Results from a US study suggest that bariatric surgery is associated with significant reductions in medication and general healthcare costs in patients with Type 2 diabetes.

“Health insurance should cover bariatric surgery because of its health and cost benefits,” suggest the researchers.

These results are in agreement with previous studies demonstrating a significant reduction in or resolution of Type 2 diabetes symptoms following bariatric surgery, as reported by MedWire News.

Martin Makary (The Johns Hopkins University School of Medicine, Baltimore, Maryland) and colleagues followed-up 2235 patients with Type 2 diabetes who underwent bariatric surgery in seven US states between 2002 and 2005. Their pre- and post-operative use of diabetes medication and yearly healthcare costs were assessed using administrative claims data.

Writing in the Archives of Surgery, the team reports that 74.7% of the cohort had stopped using diabetes medication therapy at 6 months, 80.6% at 1 year, and 84.5% at 2 years after surgery.

Overall, a significant reduction in use of diabetes medication was observed for all drug classes.

The median cost of bariatric surgery was US $29,959 (€23,369) per person.

Following surgery, yearly total healthcare costs increased by 9.7% in year 1, but decreased by 34.2% in year 2 and by 70.5% in year 3, relative to pre-surgery costs. This translated to an approximate US $4498 (€3509) reduction in annual healthcare costs by year 3 compared with pre-surgery.

“Future research may help elucidate the role of bariatric surgery in general medical care by studying its effect on common operations, maternal and neonatal outcomes, and long-term health outcomes,” write Makary et al.

“Ultimately, bariatric surgery - or a future less-invasive variant - could play a key role in the management of common medical conditions, such as heart disease and diabetes-related organ failure.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Patients who perceive their health to be less than excellent at the time of diabetes diagnosis have an increased 5-year risk for cardiovascular (CV) and all-cause mortality compared with those who rate their health as optimal, report Danish researchers.

Indeed, patients who felt their health was suboptimal had “5-year mortality similar to that of patients with prevalent CV disease, even when biochemical, clinical and life-style variables were controlled for,” say Niels de Fine Olivarius (University of Copenhagen) and team.

They add: “The patient seems to have knowledge about own health, which cannot be explained by patient’s objective health status as it is described with present-day technology.”

In the study, 1323 patients newly diagnosed with diabetes and aged 40 years or older completed baseline health questionnaires in which they rated their general health as excellent, good, fair, poor, or very poor.

During a mean follow-up period of 5.3 years, 298 patients died. Of these deaths, 55% were CV-related.

Multivariate analysis revealed that patients who rated their health as less than excellent had an increased 5-year all-cause mortality risk compared with those who rated their health as excellent, with a 2.45-, 2.35-, and 2.03-fold increase in all-cause mortality risk for patients with a good, fair, and poor/very poor self-rated general health (SRH), respectively, compared with those with an excellent SRH.

A similar trend was also noted for 5-year CV mortality risk, with a 3.13-, 2.93-, and 1.77-fold increase in CV mortality risk for patients with a good, fair, and poor/very poor SRH, respectively, compared with an excellent SRH.

Of note, male gender, low body mass index, and cancer at time of diabetes diagnosis were also associated with increased 5-year all-cause mortality risk, and urinary albumin associated with an increased 5-year risk for CV mortality.

The researchers conclude: “This finding could motivate doctors to discuss perceptions of health with newly diagnosed diabetic patients and be attentive to patients with suboptimal health ratings.

“Our findings also confirm that life-style changes and optimizing treatment are particularly relevant for relatively young and inactive patients.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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A 24-week dietary and lifestyle intervention program has been shown to result in significant reductions in body mass index (BMI) and weight and improve diabetes knowledge of schizophrenia patients with Type 2 diabetes.

Previous research has shown that people with schizophrenia are about twice as likely to develop diabetes as the general population, explain Christine McKibbin (University of Wyoming, Laramie, USA) and team.

They add: “The complexities of diabetes self-management (ie, careful balance between diet, physical activity, and in some cases, medication) may pose unique problems for patients with schizophrenia. Therefore it is important that diabetes management and education programs be tailored for this group.”

Writing in the journal Schizophrenia Research, the researchers report that that a group-based healthy lifestyle intervention - Diabetes Awareness and Rehabilitation Training [DART] - for patients with schizophrenia and diabetes significantly improves diabetes self-efficacy and leads to significant reductions in weight by the end of the 6-month intervention.

DART involves a 24-week intervention involving basic diabetes education, nutrition education, and lifestyle education and advice. Simple guidelines were provided such as switching from regular to diet soda and eating slowly.

In total, 62 participants with schizophrenia and diabetes, aged at least 40 years, were randomly assigned to receive DART or usual care with information (UCI), which consisted of brochures from the American Diabetes Association relevant to diabetes management.

To investigate the longer-term effects of DART, the researchers followed-up 52 participants 6 months after the end of the intervention.

They found that BMI had fallen by a mean of 1 point in the DART group, from 33.9 kg/m² at randomization to 32.9 kg/m² after 12 months, compared with a mean rise of 1.4 points in the UCI group, from 32.6 to 34.0 kg/m², respectively.

Patients in the DART group also had a mean weight loss of 5 lbs after 12 months compared with a mean increase of 7 lbs in the UCI group.

The findings remained true after accounting for differences in antipsychotic or diabetes treatment.

DART participants also showed an increase in diabetes knowledge at 12 months, compared with no such improvement in the UCI patients.

McKibbin and team conclude: “The current follow-up study not only showed that participants retained some knowledge that they had gained over the course of treatment, but also that they experienced sustained improvements in anthropometric outcomes (i.e., weight/BMI and waist circumference).”

They add: “Future research should examine diabetes management interventions in larger samples of persons with schizophrenia and Type 2 diabetes.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Patients with diabetes and hypertension have an increased risk for adverse cardiovascular events (CVE) and/or albuminuria if they have higher nocturnal than daytime blood pressure (BP), a Brazilian study suggests.

Joao Felício (Universidade Federal do Pará, Belem) and colleagues explain that autonomic neuropathy - which can arise from a state of hyperglycemia - may account for the nocturnal BP elevation observed in some patients with diabetes.

The researchers performed baseline and 2-year, 24-hour ambulatory BP measurement on 70 hypertensive patients with diabetes.

All patients had normal urinary albumin excretion (UAE), urinary protein excretion (UPE), and excretion glomerular filtration rate (eGFR) at baseline.

Over a 2-year follow-up period, 11 patients developed diabetic nephropathy (DN) and four suffered a CVE, defined as myocardial infarction, stroke, or angina.

Writing in the journal Cardiovascular Diabetology, the team reports that all patients had similar daytime systolic and diastolic BP.

However, the findings for night-time BP differed, with higher systolic and diastolic BP among the patients with DN or CVE compared with those without these conditions, at 138 versus 129 mmHg, and 83 versus 75 mmHg, respectively.

Basal nocturnal systolic BP was positively associated with DN, CVE, and end-of-study UAE, however, a fall in basal systolic and diastolic nocturnal BP was negatively associated with end-of-study UAE.

Patients who developed DN had smaller nocturnal BP reductions compared with those without DN, with a mean systolic and diastolic BP reduction of 3 versus 12 mmHg, and 4 versus 15 mmHg, respectively.

Felício et al conclude that the lack of normal nocturnal BP fall associated with increased risk for CVE and DN may be due to “other conditions, such as obstructive sleep apnea and renal failure with fluid retention.”

They therefore call for other studies to investigate the mechanism by which nocturnal BP changes arise in patients with diabetes.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Emodin, a natural compound that can be extracted from several Chinese herbs, has been shown to inhibit the enzyme 11b-Hydroxysteroid dehydrogenase type 1 (11?-HSD1) in mice, suggesting a potential therapeutic target for treating Type 2 diabetes and other metabolic conditions.

The 11?-HSD1 enzyme stimulates glucocorticoid secretion, which, in turn, has been linked to insulin resistance and Type 2 diabetes when present in excess. Therefore inhibition of 11?-HSD1 provides a potential pathway for treating Type 2 diabetes.

Ying Leng and colleagues from the Chinese Academy of Sciences in Shanghai, China, screened a collection of phytocompounds for their ability to inhibit 11?-HSD1. Emodin, an anthraquinone derivative mostly from Rheum palmatum, was found to be the most potent selective 11?-HSD1 inhibitor.

The team tested the inhibitory activity of emodin in vitro, against human and mouse recombinant 11?-HSD1 generated in HEK-293 cells, and in vivo, in C57BL/6J mice with prednisone- or dexamethasone-induced insulin resistance. The effect of emodin on metabolic abnormalities in diet-induced obese (DIO) mice was also assessed.

Emodin was a significant inhibitor of human and mouse recombinant 11?-HSD1, with IC₅₀ scores of 186 and 86 nM, respectively. In addition, it was found to reverse prednisone-, but not dexamethasone-induced insulin resistance in C57BL/6J mice.

“Dexamethasone is a synthetic cortisol analogue, whereas prednisone is a synthetic cortisone analogue and needs to be catalysed by 11?-HSD1 in the liver to convert it into its active metabolite, prednisolone,” explain Leng et al.

“Therefore, the finding that emodin prevented prednisone-induced insulin resistance confirmed that chronic administration of emodin can inhibit hepatic 11?-HSD1 activity in vivo.”

As reported in the British Journal of Pharmacology, the researchers also found that oral administration of emodin lead to improved lipid metabolism and insulin sensitivity in DIO mice, as well as lower hepatic phosphoenolpyruvate carboxykinase, glucose-6-phosphatase mRNA, and blood glucose.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Laproscopic sleeve gastrectomy (LSG) may resolve or improve Type 2 diabetes in morbidly obese patients, Canadian researchers report.

“While approximately two-thirds of people experience complete resolution of their diabetes [after LSG], the remaining 30% of patients have significant improvement,” say Richdeep Gill (University of Alberta, Edmonton) and colleagues.

The researchers explain that although the LSG-diabetes mechanism is not fully understood, it is likely that the removal of the gastric fundus during LSG causes a reduction in the level of the insulin-stimulating hormone ghrelin subsequently provoking an increase in insulin secretion.

This, they say, may improve the inadequate insulin secretion suggested by previous studies as a cause of diabetes in obese patients.

As reported in the journal Surgery for Obesity and Related Diseases, the researchers reviewed data from 27 studies on the outcomes of 673 patients with Type 2 diabetes and a mean body mass index (BMI) of 47.4 kg/m² who all underwent LSG.

The team found that, overall, patients lost a mean 47.3% of their excess weight, and achieved a mean reduction in blood glucose and glycated hemoglobin (HbA1c) of 88.2 mg/dl, and 1.7%, respectively, 13.1 months after LSG.

Data from 26 of the studies showed that two thirds (66.2%) of patients who underwent LSG has a resolution in their diabetes. This was defined the discontinuation of all hypoglycemic medications and/or insulin, normal fasting plasma glucose, normal post-prandial glucose excursions, and normal HbA1c.

In addition, 26.9% of all patients in these trials had an improvement, but no resolution of diabetes, and 13.1% maintained their pre-LSG HbA1c and blood glucose levels.

Gill et al say that despite these encouraging findings: “It remains to be seen if the LSG-related resolution or improvement of Type 2 diabetes will translate into long-term decrease in patient mortality.”

They conclude: “LSG is a promising procedure for the treatment of morbid obesity and Type 2 diabetes.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Few Australian patients with Type 2 diabetes meet Australian National Health Foundation (NHF) guidelines for daily sodium or potassium intake, researchers report.

These guidelines recommend a daily sodium and potassium intake of less than 100 mmol and more than 120 mmol, respectively, for individuals with a high risk for cardiovascular (CV) disease.

However Elif Ekinci (Austin Health, Victoria, Australia) and team found that “only 3% of male patients and 14% of female patients with Type 2 diabetes met the Australian NHF guidelines for sodium consumption.”

The researchers assessed the 24-hour urinary sodium (uNa), potassium (uK), creatinine (uCr), urea (uUrea), and glucose (uGlc) levels of 122 Australians with Type 2 diabetes, over a mean of 5 years, collecting a mean 1.9 samples per patient per year.

At baseline, all patients received dietary advice stressing actions such as avoiding high-energy processed foods and consuming lots of fresh fruit and vegetables.

By the end of the study, the mean patient uNa level was higher than the NHF recommendation, at 170 and 142 mmol/day in men and women, respectively. Mean uK level, however, was lower than the NHF recommendation, at 75 and 62 mmol/day in men and women, respectively.

After adjustment for insensible sodium and potassium losses, a significantly smaller proportion of men met the NHF sodium guidelines than women, at 3% versus 14%. However, significantly fewer women than men met NHF potassium guidelines, at 3% versus 14%.

Of note, body mass index (BMI), uUrea level, urine volume, and uGlu level were all independent predictors of uNa level.

“The strong association of urinary sodium with BMI is likely to reflect excessive consumption of sodium-rich processed food,” the researchers hypothesize in the journal Diabetic Medicine.

They say that hypertensive and normotensive individuals could reduce their systolic blood pressure (SBP) by 5 and 2.5 mmHg, respectively, simply by reducing their salt intake by 3g per day.

This reduction in SBP “would be expected to produce a CV benefit in the general population equating to an approximate 13% reduction in stroke and 10% reduction in ischemic heart disease,” they conclude.

Ekinci et al add, however, that “it remains to be shown whether salt restriction can be maintained outside study conditions and whether it can reduce CV outcomes in diabetes.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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A high consumption of green leafy vegetables, such as spinach, kale, and lettuce, significantly reduces the risk for developing Type 2 diabetes, results from a systematic review and meta-analysis suggest.

“The findings add to the growing body of evidence that lifestyle is key for the prevention of Type 2 diabetes,” lead study author Patrice Carter (University of Leicester, UK) told MedWire News.

In total, six studies involving a total of 223,512 participants were included in the analysis. The follow-up period for the studies ranged from 4.6 to 23 years.

Prospective cohort studies that included a measure of intake of fruits, vegetables, or a combination of the two and an assessment of Type 2 diabetes risk were considered suitable for the analysis. Of the six studies identified, four also provided information on the intake of green leafy vegetables.

Pooled estimates showed that eating 1.35 (highest intake) compared with 0.20 (lowest intake) servings of green leafy vegetables per day was associated with a significant 14% reduction in risk for Type 2 diabetes.

Pooled estimates of highest versus lowest intake of fruit, vegetables, or both, did not show a significant reduction in risk for Type 2 diabetes, but there was a nonsignificant trend for improvement.

Carter emphasized that “this should not be ignored and shows more research would be beneficial.”

When asked about possible reasons for the observed risk reduction, Carter commented: “Green leafy vegetables have a number of potential benefits for reducing diabetes risk, they are high in antioxidants and magnesium. They also contain fatty acids which may increase insulin sensitivity of cells.

“Further research is needed to determine why green leafy vegetables are so important.”

The research is published in the British Medical Journal.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Researchers report that poor blood glucose control increases the risk for myocardial infarction (MI) irrespective of other cardiovascular (CV) risk factors, including diabetes, and patient ethnicity.

“Every 1% increment [in glycated hemoglobin (HbA1c)] independently predicts a 19% higher odd of MI after accounting for other MI risk factors including diabetes,” report Hertzel Gerstein (McMaster University, Hamilton, Ontario, Canada) and team.

They say that their findings show that “dysglycemia increases CV risk through a mechanism that appears to be independent of these other CV risk factors, and that this mechanism is relevant with and without a history of diabetes, and operates on a global level.”

As reported in the journal Diabetologia, the researchers measured the HbA1c levels of 15,780 participants from 52 countries, with (n=6761) and without a history of MI (n=9019).

Of these patients, 12.6% (1993) had diabetes and 87.4% (13,787) did not.

The findings showed that patients with a previous history of MI had a higher mean HbA1c level than those with no MI history, at 6.15% versus 5.85%, respectively.

After adjustment for MI risk factors such as diabetes and hypertension, patients in the highest HbA1c quintile (HbA1c ?6.12%) had a 1.55-fold increased relative risk for MI compared with those in the lowest quintile (HbA1c <5.4%).

Further analysis of HbA1c as a continuous variable revealed a similar pattern, even after adjusting for diabetes status, age, and gender.

Furthermore subgroup analyses showed the same positive association between HbA1c and MI, with the highest increases in MI risk observed among those of a young age (less than 65 years for males, and less than 55 years for females), those without hypertension or diabetes, and those of specific ethnicities such as European and South Asian.

Gerstein et al conclude: “These findings clearly show that dysglycemia as measured by HbA1c level in people with or without a history of diabetes is a strong, independent CV risk factor throughout different regions of the world and ethnicities.”

They add: “Strategies that reduce the prevalence of dysglycemia by preventing or reversing diabetes, or by slowing the rise of HbA1c with time may reduce the global burden of MI.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Patients who undergo surgical intervention for mitral valve disease (MVD) may experience improvements in glucose metabolism and insulin resistance due to a reduction in atrial natriuretic peptide (ANP) and free fatty acid (FFA) levels, Italian researchers suggest.

“Therefore we hypothesize that the heart, under particular pathologic conditions… could become an active endocrine organ able to increase lipolysis and FFA levels influencing insulin sensitivity and glucose tolerance,” say Lucilla Monti (San Raffaele Scientific Institute, Milan) and colleagues.

They add, however, that patients who undergo coronary artery bypass grafting (CABG) for coronary heart disease (CHD) do not experience similar improvements in glucose metabolism.

The team assessed pre- and post-surgery ANP, FFA, and insulin levels, and diabetes status in 50 patients with MVD who underwent mitral valve surgery, and 55patients with CHD who underwent CABG. These factors were also assessed in 166 matched healthy controls.

Prior to surgery, 56% and 67% of patients with MVD and CHD, respectively, had impaired glucose tolerance or diabetes newly diagnosed by oral glucose tolerance testing (OGTT), with the highest and lowest FFA and ANP levels found among MVD patients and healthy controls, respectively.

As reported in the Journal of Nutrition, Metabolism, & cardiovascular diseases, after surgery, the percentage of patients with impaired glucose tolerance or diabetes fell by 10% among MVD patients, but remained the same in CHD patients.

In addition, post-surgery fasting FFA and ANP levels fell by 33% and 55%, respectively, among MVD patients, while smaller decreases of approximately 15% and 20%, respectively, occurred among CHD patients.

Monti et al say that their findings “strongly suggest,” although they do not demonstrate, a causal relationship between increased ANP, FFA, insulin resistance, and impaired glucose tolerance after OGTT in MVD. They conclude: “Future studies are needed to understand this important issue.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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