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Robert J. Rushakoff, MD, FACP and Ernest H. Rosenbaum, MD
- Facts from the National Institute of Health
Knowing these facts, survivors need to have diabetic evaluation.
- - Diabetes is the fifth leading cause of death in the U.S. (224,000 deaths each year).
- 1 in 3 babies born today (and 1 in 2 non-whites) will develop diabetes.
- By 2050 there will be 1,000,000 diabetic-related deaths yearly.
- Diabetes is the leading cause of blindness, kidney failure, and non-traumatic leg amputations.
- A chronic disease, diabetes mellitus can affect the entire body. Two major problems occur with diabetes. First, the body is not able to store and use sugar (glucose) appropriately, and this leads to high levels of glucose in the blood (hyperglycemia). Second, as a result of the hyperglycemia, complications of diabetes may occur - eye disease, kidney disease, nerve disease, and atherosclerosis or heart disease and strokes. In the past decade, large studies in both the United States and Europe have shown conclusively that with good control of the blood glucose levels (lowering the glucose level to nearly normal), the risk of developing the complications of diabetes can be dramatically reduced. In addition, these studies have also shown that by lowering cholesterol and blood pressure levels, the risk of heart disease and stroke can also be reduced. It is clear that control of diabetes and its associated conditions is of primary importance and will lead to a healthier, longer life. Prevention of diabetes in the first place would, of course, keep these devastating complications from ever occurring. Strategies for prevention of diabetes and treatment options are discussed below. How do we know if you have diabetes? You may have symptoms of high blood sugar. These are:
- - Excessive thirst
- Frequent urination
- By current criteria, if you have these symptoms and have a random blood sugar level that is high, (generally over 200 mg/dl) then you have diabetes. If you do not have any symptoms, and your fasting blood sugar is over 126 mg/dl on two different days, then you also have diabetes. Fasting blood sugar levels considered normal fall between 70 and 100 mg/dl.
There are two major types of diabetes: Type 1 and Type 2.
In type 1 diabetes, the insulin-producing cells of the pancreas are destroyed slowly, it is believed by an autoimmune process, and eventually not enough insulin can be made to maintain normal glucose levels. Lifelong insulin use is required in order to survive. Although most people who develop this type of diabetes do so before age 30, it can occur at any age. About 5% of all people with diabetes have type 1.
Approximately 90% of diabetes cases are type 2, and most people with type 2 diabetes develop it after the age of 40, though it may occur at any age. In fact, there is now an epidemic of type 2 diabetes in teenagers. Most people with this type of diabetes are overweight. While diet and exercise are an important base for all treatment of type 2 diabetes, unless they lose weight most people will require multiple medications to control their glucose levels. As the disease progresses, insulin levels decrease and to treat type 2 diabetes, insulin will generally be required.
A conventional view of type 2 diabetes involves hyperglycemia (high blood sugar) caused by obesity-association insulin resistance and pancreas beta cell loss. It is a disease of glucose metabolism treated with anti-hyperglycemic agents, including insulin and other drugs. There's an alternate view that insulin resistance and beta cell loss are due to metabolic trauma caused by ectopic lipid deposition or lipotoxicity (fat toxicity). Getting rid of the fat load might be a major part of the treatment. This has been shown to be effective with weight loss and gastric (stomach reduction) banding surgery and a remission of diabetes in 73% of obese patients with type 2 diabetes.
- Complications of Diabetes
With the treatment of diabetes as described below, it is relatively easy to control blood sugar levels in a range that will allow you to feel normal. Unfortunately this degree of control has not been good enough to decrease the risk of developing complications. Recall that 50% of people with diabetes do not even know that they have the disease. It is not unusual for people to have advanced complications even before they realize they have the disease. The complications include:
- - Retinopathy is the eye disease in diabetes which damages the blood vessels on the retina (inside back wall) of the eye. These blood vessels can leak fluid or blood, and lead to diminished vision or blindness.
Diabetes-related eye diseases may skyrocket over the next four decades, researchers say. with elderly Hispanics and blacks hit hardest because of higher rates of type 2 diabetes." In particular, the "report projects that the number of adults 40 and older with diabetic retinopathy -- the leading cause of blindness among working-age adults -- will reach 16 million in 2050, up from 5.5 million in 2005." In addition, "the study estimates that the number of diabetics with glaucoma will quadruple to 1.4 million, while the number with cataracts will more than triple to 10 million." Study author Jinan B. Saaddine, MD, M.P.H., of the Centers for Disease Control and Prevention, said the findings are a call for the medical community "to do more to prevent diabetes to start with."1
"The number of Americans with diabetic retinopathy is expected to increase from 5.5 million to 16 million by the year 2050." Researchers from the Centers for Disease Control and Prevention (CDC) "analyzed data from the 2004 National Health Interview Survey and the U.S. Census Bureau to predict the number of Americans with diabetes who will have diabetic retinopathy, vision-threatening diabetic retinopathy, glaucoma, and cataracts in 2050, when the country's population is expected to be 402 million." The investigators also predicted that vision-threatening diabetic retinopathy cases "will increase from 1.2 million to 3.4 million," and that "cataract cases among whites and blacks age 40 or older with diabetes will increase 235%. In addition, "glaucoma cases among Hispanics age 65 and older with diabetes will increase."
It has also been noted that women 53-73, who consumed diets with a relatively high glycemic index had a greater risk of developing early age-related macular degeneration and cataracts.
- Nephropathy is the kidney disease from diabetes. People who develop this complication initially have increasing amounts of protein which leak into the kidneys and urine. The ability of the kidneys to filter the blood decrease to the point that dialysis or a kidney transplant is needed.
- Neuropathy, or nerve damage, occasionally can cause severe burning pain to occur, especially in the feet. More commonly, there may be a tingling, numbness or even complete loss of sensation in the feet and sometimes in the hands. The loss of sensation can be extremely dangerous as trauma to the feet will go unrecognized and even a minor injury can lead to ulcer formation and amputation.
- Cardiovascular disease in diabetics also is associated with an increased risk of heart attacks and strokes. Studies have shown that people with type 2 diabetes, but not a known history of heart disease, have the same risk of a heart attack as a person without diabetes who has already had a heart attack! Another condition, claudication (walking or climbing stairs may lead to extreme calf pain that resolves when the movement is stopped) is from blocked arteries in the legs.
Blood pressure differs in individuals and throughout the day, and the question posed was for diabetics is tight blood pressure regulation beneficial for reducing the risk for diabetic death, microvascular disease, strokes, and heart attacks?2
In this study in the United Kingdom of type 2 diabetes, 1,148 patients with hypertension were followed with tight control measures. There was a significant reduction in blood pressure during the trial, measuring diabetic-related deaths, microvascular disease, and strokes versus those with less tight blood pressure control. There was no reduction in myocardial infarction or death from any cause, but there was a risk reduction for peripheral vascular disease associated with high blood pressure. Control had a more significant outcome.
Their conclusion was improved blood pressure control was not sustained, and although early improvement in blood pressure control was seen with both type 2 diabetics and hypertension with a reduction in complications, it appeared that blood pressure control had to be continued if any benefits were to be maintained. The bottom line is continuous blood pressure control throughout life is needed.
- Reducing the risk of developing these complications has been the major goal in controlling diabetes. In a recent medical study, the group with excellent glucose control had a 50-70% reduction in risk of developing complications of diabetes, and a similar reduction in progression. For all people with diabetes the goal is to keep blood glucose as close to normal as possible.
When diabetics aggressively control their blood pressure and cholesterol levels, the risk of cardiovascular disease also decreases dramatically.
- - Exercise is of equal importance. The exercise must be almost daily for at least 30 minutes in order to help achieve significant lowering of blood glucose levels.
Approximately 24 million Americans have diabetes; although, about one-third of them are unaware of this condition, and another 57 million have been estimated to have what is known as pre-diabetes, which, in general, can be controlled and can help prevent overt diabetes. Those with diabetes are at increased risk for heart disease and cancer, and there is a great chance that this can be largely avoided by using preventive medical techniques. (Pre-diabetes is marked by a blood sugar level higher than normal but not yet in the diabetic range.)
Lifestyle changes can help improve the effectiveness of insulin in the body. By reducing high insulin levels, the risk of cancer can also be decreased, and it can help halt metabolic changes, which promote increased growth and development of cancer cells.
In the Nurses' Health Study, those overweight were five- to ten-times more likely to develop diabetes than those with a healthy BMI, and obese women were 30-times more likely to develop diabetes.
Even a modest 5-7% decrease in body weight (10-14 lbs for those weighing over 200 pounds) may be enough. Reduction of calorie consumption by 450 calories per day can be beneficial.
Physical exercise is also very important - recommended 150 minutes per week, such as thirty minutes or other moderate activities five days a week. This improves insulin resistance.
Proper diet can also help prevent the onset of type 2 diabetes. The standard American diet was recently evaluated in a very large study in the United States, the Diabetes Prevention Program (DPP). Three thousand two hundred people at high risk for developing diabetes were divided into groups. Those in the lifestyle intervention group received intensive counseling on effective diet, exercise, and behavior modification, and reduced their risk of developing diabetes by 58%. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71%.
For type 2 diabetes, the current best treatment for type 2 diabetes is preventing the onset in the first place with an improved healthy diet and exercise.
Insulin resistance can be reduced after three to four months of daily aerobic activity with lower circulating insulin levels and less inflammation, lowering the risk for cancer and heart disease. Weight control is vital. A low-saturated fat diet high in fiber, rich in fruits, vegetables and grains offers optimal benefits.
Unfortunately, many people are unable to meet the dietary and exercise recommendations. Diet is often difficult to modify with aging. In addition, exercise may be difficult secondary to other medical conditions such as osteoarthritis or heart disease. As 95% of people who develop diabetes have type 2, prevention of this type: will have a major impact. Those who exercise have a much lower chance of developing diabetes than those who do not exercise.
To check your diabetic risk, there is a Diabetes Risk Calculator at the American Diabetic Association's website, www.diabetes.org, which can help evaluate your risk of diabetes.
- 1. Those with glucose tolerance are at higher risk to develop diabetes within ten years.
2. Intensive diet changes.
- - Reduce intake of fat and saturated fat
- Increase fiber
- 3. Exercise counseling and activities.
- - Increase physical activity
- 1. More meal preparation is outsourced from family to commercial processors with lipid-rich, calorie-dense foods. Over the last thirty years, this resulted from a 168-kcal per day to a 355-kcal per day increase in caloric intake in men and women, and a substantial reduction in physical exercise and more immobilizing activities - car driving rather than walking or bicycling. The excess calories led to overweight and obesity.
2. It was found, through insulin assays, that overweight individuals with normal glucose levels had a higher insulin level than normal-weight individuals. There's coexistence, of hyperinsulinemia and normal glycemia (blood sugar), which implied insulin resistance. It was a relationship to the metabolic syndrome.
3. McGarry, 1992, postulated that the abnormal metabolism of lipids, not glucose, was the primary metabolic defect in type 2 diabetes.
4. Lee, in 1994, showed an accumulation of ectopic lipids in the pancreatic beta islet cells, causing destruction and precipitating hyperglycemia due to decrease insulin secretion availability.
- The Process:
- An increase in calories - a surplus - leads to hyperinsulinemia, and this leads to increased expression of lipogenic transcription factor SREBP-1c, leading to increased lipogenesis. This leads to increased adiposity (obesity), which leads to ectopic lipid deposition, leading to insulin resistance, and this leads to beta cell lipotoxicity, and that leads to hyperglycemia (due to lack of insulin production). Over-nutrition with excess calories results in increased insulin secretion, leading to fat adiposity in the adipocytes (fat cells), which could also involve muscles and liver.
- Two important clinical indications of the lipocentric concept:
- 1. A modest weight loss by calorie restriction and exercise can reduce insulin resistance and hyperglycemia, even without desired cosmetic effect. Overweight people should restrict calories to prevent disease, even if they don't achieve optimal weight loss.
2. For obese persons with poorly controlled insulin-resistant type 2 diabetes, U500 insulin makes it easier to administer the necessary dose to overpower insulin resistance.
- The treatment of hyperglycemia is important, and the best way is to eliminate the caloric surplus which will then reduce hyperinsulinemia and lipogenesis. This will decrease lipogenesis and ectopic lipid deposition, and the hyperglycemia will gradually decline. If not, use of anti-diabetic drugs and reduction of food intake reduce ectopic lipid load, or both can be utilized. The number one choice is to reduce caloric surplus, lose weight, which will then reduce diet-driven hyperinsulinemia and excessive lipogenesis, which is responsible for abnormal glucose metabolism. These lifestyle changes can reduce the risk of type 2 diabetes, especially being lean with weight control.
In a seven-year study in Finland, there was a 43% reduction in the relative risk of diabetes. (International Journal of Obesity.) Dr. Tuomilehto stated, "Improving weight and diet with exercise can postpone the onset of diabetes." 3
There was an increase in the rate of diabetics between 2005 and 2007 from 4.8 per thousand a decade earlier to 9.1 annually per thousand persons now (CDC and American Diabetes Association, www.diabetes.org). The American Diabetic Association relates the increase for type 2 diabetes to increased obesity. A decrease in obesity would reduce the risk of diabetes.
The glycemic index is a way of measuring how the body converts food to sugar. One in three persons over 75 develops AMD, the leading cause of blindness in older Americans, and this is a particular problem as Americans live longer, and the rate is expected to increase from 3.3 million Americans in 2009 to 5.5 million by 2020. (National Eye Institute reference.)
Reducing foods that increase the glycemic-index scale can reduce the risk for AMD. Switching from five slices of white bread to five slices of whole wheat bread is a good example. It has already been noted that high levels of vitamin E, beta-carotene, vitamin C and zinc may help reduce the risk of advanced AMD.
Low-glycemic diet may lower blood sugar in patients with diabetes, study suggests. According to a study published in of the Journal of the American Medical Association, "a diet of 'low-glycemic foods' -- such as beans, nuts, peas, lentils and pasta -- was superior to a high-cereal-fiber diet -- think pumpernickel, rye pita, quinoa, large flake oatmeal and oat bran -- when it comes to lowering blood sugar and other risk factors for heart disease in people with diabetes."4 For the study, "the low-glycemic-index dieters in the study ate plenty of legumes, peas, lentils, nuts, barley, oatmeal, pasta, and rice that were boiled briefly," This group "also ate low-glycemic-index breads, including pumpernickel, rye, and breads made with quinoa and flaxseed. The foods were also paired with an eye toward keeping the post-meal blood sugar spike low." The second "group of dieters ate more traditional carbohydrates including whole-grain breads and breakfast cereals, brown rice, and potatoes with skins on." Furthermore, "both groups of dieters limited saturated fats, trans fats, and white flour;" both groups "were told to avoid pancakes, muffins, doughnuts, white bread, bagels, rolls, cookies, cakes, popcorn, french fries, and chips;" and "both groups also ate five servings of vegetables and three servings of fruit a day, but the low-GI dieters avoided tropically grown fruits like mangos, bananas, and pineapple, which tend to have higher GI scores." Investigators found that "six months of a low glycemic index diet cut mean glycosylated hemoglobin levels by 0.5 percentage points (95 % CI 0.39 to 0.61), compared with a reduction of 0.18 percentage points on a high-cereal fiber diet (95 % CI 0.07 to 0.29) in [the] 210-patient randomized trial," Additionally, "the low glycemic index diet also showed more favorable effects on blood lipid profiles, including an increase in mean high-density lipoprotein levels of 1.7 mg/dL (95 % CI 0.8 to 2.6), compared with a slight decrease in patients on the high-cereal fiber diet (-0.2 mg/dL, 95 % CI -0.9 to 0.5)."
Note: There is evidence that drinking coffee is linked to a lower diabetic risk. American Journal of Epidemiology - 12,204 non-diabetic middle-aged men who drank four or more cups of coffee had a lower risk of type 2 diabetes. How coffee works on diabetes is unknown. An ingredient, magnesium or chlorogenic acid might help regulate blood sugar or making another metabolic change - increasing insulin sensitivity. Research also showed decaf was associated with an even greater risk reduction, more than 30%.5,6,7
There is a need for a more effective dietary strategy both for prevention and management of diabetes. Many anti-hyperglycemic drugs to improve glycemic control in type 2 diabetes are being used, to improve cardiovascular outcomes.
One strategy is to use a low-glycemic index diet to control diabetes, increase high-density lipoprotein cholesterol (HDL-C), and lower serum triglyceride and C-reactive protein, to reduce cardiovascular events.
Studies were done on the use of the alpha-glucosidase carbohydrate absorption inhibitor, Acarbose, which lowers the glycemic index diet by slowing the absorption of carbohydrates and reducing the progression to diabetes in high-risk individuals, hypertension and the risk of cardiovascular disease.
This was a study evaluating the effect of a low-glycemic index diet in patients with type 2 diabetes controlled with oral medications with HbA1C concentrations between 6.5 and 8.0%.
Overweight patients with diabetes appear more likely to achieve remission with weight-loss surgery. Preliminary research indicates that obese patients with type 2 diabetes who had gastric banding surgery lost more weight and had a higher likelihood of diabetes remission compared to patients who used conventional methods for weight loss and diabetes control". 8,9
Bariatric stomach surgery can help reduce chronic caloric surplus and lipid overload, and if hyperglycemia still persists despite diet restriction and weight loss, insulin may be required "as a last resort."
Of 60 patients, 73% with surgical treatment achieved a normal blood sugar compared to 13% in the conventional treatment group. Drastic weight loss in the surgery group - 10 times the weight loss of the traditional therapy group - was believed to lead to diabetic remission and improvement in blood sugar levels over a two-year period. A seven-year follow-up showed a 40% decreased mortality in bariatric patients versus the control group of severely obese subjects, who did not have weight loss surgery. This is believed to result in a decrease in both cancer and heart disease. Morbidly obese patients improved with diabetes, sleep apnea, hypertension, elevated cholesterol and heart disease versus a group who did not receive surgery.
The emotional eating problem does not decrease following surgery. It is hard to restrain the physical ability to consume food, which is helped by surgery, but does not help the emotional dependence on food. Psychological and supportive care can be helpful.10,11,12
Diabetes and Cancer
About 20 million Americans have diabetes mellitus (about 7% of the U.S. population). Some cancers (breast, colorectal, endometrial, liver, pancreas) occur more commonly in diabetics. The question is, is there increased cancer mortality in diabetics with cancer?
With the literature review, it appears diabetes is a risk factor for some cancers. This was a study trying to correlate pre-existing diabetes and all-cause mortality in cancer patients. The conclusion was that patients diagnosed with cancer, who had pre-existing diabetes, were at increased risk for long-term, all-cause mortality versus those without diabetes. Study suggests patients with both cancer and diabetes face increased mortality risk. A paper appearing in the Dec. 17 issue of the Journal of the American Medical Association reveals that "cancer patients who already have diabetes have a greater chance of dying of the disease than cancer patients who do not have the blood-sugar disorder." And, "if researchers can tease out the reason why, they might have an opportunity to reduce cancer deaths by focusing on diabetes-related health problems," says lead author Frederick Brancati, MD, of the Johns Hopkins Bloomberg School of Public Health.13 During the study, investigators "conducted a systematic review and meta-analysis of published clinical trials," finding "48 articles that evaluated the effect of pre-existing diabetes on cancer outcome, including 23 that could be combined in a meta-analysis," "The data indicated that "diabetes was significantly associated with increased long-term, all-cause mortality for: cancers of the endometrium, where the hazard ratio was 1.76; breast cancer, where the hazard ratio was 1.61; colorectal cancer, where the hazard ratio was 1.32." Furthermore, "diabetes was also associated with non-significant increases in mortality risk for prostate, gastric, hepatocellular, lung, and pancreatic cancer." "Researchers did offer several potential explanations for the association," including the theory "that a physiologic environment of hyperinsulinemia and hyperglycemia might cause greater tumor cell proliferation. A second possibility is that there may be differences in cancer treatment between patients with and without diabetes." The team also speculated that "patients with preexisting diabetes may have a poorer response to cancer therapies," and "individuals with preexisting diabetes might present with cancer at a more advanced stage because of suboptimal cancer screening practices." Lastly, "the diagnosis and treatment of cancer might distract both the patient and practitioner from the appropriate management of diabetes, such as controlling hyperglycemia, lipid levels, and blood pressure," the authors hypothesized.
Diabetes Mellitus among Cancer Survivors
Diabetes is an important comorbidity and can affect a cancer patient's survival.14 Elevated fasting glucose and increased abdominal adiposity have a three-fold increase in risk of cancer recurrence versus patients without these factors.15 This trial used mixed aerobic and strength training exercises to decrease insulin levels in breast cancer survivors. High insulin levels and C-peptide at the time of breast cancer diagnosis are associated with a poorer prognosis. In the Ligibel study, increased insulin levels were seen in sedentary individuals and were associated with an increased breast cancer recurrence and death.16
Vitamin D and Diabetes
Study published in the journal Diabetologia suggests vitamin D3 may help prevent type 1 diabetes in children. "Sun exposure and vitamin D levels may play a strong role in risk of type 1 diabetes in children." Cedric F. Garland, Dr.PH., of the University of California San Diego, and colleagues, found that children "living at or near the equator, where there is abundant sunshine, have low incidence rates of type 1 diabetes."17 But, "children who live in countries at higher latitudes, such as Canada, where there is less sunlight for much of the year, are far more likely to develop juvenile diabetes." The authors said that their findings lend "new support to the concept of a role of vitamin D in reducing risk of this disease."
"This is the first study, to our knowledge, to show that higher serum levels of vitamin D are associated with reduced incidence rates of type 1 diabetes worldwide." For the study, the researchers "analyzed type 1 diabetes incidence rates" worldwide. Based on their results, they "suggest[ed] that childhood type 1 diabetes may be preventable with a modest intake of vitamin D3 (1,000 IU/day), ideally with five to 10 minutes of sunlight around noontime, when good weather allows." But, Garland cautioned that "[i]nfants less than a year old should not be given more than 400 IU per day without consulting a doctor. Hats and dark glasses are a good idea to wear when in the sun at any age, and can be used if the child will tolerate them."
The authors "attempt[ed] to control for confounding factors such as the level of medical care," in the 51 regions where they examined type 1 diabetes rates. But, "[t]hey confirmed that incidence rates were generally highest in high latitude regions, independent of per capita health expenditures." For instance, in Finland, which has high per capita health expenditures, the study showed that "about 37 out of 100,000 boys under the age of 14 develop type 1 diabetes." Conversely, in Cuba, which has lower per capita health expenditures, "the rate is closer to two in 100,000."
Older Patients and Diabetes
Intense glucose control with a hemoglobin A1c level of less than 7% decreases the risk of multiple complications in patients with diabetes versus moderate glucose control with the hemoglobin A1c 7-9%.18 Their conclusion was for older diabetic patients, the presence of multiple comorbid illnesses and/or functional impairment is probably more important as a predictor of a limited life expectancy, and there appears to be diminishing expected benefits, which will be obtained for type 2 diabetics with intensive, tight glucose control. Age is another factor, and it is a balance, between the comorbid illnesses, functional impairment, and an intensive glucose control program.
Two diabetes drugs may double the risk of fractures in women, analysis suggests. "Two widely prescribed diabetes drugs, Avandia (rosiglitazone maleate) and Actos (pioglitazone hydrochloride), double the risk of fractures in women but not in men," according to a meta-analysis published in the online edition of the Canadian Medical Association Journal. Dr. Yoon Loke, clinical senior lecturer at the University of East Anglia, and colleagues, "evaluated 10 trials that included 13,715 diabetics taking Avandia, Actos, or neither drug."19 The researchers found that "when the data [was] analyzed by gender, five of the trials showed a significant increase in fracture risk among women (OR 2.23, 95 % CI 95 % CI 1.65 to 3.01 P<0.001) and none in men," The meta-analysis "was limited by the small amount of data available for analysis, which did not allow for separate assessment of each drug." Furthermore, "none of the studies analyzed was designed to prospectively evaluate fracture risk."
Diabetes is a common, chronic disease. It can lead to eye disease, kidney disease, and nerve damage, and is a risk factor for cardiovascular disease. Most people with diabetes are overweight and have type 2 diabetes. Although excellent control of blood sugar levels can decrease the risk of the above complications, prevention of this type of diabetes through lifelong diet modifications and exercise remains the best option for a healthy life.
A recent report by Oluf Pedersen and colleagues of the Steno Therapy Diabetes Center in Copenhagen suggests that intensive therapy may reduce risk of death in some patients with type 2 diabetes, "who are already showing signs of some kidney damage may be able to significantly lower their risk of death by treating multiple risk factors at once."20 They "randomly assigned 160 people with type 2 diabetes and persistent microalbuminuria (urinary protein) to receive either intensive management or standard therapy."
The study addressed tight glucose (sugar) regulation and the use of rennin-angiotensin system blockers regardless of blood pressure. Participants "in the intensive treatment group were also supposed to eat a low-fat diet, quit smoking, and get 30 minutes of exercise several times a week" and "also received low-dose aspirin and lipid-lowering agents, along with behavior modification." The researchers found that "there was an absolute 20% difference in the death rate compared to the conventional group."
Dr. Pedersen concluded, "It's not enough to just know your blood glucose, cholesterol, and blood pressure levels. You need to take action, and do something about your risk factor[s] early on, and stick with it."
A report from The Action to Control Cardiovascular Risk in Diabetes study "showed that an intensive program to lower blood sugar actually increased risk of death." According to John Buse, MD, vice chairman of the study's steering committee, "The intensity of what we did is done virtually nowhere on the planet," and it goes "far beyond what's common in clinical practice."21
Dr. Buse president of medicine and science at the American Diabetes Association advises diabetes patients to "get your blood pressure controlled, cholesterol controlled, and do a reasonable job on controlling your diabetes. Many factors, "not just blood sugar, "influence the overall health of patients with diabetes." You need to control blood pressure and cholesterol - and overall health.
- Jinan B. Saaddine, MD, MPH; Amanda A. Honeycutt, PhD; K. M. Venkat Narayan, MD, MBA; Xinzhi Zhang, MD, PhD; Ron Klein, MD, MPH; James P. Boyle, PhD Projection of Diabetic Retinopathy and Other Major Eye Diseases Among People With Diabetes Mellitus, Arch Ophthalmol, 2008;126(12):1740-1747.
- Holman RR, Paul SK, Bethel MA, Neil HA, Matthews DR, Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med. 2008 Oct 9;359(15):1565-76. Epub 2008 Sep 10.
- Lindström J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemiö K, Häamäläinen H, Härkönen P, Keinänen-Kiukaanniemi S, Laakso M, Louheranta A, Mannelin M, Paturi M, Sundvall J, Valle TT, Uusitupa M, Tuomilehto J; Finnish Diabetes Prevention Study Group, Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006 Nov 11;368(9548):1673-9.
- Jenkins DJ, Kendall CW, McKeown-Eyssen G, Josse RG, Silverberg J, Booth GL, Vidgen E, Josse AR, Nguyen TH, Corrigan S, Banach MS, Ares S, Mitchell S, Emam A, Augustin LS, Parker TL, Leiter LA, Effect of a low-glycemic index or a high-cereal fiber diet on type 2 diabetes: a randomized trial, JAMA 2008 Dec 17;300(23):2742-53.
- Paynter NP, Yeh HC, Voutilainen S, Schmidt MI, Heiss G, Folsom AR, Brancati FL, Kao WH. Coffee and sweetened beverage consumption and the risk of type 2 diabetes mellitus: the atherosclerosis risk in communities study. Am J Epidemiol. 2006 Dec 1;164(11):1075-84. Epub 2006 Sep 18.
- Rushakoff, RA, Goldfine,ID, Beccaria, LJ, Mathur, A, Brand, RJ, Liddle RA, Reduced postprandial cholecystokinin (CCK) secretion in patients with noninsulin-dependent diabetes mellitus: evidence for a role for CCK in regulating postprandial hyperglycemia J Clin Endocrinol Metab. 1993 Feb;76(2):489-93.
- van Dam, RM, PhD; Hu, FB, MD, PhD, Coffee Consumption and Risk of Type 2 Diabetes - A Systematic Review, JAMA, Vol. 294 No. 1, July 6, 2005
- Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M, Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled tria JAMA. 2008 Jan 23;299(3):316-23
- Unger RH Reinventing type 2 diabetes: pathogenesis, treatment, and prevention JAMA. 2008 Mar 12;299(10):1185-7.
- Mattar SG. Lifting the unbearable weight of morbid obesity. Ann Surg. 2008 Jan;247(1):28-9.
- Nguyen NT, Slone JA, Nguyen XM, Hartman JS, Hoyt DB. A Prospective Randomized Trial of Laparoscopic Gastric Bypass Versus Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity: Outcomes, Quality of Life, and Costs. Ann Surg. 2009 Aug 27
- Sjöström L, Gummesson A, Sjöström CD, Narbro K, Peltonen M, Wedel H, Bengtsson C, Bouchard C, Carlsson B, Dahlgren S, Jacobson P, Karason K, Karlsson J, Larsson B, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Carlsson LM; Swedish Obese Subjects Study. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol. 2009 Jul;10(7):653-62. Epub 2009 Jun 24
- Barone BB, Yeh HC, Snyder CF, Peairs KS, Stein KB, Derr RL, Wolff AC, Brancati FL, Long-term all-cause mortality in cancer patients with preexisting diabetes mellitus: a systematic review and meta-analysis. JAMA. 2008 Dec 17;300(23):2754-64.
- Stava CJ, Beck ML, Feng L, Lopez A, Busaidy N, Vassilopoulou-Sellin R, Diabetes mellitus among cancer survivors. J Cancer Surviv. 2007 Jun;1(2):108-15.
- Pollak, MN, Chapman, JW, Shepherd, L,Meng,D, Richardson, P, Wilson, C, Orme, B, Pritchard, KI, Insulin Resistance Estimated on Serum C-Peptide Levels Associated with Reduced Event-Free Survival for Postmenopausal Women, Journal of Clinical Oncology, 2006 ASCO Annual Meeting Proceedings (Post-Meeting Edition). Vol 24, No 18S (June 20 Supplement), 2006: 524
- Pasanisi P, Berrino F, De Petris M, Venturelli E, Mastroianni A, Panico S., Metabolic syndrome as a prognostic factor for breast cancer recurrences, Int J Cancer. 2006 Jul 1;119(1):236-8.
- Mohr SB, Garland CF, Gorham ED, Garland FC, The association between ultraviolet B irradiance, vitamin D status and incidence rates of type 1 diabetes in 51 regions worldwide Diabetologia, 2008 Aug;51(8):1391-8. Epub 2008 Jun 12
- Huang, ES, Zhang, Q, Gandra, N, Marshall H. Chin, MH, Meltzer,DO., The Effect of Comorbid Illness and Functional Status on the Expected Benefits of Intense Glucose Control in Older Patients with Type 2 Diabetes, Ann Intern Med, 2008; 149: 11-19.
- Loke YK, Singh S, Furberg CD., Long-term use of thiazolidinediones and fractures in type 2 diabetes: a meta-analysis. CMAJ. 2009 Jan 6;180(1):32-9. Epub 2008 Dec 10.
- Gaede P, Lund-Andersen H, Parving HH, Pedersen O, Effect of a multifactorial intervention on mortality in type 2 diabetes, Steno Diabetes Center, Copenhagen, Denmark, N Engl J Med. 2008 Feb 7;358(6):580-91.
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