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Posts Tagged ‘diabetes’

A full year after we reported it here (and several years after initially being reported in the literature), mainstream media has finally picked up the story about gastric bypass surgery for the definitive treatment of diabetes.   The story made all of the heavies; the Washington Post, the Wall Street Journal, and the Los Angeles Times.

Unfortunately, all of these outlets seem unaware of the existing literature in this area – these results while encouraging, are not surprising.  Similar results have been demonstrated in several other (but smaller) studies for the past ten years, which led to previous recommendations (last summer) for the adoption of gastric bypass surgery as a first-line treatment for diabetes in obese patients.

The publication of two new studies showing clear benefits for diabetics undergoing bariatric surgery has brought this news to the forefront.  In both of these studies, diabetic patients were able to stop taking oral glycemics and insulins after surgery within days..

As this front page story from the New York Times notes – these results do not apply to the more widely marketed ‘lap-band.’  This comes to no surprise to dedicated followers at Cartagena Surgery, who have been reading articles on this topic since our site’s inception in late 2010.

You heard it here first.  For more information on this topic, see our tab on Diabetes & Bariatrics under the ‘surgery’ header. We’ve included a small selection from our archives here.

Bariatric surgery headlines – August 2010

Gastric bypass surgery gets the international federation of diabetes approval.

Gastric bypass as treatment for diabetes

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I met with Dr. Asad Khan for lunch at a recent medical conference.  Dr. Khan and I are old friends from our training days back in West Virginia.  I was a new nurse practitioner (still wet behind ears) in Cardiothoracic Surgery, and Dr. Khan was completing his last year of his nephrology [kidney] fellowship. At that time, West Virginia University had a robust cardiothoracic surgery program and performed cardiac surgery on a large ESRD (end-stage renal disease) population [patients on dialysis.]

As I worked with the soft-spoken Karachi-born physician, I came to rely on him frequently for his excellent clinical judgement and insight.  Now that I have the chance to sit down and catch up with Dr. Khan – I take the opportunity to find out more about his current practice as the Director of six Davita hemodialysis centers in and around College Station, Texas, and to ask Dr. Khan to talk about ways people can prevent and treat renal insufficiency / kidney damage.

Cartagena Surgery: Wow.. It’s good to see you.  It’s been a long time.  Would you tell me more about your current practice?

Dr. Khan:  As I mentioned previously, I am now the Director of several dialysis centers in Texas.  These free-standing clinics have a lot of expanded programs that are very different from the hospital dialysis program [where we trained.]

Cartagena Surgery:  Earlier you mentioned something about bedtime dialysis.  Would you tell me more about that?  I know dialysis can be exhausting – it sounds like an interesting program.  Do patients show up in their pajamas?

Dr. Khan:  Actually, despite the fact that Davita’s nocturnal dialysis programs exist nationwide, not very many patients chose this option.  But it is a good alternative to standard daytime programs, because it allows patients to maximize their time.  By dialysing at night while sleeping, patients are free to pursue their normal activities during the day; work, school or other activities of daily living without interrupting their daily schedule for dialysis.  And yes, some of them do arrive in their pajamas.

Cartagena Surgery:  What steps can people take to protect their kidneys, and prevent chronic kidney disease?

Dr. Khan:  Well the best way people can prevent kidney damage is to prevent and treat the two main diseases that cause kidney damage; namely hypertension and diabetes.   By remaining physically active, eating healthy foods (and following a low- salt diet), and maintaining a healthy weight (BMI less than 25) people can reduce the risk of developing both of these harmful diseases.

Even if they already have high blood pressure or diabetes – these basics tenets of health & wellness can help people control these conditions with the addition of medications.  We know through decades of cardiovascular research such as the Framingham Study and the more recent NHANES surveys that hypertension and diabetes play a big role in the development of coronary disease.  But the results regarding the role of hypertension and kidney disease were surprising.

Several recent cardiac risk studies showed that not only did kidney disease accelerate the development of coronary artery disease (CAD) and dramatically increase the risk of cardiac death – but that even minor elevations of blood pressure over time were correlated with greatly increased risk of chronic kidney disease (CKD).

Most people don’t realize that even a ten point increase in baseline blood pressure (from 130 systolic to 140 systolic) translates to kidney disease/ kidney failure occurring SEVEN years earlier.

Studies also show that one of the most important ways to prevent on-going kidney disease is medication compliance.  When people take the anti-hypertensive medications as prescribed, there is a significant reduction in the development and advancement of chronic renal disease.

Cartagena Surgery:  You mentioned the role of diabetes and hyperglycemia in the development of kidney disease.  Would you explain a bit more about that?

Dr. Khan:  As you know, diabetes is diagnosed relatively late in this country.  The average person has already had diabetes for over seven years prior to receiving a formal medical diagnosis, and this doesn’t even include the vast numbers of people who are told that they have ‘pre-diabetes’ but aren’t given any medications to control it.  All of these people – these undiagnosed people – ALREADY have kidney damage.  I know you give a lecture on the role of diabetes and CAD – and  talk about the importance of treating and preventing proteinuria.  This proteinuria, or protein in the urine is a sign of the damage that is already occurring in this population.   While the detection of this condition is relatively easy – from a simple urine sample – it’s often overlooked.  By the same token, the treatment of this condition, using relatively inexpensive medications called ace-inhibitors (or ARBS) is essential, but not often stressed to patients.  Many of these patients don’t even know WHY these medications have been prescribed for them.  If you don’t know why you are taking something – then you are less likely to take it regularly.

[cartagena surgery: as we discussed in a previous post – these medications are a type of blood pressure medication, but are often used for other reasons such as the prevention of diabetic nephropathy – aka diabetes-related kidney disease.]

Cartagena Surgery: well, thank you for all your time today, I know you have to get back to your conference – you’ve given us some great information. 

Readers – if you have questions or want to know more, (or if you have kidney disease) you can contact Dr. Khan directly.  (He also an internal medicine specialist – and was a primary care physician for several years before becoming a nephrologist, so he’s an expert at treating hypertension, diabetes and other chronic medical conditions besides kidney disease.)

Dr. Asad Khan, MD

Bryan Kidney Center Inc

2110 E Villa Maria Rd

Bryan, TX  77802

 (979) 402-3152

In related news –

a new article published in Medpage Today reports that aggressive treatment for pre-diabetes (including a hemoglobin A1C of 5.7% ) is more cost-effective in long run (by preventing costly diabetes-related complications.)

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Ironically, just a few days ago we were talking about lung cancer and discrimination against patients with lung cancer in the post, The Pearl Ribbon.   Now a new article published in Physicians Money Digest,  suggests that one of the latest trends is discrimination against the obese.  As obese people can tell you – this discrimination has always existed in some form, and from all avenues in society including medicine.

However, this new trend consists of doctors avoiding accepting obese patients in their practice, mainly to avoid the increased workload related to obesity related complications.  That’s right – as discussed in the article by Laura Mortokowitz, which I have re-posted below -some doctors are avoiding caring for obese patients because they do not want to provide care to patients with higher risks of certain complications – diabetes, heart disease, etc.

As someone who works in heart surgery, I can see this issue from both sides.  As many of you know – I am sometimes disheartened by the sheer overwhelming volume of disease (due to diabetes) and the amount of suffering involved for my patients.  I am particularly distressed at times when I see the amount of preventable suffering, and damage my patients experience from not controlling their blood pressure, checking their glucose or taking their medications.  But my patients are already sick – that’s why the are seeing a heart surgeon.  So, I often mourn these lost opportunities to prevent disease (heart attacks, strokes etc.), and I can see how primary care providers, and other providers may feel emotional fatigue and frustration at times.

But, other the other hand –  not every obese person is a stroke or heart attack waiting to happen.  Many of these people can be helped – by education, counseling or even bariatric surgery.  If these people are aggressively followed and cared for, risk reduction can help prevent catastrophic complications – by managing medical conditions that may develop – with aggressive cholesterol control, blood pressure management, etc.

Lastly, medicine is not an exact science – while risks may be greatly increased in many obese people – it is not a guarantee.. Just as it’s a false assumption that all overweight people are sedentary (ie. ‘fat and lazy’), not all overweight people will develop any or all of the complications we’ve discussed before.   But it is guaranteed that these obese patients will suffer, if this trend continues and more and more doctors shun them.

But my door is always open.

By Laura Mortkowitz, Wednesday, November, 16th, 2011
A recent move by Florida ob-gyn physicians to begin turning away overweight patients on the grounds that they were too risky might be the beginning of a new trend. According to Michael Nusbaum, MD, FACS, the health reform bill’s Accountable Care Organizations essentially de-incentivize physicians from taking on morbidly obese patients.
As they stand now, ACOs look at quality measures and they base reimbursements on complications. Doctors already know that a high complication rate will mean less money, and obese patients are considered high-risk patients by definition.
“Under the current bill, the Accountable Care Organizations are looking strictly at outcome measures, so unless that changes I don’t see the perception by physicians changing toward who they’re going to want to treat and who they’re not going to treat,” says Nusbaum, the Medical Director at The Obesity Treatment Centers of New Jersey.
This new practice is not something that would have occurred in the past for two reasons: one, physicians might be reluctant to treat an obese patient, but it was rare to turn them away completely; and two, it was very rare to treat a morbidly obese patient a couple of decades ago.
However, over the last 10 years, the percentage of the population that is overweight has increased dramatically. Today, close to 70% of the population is at least overweight, according to data from the Centers for Disease Control and Prevention. Even more concerning, is the fact that pediatric obesity has tripled over the last 20 years.
“Is the health care system to take care of morbidly obese patients? I would argue that it’s not,” Nusbaum says. “Pretty clearly it’s not. The problem with the health care system is that it lacks infrastructure.”
Most machines and tables can only hold up to 350 pounds, and any patients that exceed that weight might not even be able to get treated at a hospital that doesn’t have the equipment to handle an obese patient. According to Nusbaum, it should be a requirement that hospitals are equipped to treat any morbidly obese patient.
“Nobody is even talking about it,” he says. “Everybody is afraid to even talk about this.”
And it doesn’t seem as if new health laws are encouraging to the treatment of obesity. Under the new health bill’s Essentials Benefit Package, bariatric surgery is not covered because morbid obesity is being considered a poor lifestyle choice. As a result, insurance companies “have become emboldened to say, ‘Well, we’re not going to cover it either,’” Nusbaum says.
In New Jersey, Blue Cross/Blue Shield has 14 insurance policies, and eight of them do not cover bariatric surgery at all.
“What you’re seeing happening is a change in attitude to bariatric surgery and in my opinion a discrimination against those people who have weight issues,” Nusbaum says.
However, there was a rather positive turn of events in Michigan, where bariatric surgery will be covered in 2012 after it was dropped for all of this year.
“They noticed that while they were making money in the short term — they were saving money — they were losing more money by not taking care of these patients,” Nusbaum says. “[The patients] were getting sicker. It was very short sighted.”

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As reported at Medpage – the latest Diabetes estimates were released by the International Diabetes Foundation (IDF) this week at the EASD (European Association for the Study of Diabetes) as the news was even grimmer than predicted just a few short months ago: Researchers now estimate 366 million people HAVE diabetes worldwide – greatly surpassing all previous estimates – causing 4.6 million deaths every year.

Leading physicians at this year’s conference continued to stress the importance of Early diagnosis and treatment of Diabetes to prevent serious complications (and death).  This is something we’ve talked about here at Cartagena Surgery – the need for early diagnosis, prompt treatment and aggressive risk reduction.

Preventing diabetes remains a key element of this strategy, but one which we are failiing miserably.  Simple dietary changes such as reducing the consumption of sugar-laden beverages appears to be impossible to implement as we are hopelessly entrenched in American diets (and Indian, Chinese and other nations – as they adopt our fast-food habits).

As many of my face-to-face patients already know, one of the best lines of defense is also one of the oldest in our arsenal of oral anti-glycemics.  For all of my patients who have heard my metformin spiel in person, feel free to skip ahead.  As we’ve discussed in lectures and presentations – Metformin, that simple drug from the 1970’s (one of my $4 faves) has so many side benefits – and the potential cancer benefits are encouraging.. [what’s not encouraging  – is the difficulty getting patients to take their medications regularly – even humble Metformin which is one of the safest, most effective – (clinically proven!) and cheapest diabetes drugs available.]

*as many readers and patients know – this is the one topic where even Cartagena Surgery gets overwhelmed at times.. There is just so much disease/ disability and suffering but it seems like no one is listening or cares enough about themselves to change their habits.**  Please – dear readers – prove me wrong, and write me letters to let me know how you are taking control of your diabetes and your health..

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If you remember, in my blogs about the health benefits of coffee (here, here and here) as well as a previous blog on the health risks related to sugary soft drinks, I promised to bring you more information about our favorite devil-in-disguise, Starbucks.  (I will give them credit for making this information easily accessible, even if it is tiny print.)

I call Starbucks this because on initial consideration..

Coffee: Good!      Big super-sized coffees: Even Better!  and look – a Regular black coffee, no cream, no sugar, any size (including their super-size Venti) is only FIVE calories..

Coffee loaded with cream and sugar:  Not so good.  (How bad is it – you ask? or you should be asking)

well once you start drinking their specialty drinks (and I must be the only person who drinks regular coffee anymore) – that’s when you get into trouble.. so knowing that everyone loves their super-sized coffees, I’ve skipped right to the “Venti” calorie counts..

Cafe Latte with skim milk: 170 calories

Cafe Latte with 2% milk:  240 calories and NINE grams of fat

Cafe Mocha (without whipped cream in these examples)

with nonfat-milk: 280 calories

with 2% milk: 340 calories and 10 grams of fat (that’s a reasonable sized salad with a vinaigrette dressing and maybe cheese or not-so-healthy add-ons)

Vanilla (or other flavored) Lattes:

with non-fat milk: 250 calories (all sugar)

with 2% milk: 320 calories and eight grams of fat

Even the ‘skinny’ lattes have 160 calories..

The specialty espressos are no better (in fact – some are worse, as you will see)

Carmel macchiato:

 with non-fat milk: 240 calories, one gram of fat

with 2% milk:  300 calories, 8 grams of fat

White chocolate mocha (without whipped cream – I think they were afraid of putting the whipped cream calorie counts on this brochure)

with non-fat milk: 450 calories and 7 grams of fat (that’s a decent meal’s worth of calories!!)

with 2% milk: 510 calories and fifteen grams of fat – for a ‘coffee’ !  (I think you can see here how a few of these coffees a week can certainly pile on the pounds.)

Now, if you think that’s no big deal – go on over to www.Fitday.com (and don’t lie to yourself about your exercise) and put in your information (they have free accounts) and figure out how much walking, jogging or aerobics you have to do to equal out that one coffee.. Hint: It’s a lot more than you’d think – or we wouldn’t be in this mess!

The other items on the menu (including the teas) are no better once you pile in the milks, sugars and other garbage.

What about coffee with soy milk?  Isn’t that supposed to be good for you?  Well, in theory, perhaps.. But actually, for some products, the fat and calorie counts for Starbucks products with soy milk go way, way up.

Cafe Latte with soy milk: 220 calories, 6 grams of fat

Cafe Mocha (no whipped cream) with soy milk: 320 calories, 8 grams of fat

Vanilla Latte with soy milk: 300 calories with 6 grams of fat

Carmel macchiato with soy milk: 280 calories with 6 grams of fat

White chocolate mocha: (no whipped cream): 490 calories, 12 grams of fat

all of this – for a little eye-opener in the morning – time to stick with the regular coffee!

In fairness – I am not picking on Starbucks, they are just the most popular.  Even the local 7 – 11 has a coffee flavored slushy drink that is packed full of sugar and calories.  Of course it’s delicious – but really, that’s besides the point.  Obesity and diabetes are just a mathematical formulation – and it seems many of us are failing the subject entirely.

The Lancet, a well reputed medical journal has just published a series on Obesity, and the numbers are frightening – researchers estimate that by 2030 – (really not that far away) over 165 million Americans will be obese.

The costs of this to society are enormous, and frankly staggering.  Bloomberg published a story estimated an additional 66 BILLION dollars PER year in obesity related costs.  That isn’t just a threat to our health as a nation, but our financial future.

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In a new story by Megan Brooks over at Medscape, “Gastric Bypass Has Advantages in Less Obese Patients” – the latest news from an Orlando conference confirms what cartagena surgery fans already know; that gastric bypass surgery is a viable and effective option in moderately obese patients (particularly patients with diabetes.)  This is encouraging in the continuing battles between patients and insurance providers.

As we’ve said before – it’s important to treat obesity definitively before patients develop serious and potentially life threatening complications such as diabetes and hypertension, and the sequelae related to this (coronary artery disease, ischemic limbs, stroke, renal failure).

In order to treat this effectively and aggressively, we shouldn’t wait until the problem is out of control.  A patient shouldn’t have to be 600 pounds for the doctors to consider bariatric surgery – we should help people before that.

I’ve re-posted the article below. [italics are mine.]

Gastric Bypass Has Advantages in Less Obese Patients

June 16, 2011 — There are benefits to performing laparoscopic Roux en Y gastric bypass (RYGB) in obese patients who have a body mass index (BMI) below 35 kg/m2, according to a study reported at the American Society for Metabolic and Bariatric Surgery 28th Annual Meeting in Orlando, Florida.

Among patients who underwent the surgery, the rates of remission of type 2 diabetes were higher in those with a BMI below 35 kg/m2 than in those with higher BMIs. The “less obese” patients also lost a greater percentage of their excess weight in the first year after surgery than their peers with higher BMIs.

“The study raises the question of whether early referral leads to better outcomes,” John Morton, MD, director of bariatric surgery at Stanford Hospital & Clinics at Stanford University in Palo Alto, California, and an investigator with the study, noted in a conference statement.

“Bariatric surgery is tremendous for weight loss, but its other big advantage is improving medical problems, in particular type 2 diabetes,” Dr. Morton noted in an interview with Medscape Medical News.

Outcomes Better at Lower BMI

Current guidelines from the National Institutes of Health recommend that gastric bypass be reserved for patients who have a BMI of 35 kg/m2 or higher and an obesity-related condition, or who have a BMI of at least 40 kg/m2.

Dr. Morton’s team took a look back at 980 patients who underwent laparoscopic RYGB at their institution between 2004 and 2010. “We ask patients to lose some weight before surgery because it’s a good way to make sure they are committed to the program, and it makes the surgery a little bit safer,” Dr. Morton said. “Therefore, we had some patients below a BMI of 35 kg/m2 at the time of surgery.”

For the analysis, the patients were grouped according to their presurgery BMI: below 35 kg/m2, 35 to 39.9 kg/m2, 40 to 49.9 kg/m2, and above 50 kg/m2.

“When we examined type 2 diabetes resolution rates, we found that those with the lowest BMI had the best resolution rates,” Dr. Morton reported. All 12 patients with a BMI below 35 kg/m2 no longer had type 2 diabetes after surgery, whereas patients with higher BMIs had remission rates of roughly 75%.

We are looking to entertain the idea that maybe obese patients should have the option of surgical intervention for their diabetes sooner rather than later because, as the study showed, as the BMI gradient goes up, your diabetes resolution rate with surgery goes down,” Dr. Morton said.

The researchers also found that patients with a BMI below 35 kg/m2 who had the surgery had lost more of their excess weight at 3, 6, and 12 months than patients with a higher BMI.

After 1 year, the patients with BMIs below 35 kg/m2 had lost 167% of their excess weight. By comparison, those with a BMI from 35 to 39.9 kg/m2 had lost 112%, those with a BMI from 40 to 49.9 kg/m2 had lost 85%, and those with a BMI above 50 kg/m2 had lost 67% of their excess weight.

Laparoscopic RYGB also took less time in patients with the lowest BMI (170 minutes) than in those with higher BMIs (177 minutes, 182 minutes, and 194 minutes, respectively).

Reevaluation of BMI Guideline Needed

In an interview with Medscape Medical News, John David Scott, MD, a bariatric surgeon at Greenville Hospital System University Medical Center in South Carolina, who was not involved in the study, said that “the BMI level of 35 is an arbitrary standard set many years ago that certainly needs to be reevaluated.”

“Most of the evidence that has been coming out lately has shown not only a positive weight loss benefit for that particular group, but also positive overall health effects,” he added. “In particular, the resolution of diabetes is astounding. To be able to offer patients a surgical cure for their type 2 diabetes is very exciting,” Dr. Scott said.

Dr. Morgan has disclosed no relevant financial relationships. Dr. Scott reports receiving speaker fees from WL Gore & Associates and fellowship support from Ethicon Endo Surgery.

American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting: Abstract P-54. Presented June 16, 2011.

In other news, from the same conference (Megan Brooks reporting) – patients undergoing successful bariatric surgery (with resultant weight loss) had decreased rates of heart attacks and stroke.
“Bariatric Surgery good for the Heart”

June 16, 2011 — Bariatric surgery and the significant weight loss it achieves can  significantly reduce the incidence of myocardial infarction (MI), stroke, and premature death, according to a study presented at the American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting in Orlando, Florida.

“In addition to weight loss, bariatric surgery offers patients a whole host of health benefits, including a reduction in the risk of major cardiovascular problems,” study presenter John David Scott, MD, a bariatric surgeon at Greenville Hospital System University Medical Center in South Carolina, noted in an interview with Medscape Medical News.

“There is a long line of studies showing that bariatric surgery affects cardiovascular outcomes,” Dr. Scott noted. “The difference between our study and other studies is that we looked at major cardiovascular events (heart attack and stroke), whereas a lot of other studies have looked at risk for these events.”

The researchers reviewed data on 9140 morbidly obese individuals, 40 to 79 years of age, who had undergone bariatric surgery (n = 4747), gastrointestinal (GI) surgery (n = 3066), or orthopedic surgery (n = 1327) in South Carolina between 1996 and 2008.

The GI group (hernia or gallbladder) and the orthopedic group (joint replacement) served as control groups because of their similar health and risk profiles, the authors note.

All patients had similar a health status before surgery and no history of MI or stroke. The patients were followed to the end points of first MI, stroke, transient ischemic attack, or death.

“Life-table analysis demonstrated significantly improved event-free survival in the bariatric patients within 6 months of surgery, and it was sustained over time,” the authors note in the meeting abstract.

Five years after surgery, an estimated 85% of bariatric surgery patients were free of MI and stroke, compared with 73% of orthopedic patients and 66% of GI patients, the researchers say.

At 10 years, event-free survival was 77% in the bariatric group, 64% in the orthopedic group, and 62% in the GI group (P < .05).

After adjustment for differences in age and relevant comorbidities, bariatric surgery was an independent predictor of event-free survival. Compared with orthopedic surgery, the hazard ratio (HR) was 0.57 (95% confidence interval [CI], 0.47 to 0.69); compared with GI surgery, the HR was 0.35 (95% CI, 0.29 to 0.43).

“Important Area of Emerging Study”

In a statement from the ASMBS, Anita Courcoulas, MD, MPH, director of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center, Pennsylvania, who was not involved in the study, said: “The impact of bariatric surgery on both cardiovascular risk factors and events is an important area of emerging study.”

The findings, she said, are “suggestive of an association between undergoing bariatric surgery and improved event-free survival. This relationship needs to be further explored with prospective clinical data, but still highlights the importance of understanding the broader impact of bariatric surgery on long-term outcomes.”

In an interview with Medscape Medical News, John Morton, MD, director of bariatric surgery at Stanford Hospitals & Clinics at Stanford University in Palo Alto, California, who was also not involved in the study, made the point that “obesity affects every single body part and if you are able to affect the weight, you’re going to help other medical problems — particularly the ones that are inflammatory-mediated.”

“Obesity is really an inflammatory-mediated disease, and stroke, cardiac risk, and even diabetes are now being recognized as inflammatory-related. With weight-loss surgery, direct markers of inflammation go down and, more importantly, these diseases get better,” Dr. Morton explained.

Studies have shown that morbidly obese patients can lose 30% to 50% of their excess weight in the first 6 months after surgery, and 77% as early as 1 year after surgery.

American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting. Abstract PL-105. Presented June 15, 2011.

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We are going to switch gears a little bit today.  Instead of our usual discussions relating to surgery, surgical procedures and medical (surgical) tourism – we are going to spend some time talking about Diabetes in a series of posts.

In my role as a nurse practitioner, I became surprisingly familiar with diabetes.  I say surprisingly because as an acute care nurse practitioner specializing in surgery, I never expected to have to fill the role of family doctor or family practitioner.  However, the prevalence of diabetes in this country (USA) is so incredibly pervasive, particularly undiagnosed diabetes – that every health care provider should become well-versed in the treatment of diabetes, and diabetes related conditions.

Diabetes = Coronary Artery Disease!

Working in heart surgery also means that patient education is critical for diabetics, particularly newly diagnosed diabetics[1].   Now one of the things that complicates the issue significantly is providers’ hesitancy to label people as “diabetics” due to insurance implications and all sorts of other issues.  So a lot of primary care providers are dancing around the issue, soft-pedaling the news and generally ignoring or under treating this disease.   As someone who treats the complications of these decisions everyday, (heart attacks, ischemic limbs, infections, etc.) I vehemently disagree with this strategy.

 How can I get my patient to take this seriously, and treat their diabetes aggressively, if I don’t?

Some of the things we need to do to treat Diabetes effectively are:

1. To detect it (estimates place the number of undiagnosed Americans at greater than 17 million people)

The best way to detect Diabetes is to use the newer generation of tests, specifically the hemoglobin A1c.  This test looks at the average glucose levels over several months.  This helps to rule out false elevations from acute illness, injury or surgery.  It also prevents under diagnosing from the tendency to ‘ignore’ one or two abnormal glucose readings.  “Oh, his glucose was 160; we’ll check it again in three months.”  That’s three more months that the patient goes untreated.  (Despite being abnormal, many of the older guidelines ignore readings of less than 180, and require two or more readings for diagnosis.  (Normal glucose is 70 -105 or 110, depending on source.)

2.   To treat it – using SAFE and effective medications.

Many people would be surprised to know that the best drugs for treating Diabetes are the older (cheaper) medications such as metformin (Glucophage) which has been used since 1977.  It’s readily available on many $4.00 pharmacy plans.

Many of the newer, fancier drugs (Avandia is the best known) have been linked to serious complications such as myocardial infarctions (or heart attacks).  Many of the other new drugs have no side benefits[2].  A good prescriber finds the best combination of medications to have the most beneficial effects, limited negative side effects and is cost effective.  Why treat five problems with twenty drugs (expensive with multiple drug interactions) when you can do it with four medications?

3. Finally – and most importantly, lets do more to prevent it.  Let’s all stop soft pedaling, and speak frankly and truthfully with our patients.  Diabetes is a horrible disease, so let’s stop pretending it isn’t.

Instead of trying to be the good, likable provider who turns a blind eye to health destroying behaviors – we need to be direct, and address these issues.  A glucose of 200 isn’t ‘good enough’.  Testing glucose once in a while isn’t ‘good enough’.    You may not like me when I tell you to absolutely, completely stop drinking soft drinks[3] (NEVER drink another soft drink), or to get out and start walking, (or a myriad of other things we’ll talk about) but if that helps reduce your risk of diabetes, prevents diabetic complications and ultimately lengthens and improves your quality of life – then that is a trade-off I am willing to make.


[1] In my previous practice, all patients had a hemoglobin A1c as part of their pre-operative laboratory work-up.  Up to 25% of the patients having heart surgery were found to have elevated A1c levels, and were undiagnosed diabetics.

[2] Just as medications have side effects – many drugs such as metformin have side benefits.   One of the side benefits of metformin is the protective blood vessel effect – patients that take metformin have fewer amputations than patients on other anti-diabetic drugs. Metformin has also been shown to be an important tool in the treatment of certain cancersSeveral research studies show that the use of metformin has been linked to decreased tumor growth in breast cancers.

[3] I am planning for a future article to discuss this in-depth, and present the research.  Please contact me if there is other Diabetes related content you would like to see.

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