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Activity and Insulin: The Basics. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 49-51.
This chapter about the interplay between physical activity and insulin is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors emphasize the benefits of physical activity, including feelings of health, well-being, and more energy; lower blood pressure and improved heart health; improved strength, endurance, and flexibility; weight loss or easier weight maintenance; and decreased insulin resistance. The authors walk readers through the steps of testing blood glucose levels before physical activities and how to proceed based on the result. One illustration depicts a suggested activity pyramid for good health. 1 figure.
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Alcohol Consumption And Diabetes. Practical Diabetology. 21(1): 27-30. March 2008.
This article reviews the risks and benefits of moderate alcohol intake and recommendations practitioners should make for their patients with diabetes. The author cautions that even moderate alcohol intake can interfere with diabetes self-care judgment and may increase lipid levels in some patients with hypertriglyceridemia. However, alcohol can lower insulin resistance, improve glycosylated hemoglobin (HbA1c) levels, lower triglycerides, raise high-density lipoprotein (HDL), reduce blood pressure, and decrease cardiovascular mortality. The author reviews these benefits of moderate alcohol intake, discusses the definition of moderate intake, considers studies that compare the use of wine to other types of alcohol, and offers simple recommendations for physicians working with a diabetes population. The author concludes that practitioners can recommend chronic moderate consumption of alcohol for adults with diabetes who have no contraindications such as risk for alcoholism or hypertriglyceridemia or liver disease. 1 figure. 1 table. 37 references.
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Case Study: Conception as a Potential Consequence of Diabetes Treatment. Clinical Diabetes. 26(2): 83-84. Spring 2008.
This article presents a case report of a 45-year-old caucasian woman with a medical history of type 2 diabetes, polycystic ovarian syndrome (PCOS), hypertension, and gastroesophageal reflux disease. She had a history of one normal, healthy pregnancy and delivery without complication. The authors describe her clinical care, notably the antihyperglycemic medications, including pioglitazone, which has a potential effect of increasing fertility in women with PCOS. The authors review the patient’s nonadherence to some of the antihyperglycemic agents, her concerns about hypoglycemia, patient education needs, her unexpected pregnancy, and the changes in medications that were required as a result of the pregnancy, notably, weaning off the analgesics that were prescribed for her neuropathic pain. The patient experienced a miscarriage at approximately 8 weeks’ gestation, after which she expressed interest in attempting another pregnancy. She was encouraged to improve her glycemic control and blood pressure before attempting another pregnancy. The authors describe the relationship between PCOS and insulin resistance, the mechanisms by which metformin and thiazolidinediones increase fertility in women with PCOS, and the importance of preconception care in all women with diabetes. Tight glycemic goals should be met before conception to reduce the risks of spontaneous abortions and fetal malformations. Medication alterations to improve safety during pregnancy should include discontinuation of oral hypoglycemic agents, statins, and angiotensin-converting enzyme (ACE) inhibitors. 9 references.
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Controversies in Obesity, Diabetes and Hypertension (CODHy) Meeting. What Is It All About?. Diabetes Care. 31( Suppl 2): S111-112. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy), introduces the conference, held in Berlin in October 2006. The conference was designed to provide clinicians with answers to unresolved questions of clinical relevance, to provide a deeper understanding of and ability to integrate new research findings into clinical practice, and to consolidate current knowledge by way of evidence-based research. The diabetes sessions focused on the recent introduction of new treatment modalities, notably insulin analogs and insulin pump therapy, for diabetes management. The relative advantages and risks of analogs and continuous subcutaneous insulin infusion therapy, new glucose monitoring technologies, and inhaled insulin were discussed at the conference. Other topics covered include new treatments for type 2 diabetes; the pathophysiology of type 2 diabetes; the complications of diabetes, including the interplay of oxidative stress, insulin resistance, hypertension and diabetes, as well as cardiovascular complications; the pathophysiology of hypertension and the role of specific drug combinations in the management of patients with both diabetes and hypertension; and obesity-related insulin resistance. The authors of this introductory article stress that, in this special supplement issue, the controversies are presented alongside the reviews of specific topics, leaving the reader to decide which pieces of data are convincing enough to be integrated into their daily practice.
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Diabetes And Obesity: Part 2. Diabetes Care. 31(1): 176-182. January 2008.
This is the fifth in a series of articles based on presentations given at the American Diabetes Association’s 67th Scientific Sessions in June 2007 in Chicago. This article focuses on presentations on the interrelationship between diabetes and obesity. Topics include obesity prevention and treatment, lifestyle modification for weight loss, prevalence of obesity, the prognosis for long-term survival for people with obesity, multidisciplinary interventions for obesity, minimizing the weight gain often associated with insulin therapy, weight gain in people with type 1 diabetes, analog insulins and weight gain, pramlintide, dyslipidemia, pharmacologic strategies for weight loss in individuals with type 2 diabetes, phentermine, the cannabinoid receptor blocker rimonabant, exenatide, weight loss diet recommendations, comorbidities associated with obesity and insulin resistance, the role of obstructive sleep apnea (OSA), polycystic ovary syndrome (PCOS), risk of cardiovascular disease (CVD), nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), lipotoxic heart disease, pregnancy and weight gain in women with diabetes, increasing incidence of diabetes diagnoses, insulin sensitivity, and the metabolic syndrome. The author provides the names and locations of the presenting researchers for readers who want to follow up and obtain additional information about the research summarized in this article. 13 references.
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Diabetes Numbers At-A-Glance. Rev. ed. Bethesda, MD: National Diabetes Education Program. 2008. 2 p.
This brochure, printed as an information card, summarizes many of the monitoring tests and recommended levels for people who have diabetes. Included on the card are the criteria for diagnosis of pre-diabetes; criteria for diagnosis of diabetes; and treatment goals for the ABCs of diabetes, which are A1c or glycosylated hemoglobin, blood pressure, and cholesterol and lipid profiles. The guidelines are recommended for nonpregnant adults, and readers are reminded to individualize treatment goals as necessary. The reverse side of the card lists the recommended diabetes patient management schedule, summarizing recommended care for each regular diabetes visit, for quarterly visits, annual tests, and lifetime recommendations. Readers are referred to the National Diabetes Education Program (NDEP) contact sites at 1–800-438-5383 or www.ndep.nih.gov for more information.
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Diabetes Overview. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 16 p.
This fact sheet provides an overview of information about diabetes, defined as a disorder of metabolism. The fact sheet describes the three main types of diabetes: type 1 diabetes, an autoimmune disease in which the pancreas produces little or no insulin; type 2 diabetes, in which the body does not produce enough insulin or uses insulin inefficiently; and gestational diabetes, which is associated with pregnancy and a subsequent increased risk for type 2 diabetes. The fact sheet discusses diagnostic considerations, the condition of pre-diabetes, the complications that may be associated with diabetes, epidemiology of type 1 and type 2 diabetes, and patient care for people with diabetes. The fact sheet describes current research efforts in the diabetes arena, including the Diabetes Prevention Trial–Type 1 (DPT-1), the Environmental Determinants of Diabetes in the Young Consortium (TEDDY), Type 1 Diabetes TrialNet, the Immune Tolerance Network, the Trial to Reduce IDDM in the Genetically at Risk (TRIGR), islet transplantation studies, the Diabetes Prevention Program (DPP), studies on type 2 diabetes in children and teens, and studies focusing on preventing and treating cardiovascular disease in people with type 2 diabetes. Contact information for three resource organizations is listed: the American Diabetes Association at www.diabetes.org or 1–800–342–2383, the National Diabetes Education Program at www.ndep.nih.gov or 1–888–693–6337, and the Juvenile Diabetes Research Foundation International at ww.jdrf.org or 1–800–533–2873. A final section provides contact information and a brief description of the goals and activities of the National Diabetes Information Clearinghouse (NDIC), a Government service that provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. 1 figure.
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Diabetes. Washington, DC: National Women’s Health Information Center. 2008. 6 p.
This fact sheet answers common questions about diabetes, including type 1 diabetes and type 2 diabetes. Topics covered include a definition of diabetes and its complications, the condition of pre-diabetes or metabolic syndrome, the different types of diabetes, who gets diabetes and what causes the disease, risk factors for diabetes, how to know whether testing for diabetes is needed, the signs and symptoms of diabetes, good self-care for people with diabetes, important self-care for pregnant women with gestational diabetes, and how to prevent type 2 diabetes. Most of the suggestions for improved health, regardless of diabetes diagnosis, focus on achieving and maintaining a healthy weight, eating a nutritious diet, and exercising. The fact sheet refers readers to five resource organizations for more information: the American Diabetes Association at www.diabetes.org or 1–800–342–2383, the National Diabetes Education Program at www.ndep.nih.gov or 1–888–693–6337, the Juvenile Diabetes Research Foundation International at ww.jdrf.org or 1–800–533–2873, the Centers for Disease Control and Prevention at www.cdc.gov/diabetes or 1–800–232–4636, and the National Diabetes Information Clearinghouse (NDIC) at www.niddk.nih.gov or 1–800–860–8747. One side bar briefly reports the story of two women, one with type 2 diabetes and one with gestational diabetes, and how they took care of themselves and their diabetes. 2 figures. 1 table.
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Diagnosing and Managing Latent Autoimmune Diabetes in Adults. Practical Diabetology. 21(1): 32-37. March 2008.
This article reviews the diagnosis and management of latent autoimmune diabetes in adults (LADA), defined as a slowly progressive form of autoimmune diabetes mellitus characterized by mature age at diagnosis, the presence of pancreatic autoantibodies, and the lack of an insulin requirement at diagnosis. The author notes that patients with LADA present with better-preserved beta-cell function than those with classic type 1 diabetes mellitus, but they usually experience a rapid and progressive loss of beta-cell function and tend to become rapidly unresponsive to intervention with oral medications and parenteral agents such as incretin mimetics. The article discusses the importance of the correct diabetes diagnosis, differentiating autoimmune diabetes from diabetes caused by insulin resistance, the prevalence of LADA, the pathogenesis of LADA, screening and testing that can be done for LADA, and treatment strategies for these patients. The author concludes that, although treatment guidelines for LADA have not been published, intensive management with insulin therapy provides a theoretical advantage by preserving any remaining endogenous pancreatic beta-cell function and minimizing long-term complications. 2 tables. 23 references.
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Diagnosis of Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 13 p.
Diabetes is a disease in which blood glucose levels are above normal. People develop diabetes because the pancreas does not make enough insulin or because the cells in the muscles, liver, and fat do not use insulin properly. This fact sheet reviews the different types of diabetes and provides basic information for people who have just received a diagnosis of diabetes. Topics include type 1 diabetes; type 2 diabetes; gestational diabetes; latent autoimmune diabetes in adults (LADA); pre-diabetes or the metabolic syndrome; diagnostic tests used to confirm diabetes, including the fasting plasma glucose (FPG) test, the oral glucose tolerance test (OGTT), and the random plasma glucose test; risk factors for type 2 diabetes; who should consider being tested for diabetes and pre-diabetes; steps that can delay or prevent type 2 diabetes; and management strategies for diabetes, notably meal planning, physical activity, and medications. The fact sheet emphasizes that people with pre-diabetes can delay or prevent type 2 diabetes by losing a modest amount of weight through regular physical activity and a diet low in fat and calories. The fact sheet describes the use of the body mass index (BMI). One chart reprints the BMI tables. The booklet concludes with contact information for related resource organizations, including the American Association of Diabetes Educators, the American Diabetes Association, the Juvenile Diabetes Research Foundation International, and the National Diabetes Education Program. A final section outlines the goals and activities of the National Diabetes Information Clearinghouse (NDIC). 5 tables.
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Efficacy And Safety of Rimonabant for Improvements of Multiple Cardiometabolic Risk Factors in Overweight-Obese Patients: Pooled 1-Year Data From the Rimonabant in Obesity (RIO) Program. Diabetes Care. 31(Suppl 2): S229-S240. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reports on a study undertaken to better define the effectiveness and safety of rimonabant, the first selective cannabinoid type 1 receptor antagonist. The study was conducted in a large population of overweight and obese patients using pooled efficacy data from three Phase III nondiabetes Rimonabant in Obesity and Related Metabolic Disorders (RIO) studies, selected efficacy data from the RIO-Diabetes study, and pooled safety data for all four RIO studies. The RIO studies included patients who were either overweight with at least one comorbidity—e.g., hypertension, dyslipidemia, or type 2 diabetes—or obese. All patients received daily treatment with rimonabant, 5 or 20 milligrams (mg), or placebo for 1 year, plus a hypocaloric diet featuring a 600-calorie-per-day deficit and advice on increased physical activity. The study included data from 3,165 subjects without diabetes and 692 subjects with diabetes. After 1 year of randomized treatment, changes from baseline in those nondiabetic subjects on 20 mg of rimonabant were as follows: body weight, reduction of 6.4 kilograms; waist circumference, reduction of 6.4 centimeters; high-density lipoprotein (HDL) cholesterol, increase of 16.4 percent; triglycerides, decrease of 6.9 percent; and reductions in fasting insulin and assessment for insulin resistance. In the population with diabetes, 20 mg of rimonabant reduced A1C levels by 0.6 percent. Analyses of the data suggested that 45 to 57 percent of the effect of rimonabant could not be explained by the observed weight loss. Serious adverse events were infrequent with rimonabant and almost equivalent to placebo. Overall, discontinuation rates were similar across treatment groups, except discontinuation from adverse events, which occurred more frequently with 20 mg of rimonabant versus placebo and included depressive disorders, nausea, and mood alterations. The authors conclude that in overweight or obese patients, 20 mg per day of rimonabant produced weight loss and significant improvements in multiple cardiometabolic risk factors. 2 figures. 6 tables. 38 references.
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Executive Summary: Standards of Medical Care in Diabetes: 2008. Diabetes Care. 31(Suppl 1): S5-S11. January 2008.
This executive summary is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” The position statement contains all of the ADA’s key recommendations, including national standards for diabetes self-management education (DSME). The executive summary outlines the revisions to the clinical practice recommendations made for 2008, covering the diagnosis of diabetes, testing for pre-diabetes and diabetes, testing for type 2 diabetes in children, the detection and diagnosis of gestational diabetes mellitus, the prevention or delay of type 2 diabetes, self-monitoring of blood glucose (SMBG), glycemic goals, medical nutrition therapy, DSME, physical activity, psychosocial assessment and care, hypoglycemia, immunization, hypertension control, dyslipidemia management, antiplatelet agents, smoking cessation, coronary heart disease (CHD), nephropathy, retinopathy, neuropathy, foot care, children and adolescents, preconception care, older adults, diabetes care in the hospital, diabetes care in schools and daycare settings, diabetes care at diabetes camp, diabetes management in correctional institutions, emergency and disaster preparedness, and third-party reimbursement. The standards are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. Targets that are desirable for most patients with diabetes are provided. The recommendations included are screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes. For each recommendation, the ADA has assigned a letter grade that represents the level of supporting evidence.
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Insulin Resistance and Hyperinsulinemia: Is Hyperinsulinemia the Cart or the Horse?. Diabetes Care. 31(Suppl 2): S262-S268. February 2008.
This article reviews insulin resistance, recently recognized as a strong predictor of disease in adults and a condition that, as the leading element of the metabolic syndrome, has become a renewed focus of research. Insulin resistance exists when insulin levels in the blood are higher than expected, relative to the level of blood glucose. The authors note that many causes and consequences of insulin resistance and hyperinsulinemia have been identified, but the direct contributions of insulin itself in causing or sustaining insulin resistance have received little sustained attention. The authors examine situations where insulin itself appears to be a proximate and important contributor to insulin resistance. They discuss hormones that regulate tissue sensitivity to insulin; transgenic hyperinsulinemia, in a mouse study; the disruption of insulin secretion by insulin resistance; primary hyperinsulinemia in vivo, where insulin resistance is associated with continuous exposure to high levels of insulin; the use of pulsatile insulin to minimize desensitization; basal hyperinsulinemia with insulinomas; and mechanisms of insulin-induced resistance to insulin. The authors conclude that hyperinsulinemia in the basal state, due to any cause, produces widespread insulin resistance. All tissues that have insulin receptor pathways will be affected, including the pancreatic beta-cell and possibly the brain. 3 figures. 65 references.
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Insulin Resistance and Pre-diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 8 p.
Insulin resistance is a condition in which the body produces insulin but does not use it properly. Insulin, a hormone made by the pancreas, helps the body use glucose for energy. Glucose is a form of sugar that is the body’s main source of energy. This fact sheet describes insulin resistance and pre-diabetes. When people are insulin resistant, their muscle, fat, and liver cells do not respond properly to insulin. Insulin resistance increases the chance of developing type 2 diabetes and heart disease. Pre-diabetes is defined as a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. The fact sheet describes the causes of insulin resistance, the symptoms of insulin resistance and pre-diabetes, diagnostic approaches to these conditions, risk factors, ways to reverse insulin resistance and pre-diabetes, body mass index (BMI), and the role of medicines in reversing insulin resistance. The fasting glucose test and the glucose tolerance test may be used to identify and diagnose insulin resistance and pre-diabetes. Causes of insulin resistance and pre-diabetes include genetic factors, excess weight, and lack of physical activity. Being physically active, making wise food choices, and reaching and maintaining a healthy weight can help prevent or reverse insulin resistance and pre-diabetes. The fact sheet concludes with a section that describes current research studies in this area. Contact information for three organizations is provided: the American Diabetes Association at www.diabetes.org or 1–800–342–2383, the National Diabetes Education Program at www.ndep.nih.gov or 1–888–693–6337, and the National Heart, Lung, and Blood Institute Information Center at www.nhlbi.nih.gov or 301–592–8573. The back cover of the fact sheet describes the goals and activities of the National Diabetes Information Clearinghouse (NDIC), a Government service that provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. 1 table.
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Lipoprotein Management in Patients With Cardiometabolic Risk: Consensus Statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 31(4): 811-822. April 2008.
This article presents the consensus statement from the American Diabetes Association and the American College of Cardiology Foundation on lipoprotein management in patients with cardiometabolic risk (CMR) factors. The risk factors for type 2 diabetes and cardiovascular disease (CVD) include obesity, insulin resistance, hyperglycemia, dyslipoproteinemia, and hypertension. These conditions can cluster or occur in isolation, and they are exaggerated by physical inactivity and smoking. This article reports on the consensus development conference held in July 2007 that focused on lipoprotein management in patients with CMR. The consensus statement covers five areas: the extent to which lipoproteins contribute to CVD, the clinically important lipoprotein parameters, other factors to be considered in the evaluation and treatment of patients with lipoprotein abnormalities, the principles and objectives of treatment of lipoprotein abnormalities, and new research-based information that would help improve lipoprotein management. Specific treatment strategies discussed include those to reduce low-density lipoprotein (LDL) levels, determining cut points for initiating therapy, the therapeutic options for LDL cholesterol lowering, assessing response to therapy, and treatment goals for adults with CMR and lipoprotein abnormalities. Recommendations include statin therapy for most adult patients with CMR and dyslipoproteinemia; treatment goals that include the high lifetime risk of patients with dyslipoproteinemia and CMR; the use of apoB to help guide therapy; and a focused, multifaceted public health effort, focused on lifestyle modification, to reduce mean population levels of atherogenic lipoproteins. The authors conclude by calling for studies on residual risk for patients on long-term statin therapy, the role of elevated triglycerides, high-density lipoprotein (HDL) cholesterol, combination therapy, the benefits of lipoprotein management in other high-risk subsets, and the utility of biomarkers. 1 figure. 1 table. 93 references.
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Standards of Medical Care in Diabetes: 2008. Diabetes Care. 31(Suppl 1): S12-S54. January 2008.
This section is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. Targets that are desirable for most patients with diabetes are provided. The recommendations included are screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes. For each recommendation, the ADA has assigned a letter grade that represents the level of supporting evidence. Standards of care are categorized into 11 sections: classification and diagnosis; testing for pre-diabetes and diabetes in asymptomatic patients; detection and diagnosis of gestational diabetes mellitus (GDM); the prevention or delay of type 2 diabetes; diabetes care, including medical nutrition therapy (MNT) and diabetes self-management education (DSME); the prevention and management of diabetes complications, including hypertension, cardiovascular disease, dyslipidemia, nephropathy, retinopathy, neuropathy, and foot care; diabetes care in specific populations, including children, adolescents, and older adults; diabetes care in specific settings, such as hospitals, schools, daycare settings, diabetes camps, and correctional institutions; hypoglycemia and employment/licensure; third-party reimbursement for diabetes care, self-management education, and supplies; and strategies for improving diabetes care. 15 tables. 332 references.
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What is Diabetes? (Type 2) 4th ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program explains the differences between type 1 and type 2 diabetes. The program focuses on type 2 diabetes, covering the symptoms, risk factors, long-term complications, and treatment approaches. Viewers are reminded of the impact of excess weight on the development of diabetes. The program discusses insulin resistance, target ranges of blood glucose, healthy food choices, the diabetes food guide pyramid, carbohydrate counting, fats, portion sizes, the role of physical activity, blood glucose monitoring, and the use of medications to help keep diabetes under control. The video depicts a variety of people with type 2 diabetes and shares their experiences with diagnosis and diabetes management. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Working With Patients to Enhance Medication Adherence. Clinical Diabetes. 26(1): 17-19. Winter 2008.
This article provides practical suggestions for physicians and nurses who want to help their patients follow their medications regimens effectively. The authors stress that optimal medication adherence improves clinical outcomes and can even lower health care costs by reducing morbidity and decreasing health care use. There are many reasons for patient nonadherence, including depression, side effects, poor provider-patient communication, inadequate knowledge on the part of both patients and providers about a drug and its use, psychological insulin resistance, complicated dosing schedule, costs, and other access issues. The authors outline a number of strategies, introduce a collaborative approach by clarifying the patient-physician/team partnership, explain key information when prescribing a medicine, assess adherence, simplify medication-taking, identify difficulties and barriers related to medication-taking, provide behavioral support, and schedule follow-up contacts specifically for medications. A patient education handout on this topic follows this article in the journal. 2 figures. 17 references.
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2006 American Diabetes Association Nutrition Recommendations and Interventions for the Prevention and Treatment of Diabetes. Diabetes Spectrum. 20(1): 49-54. Winter 2007.
This article summarizes the guidelines as presented in the 2006 American Diabetes Association Nutrition Recommendations and Interventions for the Prevention and Treatment of Diabetes. These recommendations reaffirm the importance of medical nutrition therapy (MNT) in the prevention of diabetes, treatment of existing diabetes, and prevention and treatment of the complications of diabetes in which MNT plays a role. The authors highlight major points of emphasis in the 2006 recommendations and note changes from previous recommendations—notably, the 2002 recommendations. Topics include overweight and obesity, pre-diabetes, diabetes treatment, nutrition interventions, type 2 diabetes, pregnancy, older adults, and complications of diabetes. The authors conclude by stressing the importance of monitoring individual outcomes from MNT so that appropriate changes in the overall management plan for diabetes can be implemented. 1 table. 12 references.
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Achieving Glycemic Goals in Type 2 Diabetes. Diabetes Care. 30(1): 174-180. January 2007.
This is the fourth in a series of articles reporting on presentations given at the American Diabetes Association's 66th Scientific Sessions in Washington, DC, June 2006); these papers focus on achieving glycemic goals in type 2 diabetes. Topics include problems achieving recommended glycemic goals in patients with type 2 diabetes, considerations for the use of insulin in this population, aspects of insulin resistance, type 2 diabetes treatment by cytokine modulation, the use of insulin sensitizers, thiazolidinedione (TZD) treatments, new type 2 diabetes treatment approaches, nonalcoholic steatohepatitis, and PROactive analyses. For each topic, the report summarizes the research study and its findings; references are included for readers who want additional information about the findings. 22 references.
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C-Reactive Protein and Cardiovascular Risk in the Metabolic Syndrome and Type 2 Diabetes: Controversy and Challenge. Clinical Diabetes. 25(1): 16-22. Winter 2007.
Although recent findings link high levels of C-reactive protein (CRP) with occurrence of future cardiovascular events, views about its biological activity and predictive value vary. This article considers CRP and cardiovascular risk in the metabolic syndrome and in type 2 diabetes. The authors note that the conditions under which CRP indicates or mediates inflammatory processes remain undefined. The authors review evidence that points to a role of inflammation in the development of insulin resistance, type 2 diabetes, and the progression of atherosclerosis. They note that the interaction among various cytokines and cell types in these pathogenic processes remains unclear. A final section reviews the indications of measuring CRP in clinical practice. The authors conclude that debates continue for and against the use of CRP measurements as a part of screening for global risk assessment for cardiovascular disease. However, evidence that inflammation underlies both the metabolic syndrome and diabetes continues to mount, so the role of CRP as a marker appears less controversial. 2 figures. 62 references.
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Cardiovascular and Metabolic Disease in Menopause: Exploring the Mechanisms. Review of Endocrinology. 1(3): 32-34. July 2007.
This article discusses strategies for the prevention of cardiovascular disease (CVD) and metabolic disease in menopause, including diet, exercise, and soy protein supplementation. The authors note that morbidity and mortality rates from CVD increase after natural and surgical menopause, and the incidence of diabetes dramatically increases after menopause. The authors review the components of metabolic syndrome, including insulin resistance, dyslipidemia, inflammation, vascular function, and adiposity; the role of hormone replacement therapy (HRT); and the use of soy protein. The classic method for counteracting the decrease in energy expenditure with the subsequent increase in abdominal adiposity with aging and menopause is with caloric restriction and exercise; the use of soy protein as a specific dietary supplement shows some promise in preventing the development of risk factors for CVD and metabolic disease in this population. 1 table. 51 references.
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Cellular Mechanisms for Insulin Resistance in Normal Pregnancy and Gestational Diabetes. Diabetes Care. 30(Suppl 2): S112-S119. July 2007.
This article reviews the cellular mechanisms for insulin resistance in normal pregnancy and gestational diabetes. Topics covered include recent insights relating placental hormones and adipokines in the insulin resistance of pregnancy, mechanisms underlying reduced glucose transport in skeletal muscle fibers isolated from obese pregnant women and further reduction in GDM, and insulin resistance in adipose tissue. The authors note that the insulin resistance of normal pregnancy is multifactorial in nature, involving a reduced ability of insulin to phosphorylate IR, decreased expression of IRS-1, and increased levels of the p85alpha subunit of PI 3-kinase. IRS-1 is further decreased in most GDM subjects compared with obese pregnant women at term. However, in GDM, there are reciprocal and inverse changes in the degree of serine and tyrosine phosphorylation of IR and IRS-1 that further inhibit signaling, leading to substantially reduced GLUT4 translocation and decreased glucose uptake beyond that of normal pregnancy. The authors conclude that the combination of subclinical inflammation, placental hormones, reduced adiponectin secretion, and excess lipolysis conspire to cause severe insulin resistance in liver, muscle, and adipose tissue in women with GDM. 2 figures. 84 references.
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Diabetes And Obesity. Part 1. Diabetes Care. 30(12): 3145-3151. 2007.
This is the fourth in a series of articles based on presentations at the American Diabetes Association’s 67th Scientific Sessions, which took place in Chicago in June 2007, discussing aspects of the interrelationships between diabetes and obesity. Topics include the interplay between obesity and insulin resistance, cardiovascular risks in nonoverweight insulin-resistant patients, adiposity and how it changes as patients age, abnormal androgen metabolism, whether fitness protects against obesity, the association between fitness and glycemic abnormality, the central nervous system response to insulin, central regulation of food intake, inflammation as the basis of both obesity and diabetes, and the genetic aspects of obesity. 70 references.
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Diabetes, the Metabolic Syndrome, and Ischemic Stroke: Epidemiology and Possible Mechanisms. Diabetes Care. 30(12): 3131-3140. December 2007.
Diabetes is a major risk factor for developing stroke, yet this risk is often not realized or understood by patients with diabetes. This article explores the potential underlying mechanisms that lead to increase incidence of stroke among people with diabetes. The authors consider metabolic syndrome and its components, the impact of diabetes and hyperglycemia on stroke outcomes, and current approaches to reduce and prevent stroke in this high-risk population. The article focuses primarily on type 2 diabetes because that is the type that affects the majority of those diagnosed with diabetes. Specific topics include insulin resistance, hypertension, hyperlipidemia, obesity, microalbuminuria, endothelial dysfunction and nitric oxide, hypercoagulability conferred by diabetes, and carotid intima-media thickness. 166 references.
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Diabetes-Related Autoantibodies and Gestational Diabetes. Diabetes Care. 30(Suppl 2): S127-S133. July 2007.
This article reviews the role of diabetes-related autoantibodies in the development of gestational diabetes mellitus (GDM). The authors discuss the heterogeneity of autoimmune diabetes, diabetes-related autoantibodies (DRAs) and pregnancy complicated by diabetes, the transplacental passage of DRAs, DRAs and the risk of maternal glucose intolerance or diabetes, and autoimmune GDM as a distinct pre-diabetes stage. The authors conclude that autoimmune GDM is a heterogeneous condition, covering approximately 10 percent of all Caucasian women diagnosed with GDM. This condition may display the various types of expression of the immune reactivity against the beta cell. The authors propose that autoimmune GDM be regarded as a distinct clinical entity, which may be considered a peculiar and complex pre-diabetes state. 1 figure. 3 tables. 85 references.
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Diagnosing and Managing the Metabolic Syndrome in Adults, Children, and Adolescents. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 43-87.
The term “metabolic syndrome” refers to a clustering of specific cardiovascular disease (CVD) risk factors whose underlying pathophysiology is believed to be related to insulin resistance. This chapter about diagnosing and managing metabolic syndrome in adults, children, and adolescents is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author briefly reviews the history of understanding metabolic syndrome, including its epidemiology, and then covers the risk factors; the role of obesity; treatments that focus on behavioral and lifestyle interventions; drug therapy, particularly for risk reduction intervention; the role of primary care physicians; and the importance of early recognition of symptoms and aggressive behavioral intervention. The author concludes by reiterating that health care providers should screen all at-risk children and adolescents for components of metabolic syndrome while promoting healthy lifestyle interventions with both the parents and the patient. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 6 figures. 16 tables. 118 references.
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Do We Know What Homeostasis Model Assessment Measures?: If Not, Does it Matter?. Diabetes Care. 30(10): 2725-2728. October 2007.
This commentary considers homeostasis model assessment (HOMA), a method used to assess insulin resistance and secretion. The authors comment in response to an earlier point-counterpoint article in this journal from September 2007. The authors primarily address concerns that HOMA is not a really accurate testing method. Inaccurate measures require greater sample sizes to detect associations and impair the ability to adjust for important potential confounding factors. The authors note that surrogate measures of insulin sensitivity have been recently developed that provide an increase in accuracy over measures based on fasting glucose and insulin alone. Using this statistical modeling approach has the potential to improve the ability to estimate insulin resistance with data that is readily available. They conclude by calling for additional testing for HOMA and the updated version HOMA2 so as to develop better ways to measure insulin sensitivity and secretion. 29 references.
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Easing the Transition to Insulin Therapy in People With Type 2 Diabetes. Diabetes Educator. 33(Suppl 7): 232S-240S. July - August 2007.
This article is from a special supplement about an American Association of Diabetes Educators’ continuing education program called The Tipping Point: Overcoming Psychological Insulin Resistance, held in Los Angeles in August 2006. In this article, the author considers ways to ease the transition to insulin therapy in people with type 2 diabetes. The author begins with a section on strategies that can help preserve beta cell function, including the use of combination therapy and data found in the United Kingdom Prospective Diabetes Study (UKPDS). The author then makes the case for early basal insulin supplementation, outlines some of the potential barriers to insulin therapy, and describes the role of insulin beyond simply being used for glucose control. A treatment algorithm for incorporating insulin into the care of patients with type 2 diabetes is included. The author concludes that most people with type 2 diabetes do not achieve treatment targets with oral therapy alone and will likely require insulin therapy eventually. Initiation of insulin earlier in the disease process can reduce hyperglycemia, reduce microvascular and macrovascular risk, and potentially improve or preserve beta cell function. 7 figures. 1 table. 27 references.
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Evaluation of Inaccuracies in the Measurement Of Glycemia in the Measurement of Glycemia in the Laboratory, by Glucose Meters, and Through Measurement of Hemoglobin A1c. Clinical Diabetes. 25(2): 43-49. Spring 2007.
This article provides a framework for clinicians who are analyzing the differences between blood glucose measurement as it is obtained from laboratory glucose tests, home glucose meters, and hemoglobin A1c tests. The authors stress that the accurate measurement of blood glucose is extremely important in the diagnosis of diabetes and pre-diabetes, where the laboratory values are crucial; in the management of diabetes, where glucose meter values are crucial; and in attainment of goals in diabetes, where hemoglobin A1c measurement is crucial. The article focuses on pitfalls that may interfere with accuracy of glucose measurement in each of these three areas and how this inaccuracy may be evaluated and managed in the primary care setting. Specific variables that may affect blood glucose measurement can include fasting techniques, serum or plasma glucose samples, centrifugation techniques, the kind of enzyme assay that is used, sampling location, the use of continuous monitors, glucose meter accuracy, the presence of hemoglobinopathy, and being on hemodialysis. The authors present three case examples to illustrate the concepts under discussion. 3 tables. 38 references.
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Exenatide Use in Real Life: Two Illustrative Cases. Practical Diabetology. 26(4): 22-27. December 2007.
This article presents two cases that illustrate the use of the incretin-based injectable therapy exenatide to treat type 2 diabetes. The author notes that despite many advances in diabetes therapy, the disease continues to be characterized by insulin resistance, progressive deterioration in beta-cell function, and the need to increase therapy over time. The first case patient is a 52-year-old female diagnosed with type 2 diabetes at age 46. The author describes her symptoms, dose-limiting problems with side effects from standard antidiabetes drugs, and the benefits of incorporating exenatide into her regimen. The author discusses the clinical trials on exenatide as well as its glycemic effects. The second case patient is a 41-year-old man with a 14-year history of type 2 diabetes, along with hypertension and hypertriglyceridemia. He had a family history of cardiovascular disease, had gained weight over the last several years, and had struggled with achieving adequate blood glucose control. The author reports this patient’s clinical course after exenatide was added to his regimen, commenting on his unusual weight loss as well as problems with nausea. The article concludes with a discussion of the indications for exenatide, noting that for the same degree of glycemic improvement, exenatide treatment results in weight loss instead of weight gain, although with higher rates of gastrointestinal adverse effects than with insulin therapy. The author recommends the use of exenatide after the failure of oral agents and before the introduction of insulin. 2 tables. 18 references.
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Gestational Diabetes, Pregnancy Hypertension, and Late Vascular Disease. Diabetes Care. 30(Suppl 2): S246-S230. July 2007.
This article considers the morbidities, in addition to diabetes, that may be experiences by patients whose pregnancies are complicated by gestational diabetes mellitus (GDM). Both hypertension and vascular disease have been examined in research studies as conditions that may be predicted by GDM. Topics include nondiabetic versus GDM pregnancy and their effects on insulin resistance and other metabolic variables; insulin resistance, GDM, and gestational hypertension; systemic inflammation and GDM; subclinical inflammation, vascular dysfunction and GDM; and late vascular sequelae after pregnancy hypertension. The author concludes that the complexity of the several pathogenic pathways that cause hypertension and vascular disease, and the prolonged interval that appears to predate clinical morbidity, have hindered inquiry into the association between GDM and vascular disorders. 1 table. 24 references.
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Gestational Diabetes. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.
This brief fact sheet reviews gestational diabetes, a form of diabetes that can develop during pregnancy, usually during the second trimester. During pregnancy, the placenta produces hormones that help the baby develop. These hormones can also block the effects of insulin in the mother’s body, increasing her blood glucose levels. The fact sheet answers common questions about gestational diabetes mellitus (GDM), discussing the risk factors for the disease, possible symptoms, associated complications, the dangers of GDM to mother and baby, treatment approaches, and how readers can best use the information provided in the fact sheet. One table lists the possible symptoms of GDM. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. The fact sheet is also available in Spanish. 1 figure. 4 references.
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Human Placenta in Gestational Diabetes Mellitus: The Insulin and Cytokine Network. Diabetes Care. 30(Suppl 2): S120-S126. July 2007.
The physiological environment in a person with diabetes can be considered a network of substances (hormones, nutrients, cytokines) with altered concentrations. The abnormal maternal metabolic environment may generate stimuli within the adipose tissue and the placental cells, resulting in increased production of inflammatory cytokines whose expression is minimal under normal pregnancy. This article considers this insulin and cytokine network in women diagnosed with gestational diabetes mellitus (GDM). Topics include the insulin receptor network, the cytokine network, and the placenta as both source and target of cytokines. The authors conclude that the discovery that some adipokines are produced by the placenta opens new perspectives for understanding the specificity of pregnancy-induced insulin resistance. The authors note the importance of functional interplays between the placenta and maternal white adipose tissue in GDM. 5 figures. 74 references.
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Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for Care. Diabetes Care. 30(3): 753-759. March 2007.
The availability of interventions that have been shown to decrease the development of diabetes has stimulated consideration as to whether such interventions should be recommended and implemented, in whom, and under what circumstances. To address these issues, the American Diabetes Association (ADA) convened a consensus development conference in October 2006, focusing on the prediabetes states of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). This article reports on the answers to some of the questions that the consensus development conference addressed. Topics include definitions of IFG and IGT and their natural history; the pathogenesis of these conditions; how to alter the natural history of IFG and IGT; interventions that prevent the progression from IFG/IGT to diabetes and whether these interventions can also prevent the worsening of diabetes-related risk factors, including those connected to cardiovascular disease; the data that supports interventions undertaken to prevent or delay diabetes in people who have IFG/IGT; and patient selection for screening, methods for screening, and strategies to delay the adverse consequences of IFG/IGT. 1 figure. 2 tables. 59 references.
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Insulin Resistance Concepts. Diabetes Care. 30(5): 1320-1326. May 2007.
This is the first in a series of four articles summarizing presentations given at the World Congress on the insulin resistance syndrome (IRS). Topics include the clinical aspects and mechanisms of insulin resistance, insulin resistance and the brain, and biological rhythms and insulin resistance. The author includes direct quotes from the presentations and extensive references for readers wishing to obtain additional information. 35 references.
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Insulin Sensitization by Selective Inhibition of 11Beta-Hydroxysteroid Dehydrogenase Type 1. Review of Endocrinology. 1(2): 52-55. June 2007.
This article reports on studies of drugs that foster insulin sensitization by selective inhibition of 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1). Blood concentrations of glucocorticoids such as cortisol are regulated by the hypothalamic-pituitary-adrenal (HPA) axis. Elevated cortisol levels are physiologically useful in response to stress. However, subtle dysregulation of the HPA axis may be associated with insulin resistance, hypertension, and hypertriglyceridemia in the metabolic syndrome. The authors note the possibility that reducing glucocorticoid action could provide a new therapy for type 2 diabetes, obesity, and the metabolic syndrome has been known for some time. They focus on the enzyme 11beta-HSD1 and its inhibitors. 11beta-HSD1 is expressed predominantly in the liver and adipose tissue and may have greater effects on metabolism than on the HPA axis and the immune system. The authors review drug studies of 11beta-HSD1 inhibitors in animals and in humans. The article concludes with some of the potential concerns about using these inhibitors. Clinical trials of new agents are needed to determine whether the benefits observed in rodent models can be similar in humans. 2 figures. 49 references.
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Interventional Cardiology And the Patient With Type 2 Diabetes. Practical Diabetology. 26(3): 6-13. September 2007.
People with diabetes are approximately three times more likely to experience a cardiovascular event than individuals without diabetes. This article discusses interventional cardiology and patients with type 2 diabetes. The authors cover the endovascular bed in diabetes, metabolic risk factors associated with type 2 diabetes, how to assess the risk of cardiovascular disease in patients with diabetes, the medical treatment of patients with type 2 diabetes and reversible myocardial ischemia, and optimal revascularization strategies in diabetes. Cardiovascular risk factors such as high cholesterol and blood pressure appear to be associated with insulin resistance at a molecular level, and therefore a large population of diabetes patients requires revascularization procedures. However, selection of the best myocardial revascularization strategy for diabetes patients with multivessel disease has proven controversial. The article includes one case report of a 50-year-old man with a 20-year history of type 2 diabetes; the authors focus on that patient’s risk for heart attack and stroke. They conclude by reiterating that aggressive control of blood glucose levels reduces the risk of microvascular disease and improves the overall outcome for the patient. 1 figure. 1 table. 26 references.
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Introduction to Diabetes. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 1-42.
Although they receive an average of only 4 hours of professional training on diabetes, primary care physicians manage 90 percent of the patients with diabetes in the United States. This introductory chapter is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. The author addresses all aspects of outpatient and hospital-based diabetes care for various age groups and focuses on behavioral interventions for enhanced patient adherence. In this chapter, the author reviews the rationale and importance of primary care intervention for people with diabetes and pre-diabetes, also called metabolic syndrome. The author notes that most patients with diabetes require pharmacologic regimens that are well-established, widely used, and safe, allowing primary care physicians to provide care for many of their own patients and refer more complex cases to specialists. Patients with chronic, poorly controlled hyperglycemia may have multiple complications that require the coordination and management skills of their health care provider. The author concludes the expertise in behavioral change and disease self-management is central to the successful care of any chronic disease, especially diabetes. 4 figures. 6 tables. 25 references.
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Managing Diet and Obesity in Type 2 Diabetes: Joslin Diabetes Center's Nutrition Guideline. Practical Diabetology. 26 (2): 6-10. June 2007.
This article reviews the nutrition guidelines from the Joslin Diabetes Center for managing diet and obesity in patients with type 2 diabetes. The author first reviews the role of obesity in type 2 diabetes and the complications associated with cardiovascular disease (CVD). The article then outlines nutrition guidelines, explaining the target population, the goals for people with type 2 diabetes or prediabetes, general guidelines, weight reduction, carbohydrates, protein, dietary fats, physical activity, and behavior modification. A final section reviews the application of these guidelines, reminding readers that implementation of any new program takes time. The expected outcomes include moderate weight loss, improvement in insulin sensitivity, improvement in postprandial hyperglycemia, and improvement in traditional risk factors for cardiovascular disease. 26 references.
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Managing Type 2 Diabetes In Adults. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 118-191.
Type 2 diabetes is a metabolic disorder characterized by abnormalities at multiple organ sites, including the pancreatic beta cells, skeletal muscles, adipose tissue, and liver. The successful management of type 2 diabetes requires an understanding of the pathophysiology of insulin resistance, a strategy to promote lifestyle modifications, surveillance for identifying and preventing long-term lifestyle modifications, knowledge of intensive pharmacologic interventions, and professional skills for providing patient education. This lengthy chapter about diagnosing and managing type 2 diabetes in adults is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author stresses that pursuing an aggressive approach to diabetes management can lead to positive treatment outcomes and improvement in the quality of life for these patients. The author also notes that because most patients with type 2 diabetes will eventually require insulin therapy, physicians should not hesitate to discuss this possibility during the early stages of the disease. Doing so will likely make the transition from oral agents to injectable therapy more acceptable to the patient. The author guides readers from diagnosis through patient care strategies, patient education, and monitoring for disease progression and complications. Readers are reminded that type 2 diabetes is not a “mild” form of diabetes. Physicians should screen high-risk patients for this disease, initiate aggressive treatment immediately after the diagnosis is confirmed, and advance the therapeutic interventions as needed to maintain as near normal A1C levels as possible to prevent long-term diabetes-related complications. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 13 figures. 18 tables. 183 references.
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Medical Nutrition Therapy and Lifestyle Interventions. Diabetes Care. 30(Suppl 2): S188-S193. July 2007.
In pregnancies complicated by gestational diabetes mellitus (GDM), excellent glucose control is as important as appropriate weight gain and adequate nutrient intake. This article reviews the recommended medical nutrition therapy (MNT) and lifestyle interventions for women with GDM. The author considers some of the controversies in GDM management including: how far to manipulate energy intake, dietary composition (carbohydrates and fats), and gestational weight gain. Signs that food restrictions have gone too far include weight loss or lack of weight gain, undereating to avoid insulin therapy, positive urinary ketones, and intentional restriction of healthy foods. If a balance between nutrient needs and glucose control cannot be achieved, then concurrent medication therapy is needed to assist in reducing insulin resistance and supplementing insulin production to provide normoglycemia and improved pregnancy complications. The author focuses on the self-management aspects of MNT, noting that patient education, support, and follow-up are required to assist the woman in making lifestyle changes essential to successful nutrition therapy. In addition, women with GDM are at increased risk for type 2 diabetes; learning to manage GDM with lifestyle change provides an opportunity to affect personal risk factors and the health of the whole family. 3 tables. 49 references.
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Micro- and Macrovascular Disease in Diabetic Neuropathy. IN: Veves, A.; Malik, R.A., eds. Diabetic Neuropathy: Clinical Management. 2nd ed. Totowa, NJ: Humana Press. 2007. pp 259-274.
This chapter on microvascular and macrovascular disease is from a comprehensive textbook that provides general practitioners details on the latest techniques for the clinical management of diabetic neuropathy. The authors note that diabetes is often considered a vascular disease because of the early and extensive involvement of the vascular-tree seen in people with diabetes and those with pre-diabetes or the metabolic syndrome. They investigate the interplay between the circulation and the development of diabetic neuropathy, and how the development of diabetic neuropathy affects the vasodilatory capacity of the microcirculation. The interaction between changes in the vasculature and peripheral nerves is bidirectional and results in changes in both blood flow and neuronal function. The authors consider some treatment strategies including arterial reconstruction and the reduction of conventional risk factors for macrovascular disease, such as hypertension, raised triglyceride levels, body mass index, and smoking. 7 figures. 65 references.
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Mitigating Cardiovascular Risks in Diabetes. Practical Diabetology. 26(4): 14, 17. December 2007.
This article explores strategies to reduce the cardiovascular risks that accompany diabetes. The author reviews the causes of increased cardiovascular risk in diabetes, including the traditional factors of hypertension, hyperlipidemia, obesity, smoking, and hyperglycemia, as well as the less well-known risks of endothelial dysfunction, insulin resistance, inflammation, hypercoagulability, the postprandial hyperglycemic state, and treatment targets for hyperglycemia, hypertension, hyperlipidemia, obesity, and physical activity. The author concludes that a multidisciplinary approach is required to choose, implement, and help the patient maintain effective treatment to reduce cardiovascular risk. 17 references.
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Modifying Insulin Resistance to Prevent Stroke: The IRIS Trial. Practical Diabetology. 26(2): 19-23. June 2007.
Decades of epidemiologic studies have strongly suggested a major, and probably independent, role of insulin resistance in the genesis and progression of macrovascular diseases, including stroke. New drug agents that enhance insulin sensitivity present an opportunity to test the link between insulin resistance and macrovascular diseases. After an introductory section on the role of insulin resistance in stroke, this article describes the Insulin Resistance Intervention after Stroke (IRIS) Trial, undertaken to help resolve the controversy about insulin resistance and stroke. The IRIS trial will assess the effectiveness of pioglitazone in improving cardiovascular outcomes in insulin-resistant nondiabetic ischemic stroke survivors. The primary end points are recurrent stroke and myocardial infarction. The secondary end points include the individual components of the primary end point, acute coronary syndrome, development of overt type 2 diabetes mellitus, all-cause mortality, cognitive decline, and hospitalization for heart failure. Patients were still being recruited to the trial as of June 2007. 1 table.
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Other "Insulin Resistance": Overcoming Barriers to Insulin Use and Encouraging Diabetes Self- Management. Diabetes Educator. 33(Supl 4): S80-S81. April 2007.
This introductory section of a special, continuing education supplement to Diabetes Educator helps readers understand some of the barriers to insulin use among their clients. The author reports that although the number and quality of treatments available for type 2 diabetes management have increased, nearly 60 percent of individuals diagnosed with type 2 diabetes maintain A1C levels higher than the recommended target of 7 percent. This continuing education supplement has the goal of exploring solutions to three challenging components of the treatment regimen for type 2 diabetes: medical nutrition therapy and exercise, self-monitoring of blood glucose levels, and successful transition to insulin therapy. 5 references.
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Pathophysiologic Changes Occur in Women Years Before Clinical Diagnosis of Type 2 Diabetes. Review of Endocrinology. 1(3): 40-44. July 2007.
This article explores the traditional and emerging cardiovascular risk factors that may predict the progression from normoglycemia to prediabetes, as well as any gender differences in the risk factor distributions. The authors briefly report on their epidemiologic case-control study of alcohol intake patterns and risk of cardiovascular disease (CVD); the full report was published previously (Stranges, S., et al. Hypertension. 2005). Compared with controls, the prediabetic women were older and had a higher mean waist circumference after adjustment for age, ethnicity, and year of study enrollment. The results demonstrated higher levels of markers of endothelial dysfunction and thrombosis as well as hypertension in women who progressed from normoglycemia to prediabetes. The authors conclude that this shows pathophysiologic changes begin long before the clinical diagnosis of diabetes is made. Clinicians are encouraged to assess each patient’s risk for developing diabetes and coronary artery disease and implement interventions as early as possible with lifestyle modification to prevent or delay type 2 diabetes and CVD. 4 tables. 23 references.
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Polycystic Ovary Syndrome. IN: Unger, J. Diabetes Management in Primary Care. 2007. p. 88-117.
Polycystic ovary syndrome (PCOS) is one of the most common causes of menstrual irregularity and infertility in the United States. In addition, women with PCOS constitute the largest group of women at risk for developing cardiovascular disease (CVD) and diabetes. This chapter on PCOS is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author begins with a discussion of the prevalence and pathogenesis of PCOS and then covers diagnosis, clinical evaluation, the links between PCOS and metabolic syndrome, cancer risks associated with PCOS, and treatment strategies. The author notes that early recognition of this disorder may reverse the physical signs associated with the disease while correcting the metabolic abnormalities that can pose a significant health risk for untreated individuals. The use of insulin sensitizers can improve ovulatory function, lower insulin resistance, lower androgen levels, and increase the likelihood of becoming pregnant. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 9 figures. 7 tables. 76 references.
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Pre-Diabetes: What You Need to Know. [Prediabetes: Lo Que Debe Saber]. Bethesda, MD: National Diabetes Information Clearinghouse. 2007. 4 p.
This fact sheet, printed in both English and Spanish, reviews the condition of pre-diabetes, defined as blood glucose levels that are higher than normal but not high enough to be called diabetes. Glucose is a form of sugar the body uses for energy and too much glucose in the blood can damage the body over time. Pre-diabetes is also called impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). The fact sheet answers questions about pre-diabetes, including how to know if pre-diabetes is present, who should be tested for the condition, risk factors, and treatment options, notably weight loss. Readers are referred to the National Diabetes Education Program (NDEP) and the National Diabetes Information Clearinghouse (NDIC) for more information about pre-diabetes and preventing diabetes. The same information is printed in Spanish on the second two pages of the document.
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Prediabetes. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.
This brief fact sheet reviews pre-diabetes, a condition in which the body becomes resistant to the effects of insulin. Insulin is a hormone produced by the pancreas that helps the body take sugar from the bloodstream and carry it to cells where it is used for energy. The fact sheet answers common questions about pre-diabetes, discussing the risk factors for the disease, possible symptoms, diagnostic and screening tests used to monitor and diagnose pre-diabetes, complications associated with pre-diabetes, how to prevent and treat pre-diabetes, and how readers can best use the information provided in the fact sheet. One figure lists the diagnostic results of fasting blood glucose (FBG) and oral glucose tolerance (OGT) tests in the categories of normal, pre-diabetes, and diabetes. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. The fact sheet is also available in Spanish. 1 figure. 4 references.
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Preventing Metabolic Syndrome: Diet, Exercise, Both, or More? Review of Endocrinology. 1(3): 23-25. July 2007.
This article considers approaches to preventing metabolic syndrome, a cluster of symptoms including central obesity, insulin resistance, dyslipidemia, and hypertension. Individuals with three or more of these disorders have a two to three times greater risk of premature death or having a myocardial infarction or stroke, and a three to five times greater risk of developing diabetes. The authors review the standard exercise and weight loss prescriptions that have been tested in clinical studies, comparing the effects of caloric restriction through diet or diet in conjunction with exercise on several aspects of human biology. The study examined changes in weight and body composition and cardiometabolic risk factors such as lipid profile, insulin sensitivity, and aerobic fitness. The data showed that, when the degree of energy restriction is carefully matched, improvements in body composition and fat distribution in overweight men and women depend on the net energy deficit and that the inclusion of exercise does not contribute any added benefit. However, exercise plays an equivalent role to caloric restriction in terms of energy balance, and exercise improves aerobic fitness, which has other important cardiovascular and metabolic implications. The authors conclude that healthy lifestyle interventions, in conjunction with effective drugs as needed, remain the appropriate strategies to treat patients with metabolic syndrome. 1 figure. 21 references.
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Prevention of Cardiovascular Disease. Diabetes Care. 30(2): 423-431. February 2007.
This is the fifth in a series of articles on presentations given at the American Diabetes Association’s 66th Scientific Sessions held in Washington, DC, in June 2006. In this entry, the author summarizes some of the presentations on aspects of the interrelationships between cardiovascular disease (CVD) and diabetes, the theme of obesity, and the benefits and adverse consequences of peroxisome proliferator-activated receptor (PPAR) agonists. Other topics include the metabolic syndrome and pre-diabetes, thiazolidinediones and dyslipidemia, diabetic dyslipidemia, the PROactive Trial, the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) Study, lipid-lowering treatments for diabetes, PPARs and heart failure versus edema, and dual PPAR agonists. The author includes direct quotes from the presentations and extensive references for readers wishing to obtain additional information. 30 references.
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Prevention of Type 2 Diabetes in Women With Previous Gestational Diabetes. Diabetes Care. 30(Suppl 2): S242-S245. July 2007.
This article outlines strategies for the prevention of type 2 diabetes in women with previous gestational diabetes mellitus (GDM). The author discusses the prevalence of diabetes after GDM, predictors of type 2 diabetes after GDM, current recommendations for postpartum follow-up, and clinical trials that focus on postpartum interventions to prevent or delay diabetes. The author notes that it is clear that GDM confers a lifelong increased risk for the development of diabetes, and, in most cases, this turns out to be type 2 diabetes. Progression from GDM to type 2 diabetes correlates with progressive beta cell failure to compensate for the ongoing insulin resistance. The author concludes that more consistent recommendations, together with a professional and public health campaign to raise the awareness of GDM as a diabetes predictor, will be necessary to improve the postpartum care of women at highest risk. 2 tables. 25 references.
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Probe to Bone: What Do the Data Tell Us?. Diabetes Care. 30(6): 1663-1669. June 2007.
This article is the second in a series of four articles about presentations at the World Congress on the insulin resistance syndrome (IRS), reviewing the relationship between insulin resistance and nonalcoholic fatty liver disease (NAFLD) and aspects of insulin resistance in children and adolescents. Topics include diagnostic approaches to NAFLD, the increases in hepatic free cholesterol and lipid peroxidation in NAFLD, the evaluation and management of NAFLD, tests used to diagnose and monitor liver function, management approaches, the avoidance of alcohol and drugs, correction of underlying risk factors, the problem of liver complications arising after bariatric surgery in obese patients, drug therapy for diabetes that may affect NAFLD, cardiovascular disease risk factors, diagnosing insulin resistance in childhood and adolescence, the incidence of metabolic syndrome, the impact of parents with insulin resistance on the incidence of metabolic syndrome in their children, the fetal origins of IRS, long-term complications of IRS, type 2 diabetes in youth, the spectrum of insulin resistance among obese children, nonalcoholic steatohepatitis (NASH) in children and adolescents, and insulin sensitivity changes during puberty. 53 references.
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Provider Psychological Insulin Resistance: Easing the Transition. Diabetes Educator. 33(Suppl 7):245S-247S. July - August 2007.
This article is from a special supplement on an American Association of Diabetes Educators’ continuing education program on The Tipping Point: Overcoming Psychological Insulin Resistance, held in Los Angeles, California, in August 2006. In this article, the author discusses provider psychological insulin resistance (PIR) and ways to ease the transition to insulin therapy for their patients with type 2 diabetes. Topics include the use of a patient care team for health care delivery, the role of the patient care team in easing provider PIR, the need to keep the insulin regimen simple when it is first implemented, the role of diabetes self-management education (DSME) and group education strategies, and resources for community physicians, including ways to educate oneself and one’s office staff about insulin therapy. The author concludes that some reasons for the resistance to insulin therapy about health care providers include lack of belief in the efficacy of insulin for type 2 diabetes and insufficient training and resources in the primary care setting. A simplified treatment regimen, such as the addition of basal insulin at bedtime while maintaining therapy with oral antidiabetes agents, may be an effective way to initiate insulin therapy.
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Psychological Insulin Resistance: Scope of the Problem. Diabetes Educator. 33(Suppl 7): 228S-231S. July - August 2007.
This article is from a special supplement about an American Association of Diabetes Educators’ continuing education program called The Tipping Point: Overcoming Psychological Insulin Resistance, held in Los Angeles in August 2006. In this article, which serves as an introduction to this supplement, the author summarizes the scope and details of the problem of psychological resistance to the use of insulin, particularly in people with type 2 diabetes. The author introduces the idea of “treating to target” in type 2 diabetes, which includes early intervention with metformin in combination with lifestyle changes and continuing, timely augmentation of therapy with additional agents, including the early initiation of insulin therapy. Topics covered include the prevalence of treatment failure, the causes of delayed incorporation of insulin treatment, patient attitudes, and provider attitudes. The author notes that health care providers who delay the initiation of insulin therapy are more likely to delay use of all diabetes medications until the patient is at a poor level of control, resulting in a long period of exposure to hyperglycemia. Lack of time and inadequate training in insulin therapy, beliefs about patient adherence to treatment regimens, and the tendency of patients to blame themselves for suboptimal glycemic control are some of the reasons that more than two-thirds of Americans with type 2 diabetes are not achieving published glucose targets. The author concludes by encouraging diabetes educators to provide accurate information about the use of insulin and its benefits and to encourage open dialogue to explore any fears or misconceptions patients may have. 1 figure. 3 tables. 10 references.
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Psychological Insulin Resistance: The Patient Perspective. Diabetes Educator. 33(Suppl 7): 241S-244S. July - August 2007.
This article is from a special supplement about an American Association of Diabetes Educators’ continuing education program called The Tipping Point: Overcoming Psychological Insulin Resistance, held in Los Angeles, in August 2006. In this article, the author offers the type 2 diabetes patient’s perspectives on psychological insulin resistance (PIR). The author reminds readers that because type 2 diabetes is a progressive disease, most patients will likely require insulin therapy at some point. However, studies of compliance rates with oral antidiabetes drugs and insulin show that compliance rates range from 36 to 93 percent, with the average compliance rate for insulin being about 63 percent. Thus, PIR poses a significant barrier to what is already a difficult situation. The author reviews the attitudes toward insulin therapy, beliefs underlying PIR, the belief on most patients’ part that insulin is ineffective, strategies for overcoming PIR, the problem of clinicians who harbor negative beliefs about insulin therapy, and anxiety about insulin therapy and potential episodes of hypoglycemia. The author concludes by encouraging diabetes educators to play an important role in educating physicians, patients, and the community about the role of insulin in type 2 diabetes and to share the good news about the safety and effectiveness of contemporary insulin preparations. Insulin therapy can be an appropriate, effective, and flexible treatment option during all stages of type 2 diabetes. 2 figures. 1 table. 19 references.
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Retinal Vascular Changes in Pre-Diabetes and Prehypertension: New Findings and Their Research and Clinical Implications. Diabetes Care. 30(10): 2708-2715. October 2007.
Recent advances in digital retinal photography and imaging techniques have allowed precise viewing and classification of subtle changes in the retina. This article describes how these noninvasive tests can be used to measure retinal vascular changes in people with pre-diabetes and early hypertension. The authors divide these changes into four groups: classic retinal vascular changes in diabetes and hypertension, also called diabetic retinopathy; isolated retinopathy signs in individuals with diabetes or hypertension; changes in retinal vascular caliber; and changes in retinal vascular architecture. The authors note that new studies have shown retinal vascular changes are common in the general population and may precede the subsequent development of overt diabetes and hypertension. In addition, new patterns are emerging that show specific retinal vascular changes that may be related differently to hyperglycemia and blood pressure. The authors call for additional research to establish and name the gradations of retinal microvasculature and studies that consider whether modification of risk factors or institution of treatment may improve retinal vascular measures. 1 figure. 1 table. 117 references.
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Sex Hormones, Sleep, and Diabetes. Diabetes Wellness News. 13(4): 3. April 2007.
This article considers the interplay of testosterone, sleep, and diabetes. The author briefly reviews some recent research that demonstrated that men who had the lowest testosterone levels were four times as likely to have diabetes as those with the highest levels. Another study appeared to contradict these findings, nothing that low testosterone levels were a result of, rather than a cause of, poor metabolic control. A final section considers a study that suggested that chronic sleep loss will precipitate type 2 diabetes and insulin resistance. Short sleep leads to increased hunger, obesity, and diabetes, and accumulated sleep deficit may be playing some as yet unidentified role in the diabetes epidemic.
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Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. 30(Suppl 2): S251-S260. July 2007.
This article presents the summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus, held in Chicago in November 2005. The meeting provided a forum for review of new information concerning GDM in the areas of pathophysiology, epidemiology, perinatal outcome, long-range implications for mother and her offspring, and management strategies. New information and recommendations related to each of these major topics are summarized in this article. Specific topics include GDM and insulin resistance, GDM and pancreatic beta cell function, the placenta in GDM, epidemiology, perinatal implications, interventions during pregnancy, metabolic management during pregnancy, maternal glycemia, ultrasound measurement of fetal abdominal circumference, medical nutrition therapy (MNT), intensified metabolic therapy, oral antihyperglycemic agents, fetal and maternal surveillance, timing and route of delivery, and maternal follow-up. The appendix lists the panel members who were involved in this conference. 4 tables. 11 references.
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Sweet and Sour: The Glycemic Index Debate. Diabetes Forecast. 60(11): 16, 19. October 2007.
This article reports on the ongoing controversies surrounding the use of glycemic index (GI) approaches to managing diabetes. The GI was first envisioned as a tool to help people with diabetes smooth out some of their hyperglycemic episodes. Only later was the index applied to the general population as a potential weight-loss tool. Because the GI is based on clinical science, it was originally embraced by the scientific community as accurate, but its use as a tool for diabetes control has been under scrutiny for more than 25 years. The author reports on a recent debate at the American Diabetes Association’s Scientific Sessions held in Chicago in June 2007 on the merits of the GI. Topics include the research that supports the GI, the concept of the glycemic load, insulin resistance, obesity, cardiovascular diseases, the presence of a mixed glycemic response, individual variability in glycemic response to different foods, and the importance of considering nutritional choices in addition to the GI values of food items. The author concludes by noting that the American Diabetes Association’s position supports the use of the GI as a fine-tuning dietary tool, to be used after a proper energy balance is established in a nutritionally sound meal plan.
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Tipping Point: Overcoming Barriers. Diabetes Educator. 33(Suppl 7): 248S-250S. July - August 2007.
This article is from a special supplement about an American Association of Diabetes Educators’ continuing education program called The Tipping Point: Overcoming Psychological Insulin Resistance, held in Los Angeles in August 2006. In this brief article, which serves as a conclusion to this supplement, the authors offer three case studies to illustrate successful strategies for overcoming the psychological barriers to insulin use. The case reports range from an obese 52-year-old female who has had type 2 diabetes for 8 years, to a nonobese 46-year-old male who was just diagnosed with new-onset diabetes, to an older man with a 35-year history of hypertension and a 15-year history of type 2 diabetes. In each case, the authors offer specific suggestions for patient education approaches and administration and dosage of insulin. 5 references.
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Type 2 Diabetes: Multiple Treatments for a Multicomponent Condition. IN: Beaser, R.S., ed. Joslin’s Diabetes Deskbook: A Guide For Primary Care Providers. 2nd ed. Boston, MA: Joslin Diabetes Center. 2007. pp 153-172.
This chapter on the use of multiple treatments for type 2 diabetes is from a book that gives primary care providers a comprehensive overview of diabetes care. The author of this chapter reminds readers of the complexity of type 2 diabetes, reviewing the evolution of terminology used to describe the disease. The chapter covers insulin resistance; the pathophysiology and natural history of type 2 diabetes; treatment goals; developing a medical care plan, including the medical history, physical examination, laboratory assessments, and outlining the treatment approach; the role of medical nutrition therapy (MNT); physical activity; and the indication for antidiabetes medications for people with type 2 diabetes. The author stresses that treatment of type 2 diabetes includes not only aggressive control of glucose, but also involves multiple lifestyle changes, including MNT and an activity program. Self-monitoring of blood glucose (SMBG) is vital to both monitor the disease and its treatment, and to involve the patient more effectively in his or her care.
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Type 2 Diabetes: What You Need to Know. Diabetes Tipo 2: Lo Que Debe Saber. Bethesda, MD: National Diabetes Information Clearinghouse. 2007. 4 p.
This bilingual fact sheet reviews type 2 diabetes, the most common type of diabetes. Type 2 diabetes occurs because the body does not use insulin properly, a condition called insulin resistance. Over time, the cells that produce insulin cannot keep up with the body's needs and diabetes develops. Written in a question-and-answer format, the fact sheet reviews the risk factors for type 2 diabetes, diagnostic tests that confirm the condition, self care management strategies, and how to contact the National Diabetes Information Clearinghouse for more information. Readers are advised to take care of their type 2 diabetes by keeping their blood glucose, blood pressure, and cholesterol under control through healthy eating, regular exercise, and medications as needed. The fact sheet is illustrated with colorful photographs of the components of healthy living with diabetes.
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Usefulness of ARBs in the Treatment of Metabolic Syndrome. Review of Endocrinology. 1(2): 22-25. June 2007.
This article discusses the usefulness of angiotensin-receptor blockers (ARBs) in the treatment of the metabolic syndrome. The authors review the controversy over whether the metabolic syndrome is a disease per se, including the difficulties in defining insulin resistance, the use of different criteria used to classify a patient as having the metabolic syndrome, and differing definitions from various medical associations about the choice of characteristics that make up the metabolic syndrome. The authors discuss studies that evaluated the influence of ARBs on insulin resistance and adiponectin concentrations. Some ARBs show a certain adjunctive advantage in the treatment of the metabolic syndrome because they display some favorable metabolic actions independent of their antihypertensive properties. One of these favorable actions is increased adiponectin levels, which is active in vasodilation and increases nitric oxide production in human aortic endothelial cells. 3 figures. 24 references.
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Alzheimer's Alert: Is There a Diabetes-Brain Connection?. Today's Dietitian. 8(11): 22-24. November 2006.
This article considers the interplay between diabetes and Alzheimer’s disease (AD), focusing on several recent studies that have linked diabetes to AD. One of the studies found that people with diabetes have a much higher rate of developing AD than those who do not have diabetes. The theory suggested in this study is that weight gain triggers insulin resistance, which can then cause full-blown type 2 diabetes. When blood glucose is poorly controlled, the amount available for brain cells declines, which in turn causes them to malfunction or die. Dying brain cells may set the stage for AD. The article briefly discusses a mouse study that found that the biological process that leads to AD may be triggered by a high-fat diet (and the resulting buildup of beta amyloid). The author stresses that Americans can keep their aging brain cells in good shape for as long as possible by making lifestyle changes to lose weight (thereby reducing the risk of developing diabetes) and by using self-management tools to optimally control their blood glucose. 1 table.
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Am I at Risk for Type 2 Diabetes? Taking Steps to Lower the Risk of Getting Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 14 p.
Diabetes is a disease in which blood glucose levels are above normal. People develop type 2 diabetes because the cells in the muscles, liver, and fat do not use insulin properly. The amount of glucose in the blood increases while the cells are starved of energy. Over time, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, kidney disease, nerve problems, gum infections, and amputation. This booklet, written in nontechnical language, answers common questions about type 2 diabetes. Topics covered include the causes, risk factors, signs and symptoms, and prevention of type 2 diabetes. The booklet addresses the tests used to confirm the condition and discusses pre-diabetes. A large section of the booklet walks readers step-by-step through lifestyle changes that can prevent diabetes or reduce its impact. These changes include reaching and maintaining a reasonable body weight, making wise food choices most of the time, being physically active every day, and taking any prescribed medications. One chart presents the body mass index (BMI) table. The publication concludes with a final section that briefly summarizes the activities of the National Diabetes Information Clearinghouse (NDIC), a Government service that provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. 1 table.
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Appendix 1: Abbreviations. IN: Brett, E.; Mechanick, J., eds. Nutritional Strategies for the Diabetic and Prediabetic Patient. . Boca Raton, FL: CRC Press. 2006. pp. 313-320.
This appendix is from a book that was written primarily for physicians to advance their knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. In this appendix, the editors list the abbreviations used throughout the book. Abbreviations are included for all the topics in the book: the foundations of nutritional medicine; the pathophysiology and clinical management of diabetes and prediabetes; preventive nutritional strategies in diabetic and prediabetic patients; nutritional strategies for patients with obesity and the metabolic syndrome; medical nutrition therapy (MNT) for patients with type 2 diabetes; nutrition and type 1 diabetes; the use of carbohydrate counting; continuing insulin infusion (CII) therapy and nutrition; nutritional strategies in pregestational, gestational, and postpartum diabetes patients; nutritional strategies for the patient with diabetic nephropathy; nutrition support and hyperglycemia; nutritional strategies for wound healing in diabetes patients; mitochondrial function in diabetes; the rational use of dietary supplements; and exercise and nutrition.
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Appendix 6: Case Study: Office-Based Nutritional Counseling. IN: Brett, E.; Mechanick, J., eds. Nutritional Strategies for the Diabetic and Prediabetic Patient. . Boca Raton, FL: CRC Press. 2006. pp. 331-336.
This appendix is from a book that was written primarily for physicians to advance their knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. In this appendix, the author presents a case study of office-based nutritional counseling. The example consists of several brief dialogues—less than 5 minutes each—that include the important points that will guide medical therapy over the course of multiple office visits for the prediabetes patient. The dialogue between physician and patient is included in detail, as are the patient’s blood work results through the 6-month period covered by the three visits to the doctor. The author recommends the use of patient handouts for home reading and the use of self-monitoring of blood glucose (SMBG). 3 tables.
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Atherosclerosis and Peripheral Vascular Disease: Sequelae of Obesity and Diabetes. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 221-232.
This chapter on atherosclerosis and peripheral vascular disease (PVD) is from a comprehensive textbook on obesity and diabetes. The authors use the patient with obesity and diabetes as a study to discuss the pathophysiology of atherosclerosis and the clinical presentation, diagnosis, and treatment of PVD. The authors stress that the pathophysiology of diabetes in the obese patient must be kept in mind during initial evaluation, diagnosis, and treatment regimens. The most important measure taken by patients and primary care physicians to prevent PVD is the aggressive control of risk factors (i.e., smoking, weight gain, and hypertension). Early control of these predisposing factors stymies the development of long-term complications such as insulin resistance, dyslipidemia, essential hypertension, stroke or myocardial infarcts, and central obesity (all of which are components of the metabolic syndrome). The authors also focus on the prevention of amputation in this patient population. They conclude that, with a meticulous and methodical approach to infection control, complete angiography, and arterial revascularization, the likelihood of limb salvage in the obese and diabetic patient should be nearly equal to that of limb salvage in the weight-controlled, nondiabetic patient. 34 references.
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Being Active. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 670-688.
Diabetes educators have an important and challenging role in helping individuals with diabetes and prediabetes be more physically active. This chapter on exercise and being active is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The author notes that effective behavior change strategies, coupled with a solid understanding of current recommendations for physical activity and exercise, can be powerful tools for helping individuals incorporate physical activity into their diabetes management program. The chapter covers the importance of pre-exercise medical evaluations, how to develop a physical activity program, aerobic exercise, resistance (strength) training, safety considerations, modifications for clients with diabetes complications, modifications for obesity, modifications for older adults, considerations with children and adolescents, the stages of change for exercise behavior change, promoting lifestyle physical activity, the use of the Activity Pyramid, and the use of motivational interviewing to enhance behavior change. The author concludes that the true art of exercise program planning lies in the effective use of behavior change strategies to tailor programs to each individual’s health status, personal preferences, abilities, goals, and stage of readiness. The chapter includes a list of key points, a summary of teaching strategies, case studies, suggested Internet resources, a glossary of key terms, and a list of references. 1 figure. 3 tables. 44 references.
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Can Medication Help?. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 126-138.
This chapter on drug therapy is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes the use of medications to help lower the risk of developing diabetes. There are glucose-lowering medications for people with diabetes which can work by helping the pancreas release more insulin, making the cells more sensitive to insulin, reducing the amount of glucose made by the liver, blocking digestion of carbohydrates or fat, or substituting for human insulin to help the cells use glucose. The author also outlines non-diabetes medications that may be useful, including anti-hypertensive agents or cholesterol-lowering drugs. Vitamin, mineral, and herbal supplements may also be used; the author outlines some of the studies on these alternative therapies, commenting on benefits, efficacy, and side effects reported. Readers are encouraged to work closely in tandem with their health care providers and to become an active, educated member of their own health care team. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 2 tables.
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Control Your Glucose, Control Diabetes Complications. Diabetes Health Monitor. 11(4): 15. July 2006.
This brief newsletter article reminds readers with diabetes of the importance of tight blood glucose (glycemic) control. The fact sheet covers the monitoring tests used for blood glucose (HbA1c or glycosylated hemoglobin, a measurement of blood glucose levels over time), microvascular complications, macrovascular complications, and strategies for achieving tight blood glucose control. For people with type 1 diabetes, tight glycemic control usually requires three or more daily injections of insulin or continuous treatment using an insulin pump. For people with type 2 diabetes, treatment usually involves lifestyle changes (diet and exercise) for 3 to 6 months, then adding oral medications, stepping up treatment whenever the previous regimen fails to be effective. One sidebar notes a recent finding that links increased consumption of red meat and whole milk products with insulin resistance. 1 figure.
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Conventional Treatments are Falling Short. IN: Clinical Impact of Incretin-Based Therapies on Type 2 Diabetes Management. Littleton, CO: Medical Education Resources. p. 15-19.
New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This chapter on the DPP-4 inhibitors is from a monograph on the clinical impact of incretin-based therapies on the management of people with type 2 diabetes. The monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators’ 2005 Annual Meeting. This chapter identifies the limitations of current treatments for type 2 diabetes mellitus. The authors stress that, despite the establishment of standardized glycemic goals, as well as medical and technological advances, fewer than 40 percent of people with type 2 diabetes are achieving acceptable blood glucose levels (adequate to prevent complications). The authors first discuss chronic beta-cell dysfunction, the underuse of insulin, resistance to lifestyle change, waiting too long to implement treatment options or changes, postprandial hyperglycemia, and the metabolic shortcomings of current therapies. The next section considers ways to reduce the risk of treatment failure, including the use of early and aggressive treatment, initial use of combination therapy, the treat-to-target approach, and an earlier transition to injectable insulin therapy. A final section outlines the role of GLP-1 analogues and DPP-4 inhibitors. 3 figures. 3 tables.
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Current Treatment Options. IN: Sharing the Burden: The Role of Incretins in Glucose Control. Chicago, IL: American Association of Diabetes Educators. 2006. pp. 8-9.
New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This brief section outlining the current treatment options is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators' 2005 Annual Meeting. The authors briefly outline treatment options and how they affect inadequate insulin production, insulin resistance, hepatic glucose production, and gastric emptying. In each area, the authors note how the different types of drugs may have an impact. Drugs discussed include insulins, insulin secretagogues, glinides, thiazolidinediones, biguanides, and alpha glucosidase inhibitors. The authors conclude that current therapies based on these drugs, diet, exercise, and insulin replacement have failed to curb the progression of diabetes and the development of diabetic complications. 1 figure.
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Dangerous Curves: Lifestyle Risks. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 49-56.
This chapter on the lifestyle risk factors for diabetes is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes lifestyle factors including body weight and the problems associated with extra weight, body shape, lack of exercise, and stress. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. One chart helps readers determine their body mass index (BMI) number. 2 figures. 2 tables.
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Develop a Healthy Attitude. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 75-85.
This chapter on patient attitude is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes the positive impact that a healthy attitude can have on attempts to improve one’s general well-being. The author reviews how stress can have a negative impact on both physical and emotional health, then helps readers identify stressors and then take action to improve their attitude. Stress reduction techniques covered include deep breathing, humor, stretching exercises, listening to music, taking a shower or bath, and playing with kids or pets. Longer-term coping techniques can include assessing and listing priorities, finding a support group, and becoming involved in hobbies and other enjoyable activities. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. One sidebar encourages readers to educate themselves about the symptoms of clinical depression and to seek help if they think they may be depressed. 1 table.
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Diabetes Overview. Bethesda, MD: National Diabetes Information Clearinghouse. 2006. 16 p.
This fact sheet provides an overview of information about diabetes, defined as a disorder of metabolism. The fact sheet describes the three main types of diabetes: type 1 diabetes, an autoimmune disease in which the pancreas produces little or no insulin; type 2 diabetes, in which the body does not produce enough insulin or uses insulin inefficiently; and gestational diabetes, which is associated with pregnancy and an increased risk of type 2 diabetes subsequently. The fact sheet then discusses diagnostic considerations, the condition of pre-diabetes, the complications that may be associated with diabetes, epidemiology of type 1 and type 2 diabetes, and patient care for people with diabetes. The fact sheet also describes current research efforts in the diabetes arena, including the Environmental Determinants of Diabetes in the Young Consortium (TEDDY), Type 1 Diabetes TrialNet, the Immune Tolerance Network, islet transplantation studies, the Diabetes Prevention Program (DPP), studies on type 2 diabetes in children and teens, and studies focusing on preventing and treating cardiovascular disease in people with type 2 diabetes. The contact information for four resource organizations is listed. A final section provides the contact information and a brief description of the goals and activities of the National Diabetes Information Clearinghouse. 2 figures.
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Diabetes-Cardiovascular Cutoff: Syndrome X. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 63-69.
This chapter on the interplay between diabetes and cardiovascular risk factors is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes Syndrome X (also called metabolic syndrome or insulin resistance syndrome), a group of risk factors that include overweight, glucose intolerance or insulin resistance, high blood pressure (hypertension), and high levels of cholesterol and triglycerides. The chapter includes charts for readers to understand the results found from laboratory tests measuring these risk factors. One sidebar offers suggestions for readers who need to obtain these diagnostic tests for free or at low cost. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 4 tables.
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Diagnosing Obesity, Diabetes Mellitus and the Insulin Resistance Syndrome. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 129-154.
Obesity is a disease state that has reached epidemic proportions, with increasing prevalence and serious health care consequences. This chapter on diagnosing obesity, diabetes mellitus, and insulin resistance syndrome is from a comprehensive textbook on obesity and diabetes. In the first part of the chapter, the authors present criteria for the diagnosis of overweight and obesity and for evaluation of the obese and overweight patient. The authors emphasize the importance of determining the specific type of obesity and the possible presence of other risk factors in obese individuals. The authors also review obesity-screening recommendations and rationale. They caution that obesity increases the risk of developing several comorbidities, including type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease (CVD), arthritis, sleep apnea, and some tumors. Screening procedures for type 2 diabetes mellitus are necessary because of the well-known association of diabetes with increased morbidity and mortality from acute and chronic complications and because as many as 50 percent of the diabetic population remains undiagnosed, at any given time. Insulin resistance is a state of decreased sensitivity of issues to insulin; also called the metabolic syndrome, insulin resistance is usually considered an intermediate state between diabetes and normality. 5 figures. 9 tables. 113 references.
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Diet, Exercise, and Behavioral Treatment of Obesity. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 445-456.
This chapter on diet, exercise, and behavioral treatment of obesity is from a comprehensive textbook about diabetes and obesity. The author stresses that lifestyle interventions that change eating behavior, increase physical activity, and result in modest weight loss are known to prevent or delay diabetes in persons at high risk for the disease. Modest weight loss (5 to 10 percent of body weight), often achievable by a combination of reduced caloric intake and increased physical activity, lowers the risk of diabetes and insulin resistance and improves measures of glycemia and dyslipidemia in those with diabetes. The author includes a section that discusses strategies that promote behavior change. Behavior modification is a goal-oriented therapy that helps patients identify and change behaviors that prevent them from achieving their objectives for weight loss and increased physical activity. The author concludes that in order to successfully attack the interrelated diseases of obesity and diabetes, health-care providers and medical organizations need to transform the present model into a system that provides preventive care and early detection as an integral part of standard medical practice. 3 tables. 97 references.
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Dyslipidemia Associated with Diabetes and Insulin Resistance Syndromes. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 193-212.
In addition to having markedly increased risk of coronary heart disease (CHD), patients with type 2 diabetes have much worse outcomes after a major cardiovascular event. An understanding of the pathophysiology and treatment of modifiable metabolic abnormalities that often cluster with type 2 diabetes may help reduce the incidence of and mortality from CHD in this population. This chapter on dyslipidemia associated with diabetes and insulin resistance syndromes is from a comprehensive textbook on obesity and diabetes. The authors focus primarily on the dyslipidemia associated with type 2 diabetes and obesity as part of the insulin-resistant metabolic syndrome. The authors first provide an overview of the major lipoproteins and lipoprotein metabolism, then present the characteristics and mechanisms of dyslipidemia associated with diabetes and obesity. The authors review the lipid goals according to the American Diabetes Association (ADA) and Adult Treatment Panel III (ATP III) criteria and discuss lipid-lowering treatment options. Topics include the benefits of lifestyle modification, the mechanisms of action of the lipid-lowering medications available in the United States, and clinical trial data relevant to the management of patients with diabetes and the metabolic syndrome. The chapter includes a brief discussion of dyslipidemia associated with type 1 diabetes and with insulin-resistant states including human immunodeficiency virus (HIV) and polycystic ovary syndrome (PCOS). 4 figures. 3 tables. 77 references.
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Eating Your Way to Good Health. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 95-113.
This chapter on nutrition is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author reviews the link between food and prediabetes, then describes a glossary of important food words, including calories, grams, carbohydrates, fats, protein, and other food components. The author then walks readers through the process of recording their present food intake and habits, an important first step before improvement can take place. The author encourages readers to eat fewer calories overall, to eat less ‘bad’ fat, eat more ‘good’ fat, and choose more whole and fresh foods and fewer processed carbohydrates. Moderation and variety are the two components to an overall healthy diet. Other topics covered include working with a dietitian, healthy cooking strategies, the role of grains, how to update traditional family favorites, eating healthier at restaurants, desserts, snacking to help keep blood glucose levels even, the emotional components of food, and cultural considerations. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 3 tables.
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Emerging Epidemic: Diabetes in Older Adults: Demography, Economic Impact, and Pathophysiology. Diabetes Spectrum. 19(4): 221-228. Fall 2006.
Diabetes is a major problem that will grow in magnitude as the population ages. This article reviews some of the major studies that have quantified the cost of diabetes, particularly those that focus on the demographics, economic impact, and pathophysiology of diabetes in older adults. The authors discuss increased insulin resistance, impaired insulin secretion, other pathogenic factors, progression to type 2 diabetes, normal age-related changes, the impact of obesity on diabetes, direct and indirect financial concerns, and the role of intensive therapy. The authors conclude that socioeconomic factors play a huge role in nutrition and health care and must be addressed on both an individual and societal level if efforts to prevent this devastating and costly disease are to be successful. 54 references.
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Epidemiology, Risks, And Heath-Care Expenditures for Diabetes And its Complications. IN: Opara, E., ed. Nutrition and Diabetes: Pathophysiology and Management. Boca Raton, FL: CRC Press. 2006. pp 139-160.
This chapter about the epidemiology, risks, and health care expenditures for diabetes and its complications is from a textbook that highlights the link between the problems of obesity and diabetes mellitus. The author discusses estimated health care expenditures associated with diabetes; the prevalence of diabetes; definitions for impaired glucose tolerance, insulin resistance, and diabetes mellitus; diagnostic criteria for diabetes mellitus; risk factors; diabetic complications; mortality; and level of health care. The section about risk factors considers gestational diabetes, post-transplantation diabetes, the association of obesity with diabetes, diet and diabetes, diabetes and microalbuminuria, the effects of alcohol and cigarettes, diabetes and physical limitations, and diabetes and mental health. Diabetic complications considered include coronary-vascular disease, peripheral neuropathy and peripheral vascular disease, cerebrovascular disease, erectile dysfunction, diabetic nephropathy, retinopathy, and dental disease. The chapter includes black-and-white illustrations and a lengthy list of references. 3 tables. 103 references.
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Exercise, Nutrition, and Diabetes. IN: Mechanick, J.; Brett, E., eds. Nutritional Strategies for the Diabetic and Prediabetic Patient. Boca Raton, FL: CRC Press. 2006. pp. 297-312.
This chapter on exercise, nutrition, and diabetes is from a book written to advance physicians’ knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. The authors note that in diabetes management there is a complex interplay among physical activity, nutrition, pharmacological intervention, and genomics. In prediabetes and type 2 diabetes, physical activity is an essential component of treatment because it lowers blood glucose and reduces obesity. In type 1 diabetes, exercise can result in a complex set of metabolic derangements if careful monitoring and adjustments are not in place. Exercise plays an important role in preventing cardiovascular disease and cerebrovascular disease, both of which are major causes of morbidity and mortality in the diabetes population. The chapter discusses metabolic changes with exercise, and exercise in each of four types of diabetes: type 1, prediabetes, type 2, and gestational. 1 figure. 6 tables. 129 references.
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Gestational Diabetes Mellitus. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 260-277.
Gestational diabetes mellitus (GDM), a carbohydrate intolerance first recognized during pregnancy, is a progressive disorder that includes insulin resistance and relative insulin deficiency. This chapter on GDM is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The author stresses that managing GDM requires balancing glucose control with the nutrient needs of a healthy pregnancy (i.e., appropriate weight gain and adequate nutrient intake). Achieving glucose control should not compromise the outcomes of a healthy pregnancy; if the woman cannot use nutrition therapy alone to manage her disease, oral or insulin therapy can be added. However, women with GDM have to learn and implement diabetes self-management in a very short period of time. Behavior change goals are important as changes must be accomplished quickly. GDM also signals the woman’s predisposition to develop type 2 diabetes; therefore women should be counseled to take preventive steps including weight control, healthy food choices, and physical activity. The chapter includes a list of key points, a summary of teaching strategies, case studies, suggested Internet resources, a glossary of key terms, and a list of references. 3 figures. 5 tables. 30 references.
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Glucagon Hypersecretion. IN: Sharing the Burden: The Role of Incretins in Glucose Control. Chicago, IL: American Association of Diabetes Educators. 2006. p. 7-8.
New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This section on glucagon hypersecretion is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators' 2005 Annual Meeting. Glucagon is a hormone produced in the alpha cells of the pancreas that, along with insulin, controls the level of glucose in the blood. In normal physiology, glucagon is secreted in response to low blood concentrations of glucose. Release of glucagon can also be stimulated by elevated blood levels of amino acids, as seen after consumption of a protein-rich meal. Both insulin dysfunction and glucagon hypersecretion contribute to hyperglycemia in people with type 2 diabetes. The authors note that, in this population, not only was glucagon not inhibited postprandially, but levels actually increased immediately following a meal. This paradoxical increase in glucagon secretion makes postprandial blood glucose difficult to manage, and may explain patients' frustrations with poor postprandial glucose levels, even when they are adhering to their recommended diet protocols. 1 figure.
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How Food Fuels Your Body. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 11-20.
This chapter on how the body digests and uses food is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map analogy to explain the strategies they can take to better health. In this chapter, the author reviews the components of food, including carbohydrates, proteins, fats, and vitamins and minerals; how carbohydrates are used for fuel; the role of dietary fiber; the use of fats for fuel and protection; the anatomy and physiology of the digestive system; and how insulin unlocks glucose for cells to use as fuel. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 5 figures. 3 tables.
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Inflammation: A Unifying Theory of Disease?. Harvard Health Letter. 31(6): 4-5. April 2006.
This health education newsletter article considers the theory that chronic inflammation is a common factor in many diseases, including diabetes. Inflammation, part of the immune system, is a process that depends both on the physical actions of white blood cells and the chemicals that they produce: antibodies, cytokines, and others. The author reviews present thinking on the role of inflammation in coronary artery disease, in diabetes, in cancer, and in Alzheimer disease. For example, people with high levels of C-reactive protein (CRP, a marker for inflammation) are more likely to develop insulin resistance, in which cells rebuff insulin and thus do not properly metabolize glucose circulating in the blood. A final section considers strategies to prevent inflammation, including anti-inflammatory drugs, regular oral health care, and following a low-calorie diet and undertaking moderate exercise; these strategies may prevent degenerative inflammatory disease.
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Intensive Diabetes Control: Reaping the Benefits Promised by Clinical Trials. Reducing Cardiovascular Risk in the Patient with Type 2 Diabetes (AADE Proceedings). p. 1-2. 2006.
This article, from the proceedings of a symposium on reducing cardiovascular risk in people with type 2 diabetes, explores how to make the transition from research to clinical management. The author focuses on the role of intensive diabetes management in people with type 2 diabetes mellitus (T2DM). Topics include the early cardiovascular disease (CVD) risk in the natural history of diabetes, how a combination of metabolic factors contribute to CVD risk, the current status of CVD prevention in diabetes, the role of nontraditional risk factors (such as endothelial cell dysfunction, insulin resistance, inflammation, and postprandial hyperglycemia) in T2DM CVD risk, and the benefits of insulin therapy. The author stresses that all patients with diabetes should be treated as if they already have CVD. The processes that lead to CVD in diabetes begin years before diabetes onset. Insulin treatment given to promote good metabolic control is clearly beneficial, both for its glucose-lowering and anti-inflammatory effects. The author concludes that because of the multifactorial nature of CVD and T2DM, and because both traditional and nontraditional risk factors play a role in its development, health care providers must always consider the patient's full range of metabolic control needs when developing treatment plans. 6 references.
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Liver Disease in Patients with Diabetes Mellitus. Journal of Clinical Gastroenterology. 40(1): 68-76. January 2006.
In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. This article reviews the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The author also discusses the association of diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation. The liver plays a significant role in energy homeostasis and glucose metabolism; insulin enhances glycogen synthesis within the liver and prevents glucose production. These normal physiologic processes become dysregulated with insulin resistance and type 2 diabetes mellitus. Insulin resistance may work synergistically with hepatitis C infection to make changes in the liver, in the form of steatosis, inflammation, and fibrosis development. Once this occurs, progression to diabetes may occur in patients with underlying genetic susceptibility. Current treatment for preventing liver complications is focused on therapies that improve underlying insulin resistance, including weight loss or drug therapy. 1 figure. 2 tables. 158 references.
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Macrovascular Disease in Diabetes. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 476-510.
Insulin resistance, glucose intolerance, and diabetes affect multiple aspects of vascular health. Macrovascular disease includes coronary artery disease (CAD), cerebrovascular disease, and peripheral vascular disease. This chapter on macrovascular disease in diabetes is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. CAD occurs earlier and is more extensive in people with diabetes than in those without the disease. CAD presents as angina or acute myocardial infarction, sometimes with atypical symptoms. People with diabetes and peripheral arterial disease are more prone to limb ischemia (lack of blood flow) and increased risk of amputation. Macrovascular disease has many causes, so its reduction requires addressing all risk factors, not just hyperglycemia. Risk factor reduction includes control of hypertension and lipids, a therapeutic lifestyle, smoking cessation, and use of antiplatelet therapy. The chapter includes a list of key points, a summary of teaching strategies, case studies, suggested Internet resources, a glossary of key terms, and a list of references. 7 tables. 161 references.
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Medical Nutrition Therapy. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 280-295.
This chapter on medical nutrition therapy (MNT) is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. In this chapter, the authors discuss the role of MNT in diabetes management and prevention; describe the role of MNT in glycemic control, weight control, and prevention and treatment of cardiovascular disease, including hypertension, dyslipidemia, and nephropathy; and discusses intervention strategies to achieve nutrition-related goals for youth and adults with diabetes. Weight loss through a reduction in food intake and an increase in physical activity is an important strategy in overweight or obese persons with insulin resistance or at risk for type 2 diabetes. Optimal nutrition through healthy eating is an important goal for all people with diabetes and should not be compromised to improve glycemia, lipids, or blood pressure control. Physical activity should be encouraged in all persons with diabetes, to improve glycemic control, assist with maintenance of weight, and reduce the risk of cardiovascular disease. The chapter includes a list of key points, a summary of teaching strategies, case studies, suggested Internet resources, a glossary of key terms, and a list of references. 2 tables. 82 references.
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Metabolic Alterations in Muscle Associated With Obesity. IN: Opara, E., ed. Nutrition and Diabetes: Pathophysiology and Management. Boca Raton, FL: CRC Press. 2006. pp 79-98.
This chapter about the metabolic alterations in muscle associated with obesity is from a textbook that highlights the link between the problems of obesity and diabetes mellitus. The first part of the chapter describes the differences in muscle carbohydrate, lipid, and energy metabolism between lean and obese individuals. The authors then present evidence for the theory that disturbances in muscle-lipid metabolism may cause a person to be predisposed to become obese. Specific topics include muscle mitochondria and uncoupling protein in obesity; insulin resistance in obesity, including blunted muscle insulin-signal transduction in obesity, how the activation of Protein Kinase PKC may cause insulin resistance, the relationship of skeletal-muscle insulin resistance and intramyocellular lipid accumulation, inflammatory pathways and insulin action in obesity, and mechanisms causing insulin resistance in obesity; and lipid metabolism, including fatty acid oxidation in skeletal muscle, fatty acid transport into skeletal muscle, and the metabolic inflexibility associated with obesity. The chapter includes black-and-white illustrations and a lengthy list of references. 2 figures. 113 references.
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Metabolic Syndrome. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 155-168.
This chapter on the metabolic syndrome is from a comprehensive textbook on obesity and diabetes. The metabolic syndrome is a cluster of risk factors associated with the development of cardiovascular disease (CVD). Obesity, in particular visceral adiposity, insulin resistance, and some degree of abnormal glucose metabolism coupled with dyslipidemia and abnormal blood pressure (BP) are the hallmarks of the syndrome. The authors review the pathogenetic factors associated with metabolic syndrome and its association with disease. Topics include a definition of metabolic syndrome, pathophysiology of the components associated with metabolic syndrome, prevalence of metabolic syndrome, metabolic syndrome in children and early life determinants, the metabolic syndrome and cardiovascular disease, potential treatments, and the role of weight loss and exercise. The authors conclude that a large body of epidemiological data correlates the presence of metabolic syndrome with an increased risk of CVD and overall mortality. They note that although it is difficult to identify the precise mechanisms whereby lifestyle alterations (exercise and weight loss) improve outcomes, the effects are likely to include decreases in adiposity, insulin resistance, and nutrient fluxes; altered intramyocellular and intrahepatic metabolism; and increased adiponectin levels and skeletal muscle blood flow. The authors stress that because obesity is an increasing global burden, it is expected that the number of individuals with metabolic syndrome will increase, as will the rates of morbidity and mortality from CVD. 3 figures. 3 tables. 84 references.
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Metformin: Now or Later?. Harvard Health Letter. 32(1): 4. November 2006.
This newsletter article considers the use of metformin (Glucophage) and when it should be started in people newly diagnosed with type 2 diabetes. Metformin lowers blood sugar levels by decreasing the liver’s production of sugar and by increasing the effectiveness of insulin, the hormone that escorts sugar into the cells where it can be used. Insulin resistance is one of the main features of type 2 diabetes. Metformin is a first-line medication for several reasons: It is effective, lowering blood sugar levels by about 20 percent; people do not tend to gain weight when they take it, in contrast to insulin and the sulfonylurea drugs; and it is relatively inexpensive. Proponents of this type of drug therapy say that these medications tame conditions that are too serious to allow to progress. Critics counter that not nearly enough has been invested in devising ways to make diet and exercise programs work; approaches that do not carry the side effects that medications cause. The author concludes that the most important thing for people with newly diagnosed type 2 diabetes is to get their blood glucose levels under control. If this can be achieved without the drug therapy, that is fine, but if metformin is required to reach appropriate glycosylated hemoglobin levels, patients should not hesitate to include the drug in their diabetes management plan.
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Nutrients and Peripherally Secreted Molecules in Regulation of Energy Homeostasis. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 69-86.
Obesity is directly responsible for the increasing morbidity and mortality from insulin resistance and the metabolic syndrome, diabetes, cardiovascular disease, cancer, respiratory ailments, arthritis, reproductive challenges, and psychosocial problems. Research has changed the conception of adipose tissue from that of an inert reservoir of stored energy to an active organ producing and secreting many molecules that regulate energy homeostasis. This chapter on nutrients and peripherally secreted molecules in regulation of energy homeostasis is from a comprehensive textbook on obesity and diabetes. In this chapter, the authors discuss how signals from both adipose tissue and other peripheral organs not only are integrate centrally in the brain to alter energy homeostasis, but may also influence other physiological functions, such as the neuroendocrine and reproductive hormone system. The authors review molecules expressed in the periphery, which affect substrate utilization and energy partitioning. They then present the role of nutrients and hormonal signals secreted by the adipose tissue, the pancreas, and the GI system in response to acute or chronic changes in energy homeostasis. The integration of all these peripheral signals in the central nervous system and hypothalamus is discussed in the following chapter. 3 figures. 1 table. 117 references.
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Nutritional Strategies for Patients with Obesity and the Metabolic Syndrome. IN: Brett, E.; Mechanick, J., eds. Nutritional Strategies for the Diabetic and Prediabetic Patient. Boca Raton, FL: CRC Press. 2006. pp. 55-80.
This chapter on nutritional strategies for patients with obesity and the metabolic syndrome is from a book written to advance physicians’ knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. The authors define the metabolic syndrome as a constellation of cardiovascular risk factors including abdominal obesity, low HDL cholesterol levels, high triglyceride levels, high blood pressure, and impaired fasting glucose. The syndrome is associated with an increased risk of cardiovascular disease and type 2 diabetes that is linked to insulin resistance and abdominal obesity. The chapter covers the scope of the problem, pathophysiology, identification and evaluation of the obese patient, treatment of obesity, weight loss and dietary approaches to the metabolic syndrome, the dyslipidemia component, the impaired fasting glucose component, and the hypertensive component. In each of these three latter sections, the authors discuss prevalence, pathophysiology, and lifestyle management approaches. They conclude that, to achieve improved metabolic control, dietary treatment recommendations must be individualized to the metabolic profile of the patient and must take into consideration the patient’s food preferences, lifestyle, and cultural norms. 2 figures. 9 tables. 162 references.
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Nutritional Strategies for the Diabetic and Prediabetic Patient. Boca Raton, FL: CRC Press. 2006. 349 p.
This book was written primarily for physicians to advance their knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. Contributors to the book include basic scientists, clinicians from various subspecialties, registered dietitians, and certified diabetes educators, each with expertise on a different aspect of diabetes care. The book offers 15 chapters that cover the foundations of nutritional medicine, the pathophysiology and clinical management of diabetes and prediabetes, preventive nutritional strategies in diabetic and prediabetic patients, nutritional strategies for patients with obesity and the metabolic syndrome, medical nutrition therapy (MNT) for patients with type 2 diabetes, nutrition and type 1 diabetes, the use of carbohydrate counting, continuing insulin infusion (CII) therapy and nutrition, nutritional strategies in pregestational, gestational, and postpartum diabetes patients, nutritional strategies for the patient with diabetic nephropathy, nutrition support and hyperglycemia, nutritional strategies for wound healing in diabetes patients, mitochondrial function in diabetes, the rational use of dietary supplements, and exercise and nutrition. Each chapter contains basic information for those interested in the pathophysiology of the disease process as well as clinically relevant information that has practical implications regarding nutritional support for patients with diabetes. The six appendices include a list of abbreviations, a chart of the levels of evidence and recommendation grades used for technical reviews, a chart of the dietary reference intakes of relevant nutrients, a diabetes management patient record handout, dietary tips for pregnancy and diabetes, and a case study that focuses on office-based nutritional counseling. The book concludes with a detailed subject index.
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Other Routes to Better Health. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 139-148.
This chapter on other routes to better health is the final chapter in a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author discusses the need to get regular health care, including diagnostic and monitoring tests; how to set up a prediabetes patient care team, including a primary care physician, endocrinologist, dietitian, and diabetes educator; the use of self monitoring of blood glucose (SMBG); complications, particularly cardiovascular system problems; barriers to change and how to identify them; health attitudes and beliefs; support systems, including family, friends, and colleagues; and the steps to successful behavior modification. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter.
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Oxidative Stress And Vascular Complications of Diabetes Mellitus. IN: Opara, E., ed. Nutrition and Diabetes: Pathophysiology and Management. Boca Raton, FL: CRC Press. 2006. pp 361-380.
This chapter about oxidative stress and vascular complications of diabetes is from a textbook that highlights the link between the problems of obesity and diabetes mellitus. The authors describe oxidative stress as excessive production of reactive-oxygen species (ROS) or pro-oxidant factors in the presence of diminished antioxidants. Antioxidant factors include vitamins, minerals, and enzymes that interact in a special biochemical chain to scavenge free radicals. The first section considers the pathophysiology of oxidative stress, diabetes, and vascular injury, including hyperglycemia, dyslipidemia, and insulin resistance. The authors describe clinical manifestations of diabetic angiopathy, including the microvascular complications of retinopathy and nephropathy and the macrovascular complications of coronary disease, cerebrovascular problems, and peripheral vascular problems. A final section considers possible treatment strategies for oxidative stress in diabetes. The authors conclude that as the incidence of diabetes reaches pandemic proportions, treatment approaches that target all components of this complex disease, including oxidative stress, will be needed. 2 figures. 155 references.
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Pathophysiology and Clinical Management of Diabetes and Prediabetes. IN: Mechanick, J.; Brett, E., eds. Nutritional Strategies for the Diabetic and Prediabetic Patient. Boca Raton, FL: CRC Press. 2006. pp. 15-44.
This chapter on the pathophysiology and clinical management of diabetes is from a book written to advance physicians’ knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. The authors define diabetes mellitus, review its demographics, and consider the diagnostic criteria used for diabetes. They discuss the classification of different types of diabetes, type 1 diabetes mellitus, type 2 diabetes mellitus, genetic defects of the beta cell, mitochondrial diabetes, genetic defects in insulin action, diseases of the exocrine pancreas, diseases associated with type 2 diabetes mellitus, secondary diabetes mellitus, chemicals and toxins that cause hyperglycemia, posttransplant diabetes, gestational diabetes, prediabetic conditions, and risk factors for type 2 diabetes. The authors delve into the pathophysiology of diabetes mellitus, discussing insulin secretagogues, insulin resistance and type 2 diabetes mellitus, the effects of hyperglycemia, glucose toxicity, nitric oxide, endothelial dysfunction, and diabetes complications. A final section addresses the treatment of diabetes, including the clinical management of type 1 diabetes mellitus, acute through long-term management, the clinical management of type 2 diabetes, the pharmacological treatment of type 2 diabetes, and other long-term management issues associated with type 2 diabetes. 6 figures. 4 tables. 119 references.
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Pathophysiology of Diabetes in Obesity. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 117-125.
According to the United States Department of Health and Human Services, 60 percent of the U.S. population in 2001 was either overweight or obese. Obesity is diagnosed when the percentage of body fat is high in relation to the lean body mass or when the body mass index (BMI) is 30 kilograms per meter-squared; individuals with a BMI between 25 and 29.9 are considered overweight. Overweight or obesity is present in 80 percent of individuals with type 2 diabetes. This chapter on the pathophysiology of diabetes in obesity is from a comprehensive textbook on obesity and diabetes. The authors discuss the association between obesity and type 2 diabetes, the pathogenesis of type 2 diabetes in obesity, the role of adipocytokines, and the role of body fat distribution in pathogenesis of type 2 diabetes. Insulin resistance and hyperinsulinemia are often seen in overweight and obese individuals and are by far the best predictors of type 2 diabetes. The development of type 2 diabetes in overweight and obese individuals is characterized by progressive deterioration of glucose tolerance over several years. The mechanism through which obesity increases insulin resistance is currently thought to be related to the increased circulating free fatty acids (FFAs), altered levels of adiopocytokines, altered body fat distribution, or a combination of the three. 88 references.
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Pathophysiology of the Metabolic Disorders. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 144-161.
Diabetes is a disease characterized by abnormal metabolism of carbohydrates, proteins, and fats. This chapter on the pathophysiology of the metabolic disorder is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The authors note that newly discovered hormones and systems that regulate energy balance have increased understanding of normal physiology and the pathophysiology of diabetes. The chapter covers normal fuel metabolism, the role of hormones, the different types of diabetes, and the pathogenesis of type 1 diabetes and of type 2 diabetes. Type 1 diabetes results from autoimmune beta cell destruction, leading to absolute insulin deficiency. Type 2 diabetes is a multihormonal pathophysiology involving a progressive insulin secretory defect along with insulin resistance. This disease progresses from an early asymptomatic state with insulin resistance, to mild postprandial hyperglycemia, to clinical diabetes requiring drug therapy. Obesity, weight gain in adulthood, and physical inactivity are environmental factors affecting the progression at all points along the continuum. The chapter includes a list of key points, a summary of teaching strategies, suggested Internet resources, a glossary of key terms, and a list of references. 2 figures. 3 tables. 79 references.
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Pathophysiology of Type 2 Diabetes. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. Somerset, NJ: John Wiley & Sons. 2006. pp 43-58.
This chapter on the pathophysiology of type 2 diabetes is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include the main pathophysiologic characteristics of type 2 diabetes mellitus, the physiologic effects of insulin in the body, insulin resistance and how it is measured, the role of pancreatic beta cells, the role of genetic predetermination and environmental factors in the development of type 2 diabetes, insulin secretion from the beta cell, and the natural history of type 2 diabetes development. The chapter presents four case studies, which are individually discussed, and relevant questions are posed and answered. Readers are walked through the diagnostic and patient care management processes for the case studies presented. 1 figure. 6 references.
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Pediatric Diabetes: Client Education Handouts. Chicago, IL: American Dietetic Association. 2006. (CD-ROM).
This CD-ROM of patient education handouts accompanies a book that was developed to assist nutrition health-care professionals with diabetes education and training of children with Type 1 and 2 diabetes. The CD-ROM includes 22 handouts that parallel the book’s diabetes education topics: calcium, celiac disease and diabetes, cystic fibrosis-related diabetes, dining out, exchange lists for meal planning, fiber, flexible insulin plan terms, food choice lists for kids and teens, free foods, glycemic index and diabetes, heart-healthy foods, insulin pumps, physical activity, pre-diabetes, reading food labels, sick day management, smart snacking, sugar substitutes, treating low blood glucose, type 2 diabetes, weight management for kids, and a definition of diabetes. The CD-ROM also includes seven interactive worksheets: advanced carbohydrate counting, basic carbohydrate counting, basic carbohydrate counting meal plan, a food record form, insulin action, My Meal Plan, and the kinds of foods that make the blood glucose go up.
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Pediatric Diabetes: Health Care Reference and Client Education Handouts. Chicago, IL: American Dietetic Association. 2006. 53 p.
This book was developed to assist nutrition health-care professionals with diabetes education and training of children with Type 1 and 2 diabetes. This resource provides health-care professionals with practical, age-appropriate diabetes self-management and nutrition education materials. The book covers 24 diabetes education topics: general nutrition guidelines, basic carbohydrate counting, advanced carbohydrate counting, exchange lists for meal planning, reading food labels, sugar substitutes, the use of the glycemic index, calcium, fiber, heart-healthy foods, smart snacking, free foods, dining out, weight management in children and adolescents, physical activity in youth, type 2 diabetes and pre-diabetes in youth, treating low blood glucose, sick day management, cystic fibrosis-related diabetes, celiac disease and type 1 diabetes, insulin pumps, meal plans, food records, and flexible insulin delivery plans. For each topic covered, there is a brief introduction, background information, counseling suggestions, and relevant references. The booklet concludes with seven appendices: Nutrition Goals for Children and Adolescents with Diabetes; Age-Related Traits of Youths and Delegation of Responsibilities; Estimating Calorie Needs for Youths; Blood Glucose and A1C Goals Based on Age; Typical Insulin-to-Carbohydrate Ratios Based on Age and To Be Used With a Flexible Insulin Plan; Typical Total Daily Insulin Doses; and Management of Dyslipidemia in Children and Adolescents With Diabetes. An accompanying CD-ROM of client education handouts is also available.
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Polycystic Ovary Syndrome and its Metabolic Complications. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 255-276.
This chapter on polycystic ovary syndrome and its metabolic complications is from a comprehensive textbook on obesity and diabetes. Polycystic ovary syndrome (PCOS) is a complex disorder with multiple potential etiologies and variable clinical presentations whose pathogenesis remains poorly understood. PCOS is characterized by clinical and biochemical hyperandrogenism and chronic annovulation. The syndrome is also associated with insulin resistance, obesity, increased risk of diabetes mellitus, and, possibly, cardiovascular disease (CVD). The authors review the pathophysiology, metabolic complications, and treatment of PCOS. Treatment strategies discussed include weight loss, the use of antiandrogens (spironolocatone, flutamide), oral contraceptive agents, and insulin sensitizers (metformin, thiazolidinediones, d-chiro-inositol). The authors note that obesity is present is approximately half of the patients with PCOS and obesity contributes to the disorder by increasing the magnitude of hyperandrogenism and the rates of anovulatory cycles and infertility. Treatments directed at the reduction of hyperinsulinemia reduce symptoms of PCOS and restore normal ovarian function in obese women with PCOS. 2 figures. 4 tables. 153 references.
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Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. 176 p.
This book explains prediabetes, also called the metabolic syndrome, in non-technical language. Written to help readers prevent or delay their progression to diabetes, the book uses a road map analogy to explain the strategies they can take to better health. The author includes thirteen chapters covering how food fuels the body, what happens when the fuel system breaks down, the concerns about prediabetes, health risk factors, lifestyle risk factors, the interplay between diabetes and cardiovascular disease, how to develop a good attitude about health, weight loss, nutrition, exercise, the role of medications, and working with health care providers. The book includes conversational language, with true stories and personal examples; sidebars that offer statistics about prediabetes and diabetes; important terms underlined in the text and defined in a glossary at the end; and questions for consideration at the end of each chapter. The book concludes with an annotated list of resources, suggestions for where to find additional information, a subject index, and a brief author biography. Charts, figures, and illustrations are included throughout the text.
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Preventing Cardiovascular Disease and Diabetes: A Call to Action from the American Diabetes Association and the American Heart Association. Diabetes Care. 29(7): 1697-1699. July 2006.
This article, a joint effort of the American Diabetes Association and the American Heart Association, clarifies and reinforces the notion that these two organizations remain unified and committed to reducing the burden of diabetes and cardiovascular diseases (CVD). The authors note that the importance of identifying and treating a core set of risk factors (prediabetes, hypertension, dyslipidemia, and obesity) cannot be overstated. Although unrelated to an underlying metabolic abnormality, tobacco use deserves special attention. Because recent evidence suggests that risk assessment and adherence to national guidelines remains suboptimal, the authors call for a renewed effort to prevent and treat these conditions. All health care providers are encouraged to assess patients for their global risk for CVD and diabetes. Although drug therapy is often indicated when overt disease is detected, in the early stages of these conditions lifestyle modification with attention to weight loss and physical activity may well be sufficient. 57 references.
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Progressive Loss of B-Cell Function. IN: Sharing the Burden: The Role of Incretins in Glucose Control. Chicago, IL: American Association of Diabetes Educators. 2006. p. 6-7.
New research highlighting the role of incretin hormones in beta cell function, growth, and development shows potential to provide clinical benefit to patients and to expand the current treatment options for managing type 2 diabetes. This section on the pathophysiology of diabetes is from a clinical monograph on the role of incretins in glucose control; the monograph is based on a continuing education symposium that was held in conjunction with the American Association of Diabetes Educators' 2005 Annual Meeting. The authors note that abnormalities in insulin sensitivity and insulin secretion are hallmarks of type 2 diabetes pathophysiology. Insulin resistance blunts the ability of major insulin responsive organs—adipose tissue, skeletal muscle, and the liver—to dispose of glucose. As a result of this insulin resistance, the beta cells of the pancreas must secrete more insulin in order to keep glucose levels normal. As glucose intolerance develops, beta-cell compensation fails, and glucose control is lost. Some studies have demonstrated that this decline in beta cell function occurs regardless of treatment intervention. This section concludes by noting that the abnormalities in insulin sensitivity and insulin secretion are only two of the contributors to hyperglycemia. 1 figure.
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Speed Bumps: Your Health Risks. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 43-48.
This chapter on the risk factors for diabetes is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes those things can lead to the development of prediabetes and continue to add to the risk of developing type 2 diabetes. Risk factors discussed include glucose intolerance, existing immune system problems, and side effects from medications. The author also reviews common blood glucose test results and what they mean. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 2 tables.
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Time to Get Moving. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 114-125.
This chapter on the benefits of exercise is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes how exercise can burn calories, help control weight, help increase the cells’ sensitivity to insulin, lower blood glucose levels, slow or even prevent the onset of diabetes, lower blood pressure, help the body use oxygen more effectively, and lower lipid (fat) levels in the blood. The author encourages readers to consult their health care provider before beginning a plan of exercise, then start slowly and consistently try to exercise at least five days per week. Other topics include the fun of varying one’s exercise routine, target heart rates, the benefits of simple walking, utilizing hidden exercise in everyday activities, the role of warming up and cooling down, and the need to include others in one’s exercise plan. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. One sidebar discusses how to gain and use support from friends and family for the exercise plan. 3 tables.
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Tune in to Your Ratio(s). Diabetes Self-Management. 23(2): 6-8. March April 2006.
This article explains how using the insulin-to-carbohydrate ratio can give readers with diabetes more flexibility with regard to food choices, as well as better blood glucose control. Basal insulin is the background insulin, used to maintain blood glucose levels outside of the influence of meals. Boluses of insulin are taken before each meal or substantial snack. The author notes that bolus insulin doses should be tailored to the amount of carbohydrate in a meal or snack, because carbohydrate in food is what makes the blood glucose level rise. The author also discusses the impact of fat intake on insulin resistance, the effect of protein on blood glucose levels, how to calculate a meal or snack bolus, determining the initial insulin-to-carbohydrate ratio with either the 500 rule or the weight method, how to collect and record data necessary for these methods, and the common occurrence of different insulin-to-carbohydrate ratios at different times of the day. The article includes a chart of a sample log demonstrating the information needed to determine a breakfast ratio. Readers are encouraged to work closely with their health care providers to explore this method of insulin and diabetes management. 1 table.
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Type 2 Diabetes and Pre-diabetes in Youth. IN: Pediatric Diabetes: Health Care Reference and Client Education Handouts. Chicago, IL: American Dietetic Association. 2006. pp. 26-28.
In the past decade, prevalence of type 2 diabetes, overweight, and insulin resistance in youth has increased. This chapter on type 2 diabetes and pre-diabetes in youth is from a resource book that provides health-care professionals with practical, age-appropriate diabetes self-management and nutrition education materials for children and adolescents with type 1 and 2 diabetes. In this chapter, the authors discuss the prevalence of diabetes; obesity, metabolic syndrome, and the development of type 2 diabetes and pre-diabetes in youth; symptoms of type 2 diabetes in young people; risk factors for these conditions; screening guidelines; and counseling suggestions in the areas of eating healthfully and maintaining a healthy weight, physical activity, diabetes medications, and blood glucose monitoring. 1 table. 12 references.
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Unforeseen Mechanical Breakdowns: ‘Just Because’ Risks. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 57-62.
This chapter on the unmodifiable risk factors for diabetes is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author describes those things can lead to the development of prediabetes and continue to add to the risk of developing type 2 diabetes. Risk factors discussed include age, family history (genetics), ethnicity, cultural factors (food habits), and gestational diabetes. The author reminds readers that even though these factors cannot be changed, they can influence how one deals with delaying or even preventing diabetes. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter.
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Watch Your Weight. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 86-94.
This chapter on weight management is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author outlines a three-part process to optimal body weight: stabilize one’s weight, take steps to lower body weight to appropriate levels, and maintain that weight level for the long term. The author emphasizes that even a weight loss of 5 to 10 percent of one’s total body weight can have a positive impact on health. Charts are provided to help readers determine their individual goals and to record their weight-loss record. Readers are also guided in choosing an appropriate, healthy weight loss plan, primarily focusing on reducing the number of calories consumed and selecting the healthiest, most nutritious foods. The role of exercise is also stressed. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. One sidebar discusses how to gain and use support from friends and family for the weight loss plan. 4 figures. 1 table.
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Weight Management in Children and Adolescents. IN: Pediatric Diabetes: Health Care Reference and Client Education Handouts. Chicago, IL: American Dietetic Association. 2006. pp. 23-24.
In the past decade, prevalence of type 2 diabetes, overweight, and insulin resistance in youth has increased. Children with type 2 diabetes are at a higher risk of cardiovascular disease and microvascular complications. This chapter on weight management in children and adolescents is from a resource book that provides health-care professionals with practical, age-appropriate diabetes self-management and nutrition education materials for children and adolescents with type 1 and 2 diabetes. In this chapter, the author discusses overweight and obesity in children and adolescents, and counseling suggestions. The author emphasizes the importance of small changes for behavior modification and the role of physical activity for weight loss and weight management. 5 references.
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When the Fuel System Breaks Down. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 21-30.
This chapter on the impact of insulin resistance on how the body digests and uses food is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author reviews what happens when there is either not enough insulin to carry glucose into the cells (type 1 diabetes) or when there is enough insulin but still too much glucose in the bloodstream and the body is not using it properly (type 2 diabetes). The author reviews the risk factors for type 2 diabetes, reminds readers that type 2 diabetes can develop slowly and thus be sidetracked with appropriate therapy, and summarizes the diagnostic tests used to monitor blood glucose levels and to diagnose diabetes. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 5 figures. 3 tables.
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Why Worry About It?. IN: Prediabetes Wake-Up Call: A Personal Road Map to Prevent Diabetes. Berkeley, CA: Ulysses Press. 2006. pp. 31-38.
This chapter on the problems and complications associated with diabetes is from a book about prediabetes, also called the metabolic syndrome. Written in non-technical language to help readers prevent or delay their progression to diabetes, the book uses a road map and automobile analogy to explain the strategies they can take to better health. In this chapter, the author wants to scare readers ‘half to death’ in order to impress upon them the seriousness of prediabetes and the potential implications if nothing is done to reverse the path to diabetes. The author emphasizes that people with diabetes who manage their disease well lessen their chances of complications. Complications discussed include cardiovascular disease, foot problems, diabetic retinopathy (eye disease), diabetic neuropathy (nerve disease), diabetic nephropathy (kidney disease), dental problems, and complications during pregnancy. The author uses conversational language, with true stories and personal examples, and questions for consideration at the end of the chapter. 5 figures. 3 tables.
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Your Game Plan to Prevent Type 2 Diabetes. Information for Patients. Bethesda, MD: National Diabetes Education Program. 2006. 20 p.
This booklet offers information about diabetes prevention for people at high risk for developing diabetes. The two main keys to success are getting at least 30 minutes of moderate-intensity physical activity five days a week, and eat a variety of foods that are low in fat and reduce the number of calories eaten each day. The booklet presents a "Game Plan" which is based on the Diabetes Prevention Program (DPP) research study that showed that type 2 diabetes could be prevented or delayed in people with increased risk by losing a small amount of weight and getting 30 minutes of moderate-intensity physical activity. This booklet is designed to help readers take steps to prevent diabetes, set goals, and track their progress. The chapters of the booklet cover the risk factors for type 2 diabetes and pre-diabetes, small steps for eating healthy foods, and small steps for getting more physical activity. The booklet also includes food and activity tracker pages for photocopying and a list of additional resources, with their telephone numbers and web site addresses. The booklet is illustrated with photographs of people living an active lifestyle. 2 figures. 5 tables.
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Can Childhood Obesity be Prevented?: Preschool Nutrition and Obesity. In: Preventive Nutrition: The Comprehensive Guide for Health Professionals. Totowa, NJ: Humana Press.. 2005. pp 345-381.
In the past three decades, the prevalence of obesity among preschool children has doubled. This chapter on preschool nutrition and obesity is from a comprehensive textbook on ways to improve health and reduce the risk of disease with dietary modifications (preventive nutrition). The author notes that early childhood is a time when children begin to develop eating habits that may differentially promote or discourage the development of chronic disease later in life. The goal of preschool nutrition programs is to promote dietary habits that achieve optimal health, growth, and development in a manner that also minimizes risk of nutrition-related disease. The author reviews the primary preschool nutrition programs in the United States and explores the impact of recent trends in early childhood obesity, preschool dietary intake, and physical activity issues related to dietary guidelines for healthy 2 to 5 year old children. The author concludes that energy balance in preschool children is of critical importance in the primary prevention of obesity. Preschool programs that include health education, daily physical activity, and a child-healthy diet could be an effective public health intervention strategy. 6 figures. 8 tables. 153 references.
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Current and Future Treatment of Metabolic Syndrome and Type 2 Diabetes in Children and Adolescents. Diabetes Spectrum. 18(4): 220-228. Fall 2005.
The metabolic syndrome and type 2 diabetes are occurring at alarming rates in children. The metabolic syndrome includes a cluster of risk factors for atherosclerotic cardiovascular disease (CVD) and type 2 diabetes, including insulin resistance, obesity, hypertension, and dyslipidemia. This article reviews current and potential future drugs for the treatment of obesity, dyslipidemia, hypertension, and type 2 diabetes in children. The authors also discuss surgical procedures for treating severely obese adolescents. Lifestyle modification is the mainstay of prevention and treatment for metabolic syndrome and type 2 diabetes; however, it can be costly and labor-intensive. Pharmacotherapy is considered a second line of therapy in adults, but its use in children is controversial. 75 references.
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Diabetes Definitions. Diabetes Self-Management. 22(5): 82, 85. September-October 2005.
This article brings readers up to date with three new terms used in the field of diabetes care and self-management. The first, adiponectin, is a protein secreted by fat tissue; people with insulin resistance and diabetes tend to have very low levels of adiponectin, which may have implications for the prevention and treatment of type 2 diabetes and cardiovascular disease. Insulin sensitivity factor is defined as the drop in blood glucose level, measured in milligrams per deciliter, caused by each unit of insulin taken. Knowing their insulin sensitivity factor can help people with Type 1 diabetes to determine the dose of short-acting or rapid-acting insulin to take. The third term, vitiligo, refers to a disorder in which melanocytes (the cells that make pigment in the skin, mucous membranes, and retina of the eye) are destroyed, leading to the development of white patches on the skin. Studies have suggested that vitiligo may be more common in people with type 1 diabetes. Readers are referred to the National Vitiligo Foundation (www.nvfi.org).
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Diabetes in Older People: A Disease You Can Manage. IN: Bound for Your Good Health. Bethesda, MD: National Institute on Aging. 2005. pp 18-21.
This chapter from a book that promotes overall good health encourages older people who have been diagnosed with diabetes to become very involved in their own diabetes management. The chapter begins with a description of diabetes, its complications, and the types of diabetes, including type 1 diabetes, type 2 diabetes, and pre-diabetes. The chapter discusses the symptoms of blood glucose problems, diagnostic tests used to confirm and monitor diabetes, and management strategies, including meal planning, physical activity, medication, and recordkeeping. Readers are encouraged to include other treatment and monitoring in their plan of management, including eye exams, a yearly kidney check, foot care, skin care, care of teeth and gums, and vaccinations such as flu shots and pneumonia vaccine. The final section of the chapter provides the contact addresses for four organizations through which readers can get additional information: the National Diabetes Education Program, the American Diabetes Association, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Institute on Aging Information Center. One sidebar notes that Medicare now covers most diabetes supplies; the contact number is provided (800-633-4227). The text is printed in larger-than-normal font.
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Diabetes, Heart Disease, and Stroke. Bethesda, MD: National Diabetes Information Clearinghouse. 2005. 11 p.
Having diabetes or pre-diabetes can result in an increased risk for heart disease and stroke. Diabetes is a disease in which blood glucose levels are above normal. Over time, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, kidney disease, nerve problems, gum infections, and amputation. This fact sheet answers common questions about heart and blood vessel disease associated with diabetes. Readers with diabetes are encouraged to lower their risk of heart disease and stroke by keeping blood glucose, blood pressure, and blood cholesterol levels close to the recommended target numbers. Reaching these targets can also help prevent narrowing or blockage of the blood vessels in the legs, called peripheral arterial disease. The fact sheet reviews the disease of diabetes itself, then covers pre-diabetes; the connection between diabetes and cardiovascular disease; risk factors for heart disease and stroke in people with diabetes; metabolic syndrome and how it is linked to heart disease; strategies that can prevent or delay heart disease and stroke; tests that can monitor diabetes management programs including blood glucose, blood pressure, and blood cholesterol tests; coronary artery disease; cerebral vascular disease; stroke; heart failure; peripheral arterial disease; the symptoms of heart disease; treatment options for heart disease; the symptoms of stroke; the treatment options for stroke; and current research programs and studies in these areas. The booklet concludes with contact information for related resource organizations and a brief summary of the activities of the National Diabetes Information Clearinghouse (NDIC). 2 figures. 4 tables.
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Elevated Liver Function Tests in Type 2 Diabetes. Clinical Diabetes. 23(3): 115-119. Summer 2005.
Individuals with type 2 diabetes have a higher incidence of liver function test (LFT) abnormalities than individuals who do not have diabetes. This article reviews the pathology, incidence, causes, and drug therapy related to type 2 diabetes and elevated LFTs. Mild chronic elevations of transaminases often reflect underlying insulin resistance. Elevation of transaminases within three times the upper limits of normal is not a contraindication for starting oral antidiabetic or lipid-modifying therapy. In contrast, antidiabetic agents have generally been shown to decrease alanine aminotransferase levels as tighter blood glucose levels are achieved. The most common cause of elevated LFTs in type 2 diabetes patients in non-alcoholic fatty liver disease (NAFLD). Hepatitis C virus (HCV), the leading cause of liver disease in the United States, is a known independent predictor of type 2 diabetes. The author notes that, for diabetes patients over the age of 40 years, and certainly in the setting of multiple cardiovascular risk factors or know cardiovascular disease, the potential risk of statin therapy (hepatotoxicity) is far outweighed by the proven benefit from CVD risk reduction. The author concludes by reviewing relevant research studies on the use of oral antidiabetes agents in type 2 diabetes patients with elevated transaminases.
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Glycemic Status and Development of Kidney Disease. Diabetes Care. 28(10): 2436-2440. October 2005.
Diabetes mellitus is a major risk factor for the development of kidney disease. This article reports on a study undertaken to determine if pre-diabetes status is also associated with the development of kidney disease. The study included subjects free of chronic kidney disease (CKD) from the Framingham Heart Study offspring cohort (1991-1995) and included follow up for an average of 7 years. Of the 2,398 subjects (53 percent women, mean age 54 years), 63 percent were had normal blood glucose levels, 29 percent had impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), 3.4 percent were newly diagnosed with diabetes, and 4.6 percent had known diabetes. The fully adjusted odds of developing CKD were 0.98 for those with IFG or IGT, 1.71 for those with newly diagnosed diabetes, and 1.93 for those with known diabetes, compared with those who were normoglycemic at baseline. Among participants without diabetes, metabolic syndrome was not associated with kidney disease at follow up. The authors conclude that cardiovascular disease risk factors explain much of the relationship between prediabetes and the development of CKD. The data suggest that CKD in the setting of prediabetes might be thought of as an additional complication of macrovascular atherosclerosis. 1 figure. 2 tables. 32 references.
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Healing Heart: Don't Forget Diabetes. Diabetes Forecast. 58(4): 29-32. April 2005.
This article reviews the interplay of diabetes mellitus and cardiovascular diseases. The author notes that most patients who see a cardiologist for heart disease may also have diabetes, pre-diabetes, or high glucose levels. Many cardiologists attribute the high blood glucose levels to the stress caused by heart disease or a heart attack. For that reason, they concentrate their treatment on the heart and make no attempt to control their patients' blood glucose levels. However, the standard triad of diabetes care (insulin therapy, diet, and exercise) is very appropriate for patients with cardiovascular disease as well. The author reports on the beneficial use of intensive insulin therapy during the acute treatment of a heart attack (in patients with and without diabetes), a strategy that can save lives but that is only recently becoming part of standard care protocols. The author concludes by reminding readers of the benefits of preventing heart disease with a healthy diet and lifestyle.
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Herbs That Affect Blood Glucose Levels. Women's Health in Primary Care. 8(7): 325-330. August 2005.
Some herbs can have undesirable and possibly hazardous effects on blood glucose levels in women with diabetes, yet their use is quite common. This article explores adverse drug-herb interactions, focusing on herbs that affect blood glucose levels. The author notes that many herbal products are used at the same time with antidiabetes medications, with or without the knowledge of the patient’s clinicians. Herbs discussed include ginseng, fenugreek, bitter melon, garlic, onion, and plants containing catechin-related compounds (such as green tea). Catechins have an inhibitory activity against glucose transporters in the intestine, thus diminishing the amount of glucose absorbed. The polysaccharides in ginseng can lower blood glucose levels either by decreasing glucose production by the liver or by increasing glucose use by tissues. Components in garlic and onion have been shown to cause a glucose-lowering effect. Bitter melon enhances glucose use by the liver and reduces insulin resistance. The article includes a table of the major herbs that can influence blood glucose levels, along with their possible mechanisms of action; a second table lists the reasons for which women typically use these herbs. Women tend to use herbal products in a greater percentage than do men, so it is important for clinicians to routinely ask female patients with diabetes about the use of botanicals. 1 figure. 2 tables. 62 references.
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High Risk on the Borderline: Type 2 Diabetes Rates Are Twice as High Along the U.S.-Mexico Border. Diabetes Forecast. 58(9): 70-71. September 2005.
This brief article describes the incidence of type 2 diabetes along the United States-Mexico border and the health promotion efforts that are being undertaken in this area. The 'border region' extends 60 miles on either side of the 2,040 mile-long border. Data released in 2004 showed that approximately 1.2 million of the 8 million border region residents have type 2 diabetes. In addition, 14 percent of the border population has pre-diabetes and more than half of the adult population is overweight or obese. The author notes that a combination of factors including ethnicity, diet, and limited access to health care put residents there at higher risk. The article concludes with a brief description of the second phase of the U.S.-Mexico Border Diabetes Prevention and Control Project, which will concentrate on improving health care along the border, teaching diabetes management to patients and their families, and using community organization to educate residents and encourage healthier habits.
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I Can Lower My Risk for Type 2 Diabetes: A Guide for American Indians. Bethesda, MD: National Diabetes Information Clearinghouse, 2005. 16 p.
Although people with diabetes can prevent or delay complications by keeping blood glucose levels close to normal, preventing or delaying the development of type 2 diabetes in the first place is even better. This booklet, written in nontechnical language, answers common questions about type 2 diabetes and its prevention and management. The booklet begins with a letter from a Native American physician and a note that describes the results of the Diabetes Prevention Program, which demonstrated successful strategies for preventing diabetes in people at high risk for the condition. Topics include the different types of diabetes, the signs and symptoms of type 2 diabetes, the condition pre-diabetes, risk factors for type 2 diabetes, how to know if one should be tested for diabetes, and how to lower the risks for diabetes. Another section describes research that focused on a population of Pima Indian volunteers. Two forms are included for readers to keep track of their daily food and drink intake and their daily physical activities. A final section summarizes the activities of the National Diabetes Information Clearinghouse. 3 figures. 5 tables.
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Identification of Individuals With Insulin Resistance Using Routine Clinical Measurements. Diabetes. 54(2): 534-539. February 2005.
Insulin resistance is a precursor of type 2 diabetes and perhaps of cardiovascular disease as well. The latter association, which is independent of diabetes, may be partially a consequence of the relationship between insulin resistance and the metabolic syndrome (obesity; impaired glucose regulation; dyslipidemia; and hypertension). This article reports on a study undertaken to identify insulin-resistant patients. The authors developed decision rules from measurements of obesity, fasting glucose, insulin, lipids, blood pressure and family history from 2,321 individuals (2,138 without diabetes) using the euglycemic insulin clamp technique at 17 European sites, San Antonio, Texas, and the Pima Indian reservation. The authors report on three classification tree models developed from their results. The distribution of whole-body glucose disposal rates is bimodal. The authors conclude that the presence of bimodality facilitates the choice of a cut point for defining insulin resistance that has some basis in the underlying biology and is not wholly arbitrary. The results permit decision rules for identifying individuals with insulin resistance based on routine clinical measurements. 4 figures. 1 table. 28 references.
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Identifying Children at Risk for Obesity, Type 2 Diabetes, and Cardiovascular Disease. Diabetes Spectrum. 18(4): 213-220. Fall 2005.
Health care providers need to recognize the critical periods for the development of childhood obesity for initiation of interventions to prevent obesity. Treatment options once obesity occurs are limited. This review article provides information to assist health care providers in identifying those children and adolescents more vulnerable to becoming obese and developing associated comorbidities. Greater body weight predisposes children to many of the medical complications of obesity that are also found in adults, including hypertension, dyslipidemia, impaired glucose metabolism, and hyperinsulinemia. Race, genetic predisposition, sedentary lifestyle, duration of overweight, and underlying conditions are major determinants of risk for type 2 diabetes and cardiovascular disease (CVD). The authors note that the appropriate risk stratification for adolescents could guide clinicians in recognizing overweight youth who are at higher risk of developing prediabetes, diabetes, or cardiovascular disease (CVD) and lead to a prompt intervention. Stratification of adolescents based on severity of overweight, estimates of beta cell activity and insulin resistance, and cardiovascular risk profile may be useful for the longitudinal follow-up of overweight youth. The authors conclude by encouraging health care providers of overweight children to pursue efficient screening procedures earlier in the progression of overweight in order to prevent adolescents from developing these diseases. 4 tables. 53 references.
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Impact of Smoking and Quitting Smoking on Patients with Diabetes. Diabetes Spectrum. 18(4): 202-208. Fall 2005.
The negative impact of smoking on people with diabetes is even greater than on the general public. Macrovascular and microvascular complications ensue more quickly in smokers with diabetes and risk of mortality increases. In addition, the increased blood pressure and altered lipid profiles in smokers with diabetes could encourage development of the insulin resistance syndrome, setting patients up for further cardiovascular problems. This article stresses the importance of smoking cessation programs for people with diabetes. In addition to group programs that use behavioral change methods to devise specific strategies for smoking cessation and to prevent unique problems, such as postcessation weight gain and depression, the author outlines the variety of medications that are available to assist with smoking cessation. Studies have not proven any one smoking cessation medication to be more effective than another, so the choice for pharmacotherapy depends on the unique needs of the individual. Bupropion may be a reasonable choice because of its use for depression and its ability to delay weight gain. The author concludes that health care providers should give smoking cessation interventions high priority for diabetes control. For those patients who are ready to quit, smoking cessation medication should be provided with specific follow-up care or referral to a cessation clinic. 4 tables. 31 references.
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Insulin Resistance and Preeclampsia in Gestational Diabetes Mellitus. Diabetes Care. 28(8): 1995-2000. August 2005.
This article reports on a study that compared the degree of insulin resistance in women with gestational diabetes mellitus (GDM) who do and do not develop preeclampsia. The prospective cohort study included initially normotensive women with GDM who underwent oral glucose tolerance tests (OGTTs), intravenous glucose tolerance tests (IVGTTs), and glucose clamp studies in the early third trimester (n = 150) and 15 months postpartum (n = 89). A total of 29 women (19 percent) developed preeclampsia, which was mild in 21 women and severe in eight. At entry to the study, there were no differences in age, weight indexes, and glycemic measures between the nonpreeclamptic and preeclamptic groups. Women with GDM were uniformly insulin resistant. Those with preeclampsia were significantly taller, were more often nulliparous (no previous pregnancies), and had higher entry systolic blood pressure. At 15 months postpartum, blood pressure levels remained significantly higher in the preeclamptic group (n = 19) compared with the nonpreeclamptic group (n = 70). No differences in any glycemic or insulin resistance measures were found. 1 figure. 2 tables. 28 references.
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Joslin's Diabetes Mellitus. 14th ed. Philadelphia, PA: Lippincott Williams and Wilkins. 2005. 1209 p.
The comprehensive diabetes textbook reflects the practice and experiences of the physicians of the Joslin Diabetes Center and updates the information presented in the last version of the text published 10 years ago. The text offers 70 chapters in eight sections: basic mechanisms of islet development and function; hormone action and the regulation of metabolism; the definition, genetics, and pathogenesis of diabetes; obesity and lipoprotein disorders; treatment of diabetes mellitus; biology of the complications of diabetes; clinical aspects of managing diabetic complications; and hypoglycemia and islet cell tumors. Specific topics include genetic regulation of islet function, insulin biosynthesis, insulinlike growth factors, glucagon and glucagonlike peptides, fat and protein metabolism in diabetes, maturity-onset diabetes of the young (MODY), syndromes of extreme insulin resistance, diabetes in minorities in the United States, lipid disorders in diabetes, medical nutrition therapy (MNT), psychological issues in diabetes, iatrogenic hypoglycemia, the economic and social costs of diabetes, diabetic neuropathy, diabetic nephropathy, diabetic retinopathy, cardiovascular disease in diabetes, erectile dysfunction, diabetes and wound healing, and endocrine tumors of the pancreas. Each chapter is illustrated with tables and figures and includes a list of references; a subject index concludes the volume.
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Managing Prediabetes: Self-Care Handbook. South Deerfield, MA: Channing Bete Company. 2005. 31 p.
This booklet is designed to educate people who have been diagnosed with pre-diabetes, a condition in which the blood glucose levels are elevated, but not to such an extent that a diagnosis of diabetes is warranted. The booklet covers the dangers of prediabetes, the risk factors for diabetes, diagnostic tests and monitoring strategies that may be used, lifestyle changes, setting goals, determining a healthy weight, weight loss tips, nutrition basics, meal planning, the role of exercise, keeping records of food and activities, dealing with stress, and family considerations. The booklet is filled with charts and illustrations, places to record individualized information, and black-and-white photographs of a variety of people undertaking a variety of activities. A tear-out card is included that readers can bring with them to their health care appointments; the card includes room to record blood glucose test results and special instructions. The booklet concludes with a list of the answers to common questions about prediabetes, as well as a list of resource organizations through which readers can get more information. 5 figures. 5 tables.
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Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 28(9): 2289-2304. September 2005.
The term 'metabolic syndrome' refers to a clustering of specific cardiovascular disease (CVD) risk factors whose underlying pathology is thought to be related to insulin resistance. In this review article, the authors examine the evidence for the definition and underlying pathogenesis of the metabolic syndrome, as well as analyze the evidence for the association between cardiovascular diseases and the metabolic syndrome. The authors also discuss the evidence for the goals and impact of treatment. The authors found that while there is no question that certain CVD risk factors are prone to cluster, the metabolic syndrome has been imprecisely defined, there is a lack of certainty regarding its pathogenesis, and there is considerable doubt regarding its value as a CVD risk marker. The authors conclude that too much critically important information is missing to warrant the designation as a 'syndrome.' Clinicians are advised to evaluate and treat all CVD risk factors without regard to whether a patient meets the criteria for diagnosis of the metabolic syndrome. 2 figures. 3 tables. 168 references.
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National Diabetes Fact Sheet, United States, 2005. Phoenix, AZ: Centers for Disease Control and Prevention. 2005. 10 p.
Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes can lead to serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications. This lengthy fact sheet reviews the different types of diabetes, treatment strategies, the problem of prediabetes, the prevalence and incidence of diabetes in the United States (including differences between ethnic groups), the epidemiology of diabetes complications, and the importance of management and prevention approaches to minimize the impact of diabetes complications. The direct and indirect costs of diabetes are also estimated. The fact sheet concludes with a list of the web site addresses of organizations that collaborated in compiling the information for the fact sheet and with a glossary of related terms. 6 figures.
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Obesity and Chronic Disease: Impact of Weight Reduction. In: Preventive Nutrition: The Comprehensive Guide for Health Professionals. Totowa, NJ: Humana Press. 2005. pp 383-401.
Obesity continues to rise and is most acute, as a public health issue, in pediatric and adolescent populations. This chapter on obesity and chronic disease, specifically the impact of weight reduction, is from a comprehensive textbook on ways to improve health and reduce the risk of disease with dietary modifications (preventive nutrition). Weight reduction coupled with increases in physical activity remains the safest and most effective means to reduce insulin resistance. This chapter reviews the latest developments regarding metabolic syndrome and its implications for disease. Topics covered include impaired glucose tolerance and type 2 diabetes, body mass index and diabetes index, visceral adiposity and diabetes risk, metabolic alterations and insulin resistance, weight loss and glycemic control, diabetes and coronary heart disease (CHD), hypertension, cardiovascular disease, dyslipidemia, the metabolic syndrome, obesity and the risk of breast cancer, and patient care management of obese patients. The author concludes that although it is obvious that weight loss will reduce risk factors for disease, the relationship to mortality remains tentative. 6 figures. 2 tables. 95 references.
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Obesity and Insulin Resistance in Childhood. In: Preventive Nutrition: The Comprehensive Guide for Health Professionals. Totowa, NJ: Humana Press. 2005. pp. 293-320.
Obesity in adults and children is related to increased morbidity and mortality in a number of diseases, most importantly type 2 diabetes and cardiovascular diseases. This chapter on obesity and insulin resistance in childhood is from a comprehensive textbook on ways to improve health and reduce the risk of disease with dietary modifications (preventive nutrition). The authors focus on the etiology and pathology of insulin resistance (IR) but also discuss possible preventive measures. Topics include insulin resistance syndrome, the assessment of obesity, regulation of body weight, genetic influences, adipocytokines, glucocorticoids, thrifty genotype and thrifty phenotype, energy intake, the metabolic effects of diet composition, glycemic index, fatty acids, physical activity, sociocultural environment factors, treatment strategies, and preventive efforts. Increased resistance to insulin in liver, muscle, and adipose tissue is regarded as an important explanation behind the disturbances in glucose and lipid metabolism. The authors conclude that although genetic and early nutritional factors may influence the susceptibility to weight gain, the major underlying cause of the obesity epidemic is the spread of a sedentary Western lifestyle. Although it may be easier to treat obesity in children than in adults, it is obvious that the best strategy is primary prevention targeting all children. Effective preventive measures must not focus only on individual behavior but also on the social and physical environment for children, supporting more daily physical activities and health diets. 6 figures. 185 references.
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Pathophysiology of Gestational Diabetes Mellitus. IN: Thomas, A.M.; Gutierrez, Y.M., eds. American Dietetic Association Guide to Gestational Diabetes Mellitus. Chicago, IL: American Dietetic Association. 2005. pp. 9-16.
This chapter on the pathophysiology of gestational diabetes mellitus (GDM) is from a Guide that serves as a resource for health professionals involved in the care of women who develop diabetes during their pregnancy. The Guide helps readers to promote sound nutrition principles in GDM, to achieve optimal outcomes for the woman and her infant. The author of this chapter begins by describing the major physiological changes in glucose, amino acids, and lipid metabolism in normal pregnancy. The chapter then goes on to address the role of insulin and placental hormones in glucose homeostasis; the effect of GDM on maternal nutrient metabolism and insulin secretion; and the effect of GDM on the fetus. The author concludes that the pathophysiology of GDM is unclear and continues to be an area of research. Maternal hyperglycemia can result from an increase in insulin resistance or the inability to increase insulin production to meet the demands of pregnancy. Fetal macrosomia, the most common complication associated with GDM, is associated with maternal hyperglycemia, which in turn possibly causes fetal hyperglycemia and hyperinsulinemia. 1 figure. 1 table. 35 references.
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Prevention of Pediatric Obesity: Examining the Issues and Forecasting Research Directions. In: Preventive Nutrition: The Comprehensive Guide for Health Professionals. Totowa, NJ: Humana Press. 2005. pp 321-343.
Obesity in adults and children is related to increased morbidity and mortality in a number of diseases, most importantly type 2 diabetes and cardiovascular diseases. This chapter on the prevention of childhood obesity is from a comprehensive textbook on ways to improve health and reduce the risk of disease with dietary modifications (preventive nutrition). The authors first discuss why the prevention of childhood obesity is a high priority, then review causal mechanisms of childhood obesity, with attention to environmental factors that may have contributed to the recent increases in prevalence of childhood obesity. The next section reviews existing programs for the prevention of childhood obesity as well as their clinical effectiveness. The final section examines theoretical issues for future prevention research regarding children and adolescents. The authors also review practical clinical recommendations from the American Academy of Pediatrics. The authors conclude by cautioning that childhood obesity is a complicated disorder because it is clearly genetically influenced, although its manifestation may depend on environmental pressures. School-based prevention programs targeting reduced television viewing have been shown to help prevent weight gain in children. 4 figures. 3 tables. 144 references.
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Preventive Nutrition: The Comprehensive Guide for Health Professionals. 3rd ed. Totowa, NJ: Humana Press. 2005. 984 p.
Evidence-based nutritional interventions are a critical component of preventive medicine approaches to prevent an increasing number of diseases and diminish their consequences. This textbook contains 37 chapters that help to define the areas where health professionals can improve health and reduce the risk of disease with dietary modifications. The chapters are organized into nine sections: preventive nutrition overview; cancer prevention; cardiovascular disease prevention; diabetes and obesity; bone diseases; prevention of major disabilities; optimal pregnancy and infancy outcomes; global perspectives on preventive nutrition; and critical issues for the 21st century. Specific topics covered include an historic perspective on preventive nutrition; non-nutritive components in food as modifiers of the cancer process; dietary supplements; soy consumption; tomato, lycopene, and prostate cancer; iron and heart disease; folic acid; n-3 fatty acids from fish and plants; antioxidant vitamin supplementation; obesity and insulin resistance in childhood; prevention of pediatric obesity; obesity and chronic disease, including the impact of weight reduction; osteoarthritis; osteoporosis; antioxidant nutrients; micronutrients and immunity in older people; maternal nutrition; neurodevelopment; nutrition and food policy in Norway; prevention of malnutrition in Chile; the effect of Westernization of nutritional habits on obesity prevalence in Latin America; the effects of a Western diet on risk factors of chronic diseases in Asia; alcohol; the influence of medication on nutritional status; health claims for foods and dietary supplements; and teaching preventive nutrition in medical schools. Each chapter includes bulleted key points at the beginning of each chapter, a detailed table of contents, complete definitions of terms, tables, graphs and figures, a conclusion section, and a list of references. The volume concludes with a detailed subject index.
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Promoting Lifestyle and Behavior Change in Overweight Children and Adolescents with Type 2 Diabetes. Diabetes Spectrum. 18(1): 9-11. Winter 2005.
This article considers strategies to promote lifestyle and behavior change in overweight children and adolescents with Type 2 diabetes or the risk of developing Type 2 diabetes. The author reviews the current epidemic of obesity in children and adolescents, considering the role of access to television, other sedentary activities, the lack of physical activities, and increased portion sizes, fast food, and soft drinks. These factors result in an environment in which children consume more energy than they expend. In addition, as puberty progresses, glucose disposal decreases, indicating an insulin resistance during this stage of development; this can tip the scale in those at high risk of developing diabetes. The author discusses other health concerns in obese youngsters, including cardiovascular disease, orthopedic problems, sleep apnea, and depression; the relationship between obesity and self esteem in adolescents, including the problem of bullying; the importance of an integrated plan of nutrition and physical activity, enhanced by emotional support from parents, family, and the health care team, as a strategy of diabetes care; and current research activities in this area, including the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study. 1 table. 7 references.
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Sailing on a Wave of New Research: Part 2. Diabetes Forecast. 58(11): 45-48. November 2005.
This article, the second in a two-part series, summarizes recent research findings that were reported at the American Diabetes Association's 65th Scientific Sessions, held in San Diego (2005). This article covers undiagnosed kidney disease in people with type 2 diabetes, diet soda and weight gain in both type 1 and type 2 diabetes, poor diabetes control and depression in children and adolescents with type 1 diabetes, the use of exercise to prevent gestational diabetes, and eye disease (retinopathy) that may develop before clinical diabetes develops. Some of the information reported is from the Diabetes Prevention Program (DPP), a study that showed that weight loss, exercise, or treatment with the diabetes drug metformin can cut the risk of developing diabetes in people with pre-diabetes.
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Smoking and Incidence of Diabetes Among U.S. Adults: Findings from the Insulin Resistance Atherosclerosis Study. Diabetes Care. 28(10): 2501-2507. October 2005.
This article reports on a study undertaken to determine the association between smoking and incident (new) diabetes among adults in the United States. The authors used the Insulin Resistance Atherosclerosis Study (IRAS) to examine the relationship between smoking status categories (never, former, and current) and incident 5-year type 2 diabetes among 906 participants free of diabetes at baseline. The study also considered the effect of pack-year categories (never, former less than 20 pack-years, former more than 20 pack-years, current less than 20 pack-years, and current more than 20 pack-years) upon diabetes incidence. Results showed that, of current smokers, 96 (25 percent) developed diabetes at 5 years, compared with 60 (14 percent) never smokers. After multivariate adjustment, smokers exhibited increased incidence of diabetes compared with never smokers. Similar results were found among current smokers with greater than 20 pack-years with normal glucose tolerance. The authors conclude that smoking shares a robust association with incident diabetes. 1 figure. 2 tables. 32 references.
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Strength Training in Diabetes Management. Diabetes Spectrum. 18(2): 71-75. Spring 2005.
Strength, or resistance, training has not enjoyed the same popularity as aerobic exercise but there is now a substantial body of evidence demonstrating the merits of strength training. This article reviews the benefits of strength training as part of a comprehensive program of diabetes management. The author discusses the role of strength training, metabolic and cardiovascular disease risk factors, insulin resistance, truncal obesity, promoting strength training and safety considerations. A typical strength training program involves one to three sets of several different exercises targeting the major muscle groups; additional exercises can be added for smaller muscle groups. Attention must be given to proper lifting mechanics, and breathing patterns should remain normal. Compound, multiple-joint exercise are generally recommended over single-joint, isolation-type movements. Strength training has been demonstrated to be safe and effective in patients with chronic diseases, including diabetes and cardiovascular disease. The author stresses that individual patient considerations must be taken into account when prescribing exercise. The health care team should be involved in assessing and recommending exercise for patients with diabetes. 41 references.
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Stress Connection. Today's Dietitian. 7(4): 18-20. April 2005.
This article explores the potential negative impact of stress on a person’s program of diabetes management. Chronic stress was linked with poor glycemic control in the 1970s and the understanding of the interrelationship has continued to grow, yet patients are still often unaware of how stress can influence their diabetes control. The author discusses the physiologic response to stress (hormones and genes), and the secondary effects of the stress response, including excess weight gain, increased insulin resistance, elevated risks of cardiovascular disease, and depression. The latter part of the article briefly reviews the types of relaxation methods that can be employed to help with stress reduction, including progressive muscle relaxation (PMR), bilateral stimulation, eye movement desensitization and reprocessing, deep breathing, and exercises that incorporate yoga, tai chi, or chi gong. The author encourages dietitians to learn more about stress reduction and help their clients become aware of the sources of stress and maladaptive behaviors in their lives in order to help them achieve glycemic control and an improved quality of life. 3 references.
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Tackling Diabetes Head-On: Joslin Diabetes Center's New Nutrition Guideline. Diabetes Self-Management. 22(6): 40-44. November-December 2005.
This article reiterates current evidence of the link between obesity and diabetes. Weight loss is related to improved diabetes control and may even prevent the occurrence of type 2 diabetes. The author describes approaches that tailor meal planning, weight-loss efforts, and physical activity recommendations to the individual in order to achieve more success. The author discusses the condition of prediabetes (blood glucose levels higher than normal but not high enough to be defined as diabetes); lifestyle changes including weight loss that can prevent the development of diabetes; the hypothesis that diabetes is an inflammatory condition and a part of the immune system; the risk factors associated with abdominal, or visceral, fat, including the development of diabetes, heart disease, and high blood pressure; and nutrition recommendations. The author then describes the Joslin Nutrition Guideline, which incorporates newer nutrition research that focuses on changing the diet composition is discussed. The idea is that while weight loss is still recommended as a goal, making a change in the amount of carbohydrate, protein and fat that is eaten, even without drastically cutting back on calories, may help to improve blood glucose control and reduce the amount of visceral fat. Regular physical activity is noted as a key part of Joslin's recommendation for a structured lifestyle plan. One sidebar summarizes a sample meal plan. Readers are referred to the Joslin Diabetes Center's website (www.joslin.org) for more information. 1 figure.
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Treating Type 2 Diabetes in Children. Diabetes Self-Management. 22(4): 80-83. July-August 2005.
This article explains the comprehensive plan of diabetes care that is involved in treating type 2 diabetes in children. The author first defines type 2 diabetes and discusses the increasing incidence of type 2 diabetes, along with an increasing incidence of obesity in children. The link between being overweight and diabetes is insulin resistance: overweight contributes to insulin resistance. Other topics include the diagnostic tests used to confirm type 2 diabetes; risk factors, in addition to obesity, for type 2 diabetes; treatment options, including diet and exercise, insulin and drugs, blood pressure control, blood lipid control, and regular checkups, including HbA1c tests (a blood test that measures blood glucose levels over time); the importance of taking a family-centered approach to diabetes management and lifestyle changes; and the importance of dealing with the psychosocial aspects of a diabetes diagnosis and ongoing care. The author concludes by encouraging parents to access the many resources available to help their family cope with diabetes.
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Type 2 Diabetes in Children and Adolescents: Risk Factors, Diagnosis, and Treatment. Clinical Diabetes. 23(4): 181-185. Fall 2005.
Due to the current epidemic of obesity among children and adolescents, physicians can logically expect to encounter increasing numbers of young patients presenting initially with signs and symptoms associated with uncontrolled hyperglycemia (high blood glucose) and relatively advanced cases of diabetes. This article reviews the risk factors, diagnosis, and treatment of type 2 diabetes in children and adolescents. The authors use the case of a young adolescent (a 13-year-old Hispanic girl) with multiple risk factors for type 2 diabetes. The authors first discuss the role of family history and genetics, insulin resistance, criteria for diagnosis of diabetes, and classification of diabetes. One section covers some of the issues to consider when initiating a therapeutic regimen for this patient population, including illness severity and stage, anticipated adherence, developmental stage, and family socioeconomic status and level of support. Lifestyle changes that involve the entire family, including detailed attention to diet and exercise, constitute the foundation of an effective treatment plan. The authors also discuss drug therapy, including the use of insulin. Health care providers are encouraged to match a younger patient's level of commitment with an appropriately designed therapy, considering any possibilities to increase the likelihood of adherence and compliance to therapy. 2 figures. 27 references.
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Understanding the Links Between Insulin Resistance, Diabetes, and Cardiovascular Risk. Practical Diabetology. 24(2): 6-14. June 2005.
Insulin resistance is central to the abnormalities that make up the metabolic syndrome, which is now believed to affect almost a quarter of the population in the United States. Hypertension (high blood pressure), obesity, dyslipidemia (disorder blood lipids, such as cholesterol), and hyperglycemia (high levels of blood glucose) are components of the metabolic syndrome. This review article helps health care providers understand the links between insulin resistance, diabetes, and cardiovascular risk. The authors focus on two principal effects of hyperinsulinemia: the associated dyslipidemia, also known as the lipid triad; and the important role of oxidative stress (redox imbalance). The authors contend that vascular damage from proatherogenic dyslipidemia in the setting of chronic oxidative stress is responsible for as much as 65 percent of the mortality from insulin metabolic disorders. The authors provide a chart summarizing the clinical management of components of the metabolic syndrome. 5 figures. 2 tables. 31 references.
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Weight Management Using Lifestyle Modification in the Prevention and Management of Type 2 Diabetes: Rationale and Strategies. Clinical Diabetes. 23(3): 130-136. Summer 2005.
Overweight and obesity are strongly linked to the development of type 2 diabetes and can complicate its management. This article reprints a statement of the American Diabetes Association on the rationale for weight management using lifestyle modification in the prevention and management of type 2 diabetes. The statement describes strategies for achieving and maintaining a healthy body weight through lifestyle modification. The use of weight loss medications and bariatric surgery are not covered by this statement. Topics include the benefits of weight loss, indications and goals for weight loss therapy, diet strategies, the role of physical activity, facilitating lifestyle change in the primary care physician's office setting, and maintaining weight loss. The statement concludes that moderate weight loss improves glycemic control, reduces cardiovascular disease risk, and can prevent the development of type 2 diabetes in those with pre-diabetes. Therefore, weight loss is an important therapeutic strategy in all overweight or obese persons who have type 2 diabetes or are at risk for developing diabetes. 4 tables. 31 references.
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Women, Polycystic Ovary Syndrome and Type 2: We Are Family. Diabetes Forecast. 58(12): 63-66. December 2005.
This article describes the impact that polycystic ovary syndrome (PCOS) can have on women with type 2 diabetes. PCOS is a reproductive and metabolic condition that is closely linked to diabetes and is associated with the interplay between insulin and androgens. The author discusses the symptoms of PCOS, the increased risk for women with PCOS of developing type 2 diabetes, insulin resistance, diagnostic tests used to confirm PCOS, treatment strategies, and the importance of early intervention. The author notes that lifestyle factors (keeping one's weight under control and exercising) are extremely effective for improving insulin sensitivity.
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6 Good Ways to Lower Your Risk of Diabetes. Santa Cruz, CA: Journeyworks Publishing. 2004. 2 p.
Recent studies have shown that type 2 diabetes can be prevented or delayed by simple lifestyle changes. This brochure suggests strategies to lower one's risk of diabetes. Written primarily for the person at risk of type 2 diabetes, the brochure offers the suggestions in six categories: lose weight if necessary; eat a healthy diet; stay physically active; quit smoking; learn about risk factors, including the symptoms of diabetes or pre-diabetes; and talk with one's health care provider. The web site of the National Diabetes Education Program is provided (www.ndep.nih.gov). The brochure is illustrated with colorful line drawings.
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All About Insulin Resistance. Alexandria, VA: American Diabetes Association. 2004. 2 p.
Cardiovascular disease (CVD) is the leading cause of death among people with diabetes, accounting for at least two out of three diabetes-related deaths. This fact sheet on insulin resistance is from a set of 26 reproducible patient education handouts on topics related to diabetes CVD. Insulin resistance is a condition that increases the patient's chances of developing type 2 diabetes and heart disease. Eventually, one's blood glucose levels rise above normal in people with insulin resistance. However, cutting calories, adding physical activity to one's daily routine, and losing weight can reverse insulin resistance. The fact sheet discusses the physiology of insulin and blood glucose, the risk factors for insulin resistance, diagnostic tests used to confirm insulin resistance, and strategies to prevent or reverse insulin resistance. The fact sheet includes checklists of recommended approaches to cut calories and be more physically active. 1 figure.
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All About Pre-Diabetes. Alexandria, VA: American Diabetes Association. 2004. 2 p.
Cardiovascular disease (CVD) is the leading cause of death among people with diabetes, accounting for at least two out of three diabetes-related deaths. This fact sheet on pre-diabetes is from a set of 26 reproducible patient education handouts on topics related to diabetes CVD. Pre-diabetes is a condition in which blood glucose (sugar) levels are higher than normal but are not high enough to be considered diabetes (type 2 diabetes). Readers are encouraged to incorporate lifestyle changes that can delay or prevent the development of type 2 diabetes. These changes include cutting down on calories and fat, being physically active, and losing weight. The fact sheet describes these strategies, and discusses risk factors for diabetes, diagnostic tests that might be used to confirm pre-diabetes (fasting plasma glucose test, and oral glucose tolerance test), how to reverse pre-diabetes, and the use of medications to treat pre-diabetes. The fact sheet includes blank space for readers to record their goals for behavior changes.
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Am I at Risk for Type 2 Diabetes? Taking Steps to Lower the Risk of Getting Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse, 2004. 12 p.
Diabetes is a disease in which blood glucose levels are above normal. People develop type 2 diabetes because the cells in the muscles, liver, and fat do not use insulin properly. The amount of glucose in the blood increases while the cells are starved of energy. Over time, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, kidney disease, nerve problems, gum infections, and amputation. This booklet, written in nontechnical language, answers common questions about type 2 diabetes. Topics covered include the causes, risk factors, signs and symptoms, and prevention of type 2 diabetes. The booklet also addresses the tests used to confirm the condition and discusses pre-diabetes. A large section of the booklet walks readers through lifestyle changes that can prevent diabetes or reduce its impact. These changes include reaching and maintaining a reasonable body weight, making wise food choices most of the time, being physically active every day, and taking any prescribed medications. The publication concludes with a final section that briefly summarizes the activities of the National Diabetes Information Clearinghouse. 1 table.
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Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care: 27(2): 596-601. February 2004.
Antipsychotic medications, notably second generation antipsychotics (SGAs) are an important component in the medical management of many psychotic conditions. Although the SGAs have many notable benefits compared with their earlier counterparts, their use has been associated with reports of dramatic weight gain, diabetes, and an atherogenic lipid profile. This article reports on a consensus development conference on SGAs and obesity and diabetes. The consensus statement addresses five issues: the current use of antipsychotic drugs; the prevalence of obesity, prediabetes, and type 2 diabetes in the populations in which the SGAs are used; the relationship between the use of these drugs and the incidence of obesity or diabetes; monitoring patients for the development of significant weight gain, dyslipidemia, and diabetes, and treatment strategies if these conditions develop; and the research needed to better understand the relationship between these drugs and significant weight gain, dyslipidemia, and diabetes. The authors conclude that when prescribing an SGA, a commitment to baseline screening and follow up monitoring is essential in order to mitigate the likelihood of developing CVD, diabetes, or other diabetes complications. 4 tables. 25 references.
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Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. 496 p.
This textbook provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. The book offers 12 chapters: the diagnosis, classification, and epidemiology of diabetes mellitus; general principles of treatment; nutrition and physical activity in diabetes; oral antidiabetes agents; insulin therapy; hyperglycemic and hypoglycemic emergencies; complications of diabetes mellitus, notably the implications for primary care settings; the emerging role of insulin resistance in the understanding of reducing cardiovascular risk in type 2 diabetes and the metabolic syndrome; office management of the patient with diabetes; diabetes management in children and adolescents; diabetes and pregnancy; and diabetes self-management education. Each chapter concludes with a list of references. One appendix lists resources for additional information and support. A detailed subject index concludes the text.
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Depressive Symptoms, Insulin Resistance, and Risk of Diabetes in Women at Midlife. Diabetes Care. 27(12): 2856-2862. December 2004.
This article examined the relationship between depressive symptoms and insulin resistance and risk of diabetes in a multi-ethnic community sample of middle-aged women participating in a longitudinal study of women's health and aging. The prospective study included 2,662 women in the ethnic groups of Caucasian, African-American, Hispanic, Japanese-American, and Chinese-American. Depression predicted a 1.66-fold greater risk of diabetes, however, this became nonsignificant after adjustment for central adiposity (body fat). After risk factor adjustment, depression predicted a 2.56-fold greater risk of diabetes in African-Americans only. Depression is associated with higher HOMA-IR (homeostasis model assessment of insulin resistance) and new diabetes in middle-aged women. The authors conclude by reiterating that central adiposity mediated the relationship between depression and diabetes; depressed women had greater adiposity, which in turn accounted for the elevation in diabetes incidence. 2 tables. 37 references.
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Diabetes and Cardiovascular Disease Toolkit. Alexandria, VA: American Diabetes Association. 2004. (Instructional Packet).
Cardiovascular disease (CVD) is the leading cause of death among people with diabetes, accounting for at least two out of three diabetes-related deaths. Physicians are encouraged to talk with diabetes patients about their increased risk for heart disease and stroke. This CD-ROM offers a set of 26 reproducible patient education handouts on topics related to diabetes CVD. Topics include pre-diabetes, getting the best care for diabetes, taking care of type 2 diabetes, blood glucose levels in people with type 2 diabetes, insulin resistance, making wise food choices, choosing dietary fats wisely, cooking with heart healthy foods, how to read food labels, carbohydrate counting, weight loss, physical activity, how to begin a program of exercise, behavior change, recognizing and handling depression, treating high blood pressure (hypertension), treating high cholesterol (hypercholesterolemia), the signs of a heart attack, prevention strategies, taking aspirin, stroke, peripheral arterial disease, medical tests and procedures for finding and treating heart and blood vessel disease, managing medicines, and recordkeeping strategies. The CD-ROM requires Acrobat Reader to view each document.
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Diabetes Screening in Children: When and How. Consultant. 44(13): 1609-1610. November 2004.
This article considers guidelines for screening in children from families where either Type 1 or Type 2 diabetes are already present. The authors discuss the two types of diabetes separately, contending that there are completely different issues at stake. In children with a strong family history of Type 1 diabetes, primary autoantibody screening is recommended to identify those who are at risk. Readers are reminded, however, that 85 percent of children with newly diagnosed Type 1 diabetes have no family history of the disease. They stress that for children in the general population, the newer strategy of primary genetic (HLA) screening at birth, followed by antibody screening in a research setting for those identified as high risk, makes more sense. The main determinants of Type 2 diabetes risk remain the triad of poor diet, insufficient exercise, and obesity. In children who are obese, who have physical evidence of insulin resistance (such as acanthosis nigricans), or who have a strong family history of Type 2 diabetes, screening for prediabetes and the metabolic syndrome is clearly indicated. The authors conclude that lifestyle changes that encourage weight loss and exercise are the most effective way to avoid the eventual development of diabetes in these children. However, early use of metformin can also help delay the onset of diabetes in children with impaired glucose tolerance. 1 reference.
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Diagnosis of Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2004. 6 p.
Diabetes is a disease in which blood glucose levels are above normal. People develop diabetes because the pancreas does not make enough insulin or because the cells in the muscles, liver, and fat do not use insulin properly. This fact sheet reviews the different types of diabetes and provides basic information for people who have just received a diagnosis of diabetes. Topics include type 1 diabetes; type 2 diabetes; gestational diabetes; pre-diabetes; diagnostic tests used to confirm diabetes; the fasting plasma glucose (FPG) test; the oral glucose tolerance test (OGTT); the random plasma glucose test; risk factors for type 2 diabetes; who should consider being tested for diabetes; steps that can delay or prevent type 2 diabetes; and management strategies for diabetes, notably meal planning, physical activity, and medications. The body mass index (BMI) tables are included in one chart. The booklet concludes with contact information for related resource organizations and a brief summary of the activities of the National Diabetes Information Clearinghouse (NDIC). 4 tables.
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Effect of Oestrogen Plus Progestin on the Incidence of Diabetes in Postmenopausal Women: Results from the Women's Health Initiative Hormone Trial. Diabetologia. 47(7): 1175- 1187. July 2004.
This article reports on a randomized, double-blind trial that compared the effect of daily 0.625 milligrams of conjugated equine estrogen plus 2.5 milligram of medroxyprogesterone actate (progestin) with that of a placebo during 5.6 years of follow up in 15,641 postmenopausal women enrolled in the Women's Health Initiative Hormone Trial. The women were aged 50 to 79 and all had an intact uterus. Diabetes incidence was determined by self-report of treatment with insulin or oral hypoglycemic medications. The results showed a cumulative incidence of treated diabetes of 3.5 percent in the hormone therapy group and 4.2 percent in the placebo group. There was little change in the hazard ratio after adjustment for changes in body mass index (BMI) and waist circumference. During the first year of follow up, changes in fasting glucose and insulin indicated a significant fall in insulin resistance in actively treated women compared to the control subjects. The authors conclude that combined estrogen and progestin therapy reduces the incidence of diabetes, possibly mediated by a decrease in insulin resistance unrelated to body size. 2 figures. 5 tables. 61 references.
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Effects of Glycemic Control on Diabetes Complications and on the Prevention of Diabetes. Clinical Diabetes. 22(4): 162-165. Fall 2004.
This article reviews randomized, controlled clinical trials (RCT's) completed during the past several years or currently underway that have addressed glycemic control. Landmark RCTs have demonstrated that meticulous glycemic (blood glucose) control reduces the risk of microvascular (small blood vessel) and neurological (nerve) complications of diabetes. Studies in pre-diabetes have shown that early intervention slows progression to diabetes. Ongoing studies are examining the effects of glycemic interventions on macrovascular complications of diabetes, the impact of early treatment on the course of diabetes, and whether there are differences depending on the type of the intervention used, including aggressive control of blood pressure and normalization of lipids (fats). Some of the studies discussed include the Diabetes Control and Complications Trial (DCCT), the U.K. Prospective Diabetes Study (UKPDS), the Stockholm Diabetes Intervention Study (SDIS), the Veterans Affairs Diabetes Trial (VADT), the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the U.S. Diabetes Prevention Program (DPP), the Heart Outcomes Prevention Evaluation (HOPE) trial, the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) study, the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) study, the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial, Actos Now for Prevention of Diabetes (ACT-NOW), the Outcome Reduction with an Initial Glargine Intervention (ORIGIN), A Diabetes Outcome Progression Trial (ADOPT), and the Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes (RECORD) study. 2 tables. 32 references.
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Gestational Diabetes Mellitus. Clinical Diabetes. 23(1): 17-24. December 2004.
Gestational diabetes mellitus (GDM) is a common condition characterized by glucose intolerance that begins or is first detected during pregnancy. GDM results from an increased severity of insulin resistance as well as an impairment of the compensatory increase in insulin secretion. This article reviews the diagnosis and care of GDM. The authors stress that the detection of GDM is important because of its associated maternal and fetal complications. The authors discuss the diagnostic criteria used for GDM, its pathogenesis, potential complications, screening guidelines, treatment options (glucose monitoring, medical nutrition therapy, exercise, insulin, oral agents), antepartum fetal assessment, peripartum considerations, and postpartum considerations. The authors conclude that treatment with medical nutrition therapy, close monitoring of glucose levels, and insulin therapy if glucose levels are above recommended levels can help to reduce these complications. In addition, certain types of exercise appear to have potential benefits in women without any contraindications. 1 table. 47 references.
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Guiding Principles for Diabetes Care: For Health Care Providers. Bethesda, MD: National Diabetes Information Clearinghouse (NDIC). 2004. 8 p.
The goal of the National Diabetes Education Program (NDEP) is to reduce the morbidity and mortality caused by diabetes and its complications through programs that increase awareness of the seriousness of the disease and the value of its treatment and prevention. The NDEP has developed these Guiding Principles for Diabetes Care to help the health care team help patients manage the disease effectively. In addition, the guidelines can be helpful for payers of health care, managed care organizations, and large employers who seek to establish diabetes care principles, to assess quality, and to assure quality diabetes care and treatment service options in health plans. The principles outline seven essential components of quality diabetes care that form the basis of NDEP's public and professional awareness programs. The principles are: identify people with pre-diabetes and undiagnosed diabetes; provide ongoing, patient-centered care; offer diabetes education; treat diabetes comprehensively; monitor blood glucose control using the A1c test; prevent long-term diabetes problems; and identify and treat long-term diabetes problems. A brief list of NDEP resources is included for readers seeking additional information. 2 figures.
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Insulin Sensitivity, Insulinemia, and Coronary Artery Disease. Diabetes Care. 27(3): 781-787. March 2004.
This article reports on a study undertaken to evaluate whether low insulin sensitivity (Si) is associated with coronary artery disease (CAD), independent of other cardiovascular risk factors. The authors studied 1,482 women and men, age 40 to 69 years old, African American (28 percent), Hispanic (34 percent), or non-Hispanic white (38 percent), with normal (45 percent), impaired (23 percent) or diabetic (32 percent) glucose tolerance. CAD was found in 91 participants. The odds ratio for CAD was greatest among individuals in the two lowest quintiles of Si compared with the highest Si quintile. The association between Si and CAD was partially mediated by insulin, HDL cholesterol and triglyceride levels, hypertension, diabetes, and obesity, but not LDL cholesterol or cigarette smoking. 2 figures. 2 tables. 41 references.
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Insulin Therapy. In: Harmel, A.P. and Mathur, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 109-145.
More types of insulin are becoming available, ranging from the traditional insulins to insulin analogues. This diversity of choice, in terms of onset and duration of action, allows use of exogenous insulin to mimic normal physiology more closely, thereby allowing for improvements in glycemic control with less hypoglycemia. This chapter on insulin therapy is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. The beginning of the chapter focuses on choosing the concentrations and types of insulin to use. Other characteristics of insulin preparations, such as species source and purity, are discussed later in conjunction with a description of the immunologic responses to insulin therapy. Other topics covered include insulin allergy, insulin resistance, and insulin-induced lipoatrophy. One section also considers initiation of insulin therapy in hospitalized patients. The chapter includes illustrative case reports. 10 figures. 11 tables. 109 references.
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Is it Resistance?. Diabetes Forecast. 57(12): 50-53. December 2004.
This article helps readers with type 1 diabetes who have recently switched to the use of an insulin pump understand potential problems with insulin absorption. The author notes that many patients are misdiagnosed as having insulin resistance when they first switch over to the insulin pump. Absorption problems are more common among people who have injected insulin by syringe for many years; injecting in the same areas can cause scarring that blocks absorption. Injected insulin can also stimulate the growth of fat cells, which affects the blood supply to the area and subsequently, insulin absorption into the blood. The author shares the story of one patient and how he coped with the absorption problem by switching away from the abdominal area and using an insulin infusion site on his back instead. The author also reviews the steps that patients can take, with their health care providers, to determine whether poor absorption is the cause of fluctuating blood glucose levels after switching to an insulin pump. The author focuses on the vital importance of moving injection or infusion sites frequently (site rotation). Overall, people using insulin pumps have far less risk of developing the fatty deposits and scar tissues that block absorption than those injecting insulin with traditional syringes (primarily because the insulin pumps deliver tiny amounts of insulin at one time).
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Overview of Diabetes and Its Management. Timonium, MD: Available from Milner-Fenwick, Inc.. 2004. [CD-ROM Instructional Program]
This CD-ROM, recently updated to reflect the newest information about medications, pre-diabetes, diabetes and heart disease, and healthy behaviors, provides a 'lecture in a box,' designed to be used in diabetes education programs. The publication includes 112 full-color slides that cover ten important topic areas: introduction, diagnosis and goals, management, healthy food choices, physical activity, medications, short-term complications, sick day management, long-term complications, and diabetes and emotions. The CD-ROM includes leader's notes that are designed to help educators communicate key concepts to patients, community audiences, or healthcare professionals. The CD-ROM uses PowerPoint format, offering the flexibility to combine slides with other resources and create presentations for any setting. The leader's notes are provided in both a Word rich text format file and a PDF file. This program is available in either English or Spanish.
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Reducing Cardiovascular Risk in Type 2 Diabetes and the Metabolic Syndrome: The Emerging Role of Insulin Resistance. In: Hormel, A.P. and Mother, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 239-257.
Both type 2 diabetes and the metabolic syndrome are associated with a significant increase in the risk of cardiovascular disease (CVD), including coronary heart disease (CHD), peripheral vascular disease, and stroke. CVDs are arguably the most common and clinically important complications of diabetes in adults. Reducing the risk of CVD is of paramount importance and represents a key component of care for patients with diabetes or the metabolic syndrome. This chapter on reducing CVD risk and the emerging role of insulin resistance is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. In this chapter, the author reviews the current risk of CVD in diabetes and outlines the relationship between diabetes and the metabolic (or insulin resistance) syndromes. The author includes a summary of the multiple risk factors present in these patients and then provides a systematic approach to CVD risk management in these complex patients (with a brief review of clinical trials supporting these interventions). 5 figures. 3 tables. 90 references.
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What is a Normal Glucose Value?: Differences in Indexes of Plasma Glucose Homeostasis in Subjects with Normal Fasting Glucose. Diabetes Care. 27(10): 2470-2477. October 2004.
This article reports on a study undertaken to evaluate differences in indexes of plasma glucose and insulin homeostasis and cardiovascular disease risk factors among subjects with normal fasting glucose (NFG), impaired fasting glucose (IFG), or glucose intolerance. The authors compared insulin secretion and insulin sensitivity using several indexes derived from an oral glucose tolerance test (OGTT) in 668 subjects from the Quebec Family Study who had varying degrees of FPG. Results showed a progressive decline in indexes of beta-cell function and insulin sensitivity when moving from NFG to Type 2 diabetes. Compared with subjects with low NFG, subjects with high NFG were more insulin resistant, had higher insulin and C-peptide responses during an OGTT, and had reduced insulin secretion (corrected for insulin resistance). Subjects with high NFG were also characterized by higher plasma triglyceride levels and reduced HDL cholesterol concentrations and by a smaller LDL particle size. All these differences remained significant, even after adjustment for age, sex, body mass index (BMI), and waist circumference. In addition, subjects with mid NFG were characterized by impaired insulin secretion, decreased insulin sensitivity, higher triglyceride concentrations, and lower HDL cholesterol concentrations compared with subjects with low NFG. 2 figures. 3 tables. 33 references.
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