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Posts Tagged ‘preventing complications from diabetes’

New recommendations out of a recent conference in Austria as reported by the Heart.org.  This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org,  in”Case made for metabolic bariatric-surgery eligibility criteria,”  new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs.  Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes.  That’s because the majority of type II diabetic patients are  overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes.  Many of the surgeons previously interviewed for numerous projects here at Cartagena Surgery were involved in several early studies on the effects of surgery in moderate overweight patients with diabetes.

More interestingly, researchers at the conference are also suggesting possible gastric bypass procedures for patients with ‘pre-diabetes’ or patients with an hemoglobin A1c greater than 5.7 % but less than 6.5% (6.5% is the cut off for diagnosis of diabetes.)

This is wonderful news – it means committees and such are finally getting around to following all of the research that has been published and presented over the last ten years..  But then it just one more important step…

Call it by its name

So I have my own suggestion to doctors and researchers – and it’s one that I’ve made been – a nomenclature change.  We need to stop calling it “pre-diabetes”, because the name is a falsehood – and leads everyone (patients, nurses and doctors astray.)

– Greater than 95% of patients with ‘pre-diabetes’ will develop diabetes – so without a drastic intervention (far beyond diet and exercise)  it’s pretty much a certainty.

– Many of the devastating complications of diabetes develop during this so-called pre-diabetic period.

– Doctors are now recommending surgical treatment to cure this “pre” disease state.

So….  

if almost everyone who has ‘pre-diabetes’ gets diabetes, and it’s already causing damage PLUS we now recommend a pretty radical lifestyle change (surgical removal of most of the stomach) —> that sounds like a disease to me.  Call it early diabetes, call it diabetes with minimal elevation of lab values, but call it what it is….Diabetes..

This is critical because without this firm diagnosis:

insurance won’t pay for glucometers, medications, diabetic education, dietary counseling (or surgery for that matter).  That’s a lot of out-of-pocket expenses for our patients to bear, for something that is treated like a ‘maybe’.

– patients (and healthcare providers) alike won’t take it seriously..  Patients won’t understand how crucial it is to take firm control of glucose management, patients won’t be started on preventative regimens to prevent the related complications like renal failure, heart disease and limb ischemia.

– Patients may not receive important screening to prevent these complications – and we already know that at the time for formal diagnosis (usually SEVEN years after initial glucose derangements are seen) – these patients will already have proteinuria (a sign of kidney disease), retinopathies, vasculopathies and neuropathies..

I work with providers every day, and the sad fact is that too many of them (us) shrug their shoulders and say – yeah – he /she should eat better, get more exercise, shrug.. But they don’t treat the disease – they don’t start checking the glucose more often, they don’t start statin drugs, the don’t screen for heart disease and they don’t consult the specialists – the diabetic educators, the nutritionists, the endocrinologists – and yes, the bariatric surgeons…

Chances are if your doctors and your nurses don’t take it seriously; and don’t make a big deal out of it – and don’t talk to you, at length about what “pre-diabetes” IS and what it really means for your life and your health –

then neither will you.

For related content:  see the Diabetes & Bariatric tab

the Weight of a Nation: the obesity epidemic

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Gastric bypass to ‘cure’ diabetes goes mainstream

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Busy day today – I am giving a talk with the local Mended Hearts chapter as part of “Heart Month.”  Mended Hearts is a patient-run organization/ support group for people who have had heart attacks, stents or heart surgery.  It’s a place where people can go for encouragement, education or support after a life-changing cardiac event.  I’ve worked with Mended Hearts in the past, so I was pleased when they invited me to give one of my favorite talks this weekend. (I’ve been giving variations on this talk since 2008).

(Some people might consider it a bit ironic that I am giving a lecture on prevention to a group of people who have already been diagnosed with CAD – but we are also talking about overall wellness/ and preventing future events.)

It’s one of my favorite lectures because it’s an informal style presentation – so I encourage listeners to participate in the discussion – and ask questions.  We also review a case study at the end – where we have a bit of role reversal as I invite listeners to be the NP for a minute and devise treatment strategies for the imaginary patient..  (and my audience usually does a great job – which just proves how powerful a motivated person can be when it comes to healthcare.. If all people were like my audiences, people would be a lot healthier.)   I’ve included a quick summary of my lecture here for interested readers.  (Just the basics – for more specific or detailed information such as information on lipo-proteins, see your doctor.)

Aggressive Risk Factor Reduction 

When talking about healthcare and risk factor reduction, we need to use measurable, and achievable goals.. No ‘nebulous’ statements like ‘improve blood pressure’, or ‘lose weight.’  Instead – we give concrete, and specific goals based on the most relevant and up-to-date clinical evidence.

1.  Hypertension / Blood pressure control – normal B/P is 110/ 70.   National guidelines for diabetics recommends systolic blood pressure less than 130, and a diastolic b/p less than 90.

2.  Hyperlipidemia/ dyslipidemia

LDL cholesterol less than 70

HDL greater than 50

– statin therapy recommended for all diabetics.
3.  Microaluminuriasmall protein particles found in urine.  This is an early indicator of on-going kidney damage.   All diabetics should be on an ace-inhibitor (the ‘prils’ such as lisinopril, fosinopril, enalapril).

These medications will help SLOW the damage, but the best treatment is TIGHT glucose control.

4.  Hyperglycemia – (not diabetes)

Hyperglycemia causes damage.  Period.  This includes so-called ‘pre-diabetes’ and gestational diabetes (see slides for more information.)

– Check your hemoglobin A1c, and control your glucose

– Fasting and post-prandial (2 hours after meals) glucose testing.  Remember that post-prandial readings will rise earlier in the course of the disease, so if you re only testing in the mornings – you might miss crucial information needed for your treatment.

– Currently ONLY metformin and insulin therapies have been shown to have long-term benefits.  (The twenty – plus other medications may make ‘the numbers’ look pretty – but there is little long-term evidence to support their use.

Previously, we skirted around to test ALL of our cardiothoracic patients as part of a screening protocol – new guidelines recommend screening of all hospital patients.

5. Endothelial inflammation – hyperglycemia ‘encourages’ endothelial inflammation and vascular damage (it’s the hallmark of the disease) so the best way to treat this is with anti-platelet therapy such as a baby aspirin (ASA).  Recent literature suggests that ASA may do more harm than good in some people, so check with your doctor..

There’s a lot more information to go over (it’s a 45 minute talk) so I’ve decided to post my lecture slides here for anyone to use, but I do ask that people please give appropriate credit.  Cardiac Complications of Diabetes ppt slides.

More references:

Australian treatment guidelines

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