Retinopathy Update

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American Diabetes Association Updates on Diabetic Retinopathy

 

Improvements in assessment and treatment of diabetic retinopathy position statement

Diabetic retinopathy (DR) is a complication of diabetes that affects vision.

High blood sugar levels can damage the blood vessels starving the retina of vital nutrients and oxygen resulting in blurry vision. Without appropriate treatment this condition may lead to complete vision loss.

The four stages of retinopathy range from mild non-proliferative diabetic retinopathy (NPDR) to moderate NPDR, to severe NPDR, to the most advanced stage – proliferative diabetic retinopathy (PDR).

DR is  a neurovascular complication of both type 1 and type 2 diabetes and its rate of occurrence depends on the level of glycemic control and the duration of diabetes.

Other risk factors associated with DR include hyperglycemia, nephropathy, hypertension, and dyslipidemia. Studies have proven that reduction in blood pressure (BP) decreases the progression of retinopathy in people with type 2 diabetes, but strict BP targets (systolic blood pressure of 120 mmHg vs. 140 mmHg) do not provide additional benefits. In another study, retinopathy progression was slowed in patients with dyslipidemia by adding fenofibrate, mainly in NPDR at baseline. In addition, several studies propose that pregnant patients with type 1 diabetes may exacerbate retinopathy with poor glycemic control during conception and may threaten their vision.

Optimization of blood glucose, blood pressure, and serum lipid levels in conjunction with appropriately scheduled dilated eye examinations can decrease the risk of vision loss from DR complications, but a substantial amount of those affected with diabetes develop diabetic macular edema (DME) or proliferative changes that require intervention. Large prospective randomized studies have shown that the use of intensive therapy could possibly prevent or delay DR with the goal of attaining near-normoglycemia. Although, intravitreal injection of anti–vascular endothelial growth factor agents may treat DME and PDR, it may threaten reading vision.

A meta-analysis study, conducted worldwide from 1980–2008 and consisting of 35 studies, predicted the global prevalence of DR to be 35.4% and PDR to be 7.5%. In developed countries, DR is mostly the cause of new cases of blindness among those 20 to 74 year old and eye disorders, such as glaucoma and cataracts, are frequently seen in diabetes patients. However, recent advancements in systemic therapy of diabetes have helped patients to improve their metabolic control. The statement incorporates these medical developments for the use of physicians and patients to aid in diagnosis and treatment of DR. It also provides an opportunity to improve glucose management and avoid or delay potential progression of the retinopathy.

The statement includes that screening recommendations for patients with diabetes depend on the rates of appearance and progression of DR and the associated risk factors. Ophthalmologist or optometrist examinations in patients with type 1 and 2 diabetes should be within 5 years after onset of diabetes and at the time of diabetes diagnosis, respectively. Women planning for pregnancy or who are pregnant with pre-existing diabetes should be examined before pregnancy or in the first trimester. In diabetes patients where no evidence of retinopathy is found, follow-up eye exams can be scheduled every two years. If any retinopathy is identified, then subsequent dilated-pupil retina exams are advised at least yearly, but more frequently if progressive retinopathy is diagnosed.

Fortunately, the cost-effectiveness of screening and traditional laser treatment for DR has been established with no more disputes. It is focused on telemedicine’s impact on the detection and eventual management of DR that appears to be most effective with lower ratio of providers to patients, with prohibitive distance to reach a provider, or when the alternative is no patient screening. The latest advancement in retinopathy treatment, anti-VEGF therapy has been taken into consideration, as they are more cost-effective than laser monotherapy for DME. Also, having retinopathy is not contraindicated with aspirin therapy for cardioprotection because studies suggest that aspirin does not increase the risk for retinal hemorrhage. Nonetheless, future studies are needed to determine the cost-effectiveness of anti-VEGF as a first-line treatment option for PDR.

Practice Pearls:

  • Optimize glycemic control, blood pressure, and serum lipids to reduce the risk or slow the progression of diabetic retinopathy.
  • Follow the screening recommendations for patients with diabetes for eye examination by ophthalmologist or optometrist.
  • The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection because aspirin does not increase the risk of retinal hemorrhage.

Reference:

Javitt JC, Canner JK, Sommer A. Cost effectiveness of current approaches to the control of retinopathy in type I diabetics. Ophthalmology 1989;96:255–264 42

Pasquel FJ, Hendrick AM, Ryan M, Cason E, Ali MK, Narayan KMV. Cost-effectiveness of different diabetic retinopathy screening modalities. J Diabetes Sci Technol 2015;10:301–307

Solomon SD, Chew E, Duh EJ, Sobrin L, Sun JK, VanderBeek BL, Wykoff CC, and Gardner TW. Diabetic Retinopathy: A Position Statement by the American Diabetes Association. Diabetes Care. Mar 2017; 40(3): 412-418.https://doi.org/10.2337/dc16-2641

 

Fit to serve: Pecan shortbread cookies

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Low Carb Pecan Shortbread Cookies

Ingredients

1 cup (2 sticks) unsalted butter at room temperature

1 ¼ cup of sugar substitute (I use Swerve)

1 teaspoon of vanilla extract

2 ½ cups of finely ground almond flour

1 teaspoon of baking powder

½ teaspoon sea salt

½ cup of coarsely chopped pecans (you may omit or substitute other nuts of your choice)

Directions

  1. Pre-heat oven to 325 degrees. Line two cookie sheets with parchment paper or leave un-greased.
  2. In a stand-up mixer cream the butter, sugar substitute and vanilla until well incorporated.
  3. Add the almond flour, sea salt, baking powder and blend till mixed. Once combined add the chopped pecans and mix again.
  4. Spread the dough in a 10×10 square pan or drop cookie dough by spoonful’s onto a ungreased cookie sheet. Place pan or cookie sheet in the fridge to cool for 30 minutes. This will ensure that the cookie has the traditional crisp texture in shortbread.
  5. I like to score and add fork tine marks on my bars before placing in the oven to allow for easy cutting afterwards. This is not necessary if you are making individual cookies.
  6. Bake in a 325 degrees’ oven until they are lightly golden brown about 25-30 minutes
  7. Allow the shortbread cookies to cool before eating and storing.

Makes 2 1/2 dozen cookies at 2.5 net carbs per cookie

 

What should happen to you if you are admitted to hospital with an acute illness?

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Adapted from BMJ 24 June 17 Managing adults with diabetes in hospital during an acute illness by Tahseen Chowdhury, Hannah Cheston and Anne Claydon.

Around one in five inpatient beds are occupied by someone who has diabetes. As patients, one in ten will have a severe hypo in hospital and in any one week, one in four will have an error made regarding their medication.

Poorly managed hyperglycaemia in patients with an acute illness do worse, stay in hospital longer and can even cause death. Blood sugars can be harder to manage because of the ongoing illness, erratic eating habits, changes to liver and kidney function, and changing medication, particularly starting and stopping steroids and metformin.   But here is no evidence that tight glycaemic control for hospital patients improves outcomes other than during cardiac surgery and liver transplantation.

The consensus is that blood glucose values between 6-10 mmol/L is probably optimal, given the need to prevent hypos, and that a range of 4-12 is acceptable.

The sorts of things that can cause high blood sugars in hospital are: sepsis, steroids, omission of insulin or oral hypoglycaemic medication, an overtreated hypo, stress and anxiety, surgery, a relative lack of insulin and long term poor glucose control.

In type one patients and type twos on insulin they should not stop their insulin even when fasted or when oral intake is poor.  At the very least basal insulin needs to be continued. The DAFNE plan is that blood sugars over 11 should be corrected by 2-6 units of rapid acting insulin and levels checked every 2 hours. Correction doses are advised not to be given at intervals more than every 4 hours to reduce insulin stacking.  Staff are advised to ASK THE PATIENT what they would normally do outside hospital.  

Treatment for diabetic ketoacidosis should be initiated if the blood ketone level is 3mmol/L or above.  In mild or moderate cases subcutaneous insulin may be used, but if severe, intravenous insulin will be needed.

When dealing with type two patients, where there is less risk of ketoacidosis, higher blood sugar levels may be acceptable over the short term. It is important to ask the patient if they are actually getting their correct medication. It is helpful to figure out exactly WHY the patient’s blood glucose is elevated, as this can be the clue to effective treatment, eg an ongoing urine infection.

Most hospitals have a diabetes liaison team and they can be particularly helpful in for instance surgical wards where staff may have less expertise in treating diabetic patients.

Insulin is sometimes required if a type two patient needs blood sugars stabilised promptly.  Doses will need frequent review as the patient becomes more active and eats more as they improve and as their condition returns to their normal state.

BMJ 2017;357:j2551

Sheri Colberg: Joint health is critical to staying active

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Joint Health Is Critical to Staying Active

Diabetes in Control

Without properly functioning joints, our bodies would be unable to bend, flex, or even move. A joint is wherever two bones come together, held in place by tendons that cross the joint and attach muscles to a bone on the other side and ligaments that attach to bones on both sides of the joint to stabilize it. The ends of the bones are covered with cartilage, a white substance formed by specialized cells called chondrocytes. These cells produce large amounts of an extracellular matrix composed of collagen fibers, proteoglycan, elastin fibers, and water. Tendons and ligaments are also made up primarily of collagen.

Joints can be damaged, however, making movement more difficult or painful. Joint cartilage can be damaged by acute injuries (i.e., ankle sprain, tendon or ligament tears) or overuse (related to repetition of joint movements and wear-and-tear over time). Damage to the thin cartilage layer covering the ends of the bones is not repaired by the body easily or well, mainly because cartilage lacks its own blood supply.

Aging alone can lead to some loss of this articular cartilage layer in knee, hip, and other joints—leading to osteoarthritis and joint pain—but having diabetes also potentially speeds up damage to joint surfaces. Although everyone gets stiffer joints with aging, diabetes accelerates the usual loss of flexibility by changing the structure of collagen in the joints, tendons, and ligaments. In short, glucose “sticking” to joint surfaces and collagen makes people with diabetes more prone to overuse injuries like tendinitis and frozen shoulder (1; 2). It may also take longer for their joint injuries to heal properly, especially if blood glucose levels are not managed effectively. What’s more, having reduced motion around joints increases the likelihood of injuries, falls, and self-imposed physical inactivity due to fear of falling.

Reduced flexibility limits movement around joints, increases the likelihood of orthopedic injuries, and presents a greater risk of joint-related problems often associated with diabetes, such as diabetic frozen shoulder, tendinitis, trigger finger, and carpal tunnel syndrome. These joint issues can come on with no warning and for no apparent reason, even if an individual exercises regularly and moderately, and they may recur more easily as well (3). It is not always just due to diabetes, though, since older adults without diabetes experience inflamed joints more readily than when they were younger.

So what can you do to keep your joints mobile if you’re aging (as we all are) and have diabetes? Regular stretching to keep full motion around joints can help prevent some of these problems, and also include specific resistance exercises that strengthen the muscles surrounding affected joints. Vary activities to stress joints differently each day. Overuse injuries occur following excessive use the same joints and muscle in a similar way over an extended period of weeks or months, or they can result from doing too much too soon.

Doing moderate aerobic activity that is weight-bearing (like walking) will actually improve arthritis pain in hips and knees (4). People can also try non-weight-bearing activities, such as aquatic activities that allow joints to be moved more fluidly. Swimming and aquatic classes (like water aerobics) in either shallow or deep water are both appropriate and challenging activities to improve joint mobility, overall strength, and aerobic fitness. Walking in a pool (with or without a flotation belt around the waist), recumbent stationary cycling, upper-body exercises, seated aerobic workouts, and resistance activities will give you additional options to try.

Finally, managing blood glucose levels effectively is also important to limit changes to collagen structures related to hyperglycemia. Losing excess weight and keeping body weight lower will decrease the risk for excessive stress on joints that can lead to lower body joint osteoarthritis (5). Simply staying as active as possible is also critical to allowing your joints to age well, but remember to rest inflamed joints properly to give them a chance to heal properly. You may have to try some new activities as you age to work around your joint limitations, but a side benefit is that you may find some of them to be enjoyable!

References:

  1. Abate M, Schiavone C, Pelotti P, Salini V: Limited joint mobility in diabetes and ageing: Recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 2011;23:997-1003
  2. Ranger TA, Wong AM, Cook JL, Gaida JE: Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Br J Sports Med 2015;
  3. Rozental TD, Zurakowski D, Blazar PE: Trigger finger: Prognostic indicators of recurrence following corticosteroid injection. J Bone Joint Surg Am 2008;90:1665-1672
  4. Rogers LQ, Macera CA, Hootman JM, Ainsworth BE, Blairi SN: The association between joint stress from physical activity and self-reported osteoarthritis: An analysis of the Cooper Clinic data. Osteoarthritis Cartilage 2002;10:617-622
  5. Magrans-Courtney T, Wilborn C, Rasmussen C, Ferreira M, Greenwood L, Campbell B, Kerksick CM, Nassar E, Li R, Iosia M, Cooke M, Dugan K, Willoughby D, Soliah L, Kreider RB: Effects of diet type and supplementation of glucosamine, chondroitin, and msm on body composition, functional status, and markers of health in women with knee osteoarthritis initiating a resistance-based exercise and weight loss program. J Int Soc Sports Nutr 2011;8:8

 

In addition to my educational web site, Diabetes Motion (www.diabetesmotion.com), I also recently founded an academy for fitness and other professionals seeking continuing education enabling them to effectively work with people with diabetes and exercise: Diabetes Motion Academy, accessible at www.dmacademy.com. Please visit those sites and my personal one (www.shericolberg.com) for more useful information about being active with diabetes.

Fit to serve: Bacon carbonara casserole

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Once we made eating a low carb keto diet a lifestyle change, we really thought we would never have anything that even remotely looked like pasta again. This of course was until I discovered spaghetti squash. Although not devoid of carbs, it’s certainly a much healthier lower in carb option.

Using spaghetti squash as a pasta alternative is great because of its mild flavor. It simply takes on the flavor profile of whatever sauce you choose to use. In addition, it has an amazing pasta-like texture that has you questioning if you aren’t just have a real bowl of pasta and cheating. You can actually even twirl the spaghetti squash around your fork, like you do with real spaghetti. Now that’s when I was sold.

Unlike zucchini and other vegetables that are spiraled into a pasta-like texture, spaghetti squash does not give your dishes extra moisture. Don’t get me wrong I use zucchini all the time to make a low carb lasagna, but if not eaten right away the extra moisture the zucchini releases can turn some people off.

I finally decided to sit down and share a recipe using spaghetti squash after getting a few family requests. Although it’s a very popular pasta option in our low carb keto community, it’s still has not been discovered by many.

My creamy bacon carbonara sauce with spaghetti squash is filling enough to stand as a meal, which is why I opted not to add any additional protein in the form of chicken.

Low Carb Bacon Carbonara Casserole

Ingredients:

1 large spaghetti squash (cooked)

3 eggs

¼ cup of butter

1 small onion finely chopped

½ pound bacon (reserve ½ cup for topping)

½ cup of chopped mushrooms

2 cups of heavy whipping cream

1 ½ cups of grated cheese parmesan cheese (reserve ½ cup for topping)

dash of nutmeg

¼ cup of finely chopped parsley (for topping)

½ teaspoon of sea-salt

1 clove of crushed garlic

¼ teaspoon of black pepper

½ teaspoon of sea-salt (or to taste)

dash of red pepper flakes

Spaghetti Squash Cooking Instructions

Cook your spaghetti squash sliced in a 375-degree oven for 30 minutes. Or if you prefer you can do what I do and cook it whole in the microwave oven. I pierce the skin of the spaghetti squash several times and microwave at a high temperature for about 6 minutes. Once cooked and allowed to cool, I slice the squash in half and take out the center seeds. Using a fork, scrap the inside of the squash to get the spaghetti-like strands. Place the squash strands in an oven-proof bowl in preparation for the sauce.

Low Carb Bacon Carbonara Sauce

  1. Cook in a large frying pan over medium-high heat the bacon, once slightly crispy set aside. Reserve ¼ up of the bacon grease to cook the onion, garlic and mushrooms until tender.
  2. Remove the sautéed mushrooms, garlic and onions and add the butter to the pan.
  3. Reduce the heat to low-medium and add the cream, parmesan cheese, and spices minus the parsley. Cook on low until the sauce starts to thicken. Turn the stove off and allow to cool. Whisk in the 3 whole eggs, making sure that the eggs are fully incorporated. Note: It’s important that you don’t add the raw eggs to the sauce if it’s really hot, to avoid scrambling the eggs.
  4. To the now thickened sauce add the cooked mushrooms, onion, garlic and bacon and stir to combine well.
  5. Pour the carbonara sauce over the cooked spaghetti squash and transfer into an oven-proof casserole.
  6. To the casserole add the reserved parmesan cheese, bacon and parsley as a toping.
  7. Bake in a 350-degree oven for 30-35  minutes.

Makes 6 servings at 9 net carbs.

Enjoy in good health!

Stephan Guyenet: Why your brain makes you fat

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In this interview, which you can listen to or read,  neuroscientist Stephan Guyenet discusses various topics related to a big issue with a lot of people, how we get fat and what we can do about it, with Kris Kresser.

 

https://chriskresser.com/why-your-brain-makes-you-fat-with-stephan-guyenet/?utm_source=activecampaign&utm_medium=email&utm_term=rhr-why-your-brain&utm_content=&utm_campaign=blog-post

Diabetic children miss out on hospital checks

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Paediatric endocrinology clinics have a  non-attendance rate of 11.4% in the south west of the UK. The majority of these patients have diabetes.

Children who did not attend were more likely to  come  from families living in areas of high deprivation and to have a child protection alert in their hospital records.

In 60% of the cases, the GP was not informed that the child had not appeared, so they were not in a position to follow the child up themselves. Some of the children were sent other appointments, some were given an open attendance appointment and some were discharged.

About half of the children were eventually seen within a year and a third attended A and E. Almost a quarter went back to see the GP and half of these were re-referred.

My comments: In my own practice I am aware that a minority of parents are very poor at attending diabetic clinics with their children. We are always informed and keep out an eye for opportunistic intervention when the child attends for another matter. Our hospital has a good nurse liaison service and they do their best to keep a dialogue open with the parents and visit at home. Sometimes lack of money for bus fares is given as an issue. Sometimes work commitments or having to make arrangements to look after other children in the family is the reason. For one reason or another, the child’s diabetes management does not have the priority that it is given in other homes, and that doesn’t work out well on the long term.

Reported in BMJ 24th June 2017 by Ingrid Torjesen BMJ 2017;357:j2983

 

Fit to serve: Brown Butter Cake

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Low Carb Brown Butter Cake

Ingredients:

2 cups of (4 sticks) unsalted butter melted and lightly browned

6 large eggs

2 cups of finely milled almond flour

2 cups of sugar substitute

1 ½ teaspoon of baking powder

½ teaspoon of sea salt

Directions:

1.    Pre-heat oven to 350 degrees. Lightly grease a 10-inch spring-form pan with butter.

2.    Melt and lightly brown the butter in a saucepan and allow to cool completely.

3.    Beat all the eggs and sugar substitute in a stand-up mixer on high until mixture is thick and a shade of pale yellow, about 6 minutes.

4.    Add the almond flour by ¼ cup increments into the egg and sugar-substitute batter folding gently with a rubber spatula. *Do not over stir, mix only to combine

5.    Once the batter has been mixed add the now cooled melted brown butter gently fold into the batter until fully incorporated.

6.    Pour the batter into the prepared pan.

7.    Bake the cake for 35-40 minutes until a toothpick inserted in the center comes out clean.

8.    Allow this cake to cool completely before serving. Store in the refrigerator.

Enjoy in good health!

Cake makes 16 servings at 3.2 net carbs per slice

Kris Kresser: Bone broth is a traditional and nutritious addition to your meal plan

Whistle while you work

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Physical exercise improves your sense of wellbeing but different intensities give different results.

Healthy adults were tested after doing various types of exercises and activities and compared how they felt.

Office work and driving a car were considered light intensity and were associated with  an improved mood.

Housework or walking  were considered moderate activities and not only improved mood but reduced pain, in those that suffered this.

Doing nothing reduced people’s moods.

Journal of Health Psychology doi:10.1177/1359105317691589

Adapted from article in Human Givens Vol 1 2017