Posts Tagged ‘Type 2 diabetes’

NIH Director Address Gastric Bypass Surgery and Diabetes

July 30th, 2013

Francis Collins, director of the National Institutes of Health, has a new blog out on how gastric bypass surgery affects the development of type 2 diabetes.

D is For Disease, Death and Disability

July 8th, 2013

Supposed you woke up and the TV news and newspapers revealed that scientists had discovered a global threat affecting all races, both genders, reducing lifespans and causing millions of cases of disabilities, likely to cost billions of dollars a year. There was no clear cause and no treatment which seemed available, except, in some cases, surgically removing part of the GI track seemed to work…for a while.

What would you say? “Who cares”? “It’s their own fault”? “How much is this going to cost me?”  Perhaps, you would call your Congressional representative and Senator and demand a crash research program to find a cure? Or you could quibble for, say, forty years or so, over who is to blame and whether this “threat” is a condition, syndrome, risk factor or (God forbid!) a disease? Well, the latter is pretty much what we have been doing about obesity. Three new papers show the impact of obesity on mortality, disability and disability-related health care costs, reminding us of the toll this disease takes on the human body.

First, regarding mortality, a great number of studies have been published and the public is still confused. Now, Chang and colleagues, have published a paper in which they are able to predict life years lost associated with obesity-related diseases for non-smoking US adults. They found that obesity-related comorbidities are associated with large decreases in life years and increases in mortality rates. Years of life lost is more marked for younger than older adults, for blacks more than whites, for males than females and for more obese than less obese. Their study confirmed that being obese or underweight increased the risk of mortality. Furthermore, an obesity-related disease, such as coronary heart disease, hypertension, diabetes and stroke, increased the chances of dying and decreased life years by 0.2 to 11.7 years, depending on gender, race, BMI and age.  Obesity-related diseases were expected to shorten lifespan of people in their 20s by more than 5 years, while people in their 60s were predicted to lose just under one year of life. See, Chang SH, Pollack LM, Colditz, Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults.

Obesity-related diseases are also only partially understood. Type 2 diabetes and heart disease are commonly associated with obesity but there are a host of other conditions which are less well-known and appreciated. Among these are the disabling conditions associated with obesity. Brian S. Armour, et al, have looked at disability prevalence among persons who are obese. Of the 25.4% of US adults who are obese (53.4 million), 41.7% reported a disability in contrast to 26.7% of those at a healthy weight and 28.5% of those who were overweight. Movement difficulty was the most common type of basic action difficulty, affecting 32.5% of the adults with obesity. Of course, movement difficulties can hinder physical activity for weight loss.

Work limitations affected 16.6% of the adults with obesity. Visual difficulty was the common sensory difficulty at 11.5%, probably attributable to type 2 diabetes.  20.5% of adults with obesity reported complex activity limitation, compared to 12% of those at a healthy weight. All estimates for disability were significantly higher for people who were obese compared to those with a healthy weight. The prevalence of cognitive difficulty, contrary to Hank Cardello’s implications, was low at 3.6% for persons with obesity. However, persons at a healthy weight had higher cognitive difficulty than those who are overweight, 2.9% v. 2.4%. Armour BS, Courtney—Long EA, Campbell VA, Wethington HR, Disability Prevalence among health weight, overweight, and obese adults. Obesity, 2013 Apr.21 (4); 852-5.

Wayne L. Anderson, Joshua M. Weiner and colleagues widen the picture of persons who are obese with disabilities in terms of health care costs. Their new study estimates the additional average health care expenditures for overweight and obese adults with and without disabilities. They found that people with disabilities who were obese had almost three times the additional average costs of obesity compared to people without disabilities, $2,459 v. $889. Prescription drug costs were 3 times higher and outpatient expenditures were 74% higher. People with disabilities in the 45-64 year age group had the highest obesity expenditures. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities. The authors note, “A substantial portion of people with disabilities are obese. People with disabilities are at higher risk of obesity because some conditions such as arthritis and diabetes are characterized by high levels of functional impairment. Arthritis can readily limit mobility, which may result in substantial weight gain over time. For diabetes, weight gain can be a byproduct of insulin use if patients do not effectively manage their weight. The coexistence of disability, obesity, and serious chronic conditions may result in very high health care expenditures.” Anderson WL, Wiener JM, Khatutsky G, Armour, BS Obesity and People with Disabilities: The Implications for Health Care Expenditures. Obesity, 2013 June 26, (epub ahead of print).

So, obesity is a driver of mortality and morbidity but is not a disease? Eh?


Bariatric Surgery for low BMI Evaluated

June 12th, 2013

The Agency for Healthcare Research and Quality has issued a Comparative Effectiveness Review on “Bariatric Surgery and Nonsurgical Therapy in Adults with Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m2

Bariatric surgery is standard medical practice for patients with a BMI of 40 kg/m2 or for patients with a BMI between 35 and 40 kg/m2 who have significant comorbid conditions, such as type 2 diabetes. In recent years, there has been considerable discussion around providing bariatric surgery for patients with a BMI between 30 and 35 kg/m2 for type 2 diabetes and other metabolic conditions.

The reviewers for AHRQ concluded, “According to blood glucose outcomes, there is moderate strength evidence of efficacy for RYGB (Roux-en-Y Gastric Bypass), LAGB (Laparoscopic adjustable Gastric Banding), and SG (Sleeve Gastrectomy) as treatment for diabetes and IGT (impaired glucose tolerance) in patients with a BMI between 30 kg/m2 and 35 kg/m2 in the short term (up to 2 years). The strength of evidence for BPD (biliopancreatic diversion with duodenal switch) is rated low because there are fewer studies, and these have smaller sample size. Evidence on comparative effectiveness of surgical procedures is insufficient. Short-term adverse events are relatively minor; strength of evidence is low due to small sample size with low power to detect rare events. Strength of evidence is insufficient regarding adverse events in the long-term (2 years or more postsurgery). Longitudinal studies of bariatric surgery patients are needed to assess overall safety and comparative effectiveness regarding diabetes-related morbidity such as kidney failure and blindness.”


Diabetes Rates Soar

November 28th, 2012

The Center for Disease Control and Prevention (CDC) has reported that the prevalence of diagnosed diabetes has increased in all US states, the District of Columbia and Puerto Rico between 1995 and 2010. The prevalence increased by 50% or more in 42 states and by 100% or more in 18 states. The states with the largest increases were Oklahoma, Kentucky, Georgia, Alabama and Washington. According to the CDC press release, in 1995 only 3 states had diagnosed diabetes prevalence of 6% or more; by 2010, all 50 states had a prevalence over 6%.

The press release, (rather amazingly to my point of view) states, “Type 2 diabetes, which may be prevented through lifestyle changes, accounts for 90 percent to 95 percent of all diabetes cases in the United States. CDC and its partners are working on a variety of initiatives to prevent type 2 diabetes and to reduce complications in those already diagnosed. CDC leads the National Diabetes Prevention Program, a public-private partnership that brings evidence-based programs for preventing type 2 diabetes to communities. The program is helping to establish a network of lifestyle-change classes for overweight or obese people at high risk of developing type 2 diabetes.” Of course the evidence-based program they refer to are the Diabetes Prevention Program, which found lifestyle prevention was only effective in young retirees and the Look AHEAD trial, which was terminated prematurely because the lifestyle group had no better outcomes than the control group. Why does the CDC continue to hype bang-the- lifestyle-drum when they know it doesn’t work?


Type 2 Diabetes Harder to Treat in Children

May 1st, 2012

An article by Denise Grady in the New York Times reports on a study that type 2 diabetes in children is harder to treat and more virulent that in adults. The article recounts story of Sara Chernov who learned she had type 2 diabetes when she was 16. “ Her grandfather had had both legs amputated as a result of the disease and one of the first questions she asked was when she would lose her legs and her eyesight. A doctor scolded her for being fat and told her she had to lose weight and could never eat sugar again. She left the office in tears and did not go back.” NYT: Obesity type 2 diabetes worse in children See the article at NEJM: Clinical Trial Glycemic Control in Youth

This is one of those “really bad news” papers. Patients were 10 to 17 years old and treated with metformin to reach a HbA1c level below 8% They were randomized to metformin alone or metformin with rosiglitazone or lifestyle-intervention focusing on weight loss through eating and activity behaviors. Of the 699 participants, only 45.6% reached the primary outcome over an average of 3.86 years of follow-up. Rates of failure were 51% for metformin alone, 38.6% for metformin plus rosiglitazone and 46.6% for metformin plus lifestyle. Metformin alone was least effective in non-Hispanic black participants and metformin plus rosiglitazone was most effective in girls.

Serious adverse events were reported in 19.2% of participants; including 18.1% in the metformin group, 14.6% in the metformin-rosiglitazone group and 24.8% in the metformin plus lifestyle group.

Differences in outcomes were not attributable to adherence or changes in BMI.


How Blame Gets in the Way

February 5th, 2012

Recommended reading. Sara Sklaroff has written an eloquent essay on what it means to live with type 2 diabetes. On Our Own: Why We Who Struggle To Live With Diabetes Could Use A Helping Hand

FDA Approves Once Weekly Drug for Diabetes; Shows Weight Loss

January 28th, 2012

The Food and Drug Administration has approved Amylin Pharmaceutical’s Bydureon for thetreatment of type 2 diabetes. This is the first once-weekly treatment for type 2 diabetes. It is hoped that this feature will lead to higher adherence to the treatment regimen, although as with Byetta, it is injectable. The drug is exenatide, a GLP-1 receptor agonist. Study results showed an improvement in glycemic control.  A1C levels, a measure of blood sugar, decreased an average of 1.6 points.

Many patients with Type 2 diabetes are also overweight or obese. Many drugs for type 2 diabetes actually cause weight gain. The advantage of Bydureon (and its daily administered counterpart, Byetta) is that patients taking Bydureon can achieve weight loss, in addition to improvements in glycemia, blood pressure, and cholesterol in both overweight and obesity subjects with and without type 2 diabetes. Effects of glucagon-like peptide-1 receptor agonists on … [BMJ. 2012] – PubMed – NCBI

A very small study of 12 children and adolescents with extreme obesity also showed significant improvements, suggesting the need for a larger study. Exenatide as a weight-loss therapy i… [Obesity (Silver Spring). 2012] – PubMed – NCBI

More information is available at

NIH Recommends A1c Testing

January 26th, 2012

The National Institutes of Health has come out for expanded A1c testing. Their press release and fact sheet point out that the A1c test does not require fasting and helps identify diabetes and pre-diabetes. They recommend testing of anyone 45 years old or younger than 45 are overweight, inactive or have at least one risk factor for type 2 diabetes. New NIH fact sheet explains test for diabetes, prediabetes, January 26, 2012 News Release – National Institutes of Health (NIH)