Tuesday, May 25, 2021

Prediabetes Can Shorten a Person's Life

The CDC estimates that 88 million adult Americans have prediabetes. And most persons with prediabetes are not aware that they have the condition. The CDC’s diabetes prevention program trial that took place between 1996 and 2001 showed that lifestyle intervention could reduce the risk of progression from prediabetes to diabetes by 58% compared to people with prediabetes who were receiving usual care. And a recent study suggests that prediabetes can shorten a person’s life.

The investigators studied 2844 subjects to determine how the “years of potential life lost,” or YPLL, for persons with prediabetes compared with the YPLL of persons with diabetes and the YPLL of persons with normoglycemia. The subjects were male and female with an average age of 52. From 1976 to 1982 the participants were given oral glucose tolerance tests. Also, anthropometric measurements were made during the study period.

The researchers concluded “that adjusted life expectancy of middle-aged individuals with prediabetes” was two years shorter than the life expectancy of individuals with normoglycemia, and the expectancy of individuals with diabetes was eight years shorter than individuals with normoglycemia.  The researchers went on to say that “YPLL was greater in women, younger individuals (less than 16 year) and in those with moderate overweight.” The researchers indicated that both the intrinsic risk associated with prediabetes and the risk of progressing from prediabetes to diabetes could be factors impacting lifespan.

The study confirms the importance of addressing prediabetes, especially in middle-aged adults. Healthcare providers should endeavor to work with at-risk prediabetes patients. They should work with the patients, if appropriate, to get them into a diabetes prevention program. These programs can delay or prevent diabetes which could increase the lifespan of a person with prediabetes. Delaying or preventing diabetes can not only increase a person’s lifespan. It could also lower the person’s healthcare costs.


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Sunday, May 23, 2021

Predicting Bariatric Surgery Outcomes

Bariatric surgery is the most effective obesity treatment in use today. However, the surgery does have associated failures and related side effects. Therefore, it would be useful to have methods in place to predict the bariatric surgical success so that risks could be weighed against the probable outcomes. This would benefit patients and physicians. A recent study was done to determine if bariatric surgery outcomes could be predicted.

The two most common forms of bariatric surgery are gastric bypass and sleeve gastrectomy. For many years gastric bypass surgery was the most popular form of weight loss surgery. However, more recently, sleeve gastrectomy has gained in popularity because it is an effective weight loss method, and it is typically accompanied by less severe  side effects than gastric bypass. At any rate, in general, bariatric surgery predictive methods focus on gastric bypass and sleeve gastrectomy.

Indeed, there are failures in bariatric surgery. Researchers in Sweden concluded that in the case of laparoscopic gastric bypass surgery, there is “a marked and sustained weight loss with improvement of obesity-related comorbidity in most patients. However, 23% met at least one definition of surgical treatment failure…” So, predictive methods would be useful.

A recent retrospective study looked at 760 patients who underwent bariatric surgery. Approximately 66% of the patients experienced sleeve gastrectomy and approximately 34% of the patients experienced gastric bypass surgery. Linear regression methods were used to predict the weight loss after one year following the surgery. Twelve predictive models were developed and used to predict the weight loss for each patient.

The investigators determined that while "predicted BMI had reasonable correlation with observed values, none of evaluated models presented acceptable accuracy. All models tend to overestimate the outcome.” Therefore, more research is needed to improve bariatric surgical outcomes predictions.

With good predictive models for bariatric surgical outcomes, healthcare providers could improve the selection of bariatric surgical candidates. For those candidates that are not expected to have good outcomes, another, less expensive and risky weight loss method could be recommended. And for those candidates who are likely to have positive outcomes, the surgery could proceed. This would lower risks and save money, benefiting both the patient and physicians.


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Wednesday, April 28, 2021

Lifestyle Intervention for Prediabetes Treatment in the Elderly

Using prediabetes definitions, the Diabetes Prevention Program (DPP) trial showed that lifestyle intervention could delay or prevent diabetes for those persons experiencing prediabetes. While the primary outcome of the trial was diabetes and not a reduction of cardiovascular risk, cardiovascular risk factors such as high blood pressure and high cholesterol were monitored.  However, a recent study did shed light on the effect of lifestyle intervention on cardiovascular risk for older persons.

Indeed, one of the primary goals of the study was to determine if reversion to normal glucose from prediabetes could reduce cardiovascular risk in older people. The study was done by investigators in Germany. The investigators used results from the KORA S4 study which was a population-based health survey. The age range of the participants in the study was 55 to 74 years of age.

To determine prediabetes, the investigators used the following definitions of prediabetes: For HbA1c, they used a range of 5.7 to 6.4 percent. For oral glucose tolerance tests, the investigators used a range of 140 to 199 mg/dl. The investigators found that by lowering the weight and waist circumference, an older person could increase his or her “probabilities of returning to” normal blood glucose and maintaining normal blood glucose.

The investigators concluded that “in older adults, even moderate weight reduction contributes to reversion from prediabetes to normoglycaemia and to maintaining normoglycaemia." This conclusion supports the results from the original DPP trial. In fact, the results from the trial indicated that lifestyle intervention is, in general, more effective in prediabetes treatment for persons over 60 years of age than for younger persons.

Healthcare providers should consider these results and use the results in consultations with older patients who are diagnosed with prediabetes. The efforts could be beneficial to the patients, and the effort might even improve an organization’s financial position by giving the healthcare organization a strong platform for negotiating contracts with insurers.


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Sunday, April 25, 2021

The Mediterranean Diet May Slow the Progression of Chronic Kidney Disease

It is estimated that chronic kidney disease (CKD) is experienced by 15% of the US adult population. The disease is serious and can lead to kidney failure and death. And approximately 90% of those who have CKD don’t even know they have the disease. It has been suggested by some that diet and exercise can be important elements in CKD treatment.

Estimated glomerular filtration rate or eGFR is a frequently used measurement in diagnosing CKD. Lower than normal eGFR measurements often indicate some reduction in kidney function. And one study has shown that the Mediterranean diet and increased physical activity can be effective in slowing the decline of eGFR and, thus, kidney function degradation.

Researchers in the study looked at 6719 overweight or obese subjects. The subjects ranged in age from 55 to 75 years of age. And each subject had metabolic syndrome, which is defined by a set of conditions, happening together, that can increase a person’s risk of heart disease, stroke and type 2 diabetes. The set of conditions typically include “increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.”

The subjects in the above-mentioned study were randomly assigned to one of two groups. Some subjects were randomized to the group receiving an intensive weight loss intervention consisting of a Mediterranean diet and increase physical activity. And the other subjects were randomized to a group receiving normal care. The primary outcome was the change in eGFR after one year. The study was called the “PREvencion con Dieta MEDiterrianea-PLUS” or PREDIMED-PLUS trial.

At one year, there was a 40% lower degradation in eGFR for the intervention group compared to the group receiving usual care. These results showed that diet and exercise are important in CKD treatment. The researchers concluded that “the PREDIMED-Plus lifestyle intervention approach may preserve renal function and delaying CKD progression and overweight/obese adults.”

So, healthcare providers should consider counseling patients on the benefits of diet and exercise in the treatment of CKD. The providers should give specific advice on the kind of diets and exercise that are conducive to slowing the progression of CKD.


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Saturday, March 27, 2021

Laparoscopic Roux-En-Y Gastric Bypass vs Laparoscopic Sleeve Gastrectomy for Weight Loss, Type 2 Diabetes and Comorbidities

More and more U.S. citizens are obese, and many U.S. citizens have been diagnosed with type 2 diabetes. In general, bariatric surgery is used to treat obesity. However, some forms of bariatric surgery can lead to type 2 diabetes remission. Two types of bariatric surgical methods in use for weight loss are laparoscopic roux-en-y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). These two surgical methods are often considered to be treatment options for type 2 diabetes. And while LRYGB may be the most effective treatment for weight loss, a recent study indicates that LSG is as effective as LRYGB for type 2 diabetes treatment.

LRYGB and LSG are similar in some ways: For example, both surgeries "modify the upper gastrointestinal tract anatomy." And this characteristic may make LRYGB and LSG more effective at weight loss and type 2 diabetes management than some other forms of bariatric surgery. However, depending on the disease condition, there are differences in the outcomes associated with the two surgical methods.

The study, mentioned above, showed that both LRYGB and LSG were equally effective in type 2 diabetes remission, obstructive sleep apnoea and quality of life (QoL) improvement. However, LRYGB produced better remission in hypertension, but was associated with a higher complication rate.

Specifically, the researchers concluded that "Although LRYGB induced greater weight loss and better amelioration  of hypertension than LSG, there was no difference in remission of T2DM,  obstructive sleep apnoea, or QoL at 5 years. There were more complications after  LRYGB, but the individual burden for patients with complications was similar  after both operations."

It is also important to remember that there may be contraindications and other potential issues to consider when deciding on the appropriate form of bariatric surgery. The possibility of reintervention should be kept in mind, for example. Indeed, one study demonstrated that "[LSG] has significantly lower risk of reintervention in all categories studied when compared with RYGB at 5-year follow-up."

So, depending on the desired treatment outcome, the healthcare provider and the patient should work together to make the appropriate decision when it comes to bariatric surgery. 


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Tuesday, March 23, 2021

A Need for a More Restrictive Diabetes Prevention Program Inclusion Criteria

Prediabetes affects approximately 88 million adults in the U.S. And most of these people don’t know they have the condition. So, to some extent, there is a lack of treatment for prediabetes because of a lack of knowledge. Further, the inclusion criteria used to refer individuals to a National Diabetes Prevention Program (National DPP) may need some modification. The current National DPP inclusion criteria may not be restrictive enough to realize the optimum value from the prediabetes treatment.

A recent study, using simulation methods, looked at how placing restrictions in the National DPP inclusion criteria, similar to those used in the DPP trial, may improve the value of the DPP services.

The researchers, performing the study, concluded that the three-year risk of developing type 2 diabetes in the National DPP eligible population ranges from 1% to more than 90%. This means that the National DPP treats individuals who have very little risk of progressing to type 2 diabetes.

The researchers suggested that comparing the original DPP trial inclusion criteria with the National DPP inclusion criteria shows a loosening of National DPP restrictions. For example, in the DPP trial, the criteria did not include HbA1c measurements, whereas the National DPP does. The National DPP also allows participation from individuals starting at 18 years of age, where the DPP trial's starting age was 25. The National DPP allows participation by persons who had gestational diabetes, where the DPP trial did not.

To be included in the DPP trial, an individual had to have "Impaired glucose tolerance (fasting plasma glucose 95-125 mg/dL and 2hr plasma glucose 140-199 mg/dL)" These criteria are more restrictive than the criteria used by the National DPP.

The researchers determined that being more restrictive in the National DPP selection process would be more beneficial. Specifically, the researchers concluded that “Targeting active diabetes prevention to patients at highest risk could improve health outcomes and reduce costs compared to providing the same intervention to a similar number of patients with pre-diabetes without targeted selection."

Primary care organizations, offering Diabetes Prevention Programs, might want to place more restrictions on candidates for DPP programs. This might improve outcomes and lower cost.


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Friday, February 26, 2021

HbA1c May be Superior to FBG in Diagnosing Prediabetes

 FPG (fasting plasma glucose), HbA1c, and the OGTT (oral glucose tolerance test) are used in determining if someone has prediabetes or diabetes. Indeed, all three measures are employed by the National Diabetes Prevention Program (National DPP) to determine eligibility for the National DPP. So, these blood based tests are important, and understanding which one of the three measurements is the most valid in assessing prediabetes and diabetes is a worthwhile undertaking. One recent study has focused on determining the validity of the measurements.

The OGTT is considered by some to be the gold standard for diagnosing diabetes and prediabetes. However, it is not always practical to perform the test, and results are not always reproducible. Therefore, while the OGTT is considered to be more accurate for some high risk patients than the HbA1c test, the HbA1c test is widely used since it is more practical and it is considered to be a valid test. So, determining how the test stacks up against the FPG test is high on the priority list.

In the above mentioned study, 201 patients were looked at. And the investigators concluded that “HbA1c is a more sensitive test compared to FPG in the diagnosis of DM. Prospective studies with broad participation at national and international levels are needed to redefine HbA1c cut-off points for the diagnosis of DM and prediabetes." When this is done, "it will be possible to revise the diagnostic guidelines accordingly.”

While work needs to be done in the area of defining the cut-off points for HbA1c to improve the diagnostic value of the measurement, the above study does seem to indicate that engaging in additional research to define the Hba1c cut-off points is worth the effort.

Healthcare providers should pay attention to this study and other studies related to diabetes and prediabetes measurements. If we can increase the validity of the measurements already in place, this will lead to improved assessment of prediabetes and diabetes. This endeavor will help providers deliver more accurate assessments to patients, enabling patients to take the appropriate actions.


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