Category: research

First ever guidelines for assessing and treating the diabetic foot

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4276166167_e2cf9e2e47_oThe Society for Vascular Surgery, the American Podiatric Medical Association and the Society for Vascular Medicine collaboratively publish first-ever set of clinical practice guidelines for treating the diabetic foot. These  took three years to develop and are available online.

 

Specific areas of focus included (1) prevention of diabetic foot ulceration, (2) off-loading, (3) diagnosis of osteomyelitis, (4) wound care, and (5) peripheral arterial disease.

They include preventive recommendations such as those for adequate glycemic control, periodic foot inspection, and patient and family education.

They recommend using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation. In patients with plantar diabetic foot ulcer (DFU), they recommend off-loading with a total contact cast or irremovable fixed ankle walking boot.

In patients with a new DFU, they recommend probe to bone test and plain films to be followed by magnetic resonance imaging if a soft tissue abscess or osteomyelitis is suspected.

They provide recommendations on comprehensive wound care and various débridement methods. For DFUs that fail to improve (>50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, they recommend adjunctive wound therapy options.

In patients with DFU who have peripheral arterial disease, they recommend revascularization by either surgical bypass or endovascular therapy.

Whereas these guidelines have addressed five key areas in the care of DFUs, they do not cover all the aspects of this complex condition. Going forward as future evidence accumulates, they plan to update recommendations accordingly.

Diabetes is one of the leading causes of chronic disease and limb loss worldwide, currently affecting 382 million people. It is predicted that by 2035, the number of reported diabetes cases will soar to 592 million. This disease affects the developing countries disproportionately as >80% of diabetes deaths occur in low- and middle-income countries.

As the number of people with diabetes is increasing globally, its consequences are worsening. The World Health Organization projects that diabetes will be the seventh leading cause of death in 2030. A further effect of the explosive growth in diabetes worldwide is that it has become one of the leading causes of limb loss. Every year, >1 million people with diabetes suffer limb loss as a result of diabetes. This means that every 20 seconds an amputation occurs in the world as an outcome of this debilitating disease. Diabetic foot disease is common, and its incidence will only increase as the population ages and the obesity epidemic continues.

Approximately 80% of diabetes-related lower extremity amputations are preceded by a foot ulcer. The patient demographics related to diabetic foot ulceration are typical for patients with long-standing diabetes. Risk factors for ulceration include neuropathy, PAD, foot deformity, limited ankle range of motion, high plantar foot pressures, minor trauma, previous ulceration or amputation, and visual impairment. Once an ulcer has developed, infection and PAD are the major factors contributing to subsequent amputation.

Available U.S. data suggest that the incidence of amputation in persons with diabetes has recently decreased; toe, foot, and below-knee amputation declined from 3.2, 1.1, and 2.1 per 1,000 diabetics, respectively, in 1993 to 1.8, 0.5, and 0.9 per 1,000 in 2009. However, including the costs of outpatient ulcer care, the annual cost of diabetic foot disease in the United States has been estimated to be at least $6 billion. A Markov modeling approach suggests that a combination of intensive glycemic control and optimal foot care is cost-effective and may even be cost-saving.

DFUs and their consequences represent a major personal tragedy for the person experiencing the ulcer and his or her family as well as a considerable financial burden on the healthcare system and society. At least one-quarter of these ulcers will not heal, and up to 28% may result in some form of amputation. Therefore, establishing diabetic foot care guidelines is crucial to ensure the most cost-effective healthcare expenditure. These guidelines need to be goal focused and properly implemented.

This progression from foot ulcer to amputation leads to several possible steps where intervention based on evidence-based guidelines may prevent major amputation. Considering the disease burden and the existing variations in care that make decision-making very challenging for patients and clinicians, the SVS, American Podiatric Medical Association, and Society for Vascular Medicine deemed the management of DFU a priority topic for clinical practice guideline development. These recommendations are meant to pertain to all people with diabetes regardless of etiology.

Practice Pearls:
•“The Management of the Diabetic Foot,” was developed after three years of studies and later published online and in print in the Journal for Vascular Surgery.
•This progression from foot ulcer to amputation lends to several possible steps where intervention based on evidence-based guidelines may prevent major amputation.
•Every year, >1 million people with diabetes suffer limb loss as a result of diabetes.

Researched and prepared by Steve Freed, BPharm, Diabetes Educator, Publisher and reviewed by Dave Joffe, BSPharm, CDE

Anil Hingorani, MD Glenn M. LaMuraglia, MD, Journal of Vascular Surgery Feb 2016 , Volume 63, Issue 2, Supplement, Pages 3S–21S

April 23rd, 2016 Diabetes in Control

How your language can affect your lifestyle habits

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An interesting study seems to show a marked correlation between how the language you speak affects your motivation to do things that will only benefit you in the future. This means dieting, saving, exercising and paying into pensions.

Languages like Finnish don’t have a strong future orientation. You need to add words to “now speak” to describe the future. As a result, behaviours associated with current discomfort for future gain, seem more immediate compared to other languages such as English for example.  In English, there is a whole tense to describe the future. I am going to…. I will ….and so forth. As a result, well, tomorrow can seem a bit like manana….it never seems to come around.

Seems incredible?  This article and associated video explains:

 

http://www.theatlantic.com/business/archive/2013/09/can-your-language-influence-your-spending-eating-and-smoking-habits/279484/

 

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Dogs improve the immune response of babies

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A Finnish study has shown that growing up with a dog in the house improves the immune response of babies. Early respiratory infections, gastroenteritis and allergic reactions are reduced.

If a man has type one diabetes his chance of passing this on to his children is one in three. Maternal type one diabetes also increases the risk of type one in children but to a much lesser degree. Genetic susceptibility is reduced to a small extent if the baby is brought up in a house where the dog lives in the house. Unfortunately cats don’t confer the same benefit.

Reported in JAMA Paediatrics 2014 and BMJ 19th July 2014

Depression doubles stroke risk even when treated

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Persistent depression is associated with twice the risk of stroke in adults over 50.

Researchers interviewed 16,178 people every two years from 1998 over a 12 year period and assessed depressive symptoms and stroke. They showed that those people who scored significantly for depression on at least two consecutive interviews had double the risk of having a first stroke in the two years after the assessment compared to those with low depressive symptoms. The risk was slightly higher for women and those who had had previous depressive symptoms.

Paola Gilsanz of Harvard University said, ” Our findings suggest that depression may increase stroke risk over the long term. This risk remains elevated even if depressive symptoms have resolved, suggesting a cumulative mechanism linking depression and stroke. Physiological changes may lead to vascular damage over the long term. Depression is also linked to hypertension, ill effects on the autonomic nervous system and inflammatory responses that all cause vascular disease. In addition depressed people are more likely to smoke and by physically inactive.”

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From Research News BMJ 23 May 2015

 

Children born after the 1980’s fatter than previous generations

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Children born in the UK since the 1980’s are two to three times more likely to be overweight or obese the the age of 10 compared to those born in previous generations. This was  found in an analysis of children’s weights from the 1940’s onwards.

The results of 56,632 children are concerning researchers who say that these finding indicate that these children are an an increased risk of chronic health conditions such as coronary heart disease and type two diabetes.

Based on an article by Susan Mayor BMJ 23 May 2015

 

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Drugs that change your weight

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Researchers conducted a systematic review and meta-analysis  of 257 randomised controlled trials and  summarized the evidence about commonly prescribed drugs and their association with weight change.

They included 257 randomized trials (54 different drugs; 84,696 patients enrolled). Weight gain was associated with the use of: amitriptyline (1.8 kg), mirtazapine (1.5 kg), olanzapine (2.4 kg), quetiapine (1.1 kg), risperidone (0.8 kg), gabapentin ( 2.2 kg), tolbutamide (2.8 kg), pioglitazone (2.6 kg), glimepiride (2.1 kg), gliclazide (1.8 kg), glyburide (2.6 kg), glipizide (2.2 kg), sitagliptin (0.55 kg), and nateglinide (0.3 kg).

Weight loss was associated with the use of: metformin (1.1 kg), acarbose (0.4 kg), miglitol (0.7 kg), bupropion (1.3 kg), and fluoxetine (1.3 kg).

For many other remaining drugs (including antihypertensives and antihistamines), the weight change was either statistically nonsignificant or supported by very low-quality evidence.

 

JP Domecq. The Journal of Clinical Endocrinology and Metabolism Drugs Commonly Associated With Weight Change: J. Clin. Endocrinol. Metab. 2015 Jan 15;100(2)363–370, From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

Published in Diabetes in Control Feb 1Metformin_500mg_Tablets

 

Diabetes duration and control affects intellectual decline

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People who have diabetes diagnosed in midlife have a higher risk of cognitive decline over the following 20 years compared to people with normal glucose levels. A prospective study done in the USA showed that there was a 19% increased risk of cognitive decline over the 20 years for those who had diabetes. This meant that having diabetes aged cognitive function by about five more years than normal.

The level of decline was associated with the degree of control of the diabetes. Those with HbA1cs over 7% were more at risk than those with a better degree of control.  Increased duration of diabetes also led to a higher risk.

The study reviewed 13,351 year olds who were aged 48-67 at the start of the study for 20 years. Associate professor of epidemiology Elizabeth Selvin of John Hopkins University said of her findings, ” The lesson is that to have a healthy brain when you are 70, you need to eat right and exercise when you are 50. Maintaining cognitive function is a critical aspect of successful ageing. Preventing diabetes and improving glucose control in people with diabetes offers important opportunities for preventing cognitive decline and delaying progression to dementia”.

 

No proven benefit to replacing saturated fat with polyunsaturated fat

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19349485773_214c8033a3_bAn analysis of the Minnestota Coronary Experiment (1968-73) data has shown that there was no evidence from randomised controlled trials that the serum cholesterol lowering effects of replacing saturated fat with linoleic acid resulted in any reduction from coronary heart disease and total mortality.

The data was re-analysed by Ramsden and Zamora et al and published in the BMJ on 16 April 16.

J Lennert Veerman comments: ” A diet enriched with linolieic acid did not reduce mortality. Indeed participants had a higher mortality than controls. These unexpected results proved difficult to stomach for researchers at the time. The trial ended in 1973 but it took till 1989 for the results to be published. In the past decade old certainties about dietary fats have been questioned and some have been abandoned. Last year US dietary guidelines removed dietary cholesterol and total fat as risk factors worth worrying about.

If blood cholesterol values are not a reliable indicator of cardiovascular risk, then a careful review of the evidence that underpins dietary recommendations is warranted. Ideally recommendations should be based on clinical outcomes, not surrogates such a cholesterol concentration.

From an article in BMJ 16th March 2016

Bacteria that causes gum disease and arterial plaques identified

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A study, published in Infection and Immunity, has clarified the mechanism behind a known link between gum disease and heart disease. Periodontitis, which results in an infection that damages the soft-tissue surrounding teeth and the bone supporting the teeth, is commonly caused by Porphyromonas gingivalis. P. gingivalis is a Gram-negative anaerobe that colonizes mouth tissues for lengthy periods of time after initial infection. It is commonly found within the arterial plaques common to heart disease patients.

The study authors discovered that the bacteria alters the gene expression of pro-inflammatory proteins that also promote coronary artery atherosclerosis. This was discovered by infecting cultured human aortic smooth muscle cells with P. gingivalis. Aortic smooth muscle cells were used because they contract the aorta after the pumping of the heart stretches it out.

After P. gingivalis was injected into the cells, the bacteria released gingipains. Gingipains are enzymes that change the ratio between different angiopoietins (inflammatory proteins) in such a way that inflammation is increased. The pro-inflammatory angiopoietin 2 had its expression increased by the gingipains, whereas the anti-inflammatory angiopoietin 1 had its expression reduced. P gingivalis was found to affect the levels of these proteins independent of tumor necrosis factor (TNF).

The study is significant because it helps to pinpoint the relationship between periodontitis and heart disease. Further research can help clarify potential targets for treatment of atherosclerosis.

Practice Pearls:
•Periodontitis and heart disease share a common pathogen, P. gingivitis.
•A study found that P. gingivitis alters gene expression to increase production of the pro-inflammatory protein angiopoietin 2 and decreases presence of the anti-inflammatory protein angiopoietin 1. This results in increased atherosclerosis.
•The study further clarifies the cardiovascular risk of poor oral health and hygiene.

Paddock C. Scientists uncover bacterial mechanism that links gum disease to heart disease. published in the journal Infection and Immunity. September 14, 2015.

Published in Diabetes in Control September 15

Diabetics benefit from moderate red wine with meals

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Red wine consumption has been linked with improved cardiovascular outcomes in patients. The results of a new study published in the Annals of Internal Medicine suggest that these benefits extend to diabetic patients as well. In addition, moderate consumption did not cause liver damage.

The study was a two-year randomized clinical trial that took place in Israel. The study included 224 randomly assigned subjects who were all following the Mediterranean diet without caloric restriction. All subjects were alcohol-abstaining and had well-controlled type 2 diabetes. The subjects were randomly assigned to drink 150 mL of mineral water, white wine, or red wine with dinner for the duration of the trial.

The study authors looked at two primary outcomes: lipid profiles and glycemic control. Patients in the red wine group saw their HDL cholesterol levels significantly increased by 2.0 mg/dL (95% CI, 1.6 to 2.2 mg/dL; P < 0.001) and their apolipoprotein(a)1 levels increased significantly by 0.03 g/L (95% CI, 0.01 to 0.06 g/L; P = 0.05). Furthermore, their total cholesterol to HDL cholesterol ratio decreased by an average of 0.27 (95% CI, -0.52 to -0.01; P = 0.039). Red wine also reduced the number of components of metabolic syndrome by 0.34 more than the mineral water group (95% CI, -0.68 to -0.001; P = 0.049).

Red and white wine patients who were slow ethanol metabolizers (carriers of the ADH1B*1 alcohol dehydrogenase allele) had significant improvements in fasting plasma glucose, insulin resistance, and hemoglobin A1c. Fast ethanol metabolizers (patients homozygous for ADH1B*2) did not see these benefits.

There were no changes among the groups for blood pressure, adiposity, drug therapy, symptoms, or liver function. This suggests that moderate wine with dinner will not cause liver damage. There was one quality of life improvement that patients in both wine groups saw over the mineral water drinkers: increased sleep quality (P = 0.040). Overall, this study suggests that moderate red wine intake in well-controlled diabetics in conjunction with a healthy diet is safe and improves lipid profiles. Patients who are slow ethanol metabolizers may also have glycemic control benefits.

This trial did have several flaws though. Patients and researchers both knew which group consumed what beverage. This could potentially have influenced the increased sleep quality reported in both wine groups. Perhaps more importantly, all the patients in this study were already adhering to a healthy Mediterranean diet, which is suspected to improve heart health itself and had well-controlled diabetes. Further studies are needed to elucidate the mechanisms and extent of ethanol’s benefits, especially in patients who are not well-controlled or consuming ideal diets. Patients should be cautioned that red wine consumption is not a substitute for heart or diabetes medicine.

Practice Pearls:
•In a study of well-controlled diabetes patients adhering to the Mediterranean diet, 150 mL of red wine with dinner improved lipid profiles.
•Patients who were slow ethanol metabolizers had improvements in glycemic control in both the red wine and white wine groups.
•The red wine and white wine groups did not have differences in liver function with the mineral water group.

Gepnyer Y, Golan R, Harma-Boehm I, et al. Effects of Initiating Moderate Alcohol Intake on Cardiometabolic Risk in Adults With Type 2 Diabetes: A 2-Year Randomized, Controlled Trial. Ann Intern Med. 2015 Oct 13. Epublished ahead of print. doi: 10.7326/M14-1650.

From Diabetes in Control October 15