Category Archives: Diabetes Complications

July 27, 2016 · 3:54 AM

Bariatric Surgery Reduces Microvascular Complications of Type 2 Diabetes

bariatric surgery, Steve Parker MD

Band Gastric Bypass Surgery (not the only type of gastric bypass): very successful at “curing” T2 diabetes if you survive the operation

Folks with T2 diabetes who undergo weight-loss surgery (bariatric surgery) often see a reversal or remission of their diabetes. The reversal doesn’t always last.

In either case, bariatric surgery does seem to reduce the risk if microvascular complications, namely retinopathy (eye disease), neuropathy (nerve pain or numbness), and nephropathy (kidney disease).

The conclusion of a recent study:

“Our results indicate that remission of type 2 diabetes after bariatric surgery confers benefits for risk of incident microvascular disease even if patients eventually experience a relapse of their type 2 diabetes. This provides support for a legacy effect of bariatric surgery, where even a transient period of surgically induced type 2 diabetes remission is associated with lower long-term microvascular disease risk.”

Source: Long-term Microvascular Disease Outcomes in Patients With Type 2 Diabetes After Bariatric Surgery: Evidence for the Legacy Effect of Surgery | Diabetes Care

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January 2, 2016 · 10:19 PM

What’s the Deal With Hypoglycemia Unawareness?

Some people with diabetes, particularly after having the condition for many years, lose the ability to detect hypoglycemia—low blood sugar—just by the way they feel. This “hypoglycemia unawareness” is obviously more dangerous than being able to detect and treat hypoglycemia early on. Blood sugar levels may continue to fall and reach a life-threatening degree. Hypoglycemia unawareness can be caused by impairment of the nervous system (autonomic neuropathy) or by beta blocker drugs prescribed for high blood pressure or heart disease. People with hypoglycemia unawareness need to check blood sugars more frequently, particularly if driving a car or operating dangerous machinery.

How Is Hypoglycemia Treated?

Folks who can indeed perceive signs or symptoms of hypoglycemia usually won’t notice them until their blood sugar is under 65 mg/dl (36 mmol/l).

If you have diabetes, your personal physician and other healthcare team members should teach you how to recognize and manage hypoglycemia. Immediate early stage treatment involves ingestion of glucose as the preferred treatment—15 to 20 grams. You can get glucose tablets or paste at your local pharmacy without a prescription. Other carbohydrates will also work: six fl oz (180 ml) sweetened fruit juice, 12 fl oz (360 ml) milk, four tsp (20 ml) table sugar mixed in water, four fl oz (120 ml) soda pop, candy, etc. Fifteen to 30 grams of glucose or other carbohydrate should do the trick. Hypoglycemic symptoms respond within 20 minutes.

If level of consciousness is diminished such that the person cannot safely swallow, he’ll need a glucagon injection. Non-medical people can be trained to give the injection under the skin or into a muscle. Ask your doctor if you’re at risk for severe hypoglycemia. If so, ask him for a prescription so you can get an emergency glucagon kit from a pharmacy.

Steve Parker, M.D.

low-carb mediterranean diet

Front cover of book

 

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January 21, 2015 · 8:38 AM

Elevated Fasting Blood Sugar Linked to Pancreatic Cancer

A recent meta-analysis found that elevated fasting blood glucose levels, even in the prediabetic range, are associated with higher risk of developing pancreatic cancer. This is important because you can take action today to lower your fasting blood sugar level, which may lower your risk of pancreatic cancer over the long-term. The researchers conclude that…

“Every 0.56 mmol/L [10 mg/dl] increase in fasting blood glucose is associated with a 14% increase in the rate of pancreatic cancer.”

In the developed world, your risk of getting an invasive cancer is roughly one in four. Pancreatic cancer is the most lethal. Surgery is the way to cure it, but at the time of diagnosis only two in 10 patients are candidates for surgery because the cancer has already spread. Pancreatic cancer is the fourth leading cause of cancer death in the USA and the fifth in the UK. Nevertheless, pancreas cancer is not terribly common; the US has 50,000 new cases annually. As a hospitalist, I run across one or two new cases of pancreas cancer every year.

We’ve known for years that type 2 diabetes is linked to pancreatic cancer, with diabetics having twice the risk of nondiabetics.

What if you have elevated fasting blood sugars? There’s no proof that reducing them to the normal range will reduce your risk of pancreatic cancer. But if it were me, that’s what I’d shoot for.

Other that type 2 diabetes and prediabetes, some other risk factors for pancreas cancer are:

  • heredity
  • smoking
  • sedentary lifestyle
  • body mass index over 30 (obesity in other words)

You can alter most of those risk factors. Why not get started now?

Steve Parker, M.D.

PS: If you’re not sure if your fasting blood sugar’s elevated, click here.

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December 5, 2014 · 3:20 PM

Breaking News! Obesity Can Cut Years Off Your Life

Are you tired of this stock photo yet?

Are you tired of this stock photo yet?

MedPageToday has the details. A quote:

In a computer modeling study, very obese men lost just over 8 years of life compared with normal-weight men, and very obese women lost as many as 6 years, Steven Grover, PhD, of McGill University, and colleagues reported online in the Lancet Diabetes and Endocrinology.

They also found that very obese men and women (defined as a body mass index [BMI] of 35 and higher) lost about 19 years of healthy life, defined as living free of chronic disease such as diabetes and cardiovascular disease.

Note that “very obese” in this context has a specific definition: body mass index 35 or higher. Calculate yours.

The number of life years lost to obesity and disease were highest for those who were very obese in young adulthood and presumably stayed obese for years. In other words, becoming very obese at age 60 is not as dangerous as at 25.

I first got interested in weight loss in the 1990s when I had an office-based primary care medical practice. It was obvious that many of the medical problems I was treating were related to years of obesity. Believe me, you’re much better off preventing those problems via diet and exercise.

Click for The Lancet study abstract.

Steve Parker, M.D.

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October 4, 2014 · 2:00 AM

Low-Fat Diet Loses to Mediterranean Diet in Heart Disease Prevention

The American Journal of Medicine has an article entitled “Diets to Prevent Coronary Heart Disease 1957- 2013: What Have We Learned?” The authors conclude:

The Mediterranean-style diet, with a focus on vegetables, fruit, fish, whole grains and olive oil, has proven to reduce cardiovascular events to a degree greater than low fat diets, and equal to or greater than the benefit observed in statin trials.

The only bone I’ll pick with that quote today is that folks with diabetes and prediabetes often have unacceptable blood sugar spikes when they eat whole grains. That’s one reason I designed the Low-Carb Mediterranean Diet.

Steve Parker, M.D.

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October 1, 2014 · 9:06 AM

New ADA Criteria for Diagnosis of Gestational Diabetes

You can't tell if she has gestational diabetes just by looking

You can’t tell if she has gestational diabetes just by looking

Gestational diabetes occurs in 5% of pregnancies in the U.S., affecting more than 240,000 births annually. Compared to caucasians, gestational diabetes mellitus (GDM) occurs more often in blacks, native Americans, Asians, and Latinos.

So What’s the Big Deal?

Numerous problems are associated with GDM, for both the mother and the baby:

  • dangerously high blood pressure (preeclampsia)
  • excessive amount of amniotic fluid (the baby in the uterus floats in this fluid)
  • delivery requiring an operation
  • early or premature delivery
  • death of the baby
  • birth trauma, such as broken bones or nerve injury
  • metabolic problems in the baby (low blood sugar, for example)
  • abnormally large baby (macrosomia, a major problem)

How Is Gestational Diabetes Diagnosed?

All pregnancies are characterized by some degree of insulin resistance and high insulin levels: they are necessary for the baby.  Nevertheless, healthy pregnant women run blood sugars 20% lower than when they are not pregnant.

Most women should undergo a screening test for gestational diabetes around the 24th to 28th week of pregnancy.  Screen earlier if undiagnosed type 2 diabetes is suspected or if risk factors for diabetes are present.  The American Diabetes Association (2014 guidelines) recommends either one of two screening tests.

  • “One-step test.” It’s a morning oral glucose tolerance test after at least eight hours of fasting. Fasting blood sugar is tested then he woman drinks 75 grams oral of glucose.  Blood sugar is tested again one and two hours later.  This blood sample is obtained by a needle in a vein, not by finger prick.  Gestational diabetes is diagnosed if any of the following apply: 1) fasting glucose is 92 mg/dl (5.1 mmol/l) or higher, 2) 0ne-hour level is 180 mg/dl (10.0 mmol/l) or higher, or 3) two-hour level is 153 mg/dl (8.5 mmol/l) or higher.
  • “Two-step test.” This is a nonfasting test with only one needle-stick. The woman drinks 50 grams of glucose; plasma glucose is tested one hour later. But if it’s over 140 mg/dl (10.0 mmol/l), that’s a flunk and a three-hour 100-gram oral glucose tolerance test in the fasting state must be done (step two). Gestational diabetes is present if the three-hour glucose is 140 mg/dl (7.8 mmol/l) or higher. Other experts say the diagnosis requires two or more of the following:
    • fasting blood sugar > 95 mg/dl (5.3 mmol/l)
    • 1-hour blood sugar > 180 mg/dl (10 mmol/l)
    • 2-hour blood sugar > 155 mg/dl (8.6 mmol/l)
    • 3-hour blood sugar > 140 mg/dl (7.8 mmol/l)

You’ll find that various expert panels have proposed different criteria for the diagnosis. The National Institutes of Health in the U.S. published their consensus statement in 2013.

There’s no need for the screening test if a random blood sugar is over 200 mg/dl (11.1 mmol/l) or a fasting sugar is over 126 mg/dl (7 mmol/l): those numbers already define diabetes, assuming they are confirmed with a second high reading.  A random blood sugar over 200 mg/dl (11.1 mmol/l) should probably be repeated for confirmation.  Gestational diabetes can be diagnosed at the first prenatal visit if fasting blood sugar is 92 or over mg/dl (5.1 mmol/l or over) but under 126 mg/dl (7 mmol/l), or if hemoglobin A1c at the first prenatal visit is 6.5% or greater.

Women with diabetes in the first trimester have overt diabetes, not gestational diabetes.

Steve Parker, M.D.

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May 17, 2014 · 3:28 AM

Supplemental Omega-3 Fats’ Effect on Heart Disease, Stroke, Cancer, and Death: No Relationship In a General Population

Salmon is one the the cold-water fatty fish loaded with omega-3 fatty acids

Salmon is one the the cold-water fatty fish loaded with omega-3 fatty acids

I’ve been sitting on this research report a few years, waiting until I had time to dig into it. That time never came. The full report is free online (thanks, British Medical Journal!). I scanned the full paper to learn that nearly all the studies in this meta-analysis used fish oil supplements, not the cold-water fatty fish the I recommend my patients eat twice a week.

Here’s the abstract:

Objective: To review systematically the evidence for an effect of long chain and shorter chain omega 3 fatty acids on total mortality, cardiovascular events, and cancer.

Data sources: Electronic databases searched to February 2002; authors contacted and bibliographies of randomised controlled trials (RCTs) checked to locate studies.

Review methods Review of RCTs of omega 3 intake for 3 6 months in adults (with or without risk factors for cardiovascular disease) with data on a relevant outcome. Cohort studies that estimated omega 3 intake and related this to clinical outcome during at least 6 months were also included. Application of inclusion criteria, data extraction, and quality assessments were performed independently in duplicate.

Results: Of 15 159 titles and abstracts assessed, 48 RCTs (36 913 participants) and 41 cohort studies were analysed. The trial results were inconsistent. The pooled estimate showed no strong evidence of reduced risk of total mortality (relative risk 0.87, 95% confidence interval 0.73 to 1.03) or combined cardiovascular events (0.95, 0.82 to 1.12) in participants taking additional omega 3 fats. The few studies at low risk of bias were more consistent, but they showed no effect of omega 3 on total mortality (0.98, 0.70 to 1.36) or cardiovascular events (1.09, 0.87 to 1.37). When data from the subgroup of studies of long chain omega 3 fats were analysed separately, total mortality (0.86, 0.70 to 1.04; 138 events) and cardiovascular events (0.93, 0.79 to 1.11) were not clearly reduced. Neither RCTs nor cohort studies suggested increased risk of cancer with a higher intake of omega 3 (trials: 1.07, 0.88 to 1.30; cohort studies: 1.02, 0.87 to 1.19), but clinically important harm could not be excluded.

Conclusion: Long chain and shorter chain omega 3 fats do not have a clear effect on total mortality, combined cardiovascular events, or cancer.

Reference: Hooper, Lee et al. Risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer: systematic review. BMJ  2006;332:752-760 (1 April), doi:10.1136/bmj.38755.366331.2F (published 24 March 2006).

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April 18, 2014 · 6:15 AM

Heart Attack and Amputation Rates Much Improved in Diabetics

MedPageToday has the details. This jibes with my experience over the last 30 years. A quote:

An analysis of national data found that rates of myocardial infarction (MI) in diabetic patients dropped about 68%, and amputation rates were halved between 1990 and 2010, Edward Gregg, PhD, of the CDC in Atlanta, and colleagues reported in the April 17 issue of the New England Journal of Medicine.

Strokes and deaths from hyperglycemic crisis also fell dramatically.

The number of adults reporting a diagnosis of diabetes more than tripled during the study period.

Steve Parker, M.D.

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December 19, 2013 · 4:32 PM

High Blood Sugar Raises Risk for Dementia, Even For Non-Diabetics

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“Let’s work on getting those blood sugars down, honey.”

On the heels of a report finding no association between Alzheimer’s disease and abnormal blood sugar metabolism, MedPageToday features an new study linking high blood sugars to future development of dementia. And diabetics with sugar levels higher than other diabetics were more prone to develop dementia.

Some of you have already noted that not all cases of dementia are Alzheimer’s dementia. But Alzheimer’s accounts for a solid majority of dementia cases, about eight in 10 cases.

Some quotes from MedPageToday:

During a median follow-up of 6.8 years, 524 participants [of the 2,000 total] developed dementia, consisting of 74 with diabetes and 450 without. Patients without diabetes and who developed dementia had significantly higher average glucose levels in the 5 years before diagnosis of dementia (P=0.01). The difference translated into a hazard ratio of 1.18 (95% CI 1.04-1.33).

…

Among the patients with diabetes, glucose levels averaged 190 mg/dL in those who developed dementia versus 160 mg/dL in those who did not. The difference represented a 40% increase in the hazard for dementia (HR 1.40, 95% CI 1.12-1.76).

—Steve Parker, M.D.

Reference: Crane PK et al. “Glucose Levels and Risk of Dementia” N Engl J Med 2013; 369: 540-548.

Reminder: Conquer Diabetes and Prediabetes is now available on Kindle.

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September 25, 2013 · 11:59 PM

Longevity of Type 1 Diabetics Much Improved, But Still Far From Ideal

When I started my medical career three decades ago, it was uncommon to see a type 1 diabetic exceed 60 years of age. Thank God that has been changing for the better. A recent Scottish study found life expectancy in type 1 diabetics, compared to the general population, was 11 years shorter for men and 14 years shorter for women. In 1975, the gap was 27 years. One of the investigators was quoted by the article at MedPageToday:

“There is absolutely no doubt that glucose control is important for long-term outcomes in people with type 1 diabetes.”

From the Framingham Heart Study: Compared to those without diabetes, women and men with diabetes at age 50 died 7 or 8 years earlier, on average. This study population was a mix of type 2 and type 2 diabetes, with type 2 predominating, I’m sure.

Steve Parker, M.D.

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