Cardiovascular outcomes are improving for type two diabetics

Photo by Craig McKay on Pexels.com

There have been large reductions in myocardial infarction, cardiac death, and all cause mortality over the last fifteen years in Denmark for type two diabetics. For instance, the cumulative seven year risk of myocardial infarction reduced from6.9% to 28%. These reductions occurred over a period of time when there has been a lot more emphasis on using drugs to reduce cardiovascular risk. (Diabetes Care 2021)

In Sweden blood was tested to see how much dairy products were being consumed. Those who consumed the most dairy fat had 25% less risk of myocardial infarction compared to the lowest risk.

As many dietary guidelines recommend limiting dairy products in order to limit saturated fat intake, perhaps they should take note.

An article in the American Journal of Clinical Nutrition suggests that if the carbohydrate – insulin model of obesity is correct, then instead of calorie control diets and exercise to reduce obesity, focus should be put on low carbohydrate diets.

Dr Mark Cucuzella: Online resources for low carbing for patients and doctors

Adapting Medication for Type 2 Diabetes to a Low Carbohydrate Diet- Frontiers 2021

https://www.frontiersin.org/articles/10.3389/fnut.2021.688540/full

The above link gives the full paper from Dr Cucuzella about the medication adaptations, including insulin adaptations that need to be done if you are transitioning to a low carb diet. There is a helpful traffic light summary. Some medications do not need altered and these are discussed too.

Diet Doctor video on article “Why deprescription should be your new favorite word”

What your new diet will consist of and how to avoid unnecessary expense or complicated recipes is fully discussed in the following links. They are the same booklet but in different formats.

Our new “Low Carb on any Budget  – A Low-carb Shopping and Recipe Starter Begin a Life Free of Dieting and Indulge Yourself in Health” patient guide- Print and share with your patients

Pdf version

www.tinyurl.com/lowcarbanybudget

online flipbook

www.tinyurl.com/lowcarbanybudgetebook

For clinicians through guideline central

These booklets are quite complex and are for doctors who want to know more about low carb diets and fine tuning of medication and insulin. The first is in USA units and the second is the UK format. It does no harm for any diabetic or their carers to read these too but bear in mind that they do go into some depth.

-Guideline Central: Low-Carbohydrate Nutrition Approaches in Patients with Obesity, Prediabetes and  Type 2 Diabetes

http://eguideline.guidelinecentral.com/i/1180534-low-carb-nutritional-approaches-guidelines-advisory/0?

UK version – http://eguideline.guidelinecentral.com/i/1183584-low-carb-nutrition-queens-units/0? 

Physical activity can improve cognitive function if you have type two diabetes

Photo by Polina Tankilevitch on Pexels.com

Adapted from Diabetes in Control Aug 10 2021 by Macrina Ghali, Pharm D candidate, Florida.

Hyperglycaemia has been linked to reduced cognitive function and can impair life through impairing memory and language. Mistakes with medication are more likely. Some studies have shown that exercise can reduce the risk of dementia on the long term.

The meta-analysis sought to answer the question, does cognitive ability change from baseline, while on the exercise programme compared to the non-exercising controls? Just over 2,500 patients with diabetes were analysed, almost evenly split to control groups and exercise groups.

The exercise group did aerobic exercise, resistance exercise and non aerobic exercise. The control groups did monthly telephone calls, stretching, gentle movement and education. The interventions ranged in time from 12 months to 9.8 years and sample sizes ranged from 47 to over a thousand.

Standard tests such as the mini-mental state examination, mental state examination and global cognitive score were undertaken.

Surprisingly the study found that the greatest change in cognitive scores between both groups was in the studies done for 12 months rather than longer periods. They were not sure if this was due to patient drop out or the development of dementia. They think that more studies would need to be done to clarify the issue.

Meanwhile they think that physical activity programmes should be started soon after diagnosis of type two diabetes to prevent a worsening of cognitive functioning as time goes on.

Tim Noakes: Nutrition Network Courses for Health Professionals

Homepage | Nutrition Network (nutrition-network.org)

Tim Noakes shot to fame in the low carb community by being accused of malpractice by two South African dieticians for giving dietary advice when he was not a registered dietician. After five long miserable years and the support of international colleagues he won the case. Anna Dahlquist, a Swedish GP had gone through the same thing a few years before this, and not only won her case, but managed to get the Swedish food guidelines for people with diabetes changed.

Professor Noakes has established online training for health professionals covering a variety of useful topics. Participants can be from all over the world and will receive accreditation. The full list of topics can be found by clicking on the homepage in BOLD above.

University College London: Diabetes has trebled in England in the last 25 years

Researchers from UCL analysed the results the latest results from the Health Survey for England.

Data from 8,200 adults and 2,000 children living in private households showed that diabetes has risen in men from 3% to 9% and from 2% to 6% in women since 1994.

Those from poorer households and those with obesity are much more likely to be affected than the slim and affluent. 16% from the poorest homes had diabetes compared to 7% in the highest income group. If you are of normal weight there is a 5% chance of diabetes, 9% if you are overweight and 15% if you are obese.

Obesity is a marker for poverty. 39% of women in deprived areas were obese compared to 22% from least deprived areas. The weight of children was closely correlated with their parents.

Professor Jennifer Mindell said,” Diabetes has become more common in both high and low income countries over the last few decades. It increases the risks of circulatory diseases and cancers. This year we have also seen a rise in serious infection and death such as with Covid-19. Obesity reduction would help all of these problems.”

The survey also asked about GP visits. 69% of men and 82% of women had consulted a GP in the previous six months. GP consultations are more common in older ages, especially among men and those who are overweight or obese. 84% said they went about their physical health problems, 11% for physical and mental problems and 5% for an emotional or mental health problem. Women tended to seek more help for mental health problems than men.

Echoing all the other parameters, consultations for mental health problems were more frequent in those with lower incomes. 25% consulted from the lowest income group compared to 15% from the most affluent group.

Elizabeth Fuller, Research Director at NatCen said, ” One in five women and one in eight men screened positive for a possible eating disorder. This can mean eating too much or too little, obsessing with weight or body shape, having strict routines around food or purging after eating. People who are obese, younger adults and women are more likely to be affected.”

Public health collaboration online conference 2021

Sam Feltham has done it again. This year’s conference is now available on you tube right now.

Last weekend there were many contributors from diverse fields including members of the public, doctors, academics, and the scientific journalist Gary Taubes who gave the opening talk about ketogenic diets.

The courses that particularly interested me were about the experiences of type one diabetics who had adopted the low carb approach, how to achieve change, and how to increase your happiness.

There are talks about eating addiction and eating disorders, statins, and vegetable oil consumption.

Much of the material will be familiar to readers of this blog. There are some new speakers and topics which do indicate that a grassroots movement in changing our dietary guidelines is gaining ground.

Blood pressure difference between arms can be a risk factor for cognitive decline…as well as other things.

From Systolic inter-arm blood pressure difference and cognitive decline in older people, a cohort study. Christopher E Clark. BJGP July 2020

 

A prospective study was done in 1,113 Italians whose average age was 66.4 years. Even a difference of only 5 degrees between the arms was associated with a greater level of cognitive decline.

My comment: In UK GP practices, only one arm is used to check the blood pressure. In my case, it was the arm that was nearest to the desk. Perhaps we should check both ? Inter-arm BP differences are both associated with cardiovascular disease, and this in turn affects dementia. Then of course, is the question, what can you do about it? For a further discussion of the subject here is Pharmacist Antonio Bess from Diabetes in Control.

Cognitive Decline: Just Life, or a Preventable Disease?
Feb 22, 2020

Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Antonio Bess, Pharm D Candidate, Florida Agricultural & Mechanical University School of Pharmacy

Cognitive decline is associated with many diseases and medications, but the exact mechanisms are not clearly understood.
Diabetes, obesity, and declining cognitive function are all associated with increased prevalence with increasing age.

Diabetes is a known risk factor for eye, kidney, neurological and cardiovascular diseases, but its effect on declining cognitive function has been in question. Previous studies have found associations between patients who have diabetes and poor glycemic control and significantly faster cognitive decline. Other studies have demonstrated a pattern in which diabetes, high blood pressure, and high body mass index in midlife predict dementia in late life.

In this prospective study, individuals were followed for up to ten years to find associations between indices in diabetes, insulin resistance, obesity, inflammation, and blood pressure with cognitive decline. The indices of interest were measured separately among those with and without central obesity.
The Monongahela‐Youghiogheny Healthy Aging Team is a population‐based cohort of participants recruited randomly from 2006 to 2008, who were 65 and older, and were from a group of small towns in southwestern Pennsylvania. The study is focused on the epidemiology of cognitive decline and dementia in an area that still has not recovered economically from the collapse of the steel industry in the 1970s.

Participants were analyzed at study entry, and annual follow up. To measure cognitive function, participants were given a panel of neuropsychological tests tapping the domains of attention/processing speed, executive function, memory, language, and visuospatial function. At study entry and annually, BP, BMI, waist‐hip ratio, and depressive symptoms  were measured.
Key variables at the time of blood draw, including age, sex, race (white vs. nonwhite), education (high school [HS] or less vs. more than HS), APOE*4 allele carrier status, mCES‐D score, BMI, WHR, systolic BP (SBP), and the following laboratory assay variables: CRP, glucose, HbA1c, insulin, HOMA‐IR, resistin, adiponectin, and GLP‐1 were all reviewed to identify predictors of cognitive decline.
Among 1982 participants who were recruited and underwent full assessment at baseline from 2006 to 2008, only 478 individuals were able to provide fasting blood samples. Of this group of individuals, the median age was 82 years; 66.7% were women; 96.7% were white, and 49.0% had more than HS education.

Compared to the 1504 original participants without fasting blood data, at baseline, these 478 were significantly younger (74.6 vs. 78.6 years; P < .001); more likely to be women (66.7% vs. 59.2%; P = .004); more likely to be of European descent (96.7% vs. 94.1%; P < .001); more likely to have at least HS education (49.0% vs. 38.6%; P < .001); but about equally likely to be APOE*4 carriers (19.3% vs. 21.5%; P = .350).
In unadjusted analysis in the sample as a whole, faster cognitive decline was associated with greater age, less education, APOE*4 carriage, higher depression symptoms (mCES‐D score), and higher adiponectin level. HbA1c was significantly associated with cognitive decline.

After stratifying by the median waist-hip ratio, HbA1c remained related to cognitive decline in those with higher waist-hip ratios. Faster cognitive decline was associated, in lower waist-hip ratio participants younger than 87 years, with adiponectin of 11 or greater; and in higher waist-hip ratio participants younger than 88 years, with HbA1c of 6.2% or greater. Higher adiponectin levels predicted a steeper cognitive decline in the lower waist-hip ratio group.
Abdominal obesity plays a crucial role in cognitive decline in those with diabetes. The microvascular disease may play a more significant role than macrovascular disease. Midlife obesity contributes to cognitive decline but there was no midlife data in this study. Future studies should include a large minority, midlife population. Adiponectin levels need to be carefully assessed as well.

Practice Pearls:
In individuals younger than 88 years old, central obesity can lead to faster cognitive declines.
Obesity, diabetes, and aging contribute to cognitive decline, so it’s hard to distinguish the most significant risk.
Adiponectin may be a novel independent risk factor for cognitive decline and should be reviewed.

Ganguli, Mary, et al. “Aging, Diabetes, Obesity, and Cognitive Decline: A Population‐Based Study.” Journal of the American Geriatrics Society, John Wiley & Sons, Ltd, Feb. 2020, p. jgs.16321, doi:10.1111/jgs.16321.
Ganguli, Mary, et al. Aging, Diabetes, Obesity, and Cognitive Decline: A Population-Based Study. 2020, pp. 1–8, doi:10.1111/jgs.16321.
Tuligenga, Richard H., et al. “Midlife Type 2 Diabetes and Poor Glycaemic Control as Risk Factors for Cognitive Decline in Early Old Age: A Post-Hoc Analysis of the Whitehall II Cohort Study.” The Lancet Diabetes and Endocrinology, vol. 2, no. 3, Elsevier Limited, Mar. 2014, pp. 228–35, doi:10.1016/S2213-8587(13)70192-X.
Cukierman, T., et al. “Cognitive Decline and Dementia in Diabetes – Systematic Overview of Prospective Observational Studies.” Diabetologia, vol. 48, no. 12, Springer, 8 Dec. 2005, pp. 2460–69, doi:10.1007/s00125-005-0023-4.

Antonio Bess, Florida Agricultural and Mechanical University College of Pharmacy

Should you get tested for coeliac?

From Allergy and Autoimmune Disease for Healthcare Professionals October 9 2019

Apparently 70% of people who have coeliac have yet to be tested for it.

Who may have it?

4.7% of those with irritable bowel syndrome.

20% of those with mouth ulcers.

8% of infertile couples.

16% of type one diabetics.

7.5% of first degree relatives of people with coeliac.

About 50% of people who are diagnosed have iron deficiency diagnosis  at the time of coeliac diagnosis.

Other people who need to be tested may have:

Pancreatic insufficiency

Early onset osteoporosis or osteopenia

vitamin and mineral deficiencies

gall bladder malfunction

secondary lactose intolerance

peripheral and central nervous system disorders

Turner’s syndrome

Down’s syndrome

Dental enamel defects

persistent raised liver enzymes of unknown cause

peripheral neuropathy or ataxia

metabolic bone disorders

autoimmune thyroid disease

unexplained iron, vitamin D or folate deficiency

unexpected weight loss

prolonged fatigue

faltering growth

second degree relative with coeliac disease

My comment: I had years of  the mouth ulcers, iron deficiency anaemia and irritable bowel symptoms which all resolved completely on a wheat free diet. The problem is that if I did want tested I would need to go back on wheat for a minimum of six weeks to give my antibodies a chance to build up sufficiently to test positive.  Thus, best to get a test BEFORE you go on a wheat free diet.

 

 

Younger women more likely to get urine infections with Flozins

From Univadis Nakhleh A et al. Journal of Diabetes Complications 18th April 2020

It is well known that patients on Flozins are much more prone to urine infections and thrush due to the extra sugar in the urine which is excreted by taking these drugs, also known as SGLT2 inhibitors.

An Israeli study of over 6 thousand women with type two diabetes sought to clarify who was more or less likely to be affected by this very annoying problem.

They found that those most likely to get urine infections were:

Women who had existing gastro intestinal problems

Pre-menopausal women

Women who had been taking oral oestrogen in the form of the contraceptive pill or HRT

Women less likely to be affected:

were older (over 70)

had prior existing chronic kidney disease

My comment: From my GP experience I found that these drugs were highly effective and generally well tolerated. A few patients were indeed badly affected by recurrent urine infections and thrush and had to discontinue the drugs.

 

 

NICE: Blood Pressure Update

From Diagnosis and management of hypertension in adults. NICE guideline update 2019

BJGP Feb 2020 by Nicholas R Jones et al.

The last update by NICE was in 2011. The key changes are explained in this article.

High blood pressure is blood pressure over 140/90 if measured in the clinic.

Home measurements can be more reliable due to a natural rise in blood pressure in the clinic setting. Ambulatory monitoring can be done, but it is not always available or tolerated. My comment: The machine can be very uncomfortable and disrupts sleep. 

To take your blood pressure at home, take two readings, one minute apart, twice a day for 4 to 7 days.  Don’t count the first days readings. Then take the average of the others.

Hypertension is diagnosed if the average of home or ambulatory monitoring is over 135/85.

The BP should be taken standing for those people over 80, who have type two diabetes and if you have postural hypotension. You need to stand for at least a minute before taking the blood pressure and it is best to avoid talking. 

A blood pressure difference between the arms of over 15 mmHg is a marker for vascular disease. Thereafter the arm with the highest measurements should be chosen for monitoring.

Urgent admission is needed if the bp is over 180/110.

Target organ damage is assessed with looking at the retina, urine testing, U and E and eGFR, ECG and a cardiovascular risk score such as QRISK. Check up should be annually.

Lifestyle advice should be emphasised as this can result in taking fewer drugs.

People with blood pressures over 140/90 at the clinic or 135/85 who are aged 60 to 80 are currently advised to have treatment for their blood pressure. People over the age of 80 are fine with blood pressure targets lower than 150 systolic.

The treatment target for people with diabetes is now 140 systolic which is now the same as the general population.

The drugs to treat hypertension are:

ACE or ARB if type 2 diabetes, age under 55 or African or Caribbean origin.

The next step is to add a calcium channel blocker or thiazide like diuretic.

The next step is a combination of ACE or ARB, CCB and Thiazide.

If the potassium is less than 4.5, Spironolactone can be added as a next step.

If the potassium is over 4.5 then an alpha or beta blocker.

For all other patients the first step is a CCB or Thiazide. 

The next step is an ACE, ARB or Thiazide.

Then any combination of these.

If the potassium is under 4.5 then spironolactone can be added.

If the potassium is over 4.5 then an alpha or beta blocker can be added.