Diabetes Office Visit

Fixing The 9 ,prevents heart disease and amputation

2012-02-22T12:13:00.001-08:00

I was reading Internal Medicine News this morning and one article got my attention.

Amputations decline 65% in Diabetic patients
by Diana Mahoney
The major finding was , the rate of hospitalizations for non traumatic amputations has decreased from 11.2/1000 persons in 1996 to 3.9/1000 persons in 2008. This informations was collected and reported by the Centers For Disease Control (CDC )

This is good news and probable means that we are all doing a better job with preventive health care.

The bad news was reported in Diabetes Care 2012;35: 273-7. They reported that even with the significant decline in amputations , the amputation rate is still eight times higher than in the non-Diabetic population.
(3.9 vs 0.5 persons per 1000)

comment ;
When was your last Diabetes Foot Exam ?

Do you know what a Diabetes Foot Exam is ? It is more then a quick look at your foot

This subject brings up something that has bothered me for years about our approach to diabetes care.

Diabetes risk management by default is primarily physician and institution based .
I helped develop a computer assisted Diabetes Wellness Assessment Program (DWAP) for my medical group with a goal of reducing the risk of heart disease and other diabetes complications. This was very successful in improving diabetes risk factor management . However, even with the great effort and expense by the doctors , nurses , diabetes educators and administration , we were not 100% successful .
We had the most success in test and exams that were set up to be done automatically such as lab. test and we had the least success with test and exams requiring input and recall by patients, physicians and staff with things like foot exams and achieving some of the goals.

I have felt for a long time that one essential ingredient in our plan was overlooked.

We neglected to adequately empower each patient with the responsibility for their own care and
we also made risk management to complicated.

Finding a way to Simplify diabetes care and Empower Patients to be more involved in their own care was the reason for me writing , Diabetes Office visit .

The basic principle of the book and iPhone , iPad app is to empower patients to set target goals for their test and exams, then reach those goals with the help of their doctor and prevent the complications of diabetes.

I manage to hide these basic concepts with to much verbiage, discussing back ground and studies supporting the reasons for the test.

My son in law, Vince, and Herman Cain helped me simplify and make my idea more useful.

Herman Cain promoted the idea of his 9-9-9 plan for simplifying our tax code.

My son in law helped me realize that reaching diabetes treatment goals is simply a game of numbers and that understanding the numbers is not necessary for fixing them.

The understanding and meaning of those numbers will come with time and repetition .

So I have now shortened my book concept to Fixing the 9 for people with Diabetes and Fixing the 6 for non -diabetics with a primary goal of reducing the number one killer for all of us , Heart Disease

Fixing those 9 risk factor will have a little side benefit of reducing the risk of eye and foot problems

please go to the Diabetes office Visit Training Video tab above for more information on goals setting and risk management ideas . I developed the video for Iphone and iPad users but it help you understand the ideas behind goal setting and risk management .

Have fun , Be Smart and Defeat Diabetes,
David Calder,MD

Should Sulonylureas be retired ?

2012-02-20T10:21:00.000-08:00

Should sulfonylureas be retired ?

My answer is a strong YES .
The short answer is that we have better safer medications that actually preserve Beta cell function. The sulfonylureas are just as effective at lowering abnormal glucose levels but at the cost of increased risk of hypoglycemia , they seem to burn out any remaining Beta cells , cause weight gain and are suspect for increase risk of cardiovascular disease .

These medicines served us very well and helped a lot of people when the only choices of medications for type 2 diabetes was animal based insulins and sulfonylureas . Technology and better understanding of type 2 diabetes has made dramatic improvements in diabetes care and these drugs should join urine glucose test and move into the history of diabetes care.

Names on my list for receiving a gold watch and a slap on the back for a job well done during their day
chlopromamide ( Diabinase )
tolazamide ( Tolinase)
Tolbutamide
Glipazide (Glucatrol )
gliclazide (Damicron )
Glyburide ( Diabetea, Glynase )

Glimapiride ( Amaryl ) Amaryl could remain on the on call list for the occasional
patient who could benefit .

Will they be retired is probable no ?
These meds will not go away because they are inexpensive and they are effective for lowering
glucose levels.

Have Fun , Be Smart and Defeat Diabetes
David Calder,MD

Diabetes Office Visit App. updates are almost complete

2012-02-18T09:26:00.000-08:00

New updates are almost complete on the iPhone,iPad App. The update will include the ability to view your lab. results in mg/dl or mm/l . Data entry for goal setting and cardiovascular risk risk management is improved. The next update will make Diabetes Office Visit App available for mac computers and Pc computers.

Diabetes Office visit App iTunes add update

I have revised my iTunes explanation of the Diabetes Office Visit App. Comments ,corrections and discussion is welcome .

The only comprehensive diabetes management App - see more

**CREATED BY David Calder MD to provide an always at your finger tips comprehensive diabetes management tool , that will simplify your diabetes care and help you preserve your good health.

" Diabetes Office Visit app. " is designed to help you ,

Set goals> reach goals> and prevent complication

:" Diabetes office visit app " is designed specifically to deal with all risk

associated with having Diabetes.

Diabetes control is more than just controlling blood glucose levels.

Cardiovascular disease is the major risk for people with Diabetes and

pre -diabetes.

"DIABETES OFFICE VISIT APP" includes

" RISK MANAGEMENT SECTION " provides the tools for tracking and managing the risk factors ( Blood

Pressure , LDL cholesterol , HDL cholesterol , Triglycerides , Apo b

levels and albumin/ creatinine ratio ) associated with Diabetes and

heart disease.

"GOAL SETTING SECTION " provides you with the recommend target goals and the ability to

adjust those goals to meet your specific situation.

Having target goals makes diabetes care much simpler. If you know

the target goals- then any thing that is not meeting that goal is a

reason for discussion with your physician

” YOU FAIL TO ACHIEVE 100% OF THE GOALS YOU DON'T SET”.

" GLUCOSE MANAGEMENT SECTION " is designed by me to present the the information needed by you

and your physician to make management decisions . Collecting

and presenting the right data to your health care provider is

crucial to making the correct glucose management decisions.

You can follow just your glucose results or add carbohydrate

intake, exercise or medications if needed.

The ebook discusses when to test and how to present your data to

your health care provider.

" e BOOK SECTION " Provides all of the above tools , plus a better understanding of

treatment goals and a light hearted look at our diet problems and

geezerhood treatment decisions and diabetes .

Diabetes office visit deals one of the biggest diabetes associated

risk , COMPLACENCY .

(the feeling of quite security often while unaware of a

potential danger )

" DIABETES OFFICE VISIT WEB SITE " This web site and "The Doctor is in" section is designed to answer

any diabetes related questions and includes a almost daily blog

focused on improving your understanding of basic management

concepts. The 10 minute App training video will help you find and

use all of this app's features.

www.diabetesofficevisit.com

You and I , as patients ,are ultimately responsible for managing all of the aspects of diabetes care.

Imagine what could happen if, each of us accepted the privilege and responsibility for

maintaining our own good health. Diabetes Office Visit App. provides you with the tools to make this

this happen

You can also reach me email info@diabetesofficevisit.com

dcalder@diabetesofficevisit.com

Regular mail —- Diabetes office Visit PO BOX 1170 Creswell, Oregon 97426

I will do my best to make this app work for you.

One of the technical issues we had in development was the inability of me to make test and corrections prior to its release. This resulted in 8 updates over 3 to 4 months as I found and corrected Items that did not meet my goals. I apologize for that problem

If you are unhappy with the app for any reason i will refund your money .

Thank you , have fun and be smart . You can defeat diabetes

David Calder, MD

This eBook and App is written by David Calder,MD , a diabetes specialist with over 35 years of experience , who worked hands on to design this app to help patients better manage all aspects of

their diabetes care. This app taps the knowledge and experience of Dr. Calder to help you get more out of each doctor's visit .

Cancer survival, another reason to take glucophage( metformin )

2012-02-18T09:14:00.000-08:00

Comment:

Reducing the risk of and the damage done by cancer is another benefit of taking Glucophage

( metformin ) . The abstract below supports the use of metformin as the first choice of medications for people with Type 2 Diabetes. It also provides another reason to retire all of the sulfonylureas from the list of medication used to treat Type 2 Diabetes .

Tomorrow, more reasons to retire sulfonylureas .

Have Fun be Smart and Defeat Diabetes

David Calder,MD

Diabetes Care. 2012 Feb;35(2):299-304. Epub 2012 Jan 20.

Mortality After Incident Cancer in People With and Without Type 2 Diabetes: Impact of metformin on survival.

Currie CJ, Poole CD, Jenkins-Jones S, Gale EA, Johnson JA, Morgan CL.

Source

Corresponding author: Craig J. Currie, currie@cardiff.ac.uk.

Abstract

OBJECTIVE Type 2 diabetes is associated with an increased risk of several types of cancer and with reduced survival after cancer diagnosis. We examined the hypotheses that survival after a diagnosis of solid-tumor cancer is reduced in those with diabetes when compared with those without diabetes, and that treatment with metformin influences survival after cancer diagnosis. RESEARCH DESIGN AND METHODS Data were obtained from >350 U.K. primary care practices in a retrospective cohort study. All individuals with or without diabetes who developed a first tumor after January 1990 were identified and records were followed to December 2009. Diabetes was further stratified by treatment regimen. Cox proportional hazards models were used to compare all-cause mortality from all cancers and from specific cancers. RESULTS Of 112,408 eligible individuals, 8,392 (7.5%) had type 2 diabetes. Cancer mortality was increased in those with diabetes, compared with those without (hazard ratio 1.09 [95% CI 1.06-1.13]). Mortality was increased in those with breast (1.32 [1.17-1.49]) and prostate cancer (1.19 [1.08-1.31]) but decreased in lung cancer (0.84 [0.77-0.92]).

When analyzed by diabetes therapy, mortality was increased relative to nondiabetes in those on monotherapy with sulfonylureas (1.13 [1.05-1.21]) or insulin (1.13 [1.01-1.27]) but reduced in those on metformin monotherapy (0.85 [0.78-0.93]).

CONCLUSIONS This study confirmed that type 2 diabetes was associated with poorer prognosis after incident cancer, but that the association varied according to diabetes therapy and cancer site. Metformin was associated with survival benefit both in comparison with other treatments for diabetes and in comparison with a nondiabetic population.

Pre-Diabetes treatment with Glucophage ? Statins ?

2012-02-17T12:32:00.000-08:00

This is a continuation of our discussion of our 48y/o man with Pre - diabetes.

He has been very successful at reducing his risk of progression to type 2 diabetes with his life style change efforts.

Should he consider adding a medication such as glucophage or a* GLP-1 agonist ?

There is good evidence that glucophage slows the progression to Type 2 Diabetes.
This is worth further discussion with his doctor.
The use of a GLP-1 Agonist makes sense on paper. This group of medication have been shown to correct the problem of sluggish insulin release and preserve function and survival of Beta cells , but I am not aware of any studies supporting their use for pre-diabetes yet.

His problem with elevated Triglycerides has been successfully managed with Omega -3 - Fatty acids and life style change. He is left with an elevation of his LDL at 131 mg/dl ( 3.4mm/l ) and an HDL of 36mm/dl ( .9mm/l )

Should he consider adding a *"Statin " to treatment program ?

American Diabetes Association 2012 guidelines

Lifestyle modification focusing on the

reduction of saturated fat, trans fat, and cholesterol intake; increase of n-3 fatty acids, viscous fiber and plant stanols/ sterols; weight loss (if indicated); and increased physical activity should be recommended to improve the lipid profile in patients with diabetes. (A)

Statin therapy should be added to life- style therapy, regardless of baseline lipid levels, for diabetic patients:

*with overt CVD.
* without CVD who are over the age of 40 years and have one or more other CVD risk factors.
* For lower-risk patients than the above (e.g., without overt CVD and under the age of 40 years), statin therapy should be
considered in addition to lifestyle therapy if LDL cholesterol remains .100 mg/dL or in those with multiple CVD risk
factors. (E)
* In individuals without overt CVD, the primary goal is LDL cholesterol ,100 mg/dL (2.6 mmol/l). (A)

S6 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012care.diabetesjournals.org

* In individuals with overt CVD, a lower LDL cholesterol goal of ,70 mg/dL (1.8 mmol/l), using a high dose of a statin,is an option
* If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cho-
lesterol of ;30–40% from baseline is an alternative therapeutic goal. (A)
* Triglycerides levels ,150 mg/dL (1.7 mmol/l) and HDL cholesterol .40 mg/ dL (1.0 mmol/l) in men and .50 mg/dL (1.3
mmol/l) in women, are desirable. However, LDL cholesterol–targeted statin therapy remains the preferred strategy.
* If targets are not reached on maximally tolerated doses of statins, combination therapy using statins and other lipid-
lowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either
CVD outcomes or safety. (E)
* Statin therapy is contraindicated in pregnancy. (B)

Comment:
I believe it is time to change our approach from trying to find a reason to start a Statin drug to trying to find a reason not to start a statin.

The CARDS study demonstrated the benefit of of treating people with and without overt heart disease who had one other risk factor . (for example Diabetes plus an elevated LDL )

the people taking 10 mgs. of Lipitor demonstrated significant benefit
Acute coronary event reduced by 36%
Coronary revascularizations reduced 31 %
Rate of strokes reduced by 48 %
Death rate reduced by 27 %

My favorite line from The CARDS study is, “The debate about whether all patients with type 2 diabetes warrant statin treatment should now focus on whether any patient can reliably be identified as sufficiently low risk for this safe, efficacious treatment to be withheld.”

Have fun , Be Smart and check out my Diabetes Office visit training Video on the above Tab
David Calder,MD

* GLP-1 agonist . Please the the discussions over the last few days
* " Statins " This refers to medications such as Lipitor ( atorvastatin ) and Zocor ( Simvastatin ) and others

Diagnosing Diabetes When The Test Don't Agree

2012-02-16T15:27:00.000-08:00

Save time just read the yellow highlighted lines.

A 48 y/o man with a family history of type 2 diabetes had screening test done about 1 year ago and had an elevation of his FBS to 108 mg/dl. His A1c was 6.1 . He as told that he had Pre - Diabetes . His other lab included a Triglyceride level of 350mg/dl , HDL 34mg/dl and LDL cholesterol of 120 mg/dl .
His treatment recommendation was to increase his exercise , lose weight and recheck his lab test in 1 year.
He followed the advice and also started Omega 3 Fatty acids , taking over 4 Grams/day.

Lab test one year later - A1c 6 ( 53mm/L ) Fasting glucose 98 mg/dl ( 5.4 mm/L ).
Cholesterol is 195 mg/dl (5 mm/L )
LDL cholesterol is 131 mg/dl ( 3.4mm/L )
HDL is 36 mg/dl (.9 mm/L )
Triglycerides have decreased to 148mg/dl ( 1.7 mm/L )

Question . Which test , A1c or Fasting Glucose , is the most useful for diagnosing Pre-diabetes

Reference Lab.

Criteria for the diagnosis of Diabetes Criteria for diagnosis of Pre-Diabetes
A1c > 6.5 A1c 5.7 to 6.4
Fasting Glucose > 126 mg/dl ( 7 mm/l ) Fasting glucose 100mg/dl to 125 mg/dl
( 5.6 mm/l) to ( 6.9mm/l )

Comment.

These lab results raise some interesting questions about our diagnostic tools .

The A1c test is generally thought to be less sensitive for the diagnosis of Diabetes than the Fasting
Glucose. The A1c results can be effected by pregnancy , hemolytic anemias , recent blood loss and
blood transfusions.

The American Diabetes Association suggested approach to the diagnosis of   diabetes when A1c    and Fasting glucose results do not agree is :

'The test whose result is above the  diagnostic cut point should be repeated , and the diagnosis
in made on the basis of the confirmed test"

There is another interesting caveat when comparing A1c results with Fasting Glucose results Both fasting glucose or after meal glucose contributes to the A1c test.

The A1c test is an average of all glucose results for the previous 2 to 3 months.

For example the after meal glucose results contribute only about 25 % to an A1c level of 10.2 but contributes 75% to an A1c result of 7.3.

This means that the closer the A1c results get to 6.5 The greater the after meal sugar is contributing to the result.

With the above thoughts in mind I would tend to believe the A1c result and follow the ADA recommendations and repeat the A1c test.

p.s.
This information is also useful for helping you decide whether to do more after meal test as your A1c hemoglobin approaches your A1c goal of 7

Tomorrow. What to do about the lipid test results ?

Have Fun, Be Smart and buy one of my Diabetes Office Visit Apps , ebook or paper back books or Iphone , iPad App.

David Calder, MD

Diabetes medication , the first choice is easy, the second choice is not as easy

2012-02-15T10:30:00.000-08:00

Save time just read the yellow highlighted areas also you may want to review the last few days discussion about GPL-1 Agonist and DPP-4 inhibitors before reading this.

Two articles caught my eye this morning and resulted in my reviewing the medication recommendations for the treatment of type 2 diabetes. I reviewed the American Diabetes Association , American college of Physicians . I believe there is general agreement that metformin(glucophage) is the first medication
to use.

Most people will need a second medication at some point in their diabetes care. The choice of a second medication involves more variables such as COST , weight gain or loss , age , heart , brain and kidney status, risk of hypoglycemia , lack of long term risk/ benefit data and others.

The choice of the second medication is a clinical decision made by you and your physician based on the best information available at that moment .

Guide lines

Ann Intern Med. 2012 Feb 7;156(3):218-231.

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline From the American College of Physicians.

Qaseem A, Humphrey LL, Sweet DE, Starkey M, Shekelle P; for the Clinical Guidelines Committee of the American College of Physicians.

Source

the American College of Physicians, Philadelphia, Pennsylvania; Oregon Health & Science University, Portland, Oregon; University of Kansas School of Medicine, Wichita, Kansas; and West Los Angeles Veterans Affairs Medical Center, Los Angeles, California.

Abstract

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the comparative effectiveness and safety of type 2 diabetes medications. Methods: This guideline is based on a systematic evidence review evaluating literature published on this topic from 1966 through April 2010 that was identified by using MEDLINE (updated through December 2010), EMBASE, and the Cochrane Central Register of Controlled Trials. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline included all-cause mortality, cardiovascular morbidity and mortality, cerebrovascular morbidity, neuropathy, nephropathy, and retinopathy. This guideline grades the evidence and recommendations by using the American College of Physicians clinical practice guidelines grading system.

Recommendation 1: ACP recommends that clinicians add oral pharmacologic therapy in patients diagnosed with type 2 diabetes when lifestyle modifications, including diet, exercise, and weight loss, have failed to adequately improve hyperglycemia (Grade: strong recommendation; high-quality evidence).

Recommendation 2: ACP recommends that clinicians prescribe monotherapy with metformin for initial pharmacologic therapy to treat most patients with type 2 diabetes (Grade: strong recommendation; high-quality evidence).

Recommendation 3: ACP recommends that clinicians add a second agent to metformin to treat patients with persistent hyperglycemia when lifestyle modifications and monotherapy with metformin fail to control hyperglycemia (Grade: strong recommendation; high-quality evidence).Ann Intern Med. 2011 May 3;154(9):602-13. Epub

American Diabetes Association Standards of care 2011

2011 Mar 14. 2. Therapy for type 2 diabetes

The ADA and the EASD published an expert

consensus statement on the approach

to management of hyperglycemia in individuals

with type 2 diabetes (82). Highlights

of this approach are: intervention at

the time of diagnosis with metformin in

combination with lifestyle changes (MNT

and exercise) and continuing timely augmentation

of therapy with additional

agents (including early initiation of insulin

therapy) as a means of achieving and

maintaining recommended levels of glycemic

control (i.e., A1C 7% for most

patients).

Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations.

Bennett WL, Maruthur NM, Singh S, Segal JB, Wilson LM, Chatterjee R, Marinopoulos SS, Puhan MA, Ranasinghe P, Block L, Nicholson WK, Hutfless S, Bass EB, Bolen S.

Source

The Johns Hopkins University School of Medicine and The Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Baltimore, MD 21205, USA. wbennet5@jhmi.edu

Erratum in

Ann Intern Med. 2011 Jul 5;155(1):67-8.

Abstract

BACKGROUND:

Given the increase in medications for type 2 diabetes mellitus, clinicians and patients need information about their effectiveness and safety to make informed choices.

PURPOSE:

To summarize the benefits and harms of metformin, second-generation sulfonylureas, thiazolidinediones, meglitinides, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 receptor agonists, as monotherapy and in combination, to treat adults with type 2 diabetes.

DATA SOURCES:

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception through April 2010 for English-language observational studies and trials. The MEDLINE search was updated to December 2010 for long-term clinical outcomes.

STUDY SELECTION:

Two reviewers independently screened reports and identified 140 trials and 26 observational studies of head-to-head comparisons of monotherapy or combination therapy that reported intermediate or long-term clinical outcomes or harms.

DATA EXTRACTION:

Two reviewers following standardized protocols serially extracted data, assessed applicability, and independently evaluated study quality.

DATA SYNTHESIS:

Evidence on long-term clinical outcomes (all-cause mortality, cardiovascular disease, nephropathy, and neuropathy) was of low strength or insufficient. Most medications decreased the hemoglobin A(1c) level by about 1 percentage point and most 2-drug combinations produced similar reductions.

Metformin was more efficacious than the DPP-4 inhibitors, and compared with thiazolidinediones or sulfonylureas, the mean differences in body weight were about -2.5 kg.

*Metformin decreased low-density lipoprotein cholesterol levels compared with pioglitazone, sulfonylureas, and DPP-4 inhibitors.

Sulfonylureas had a 4-fold higher risk for mild or moderate hypoglycemia than metformin alone and, in combination with metformin, had more than a 5-fold increased risk compared with metformin plus thiazolidinediones.

Thiazolidinediones increased risk for congestive heart failure compared with sulfonylureas and increased risk for bone fractures compared with metformin. Diarrhea occurred more often with metformin than with thiazolidinediones.

LIMITATIONS:

Only English-language publications were reviewed. Some studies may have selectively reported outcomes. Many studies were small, were of short duration, and had limited ability to assess clinically important harms and benefits.

CONCLUSION:

Evidence supports metformin as a first-line agent to treat type 2 diabetes. Most 2-drug combinations similarly reduce hemoglobin A(1c) levels, but some increased risk for hypoglycemia and other adverse events. Primary Funding Source: Agency for Healthcare Research and Quality.

*comment . I recall an article that found a decrease in LDL and Triglycerides and an increase in HDL cholesterol when using GLP1 agonist as their second drug.

Have Fun, be Smart and Defeat Diabetes
David Calder,MD

New Diabetes Meds= High Cost ! Hypoglycemia to the Rescue ?

2012-02-14T09:39:00.000-08:00

Hypoglycemia and the fear of hypoglycemia is the primary barrier preventing everyone with diabetes from having normal blood glucose levels.

Save time just the parts in yellow

Back ground

Every person with diabetes walks a tight rope battling two devils.
The devil of high and the devil of low sugars. Both devils can cause a person to fall and suffer the consequences .

The devil of lows has an immediate impact on a persons life and is associated , a higher death rate especially in older people and higher cost of care. The devil of high sugars is silent working behind the scenes causing damage to a persons eyes, kidneys, nerves and heart over many years. The treatment of diabetes is about trying to find the best path between these two devils.

Studies

A number of studies have shown an increase in the risk of hypoglycemia as patients work to achieve a target goal of 7 for their A1c.

The DCCT* found a tripling of the incidence of hypoglycemia in Patients with Type 1 Diabetes as they got closer to their target goal of A1c 7.

The UKPDS* study found similar results in patients with Type 2 Diabetes. This study also revealed that the risk of hypoglycemia was 4 to 6 times greater in patients talking insulin compared to
sulfonylureas.There was no significant risk of hypoglycemia with glucophage (metformin)

A more recent study , ACCORD *, found a higher mortality rate , especially, in older people struggling to achieve near normal A1c'S closer to 6. The higher mortality rate and hypoglycemia resulted in stopping this portion of the study.

Postgrad Med. 2012 Jan;124(1):124-32.

Hypoglycemia, treatment discontinuation, and costs in patients with type 2 diabetes mellitus on oral antidiabetic drugs.

Bron M, Marynchenko M, Yang H, Yu AP, Wu EQ.

Source

Principal Scientist, Takeda Pharmaceuticals International, Inc., Deerfield, IL.

Abstract

Objective: To investigate the rate and impact of hypoglycemic events among patients with type 2 diabetes mellitus (T2DM) receiving different classes of oral antidiabetic drugs (OADs). Research Design and Methods: Adult patients with T2DM were extracted from the Ingenix IMPACT claims database. The mean number of health care visits due to hypoglycemic events per patient-year was estimated. Multivariate regression models were used to: 1) assess the risk factors for experiencing a hypoglycemic event; 2) assess the effect of experiencing hypoglycemic events on antidiabetic treatment discontinuation; and 3) compare 12-month post-index date costs between patients with and without hypoglycemic events. Results: 212 061 patients with T2DM were included in the analysis. The estimated frequency of hypoglycemia-related health care visits was 0.054 per patient-year. Insulin use was associated with increased risk of developing hypoglycemia, followed by use of sulfonylureas and other OADs (eg, meglitinide and α-glucosidase inhibitors).

The impacts of thiazolidinediones, metformin, and dipeptidyl peptidase-4 on hypoglycemia risk were relatively small. Having a hypoglycemic event was associated with significantly increased risk of antidiabetic treatment discontinuation.

Patients with hypoglycemia showed significantly higher annual all-cause and diabetes-related health care costs than patients without hypoglycemia (adjusted Δ = +$5024 and +$3747, respectively; both P < 0.0001). Conclusion: Different OAD classes were associated with different levels of risk for hypoglycemic events. Hypoglycemia was associated with a higher risk of antidiabetic treatment discontinuation and significantly increased health care costs.

Comment

The cost of caring for someone who is having problems with hypoglycemia is more than the cost of care for a person without hypoglycemia.. We now have medications that will lower blood sugars allowing people to achieve A1c levels shown to reduce the risk of complications and in some cases preserve Beta cell function without the risk of hypoglycemia. The high cost of hypoglycemia in human suffering and money may push diabetes treatment more rapidly toward the use of medications with little or no risk of hypoglycemia. These medications include Glucophage ( metformin ) , GLP -1 Agonist and DPP-4 inhibitors. See yesterdays discussion for more details about these medications .

*Diabetes Control and Complication Trial Group. “The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus.” New England Journal of Medicine 329 (September 30, 1993): 977–986. [DCCT]

*UK Prospective Diabetes Study (UKPDS) Group 33. “Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes.” Lancet 352 (September 12, 1998): 837–853.

Have Fun , Be Smart and Defeat Diabetes

David Calder,MD

New Medications- High Cost- Hypoglycemia to the Rescue

2012-02-13T11:09:00.000-08:00

Managing diabetes over the years generally involves the use of a number of medications to control glucose , lipids and blood pressure. Improving your understanding of these very potent amazing medications is important to your success in defeating diabetes.

Today our discussion is about some of the newer medications with unusual names.

Most of the these new medications are altered forms of hormones and enzymes that are working in our bodies every day. I will start by reviewing the sources on these hormones in our body.

Pancreas - Beta Cells --Insulin -- allow glucose use in our tissues and regulate fat metabolism
Amylin-- slows stomach emptying, promotes a feeling of fullness, inhibits
glucagon release

Alpha cells -Glucagon- regulates the release of glucose from our liver

Intestine - produces - GLP 1 - Slows stomach emptying
Stimulate glucose sensitive insulin release and restores early rapid
insulin release
Inhibits glucagon release
Preserves Bets cell function and slows the damage to Beta cell
Promotes the development of new Beta cells
Promotes weight loss

Blood - Enzyme - DPP-4 - Destroys GLP -1 causing GLP -1 to have a very short life span .
One half of GPL-1 is destroyed every 2 minutes

Non - Diabetic
eating a piece of bread > glucose absorbed - Beta cells release insulin and Amylin > normal glucose
Intestine releases - GLP-1
Alpha cells decrease glucagon release
DPP-4 destroys GLP-1

A person with Diabetes has a dysfunction of almost all of the above systems.

Eating a piece of bread > glucose is absorbed - beta cells sluggish or no insulin > high glucose
Intestine releases inadequate amounts of GLP-1
Alpha cells continue to release glucagon
DPP-4 destroys the released GLP-1

A fresh look at some of these amazing new medications.

GLP -1 agonist - replaces the deficiency of a normal hormone in our body

DPP-4 inhibitors - interferes with the enzyme that is destroying GLP- 1 allowing it to last longer

Amylin - Replaces the deficiency of amylin

Drug names of the above medications

GLP-1 agonist DPP-4 Inhibitors Amylin
Byetta ( exenatide ) Januvia ( sitagliptin ) Symlin( pramlintide)
Bydureon ( exenatide slow release ) Onglyza ( saxagliptin ) Symlinpen
Victroza ( liraglutide ) Tragenta (linagliptin )

Comment.
It seems that the most logical choice of medications for a person with Type 2 Diabetes would be a combination of Glucophage and a GLP-1 agonist. The cost of taking a GLP-1 agonist is a big deterrent blocking the more wide spread use of this combination. Another deterrent is caution in using any new medication because significant side effect may not show up for years after millions of people are using the medication. However the biggest immediate problem is cost.

Believe it or not hypoglycemia may be coming to our rescue. See tomorrows discussion for details.

" It is more fun to prevent complication than it is to treat complications"
David Calder, MD

Glucagon effects your life every day

2012-02-12T10:32:00.000-08:00

Glucagon Emergency Kit
Time Saver Hint - Read the bold print only and save about 65 seconds of your day
Most people with Diabetes type 1 and type 2 are familiar with and may have used glucagon to treat an episode of severe hypoglycemia ( the person is unconscious or for other reasons cannot glucose orally ). They know that injected glucagon causes the release of glucose from the hypoglycemic persons liver and allows them to recover . I suggest that the person responsible for giving the injection read the directions and understand what they will need to do before the injection is ever needed.

What about glucagon and its impact on people with type 1 and type 2 Diabetes each day .Glucagon is made in The Alpha cell in our pancreas. One function of the liver is to act as a storage depot for glucose and glucagon is the key to opening that storage depot when glucose is needed to maintain body function especially the brain. The release of glucagon is the first line of defense when there is an unexpected drop in blood glucose and unfortunately it is also the first causality in our bodies defense against low blood sugar levels in process of developing Hypoglycemic unawareness.

We generally think of Glucagon and it's evolvement in preventing and correcting hypoglycemia. However it 's larger role is in the day to day struggles with controlling blood glucose levels. People with Type 1 and Type 2 Diabetes have Dysfunctional Alpha cells resulting in the inappropriate release of glucagon.
The unexplained high fasting glucose test or the unexplainable high glucose after a meal that normally does not cause much of increase in glucose , can be related to glucagon.

Alpha cells release of glucagon is tied to the problems of insulin deficiency .Low insulin levels act as a trigger for the release of glucagon and the resulting increase in blood glucose levels. Everyone with type 1 or type 2 Diabetes have insulin deficiency and inappropriate glucagon release complicating their glucose management efforts.

Some of the newer medications have been helpful in managing glucagon secretion . These medications include insulin , GLP -1 agonist , DPP-4 inhibitors and Symlin ( pramlintide ).

We discussed GLP-1 agonist yesterday tomorrow I will review more on GLP-1 and DPP-4 inhibitors( tradgenta (linagliptin) ,Onglyza ( saxagliptin) and Januvia (sitagliptin ) tomorrow.

If you have questions about any diabetes related problem please use the comment section or email me at
info.diabetesofficevisit.com

Have Fun be Smart and Defeat Diabetes
David Calder,MD

Bydureon is my first choice for a second medication

2012-02-10T14:40:00.000-08:00

GLP1 agonist such as, Byetta ( exenatide ) , Victoza ( liraglutide) and Bydureon( long - acting eventide).

One of the questions from yesterdays discussion .

What medication would you add when glucophage and life style change is no longer effective. ?

My first choice would be Bydureon because it is a once a week injection . Cost of all three of the medications in this class will play a role in any decision process. I personally would probable adapt to the least expensive one .

Other benefits of this class of medications that I did not mention yesterday . They have been shown to reduce triglyceride and LDL Cholesterol and raise HDL cholesterol and preserve Beta cell life and function.

I don't believe any of our other diabetes medications can claim that distinction except maybe ACTOS ( pioglitazone ) or Avandia ( rosiglitazone ). Undesirable side effect such as edema and increase risk of Congestive heart failure and others associated with the use of ACTOs and Avandia move them off or at least to the bottom of my list.

Another question had to do with the use of GLP1 agonist for people with Type 1 Diabetes.

I have attached a couple of abstracts below that discuss the idea .

Diabetes. 2011 May;60(5):1599-607. Epub 2011 Mar 25.

Antidiabetic actions of endogenous and exogenous GLP-1 in type 1 diabetic patients with and without residual β-cell function.

Kielgast U, Holst JJ, Madsbad S.

Source

Department of Endocrinology, Hvidovre University Hospital, Copenhagen, Denmark. urd.kielgast@hvh.regionh.dk

Abstract

OBJECTIVE:

To investigate the effect of exogenous as well as endogenous glucagon-like peptide 1 (GLP-1) on postprandial glucose excursions and to characterize the secretion of incretin hormones in type 1 diabetic patients with and without residual β-cell function.

RESEARCH DESIGN AND METHODS:

Eight type 1 diabetic patients with (T1D+), eight without (T1D-) residual β-cell function, and eight healthy matched control subjects were studied during a mixed meal with concomitant infusion of GLP-1 (1.2 pmol/kg/min), saline, or exendin 9-39 (300 pmol/kg/min). Before the meal, half dose of usual fast-acting insulin was injected. Plasma glucose (PG), glucagon, C-peptide, total GLP-1, intact glucose-dependent insulinotropic polypeptide (GIP), free fatty acids, triglycerides, and gastric emptying rate (GE) by plasma acetaminophen were measured.

RESULTS:

Incretin responses did not differ between patients and control subjects. Infusion of GLP-1 decreased peak PG by 45% in both groups of type 1 diabetic patients. In T1D+ patients, postprandial PG decreased below fasting levels and was indistinguishable from control subjects infused with saline. In T1D- patients, postprandial PG remained at fasting levels. GLP-1 infusion reduced GE and glucagon levels in all groups and increased fasting C-peptide in T1D+ patients and control subjects. Blocking endogenous GLP-1 receptor action increased endogenous GLP-1 secretion in all groups and increased postprandial glucose, glucagon, and GE in T1D+ and T1D- patients. The insulinogenic index (the ratio of insulin to glucose) decreased in T1D+ patients during blockade of endogenous GLP-1 receptor action.

CONCLUSIONS:

Type 1 diabetic patients have normal incretin responses to meals. In type 1 diabetic patients, exogenous GLP-1 decreases peak postprandial glucose by 45% regardless of residual β-cell function. Endogenous GLP-1 regulates postprandial glucose excursions by modulating glucagon levels, GE, and β-cell responsiveness to glucose. Long-term effects of GLP-1 in type 1 diabetic patients should be investigated in future clinical trials.

Regul Pept. 2005 Jun 15;128(2):149-57.

Glycaemic effects of incretins in Type 1 diabetes mellitus: a concise review, with emphasis on studies in humans.

Dupre J.

Source

London Health Sciences Centre and Robarts Research Institute, London, Ontario, Canada. debra.nielsen@lhsc.on.ca

Erratum in

Regul Pept. 2006 Mar 15;134(1):67-8.

Abstract

The remission phase of Type 1 diabetes mellitus is associated with substantial recovery of beta-cell function and with marked improvement of endogenous insulin responses to meals in the early months after diagnosis, accompanied by little or no improvement in the insulin response to parenteral glucose, suggesting that the incretin function may be important in glycaemic regulation in this phase of diabetes. Preservation of the insulin response to parenteral glucagon-like peptide-1 (GLP-1), contrasting with lack of stimulation of insulin secretion by the other known incretin gastric inhibitory polypeptide (GIP), prompted studies with exogenous GLP-1 in recent-onset Type 1 diabetes. These studies showed substantial reduction of glycaemic excursions after ingestion of mixed nutrients during intravenous infusion of GLP-1 without administration of insulin, in subjects with a range of endogenous secretion of insulin in response to meals as demonstrated by blood levels of the insulin-connecting peptide (CP). These effects were independent of stimulation of blood levels of CP and were reproduced in volunteers with no endogenous release of CP in response to meals. The glycaemic effects were associated with inhibition of abnormal rises of blood levels of glucagon, and with suppression of endogenous release of human pancreatic polypeptide (HPP), by GLP-1. It was hypothesized that a major component of the glycaemic effect is attributable to the known action of GLP-1 to inhibit gastric emptying and to inhibit glucagon secretion. Studies of the effects of GLP-1 agonists (GLP-1 and exendin-4) given together with established insulin doses before a meal supported the hypothesis. The more prolonged actions of exendin-4 were accompanied by greater and more prolonged reduction of glycaemic effects of ingestion of meals in volunteers with CP-negative Type 1 diabetes mellitus, during intensive insulin therapy, in whom delay of gastric emptying was confirmed by studies of blood levels of acetaminophen ingested with the meals. Side effect-free doses of exendin-4 given together with insulin in volunteers with CP-negative Type 1 diabetes receiving continuing intensive insulin therapy demonstrated the capacity of this combination therapy to normalize blood glucose levels after ingestion of meals that were consistent with the dietary program of the volunteers, without apparent increased risk of hypoglycaemia within a normal between-meals interval. It is suggested that further and more prolonged studies of the use of long-acting GLP-1 agonists as congeners with insulin in Type 1 diabetes mellitus are indicated.

Glucophage "failed " Now what should I do ?

2012-02-09T09:21:00.000-08:00

Time saver hint. Just read the bold print and save 46 seconds for the rest of your day

My neighbor is a 40 y/o female with type 2 diabetes for 4 years and takes glucophage 1000 mg twice a day.She has lost 15 pounds since her diagnosis and walks over 30 minutes almost daily but is still is a little thick in the middle. Recently she has noticed a gradual increase in her home glucose test and an increase in her A1c from 6.8 to 8.1 . She is concerned that her glucophage has stopped working and wants to quit taking it. I explained that her problem is not glucophage . It is still doing it's job . The problem is that her ability to produce insulin has decreased and she will probable need to add another medication.

She has an appointment with her doctor tomorrow to discuss her treatment options.
She is worried because of friends who have gained weight and have had low blood sugars on other diabetes medications . I started with my usual doctor talk below and she stopped me and explained that she does not need to know all of the details at this time.

She is looking for a simple list of the pros and cons of the other medicines that will help her better understand her options before her doctor visit tomorrow. She wants to learn more about the details later.

( Please ignore doctor talk 1,2,3,4 below for now)
Players in the game that effect the decision process.
#1 dysfunctional Beta cells in her pancreas that have sluggish insulin release and are slowly failing
#2 dyfunctional alpha cells in her pancreas in inappropriately producing and releasing glucagon
#3 her tissue resistance to insulin
#4 GLP 1 deficiency

Here is the simple list she requested.

GLP1 agonist DPP4 inhibitors acarbose Insulin sulfonylureas

Effectively reduce A1c YES YES YES YES YES

Preserve Beta cell function YES ? NO NO NO

Promotes weight loss YES NO + - NO NO

Promotes weight gain NO NO + - YES YES

Do not cause hypoglycemia YES YES YES NO NO

Once a week injection YES NO NO NO NO

Most expensive YES +- NO + - NO

What is your first choice if money is not an issue ?
What is your first choice if money is a problem ?
Will GLP-1 Agonist help some one with Type I Diabetes ?

Tomorrow we will start on doctor talk with details about the above medications.

Have fun, Be Smart and Defeat Diabetes
David Calder,MD

Good news. A once a week diabetes injection

2012-02-07T08:08:00.000-08:00

Byetta (exenatide )has been placed in microspheres . This allows one of my favorite diabetes medications to be given once each week rather than twice daily. The initial studies found better weight loss and greater reduction in A1c compared to the twice daily Byetta. The name of this slow release form of exenatide is
Bydureon.

Exenatide is a GLP-1 agonist . What does GLP-1 agonist mean ? Why is this a better choice than insulin or a sulfonylurea medication . More on that tomorrow.

Glucophage is considered to be the first choice of medications for the treatment of type 2 diabetes. I believe that Bydureon could be second except for one thing COST.

Why should we chose GLP-1 agonist despite the higher initial cost ?

More tomorrow.
Have Fun , be Smart and Defeat Diabetes
David Calder,MD

The 'Other" Omega -3- Fatty acids

2012-02-06T08:03:00.000-08:00

According to Wikipedia there are 11 forms of Omega- 3 -Fatty acids.

Three of those have received the most attention as being beneficial to our health. These include Alpha- Linolenic Acid (ALA), EPA and DHA.

I did not see ALA ( alpha - linolenic acid) listed as a primary ingredient on the packages I looked at , so it must fall into the "other" category.

ALA cannot be over looked because it is the parent fatty acid to EPA and DHA.

Alpha -linolenic acid is found in vegetables such as rape seed used to produce canola oil, flax seed, walnuts, TOFU , spinach, Romaine lettuce ,soybeans, turnip greens, brussels sprouts, raspberries green beans and others. I generally think of the sources of ALA as Beans, Greens and Nuts.

Our bodies can convert Alpha- Linolenic Acid to EPA and DHA,however;
This conversion process is not efficient so we tend to delegate this job to fatty cold water fish , such as Sardines , salmon , Cod , Tuna ,Herring ,shrimp and scollops .

In summary eating greens,beans,nuts (especially walnuts) and cold water fish is not a bad idea. It reminds me of something called the Mediterranean diet.

Have fun eat healthy and defeat diabetes
David Calder,MD

Shopping for Omega -3 Fatty Acids can be confusing

2012-02-04T08:51:00.000-08:00

HINT- Save 45.6 seconds of your day by just reading the bold print

Shopping for Omega- 3- Acids can sometimes be confusing. I was in a store yesterday that had at least 6 different brands of Omega -3 - fatty acids on their shelves.

My wife has elevated triglycerides and takes 4 to 5 grams of " Omega -3- FA" /day and I have normal triglycerides and take close to 2 gms/day. The American Heart Association recommends 1 gm/day for someone without elevated triglycerides or heart disease. I have attached a copy of the American Heart Association recommendations below. The Jelis study , that we discussed on Jan. 30 , found a 19% relative risk reduction for a cardiovascular event by taking 1.8 gms of purified EPA for people with and without known heart disease or triglyceride problems.

I feel like a well informed consumer and had a simple goal of finding the smallest capsule with the highest amount of Omega -3 Fatty acids. My wife and I spent about 20 minutes reading labels using our calculator to find the pill that best met our goals. I have 3 different bottle setting in front of me now.

# 1 1200 mg of natural fish oil concentrate with 684 mg Omega -3 -Fatty acids
smaller print EPA 410 mg
DHA 274 m
Total amount /capsule--------- 684

# 2 Fish oil 1400mg/980 omega-3
smaller print EPA 647 mg
DHA 253 mg
other *****
Total amount /capsule---------- 900 mg

# 3 Cod Liver Oil high in EPA and DHA / Omega - 3 - Fatty acid 1100 mg
smaller print EPA 400 mg
DHA 500 mg
Other *****
Total amount per teaspoon 900 mg

I am not sure which omega -3 fatty acid is named "other ". I personally prefer to use EPA and DHA because they have been shown to be effective. We chose #2 because it had a little more Mg / capsule than #1 and also had more EPA and less "other" than #3.

I plan to take 2 capsules /day and my wife will take 5 capsules /day. We have lipid panels scheduled for next month.

What is in that "Other " category ? What is alpha linolenic acid ? Find out tomorrow.

Happy shopping,
David Calder, MD
My friend , a fellow blogger and founder of 1 diseaseworldvoice.org and Laffing at Life is shopping for Omega 3's today and may have a comment about his experience.

AMERICAN HEART ASSOCIATION RECOMMENDATIONS

Fish is a good source of protein and, unlike fatty meat products, it’s not high in saturated fat. Fish is also a good source of omega-3 fatty acids. Omega-3 fatty acids benefit the heart of healthy people and those at high risk of — or who have — cardiovascular disease. Research has shown that omega-3 fatty acids decrease risk of arrhythmias (abnormal heartbeats), which can lead to sudden cardiac death. Omega-3 fatty acids also decrease triglyceride levels, slow the growth rate of atherosclerotic plaque and lower blood pressure (slightly).

AHA Recommendation
Benefits vs. Risks of Eating Fish
Top 10 Fish and Shellfish in the United States Based on Consumption
Fish with the Highest Levels of Mercury (about 1 ppm)

AHA Recommendation

We recommend eating fish (particularly fatty fish) at least two times (two servings) a week. Each serving is 3.5 oz. cooked, or about ¾ cup of flaked fish. Enjoy fish baked or grilled, not fried. Choose low-sodium, low-fat seasonings such as spices, herbs, lemon juice and other flavorings in cooking and at the table.

Fatty fish like salmon, mackerel, herring, lake trout, sardines and albacore tuna are high in two kinds of omega-3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which have demonstrated benefits at reducing heart disease.

We also recommend eating tofu and other forms of soybeans, canola, walnut and flaxseed, and their oils. These foods contain alpha-linolenic acid (ALA), another omega-3 fatty acid. Large-scale epidemiologic studies suggest that people at risk for coronary heart disease benefit from consuming omega-3 fatty acids from marine and plant sources. However, more studies are needed to show a cause-and-effect beneficial relationship between ALA and heart disease.

Increasing omega-3 fatty acid consumption through foods is preferable. However, coronary artery disease patients may not be able to get enough omega-3 by diet alone. These people may want to talk to their doctor about taking a supplement. Supplements also could help people with high triglycerides, who need even larger doses.

Population	Recommendation
Patients without documented coronary heart disease (CHD)	Eat a variety of (preferably fatty) fish at least twice a week. Include oils and foods rich in alpha-linolenic acid (flaxseed, canola and soybean oils; flaxseed and walnuts).
Patients with documented CHD	Consume about 1 g of EPA+DHA per day, preferably from fatty fish. EPA+DHA in capsule form could be considered in consultation with the physician.
Patients who need to lower triglycerides	2 to 4 grams of EPA+DHA per day provided as capsules under a physician’s care.

Patients taking more than 3 grams of omega-3 fatty acids from capsules should only do so under a physician’s care. High intakes could cause excessive bleeding in some people.

Benefits vs. Risks of Eating FishSome types of fish may contain high levels of mercury, PCBs (polychlorinated biphenyls), dioxins and other environmental contaminants. Levels of these substances are generally highest in older, larger predatory fish and marine mammals.

The benefits and risks of eating fish vary depending on a person’s stage of life.

Children and pregnant women are advised by the U.S. Food and Drug Administration (FDA) to avoid eating those fish with the potential for the highest level of mercury contamination (e.g., shark, swordfish, king mackerel or tilefish); to eat up to 12 ounces (two average meals) per week of a variety of fish and shellfish that are lower in mercury (e.g., canned light tuna, salmon, pollock, catfish); and to check local advisories about the safety of fish caught by family and friends in local lakes, rivers and coastal areas.
For middle-aged and older men and postmenopausal women, the benefits of eating fish far outweigh the potential risks when the amount of fish are eaten is within the recommendations established by the FDA and Environmental Protection Agency.
Eating a variety of fish will help minimize any potentially adverse effects due to environmental pollutants.

Potential exposure to some contaminants can be reduced by removing the skin and surface fat from these fish before cooking. Consumers should also check with local and state authorities about types of fish and watersheds that may be contaminated and visit the FDA Web site for the most up-to-date information on recommendations for specific subgroups of the U.S. population (e.g., children, pregnant women).

Top 10 Fish and Shellfish in the United States Based on Consumption – Omega-3 and Mercury Levels:

	Omega-3 fatty acids (grams per 3-oz. serving)	Mean mercury level in parts per million (ppm)
Canned tuna (light)	0.17–0.24	0.12
Shrimp	0.29	ND*
Pollock	0.45	0.06
Salmon (fresh, frozen)	1.1–1.9	0.01
Cod	0.15–0.24	0.11
Catfish	0.22–0.3	0.05
Clams	0.25	ND*
Flounder or sole	0.48	0.05
Crabs	0.27–0.40	0.06
Scallops	0.18–0.34	0.05

* ND – mercury concentration below the Level of Detection (LOD=0.01ppm)

Fish with the Highest Levels of Mercury (about 1 ppm):

	Omega-3 fatty acids (grams per 3-oz. serving)	Mean mercury level in parts per million (ppm)
Tilefish (golden bass or golden snapper)	0.90	1.45
Shark	0.83	0.99
Swordfish	0.97	0.97
King mackerel	0.36	0.73

Five of the most commonly eaten fish or shellfish that are low in mercury are shrimp, canned light tuna, salmon, pollock, and catfish. Avoid eating shark, swordfish, king Mackerel, or tilefish because they contain high levels of mercury.

Should I be Concerned that my cholesterol seems to be gradually increasing ?

2012-02-02T17:21:00.000-08:00

A note from a 48 y/o women. My recent lab. test show my cholesterol to be slowly increasing. My cholesterol was 128 mg/dl 20 years ago , 149 mg/dl 2 years ago and was 161 on my most recent test. My other test , HDL is 49mg/dl , Triglyceride 84 mg/dl and LDL was 93. Should I be concerned ?

Discussion

Cholesterol does go up a little as we mature and get a little stouter. The exact cause for the slight increase with age is not known but may be due to hormone changes as we mature. Also your weight and activity level is probable a little different now than it was 20 years ago.

*You don't smoke and I assume your BP is normal .

* Your triglycerides of 84 is very good.
Triglyceride levels over 100 mg/dl effect the potential for LDL cholesterol to cause harm

by reducing the the size of LDL cholesterol particles.

Also your low triglycerides level of 84 means that the calculation of your LDL

cholesterol is more accurate. Your LDL is 93 . The target goal is < 100 mg/dl

*Your LDL test is not measured it is calculated by subtracting HDL and 1/5 of your

triglyceride levels from your total Cholesterol .

* Measuring APO- b is a more accurate method of evaluating LDL levels. There is one

Apo b attached to each LDL particle.

Generally ordering an Apo b level is not necessary unless someones triglyceride levels

are over 150 mg/dl .

The target goals for ;

Apo b is 90 mg/dl if the LDL is <100 mg/dl

Apo b is 80 mg/dl for LDL = or < 70 mg/dl

* Non HDL cholesterol is another way of evaluating risk . It is another calculated

number. Cholesterol - HDL = Non HDL Cholesterol

This number represents all of the other various forms of cholesterol such as IDL ,LDL

and VLDL that are generally up to no good.

The target goals for:

non - HDL cholesterol is <130 mg/dl if the LDL is = or < 100 mg/dl

non-HDL cholesterol is < 100 mg/dl if the LDL is < 70 mg/dl

your calculation is; Cholesterol 161 - HDL 49 = Non HDL cholesterol is 112 mg/dl

* Your HDL and cholesterol are in a low risk range.

Your lab test suggest that you are low risk for cardiovascular disease now. I would suggest starting to make some lifestyle changes and repeating your lipid panel in 1 year.

Switching towards a Medaterreanean style eating habits is a good way to preserve your good health. I have attached a simplified version that I can remember and have found useful. (Holidays are exempt ). I have difficulty including legumes daily and 2 cups of vegetables , 4 bean salads and V8 juice has helped. I also don't care for fish and have generally stopped eating meat because I like the animals more than I like their meat . This does not mean that I will pass up an occasional hamburger or steak.

I think the article below is from WEB MD. The dietitian who wrote this did a good job.

The Mediterranean Diet: What It Is

Some experts consider the "Mediterranean diet" -- rich in plant foods and monounsaturated fats -- to be one of the healthiest in the world. The Mediterranean diet has long been associated with heart health and longevity. Beyond that, it can also be an excellent weight loss plan, as long as you eat in moderation.

The Mediterranean coastal region stretches across Europe from Spain to the Middle East. Fifty years ago, scientists noticed that people living in this region tended to be healthy and live long lives, primarily because of their diet and lifestyle. Mediterranean cuisine varies by region, but is largely based on vegetables, fruits, olives, beans, whole grains, olive oil, and fish, along with a little dairy and wine. Additionally, the Mediterranean lifestyle includes leisurely dining and regular physical activity.

Studies show that calorie-controlled diets rich in plant foods, healthy fats, and lean protein -- like the Mediterranean diet -- are a nutritious formula for weight loss. A study in the New England Journal of Medicine found that a Mediterranean diet was as effective as a low-fat diet for losing weight and also offered some metabolic benefits.

"Research continues to demonstrate that being physically active and eating a nutritious diet of primarily whole foods that are filling and satisfying can enable people to control weight," says cardiologist Arthur Agatston, MD, creator of the South Beach Diet, which is based on the Mediterranean diet model.

Some other perks of living the Mediterranean lifestyle include a reduced risk of chronic diseases such as diabetes, cancer, Alzheimer's and heart disease, says cardiologist Robert Eckel, MD, past president of the American Heart Association.

Mediterranean Diet: What You Can Eat

There is not a single "Mediterranean diet." Instead, it's a dietary pattern of plant foods, monounsaturated fats (mainly olive oil), fish, and limited amounts of animal products.

The basic Mediterranean diet pattern is as follows:

Legumes: Eat daily.
Fruit: 2.5 cups daily.
Vegetables: 2 cups daily.
Fish: More than twice weekly.
Nuts: A handful daily.
Meat/poultry: Less than 4 ounces daily.
Dairy products: 2 cups of a low-fat variety daily.
Wine: 1 daily serving for women, two for men.
Fats: Use primarily monounsaturated fats.
Eggs: Less than 4 per week.

Some tips for embracing the Mediterranean style of eating:

Select whole grains for your breads, cereals, and other starches.
Choose nuts, seeds, legumes, fish, low-fat dairy, and poultry to satisfy your protein needs (you can include lean meat on occasion as well).
Most importantly, reduce the amount of saturated and trans fats in your diet. Use olive or canola oil instead of butter or margarine.
If you choose to drink alcohol, enjoy it as a glass of wine with lunch and/or dinner.

"It's almost too good to be true -- a steaming pasta dish with tomato sauce and herbs, or a grilled piece of snapper drizzled with olive oil and fresh cracked pepper, or a great salad of greens, tomatoes, a crumble of Parmesan, and a drizzle of olive oil and lemon," says K. Dun Gifford, Oldways Preservation Trust president. "Scientists report these dishes are as healthy as it gets."

Niacin " Aims High " and Missed

2012-02-01T09:33:00.000-08:00

Hint - just read the bold print and save 77.2 seconds of your day

Niacin has never been one of my favorite medications and this study moved it a little further down, but did not completely drop it off of my list of medication to help lower Triglycerides and raise HDL.

( Sorry , I am having a problem getting the chart to transfer )
I have attached a copy of an old study demonstrating the relationship between LDL cholesterol ,HDL Cholesterol and cardiovascular risk. Look at the LDL of 100 and notice the small increment in cardiovascular risk reduction with 20mg/dl increases in HDL . Now imagine this same slide with and LDL of 70 mg/dl ( actually the LDL deceased from 74 to 62 ) and a 6mg/dl increase in HDL. It would be very difficult to pick up such a small difference in risk .

Also , with a Triglyceride level of 164 mg/dl ( 1.85 mm/l ) your doctor would not have recommended Niacin. I would like to see a sub group analysis of patients with at least a triglyceride level over 200 mg/dl (2.2 MM/l )

Another study is in progress .HPS2-THRIVE , and may answer the question.

N Engl J Med. 2011 Dec 15;365(24):2255-67. Epub 2011 Nov 15.

Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy.

AIM-HIGH Investigators, Boden WE, Probstfield JL, Anderson T, Chaitman BR, Desvignes-Nickens P, Koprowicz K, McBride R, Teo K, Weintraub W.

Collaborators (316)

Abstract

BACKGROUND:

In patients with established cardiovascular disease, residual cardiovascular risk persists despite the achievement of target low-density lipoprotein (LDL) cholesterol levels with statin therapy. It is unclear whether extended-release niacin added to simvastatin to raise low levels of high-density lipoprotein (HDL) cholesterol is superior to simvastatin alone in reducing such residual risk.

METHODS:

We randomly assigned eligible patients to receive extended-release niacin, 1500 to 2000 mg per day, or matching placebo. All patients received simvastatin, 40 to 80 mg per day, plus ezetimibe, 10 mg per day, if needed, to maintain an LDL cholesterol level of 40 to 80 mg per deciliter (1.03 to 2.07 mmol per liter). The primary end point was the first event of the composite of death from coronary heart disease, nonfatal myocardial infarction, ischemic stroke, hospitalization for an acute coronary syndrome, or symptom-driven coronary or cerebral revascularization.

RESULTS:

A total of 3414 patients were randomly assigned to receive niacin (1718) or placebo (1696). The trial was stopped after a mean follow-up period of 3 years owing to a lack of efficacy. At 2 years, niacin therapy had significantly increased the median HDL cholesterol level from 35 mg per deciliter (0.91 mmol per liter) to 42 mg per deciliter (1.08 mmol per liter), lowered the triglyceride level from 164 mg per deciliter (1.85 mmol per liter) to 122 mg per deciliter (1.38 mmol per liter), and lowered the LDL cholesterol level from 74 mg per deciliter (1.91 mmol per liter) to 62 mg per deciliter (1.60 mmol per liter). The primary end point occurred in 282 patients in the niacin group (16.4%) and in 274 patients in the placebo group (16.2%) (hazard ratio, 1.02; 95% confidence interval, 0.87 to 1.21; P=0.79 by the log-rank test).

CONCLUSIONS:

Among patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of less than 70 mg per deciliter (1.81 mmol per liter), there was no incremental clinical benefit from the addition of niacin to statin therapy during a 36-month follow-up period, despite significant improvements in HDL cholesterol and triglyceride levels. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; AIM-HIGH ClinicalTrials.gov number, NCT00120289.).

Have fun , Be Smart and Defeat Heart disease and Diabetes.

David Calder, MD

Women and Heart Disease- The Evening News Again

2012-01-31T10:14:00.000-08:00

hint - save 46 seconds just read the high lighted area

It is the evening news again. Last night one of the major news stations reported on a new study , the first proof , that "women can reduce their risk of having cardiovascular disease by taking taking a Statin ".

I think it is great that they helping every one become more aware of the value of " Statin " drugs . But maybe they should have said it confirmed previous studies.

The Heart Protection Study published in Lancet vol.360 -july 6, 2002 included women. This study of high risk individuals , found that taking Simvastatin 40 mg /day for 5 years would prevent about 70 to 100 people per 1000 from suffering a major vascular event irrespective of age, sex and presenting cholesterol concentrations.

The CARDS study also published in Lancet vol. 364 Aug.21, 2004 was done on people with Diabetes and with no previous history of heart disease but including people with known risk factors. Women were included in this study also.
The treatment group receive atorvastatin 10 mg /day . The results of the CARDS study shows that atorvastatin 10 mg /day leads to a 37% reduction in major vascular events and a 48 % reduction in strokes.

The last sentence in the CARDS study report is one of my favorite lines.

" The debate about whether all patients with Type 2 Diabetes warrant statin treatment should now focus on whether any patients can be reliably be identified as sufficiently low risk for this safe and efficacious treatment to be with held, "

I believe that we can add "all men and women "and can remove " with Type 2 Diabetes " from the above statement because we are all at risk of having vascular disease.

Remember , you are responsible for your for your health care. Don't let yourself down. Know and correct any risk factors you may have for heart disease..

Have fun , Be Smart and Defeat Heart Disease
David Calder,MD

Click on the tag below for more ideas for preventing heart disease

Diabetes Office Visit- Helps you prevent Heart Disease

Omega -3 - fatty acids and Heart Disease

2012-01-30T08:45:00.000-08:00

Hint ; save 39.2 seconds of your time by just reading the highlighted area

We know that Omega 3 fatty Acids , EPA and DHA, in Fish Oil reduce triglyceride levels but do they reduce the risk of having heart disease.

There is one study done in Japan, Jelis Study (Japan EPA Lipid intervention Study) reported in Lancet 2007;369: 1090-8

This study was included 18,000 patients with and without heart disease with total cholesterol of 251 mg/dl (6.5 mmol/L ) and LDL of 171 ( 4.4 mmol/L ) and randomized to a low dose statin alone or a statin plus 1.8 grams of EPA purified from omega - 3- fatty acids in fish oil and followed for an average of 4.6 years.
Results ;
Statin only group --- ------------ 3.5% had a major coronary event
Statin plus 1.8 grams of EPA -- 2.8% had a major coronary event

A 19% relative risk reduction in the group receiving 1.8 gms of EPA

There was a followup analysis of this study reported in Artherosclerosis 2009 may:204(1):233.
This analysis looked at people in the Jelis study with elevated Triglycerides > 150 mg/dl and
HDL < 40 mg/dl. In this higher risk group, EPA treatment resulted in a 53% relative risk reduction.

There is another planned study - REDUCE IT ( Reduction of Cardiovascular Events with EPA intervention trial ) that will specifically look at the effects of Triglyceride reduction and cardiovascular risk. Hopefully this study , to be completed in 6 years ,will provide us with a more definitive answer .

For now , Omega 3 fatty acids , are still my first choice.

Have fun , Be Smart and Defeat Diabetes
David Calder,MD

Click on the link below to learn more about ," Fixing The 9 " and preventing heart disease.

Diabetes Office Visits- Helps You Prevent Heart Disease

Diabetes ,Triglycerides, Fish Oil and Heart Disease

2012-01-29T13:43:00.000-08:00

Yesterday we discussed why the ACCORD study failed to demonstrate a reduction in the risk of heart disease with combination of simvastatin and fenofibrate .

For those of you who just want a quick summary of todays blog , just read the bold print.

Lowering Triglyceride levels and raising HDL Cholesterol is a continuing challenge.
Life style changes with weight loss and increased exercise and correcting high glucose levels work to a certain degree . Our choices of medications have been limited primarily to fibrates such as fenofibrate , Niacin and Omega -3 -fatty acids ( fish oil ) .

I was always reluctant to use fibrates because of the increased risk of Rhabdomylosis when combined with a Statin and Niacin was difficult to use because of site effects. This left me with Omega -3-fatty acids that had its on set of problems. It was only recently that we had an FDA approved source of purified fish oil with each capsule containing 840 mg of EPA =DHA. ( Lovaza). Cost became a factor because of the number of pills required to be effective. All of the above resulted in my having patients use over the counter brands of fish oil. Using over the counter medications made me uncomfortable but I did find that the results were good . I was encourage by a recent article in Consumer Report ( January 2012 page11) verifying that most of the over the counter brands did actually contain the amounts of EPA ad DHA found on the label.

There is an article in the January 2012 Internal Medicine News that is reviews more good news for us Fish Oil lovers. There may be another FDA approved source of fish oil available soon.

Fish Oil Works to lower Triglycerides
AMR101 is pure EPA. There initial study (ANCHOR Trial ) was in a group of patients with high cardiovascular risk on Statins with LDL cholesterols of 100 mg/dl or less and Triglyceride levels between 200 and 500 mg/dl . AMR 101 2 gms/day and 4 gms/ day reduced triglycerides 10.1% and
22 % respectively.

Another study using the same medication was done in patients with fasting triglyceride levels of at least 500mg/dl .This study , MARINE Study, reported in the American J. Of Cardiology 2011;108:682-90 found that 2 and 4 gms/day of AMR101 reduced Triglyceride levels 20 % and 33 % respectively.

These two studies provide more evidence that Omega 3 fatty acids work and seem to be more effective in patients with higher triglyceride levels.

Will Fish oil reduce my risk of developing heart disease ?
stay tuned
Have Fun , be Smart and Defeat Diabetes
David Calder,MD
.

News report " Diabetes treatments Deemed Harmful " The rest of the story

2012-01-28T10:10:00.000-08:00

Diabetes Treatments Deemed Harmful

By MAYS January 8 201 A major diabetes study has found that common treatments don't reduce heart trouble and some may actually cause harm. Elaine Quijano speaks with Russ Mitchell about this revealing study.

This was reported on CBS news Jan 8, 2012 and the video was shown again on Diabetes Connect today.

I could not let this pass without telling you the rest of the story. They reported that heart disease and strokes are a major cause of death and disability for people with type 2 diabetes which is correct. They also reported that lowering blood pressure from 140 to 120 systolic or that combining simvastatin ( Zocor ) and fenofibrate (tricor) did not reduce cardiovascular risk.

I believe they are referring to the ACCORD study.

The ACCORD trial, sponsored by the National Heart, Lung and Blood Institute (NHLBI), was set up to test the efficacy of 3 medical treatment strategies (blood glucose lowering, blood pressure lowering, and lipid altering) in reducing cardiovascular events in middle-aged and older people with type 2 diabetes plus established cardiovascular disease (CVD) or additional (≥ 2) cardiovascular risk factors.[1,2] The multicenter, double 2×2 factorial design ACCORD trial recruited 10,251 patients in the United States and Canada.

I have read a number of articles about the pros and cons of this study and came away with the idea that this study did make some good points;

#1 " if it ain't broke don't fix it "
#2 Ours current guides lines for the treatment of Lipids , Blood pressure and blood sugar are pretty good
#3 The treatment of diabetes is not a one size fit all disease. The treatment recommendations that we make
as physicians and other health care providers has to be tailored to fit the life situations of the person
setting in front of us at that moment in time.

I would like to discuss the " if ain't broke don't fix it " idea today.

This refers to the treatment of elevated triglycerides and low HDL as a cause for something called "residual risk ".
We have some very good tools ( primarily Statins ) for lowering LDL Cholesterol and lowering but not removing the risk of heart disease and stroke. This residual risk is thought to be related to the problems of low HDL ( <40 in men and < 50 mg/dl in women )and high triglycerides ( >150 mg/dl ).

The ACCORD trail hoped to clarify some of the issues around this problem of residual risk .The study did prove one thing " if it ain't broke don't fix it" . The use of simvastatin was so effective at lowering LDL cholesterol to an average of 78mg/dl and decreasing Triglycerides and raising HDL that only 17 % of the group receiving fenofibrate met the criteria for it's use. This means that in real life , in your doctors office ,83 % of the people would not have been treated with any thing other than simvastatin . It is unfortunate that that the study design got in the way of more helping us resolve the question of residual risk. It is no real surprise that they were unable to demonstrate any benefit from the use of fenofibrate.

Tomorrow . More on triglycerides , HDL and risk

Have fun , be smart and defeat diabetes
David Calder,MD

The idea of "if it ain't broke don't fix it " idea came from the article below.

Cardiovasc Diabetol. 2010 Jun 15;9:24.

"If it ain't broke, don't fix it": a commentary on the positive-negative results of the ACCORD Lipid study.

Tenenbaum A, Fisman EZ.

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study investigated whether combination therapy with a statin plus a fibrate, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with type 2 diabetes mellitus. However, relevant patients with atherogenic dyslipidemia represented less than 17 percent of the ACCORD Lipid population (941 out of 5518 patients).

This means that 83 % of the people treated with the combination of Simvastatin/ fenofibrate would not have been treated with fenofibrate according to the recommendation for using the drug. Low HDL and elevated triglycerides

CPAP , Hearing Aids and Diabetes- New is better !

2012-01-27T09:50:00.000-08:00

My old experience as a physician seeing patients dealing with the various sleep apnea treatments including CPAP was not that good. It seemed that most sleep apnea equipment was similar to the use of hearing aids , a lot of people owned the equipment but few consistently used it.

Advances in technology has changed both hearing aids and sleep apnea equipment into comfortable useful tools that are a pleasure to use.

My new experience as a physician and a patient using new hearing aids and CPAP for for my obstructive sleep apnea is "Oh my goodness ! Why did I wait so long ? "

The diagnosis of sleep apnea and compliance to treatment recommendations have improved significantly in recent years. The new quite comfortable simple to use equipment coupled the expertise of doctors and respiratory therapist have had a big impact on the management of this problem.

There are various surgical procedures and different oral appliances that have had limited success .

I believe that the use of CPAP "continuous positive airway pressure" continues to be the most effective. These machines are quite and automatically adjust to deliver just the right amount of pressure needed to over come the airway obstruction. The humidity of the delivered air can be adjusted to your comfort. The face masks have improved along with the machines to deliver warmed humidified air comfortable to your nose and mouth. The delivery of air directly into a person's nose with something called Nasals Pillows has been a step in the right direction.

If you have been diagnosed with sleep apnea , I suggest that you Google CPAP and also Nasal Pillows. Read and learn much as you can about the available equipment before your doctors visit . Decide on the features you would prefer to have with your equipment and if possible talk to someone who has sleep apnea and get their opinion on their pros and cons on the equipment they are using . It is possible to talk with some one ,ME . You can use the comment section below.

Your doctor will make recommendations based on his or her experience and your test results . There is a lot of CPAP equipment with multiple options
If you have done your home work then you will be a better participant in the decision process .

Have fun, Take advantage of the new wonderful advances in medical care.
David Calder, MD

Sleep Apnea,You can't diagnosis it if you don't think of it

2012-01-25T11:16:00.000-08:00

Sleep Apnea
You can't diagnosis it if you don't think of it

Obstructive Sleep Apnea is a contributor to :
* the development of Diabetes and hypertension
* to some of the management problems associated with diabetes and hypertension
( including hypoglycemia )
* To a variety of vague common every day symptoms discussed yesterday

The Diagnosis is easy and painless .
* Talk to your doctor about Sleep Apnea
* Ask for a consult to a sleep center and sleep specialist

Testing is easy and painless . No blood test involved.

* There is a simple unattended screening sleep study . This involves picking up a device that
measure pulse and oxygen saturation and a few other things at a sleep center.
This device is small and attaches to the tip of your ring finger You wear this all night
and return it to the sleep center the next morning. The results and recommendations on how to
proceed are reported to you in a few days.

Our 72 y/o patient , discussed a few days ago , had this test done. He slept 7 hours and had 99
episodes of oxygen desaturations with his oxygen (sp o2 levels) levels dropping down to
78%. ( normal is about 100 %). His study was reported as definitely abnormal and compatible
with having, Obstructive Sleep apnea. He was asked to return for a more complete study that
involved spending the night in the sleep center. The primary reason for this test was to
determine the pressure needed to overcome the obstruction to air flowing into his lungs.

CPAP was ordered and within 2 months his blood pressure was normal (<130/80 ) with no
medications, His nasal congestion and morning cough is gone and there is no snoring . His
wife is happier because she is now able to have a good nights sleep .
His A1c and lipid panel are pending.

More on CPAP and other treatments tomorrow.

Have fun , be smart and defeat Diabetes

David Calder,MD

Two sneaky diseases, Diabetes and Sleep apnea

2012-01-24T08:58:00.000-08:00

Obstructive Sleep Apnea

Who is at risk of having sleep apnea ?

* Almost everyone regardless of age however it is more common as we mature and get thicker.
* It is estimated that 2% of women and 4% of men over the age of 50 have sleep apnea
* Loud snorers , 17% of men and15% of women have obstructive sleep apnea
* Adolescents with high blood pressure are at risk of sleep apnea
* 30 % of adults with hypertension may have sleep apnea
* two thirds of people with difficult to control blood pressure had sleep apnea in one study
* Obstructive sleep apnea is associated with a 2.7 fold increased risk of having diabetes
* anyone ignoring the vague symptoms listed below

What are the symptoms ?
The symptoms are often considered as normal every day problems that we all deal with from time to time in our lives.

The symptoms and findings may or may not include;

Snoring , snoring and lapses in breathing noticed by a spouse , large neck , daytime sleepiness, fatigue , nasal congestion , morning cough , high blood pressure , having the metabolic syndrome or diabetes , spells of nausea ,sweating and light headedness, sweating at night , unrefreshing sleep , impaired concentration , personality changes and more.

Making a diagnosis of sleep apnea is easy,

Not thinking of Sleep Apnea as a possible correctable cause for our symptoms is the difficult part.

Diagnosis and treatment tomorrow
Have fun , be smart and defeat diabetes.
David Calder,MD

2012-01-23T11:58:00.000-08:00

For those of you who read the Jan. 19 discussion .
" You fail to achieve 100% of the goals you don't set "

Please click on the link below or the tab above for the continued discussion of :
"Simple and Specific Goals Empower each of us to do better "

Diabetes Office Visits- Simple and Specific Goals Empower each of us to do better

Have Fun , Be Smart and Defeat Diabetes. David Calder, MD