Category: health

Trends in standards of care for pregnant diabetes patients in the UK

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Are care standards for diabetic pregnant patients being achieved?The short answer to the question is NO. The National Diabetes Audit indicates that while the diabetes epidemic continues to grow, medical care continues to fall way short of the standards devised to reduce the burden of complications both on individuals and the economy.

Women who are pregnant tend to get off to a bad start by not being on the right dose of folic acid before they embark on the pregnancy. They are advised to take 5mg of the vitamin a day in order to reduce the chance of their baby developing spina bifida. Of the type one diabetic women 45%  met this standard but only 24% of type two diabetic women did so.

In order to eliminate foetal abnormalities related to hyperglycaemia the HbA1c should be preferably below 6.0 in the first trimester and  yet only 8% of women with type one and 22% of those with type two managed a HbA1c of 6.1% (43 mmol/mol) or less. Pregnancy is advised to be avoided all together if the HbA1c  is over 10% (86) but 12% of type ones and 8% of type two women were over this. The women most adversely affected tended to be living in the greatest areas of deprivation, and also of Asian or Black ethnicity.

Oral glucose lowering drugs apart from metformin are advised for women trying for a baby and insulin should be used if necessary to achieve blood sugar targets. Statins, ACE inhibitors (prils), and ARBS (sartans) should be stopped prior to pregnancy as these can be teratogenic.  But 57% of type two diabetic women were on at least one of these drugs at the onset of pregnancy.

Hypoglycaemia, severe enough to need hospital treatment, was experienced by 9.3% of pregnant women with type one diabetes.

Currently 67% of type one women have a caesarean section compared with 52% of type twos. The rates of stillbirth for offspring are almost 12.8 per 1000 births compared to 4.7 for the general population. Neonatal deaths are 7.6 per 1000 compared to 2.6 for the general population. The rate of congenital abnormalities approximately double that for the general population at 44.2 per 1000 compared to 22.7.  Adverse pregnancy outcomes of all types are related to the HbA1c particularly in the first and third trimesters.

Despite the growth of specialist diabetic-obstetric teams there has been very little improvement in these outcomes over the last ten years. How can we help diabetic women prepare for their pregnancies? Why are so many women and babies not getting the medical care that could help them?

Some basic advice: see your GP well before you plan a pregnancy if you have diabetes and tell them that you are planning for having a baby.

Use effective contraception until your glycaemic goals have been met. For most women this means a Hba1c of 6.5% or under and ideally under 6.0%.

Start folic acid 5mg daily.

Stop statins, ACE inhibitors, ARBs and seek alternative blood pressure control drugs instead, if you have high blood pressure.

Get your weight down to normal if at all possible.

Start a gentle exercise regime if you haven’t already started.

If you have type two diabetes discuss moving onto insulin with your consultant diabetologist.

If you have type two diabetes you will usually continue metformin but stop other drugs on the advice of your consultant diabetologist or GP.

 

Based on Analysing newly-published diabetes audits: are care standards being achieved? Written by Steve Chaplin B Pharm MSc Medical Correspondent in Practical Diabetes March 2016

Is there any point in taking calcium supplements to reduce your fracture risk?

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Mark J Bolland et al have studied whether increasing dietary and supplemental calcium can prevent fractures or not.

Calcium supplementation has long been standard practice and is usually included in vitamin D formulations for the elderly, those on long term steroids, and those who have established osteoporosis. Diabetics are also at increased risk of osteoporosis.

In this systematic review of randomised controlled trials and cohort studies dietary calcium had no effect on fracture risk at all. Calcium supplementation meanwhile only had a small and inconsistent effect on fracture prevention.

So probably not worth it then?

What could be more useful is supplementation with straight vitamin D3.

Dr Lee Wah Phin and Dr John Holden from North West England checked the vitamin D status of 302 GP patients. They took 75 mmol/l as the cut off point for low vitamin D and found that 90% of the adult population were deficient. This is in keeping with my own findings in GP in the West of Scotland.  They wonder if there should be some way of screening and supplementing  the population.

Based on BMJ 3 October 2015 and RCGP letter October 15.

 

Who gets boils?

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A London General Practice has studied all the people who came to see them over the course of a years with boils. As many of you know, diabetics are more commonly afflicted than their non diabetic friends. Is there anything you can do to reduce the chance of getting these blighters?

Well, according to the survey, not that much, if you are already pretty health conscious. Most of the factors associated with boils are not usually under your direct control. Some are, such as smoking, being overweight and having had an antibiotic prescription in the previous six months.

People who got them also tended to be from  socio-economically deprived groups. There were some gender differences but it is not well known whether this was due to true incidence or whether it was due to more tendency to consult a doctor.

Overall women attended more than men especially in younger age groups, but was this due to less tolerance for the boils?  Older men, over the age of 65 also attended more frequently, but was this because their wives made them?

There is a sharp increase in boils in adolescence onwards and then it tends to subside after men are 25 and women are 35, so hormonal factors have something to do with it. The bad news is that boils tend to recur and overall ten percent of those afflicted will be back to the doctor’s at least once in the year after they first attend.

Based on RCGP article by Laura J Shallcross October 2015.

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How good are you at looking after yourself?

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Last week I was at a workshop to teach health care professionals how to do focus centred behaviour change for diabetics. It was run by two psychologists.  One of the “documents you may wish to use with patients” was a list of self -care behaviours and next to it a grade of how good you think you are doing it.

These are the dietary based entries:

The food I choose to eat makes it easy to achieve optimal blood sugar levels.

Occasionally I eat lots of sweets or other foods rich in carbohydrates.

Sometimes I have real “food binges” (not triggered by hypoglycaemia)

The third one is assessing  emotional eating. But the first two are squarely advocating a low carbohydrate diet. Nada about dietary fat in the whole thing.

I was surprised and delighted but decided to stay silent. There were three dieticians in the room. I saw one bridle as she read the document. She asked, “Where did this come from?”.

Here is its source.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751743/

This is a German/UK collaboration with a good scientific basis.

Table 1

Diabetes Self-Management Questionnaire (DSMQ)

The following statements describe self-care activities related to your diabetes. Thinking about your self-care over the last 8 weeks, please specify the extent to which each statement applies to you. Applies to me very much Applies to me to a consider-able degree Applies to me to some degree Does not apply to me
1. I check my blood sugar levels with care and attention.
☐ Blood sugar measurement is not required as a part of my treatment.		 ☐3 ☐2 ☐1 ☐0
2. The food I choose to eat makes it easy to achieve optimal blood sugar levels. ☐3 ☐2 ☐1 ☐0
3. I keep all doctors’ appointments recommended for my diabetes treatment. ☐3 ☐2 ☐1 ☐0
4. I take my diabetes medication (e. g. insulin, tablets) as prescribed.
☐ Diabetes medication / insulin is not required as a part of my treatment.		 ☐3 ☐2 ☐1 ☐0
5. Occasionally I eat lots of sweets or other foods rich in carbohydrates. ☐3 ☐2 ☐1 ☐0
6. I record my blood sugar levels regularly (or analyse the value chart with my blood glucose meter).
☐ Blood sugar measurement is not required as a part of my treatment.		 ☐3 ☐2 ☐1 ☐0
7. I tend to avoid diabetes-related doctors’ appointments. ☐3 ☐2 ☐1 ☐0
8. I do regular physical activity to achieve optimal blood sugar levels. ☐3 ☐2 ☐1 ☐0
9. I strictly follow the dietary recommendations given by my doctor or diabetes specialist. ☐3 ☐2 ☐1 ☐0
10. I do not check my blood sugar levels frequently enough as would be required for achieving good blood glucose control.
☐ Blood sugar measurement is not required as a part of my treatment.		 ☐3 ☐2 ☐1 ☐0
11. I avoid physical activity, although it would improve my diabetes. ☐3 ☐2 ☐1 ☐0
12. I tend to forget to take or skip my diabetes medication (e. g. insulin, tablets).
☐ Diabetes medication / insulin is not required as a part of my treatment.		 ☐3 ☐2 ☐1 ☐0
13. Sometimes I have real ‘food binges’ (not triggered by hypoglycaemia). ☐3 ☐2 ☐1 ☐0
14. Regarding my diabetes care, I should see my medical practitioner(s) more often. ☐3 ☐2 ☐1 ☐0
15. I tend to skip planned physical activity. ☐3 ☐2 ☐1 ☐0
16. My diabetes self-care is poor. ☐3 ☐2 ☐1 ☐0

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It is very refreshing and welcome to see that prioritising eating based on the effects on glycaemic control for diabetics is being adopted over following dogma with no scientific basis.

 

 

Fat in the liver is a key sign for metabolic problems

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Obesity does not always go hand in hand with metabolic changes in the body that can lead to diabetes, heart disease and stroke, according to a new published study…

In a study at Washington University School of Medicine, researchers found that a subset of obese people do not have common metabolic abnormalities associated with obesity, such as insulin resistance, abnormal blood lipids (high triglycerides and low HDL cholesterol), high blood pressure and excess liver fat.

In addition, obese people who didn’t have these metabolic problems when the study began did not develop them even after they gained more weight.

The study involved 20 obese participants who were asked to gain about 15 pounds over several months to determine how the extra pounds affected their metabolic functions.
First author Elisa Fabbrini, MD, PhD, assistant professor of medicine, added that, “Our goal was to have research participants consume 1,000 extra calories every day until each gained 6 percent of his or her body weight” “This was not easy to do. It is just as difficult to get people to gain weight as it is to get them to lose weight.”

All of the subjects gained weight by eating at fast-food restaurants, under the supervision of a dietitian. The researchers chose fast-food chain restaurants that provide rigorously regulated portion sizes and nutritional information.

Before and after weight gain, the researchers carefully evaluated each study subject’s body composition, insulin sensitivity and ability to regulate blood sugar, liver fat and other measures of metabolic health.

After gaining weight, the metabolic profiles of obese subjects remained normal if they were in the normal range when the study began. But the metabolic profiles significantly worsened after weight gain in obese subjects whose metabolic profiles already were abnormal when the study got underway.

Senior investigator Samuel Klein, MD, the Danforth Professor of Medicine and Nutritional demonstrated that some obese people are protected from the adverse metabolic effects of moderate weight gain, whereas others are predisposed to develop these problems.”

“This observation is important clinically because 352774705_bb36377f90_o.jpgabout 25 percent of obese people do not have metabolic complications,” he added. “Our data shows that these people remain metabolically normal even after they gain additional weight.”

As part of the study, the researchers then helped the subjects lose the weight they had gained.

The researchers identified some key measurements that distinguished metabolically normal obese subjects from those with problems. One was the presence of fat inside the liver. Those with abnormal metabolism accumulated fat there.

Another difference involved gene function in fat tissue. People with normal metabolism in spite of their obesity expressed more genes that regulate fat production and accumulation. And the activity of those genes increased even more when the metabolically normal people gained weight. That wasn’t true for people with abnormal metabolism.

“These results suggest that the ability of body fat to expand and increase in a healthy way may protect some people from the metabolic problems associated with obesity and weight gain.” He noted that obesity contributes to more than 60 different unhealthy conditions.

Practice Pearls:

  • Some obese people are protected from the adverse metabolic effects of moderate weight gain.
  • Some key measurements that distinguished metabolically normal obese subjects from those with problems. One was the presence of fat inside the liver. Those with abnormal metabolism accumulated fat there.
  • People with normal metabolism in spite of their obesity expressed more genes that regulate fat production and accumulation.

Elisa Fabbrini. Metabolically normal obese people are protected from adverse effects following weight gain, pub Jan. 2, 2014 in The Journal of Clinical Investigation.  (Published in Diabetes in Control Jan 15)

Salt restriction can backfire for heart failure patients

kaitiscotland2 Comments

Salt_shaker_on_white_backgroundOver the years, physicians and researchers have advocated less salt consumption in heart failure patients.  Although doctors make this recommendation frequently, patients are not always compliant.  Heart failure patients who may also be hypertension patients inspired the DASH diet, which includes decreased to no sodium intake, more fruits and vegetables, skinless poultry, and less saturated and trans fat. In heart failure patients, salt increases water retention, which is quite harmful to the function of the heart.

Researchers have recently stumbled across information regarding salt intake and heart failure patients’ long-term health.  In all actuality, salt consumption just may not be harmful to that population.  This may be a sigh of relief to heart failure patients, but in an interview from consumer.healthday.com with physician Rami Doukky of Chicago, patients should not jump on the bandwagon just yet.

In a study performed by Doukky, 833 heart failure patients were evaluated with the new findings.  Divided into two groups consisting of 130 patients, one group consumed salt without any restrictions.  While the other group of subjects were salt-restricted.  Each patient was followed for a total of three years, and evaluated using an intake tracking method as well as a survey.

After analysis of results, it was found that 42% of the surveyed population following the salt-restricted diet were either admitted to the hospital with heart failure complications or they died.  In comparison,  26% of the subjects without salt restrictions developed further complications and/or death.

Although this gives heart failure patients hope, these findings need to be further studied.  The results favor no salt restriction due to a decreased percentage of complications, but different factors in each of the patients could have swayed results.  With emphasis from cardiologist Clyde Yancy at consumer.healthday.com, salt should not be automatically incorporated back into heart failure patients’ diets.  Salt is still a major contributor to high blood pressure, which can lead to cardiovascular complications.

Practice Pearls:

  • 26% of the subjects without salt restrictions developed further complications and/or death. In comparison, 42% following the salt-restricted diet were either admitted to the hospital with heart failure complications or they died.
  • Not all heart patients need to restrict their salt intake.
  • Salt reduction for some heart patients may not be helpful.

Doukky, Rami et al. “Impact Of Dietary Sodium Restriction On Heart Failure Outcomes”. JACC: Heart Failure 4.1 (2016): 24-35. Web. 17 Jan. 2016.

Consumer HealthDay,. “Reducing Salt Intake Might Harm Heart Failure Patients, Study Claims”. N.p., 2015. Web. 17 Jan. 2016.

 

Samantha Ferguson Doctorate of Pharmacy Candidate Florida A&M University, reviewed by Dave Joffe, BSPharm, CDE (Published in Diabetes in Control Jan 16)

 

Tax on Sugary Drinks Announced

EmmaLeave a comment

tax on sugary drinksYesterday’s budget news revealed a surprise – the announcement of a tax on sugary drinks.

A surprise because the Government had not previously revealed any enthusiasm for such a tax. More educated commentators and politicians than I have noted that the chancellor George Osborne may well have brought in such a headline move to disguise other less popular cuts, such as the loss of personal independence payments for people with disabilities, cuts in corporation tax and taxes for the very wealthy.

The tax on sugary drinks is due to be introduced in April 2018. It’s expected to be two-tier approach with drinks that contain 5g of sugar per 100ml taxed at one rate and those containing 8g of sugar per 100ml taxed at higher rate. There are 35g of sugar in a 330ml can of Coke for instance.

 

 

Doctors, the NHS England boss, celebrity chef Jamie Oliver and health charities were among those welcoming the budget surprise. France, Finland, Mexico and Hungary already tax sugary drinks and sales in Mexico have fallen by 12 percent since the country introduced a surcharge of 12 percent in 2014.

There is one issue – some type 1 diabetics and other diabetics who use insulin to treat their condition consume sugary drinks when they are hypo – i.e their blood sugar levels are too low and they need something that will bring those blood sugar levels up very quickly. Diabetes UK has said it will be involved in the consultation about how tax on sugary drinks can be introduced to raise this concern so that it does not impact negatively on the way people with diabetes treat their condition.

 

 

What can you do to improve erectile dysfunction?

kaitiscotlandLeave a comment

Blood vessel problems and diabetes are the leading causes of not being able to get or sustain an erection in men. “ED” is a very common diagnosis, perhaps more so now than ever before, partly due to the increase in diabetes but also because there are more treatments available now and men are less likely to suffer in silence.

Diabetics tend to get the problem 10 to 15 years earlier than other men. The degree of glycaemic control over time is a significant factor as this determines the extent of microvascular and macrovascular complications. Neuropathy, insulin resistance, endothelial dysfunction, and atherosclerosis all affect the mechanisms behind erectile function.

Even men who are not diabetic but are aged over 50 and have features of metabolic syndrome are at almost a 50% more chance of getting ED. Indeed the severity of ED reflects the degree of blood pressure, waist fat, and abnormal blood fat pattern that a man may have. If a man with diabetes has ED he is at significant risk of coronary artery disease.  Low testosterone is a risk factor for ED by itself and makes metabolic syndrome and diabetes worse as well.

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The main drugs to treat ED, such as Viagra and Cialis, rely on an intact neural response, so they don’t always work that well when this is impaired in diabetics.  Testosterone replacement therapy can reduce cardiovascular risk in men and also enhance the response to these sorts of drugs. When drugs are still not successful vacuum devices, penile injection drugs, and penile prostheses can be used.

Men can find that following a Mediterranean style of diet can improve erectile response as can exercise.

So in brief:

Keep to as normal a weight as you can.

Keep blood sugars control as good as you can for as long as you can.

Make exercise part of your daily routine.

Eat a low carbohydrate diet with plenty of olive oil, fresh vegetables and moderate amounts of fruit.

Don’t smoke.

Reduce stress.

Sleep well.

Keep your blood pressure under control.

Seek medical advice if you have abnormal blood lipids especially low HDL and high triglycerides.

Include a testosterone check if you notice your waistline creeping up or erectile problems when you have your other diabetic blood tests.

Maintain a normal blood pressure.

Ask your doctor’s advice if you are on medication because many anti- hypertensives and anti-depressants interfere with penile function.

If you do have ED and diabetes discuss cardiac assessment with your doctor.

Thermometer - Confidence Level
A thermometer with mercury bursting through the glass, and the words Confidence Level, symbolizing a positive attitude

Based on the article: Endothelial dysfunction is the link between ED, DM and CAD by  Sabair Pradhan, Doctor of Pharmacy Candidate USF College of Pharmacy. Published in Diabetes in Control February 2016.

 

 

Public Health Collaboration Website – Live

EmmaLeave a comment

PHC-Space-Top

The Public Health Collaboration (PHC) website is now live!

The website promotes the PHC, a non-profit organisation that is focused on supporting research and investigating pressing health concerns in the UK. and one of its members is our very own Dr Katharine Morrison.

The PHC was set up because members have become concerned about the rates of obesity (25 percent of adults) and type 2 diabetes in the UK, which has risen by 65 percent in the past 10 years.  The current ‘solutions’ being used to tackle the issues just aren’t working.

The PHC will be publishing solution-based reports on a quarterly basis, alongside running co-ordinated campaigns and implementing initiatives to improve public health. There’s also a conference scheduled for June.

Read more about the work of the PHC here.

Low-Carb Diets Help People with Type 2 Diabetes

EmmaLeave a comment

researchThis week’s round-up of diabetes in the news flagged up research carried out in Australia, showing that low-carb diets help people with type 2 diabetes to drastically reduce the amount of medication they need.

I’ll admit it. I’m very guilty of confirmation bias, i.e. I look for the research and the reports that back up my opinions and I would have made a rubbish scientist. However, in six months or so of weekly Google alerts for “diabetes news”, not once has my search term brought up research which proved a high-carb, low-fat diet worked…

Anyway, the latest research was carried out by CSIRO, Adelaide University, Flinders University and the University of South Australia.

40 Percent Reduction

Adelaide University researchers developed a diet and exercise programme which resulted in an average 40 percent reduction in medication levels for people with type 2 diabetes. The diet used was low in carbohydrates and higher in protein and unsaturated fats.

The programme was based on findings from a National Health and Medical Research Council funded study which compared low carb eating with the current Australia best practice approach of managing type 2 diabetes with a diet high in unrefined carbs and low in fat.

“Ground-breaking”

In a news report on the CSIRO website, CSIRO’s associate professor and principal research scientist Grant Brinkworth described the research results as “ground-breaking”, and that patients who followed low-carb diets reduced medication levels by more than double the amount of volunteers following a high-carb plan, with others managing to stop taking their medication altogether thanks to low-carb eating.

He said: “This research shows that traditional dietary approaches for managing type 2 diabetes could be outdated, we really need to review the current dietary guidelines if we are serious about using the latest scientific evidence to reduce the impact of the disease.”

Well. No new news here for us at The Diabetes Diet! We know the benefits of low-carb eating and are prepared to run the gauntlet of official disapproval. If you’d like to try out a low-carb approach to managing your blood sugar levels yourself, why not check out our book or any of the recipes on this website which will help keep meal carb counts low?

 

Picture thanks to MCM Science on flickr.