valgus. Patients should begin calf stretching as soon as possible, and they have to continue calf stretching after they’ve healed,” Paulseth said.
Surgeons contend that most patients who undergo hallux valgus surgeries are happy with the results.
“From my experience, the vast majority of patients who have gone through this procedure are very satisfied with the results and in retrospect would choose to undergo the same procedure again,” Loshigian said. “As for their initial post-op experience, the feedback I get from most patients is that it is less stressful and painful than they anticipated.”
In Brown’s estimation, that already good patient experience could be even better if the relationship between patient, doctor, and physical therapist were more collaborative.
“When patients do better quicker, the word of mouth is more positive for the doctor,” he said. “Everybody wins.”
August 2010 by Linda Weber
Friday, September 3, 2010
Green Leafy Vegetables Cuts The Risk of Diabetes by 14%
A British meta-analysis found that increasing the daily intake of green leafy vegetables can reduce the risk of Type 2 diabetes…
According to Patrice Carter, a PhD student at the University of Leicester, consuming 1.35 servings of these vegetables per day was associated with a 14% reduction in risk compared with consuming only 0.2 servings (HR 0.86, 95% CI 0.77 to 0.96, P=0.01).
A trend also was seen suggesting a benefit for consuming greater quantities of fruits and vegetables overall, although this was not statistically significant.
The incidence of Type 2 diabetes has been rising dramatically during the past two decades, with diet being a major contributor, but evidence thus far has been conflicting as to whether increasing consumption of fruit and vegetables would have an impact.
To sort through this evidence, Carter and colleagues conducted a systematic review and meta-analysis, identifying six studies that met their inclusion criteria.
The studies included a combined population of 223,512 subjects who were 30 to 74 years of age. Length of the studies ranged from 4.6 to 23 years.
Comparisons of the lowest versus highest intake of fruit and vegetables found these hazard ratios for Type 2 diabetes:
Vegetables only, HR 0.91 (95% CI 0.76 to 1.09, P=0.32)
Fruit only, HR 0.93 (95% CI 0.83 to 1.01, P=0.27)
Fruit and vegetables overall, HR 1 (95% CI 0.92 to 1.09, P=0.97)
The researchers found considerable heterogeneity between the studies, so they carried out a sensitivity analysis, examining multiple factors that could be sources of bias.
They found no influence of study location, despite one study having been conducted in China, where the traditional diet is high in fruit and vegetables. Heterogeneity also could result from differences in food group classifications, with some studies defining green leafy vegetables as lettuce, spinach, and kale, while others included Chinese greens.
The researchers pointed out that the food group of green leafy vegetables actually includes brassicas, such as cabbage and cauliflower, Compositae such as lettuce, and herbs such as parsley and dill.
They listed possible reasons why fruit and vegetables might help prevent chronic disease, among them the antioxidant effects of beta-carotene, vitamin C, and polyphenols, as well as the magnesium and polyunsaturated fatty acid content.
However, they noted that the benefits of these compounds are likely to result from consumption in foods rather than as dietary supplements, with disappointing results having been seen in earlier trials of supplements for disease prevention.
The importance of overall nutrition was echoed in an editorial by Jim Mann, PhD, of the University of Otago, in Dunedin, New Zealand, and Dagfinn Aune, BSc, of Imperial College in London, which accompanied the meta-analysis.
"Although some studies have shown associations between individual vegetables and fruits and coronary heart disease, stroke, and some cancers (for example, allium vegetables and stomach and colorectal cancer, tomatoes and prostate cancer), most current recommendations focus on food groups as a whole rather than magic bullets," they wrote.
The editorialists noted that although it may be "reasonable" to draw attention to the potential benefits of green leafy vegetables, the more important message is for increasing fruit and vegetable intake overall.
"The findings are also a useful reminder to clinicians that giving dietary advice may be just as beneficial, if not more so, than prescribing drugs to patients at risk of chronic disease," wrote Mann and Aune.
According to Patrice Carter, a PhD student at the University of Leicester, consuming 1.35 servings of these vegetables per day was associated with a 14% reduction in risk compared with consuming only 0.2 servings (HR 0.86, 95% CI 0.77 to 0.96, P=0.01).
A trend also was seen suggesting a benefit for consuming greater quantities of fruits and vegetables overall, although this was not statistically significant.
The incidence of Type 2 diabetes has been rising dramatically during the past two decades, with diet being a major contributor, but evidence thus far has been conflicting as to whether increasing consumption of fruit and vegetables would have an impact.
To sort through this evidence, Carter and colleagues conducted a systematic review and meta-analysis, identifying six studies that met their inclusion criteria.
The studies included a combined population of 223,512 subjects who were 30 to 74 years of age. Length of the studies ranged from 4.6 to 23 years.
Comparisons of the lowest versus highest intake of fruit and vegetables found these hazard ratios for Type 2 diabetes:
Vegetables only, HR 0.91 (95% CI 0.76 to 1.09, P=0.32)
Fruit only, HR 0.93 (95% CI 0.83 to 1.01, P=0.27)
Fruit and vegetables overall, HR 1 (95% CI 0.92 to 1.09, P=0.97)
The researchers found considerable heterogeneity between the studies, so they carried out a sensitivity analysis, examining multiple factors that could be sources of bias.
They found no influence of study location, despite one study having been conducted in China, where the traditional diet is high in fruit and vegetables. Heterogeneity also could result from differences in food group classifications, with some studies defining green leafy vegetables as lettuce, spinach, and kale, while others included Chinese greens.
The researchers pointed out that the food group of green leafy vegetables actually includes brassicas, such as cabbage and cauliflower, Compositae such as lettuce, and herbs such as parsley and dill.
They listed possible reasons why fruit and vegetables might help prevent chronic disease, among them the antioxidant effects of beta-carotene, vitamin C, and polyphenols, as well as the magnesium and polyunsaturated fatty acid content.
However, they noted that the benefits of these compounds are likely to result from consumption in foods rather than as dietary supplements, with disappointing results having been seen in earlier trials of supplements for disease prevention.
The importance of overall nutrition was echoed in an editorial by Jim Mann, PhD, of the University of Otago, in Dunedin, New Zealand, and Dagfinn Aune, BSc, of Imperial College in London, which accompanied the meta-analysis.
"Although some studies have shown associations between individual vegetables and fruits and coronary heart disease, stroke, and some cancers (for example, allium vegetables and stomach and colorectal cancer, tomatoes and prostate cancer), most current recommendations focus on food groups as a whole rather than magic bullets," they wrote.
The editorialists noted that although it may be "reasonable" to draw attention to the potential benefits of green leafy vegetables, the more important message is for increasing fruit and vegetable intake overall.
"The findings are also a useful reminder to clinicians that giving dietary advice may be just as beneficial, if not more so, than prescribing drugs to patients at risk of chronic disease," wrote Mann and Aune.
Wednesday, September 1, 2010
Simple Blood Test Predicts Who Might Develop Type 2 Diabetes Among Healthy Women
Doctors may have identified a new and simple way to predict risk for developing Type 2 diabetes. The result of a simple blood test may be the earliest alert to doctors and patients to implement lifestyle changes that may delay or prevent the onset of the disease….
Samia Mora, M.D., and colleagues at Harvard Medical School and the Brigham and Women's Hospital used Nuclear Magnetic Resonance (NMR) to investigate the relationship of NMR-measured lipoproteins and the development of future Type 2 diabetes. The outcome of Dr. Mora's work showed that NMR-measured lipoprotein particles were associated with development of Type 2 diabetes, independent of other risk factors, particularly HDL-cholesterol and triglycerides measured by standard laboratory methods.
According to Dr. Mora, "Our findings indicate for the first time that even before the onset of clinical Type 2 diabetes, the size and number of the lipoprotein particles may indicate which women go on to develop future disease. This could provide an important opportunity for a woman with a normal blood glucose, but an abnormal NMR lipoprotein test result, to intervene early by following a healthy diet, losing weight, and increasing her physical activity level, all known ways to reduce her chance of developing diabetes even years before she gets a high glucose reading."
Doctors typically look for increases in glucose and triglycerides, and decreases in HDL cholesterol, to determine if a patient is becoming pre-diabetic. Even before changes in glucose levels are detectable, there are significant changes in the metabolism of cholesterol and triglycerides.
LDL "bad" cholesterol, HDL "good" cholesterol and triglycerides, are carried throughout the body inside molecules called lipoprotein particles. The particles travel into artery walls where they deposit the cholesterol, which forms artery-clogging plaque. Researchers wanted to know the significance of the particle size and number in apparently healthy individuals: could these readings predict future disease? Could they, in fact, predict who might develop Type 2 diabetes in time for early intervention?
The researchers conducted a study of 26,836 initially healthy women who were then followed for 13 years, during which 1,687 developed Type 2 diabetes. Dr. Mora noted, "Our study, which was conducted in a large population of healthy women, found that larger LDL and HDL particles were associated with lower risk and smaller LDL and HDL particles were associated with higher risk of diabetes. Even in women with normal triglyceride and HDL cholesterol measured by standard tests, having smaller LDL particles imparted higher risk of diabetes."
The team concluded that NMR-measured lipoprotein particle size and number provide an opportunity to better predict a healthy woman's chance of developing future diabetes, a type of early warning system. "Our finding suggests that these lipoprotein alterations may occur years before onset of overt hyperglycemia and clinical diagnosis of diabetes, providing a potential opportunity for the early detection and prevention of Type 2 diabetes and its complications."
Although standard laboratory tests can be used to measure the cholesterol and triglycerides carried by the particles, these tests do not provide a reliable indication of the number or size of the particles in the bloodstream. Particle number and size can be measured from a small blood specimen using another test (NMR), technology that has been used in research settings for over 40 years. More recently, NMR has been used in the clinical laboratory to determine particle number and size in the blood.
Samia Mora, M.D., and colleagues at Harvard Medical School and the Brigham and Women's Hospital used Nuclear Magnetic Resonance (NMR) to investigate the relationship of NMR-measured lipoproteins and the development of future Type 2 diabetes. The outcome of Dr. Mora's work showed that NMR-measured lipoprotein particles were associated with development of Type 2 diabetes, independent of other risk factors, particularly HDL-cholesterol and triglycerides measured by standard laboratory methods.
According to Dr. Mora, "Our findings indicate for the first time that even before the onset of clinical Type 2 diabetes, the size and number of the lipoprotein particles may indicate which women go on to develop future disease. This could provide an important opportunity for a woman with a normal blood glucose, but an abnormal NMR lipoprotein test result, to intervene early by following a healthy diet, losing weight, and increasing her physical activity level, all known ways to reduce her chance of developing diabetes even years before she gets a high glucose reading."
Doctors typically look for increases in glucose and triglycerides, and decreases in HDL cholesterol, to determine if a patient is becoming pre-diabetic. Even before changes in glucose levels are detectable, there are significant changes in the metabolism of cholesterol and triglycerides.
LDL "bad" cholesterol, HDL "good" cholesterol and triglycerides, are carried throughout the body inside molecules called lipoprotein particles. The particles travel into artery walls where they deposit the cholesterol, which forms artery-clogging plaque. Researchers wanted to know the significance of the particle size and number in apparently healthy individuals: could these readings predict future disease? Could they, in fact, predict who might develop Type 2 diabetes in time for early intervention?
The researchers conducted a study of 26,836 initially healthy women who were then followed for 13 years, during which 1,687 developed Type 2 diabetes. Dr. Mora noted, "Our study, which was conducted in a large population of healthy women, found that larger LDL and HDL particles were associated with lower risk and smaller LDL and HDL particles were associated with higher risk of diabetes. Even in women with normal triglyceride and HDL cholesterol measured by standard tests, having smaller LDL particles imparted higher risk of diabetes."
The team concluded that NMR-measured lipoprotein particle size and number provide an opportunity to better predict a healthy woman's chance of developing future diabetes, a type of early warning system. "Our finding suggests that these lipoprotein alterations may occur years before onset of overt hyperglycemia and clinical diagnosis of diabetes, providing a potential opportunity for the early detection and prevention of Type 2 diabetes and its complications."
Although standard laboratory tests can be used to measure the cholesterol and triglycerides carried by the particles, these tests do not provide a reliable indication of the number or size of the particles in the bloodstream. Particle number and size can be measured from a small blood specimen using another test (NMR), technology that has been used in research settings for over 40 years. More recently, NMR has been used in the clinical laboratory to determine particle number and size in the blood.
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