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Diabetes Core Update
Diabetes Core Update February 2014
00:21:25
Diabetes Core Update is a monthly podcast that presents and discusses the latest clinically relevant articles from the American Diabetes Association’s four science and medical journals – Diabetes, Diabetes Care, Clinical Diabetes, and...
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- [00:04]
Host
Welcome to the American Diabetes Association Diabetes Core Update, where we will regularly keep you up to date on the latest clinically relevant articles from the American Diabetes Association's four science and medical journals, Diabetes, Diabetes Care, Clinical Diabetes and Diabetes Spectrum. Joining us for this program are Dr. Neal Skolnick, who is a professor of Family Medicine at Temple University School of Medicine and Associate Director in the Family Medicine Residency Program at Abington Memorial Hospital. Welcome, Dr. Skolnick.
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Dr. Neal Skolnick
Thank you. It's a pleasure to be here.
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Host
And Dr. John Russell, who is a professor of Family Medicine at Temple University School of Medicine and director in the Family Medicine Residency Program at Abington Memorial Hospital.
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Dr. John Russell
Thank you. I'm looking forward to going over this week's Army.
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Host
And now for the articles.
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Dr. Neal Skolnick
We have another great issue this month, beginning with the relationship between coffee consumption and the development of type 2 diabetes, followed by a study on fitness, fatness and survival in patients with prediabetes, then hypoglycemia and cognitive decline, followed by discussion of a study that looked at intensification of insulin regimens using premixed versus basal plus bolus therapy, then an article on obstructive sleep apnea, REM sleep and glycemic control, and finally prevention using lifestyle modification in obese youth with prediabetes. Our first study is from the February edition of Diabetes Care on caffeinated and diagnosed decaffeinated coffee consumption and the risk of developing type 2 diabetes. This study did a full literature review of cohort and nested case control studies that assessed the relationship of coffee consumption to the development of type 2 diabetes. It included 28 prospective studies with over 1,100,000 study participants that ultimately developed over 45,000 cases of type 2 diabetes. Follow up duration ranged from 10 months to 20 years. Compared with no or rare coffee consumption, the relative risk of developing diabetes and people drinking one cup of coffee a day was 0.92 or an 8% decreased risk. And that was a graded risk from one to six cups of coffee a day with 0.92 at one cup and 0.67 or a 33% decreased risk for six cups of coffee a day. There was no significant difference between caffeinated and decaffeinated coffee.
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Dr. John Russell
John so on first blush I would have thought if you had said to me if you drink more coffee, are you going to have less diabetes? I probably could argue that away in the fact that, you know, get your heart rate up and potentially you're burning off a little bit more calories. I would not have guessed that caffeinated part of the beverage and the authors and it's a dose response. So if I'm drinking more hot beverage in a day, I'm less likely to have diabetes. My question is exactly why that would come from and is one of the questions if I'm a regular coffee drinker, if I'm drinking five or six cups of coffee a day, be it coffee or decaf, perhaps I'm not drinking soda. You know, I think, you know, people are drinking something in the United States and be it, you know, bottled water, be it coffee, be it tea, be it soda, if I am drinking coffee, be it caffeinated or decaffeinated, that's a possibility. I know there are some diet books that have talked about drinking warm beverages and potentially that raising your temperature coffee itself. There's over 2 billion cups of coffee consumed in the world every day. The United States coffee consumption is about 22 gallons per capita. There's 150 million Americans that drink coffee on a daily basis, yet we've got a lot of diabetes. So I don't think it's completely protective. One of my favorite coffee facts is the Starbucks coffee emporium was originally going to be called Pequod, which was the name of one of the boats in Moby Dick. It was rejected as a name and then it came back Starbucks, which was the name of the chief mate in Moby Dick. Our next article is from the February 2014 edition of D Diabetes Care and it looked at fitness, fatness and survival in adults with prediabetes. So the purpose of the study was to look at independent and joint associations of cardiorespiratory fitness and different adiposity measures with mortality risk in individuals with prediabetes. So they looked at a cohort of over 17,000 participants and examined the association of cardiorespiratory fitness and fatness with cardiovascular disease and all cause mortality. The population was 89% men and they had pre diabetes which was defined as a sugar greater than 100 but a less than 126 fasting and the patients did not have a personal history of diabetes, heart disease or cancer over the course of the study. There were over 832 deaths during the 14 years of study. Normal weight individuals who were found to be unfit had a higher risk of all cause mortality of 1.7 hazard ratio and cardiovascular disease of 1.88 compared with normal weight and fitness. The mortality rate for fit individuals who were overweight or obese did not differ significantly from the reference group.
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Dr. Neal Skolnick
Neil John I love this study because it supports what I've come to believe in. Based on many other studies, there's a real disclarity in the liter about the relationship between weight and cardiovascular outcomes. But there's become a consistency in the literature showing that if you remain fit, you will do better with regard to total mortality, with regard to development of diabetes, with regard to cardiovascular mortality. What's really interesting here, and I think the main take home point is that if you're fit, even, even if you're overweight, fit, overweight people do better than unfit people who are normal weight. So if you have to pick one thing to work on, it's cardiorespiratory fitness. And what I like about that is that that's affected by your behavior. If you make a decision to exercise five times a week for 30 minutes a day, you can control that and you can affect the outcome. We know that when we choose diet and weight loss as a goal, we can't always achieve our goals. So creating simple goals of fitness can lead to profound effects on outcome. Our next study, also from the February edition of Diabetes Care, is on severe hypoglycemia and cognitive decline in older people with type 2 diabetes. This study done in Scotland was looked at cognitive function in 831 adults with type 2 diabetes aged 60 to 75 years of age at baseline and followed them for four years. A self reported history of severe hypoglycemia at baseline and a follow up which was called incident hypoglycemia was recorded. A history of hypoglycemia was reported by 9% of subjects and 10% reported incident hypoglycemia or hypoglycemia during the course of the study. Incident hypoglycemia was associated with poor cognitive ability at baseline. Both history of hypoglycemia before the study began and incident hypoglycemia. That is hypoglycemia that occurred during the four years of the study were associated with greater cognitive decline during follow up including after addition of vascular risk factors, cardiovascular and microvascular disease to the models.
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Dr. John Russell
John so I think hypoglycemia is something that we've certainly talked about a lot in the last year on this program and you know, guidelines over the last year really said that hypoglycemia is probably something we need to be paying more attention to. And if we look look at this in context of some of the other things that certainly we find have found out that people who have symptomatic hypoglycemia have increased mortality. Certainly when we look at any new medicine, we need to evaluate its risk of causing hypoglycemia and we look at the accord in advance trial, we want to make sure in our seniors, which was the population that this looked at, that we really aren't adhering to the same stringent A1C values and we individualize our A1C levels for seniors. So for me, this is a little bit of a kind of a chicken and egg type thing. Is the hypoglycemia itself causing some impairment and some decline, or is it just the fact that people who have impairment and decline might not really have a good judge of when they're being hypoglycem? Might not necessarily remember did they take their insulin, might not necessarily remember did they take their sulfonylurea. So I think just as we kind of reevaluate things like driving in people as they start having some early cognitive decline, I think we also need to look at someone's med list and really say, you know, is the juice worth the squeeze? If someone is starting to have cognitive decline, does it really matter that their blood sugar control was quite as tight? Our next article is from the February 2014 edition of Diabetes Care and this study looked at initiation and gradual intensification of premixed insulin lispro therapy versus basal plus minus mealtime insulin in patients with type 2 diabetes eating light breakfast. So this particular study wanted to look at two different strategies of both initiating and intensifying insulin treatment. Tested for non inferiority of premixed insulin to basal plus mealtime insulin in patients eating light breakfast. So this was an open label randomized study that went on for about a year that compared the two algorithms up to three injections of insulin Lispro mix 25 and or insulin Lispro mix 50 were basal insulin Glargine Plus. Up to three injections of insulin Lispro were used in type 2 diabetic patients uncontrolled with oral anti hyperglycemic medications and consuming less than 15% of their daily calories at breakfast. The overall hypothesis was to look for non inferiority of the premix to the basal for glycemic control measured by an A1C after 48 weeks of the patients there were 176 females which was 51% of the patients. The average age was 54, the average BMI was 29 and the baseline A1C was 9. There were about 170 randomized to the premix and 170 randomized to the basal. The endpoint A1C was 7.4 in the premix and 7.5 in the basal. This treatment difference was a decrease of 0.14 a1c which met the criteria of non inferiority. Significantly more patients in the premix achieved an A1C of targets of less than 7 compared to the basal which was 48 versus 36%. Self monitored blood glucose profiles, body weight changes, total insulin doses and overall rates of hypoglycemia were pretty much equivalent in the two groups.
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Dr. Neal Skolnick
Neil John what I think is really important about this study, which used two different approaches to intensifying an insulin regimen, one using premixed insulin twice a day, one using basal insulin plus a rapid acting insulin with meals, is that essentially both approaches decreased people's A1C by almost 2 points from a baseline of a little above 9 to about 7.4. I think in primary care we're pretty good at saying oral medicines are no longer working, let's now start insulin. And when we start insulin we're good at starting with basal insulin and titrating the dose up. But we're not always that good when someone's A1C is still uncontrolled on basalinsulin alone about knowing what to do next. And I think it's the take home point here is that there are lots of choices. One of the choices mentioned in the American Diabetes association and European Society guidelines from two years ago in medical management is simply to add rapid acting insulin before the largest meal of the day in addition to the person's baseline insulin. Another option, as demonstrated nicely in this study, is to use premixed insulin twice a day and titrate the dose up. There are good choices out there and the important take home point is to choose one of them. For people whose insulin regimens need to be intensified because of inadequate A1Cs. Our next study is on the association of obstructive sleep apnea and rapid eye movement sleep with reduced glycemic control and type 2 diabetes. It's been known for some time that there's an association between obstructive sleep apnea and diabetes and in patients with diabetes it's likely that there's an association between control of obstructive sleep apnea with CPAP and improvement in glycemic control. All participants in this study underwent a polysomnogram and glycemic control was assessed by A1Cs. There were 115 subjects REM apnea, HYPOPNEA index was independently associated with increasing levels of A1C. In contrast, non REM apnea hypopnea index was not associated with changes in A1C. The mean adjusted A1C increased from 6.3% in subjects in the lowest quartile of REM apnea hypopnea index to 7.3% in subjects in the highest quartile.
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Dr. John Russell
JOHN so sleep apnea is certainly a problem as our country has gotten larger. And I think certainly when we think about sleep apnea, I think oftentimes we think about obesity, it certainly is associated with people who are bigger, who have larger necks, etc. So certainly I think you would think that people who have, you know, obstructive sleep apnea are going to have a higher risk of diabetes just because they're going to be bigger. And I think this study actually shows that if you can improve their obstructive sleep apnea through proper use of ventilatory support, people are going to do better. But I think there's some other interesting issues with regard to sleep apnea. One is I think sleep apnea needs to be something on our differential diagnosis for someone with some secondary causes of hypertension. So I think it's something because I think there is stuff that is going on on a neuroendocrine level that is increasing people's blood sugars, as probably we're seeing in this study, but I think is also driving people's blood pressure to have changes. So certainly treating people's obstructive sleep apnea in this case decreased some of their diabetes risk, I think will also decrease people's hypertension. I think the other issue, though, is for all the people who have obstructive sleep apnea who are morbidly obese, who have bariatric surgery, and I think it's one of these indications for someone who has diabetes who is morbidly obese to have this done. It's not a cure all. So it helps 75% of people, but 25% of the people who have bariatric surgery, their sleep apnea is not going to get better. So I think when we're counseling patients, I think we need to inform them of that. The more complicated the bariatric surgery, the more intricate it's going to be, the better chance it is for relieving someone's sleep apnea. So the gastric bands would have a much lower chance than a pancreatoduodenal switch. And our last article in this edition is from the February 2014 edition of Diabetes Care and the study looked at the reversal of early abnormalities in glucose metabolism in obese youth. The results of an intensive lifestyle randomized control trial 20 to 30% of our obese youth in the United States have prediabetes and this is often found more often in minority children. The DPP T trial, the Diabetes Prevention Program demonstrated that type 2 diabetes could be prevented or delayed by intensive lifestyle modifications in adults with prediabetes. But the efficacy of similar intervention and use had not been established. So the researchers evaluated the effects of the Bright Body's healthy lifestyle program on two hour oral glucose tolerance testing in comparison with adolescents receiving the standard career. The use were randomized to a controlled trial comparing either the bright bodies with standard clinical care in obese adolescents who were 10 to 16 years of age and had a tanner stage greater than 2. They were followed with oral glucose tolerance tests at 2 hours and it was from a racially ethnically diverse population. The researchers followed the results of the oral glucose tolerance test. Cardiovascular and anthropomorphic measurements were conducted at baseline and at six months. The children attended the Bright Bodies twice per week for exercise and nutrition and behavior modification and the other group received standard care from their pediatrician. The primary outcome was a change in the two hour oral glucose tolerance test, the conversion from a two hour glucose tolerance test to a non elevated blood sugar. Overall, they found in the two hour glucose was more favorable and in the bright bodies compared with routine care. So there was a decrease of 27% in the bright bodies and 10% in the standard care. Also, the greater conversion to having sugars less than 130 on the two hour glucose tolerance test occurred statistically more often in the bright bodies versus standard care with a P value of 0.003.
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Dr. Neal Skolnick
Neil John, what a great study. So remember it's about a decade, a little over a decade when the Diabetes Prevention Program trial showed in over 3,000 obese individuals with prediabetes and in that you could decrease progression of diabetes with lifestyle modification. Remember that trial randomized that group to either usual care metformin 850 bid or intensive lifestyle modification with the goal of 7% weight loss and 150 minutes of exercise a week and you decrease progression to diabetes by 30% in the metformin group but over 60% in the intensive lifestyle modification group. But up until now there wasn't good data in youth and remember we've seen over a tripling in obesity rates in youth and with that an enormous increase in the development of type 2 diabetes. Here we see that over a short period of time, six months, an intensive lifestyle program here, the Bright Bodies program, meeting with these kids twice a week for six months. Over only six months, we see a decrease in two hour post prandtls of I think you said 27 versus negative 10. That clearly reached clinical and statistical significance. And what's exciting about this is often habits that are developed in youth are habits which are carried over into adulthood. So I think this is an important study and really the promise in prevention lies in prevention early. 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.