Interesting Diabetes Article

The_Conductor

From todays International Herald Tribune here:

Most diabetes patients lack information

NEW YORK: Dave Smith found out he had Type 2 diabetes by accident, after a urine test.

That was about nine years ago, and from then on Smith, like so many with diabetes, became fixated on his blood sugar. His doctor warned him to control it or the consequences could be dire - he could end up blind or lose a leg. His kidneys could fail.

Smith, a 43-year-old pastor in Fairmont, Minnesota, tried hard. When dieting did not work, he began counting carbohydrates, taking pills to lower his blood sugar and pricking his finger several times a day to measure his sugar levels. They remained high, so he agreed to add insulin to his already complicated regimen. Blood sugar was always on his mind.

But in focusing entirely on blood sugar, Smith ended up neglecting the most important treatment for saving lives - lowering the cholesterol level. That protects against heart disease, the disease that eventually kills nearly everyone with diabetes.

He also was missing a second treatment that protects diabetes patients from heart attacks - controlling blood pressure. Smith assumed everything would be taken care of if he could just lower his blood sugar level.

Blood sugar control is important in diabetes, specialists say. It can help prevent dreaded complications like blindness, amputations and kidney failure. But controlling blood sugar is not enough.

Nearly 73,000 Americans alone die from diabetes annually, more than from any disease except heart disease, cancer, stroke and pulmonary disease.

Yet, largely because of a misunderstanding of the proper treatment, most patients are not doing even close to what they should to protect themselves. In fact, according to the Centers for Disease Control and Prevention, just 7 percent are getting all the treatments they need.

"That, to me, is mind-boggling," said Dr. Michael Brownlee, director of the JDRF International Center for Diabetic Complications Research at the Albert Einstein College of Medicine in New York.

In part, the fault for the missed opportunities to prevent complications and deaths lies with the medical system. Most people who have diabetes are treated by primary care doctors who had just a few hours of instruction on diabetes, while they were in medical school.

Then the doctors typically spend just 10 minutes with diabetes patients, far too little for such a complex disease, specialists say.

And in part it is the fault of public health campaigns that give the impression that diabetes is a matter of an out-of-control diet and sedentary lifestyle and the most important way to deal with it is to lose weight.

Most diabetes patients try hard but are unable to control their disease in this way, and most of the time it progresses as years go by, no matter what patients do.

Smith, like 90 percent of diabetes patients, has Type 2 diabetes, the form that usually arises in adulthood when the insulin-secreting cells of the pancreas cannot keep up with the body's demand for the hormone. The other form of diabetes, Type 1, is far less common and usually arises in childhood or adolescence when insulin-secreting pancreas cells die.

And, like many Type 2 patients, Smith ended up paying the price for his misconceptions about diabetes. Last year, he had a life-threatening heart attack. Smith thought his biggest risk from diabetes was blindness or amputations. He never thought about heart disease, and he had no idea how important it was to control cholesterol levels and blood pressure. He said his doctor had not advised him to take a cholesterol-lowering or blood pressure drug, and he did not think he needed them.

Most people with diabetes are equally unaware of the danger that heart disease poses for them.

A recent survey by the American Diabetes Association conducted by RoperASW found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.

Yet, said Dr. David Nathan, director of the Diabetes Center at Massachusetts General Hospital, "when you think about it, it's not the diabetes that kills you, it's the diabetes causing cardiovascular disease that kills you."

Brownlee said he was stunned by the results of the diabetes association poll. "If you are one of those 82 percent who don't think you are at increased risk," he said, "finding out that you are and that you can decrease that risk substantially could literally change your life."

The science is clear on the huge benefits for people with diabetes of lowering cholesterol and controlling blood pressure.

With cholesterol, guidelines say that levels of LDL cholesterol, the form that increases heart disease risk, should be below 100 milligrams per deciliter and, if possible, 70 to 80. Yet, Brownlee said, diabetes patients with LDL cholesterol levels of 100 to 139 often are told that their levels - ideal for a healthy person without diabetes - are terrific.

"Many practicing doctors just don't know that an LDL cholesterol number that is normal for someone without diabetes is not normal for someone with diabetes," he said.

Smith found all that out too late. The heart attack, he said, "really blindsided me."

He also did not know the other measures proven to prevent complications in diabetes. He was correct that high blood sugar is dangerous. It can damage the small blood vessels in the eyes, leading to blindness; the nerves in the feet, leading to amputations; and the kidneys, leading to kidney failure.

But no matter how carefully patients try to control their blood sugar, they can never get it perfect - no drugs can substitute for the body's normal sugar regulation. So while controlling blood sugar can be important, other measures also are needed to prevent blindness, amputations, kidney failure and stroke. Smith was doing none of them.

He also made the common assumption that Type 2 diabetes is simply a consequence of being fat. And that losing weight will help cure it.

Obesity does increase the risk of developing diabetes, but the disease involves more than being obese. Only 5 percent to 10 percent of obese people have diabetes, and many with diabetes are not obese.

To a large extent, Type 2 diabetes is genetically determined. In many cases, weight loss can help, but, as Smith has learned, most who lose weight are not cured of the disease. He lost 40 pounds, or 18 kilograms, but still has diabetes.

"Everybody in the act of losing weight will have a pretty dramatic improvement pretty quickly," said Dr. C. Ronald Kahn, a diabetes researcher and professor of medicine at Harvard Medical School. Blood sugar levels drop precipitously and the disease seems to be under control. But that is because the metabolic process of weight loss lessens diabetes. Once weight is lost, he added, and people stabilize at a lower weight, their diabetes may remain.

When it comes to weight loss, Kahn said, "there is a range of susceptibilities in how people react."

The statistics are grim: A quarter to a third of all heart attack patients have diabetes, even though diabetes patients constitute just 9.3 percent of the population. Another 25 percent of heart attack patients are verging on diabetes with abnormally high blood sugar levels.

Most worrisome are diabetes patients who already have symptoms of heart disease, like chest pains or a previous heart attack.

"That is a terrible situation," said Dr. James Cleeman, coordinator of the National Cholesterol Education Program at the National Institutes of Health. Those patients, Cleeman said, should be stringently controlling their cholesterol and blood pressure.

The key to saving lives is to reduce levels of LDL cholesterol to below 100 and also control other risk factors like blood pressure and smoking. The cholesterol reduction alone can reduce the very high risk of heart attacks and death from cardiovascular disease in people with diabetes by 30 percent to 40 percent, Cleeman said. And clinical trials have found that LDL levels of 70 to 80 are even better for people with diabetes who already have overt heart disease.

Dr. John Buse, president-elect for science and medicine at the American Diabetes Association, said that for people with Type 1 and, especially, for those with Type 2 diabetes, there are still questions about whether and to what extent blood sugar control protects against heart disease and saves lives.

That leaves cholesterol lowering, for patients with Type 1 and Type 2 diabetes, as the most effective and easiest way by far to reduce the risk of heart disease and the only treatment proven to save lives. But doctors say achieving the recommended cholesterol levels usually means taking a statin. Some patients resist, wary of intense drug company marketing and afraid of side effects like muscle or liver damage that, although extremely rare, have frightened many away from the drugs, Brownlee and other diabetes specialists said. (Brownlee said he had no financial ties to statin makers.)

DrIndy

tight blood pressure control is much more important than tight blood sugar control in diabetes. Lowering cholesterol helps too especially if you are Type 2 diabetic where high cholesterol is directly associated with developing type 2 diabetes.

nesf

DrIndy wrote:

Lowering cholesterol helps too especially if you are Type 2 diabetic where high cholesterol is directly associated with developing type 2 diabetes.

I was wondering about this and atypical antipsychotics like Zyprexa, Risperdal etc and how much of the increased diabetes risk came from their effects on lipid levels and weight gain?

DrIndy

its the effect of the metabolic syndrome which constitutes the three sides of a triangle:

Hypertension or high blood pressure
High cholesterol
Diabetes

And inside this is all the problems like, stroke, heart disease, kidney failure, leg blood vessel disease.

You have to act on all sides of that triangle to prevent those problems.