Dietary gluten in pregnancy is related to an increased risk of type one diabetes in the child

Adapted from Antvorskov JC et al. Association between maternal gluten intake and type one diabetes in offspring. BMJ 22 September 2018

This research was based on a study of Danish women’s food frequency questionnaires completed 25 weeks after their first pregnancies ended. The incidence of diabetes in the children was then noted from January 1996 till May 2016 from the Danish Registry of Childhood and Adolescent Diabetes. After certain exclusions had been made over 63,500 were analysed.

The mean gluten intake per day was 13g ranging from 7g to more than 20g per day.

The incidence of diabetes in the child increased proportionately according to gluten intake. The women who had  20g or more intake had double the type one diabetes in their offspring compared to those who ate 7g or less.

As type one diabetes has risen seemingly inexplicably over the last few decades, there has been a lot of consideration into possible environmental triggers. Gluten is a storage protein found in wheat, rye and barley.  In animal studies, a wheat free diet in the mother has been found to dramatically reduce the incidence of diabetes in the child.

It has been suggested that gluten can affect gut permeability, gut microbiotica and cause low grade inflammation.

Although there is this association between gluten and type one diabetes it could be that other factors, for example the advanced glycation products from the baking process, that are to blame.  Unwanted additives to grain  could also be a factor eg mycotoxins, heavy metals, pesticides and fertilisers.

Mothers who eat a lot of gluten may similarly feed their children a lot of gluten. They also may pass gliadin from wheat into the breast milk.

Although this research suggests that high amounts of gluten may be problematic in pregnancy, further research will need to be done before dietary recommendations are likely to be changed.

Wondering if fasting is worth the pain?

Carbohydrate restriction regulates the adaptive response to fasting
S. Klein and R. R. Wolfe 
Department of Internal Medicine, University of Texas Medical Branch, Galveston.
The importance of either carbohydrate or energy restriction in initiating the metabolic response to fasting was studied in five normal volunteers.

The subjects participated in two study protocols in a randomized crossover fashion. In one study the subjects fasted for 84 h (control study), and in the other a lipid emulsion was infused daily to meet resting energy requirements during the 84-h oral fast (lipid study).

Glycerol and palmitic acid rates of appearance in plasma were determined by infusing [2H5]glycerol and [1-13C]palmitic acid, respectively, after 12 and 84 h of oral fasting.

Changes in plasma glucose, free fatty acids, ketone bodies, insulin, and epinephrine concentrations during fasting were the same in both the control and lipid studies.

Glycerol and palmitic acid rates of appearance increased by 1.63 +/- 0.42 and 1.41 +/- 0.46 mumol.kg-1.min-1, respectively, during fasting in the control study and by 1.35 +/- 0.41 and 1.43 +/- 0.44 mumol.kg-1.min-1, respectively, in the lipid study.

These results demonstrate that restriction of dietary carbohydrate, not the general absence of energy intake itself, is responsible for initiating the metabolic response to short-term fasting.

Metformin improves side effects of steroid treatment

From Pernicova I et al. Lancet Diabetes Endocrinol 25 Feb 2020

Long-term glucocorticoids, most often prednisolone, are prescribed for about 3% of European adults. The long term exposure can raise metabolic, infectious and cardiovascular risks.

This was a trial of 53 adults who had inflammatory disease treated with prednisolone but did not have diabetes, who were given either 12 weeks of metformin or a placebo.

The dose of prednisolone was 20mg or more for the first month and then 10mg or more for the next 12 weeks. The dose of metformin given was up to 850mg three times a day.

What improved:

Facial fatness was in seen in 52% of the placebo group but only 10% in the metformin group.

Increased blood sugar was seen in 33% of the placebo group and none of the metformin group.

There was improvement in insulin resistance, beta cell function, liver function, fibrinolysis, carotid intima media thickness, inflammatory parameters and disease activity severity markers in the metformin group.

There were fewer cases of pneumonia, moderate to severe infections and all causes of hospitalisation for adverse events in the metformin group.

What got worse:

Diarrhea was worse in the metformin group.

What didn’t get better:

Visceral to subcutaneous fat ratio was unchanged between the groups.

My comment: Looks like a clear winner for adding metformin to long term prednisolone treatments.

Take your blood pressure pills at night

Adapted from BMJ Take anti-hypertensives at night says study. Susan Major 2 Nov 19

Taking your blood pressure medication at night gives you better blood pressure control and nearly halves cardiovascular events and deaths compared to taking them in the morning.

This study was done on nearly 20 thousand patients with an average age of 60 for six years. The reductions in events included cardiovascular death, heart attacks, coronary artery revascularisation, heart failure and stroke.

Professor of cardiovascular medicine at Sheffield, Tim Chico said, ” As taking medications at bedtime poses little risk there is enough evidence to recommend that patients consider taking their medication at bedtime.”

Bariatic surgery doubles congenital abnormalities in babies

From BMJ 30 Nov 19

A retrospective analysis from Quebec of 2 million pregnant women who had delivered between 1989 and 2016 showed that offspring of women who had become pregnant after bariatric surgery had roughly twice the risk of birth defects compared to women who were not obese or who were obese but had not had surgery.

The defects were mainly heart and musculoskeletal defects.

My comment: This short report does not go into possible causes for this. You would have thought that the risk would have been reduced to the level of the non obese women. I wonder if nutritional issues have a part to play as after bariatric surgery long term vitamin supplements need to be taken. 

Don’t rush to hospital with a burn

It’s now barbeque season, and with this in mind, new research has shown that the best first aid for a burn is to run cool water over the affected skin for at least 20 minutes.This should be started as soon as possible after the event.

In a study of 2,500 children, those given the full 20 minutes treatment were less likely to need hospital admission and half as likely to need a skin graft.

 

My comment: In my childhood my mother put butter on burns. Don’t do this! It does not work. The area that I notice most people have burns is on their wrists on the thumb side. This is from removing hot dishes from the oven and brushing their arm against the hot door or oven sides. Of course you are carrying a hot, full dish of food, so can’t pull back as fast as you would like. Although many of us then run our arms under a tap, it would be a good idea to do this for longer than it takes for the immediate pain to subside. You can also use oven gauntlets in preference to gloves or folded up tea towels as these are longer in the arm. 

BMJ 2019; 367:1572

Over eating and drinking is causing liver damage in one in five young adults

Adapted from Abeysekera KWM et al. Prevalence of steatosis and fibrosis in young adults in the UK: a population based study. Lancet Gastroenterology and Hepatology. 2020 Jan 15.

A new study highlights just how common liver disease is becoming in young adults in the UK. One in five had fatty liver, known as steatosis. One in 40 had fibrosis, also known as cirrhosis. And the average age was only 24.  These results show how harmful unhealthy eating and drinking habits can be.

Subjects for the study were recruited through the Avon Longitudinal Study of Parents and Children. Transient elastography and controlled attenuation parameter scores were used for assessment of steatosis and fibrosis.

Steatosis was found in 20.7% of the participants and this was severe in 10% of those affected. Being overweight or obese was the main factor for causing this after adjusting for alcohol intake, social class and smoking.

Fibrosis was reported in 2.7% of the participants. This risk was significantly higher in those who also had an alcohol problem or addiction and already had steatosis after adjusting for smoking and social class.

The authors conclude that the obesity epidemic is affecting the current and future health of young adults by increasing their risk of non alcoholic steatohepatitis related cirrhosis, hepatocellular carcinoma, and complications of metabolic syndrome.

 

Metformin reduces oesophageal cancer

Adapted from Wang QL et al. American Journal of Gastroenterology 1st January 2020

Metformin users were at a lower risk of developing oesophageal squamous carcinoma than non metformin users.

A growing number of observational studies have shown that metformin reduces overall cancer risk and a few specific cancer types such as colon, rectal, breast and stomach.

A population based cohort study included over 400,000 metformin and an equal number of non metformin users who were matched by age and sex.

There were 3.5 cases of oesophageal cancer in the metformin group per 100,000 person/years and 5.3 in the non metformin group. This finding was true for men, women and those in their sixties.  The odds ratio was 0.68 for metformin use.

Monthly lifestyle counselling improves heart outcomes

Adapted from Intensive lifestyle counselling and cardiovascular outcomes in patients with diabetes. September 14 2019  Diabetes in Control by Nour Salhab. Pharm. D from Zhang et al Lifestyle counselling and long term clinical outcomes in patients with diabetes. Diabetes Care. Aug. 2019.

Intensive lifestyle counselling has been shown to improve blood sugars in the Look AHEAD study but it was too underpowered to show any significant conclusions regarding cardiac outcomes.

This new study looked at patients with both type one and type two diabetes who had HbAICs over 7% and were over the age of 18. Lifestyle counselling involved diet, exercise and weight loss management. The goal was to get the patient’s HBAICs under 7%.

19,293 patients were involved and the mean HbAIC at the start was 7.8%. My comment: This is a very good average compared to British diabetics! 

The mean counselling sessions were 0.46 a month and the study ran for 5.4 years.

HbAIC reduced by 1.8% for patients who got monthly counselling and 0.7% for those who got less than monthly counselling.

The primary end point was time to the first episode of angina, heart attack or stroke or death from any cause. There was a small but significant decrease in the group who had monthly counselling compared to three monthly counselling.

The counselling occurred in academic centres so may not be applicable to other settings.

My comment: This level of counselling is much more intensive than can probably be delivered in the NHS population. The blood sugar levels in the patients was also much better to start with compared to the UK population. 

A little care goes a long way

Adapted from Annals of Family Medicine 2019 doi:10.1370/afm.2421

People diagnosed by their GP with type two diabetes had a 40-50% lower mortality rate over the next ten years if they experienced their GP and practice nurses as empathetic during the year after diagnosis, compared to those who considered that their primary health carers had low empathy.

This study looked at 879 patients recruited from 49 GP practices in the east of England.

My comment: The first year is when patients get their head round the fact that they have a long term condition that could affect how long they will live and the quality of the life they have left. At diagnosis many are willing to look at lifestyle changes. Encouraging them, helping them, and helping them set appropriate goals makes a good difference to a person’s ability to change their daily routines. If you are newly diagnosed and don’t get on with your health care providers for any reason, then maybe a change of provider makes sense in the light of this research.