Wednesday, May 29, 2019

The Importance of Physical Activity in Controlling Blood Glucose

Type 2 diabetes has been a dangerous chronic illness in the US for a number of years. And now, prediabetes is gaining attention because treating prediabetes can delay or avoid type 2 diabetes. Approximately 30 million US residents have type 2 diabetes, and more than 84 million US residents have prediabetes. A healthy diet and physical activity are seen as the tools to use in the fight against type 2 diabetes and prediabetes. And one study has suggested that a too-low level of physical activity is likely to lead to type 2 diabetes.

Investigators at McMaster University in Ontario, Canada looked at the effects of walking 1,000 steps or less a day for two weeks. The investigator focused, specifically, on overweight, elderly individuals, and found that the “sudden inactivity [of walking less than 1000 steps a day] caused blood sugar to spike in the pre-diabetic adults, and it stayed high even after people returned to normal levels of activity.”

It was reasoned that the limited physical activity meant that the body didn’t use as much of the glucose as it might have with more activity. And as glucose stays in the blood, more insulin is created to remove the glucose. Eventually, tissues become less sensitive to insulin, making it more difficult for insulin to remove the glucose from the blood.

The above study demonstrates the importance of physical activity. Some experts recommend 10,000 steps each day. Others argue that the number is less than 10,000 steps. However, based on the above study, the number of steps is probably at least a thousand.

Physical activity is needed to help regulate blood glucose. Physical activity, along with diet and lifestyle change, is an important tool in the fight against prediabetes and type 2 diabetes. And clinicians should always make physical activity a part of any type 2 diabetes and prediabetes treatment plan.

Saturday, May 25, 2019

Biomarkers Can Predict Type 2 Diabetes Two Decades Before the Diagnosis

For some time, diabetes has been a dangerous chronic illness in the US. And the disease has received a lot of attention. In recent years, prediabetes has also received a great deal of attention. Prediabetes has been given attention because it is often the forerunner of type 2 diabetes. Approximately 30 million Americans have type 2 diabetes, and over 84 million Americans have prediabetes. But luckily, there are biomarkers that can predict type 2 diabetes as much as two decades before a person is diagnosed with the disease. And there are proven lifestyle changes and medications that can help one delay or avoid type 2 diabetes.

In a Japanese study, 27,392 adults who did not have diabetes were studied. They were looked at between the years of 2005 and 2016. At the start of the study, blood glucose and weight were measured. During the 11 year period, 1067 of the subjects developed type 2 diabetes. The researchers concluded that since “the vast majority of people with type 2 diabetes go through the stage of prediabetes, [the researchers'] findings suggest that elevated metabolic markers for diabetes are detectable more than 20 years before its diagnosis.”

Another study, done in Sweden, also demonstrated that risk factors for type 2 diabetes exist up to 20 years before one is diagnosed with the disease. The study followed 296,439 individuals who were nondiabetic for 20 years. During that time about 10% of the study subjects received a diagnosis of type 2 diabetes. In looking at the biomarkers, BMI, triglycerides, and fasting glucose, it was revealed that those persons who had these biomarkers at higher than normal levels were at a higher risk of type 2 diabetes, about 20 years later.

Fortunately, intensive lifestyle intervention (ILI) and medication can help avoid or prevent type 2 diabetes after one is diagnosed with prediabetes. In one study where 422 adults in Southern California were examined, it was found that ILI or ILI in combination with medications can help individuals avoid type 2 diabetes. The researchers concluded that “after an average follow-up period of almost 3 years, the annual rate of transitioning to full diabetes was 4.1% among people who received only lifestyle therapy, and 1.7% in patients on two diabetes drugs.”

Further, “none of the patients on three diabetes drugs develop diabetes.” Patients in the study who received prescriptions for two medications were on metformin and another diabetes medication. And patients on three medications were on metformin and pioglitazone and another diabetes medication, including exenatide and liraglutide.

So clinicians should be aware that predicting diabetes is possible. And delaying or avoiding type 2 diabetes is also possible. Knowing this can help clinicians better treat patients who are at high risk of type 2 diabetes.

Monday, April 29, 2019

Community Health Workers Can Deliver Patient-Centered, Evidence-Based, Value-Based Services

Today, healthcare is striving to practice medicine that is patient-centered, evidence-based, and value-based. What this means is that the patient is to be viewed as the most important person in the room, the providers are to use evidence-base medicine, and the patient gets a lot for his or her money. And it has been shown that community health workers (CHWs) can play an important role in delivering services associated with patient-centered, evidence-based, value-based medicine. A set of these services is related to the Centers for Disease Control and Prevention (CDC) sponsored Diabetes Prevention Program (DPP).

Patient-centered means providing medical care “that is focused on the patient or consumer of health care rather than on health care providers, financiers, insurers, or institutions.” “Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information.” And value-based medicine is where “providers, including hospitals and physicians, are paid based on patient health outcomes.” One way of looking at value-based medicine is patient-outcomes divided by cost (patient-outcomes/cost).

According to the CDC, “a community health worker (CHW) is a frontline public health worker who is a trusted member or has a particularly good understanding of the community served.” CHWs may work as coaches in some community organizations. These organizations include YMCA’s, churches and other community groups that offer community services. One of the important services is the Diabetes Prevention Program or DPP.

The DPP is based on a study done between 1996 and 2001. In the study, it was concluded that type 2 diabetes can be avoided or delayed in an individual who follows a healthy diet, engages in purposeful physical activity, and changes his or her lifestyle to include healthy activities. After the completion of the study, it was determined that lifestyle CHWs working as coaches could successfully motivate individuals to engage in DPP related activities.

Furthermore, healthcare providers are encouraged to refer patients to DPP organizations that have satisfied DPP standards established by the CDC.
 

Wednesday, April 24, 2019

Treating Prediabetes in a Primary Care Setting Can Be Effective

According to the  Centers for Disease Control and Prevention (CDC), prediabetes is a chronic disease. The disease affects 84% of the adults in the U.S. And having prediabetes raises the risk for a number of diseases, including diabetes heart disease stroke and other problems. The CDC established the Diabetes Prevention Program (DPP) in 2012 to address prediabetes. The DPP is based on a study, funded by the National Institutes of Diabetes and Digestive and Kidney Disease (NIDDK). The study was done and reported on between 1996 and 2002. The services delivered in the DPP are being delivered in community organizations, including YMCAs and churches. However, the DPP services can be delivered in a primary care setting.

A study was done in New Zealand using a nurse-led diabetes prevention program in a primary setting. One hundred fifty-seven patients with prediabetes were enrolled in the six month study. Two groups were formed for the study, where 85 of the participants comprised the intervention group and 72 participants were in the control group. HbA1c, BMI and waist circumference were analyzed, and it was found that these parameters decreased in the intervention group while they increased in the control.

While the differences in outcomes between the intervention group and the control groups were not statistically significant, the study showed that the DPP program can work well in a primary care setting. The program was acceptable to the patients and the nurses.

Another study confirmed the effectiveness of wellness coaching programs addressing prediabetes in a primary setting. A survey was used to evaluate the experiences of participants in a 12 week prediabetes program in a primary setting. Sixty-three percent of the participants completed the survey. And the participants were very satisfied with the program.

This means that primary care practices might want to focus on integrating prediabetes treatment procedures into the practices. The integration could reduce the number of patients who eventually experience type 2 diabetes. 
 

Friday, March 29, 2019

Using Mobile Devices to Treat Prediabetes

Type 2 diabetes is a serious disease in today's society. And the disease is well known. A less well known disease in prediabetes. Prediabetes is a chronic disease that affects 84% of the adults in the U.S. Someone with prediabetes has a higher risk for diabetes heart disease, stroke and other conditions. The  Centers for Disease Control and Prevention (CDC) established the Diabetes Prevention Program (DPP) in 2012 to address prediabetes. The DPP program is based on a study, funded by the National Institutes of Diabetes and Digestive and Kidney Disease (NIDDK). The study was performed and reported on between 1996 and 2002. The services delivered in the DPP can potentially be replicated with the use of mobile devices.
For those with prediabetes, the DPP study demonstrated that lifestyle modification, diet and increased physical activity can reduce the risk of diabetes by 58%. The DPP study was done using highly trained individuals to deliver the one-on-one counseling. These highly trained individuals included registered dietitians, and healthcare workers with master's degrees. These trained individuals worked one-on-one with the DPP participants.
The one-on-one program was subsequently translated into a group based program. Delivering the program in a group-based setting was less costly than the one-on-one program. And delivering the program using mobile devices, such as smart phones, may be a way to make the program even less costly than the group-based program. A mobile-delivered DPP has been looked at in a study.
The study was a "24-week virtual DPP with human coaching through a mobile platform." The investigators concluded that "A fully mobile DPP intervention resulted in significant weight loss and high engagement during the maintenance phase, providing evidence for long-term potential as an alternative to in-person DPP by removing many of the barriers associated with in-person and other forms of virtual DPP."
Healthcare providers might want to take note of the mobile DPP study results. Treating prediabetes is important. And using the most cost efficient delivery method will benefit the patient.

Monday, March 18, 2019

Lorcaserin, the Anti-Obesity Drug

Over the past several years, four anti-obesity drugs have been approved by the FDA. These drugs are: contrave, which is a combination of bupropion and naltrexone; qsymia, which is a combination of phentermine and topiramate; saxenda, which contains the active ingredient liraglutide that is used to treat type 2 diabetes; and lorcaserin which has the brand name Belviq. In this post, we are going to focus on lorcaserin.
In the past, some weight loss drugs were found to be harmful. Fen-phen was one of those drugs. Phentermine, which is one of the components of qsymia, was also one of the components of fen-phen. Fenfluramine was the other component drug. Fen-phen was taken off the market in the 1990s. While fen-phen was effective for weight loss, the drug was found to cause heart related problems. Fenfluramine was deemed the culprit in the combination, while phentermine was not. So fenfluramine was removed from the market.
To some extent, because of the problems fen-phen caused, all anti-obesity drugs are subjected to intense skepticism and research regarding their potential side effects. However, lorcaserin has been shown to lead to weight loss, while creating no cardiovascular safety issues. Further, the drug has been shown to have positive metabolic effects.
In a one year study of 12,000 overweight and obese subjects, a portion of the participants were randomly assigned to one group that was given a 10 mg dose of lorcaserin per day, while the other participants were assigned to a placebo group. And 38.7% of the participants in the lorcaserin group lost at least 5% of their body weight compared to 17.4% of the placebo group. The cardiovascular events in the lorcaserin group were no higher than the cardiovascular events in the placebo group.
Furthermore, when used in combination with phentermine, lorcaserin can lower food cravings during short-term energy restrictions, as shown in a study consisting of 235 participants during a 12 week treatment session.
Also, lorcaserin has been found to improve metabolic parameters. In one study, it was found that lorcaserin can lower fasting glucose and A1c with or without weight loss. And in another study, investigators concluded that lorcaserin "improved multiple cardio metabolic parameters through both weight loss dependent and independent mechanisms.”
Therefore, lorcaserin should be considered by practitioners when they are treating a patient who is overweight or obese, or who experiences overweight or obesity related metabolic diseases. 

Wednesday, February 27, 2019

Confronting Prediabetes

Although not commonly listed as a chronic disease, prediabetes is a chronic disease that carries many risks. It raises the risk of type 2 diabetes, and it raises the risk of stroke and heart attack. According to the CDC, 84% of the adults in America have prediabetes. Further, most people who have prediabetes are not aware that they have the condition. It is estimated that 90% of people who have prediabetes don’t know they have prediabetes. The sooner prediabetes is diagnosed, the faster prediabetes treatment can start. So methods to predict prediabetes and to treat prediabetes can benefit at least 1/3 of the US adult population.

One study done in China indicated that it may be possible to isolate individuals in lean populations who may be at a high risk of prediabetes and diabetes. During a six year period, approximately 800 children and adults were studied who eventually developed prediabetes or diabetes. Seven hundred and thirty seven of the studied subjects were lean at baseline and during the follow-up phase.

The investigators concluded that even if they are lean, individuals whose fasting glucose is in the top tertile of the normal fasting glucose range have a higher risk of prediabetes and diabetes. And this is often overlooked because individuals are not overweight or obese.

Furthermore, when prediabetes is diagnosed in a patient, the condition is typically not addressed by the clinician. In one study, only 22.8% of patients with prediabetes between 2013 and 2015 indicated that they were treated for the disease. Treatment for prediabetes commonly includes lifestyle change. But patients with hyperlipidemia or obesity were more likely to be treated with lifestyle change than those with prediabetes.

Therefore, based on the above studies, physicians and other practitioners should pay more attention to patients who are close to the upper limits of the normal fasting glucose and other glucose measurement guidelines. Further, practitioners should treat prediabetes more aggressively in the future. By taking the appropriate actions, practitioners can do a lot to reduce the number of patients who eventually get type 2 diabetes.

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