Category Archives: Diabetes Mellitus

A Follow-Up

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I do have one follow-up on an earlier entry about a young man with diabetes who ended up being diagnosed with celiac disease. As with any medical diagnosis, one cannot be certain that the diagnosis is correct without showing that the treatment has improved things (unless there is no effective treatment for the condition). In this case, the young man, was started on a gluten-free diet in mid-December 2007. By his return clinic visit mid-February 2008, he had gained about 30 pounds! Clearly, celiac disease was the reason for his weight loss. In addition, his diabetes blood sugar control improved (hemoglobin A1c fell from 9% to about 8%, reflecting a large improvement in average blood sugar levels).

I was a bit nervous about the fact that we had initiated treatment with the gluten-free diet before the patient saw the gastroenterologist- gi docs traditionally like to do small intestine biopsies to confirm the diagnosis of celiac disease before recommending a gluten-free diet. In this instance, the gi doc felt that the biopsy would not be useful as the patient was already on a gluten-free diet but that the response to treatment clearly confirmed the diagnosis (remember that the blood tests were strongly positive for celiac disease). So, the gi doc and I are still friends (at least I think so).

Curing Type 2 Diabetes With Bariatric Surgery?

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I tried really hard to ignore the front page article in the New York Times on Wednesday, January 23, 2008, entitled “Diabetes Study Favors Surgery to Treat Obese,” and written by Denise Grady. And, I was doing well until this morning (Sunday, January 27, 2008) despite e-mails this week from patients of mine wondering if they should get gastric banding surgery, when I saw the following headline in the Columbia Daily Tribune: “Diabetes Cure Linked To Surgery”. I now feel an intense need to respond.

Background

Those of you have read my earlier postings about obesity and the links with type 2 diabetes already know that for most people, getting type 2 diabetes takes both obesity and the genes for type 2 diabetes- it’s opportunity and genetics at their best (or worst). Type 2 diabetes is, for most people a combination of insulin deficiency and insulin resistance. Obesity causes insulin resistance and this is often enough to “tip the balance” leading to expression of the diabetes, i.e., high blood sugar levels. We have known for many, many years that early in the course of type 2 diabetes, losing weight, no matter how it is done, often leads to remission of the diabetes, which may persist long-term, but only if the weight is not regained. We even know from an excellent study called the Diabetes Prevention Trial (or “DPP” as it is widlely known) that treating obese people who have mildly abnormal blood sugar levels with diet and exercise that leads to weight loss, can greatly decrease the rate at which such people develop full-blown diabetes. Are you with me so far?

Bariatric Surgery For Obesity/Diabetes

As I discussed in earlier postings, bariatric surgery (bariatric is from the Greek work “baros,” meaning weight) is a well-accepted approach to treating severe forms of obesity that are unresponsive to medical therapies (e.g, diet, exercise). Despite the high costs and complications, for people with severe obesity, the complications of the obesity often make the surgery worthwhile. There are a number of studies worldwide that document the long-term benefits from bariatric surgery in selected patients. So now we have a report published in the Journal of the American Medical Association (JAMA) on January 23, 2008 suggesting that bariatric surgery might be the way to go in curing type 2 diabetes in its early stages.

What Did The Article Show?

The study was performed by a research team at Monash University in Melbourne, Australia. The lead author was John Dixon. Dr. Dixon and colleagues studied 60 patients with recently-diagnosed type 2 diabetes who were obese (BMIs 30-40). The investigators randomly assigned patients to either bariatric surgery (with a gastric banding procedure) or traditional treatment for the diabetes (diet, exercise, medications, etc.). They found that after 2 years, the surgery group had complete remission of the diabetes in 73% vs. only 13% in the non-surgery treatment group. The authors concluded that bariatric surgery was an effective alternative to the usual approach to treating type 2 diabetes. The authors predicted that bariatric surgery would be used more and more in the future to treat diabetes.

Is This News Or No News?

There is a National Public Radio show called “Wait, Wait Don’t Tell Me,” which is basically a quiz show on current events. In one segment of the show the host asks the guest panel members to decide if a piece of recent news is, in fact news or no news (i.e., a big deal or nothing exciting). So, let’s pretend I am on that guest panel and the host asks if the bariatric surgery study summarized above is news or no news. What would I say? I would say “no news.” Why? First, I would point out that the surgery, not surprisingly, was associated with striking weight loss compared to the non-surgery group. No duh. I would also point out that the study was very short-term- two years total, far to short to really assess the long-term benefit of a surgical procedure that costs $15,000-$25,000 in the U.S. For example, in 10 years, how many of the surgical group patients have diabetes compared to the non-surgical group patients? How many of the surgical patients had developed complications from their surgeries? You get my drift? This small, short-term study should not be used as the basis for moving to bariatric surgery as the method of choice for treating diabetes in people with mild degrees of obesity (BMIs 30-35%, like a large percentage of those in the U.S. who do not have diabetes (at least not yet). Maybe someday we will need to accept the fact that surgery is the best way to treat all obesity, with or without diabetes. We are a long way from that someday.
The New York Times article was well written and explored the various issues I have raised. The article in my local newspaper was scary. The subject of the article was a local bariatric surgeon who is clearly hoping to greatly increase the number of bariatric surgery procedures he performs in people with type 2 diabetes. I would suggest that he go slow and curb his enthusiasm until we have much more data. Of course, he may find that many insurers, including Medicare, will not jump at the chance to help out the rapidly growing number of bariatric surgeons in the U.S.

A Plea

This is as much about obesity as it is about diabetes. I hope we have not given up on the possibility of controlling our national passions for food and inactivity through means other than surgery. I like surgeons and some of them are close friends of mine but I do not like the idea of surrendering the management of obesity/diabetes to the scalpel just yet.

Weight Loss in an 18 Year Old Male with Type 1 Diabetes

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I apologize for not having an entry for about a month- a busy time with the holidays. Best wishes to all for 2008. I want to start out the new year with a case scenario. I promise it won’t be as esoteric as one of Dr. House’s cases (for those of you who don’t watch TV, Dr. House is a rather unconventional medical sleuth).

Case History

The patient is an 18 year old white male named Chad with a history of type 1 diabetes diagnosed at age 10 years. He had generally done well with the diabetes over the years; hemoglobin A1c values had been consistently in the 7-7.5% range (hemoglobin A1c is a blood test that can provide an index of the average blood glucose over the previous 3-4 months). That’s pretty good for a teenager. The patient saw me for a routine checkup in September 2007. Things seemed fine except that I noted a 5 lb. weight loss from the previous visit. There was no change in diet or activity that might explain the weight loss. I suggested that the patient monitor his weight and notify me if he lost as much as another 5 lbs. I scheduled a follow-up clinic visit for December 2007, sooner than I would have normally done so.

Note: Since the patient seemed quite healthy based on my medical history and physical examination, I elected to carry out no special studies at the time of the visit. Some physicians might have done some detective work at that time but I was comfortable to wait and watch.

Two Months Later

I saw Chad for his scheduled follow-up visit in mid-December. He had not contacted me in the interim (I encourage patients to contact me by e-mail whenever they have questions or need something done such as a prescription refill- it works very well and even in my mostly rural state of Missouri, about 90% of families have internet access). The medical history was more or less unchanged except for, perhaps, somewhat less well controlled diabetes. Again, there was no history of anything of concern; specifically, no fatigue, no gastrointestinal symptoms, no change in appetite, no history of drug or alcohol use. The physical examination was unremarkable except for another 7 lbs. weight loss. Now the patient was beginning to look a bit underweight. I was puzzled and concerned.

The Differential Diagnosis

Now it was a question of getting serious about finding out what the problem might be. Eighteen year old males do not lose substantial amounts of weight for no reason. I first decided not to “accept” as fact my medical history. Thus I felt a “fresh” look at the problem was necessary. I first considered if the weight loss was somehow related to the diabetes. Teenage girls with diabetes all know that skipping some of their insulin injections (or turning off their insulin pumps) is the quickest and easiest way to trim down- high blood glucose levels result in large glucose losses in the urine. Every gram of glucose lost is 4 calories lost. It’s not a healthy way to lose weight but it happens. Anyway, I was satisfied that Chad’s weight loss was not from poor diabetes control (a clue would have been the presence of ketone bodies, fat breakdown products, in his urine- urine ketone tests were consistently negative). Next, I wondered about disorders associated with diabetes that might be responsible for the weight loss. Type 1 diabetes is an autoimmune disease and certain other autoimmune diseases are more common in people with type 1 diabetes than in the general population. Chronic lymphocytic thyroiditis causing hypothyroidism is the most common associated autoimmune disorder but I couldn’t have accounted for the weight loss. Hyperthyroidism from Graves Disease is another autoimmune disease slightly more common in people with diabetes than in the general population and this disorder could cause weight loss from an increased metabolic rate. Against the diagnosis was the absence of an enlarged thyroid gland, normal pulse and blood pressure, and absolutely no history of anxiety, poor sleeping, or other typical hyperthyroidism signs and symptoms. Finally I thought about celiac disease, an autoimmune disease of the small bowel caused by intolerance to gluten, a major component of wheat. Celiac disease is currently “in vogue” and recent studies have documented that it is much more common in people with diabetes and in the general population than was previously known; studies show that the prevalence of celiac disease in the general population ranges from about 0.1-1% depending on the study population. The disorder is particularly common in people with northern European backgrounds- Finland has a prevalence of 1-2%. In people with type 1 diabetes, the prevalence is 2-3 fold higher than in the general population but it varies widely depending on the criteria for diagnosis and the characterisitcs of the patient population studied. Patients with celiac disease may have no signs or symptoms pointing to the diagnosis, but a variety of gastrointestinal symptoms are common. Weight loss on the basis of decreased appetite and/or malabsorption is fairly common (remember, Chad had no gastrointestinal symptoms).
One study from Italy published several years ago ( Cerutti et. al., Diabetes Care 2004;27:1294-98) followed 4322 children with type 1 diabetes ages 4-11 years. The investigators found a prevalence of biopsy-proven celiac disease in 6.8% of the children. Risks for celiac disease were increased 3-fold if the diabetes was diagnosed before age 4 years. In 90% of cases, the diabetes was diagnosed prior to the diagnosis of celiac disease.
Back to the detective work- I next considered systemic disorders- medical conditions that could cause weight loss, particularly those without obvious signs and/or symptoms. Thus I considered, inflammatory and infectious conditions (e.g., regional enteritis, tuberculosis, AIDS, other chronic infectious processes); I considered neoplasia (e.g, lymphoma); I considered illicit drug use; I considered an eating disorder (e.g., anorexia nervosa); I considered a chronic anemia- as a primary problem or secondary to another diagnosis.

Moving from Differential Diagnosis to Diagnosis

Next, I needed to take my differential diagnosis and then order appropriate laboratory tests. This is the tricky part. Should I order every imaginable test, just a few, or do one at a time, waiting for results from one before I move to the next? Doing tests one at a time would not have been very practical here- it would have been the least expensive approach but one with the likely possibility of many, many needle sticks and return visits over several weeks. I elected to focus on the most important diagnoses and ordered the following tests: a blood count, blood inflammation tests (erythrocyte sedimentation rate and c-reactive protein) blood chemistries including tests of liver function, a drug screen, HIV testing, thyroid function testing, a chest x-ray, and a celiac test panel (this includes several tests carried out at the same time). So it was one blood stick and one chest x-ray.

Test Results

I should mention that I discussed with Chad why I ordered the tests that I did, including the drug screen and the HIV tests (he readily gave permission for me to order those tests). Next it was time to wait. The results started to come in and one by one they were all completely normal until I was waiting on only the celiac test panel. So he didn’t have a drug problem, AIDS, a hidden infection, hyperthyroidism, etc. What could it be?

Finally, after a week or so the celiac panel came back wildly positive for celiac disease. We had a diagnosis and one that could explain his weight loss. Why he had no gastrointestinal symptoms (other than weight loss), I don’t know. It is interesting that the simple celiac antibody tests (anti-gliadin IgA and IgG) were normal; the more specific anti-endomysial IgA was positive as was the very specific anti-human tissue transglutaminase test (>100 U/ml with normal < 4 U/ml).

The Next Step

So, we had a diagnosis and the next step was referral to a gastrointestinal specialist for maybe a small bowel biopsy and certainly a gluten-free diet. If the diagnosis is correct (with respect to the reason for his weight loss), Chad will begin gaining weight on the gluten-free diet. This last step in diagnosis is important. We want to be certain we have identified the cause of Chad’s weight loss.

Note: Some would argue that we should have screened Chad for celiac disease even before he had any weight loss, given the increased prevalence of the disorder in patients with type 1 diabetes. I have smart colleagues who screen all patient with type 1 diabetes for celiac disease and other equally smart ones who do not. Celiac panels are very expensive and usually “negative.” I would generally screen all patient with type 1 diabetes under age 5 years for celiac disease but not older patients unless there are some signs or symptoms suggesting the diagnosis. I do recommend autoimmune thyroid disease screening for all patients with type 1 diabetes since the prevalence of thyroid disease is 30-40% in patients with type 1 diabetes, the testing is relatively inexpensive, and most patients who will ever develop autoimmune thyroid disease, have “positive” thyroid antibodies at the time they are diagnosed with the diabetes. Maybe, I’ll change my mind about all this next year? That’s clinical medicine- still lots of room for “clinical judgment.”

IS There Really a “Crisis” in U.S. Health Care: Chicken Little vs The Optimists?

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The “Group”
For quite a number of years now, I have been a member of a group composed of University of Misouri-Columbia professors. The group (which is also officially known as “The Group”), meets once a month during the academic year to hear a reasonably scholarly presentation from one of our members about whatever they wish. Invariably, presenters discuss topics related to their academic disciplines. As a physician (one of two in the group), I am expected to enlighten the attendees about something medical. Last spring, I gave a talk about the obesity epidemic and last week I spoke about type 2 diabetes, a logical extension of the talk about obesity.

My Presentation

I started out talking about what diabetes is (you already know that it’s really a group of medical disorders with three things in common- insulin deficiency, hyperglycemia, and risks for serious vascular complications). Type 2 diabetes, which used to be called maturity-onset diabetes and more recently, non-insulin-dependent diabetes (NIDDM), is the most common form of diabetes, affecting about 9.5% of the U.S. population. About 20% of people over 60 years of age have type 2 diabetes. Treating the condition accounts for a large chunk of of the money spent on health care in the U.S. (at least 35% of all Medicare expenditures!). Anyway, I was moving along through all the background information and got to the part where I stated that data show that as many as 90% of people in the U.S. with type 2 diabetes are not achieving recommended care goals, when th presentation got seriously derailed; the distinguished professors wanted to focus on how things could possibly be so bad in the richest country in the world, with the best high-tech mecical care, and which spends (by far) more than any other country in the world on health care?

Why are so many people with diabetes not achieving recommended care goals and what are the consequences?

It is much easier to address the consequences of of poor diabetes care than why it is happening. What makes diabetes serious is not the major inconvenience of the currently recommended treatment plans, but the complications that develop in so many of the patients. In fact, most of the costs of treating diabetes are for treating the complications (e.g., kidney failure, heart disease, nerve disease, peripheral vascular disease, limb amputations), all of which are preventable with currently available therapies.

The “why” part is more complicated and I will only touch on what I told my professor friends last week. First of all, U.S. health care is definitely not what it could and should be, particularly given how much money we spend on it. The U.S. is far down the list of economically developed nations in the quality of health care (as measured by longevity, infant mortality rates, etc,). The reasons include (in no order of relative importance) the following: more than 40 million people without health insurance and many more with inadequate insurance; inadequate numbers of well-trained health care providers, particularly in non-urban areas; high costs which are rising rapidly- many people cannot afford ther prescribed medications, even with insurance/Mediacare. I could go on and on and it was a bit uncomfortable presenting this information to my professor friends who seemed truly shocked by the discussion.

Where to go from here?

When it came to the part about what to do about the problems, I didn’t really have any convincing answers for my professor friends, at least in terms of a comprehensive “solution.” I have been giving this quite a bit of thought lately and will come back to health care issues soon, in future entries. Clearly, it doesn’t matter how smart a doctor is and how many great medications he has in his therapeutic armamentarium, if a patient with diabetes can’t afford the clinic visit or the medications or can’t even get an appointment for 6-7 months even with good insurance coverage, we are in trouble. We are in trouble.

More About Inhaled Insulin

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I was interested to read an article in yesterday’s (Friday, November 16, 2007) Business section of the New York Times about a new inhaled insulin preparation which is being tested. The article was written by Andrew Pollack. You may recall that Pfizer recently announced that it was dumping its inhaled insulin, Exubera, apparently because of poor sales. Alfred E. Mann, the founder of MannKind Corporation is betting his personal fortune that his new inhaled insulin will be a big hit.

Is Mr. Mann’s inhaled insulin going to be a success?

If I were an investor, I probably wouldn’t rush out and buy lots of stock in MannKind Corporation (I don’t even know if it is publically traded) but I’m glad we may have an inhaled insulin available; it’s just another treatment tool that may be useful for some patients. As I discussed in an earlier entry, I was not very impressed with Exubera when our group studied its use in teenagers with diabetes; the patients learned that just taking the shots (or using an insulin pump) was quite a bit easier (for teens, “easier” means quicker) than messing with the inhaled stuff. Unfortunately, unless one takes an inhalation every 2-3 hours around-the-clock, it is still necessary to take at least one daily injection with a long-acting insulin. The article says that Mr. Mann feels that “his” inhaled insulin will be a success because it acts quicker than any of the current fast-acting insulins, including Exubera, and that the delivery device is much smaller than the Exubera device. Well, we’ll see. I am not “sold” on the idea that quicker action (both on and off) is necessarily a big benefit since it may make it trickier to deal with the long-acting insulin needs. Also, the theory that post-meal high blood sugars are bad for a person even if overall blood sugar control is good, has never been proven despite the many drugs on the market that give their raison d’etre that the drugs are an aid (generally a very very expensive aid) in controlling post-meal highs. I’m not sold on that idea, but who knows?
Given how long it took Pfizer to clear the FDA safetly hurdles with Exubera, it may be quite a while before Mr. Mann’s insulin hits the streets. As I mentioned, the more treatment options the better. I would like to see some companies make decisions about patient care products not only on the “bottom line.”

Less Exuberance About Exubera: Pfiser To Stop Selling Its Inhaled Insulin

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There was a report in today’s New York Times Busines Day section (October 19, 2007) entitled “Pfiser to Stop Selling Diabetes Drug” written by Alex Berenson. Apparently, Pfiser announced yesterday that it would discontinue production of its inhaled insulin preparation Exubera. Sales of the “breakthrough” drug (that’s how it was hyped early on) were extraordinarily poor and one can only assume Pfiser felt it had a “dog” in its drug arsenal.

Why Exubera didn’t sell

Our research group at the University of Missouri participated in Pfiser studies of the drug tha led to its eventual FDA approval last year. We treated 8 teenagers with the drug for about 3 years. We found that the inhaled insulin worked about as well as injected insulin but were a bit surprised to find that our study patients were not all that excited about using an insulin inhaler 3-5 times a day instead of taking shots as many times a day. The inhaler was large and clumsy to use (certainly not “cool” to a teenager) and took much more time than just taking the insulin by injection. In adition, since the inhaled insulin was vey short-acting, all patients needed to take 1-2 injections of a long-acting insulin every day. So, they were still “stuck” taking shots even with the inhaled insulin. At the end of the study, based on our experience, we thought the drug, although effective and likely safe (there have been some ongoing concerns about long-term pulmonary effects), would not be a big seller. It did not help that FDA approval and subsequent availability of the drug were delayed at least 3-4 years after the studies were completed. It also hurt that the drug was not approved for patient under 18 years of age, very expensive, and not covered by many insurers.

What’s next?

I know that several other drug makers are currently planning to indroduce their own versions of inhaled insulin. I wounder if they will rethink their plans? I do hope at least one drug maker will offer inhaled insulin even if it is not a blockbuster; there are some patients who would benefit from the drug. For example, we often treat patients with type 1 diabetes with a single daily injection of a very long-acting insulin and injections of short-acting insulin with meals and snacks. Some patients really dislike the injections but are willing to take the long-acting shot and shots with each meal but they “fight” more shots with snacks- we encourage that such patients focus on 3 main meals and skip the snacks, except maybe with exercise. For such patients, inhaled insulin might be just the ticket if they really want a snack and still maintain blood sugar levels in line.

Probably more than anything, failure of the Pfiser inhaled insulin to make a big splash supports the notion that it’s not really the shots that people with diabetes dread most but it’s the whole difficult routine that is so hard to deal with.

What Should People With Diabetes Know?

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Background

In my last post, I ranted and raved about an article in the New York Times that tried to document how little information people with diabetes (and maybe their doctors?) have about their condition. In all the excitement, I neglected to outline what I think people with diabetes should know about their diabetes.

Summary of diabetes complications

We can divide diabetes complications into 2 major categories, short-term, and long-term. The short-term problems include hypoglycemia (low blood sugar levels) and keto-acidosis, a condition that mostly affects people with type 1 diabetes and is the result of severe insulin deficiency. This most often occurs in newly-diagnosed cases and in established cases with acute illnesses or other stresses that increase insulin requirements or with poor adherence to the care plan (e.g., missed insulin doses).

The second category, and the one I want to emphasize here includes chronic complications that are specific to diabetes- eye, kidney, and nerve diseases, and those that can also occur in people without diabetes but are more frequent in people with diabetes. These include heart disease, stroke, and peripheral vascular diseases.

Preventing diabetes chronic complications

As I have discussed in an earlier posting, we now understand quite a bit about diabetes complications including how to prevent them. That’s the good news. The bad news is that diabetes chronic complications still occur frequently. Why is that? In my opinion the answer is not a simple one but includes societal barriers to optimal health care (e.g., no insurance, poor insurance, insufficient skilled health-care providers) and poor education of our health-care providers and patients with diabetes. In addition, doing well with diabetes is hard work and even with all the knowledge necessary to do well, it still takes quite an effort to be successful.

A check-list of basic diabetes care requirements

If all people with diabetes had just the most basic of care in monitoring for diabetes complications, we could achieve dramatic improvements in outcomes. This would be nice for the person with diabetes and their loved ones, and for the society which would save big bucks. Experts could disagree with my choices but I can handle the criticism.

1. 2X/year- Medical check-up by a physician or other health-care provider who is up-to-date on managing diabetes. The check-up should include examination of the weight, blood pressure, eyes, and feet. Cardiovascular assessment should include detailed history and examination of the heart and peripheral pulses. Laboratory testing should include hemoglobin A1c testing (a way of assessing blood sugar levels during the previous 2-3 months)

2. 1X/yr- dilated eye examination

3. 1X/yr- kidney protein test (called microalbumin). If + protein, measure serum creatinine

4. 1X/2yr- fasting lipid profile (triglycerides, LDL- and HDL-cholesterol and total cholesterol (more frequently if being treated with lipid-lowering agents)

5. ECG and/or other cardiac testing- frequency depends on clinical situation and risk factors (e.g., hypertension, pooly-controlled blood sugars long-term, hyperlipidemia, previous heart attack, angina, stroke)

That’s the list. It’s not very complicated but obviously many people with diabetes do not get these very basic assessments as needed. Of course, just doing the tests is not enough. People with diabetes and their health-care providers need to understand what the test results mean and what to do about the infomation. Once a person is diagnosed as having diabetes, it should be virtually automatic that we teach the patient what they need to know and set up the monitoring plan. Remember, we really do know how to prevent diabetes conmplications.

Alota Gina Kolata: Should Ms. Kolata Do Her Homework Better In Reporting Diabetes News?

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Background

Today there were several articles in the New York Times (Monday, August 20, 2007) that had to do with treatment of diabetes in the U.S. Gina Kolata authored 3 of the articles, including one on the front page of the newspaper entitled “Looking Past Blood Sugar To Survive With Diabetes.” The gist of the articles was to emphasize in fairly dramatic fashion that patients with diabetes need to be concerned about complication risk factors beyond blood sugar levels. Ms. Kolata profiled Dave Smith, a 43-year-old pastor from Minnesota who was diagnosed with type 2 diabetes about 9 years ago. Apparently, Pastor Smith had a heart attack last October and was surprised to learn that diabetes is a well-known risk factor for heart disease. The article went on to document how poorly people, and presumably their health-care providers, understand diabetes complications risk factors.

What’s my gripe?

Ms. Kolata did interview a number of very smart diabetes specialists all of whom addressed the issue of diabetes complications risk factors beyond blood sugar levels (mostly blood lipid levels and blood pressure levels). So what’s my problem? Answer: scientists have known about these risk factors for quite some time and the fact that so many people apparently are clueless about them is disturbing. Is it patients with diabetes who have been taught about these risks but have ignored or forgotten them? Is it physicians who have never been taught about these risks or who have ignored or forgotten them? Is it a health-care system that creates barriers to optimal diabetes care?

What can we learn from Kaiser-Permanente?

Kaiser-Permanente is a large HMO which years ago learned that comprehensive care of people with chronic diseases was good for business and good for patients. They have devoted considerable resources to managing certain chronic diseases including cancer, heart disease, and diabetes. I do not know all the details but their outcomes data for diabetes are dramatically better than the national average. I can assure you that the Kaiser care-givers are well-aware that diabetes complications are strongly related to blood sugars, lipids (e.g., cholesterol levels), and blood pressure and do their best to decrease risks. So what’s wrong with the rest of us? Is it our lousy health-care delivery system? I don’t know the answer but I would have liked Ms. Kolata to have focused on the failures of our health-care delivery system. We do how to prevent diabetes complications, including heart disease. There is no new medical news here. Clearly, we need to do better. I am skeptical that we can achieve meaningful gains unless we invest in major changes to our health-care delivery system. Certainly the people at Kaiser have taught us that.

Last but not least

In ending this little critique I want to be certain that readers of the New York Times pieces today are not misled in thinking that blood sugar levels are not all that important risk predictors for diabetes complications. Nothing is further from the truth. It is true that the Diabetes Control and Complications Trial (DCCT) follow-up data did not show for many years (2006) that blood sugar levels were important risk factors for cardiovascular disease; links between blood sugar levels and eye, kidney, and nerve disease were shown in 1993. The fact that it took a long time for the data to achieve statistical significance was to a great extent related to the fact that patients at onset of the study in 1983 were relatively young (13-39 years of age), had diabetes of short duration, and were free from heart disease and hypertension. As noted in one of Ms. Kolata’s articles, the links between hypertension and lipid abnormalities and heart disease in patients with type 2 diabetes were established in 1998 with publication of the United Kingdom Prospective Diabetes Study (UKPDS).

So, it is now well-established that blood sugar control, lipids, and blood pressure are the key risk factors for complications in patients with either type 1 or type 2 diabetes. The good news is that these risk factors can all be treated, thereby greatly diminishing risks for development of these serious complications. As I recall it is 2007, and in my opinion, any physician who does not know this information should not be caring for people with diabetes.

I’m feeling a little guilty.  Maybe I should not have been so critical of Ms. Kolata’s articles.  After all she did document nicely our rather astonishingly poor approach to managing diabetes in the U.S.  I only wish she would have put much more emphasis on what we already know about managing diabetes and raising questions about why we are doing such a poor job in caring for people with diabetes.l

Type 1 Diabetes Mellitus and Intensive Exercise

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In today’s New York Times, there is an article entitled “Diabetic and Determined” written by Abby Ellin (New York Times. Thursday July 26, 2007, p E1). The article is all about type 1 diabetes and “ultra-athletes.” The basic message is that having type 1 diabetes shouldn’t keep a person from being an ultra-athlete if that’s what they want to do. I would agree and I was a bit surprised by the article as I thought this subject a non-issue in 2007. I guess I was wrong?

The effects of exercise on blood glucose

We will start with the assumptions that a person with type 1 diabetes can do any physical activities that a person without diabetes can do and at as as high a level of performance. This has been demonstrated many times in the laboratory and “on the field.” But, to achieve optimal performance, a person with diabetes must learn how to keep his blood glucose level in a reasonable range throughout the activity. This can be quite a challenge and requires much “trial and error” in figuring out what to do about the insulin dosing and caloric intake.

When a person exercises, the metabolic rate increases in proportion to the intensity and or duration of the exercise. This requires enegy which comes from stored carbohydrates, fats, and proteins. Initially, the major share of the stored energy comes from glucose in the blood stream. Unfortunately, there is only a very small amount of glucose in the blood and hypoglycemia (low blood glucose) would develop quickly unless the body could match, molecule for molecule, production of glucose to equal that used up for energy. Initially, that glucose comes from stored glucose in the form of glycogen (long chains of glucose molecules) in the liver and in muscle. As the exercise continues, the body converts stored fats and proteins into energy to fuel the exercising msucles while leaving enough to maintain the blood glucose level in a normal range (proteins can be converted into glucose through a process called gluconeogenesis). This is quite a feat and involves many hormonal and neuronal mechanisms. The key to all of these adaptations is insulin. With exercise and increased glucose utilization, the body decreases insulin secretion which allows stored glucose and other nutrients to be used for energy and to maintain the blood glucose level.

If I go out and jog 10 kilometers (6.2 miles), my blood glucose level will be well maintained or even may go up a bit and I don’t even need to think about it- my body has figured out just how much to lower my insulin level to allow the required amounts of glucose to be made available for the exercise while maintaining my blood glucose level. But, what if I had diabetes and took insulin injections or used an insulin pump and couldn’t count on my body to figure things out? That’s the challenge for a person with type 1 diabetes who wants to exercise.

Getting down to specifics

Today, I do not want to go into great detail on how a person with diabetes figures out how to keep his blood glucose level from falling too low (or climbing too high) while providing enough metabolic fuels for the exercise. Obviously, it involves some combination of adjusting insulin doses and caloric intake. Sometimes, people with diabetes can anticipate the exercise and lower the insulin doses before and during the exercise. Such an adjustment in insulin may allow the normal mechanism of releasing stored glucose into the blood to work as in people without diabetes. Sometimes, taking in calories to mimic the release of stored glucose is necessary (e.g, ingestion of glucose-containing liquids or solids). For very long periods of exercise, ingestion of foods containing protein and fat may also be necessary. My point is that with some practice in figuring out the insulin/calorie factors, anyone with type 1 diabetes can expect to do as much exercise as they choose and do it well.

Most physicians who specialize in managing patients with type 1 diabetes should be quite experienced in helping their patients develop exercise plans. Particularly with the introduction of insulin infusion pumps and multiple injection insulin regimens over the past 25 years, the task is much easier than it used to be. In 2007, no one should be telling people with type 1 diabetes that they can’t do this or can’t do that, and that includes vigorous exercise programs.

Why Wear A Medical ID If You Take Insulin?

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Background

The other day I heard a report on NPR about a young man who apparently was on an Amtrack train and started to act strangely. The conductor thought the problem was drug or alcohol-related and stopped the train somewhere in New Mexico and escorted the young man off the train which was their policy. The young man apparently then ran off into the woods but fortunately was later retrieved by local officials who eventually sorted things out.

Mystery solved

As it turns out, the young man had been diagnosed with type 1 diabetes the day before and had been started on insulin injections. His strange behavior was in fact drug-related but nothing illicit- it was hypoglycemia (low blood sugar) from his insulin injections. The Amtrack officials claimed they were “just following their written policies.” This is not the first time I have heard of patients with diabetes who were having hypoglycemia thought to be strange behavior due to drugs or alcohol. I remember one patient of mine from several years ago who went to New Orleans for Mardi Gras. He had type 1 diabetes and was generally in excellent control. Apparently he had 1 drink (his blood alcohol level was not elevated) and became hypoglycemic, probably from increased activity and insufficient food intake. He began acting strangely and decked a police officer who was trying to arrest him for likely alcohol intoxication or illicit drug effects. The unfortunate young man was beaten by the police and jailed until he developed diabetic ketoacidosis 3-4 days later- no one had bothered to believe what the young man was saying – that he had diabetes and was having hypoglycemia. The patient did survive the ordeal but barely.

So?

These two stories (I could curl your hair with story after story about the effects of hypoglycemia in patients with diabetes- not all of them ended well) illustrate how important it is for people who take insulin or other medications that can cause hypoglycemia (e.g., sulfonylureas) to take precautions when away from peple who know about their diabetes and how to recognize and treat hypoglycemia. For sure they should wear a medical ID- a necklace or a bracelet that identifies them as having diabetes. They should also carry a wallet card that identifies them has having diabetes (and what should be done if they are found unconscious or acting strangly). They should also carry some form of rapidly-acting carbohydrate such as glucose tablets (available at most every pharmacy). They should also test their blood sugar levels frequently and ALWAYS before driving a motor vehicle or undertaking a potentially hazardess activity (e.g., scuba diving).

What else?

People who deal with the public, particularly those who might have to deal with emergencies (e.g., police, firefighters) need to be trained to consider hypoglycemia when dealing with a person who exhibits stange behavior, has a seizure, or is found unconscious- all EMTs know to always rule out hyopglycemia when dealing with such behaviors (they also know to check for medical IDS!). I would be willing to bet that the youg man on the train was not wearing a medical ID and I know my Mardi Gras patient was not wearing an ID.