C (5:42)

JOHN so that certainly was a, was a very large, very well done study and it'd be nice if there were some simple answers. But certainly it's not a reach for any of us to think that there's societal things that are going on. But that has led to the propensity for Americans to develop diabetes. Food is a big part of that. Our government underwrites a lot of the soy and corn that is grown in the United States and really doesn't underwrite fruits and vegetables. When you look at things like soda consumption, soda consumption has about a 90% markup at our fast food stores and things like that. They want to give people soda, they want people to buy soda because they make so much money on it. Whereas the markup on fruits and vegetables is only around 5 to 10%. So there's not really the incentive for our folks to sell fruits and vegetables. If you look in our inner cities, and you mentioned food deserts that often people do not have a local grocery store where they can get fruits and vegetables, and they're getting a lot of their foods from a small market or a bodega. And that's going to have lots of soda pop, lots of sugar sweetened snacks, lots of salty snacks. And then when you just look at the safety. So, you know, once upon a time, people walk to school. Now, I think a recent CDC study that looked at children who could walk to school, who lived within a mile of their school, only about a third of them actually walked to school. And a big part of that is people don't necessarily feel safe for their child walking that mile, be it that their neighborhood is unsafe or just the people with kind of the fear of crime that seems to be on our televisions all the time are afraid that some stranger is going to abduct their child on the way to school, which for the most part is not a very common type thing. But if you watch on television how often it's reported, we would think that this is an everyday happenstance. So there are lots of reasons that people are eating the wrong things, are not moving enough. And I think one of the other things is work. I think we work more hours now than ever before. Are we sitting down as families to eat meals and we're sitting down to eat meals? Are we eating fresh prepared things? Are we doing activities by ourselves? Or instead of playing baseball, are we playing computer baseball? So there are a lot of factors that are leading to prediabetes and sadly, ultimately to diabetes. So if we're going to cure the prediabetes and diabetes epidemic in the United States, it might not be something that is just going to happen organically. In fact, organically, it's going the other way, that it might have to take a public health policy, much like fluoridating water, that we're just going to have to make some changes societally that ultimately will benefit us all. Our next article is from the August 2013 edition of Diabetes Care. And it looked at the metabolic effects of bariatric surgery in patients who have moderate obesity and type 2 diabetes. So this was a prospective randomized controlled trial of 60 subjects who had uncontrolled type 2 diabetes with an average A1C of 9.7 and moderate obesity with a BMI of greater than 36. They were randomized to intensive medical therapy. Intensive medical therapy plus having a roux en y gastric bypass or intensive medical therapy plus a sleeve gastrectomy and they were followed for 12 and 24 month evaluations as well as being evaluated at baseline. Overall, they found that glycemic control improved in all three groups at 24 months with a mean A1C of 6.7 for the gastric bypass, 7.1 for the sleeve gastrectomy and 8.4 for intensive medical therapy. There was a reduction in body fat that was similar for both surgery groups with a greater absolute reduction in truncal fat in the folks who had a gastric bypass instead of a sleeve gastrectomy. Insulin sensitivity increased significantly from baseline in the gastric bypass group 2.7 fold and did not change in either the sleeve gastrectomy or intensive medical therapy. Beta cell function increased 5.8 in the gastric bypass from baseline and was markedly greater than the intensive medical therapy but was not different from the sleeve gastrectomy.

B (10:01)

Neil John this study adds to the increasing preponderance of studies showing the really strong effects of bariatric surgery on curing diabetes. There were two studies about a year and a half ago reported in the New England Journal that similarly showed markedly positive results of bariatric surgery on reversing diabetes. There about four years ago, bariatric surgery studies in the very obese were followed out up to 10 years showing one of them showed decreased mortality. So clearly bariatric surgery is on the map as an option that is recommended as something that one might consider in the current standards of care for individuals with diabetes who are difficult to control on usual medicines and have a bmi greater than 35. And we're seeing strong positive effects and the effects are strongest with gastric bypass, less so with sleeve gastrectomy, and both significantly better than with intensive lifestyle modification alone. The next article that we are going to review is from Diabetes, specifically Spectrum on meal replacement shakes and nutrition bars. Do they help individuals with diabetes lose weight? This article reviews some of the advantages of using meal replacement shakes and nutrition bars as weight loss tools. The National Weight Control Registry is a program that tracks over 10,000 individuals who have lost a significant amount of weight and have kept it off for at least a year and identifies and investigates some of the characteristics of those individuals and what they've used to succeed achieving their long term weight loss goals. One of the important things that it was found that these individuals use are behavioral strategy tools, things like food diaries, pedometers smaller dinner plates and meal replacement shakes and nutrition bars. This article focuses on the shakes and nutrition bars. Shakes and nutrition bars may be helpful because they provide individuals with primary premeasured amounts of food with a known calorie level and by so doing allows those individuals to bypass the need to weigh meals or to estimate portion sizes that involves less decision making and makes dieting easier. In addition, another manner in which bars seem to help is via something called sensory specific satiety. That's a concept that simply says if your food choices are limited, you'll tend to eat less food than if you have an array of tasty foods in front of you. And then this review went on to discuss a number of studies. One, a study where participants replaced two out of three meals with a meal replacement option that included either shakes or nutrition bars and those individuals lost more weight than the comparison group that shows self selected similar calories eating plans using conventional foods. In fact, at three months the group consuming meal replacement options and bars lost almost 8% of their initial body weight compared to the conventional food group which was only 1.5% of their original body weight. This article goes on to review a number of other studies that have similar results to this, as well as a meta analysis of six randomized trials that showed that meal replacement shakes and bars replacing one to two meals per day during the weight loss phase and one meal a day during the maintenance phase produced weight loss efficacy equivalent to or greater than conventional calorie reduction diets.

C (14:15)

John so what is our ultimate goal for weight loss in folks with diabetes? I'm going to imagine our ultimate goals goal is for people to lose weight and keep the weight off. So it's not the weight loss for someone trying to get into a bathing suit in the summer or a certain outfit or things like that. So I think this like many other studies has shown some short term benefits. So calorie restrictions. So if I'm going to have a 250 calorie bar instead of having a 600 calorie lunch, I'm going to lose some weight. I'm going to have gained 3, 450 calories, 350 calories in that particular transaction and eventually I'll reach 3,500 calories and I'll lose a pound. So this can be helpful if I'm using these replacements as a meal and I'm not going to add extra stuff to that. The problem I think with any of these restrictive diets is long term and I think when they've looked at the more restrictive diets, the very low fat, the very low carbs, carbohydrate diets. People have been able to do them but they have not really been able to do them long term. So certainly I think you could say to a patient this is a way to get 250 calories over lunch, but is the patient going to be able to stick with that? I do think the behavioral modification systems, things like Weight Watchers and things like that, that actually have people eat real food and really change people's behavior have shown that they have done better long term with weight loss versus something like Atkins or the Ornish diet, which are much more restrictive. Our next study is from the August 2013 edition of Diabetes Care and it looked at the prevalence of meeting A1C blood pressure and LDL goals among people with diabetes from 1988 to 2010. This particular study looked at data from the NHANES trial and looked at four 1988 to 1994, 1999 to 2002, 2003 to 2006 and 2007 to 2010. There were close to 5,000 participants who were over 20 in the study and reported a previous diagnosis of diabetes and completed a household interview and physical examination. The main outcomes were A1C blood pressure, LDL cholesterol and these were compared to the American Diabetes association recommendations and they looked at whether someone was currently taking a statin. The improvement in A1Cs being less than 7 in 1988 to 1994 it was 43%. 1999 to 2002 was 44.1% 2003 to 2006 it was 57%. 2007 to 2010 it was 52%. Blood pressure less than 130 over 80 was 33% in 1988 it was 38.1% in the 99 to 2002 period, 2003 to 2006 it was 44.2 in 2007 to 2010 it was 51.1. LDLs less than 100 was only 9%. 1988 to 1994 it jumped up to 35.3 in 99 to 2002, 48% 2003 to 2006 and up to 56% in the last period of 2007 to 2010.

B (17:40)

Neil John, I think what you do with these numbers depends on whether you see the world with the glass proverbial glass, half full or half empty. We've made remarkable strides in our care of both blood sugars and risk factors in patients with diabetes. Improvements in A1C by from 43% to 52% of people meeting goals, blood pressure going from 33% years ago to over half of people achieving their blood pressure goals, and enormous improvements in meeting lipid goals. The interesting question, though is, is it now at a point where a lot of room for improvement remains, which I'm sure is true, but also the issue of individualization of goals. There's probably not as much need for improvement as one might initially think when you see these numbers. That is, you shouldn't think we're missing the boat on half of the people we're treating because remember, in the current standards of care, and it's been this way for a few years, the American Diabetes association has has emphasized individualization of A1C targets. And the reason for that is because we don't want to be treating our frail elderly or older patients with multiple comorbidities with an A1C goal less than 7 and risking the acute adverse effects of hypoglycemia. So I think it's great. We're doing a lot better than we were. We should continue to try to pay attention to doing as rigorous control as we decide is appropriate as we individualize care for the patients that are in front of us. Our next study is from the August edition of Diabetes Care on changes in the United States. Prediabetes prevalence. This study looked at Data from almost 20,000 adult individuals from the 1999-2010 NHANES Nutrition Examination Surveys. Prediabetes was defined in the usual way, an A1C of 5.7 to 6.4 or a fasting glucose of 100 up to 125 milligrams per deciliter. Very simply and clearly, for adults age greater than 18, the prevalence of prediabetes increased from 29% to 36% over that period of time from 1999 to 2010.

C (20:22)

John A Very smart man once said, people don't change when they see the light. People change when they feel the heat. And certainly having close to a third of our adult Americans at a point that they're having pre diabetes, certainly to me is a point that we're starting to feel the heat. The question is, you know, is our society recognizing this heat enough that they're going to see the light and start making some changes?

B (20:50)

For more information and links to the articles that we discussed in this issue, just go to www.diabetesjournals.org until next week, keep listening and keep learning. SA Sam.