Power of Prevention Vol. 1 Issue 2 by AACE

Power of

revention® Vol. 1, Issue 2

Diabetes

Extraordinary Journeys

O r d i n a r y P e o p l e,

Prediabetes The

5 Pound

Challenge

America’s Largest Healthcare Epidemic

Pg.13

How Small Weight Loss can have a Big Impact

ASK THE EXPERT

Pg.24

 Cinnamon & Diabetes  Red Yeast Rice & Cholesterol

Diabetes Disaster Plan

A r e Yo u P r e pa r e d ?

Special Section :

M e n ’ s PH e a l t h Power of

revention®

Power of P revention® Magazine

Table of Contents Letter from the president . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 The power of voice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Letters and E-mails from Readers Ordinary people, Extraordinary journeys . . . . . . . . . . . . . . . . . . 4 The Changing face of diabetes management . . . . . . . . . . . . . . . .

Complications of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

prediabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What You Need to Know, A Doctor’s Diagnosis

Weight management and type 2 diabetes . . . . . . . . . . . . . . . . . . . 12

Ordinary Pople, Extraordinary Journeys Patient Stories Pamela Lawson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

David Mendosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tarin Jackson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Big picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Type 2 Diabetes in Kids and Adolescents Type 1 diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 What is it? How do you manage it? Putting your disaster plan into action . . . . . . . . . . . . . . . . . . One Doctor’s Story

Testosterone and men’s Health - new insights . . . . . . . . . . . . . . 22 Endocrine Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Breaking news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Kidz Zone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Prevention on the streets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Step Inside The Family Van

Power of P revention® Magazine

Hossein Gharib, MD, MACP, MACE

Daniel S. Duick, MD, FACP, FACE

steven m. petak, md, jd, face, fclm

jeffrey r. garber, MD, FACP, FACE

President, ACE

President Elect, ACE

President, AACE

President Elect, AACE

donaLD A. BERGMAN, MD, FACE Chair, ACE Power of Prevention® Committee

Donald C. Jones

Chief Executive Officer, AACE

Bryan Campbell

Sarah Senn

Public & Media Relations Assistant

Travis Cheatham

Director of Public & Media Relations

Director of Graphic Design

Greg Willis

Ryan Emmons

Public & Media Relations Coordinator

Graphic Artist

Power of Prevention® Magazine, published by the American College of Endocrinology (ACE), the educational and scientific arm of the American Association of Clinical Endocrinologists (AACE), is dedicated to promoting the art and science of clinical endocrinology for the improvement of patient care and public health. Designed as an aid to patients, Power of Prevention® Magazine includes current information and opinions on subjects related to endocrine health. The information in this publication does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate. The ideas and opinions expressed in Power of Prevention® Magazine do not necessarily reflect those of the Publisher. ACE is not responsible for statements and opinions of authors or the claims made by advertisers in the publication. ACE will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to products, drugs, or services mentioned herein. Material printed in Power of Prevention® Magazine is protected by copyright. No part of this publication may be reproduced or transmitted in any form without prior written permission from Power of Prevention® Magazine, except under circumstances within “fair use” as defined by US copyright law. © 2008 ACE. Power of Prevention® Magazine is published by the American College of Endocrinology, 245 Riverside Avenue, Suite 200; Jacksonville, FL 32202 • 904-353-7878 • Fax 904-353-8185 • E-mail info@aace.com, Web site www.aace.com. AACE is a professional medical organization with more than 6,000 members in the United States and 84 other countries. Founded in 1991, AACE is dedicated to the optimal care of patients with endocrine problems. AACE initiatives inform the public about endocrine disorders. AACE also conducts continuing education programs for clinical endocrinologists, physicians whose advanced, specialized training enables them to be experts in the care of endocrine diseases, such as diabetes, thyroid disorders, growth hormone deficiency, osteoporosis, cholesterol disorders, hypertension and obesity. ACE is a scientific and charitable medical organization dedicated to promoting the art and science of clinical endocrinology for the improvement of patient care and public health.

Letter From

The President

Dear Reader, I am very excited to present to you the second issue of Power of Prevention® Magazine. This magazine is published by the American College of Endocrinology. Endocrinologists are the experts in the endocrine system, more commonly referred to as glands. Thyroid disease, diabetes, osteoporosis, and polycystic ovarian syndrome are all examples of conditions where an endocrinologist is the trained expert. The articles on disease management and care in this magazine were all written by endocrinologists who are members of the American Association of Clinical Endocrinologists. In our last issue, we focused on the thyroid. That’s the butterfly-shaped gland in your neck that controls your body’s thyroid hormone levels. If you have too much thyroid hormone, you can experience an accelerated heart rate, hair loss, protrusion of the eyes, and other symptoms. On the other hand, people who don’t have enough thyroid hormone can experience fatigue, weight gain, brittle nails, and more. The issue featured detailed descriptions of several thyroid conditions, as well as the Neck Check™, a simple test you can do at home to screen for thyroid irregularities. If you would like to order a copy of the Thyroid issue of Power of Prevention® Magazine, send an e-mail to archives@powerofprevention.com. This month’s magazine is focused on the largest and most costly healthcare epidemic facing America today: diabetes. More than 24 million Americans are living with diabetes, and another 57 million are living with a condition known as prediabetes. That means more than one in four Americans are living with one of these conditions. When you include the friends, family members, co-workers, and others impacted by the lives of these individuals, it is safe to say nearly everyone in this country is impacted by the diabetes epidemic. But the impact doesn’t stop there. The economy is on the forefront of everyone’s mind these days. According to the Centers for Disease Control and Prevention (CDC), the cost of diabetes care in 2007 was in excess of $174 billion. The costs are not limited to just treating diabetes, but also to treating the many complications associated with diabetes like kidney disease, heart problems, amputations, eye problems, and more. Also, patients with uncontrolled diabetes are often unable to perform their jobs at the highest level, causing a loss in productivity. Diabetes is an insidious disease that can exist for years in a patient with no physical symptoms. In fact, many diabetes patients already have one or more complications by the time they are diagnosed. Once a complication of diabetes exists, it is very difficult to reverse the damage that has already been done. There is no cure for diabetes; but there is hope. Over the past decade, a variety of new medications and treatment options have become available for patients. And while the diabetes population continues to grow, the need for newer and safer treatments grows with it. In this issue, we focus on the changing face of diabetes management. We examine the several different types of diabetes, including type 1, type 2, and prediabetes. We also look at the large number of treatment options available, and explain the differences in how each works. We take a look at the many complications associated with the disease, and take a look at one of the most alarming trends in diabetes; the growing number of children diagnosed with type 2. Again, thank you for picking up Power of Prevention® Magazine. I hope that you will find it useful and informative. I’d also like to know your thoughts on the magazine, and how we can make it even better. Send me an e-mail at feedback@powerofprevention.com with your thoughts and suggestions.

Thank you,

Hossein Gharib, MD, MACP, MACE President, American College of Endocrinology Power of

revention®

The Power of Voice L e t t e r s a n d E- m a il s f r o m R e a d e r s The art and science of endocrinology is constantly evolving. In the last issue of Power of Prevention® Magazine, we focused on the thyroid. In the areas discussing thyroid carcinoma and radioiodine therapy, the American Association of Clinical Endocrinologists would like to update two statements as follows.

In the Thyroid Carcinoma section:

How is thyroid cancer treated? Fortunately, most types of thyroid cancer can be diagnosed early and cured completely, but a thoughtful and comprehensive investigation is necessary. If thyroid cancer is suspected after review of all the information, referral to an experienced thyroid surgeon is recommended. If the diagnosis of thyroid cancer is certain or highly likely, the usual approach is to remove both sides of the thyroid gland. If the diagnosis of thyroid cancer is much less certain or cannot be made during surgery, only the side of the thyroid containing the lump may be removed. If cancer is, subsequently, confirmed, further consultation with the endocrinologist is appropriate. Additional surgery may be required to remove the remaining tissue in order to reduce the risk of recurrence of cancer. In cases when the risk of recurrence is significant, radioactive iodine treatment may be recommended in order to destroy any remaining malignant thyroid cells.

In the Radioiodine Therapy section:

I just came across the first issue of Power of Prevention® Magazine. How do I subscribe?

Nancy from Chicago Editor:

Currently, the Power of Prevention® Magazine is only available through your endocrinologist’s office. We are continuing to look into the possibility of offering the magazine on a subscription basis. If you would like to inquire further about receiving a copy of the magazine at your home, contact ssenn@aace.com.

I am an endocrinologist from Ohio and an AACE member. I have a program at the end of the month at a local elementary school. There are about 400 students. Any help or resources would be greatly appreciated.

Mike from Ohio Editor:

Dr. Mike, there is a PowerPoint® presentation, and a teacher lesson plan, available for download at powerofprevention.com. The materials teach elementary age students the benefits of healthy eating and nutrition, and are free for any teacher, educator, or doctor to download and use. If you would like assistance with the presentation materials, contact the AACE staff.

I have been successfully using your materials for a couple of years. The students are very excited when they receive the pedometers. It really brings their awareness to the discussion. Will you continue to make them available?

Pam from New York

After Removal of the Thyroid An experienced thyroid surgeon can remove most of the thyroid with a very low risk of surgical complications. In many cases, surgery followed by thyroid hormone therapy is sufficient to treat thyroid cancer. When it may not be sufficient, radioiodine can be used to destroy the remainder of the gland, which might harbor additional microscopic clusters of thyroid cancer.In that case, you may be advised not to use thyroid hormone replacement for several weeks after the operation, in order to allow the thyroid levels to drop below normal. This will lead to maximal stimulation of the remaining thyroid cells to concentrate iodine and be destroyed when you receive a dose of radioiodine. This treatment significantly reduces the possibility of recurrent cancer and also improves the ability to detect and treat any future cancer recurrences that might develop.

Editor: We have currently exhausted our supply of Power of Prevention

pedometers. We are very lucky that the demand for the pedometers was so high. Unfortunately, the current economic climate makes it very difficult to purchase additional pedometers at this time. However, we hope to be able to distribute pedometers once again in the near future.

How can I find an endocrinologist in my area?

Jeff from San Diego Editor: The American Association of Clinical Endocrinologists (AACE) is the largest group of clinical endocrinologists in the world. All of the more than 6,200 members are doctors, and all see patients everyday. You can search the AACE membership where you live by logging on to powerofprevention.com and clicking “Find an Endocrinologist.” 3

Power of

revention®

Ordinary People,

Extraordinary Journeys

his special issue of Power of Prevention® Magazine is focused on The Changing Face of Diabetes Management. New research and new medications are forever changing the way that doctors and their patients approach the disease. Over the next several pages, you will see just how those changes can impact you or your loved one who is living with diabetes. You will also get a chance to see how regular people have lived extraordinary lives in spite of, or in some cases, because of their diabetes. Starting on page 5, we will take a closer look at these medical breakthroughs, and what they mean for your treatment. That is followed by an up to date listing of the available medications so you can be informed as to just what treatment options are available to you. Of course, avoiding the complications of diabetes is one of the most important aspects of a patient’s diabetes management, so we will take a closer look at these complications and how to avoid them. Our comprehensive review of the diabetes states begins with prediabetes on page 9. With an estimated 54 million Americans living with prediabetes, it is the largest healthcare epidemic in the United States. We will discuss the diagnosis and potential treatment of the condition, and how early intervention can delay or even prevent the onset of type 2 diabetes. Type 2 diabetes is the most common form of diabetes. Starting on page 12, we will take a detailed look at the impact of weight management on type 2 diabetes, and give you a chance to take the 5 Pound Challenge! You’ll also hear from a patient who has taken his struggles with type 2 diabetes and weight worldwide. We’ve even included a special report specifically on nutrition for the diabetes patient. And finally, we take a frightening look at the growing number of children being diagnosed with type 2 diabetes. Next, we discuss type 1 diabetes on page 18. We will discuss the different approach to management from type 2. We will also hear from a patient who has decided to fight her type 1 diabetes, literally! Finally, on page 24, we will give you some insight on how you can take this knowledge and make a difference. We start with an organization that is taking the Power of Prevention® to the streets, enlisting volunteers to give free health screenings. We will also show you how to put together your own Diabetes Disaster Plan, to make sure you are prepared when disaster strikes.

4 Power of

revention®

The Changing Face of Diabetes Management by Daniel Einhorn, MD, FACP, FACE

he treatment of type 2 diabetes has never been more satisfying, or more complex. New options make life better for the person with diabetes, but more challenging for the physician and the diabetes team to determine the best options for each individual.

and lipids as if the person were already diabetic. If medication for glucose is indicated, metformin has excellent data for diabetes prevention, albeit not as good as adherence with lifestyle improvement. There is also evidence that the alpha-glucosidase inhibitors, which block carbohydrate absorption, and thiazolodendiones, which enhance insulin sensitivities, help prevent progression to diabetes. We hope that ongoing research will help define the place of therapies such as DPP-4 inhibitors (e.g., sitagliptin) and GLP1 agents (e.g., exenatide) in which there is exciting preliminary data for preservation of the beta cells, which make insulin.

First, the dogma that fitness, good nutrition, and weight loss are the cornerstones of diabetes management has never been truer. In addition, however, sleep deprivation is being increasingly recognized as an important lifestyle contributor to poor diabetes control. Lifestyle changes often are difficult and insufficient, so medication is typically needed for good control and should not be seen as a failure on anyoneâ&#x20AC;&#x2122;s part.

AACE/ACE also convened the Diabetes Algorithm Committee in February 2009 to offer guidance to clinicians and individuals on appropriate options to control glucose in type 2 diabetes. The target for optimal control is an average glucose measured by a test called A1c to be less than or equal to 6.5 percent. In individuals at risk of hypoglycemic reaction (low blood sugar) or in those with cardiovascular disease, a somewhat looser target of 7 percent or above should be considered. Essentially the goal is the best possible control with the least risk of side effect such as hypoglycemia.

Foremost in the treatment of type 2 diabetes is not glucose, but optimal control of blood pressure and lipids, such as LDL-cholesterol and triglycerides. The guideline for good blood pressure control is < 130/80 mm/Hg, for LDL-cholesterol < 100 mg/dl. Many practitioners recommend a blood pressure agent in the category of ACE-inhibitor or ARB even for those with normal blood pressure. Similarly, many recommend the same strategies used to prevent cardiovascular disease, like aspirin, fish oil, and even vitamin D. That discussion is beyond the scope of this article, which will focus on the approaches to controlling glucose.

There are many reasons to choose specific agents. Fortunately, agents which work by different mechanisms of action can be combined to get good control even when one or two agents cannot. The cornerstone of therapy today is the drug metformin. There are abundant safety data, including in childhood and pregnancy, and it is very inexpensive. To avoid stomach upset, the dose is built up slowly. The least expensive and oldest agents are the sulfonylureas, with names such as glimepiride (Amaryl) or glipizide (GITS). Their disadvantage is the potential to cause serious hypoglycemia and weight gain, especially the agent glyburide.

The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) convened the Pre-Diabetes Consensus Conference in September 2008, in Washington, DC, bringing together the top thought leaders in this field from all over the world. It focused on the 54 million Americans with prediabetes, defined as a fasting glucose of 100-125 mg/dl (impaired fasting glucose or IFG) and/ or a two-hour post challenge glucose of 141-199 mg/ dl (impaired glucose tolerance or IGT). In individuals with IFG and/or IGT, lifestyle modification is the most important treatment along with control of blood pressure

5 Power of

reventionÂŽ

The Changing Face of Diabetes Management

C ontinued

by Daniel Einhorn, MD, FACP, FACE A third class of medications is one that helps the body become more sensitive to insulin. Pioglitazone (ACTOS) and rosiglitazone (Avandia) do not have a risk of hypoglycemia and can be taken once daily anytime. They can be associated with weight gain, but less so when used in combination with other agents. They are complex and expensive agents, which should be avoided in people with congestive heart failure, and there may be some association with unusual bone fractures. Many believe that they are also a cornerstone therapy because type 2 diabetes is a disease of resistance to the action of insulin and so treating that may have many benefits. Exenatide (Byetta) is the first of a class called GLP-1 analogues, which mimic the action of the natural hormone, glucagon-like peptide. This is the first agent where weight loss occurs in a significant number of individuals and it cannot produce hypoglycemia. It does have to be administered by injection twice daily before meals, but the pen injector is painless, quick, and simple. Most clinicians believe it to be an extremely safe medication, though rare cases of pancreatitis have been reported. Sitagliptin (Januvia) is the first of the so-called DPP-4 inhibitors, which work by inhibiting the breakdown of a person’s own GLP-1. There is less glucose lowering than exenatide and with no weight loss, but it is a simple once daily pill with a side effect profile comparable to placebo, including no tendency to produce hypoglycemia.

Finally, long acting insulin such as glargine (Lantus) and detemir (Levemir) have made insulin therapy safe and much easier than ever since it is painless, has less risk of hypoglycemia and weight gain than the older insulins, and it is almost always needed at some point in the life of a person with type 2 diabetes.

We like to tell people who are newly diagnosed with type 2 diabetes that the years ahead should be the healthiest of their adult lives. With a combination of attention to diet and fitness, and with judicious use of medications, people with type 2 diabetes can lead remarkably normal and relatively healthy lives.

Daniel Einhorn, MD, FACP, FACE Daniel Einhorn, MD, FACP, FACE, is the Vice President of the American Association of Clinical Endocrinologists. Dr. Einhorn is a Clinical Professor of Medicine at the University of California, San Diego; Medical Director at the Scripps Whittier Institute for Diabetes and President of Diabetes and Endocrine Associates. Dr. Einhorn’s research and publications cover diabetes prevention and reversal, recognition and treatment of diabetic complications, new technologies and pharmaceuticals, combination therapies, and clinical decision-making. He has lectured nationally and internationally on these topics, and has chaired meetings of the American Federation of Clinical Research in Carmel, The Endocrine Society Clinical Endocrine Update (The Postgraduate Meetings) in diabetes, and over 250 regional symposia. He reviews articles for Diabetes Care, The American Journal of Medicine, and the Journal of the American Medical Association (JAMA), the Journal of Endocrinology and Metabolism, the Medical Letter, and is on the Editorial Board of Diabetes Health.

6 Power of

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Complications of Diabetes By Philip Levy, MD, MACE

iabetes mellitus occurs when the pancreas (an endocrine gland in the abdomen) cannot make enough insulin to satisfy the demands of the body. We currently recognize two types of diabetes. Type 1 is due to destruction of the cells in the pancreas that make insulin. These individuals, usually, must take insulin injections for the rest of their life. Type 1 generally occurs early in life and is of sudden onset. This type of diabetes happens at a level rate and does not seem to be increasing. In our country, only 1 of 25 people with diabetes has type 1 diabetes.

Diabetic nephropathy is another microvascular complication that refers to disease of the small blood vessels of the kidney. If nephropathy continues to progress, it can ultimately lead to kidney failure, which may have to be treated by dialysis or kidney transplantation. The early stages of nephropathy can be picked up by laboratory testing of the blood and urine. Medicines are available to prevent the kidney disease from getting worse. Tight diabetes control also helps. Diabetes, however, is the leading cause of kidney failure leading to dialysis in the adult population. Renal failure is serious and can dramatically worsen quality of life of the person with diabetes, and also shorten the lifespan of the person who has it. Once again, it is important to pick up kidney disease early and institute treatment as soon as possible. Kidney disease also makes it difficult to treat the person for other diseases because kidney failure can change the action of many drugs that we prescribe.

Type 2 diabetes is much more common than type 1. We now have about 25 million people in the US with type 2 diabetes, and the number of people affected is rising rapidly. Type 2 diabetes seems to have a more gradual onset, and is often treated with pills early in its course. This type of diabetes seems to be tied to the epidemic of overweight and obesity around the world. We used to think of it as starting at an older age, but now it is more frequently diagnosed in younger people, including children and teenagers. The US has the third largest number of people in the world with diabetes, surpassed only by India and China. The increased incidence of diabetes is a worldwide epidemic, and no country is spared.

Diabetic neuropathy refers to a complication involving the nerves of the body, perhaps by interfering with the small blood vessels supplying these nerves. The feet are usually the first to suffer and common symptoms include numbness, pins and needles feelings, pain, and eventually loss of sensation. With severe neuropathy of the feet, one cannot feel cold, heat or even touch. Under these circumstances, it is easy to produce damage to the feet. For example, if you had a nail in your shoe and couldn’t feel it, you could damage your feet.

Both types of diabetes are associated with similar complications. They are generally split into microvascular and macrovascular complications. Microvascular means small blood vessels such as the blood vessels in the eye and the kidney. Macrovascular means large blood vessels such as the blood vessels of the heart and the brain, as well as the large blood vessels of the legs. We’ll start out with the small blood vessels.

Oral Medications for Diabetes

Let’s start with diabetic retinopathy, which refers to disease of the small blood vessels of the retina caused by diabetes. Diabetic retinopathy usually starts out with small areas of bleeding in the back of the eye (the retina). The retina is the area responsible for our eyesight, and if it becomes seriously damaged eyesight becomes impaired. The result of untreated retinopathy can be blindness. Diabetic retinopathy is the leading cause of blindness in adults. Early diagnosis and treatment can prevent blindness from occurring. Everybody with diabetes should have what we call a dilated eye exam once a year. This means that the pupils are dilated with eye drops and the eye doctor can get a good look at the retina in the back of the eye. If there are early changes of retinal disease, the person can be treated. Early treatment usually consists of laser therapy to the retina. Tight control of diabetes will often keep the retinopathy from getting worse, and may even reverse the effects.

7 Power of

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Complications of Diabetes

C ontinued

If the blood supply to the feet was also involved, then you could develop open sores on the feet, which could be difficult to heal and could lead to gangrene of the foot requiring amputation. Other parts of the body could suffer as well. For example, if the nerves supplying the stomach were involved, the stomach might not empty as well as it should after eating, leading to bloating, nausea, and vomiting. One could even develop intestinal or stomach blockage with obstruction. Neuropathy can also affect balance, making it difficult to walk without falling.

risks of heart attack and death, but they will not eliminate these risks. One of the most successful treatments is lifestyle modification with exercise and diet. Type 2 diabetes is often associated with obesity. Therefore, weight loss can be extremely helpful in cutting down complication rates. The best therapy to eliminate the complications of type 2 diabetes is prevention. A healthy diet and exercise are critical. It is extremely important to try to keep your weight down and be physically active. Hopefully, we will be able to decrease the incidence of diabetes with exercise and healthy diet habits. The complications of diabetes can be serious and can even lead to a shortened life span as well as blindness, kidney failure, amputation, and severe disabling heart disease and/or stroke. The ball is in our court. With a little bit of effort we can cut down the rate of diabetes and live longer, healthier lives.

The microvascular or small blood vessel complications can cause many problems as seen above. The better the control of the diabetes, the less likely one is to have any of the small blood vessel complications of diabetes. In type 2 diabetes, however, the macrovascular or large blood vessel complications can lead to shortened life span and death. Heart attacks and strokes are much more common in people who have diabetes and can lead to serious medical problems and premature death. The number one cause of death in people with diabetes is heart attack with stroke not far behind. People with diabetes have more heart disease than people without diabetes. Other conditions such as hypertension (high blood pressure) and hyperlipidemia (elevated cholesterol levels) are also more common. Many of these people have to be treated with medications to control all of these problems. These medicines will reduce the

Injectable Medications for Diabetes

Philip Levy, MD, MACE Philip Levy, MD, MACE, is a clinical professor of medicine at the University of Arizona College of Medicine and is chairman of the Section of Endocrinology and Metabolism at Banner Good Samaritan Regional Medical Center in Phoenix, Arizona. He has practiced clinical endocrinology at Phoenix Endocrinology Clinic, LTD in Phoenix for over 40 years.

8 Power of

revention速

What You Need to Know

about Prediabetes...

A Question & Answer Session with Paul S. Jellinger, MD, MACE What is prediabetes?

Are there other complications of prediabetes other than the future risk for diabetes?

Prediabetes is a condition in which blood sugar levels are higher than normal but not high enough to qualify for the diagnosis of diabetes.

Yes. Persons with prediabetes actually have some of the same complications as persons with diabetes, only less frequently. For example, a certain number of persons with prediabetes will have diabetic eye disease (retinopathy), nerve damage (neuropathy) and early diabetic kidney disease (nephropathy) with excess protein in the urine. Also, it is generally believed that patients with prediabetes already have an increased risk of heart and blood vessel disease although not as high as those with diabetes.

How is prediabetes diagnosed? Either by a blood sugar test after an overnight fast (fasting blood sugar) or measuring the blood sugar level 2 hours after drinking a standardized sugar (glucose) solution. If the fasting blood sugar is higher than normal (100 mg%) but not high enough to be called diabetes (126 mg % or higher), prediabetes known as “impaired fasting glucose” (IFG) is present. If 2 hours after the standardized glucose solution, the blood sugar is between 140 mg% and 200 mg%, prediabetes known as “impaired glucose tolerance” (IGT) is present. An individual can have both.

What are the treatments for prediabetes? First and foremost, as mentioned above, dietary measures usually in the form of calorie and carbohydrate restriction designed to promote weight loss. Secondly, a regular moderate aerobic exercise program of approximately 30 minutes per day, 5 days a week. Both of these strategies have been shown in studies to delay or prevent the transition to diabetes. Occasionally, certain diabetes medications are used to prevent or delay the progression to diabetes as well.

Why is knowing if you have prediabetes important? Because prediabetes is a strong predictor of eventual diabetes. Action should be taken to delay the appearance of diabetes by dietary guidance, caloric restriction if overweight or obese and a regular moderate exercise program. These lifestyle tactics have been shown in studies to delay or prevent the appearance of diabetes. Although no medications are FDA approved for use in prediabetes, some studies have demonstrated the ability of certain medications that are used in diabetes to delay the progression from prediabetes to diabetes. These are occasionally used in certain situations.

Since some diabetic complications may already appear in prediabetes and an increased risk for heart and blood vessel disease already exists in prediabetes, aggressive control of both high blood pressure and elevated cholesterol to the same degree as in diabetes is necessary and is recommended. This often, but not always, requires medication to lower blood pressure and cholesterol.

Paul S. Jellinger, MD, MACE Paul S. Jellinger, MD, MACE, is a Professor of Medicine on the voluntary faculty at the University of Miami. After receiving his medical degree from Wayne State University School of Medicine, Dr. Jellinger completed a first-year medical residency at Beth Israel Hospital and a second-year residency at Mount Sinai Hospital in New York City. He, subsequently, was awarded an NIH fellowship in Endocrinology at Mount Sinai Hospital. Dr. Jellinger is a founding member of the American Association of Clinical Endocrinologists (AACE). He lectures frequently on topics related to diabetes mellitus and lipid disorders.

9 Power of

revention®

A Doctor’s Diagnosis:

Prediabetes

By Yehuda Handelsman, MD, FACP, FACE

Jane is one of my patients and her story is similar to millions in the United States. She’s a 47-year-old mom who has been coming to me for the past 10 years. Jane is somewhat overweight and has been struggling with one diet or another since I have known her. In the first few years, she was exercising regularly and aggressively. At times, Jane lost a few pounds, which she usually regained with the all too frequent relaxation of her diet. She attributed her weight gain to a hormone imbalance. At age 42, I diagnosed Jane as being hypothyroid, a condition resulting from low thyroid hormone production, causing low metabolism. I treated her with a replacement dose of thyroid hormone. While Jane felt better, her weight did not change. To lose the extra weight, she not only needed to exercise but also reduce the amount of calories she consumed. “Do you know how hard that is?” Jane asked. “As a mom, I’m always on the go. It’s difficult to find the time to exercise.” “I completely understand,” I said. “But regular exercise is a necessity if we’re going to protect you from developing diabetes, heart disease or both.” I did not see Jane for two or three years, until she came to see me about six months ago. As usual, she was pleasant, but remained overweight and had gained about five pounds. Jane told me that she had been unable to find the time to exercise because she was actively preparing her daughter for college. Knowing that Jane had a family history of diabetes and heart disease, I stressed the importance of exercise. “I am still a young woman,” she said. “I should not have to worry about heart disease, at least not yet.” Jane is a registered nurse and knows a lot about different medical conditions, so I felt comfortable speaking with her frankly: “The last blood test you had a few years ago showed a fasting glucose (blood sugar) level of 106. This level used to be considered normal but now is defined as impaired fasting glucose or IFG,” I said. “This makes you part of a group of people who are also defined as having “prediabetes.” It indicates that your body has a problem dealing with sugar and carbohydrates. In fact, you’re at risk for developing diabetes

and perhaps cardiovascular disease. You also have a greater risk of other complications of the kidney and eye as well as nerve damage (neuropathy).”

Astounded, she asked, “You mean that I’m at risk for developing diabetes?” “Yes,” I told her. This news came as quite a shock to Jane. She had a lot of questions about treating her condition and reducing her risk for heart disease and other complications. Jane wanted to be proactive and try to prevent diabetes and heart disease. However, before discussing the specifics, I decided to examine Jane again and repeat laboratory tests. A few days later, we reviewed the results together. Jane’s blood pressure was marginally elevated at 137/84 and her fasting glucose level was 118. The tests also showed that her bad cholesterol (LDL) was high at 151 and that her good cholesterol (HDL) was somewhat low for a woman at 42. Her TGL level, which measures the triglycerides or the amount of fat in the blood, was also high at 175. An ultrasound of the carotid (neck) arteries revealed some plaque formation indicating hardening of the arteries. We sat down to discuss the impact on her health. I told Jane that while she did not have diabetes at that time, she clearly had prediabetes. I explained that she had many typical risk factors for heart disease, including marginally elevated blood pressure and some lipid abnormalities. Although she did not have known heart problems, the process leading to heart and blood vessel disease had started. Jane already had some hardening of the arteries with cholesterol, a condition known as atherosclerosis. She wondered what she could do to prevent the onset of type 2 diabetes and stop the progression of heart disease. Even though Jane was a relatively young woman, who had marginally elevated blood pressure and some lipid problems, she was already at high risk to develop heart disease. We discussed her treatment options. I talked to her specifically about the recommendations for the management of prediabetes that were recently developed by the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE). Based on these recommendations, I was able to answer Jane’s questions about prediabetes:

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Who is at risk for developing prediabetes?

What lifestyle modifications do I need to make to reduce my risk?

• Individuals with a non-Caucasian ancestry

• Create a moderate-intensity physical activity program that lasts for 30 to 60 minutes and is completed at least five days a week.

• Individuals with a family history of diabetes • Individuals with impaired glucose levels and/or metabolic syndrome

• Make diet adjustments, including calorie restriction, limiting carbohydrates, and increasing fiber intake.

• Individuals with cardiovascular disease, hypertension (high blood pressure), increased levels of triglycerides, and/or low levels of good cholesterol (HDL)

• Individuals with prediabetes should reduce their weight by 5 to 10 percent. • Visit your physician to monitor blood sugar, lipid levels, and blood pressure a least once a year. Individual at a higher risk should do this more frequently.

• Individuals who are overweight or obese • Women who have had gestational diabetes, had high birth weight babies (greater than 9 lbs.), and/or has Polycystic Ovarian Syndrome (PCOS)

Are there medications approved to treat prediabetes? • While there are not any medications currently approved by the Food and Drug Administration (FDA) to treat the elevated glucose in prediabetes, drug therapy to lower blood sugar is sometimes considered in high risk patients.

What are the risks of not treating prediabetes?

• Low-dose aspirin is recommended for all people with prediabetes who do not have an increased risk of bleeding.

• Cardiovascular disease, including heart disease, stroke, and blood vessel disease • Other complications include eye disease, kidney disease and nerve damage

How can I reduce my risk for developing prediabetes?  By taking a two-track approach to prevention:  Lower blood glucose to stop the progression of diabetes and prevent complications  Address cardiovascular disease risk factors by treating lipid disorders (high cholesterol) and blood pressure

Once I finished answering her questions and reviewing the recommendations about managing prediabetes, Jane was ready to take the next step toward living a better life. She agreed to eat healthier foods and stay away from sweets and “junk food.” Jane also decided to start exercising at least three times a week. I encouraged her to increase her exercise program from three days to five days a week over time. I prescribed medication for cholesterol to try to stop the progression of atherosclerosis (hardening of the arteries) as well as low-dose aspirin. Jane was to return to the office after three months to determine the effectiveness of lifestyle modifications on her blood pressure and glucose levels in order to assess her potential need for medications. I wished her luck and encouraged her lifestyle modifications, since this was the toughest part of treatment but the most rewarding. With the knowledge she gained, Jane now possessed everything she needed to lead a healthy and successful life.

Yehuda Handelsman, MD, FACP, FACE Yehuda Handelsman, MD, FACP, FACE, is an endocrinologist in solo practice in Tarzana, California. He is the Medical Director of the Metabolic Institute of America and Senior Scientific Consultant, at the Metabolic Endocrine Education Foundation. Dr. Handelsman is founder and chair of the International Committee for Insulin Resistance. He is Associate Editor of the “Journal of Diabetes,” an International peer-reviewed journal based in China, and devoted to diabetes research, therapeutics, and education. Dr. Handelsman is on the editorial board of “Clinical Endocrine News,” has been a reviewer for several publications and position papers, and was a guest editor of a special issue of the journal “Metabolic Syndrome and Related Disorders.”

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Weight Management and Type 2 Diabetes By Ayesha Ebrahim, MD, FACE, and J. Michael González-Campoy, MD, PhD, FACE

HOW DOES OBESITY RELATE TO TYPE 2 DIABETES MELLITUS?

besity is a biological and treatable disease. This condition has physical, metabolic and psychological complications that take away from our health. The metabolic complications of obesity develop gradually. It increases the risk of heart attacks and stroke. Obesity is not a character flaw, and it is not just about the pant size or the looks. Obesity is not something we wish on ourselves, and it is not our fault if we have it. Some say that people with obesity lack character or will, and their opinion is naive. In reality, there are a myriad of biological processes that together cause the accumulation of fat mass. Our body is like a car: it needs to be refueled, and waste needs to be removed. Fuels come from what we eat. Each meal gets digested to protein, carbohydrate and fat. In turn, the intestines absorb the building blocks of each of these nutrients. In the blood we get circulating fats (cholesterol and triglycerides), circulating sugar (glucose), and the building blocks of proteins (amino acids). Energy balance is the relationship between the calories that we ingest and the calories we burn every day. Energy balance is negative if we burn more calories than we ingest. In this situation we may need to borrow calories from energy stores. Over time a negative energy balance leads to fat weight loss. Energy balance is positive if we ingest more calories than we burn. We are very good at storing these excess ingested calories in fat cells, also called adipocytes. Over time a positive energy balance leads to fat weight gain. Individual adipocytes get bigger and bigger (hypertrophy). Fat deposits get redistributed with weight gain. Some fat pools, especially the fat inside of the abdominal cavity, may then cause disease.

moves fuels from the circulation into cells. The major fuels that insulin helps move are glucose and triglycerides. When insulin does not work, glucose and triglycerides do not go into cells, they stay in the circulation. This makes the blood sugar and blood triglycerides rise. If the blood sugar goes up enough, an individual can develop type 2 diabetes mellitus. Type 2 diabetes mellitus is caused by the accumulation of fat in most people. Fat inside the abdominal cavity, also known as visceral fat, causes insulin resistance. Visceral fat becomes a treatment target for patients with diabetes. The best measure of visceral fat is the waist circumference. The more overweight a person is, the bigger the waist circumference, and the bigger the waist circumference, the higher the risk of getting diabetes. Weight loss makes blood sugar control easier, and can prevent diabetes in the first place. Even modest weight loss has tremendous benefits!

HOW DO I LOSE OR CONTROL WEIGHT AND PREVENT OR TREAT DIABETES?

our current behavior needs to be modified. To lose weight you have to achieve a negative energy balance. Your caloric expenditure needs to be more than your caloric intake. The National Diabetes Education Program, a joint venture of the NIH and CDE, which AACE and ACE support, has a program that you can embrace, “Small Steps: Big Rewards.” ■

Increase your caloric expenditure. • Get regular physical activity. • Try to be physically active at least 30 minutes every day. • If you are able, go for a brisk walk, participate in sports, start dancing classes, or engage in active games (Frisbee, sledding, making snowmen or snow angels, etc.) • If you are very overweight remember this: a two minute walk every hour on the hour becomes a 30-minute walk at the end of the day. Every hour stand up, walk away for a minute, and then walk back. Two little minutes add up!

Hormones are substances that are made in a part of the body, enter the circulation, and have biological effects in other parts of the body. They help regulate our internal environment and, therefore, play a crucial role in regulating our weight. When hormones do not work properly, illness develops. Insulin is a hormone made in the beta cells of the pancreas. Insulin works like the hose and nozzle at the gas station, it moves fuel. At the gas station the hose and nozzle move gasoline from the gas pump into a car’s gas tank. Similarly, insulin

• Decrease your caloric intake.

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By Elise M. Brett, MD, FACE, CNSP

The most important thing to do is limit portion sizes. Always go small!

■

There are medications available to help with weight loss for those who are obese (BMI≥30) or moderately overweight (BMI≥27), and have complications of obesity, such as diabetes. These medications must be used in conjunction with a reduced calorie diet and increased physical activity. The oldest medications, phentermine and diethylpropion, were approved for short-term use in 1959 and work in the brain by reducing appetite. These medications are similar to amphetamine but do not produce euphoria. They can be difficult to tolerate due to symptoms of increased heart rate, insomnia, agitation and headache. Their safety for long-term use (>2 months) has not been established. The newer agents, sibutramine (Meridia) and orlistat (Xenical, Alli) are approved for long-term use for both weight loss and weight maintenance. Most weight loss occurs during the first six months of treatment and then levels off. Orlistat works by limiting the amount of fat absorbed in the intestine and causing a loss of calories in the stool. Sibutramine works primarily in the brain to reduce appetite and cause a sensation of early fullness. Sibutramine can raise blood pressure and heart rate in some individuals and may not be appropriate for people with heart disease or hypertension. Weight loss surgery (gastric banding, gastric bypass) may be appropriate for people who are extremely obese (BMI≥40) or moderately obese (BMI≥35) with complications of obesity, such as uncontrolled diabetes, who have failed more conservative attempts to lose weight. Surgery will often result in remission of the diabetes or at least a marked reduction in the need for medication.

• Eat healthy meals rich in vegetables, fruits, and whole grains. try to eat 10 servings of fresh fruits or vegetables every day. • Eat less refined carbohydrates, such as sweets and white bread. • Limit the amount of high-sugar beverages you drink, such as soft drinks and fruit punches. • Limit the intake of high-fat foods like ice cream, butter, peanut butter and high-fat meats. • Limit alcohol to no more than 1 drink per day for women, 2 per day for men. Avoid drinking alcoholic beverages if you have any difficulty controlling them. • Always eat a balanced breakfast, and try to place most of your daily calories with this morning meal. • Have a small dinner and don’t eat after 7 p.m.

Aim to lose 5 to 10 percent of your current body weight over the next 6-12 months.

■

• For a 240-pound person, this is 1-4 lbs. per month. • Losing weight too fast can be unhealthy and often leads to rebound weight gain. • The three keys to success with weight management are patience, persistence, and realism. Set goals that you can realistically achieve, and give yourself the time to meet these weight loss goals. ■

Get your family and friends involved!

• When your support people work with you, success is easier! • Encourage your family and friends to eat healthy meals and be active with you. • Put peer pressure on everyone around you to be healthier.

Elise M. Brett, MD, FACE, CNSP, is a clinical endocrinologist in private practice in New York City. She is Assistant Clinical Professor at Mount Sinai School of Medicine and is a Certified Nutrition Support Physician.

Good nutrition and increased physical activity are lifestyle changes that must be continued long-term to keep weight off and have better diabetes control.

Take the 5 Pound Challenge Losing as little as 5 pounds can have a dramatic impact on your health. By simply losing 5 pounds, most people will see the following improvements:

See box to right

The bottom line is this: Focus on being the healthiest person you can be every day. Think of every day as an opportunity to have better nutrition and more physical activity. Medications are simply tools that your endocrinologist puts in your hands to help you. Have a healthy day every day. Then the weight will go down and the diabetes will improve!

Ayesha Ebrahim, MD, FACE

• • • • •

Improved blood sugar levels Decreased triglyceride levels Increase in HDL levels (good cholesterol) Lower Fasting Blood Sugar levels Lower A1c results

Take the 5 pound challenge and share your success stories with us at 5poundchallenge@powerofprevention.com

J. Michael González-Campoy, MD, PhD, FACE

Ayesha Ebrahim, MD, FACE, is board-certified in Internal Medicine and Endocrinology. Dr. Ebrahim earned her medical degree from King Edward Medical College in Lahore, Pakistan, in 1995, and completed a two-year Endocrinology and Metabolism Fellowship at New York Medical College. She provides endocrinology care for adolescents and adults.

J. Michael González-Campoy, MD, PhD, FACE, is Medical Director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology (MNCOME). He earned his MD and PhD from Mayo Medical School and Mayo Graduate School of Medicine in 1991. He is board certified in Endocrinology, Diabetes and Metabolism. Dr. González-Campoy is a recognized national expert on diabetes and obesity and a proponent of adiposopathy as a treatment target. Dr. González-Campoy is Clinical Assistant Professor of Medicine at the University of Minnesota.

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Ordinary People,

Pamela Lawson

Making Time for You By Sarah Senn

s a wife, mother and career woman, Pamela Lawson knows just how hard it can be to find time for yourself. She works as a Senior Scientist for General Mills, Inc., promoting health and wellness initiatives. However, between a busy family schedule and working a high-stress job, Pamela has sacrificed a healthy meal more than once.

Pamela Lawson pictured far right

In May 2008, Pamela made an appointment to see her endocrinologist. She was somewhat overweight and knew the risks that it posed to her health. Pamela was also exhausted and lacked energy. Upon initial evaluation, her physician suspected that she had prediabetes. However, test results revealed that Pamela had type 2 diabetes. The diagnosis came as a “big shock” to her. Pamela had a Master’s degree in nutrition, and she had spent years teaching the Hispanic population about preventing diabetes through a healthy diet and exercise plan. For Pamela, the diagnosis also hit close to home because her husband had been struggling with type 1 diabetes since his twenties, and Pamela’s father was diagnosed with type 2 diabetes in his seventies.

“ I took the diagnosis pretty hard,” she recalls. “I preached about the importance of nutrition and yet didn’t take the time to take care of myself.”

Soon after her diagnosis, Pamela made a commitment to herself not to let diabetes stop her in her tracks. Her endocrinologist prescribed medication to control blood sugar levels and manage her diabetes. While the medicine helped Pamela’s condition, it made her feel nauseated at times. But she decided that the short-term discomfort was worth the long-term rewards of preventing cardiovascular disease and other complications. After talking with her endocrinologist, Pamela realized that she needed to make time for her health. She made necessary lifestyle changes to reverse the effects of diabetes. Pamela consciously watches her diet and exercises regularly. At 55, she admits that it’s somewhat harder to lose weight, but she is committed to making healthy choices. Since her diagnosis, Pamela has lost 60 lbs., and she has more energy. Her A1c is just below 6 percent. While she says that it was not easy to accept her diagnosis at first, Pamela has learned to set short-term goals that she can obtain. She is finding time to focus on her family, her career and her health. When it comes down to it, Pamela explains, “You have to put yourself first once in a while and take care of yourself because, ultimately, no one else can take care of you.”

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Extraordinary Journeys

David Mendosa Through the Lens of a Diabetes Patient By Sarah Senn

avid Mendosa is a celebrity in the online diabetes community. He is one of the Internet’s most prolific writers on the topic. Like many others, David did not know what to expect when he was diagnosed with type 2 diabetes. His insightful and research-packed blog entries on topics such as diabetes testing are read by thousands. In 1994, David went to see his physician because of pain he was having. The doctor ordered blood tests and one showed that his A1c level was dangerously high, at 14.4 percent. David recalls the doctor asking, “Has anyone ever told you that you have diabetes?” The answer was no. “That diagnosis changed my life,” David explains, “I was enjoying my independence. Life had been so easy that I had put on more than a few pounds.” Before being diagnosed with diabetes, David served as a Foreign Service Officer in the US government for 15 years. In 1980, he became a freelance writer for a small business magazine. Shortly after his diagnosis in 1994, David decided to put his knack for writing to use discussing something he knew about first-hand— living with diabetes. As a journalist, he already knew how to captivate an audience, and hoped to inspire others by writing about his experiences and success. To control his diabetes, David started a low-carbohydrate diet, and took anti-diabetic medication for several years. Today, David manages his diabetes with a healthy diet, an exercise program, and with regular visits to his doctor. As a result of his new lifestyle modifications, David brought his weight down from 313 lbs to his current 152 lbs. He has been able to keep the weight off for several years. David has also maintained a lower A1c level, his most recent test result at 4.8 percent.

“I’ve never been healthier or happier,” he exclaims. David is too busy to let diabetes take control of his life, so he’s taken control of his diabetes. Now at age 73, David is an active voice in the online diabetes community. He is a contributing author to a variety of diabetes publications, and is a diabetes consultant for HealthCentral.com, a leading health information Web site for patients. David notes that staying active is essential in maintaining his condition. As an avid hiker, photographer, freelance writer and diabetes patient, he encourages other people who have diabetes to find ways to have fun with their exercise. David hopes to motivate others with his blog, “Fitness and Photography for Fun,” which integrates his need to exercise with his loves for hiking and photography. Since being diagnosed with type 2 diabetes, David has hiked through parks along the Pacific Coast and over mountain trails across Colorado. He has even crossed the Continental Divide on foot. You can visit David’s fitness blog at http://www.mendosa.com/fitnessblog/. Looking back on his experiences, David says, “What

people with diabetes have to do to control their disease is exactly what everyone has to do to prevent it.” For more information about David Mendosa, visit www.mendosa.com. 15 Power of

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The

By A. Jay Cohen, MD, FACE

e need two basic substances to get into every cell in our body, oxygen and fuel (mostly in the form of glucose). While oxygen can easily zip into our cells from the blood stream without any extra work, getting glucose (fuel) into the cell is more complex. Cells require a key (insulin) to open the doors (receptors) and allow glucose into the cell. These doors have hinges, door handles and key holes. In our everyday life, if you have a small amount of insulin (keys), it’s easy to open the doors and our cells easily obtain food (mostly glucose or sugar) from the bloodstream.

food,because the peripheral cells (mostly muscle cells) do not know there already is enough food in the blood stream. This results in elevated glucose levels in the blood stream. Whew!!! Type 2 diabetes has become much more common in kids and teens in the United States over the last 10 years, especially in those who are overweight. Between 10 and 50 percent of children with a new diagnosis of diabetes may have the form known as type 2 diabetes. This disease was almost unheard of 20 years ago. It is especially common in Hispanic youth, African Americans, Asian/ Pacific Islanders and American Indian youth, but can occur in anybody. The rapid rise in obesity, not being physically active and consumption of excessive calories seems to have led to the epidemic of children with type 2 diabetes. About 50 to 90 percent of kids and adolescents with type 2 diabetes have a parent or close relative that also has type 2 diabetes.

Type 1 diabetes is a disease in which the body does not make enough insulin because, usually, there is an (autoimmune) attack on the beta cells of the pancreas, which gradually destroy the ability to make insulin; therefore, with no “keys,” the doors of the cells cannot open, resulting in the cells starving within a sea (bloodstream) of extra food (glucose, etc.). In type 2 diabetes, many problems develop as the person usually becomes more overweight (with less exercise and eating more calories). Initially, the door hinges, door handles and keyholes get progressively stuck or “gunky” or “rusty” resulting in resistance to the usual number of keys (insulin resistance). In order to open the doors (receptors) to get food into the cells, our cells call out for additional insulin (hyperinsulinemia) and food. At first, this can work, but gradually the pancreas wears out; it cannot continue to make massive amounts of insulin and it starts to decrease the insulin secretion. Our usual storage sites for food in the body (liver and fat

Associated problems can include obesity, high blood pressure (hypertension), elevated cholesterol and fat levels in the blood stream (hyperlipidemia), irregular menses and potential risks of infertility (polycystic ovarian syndrome), and a darkened, rough skin condition in the creases of the skin (acanthosis nigricans). When these problems cluster together, they may be called metabolic syndrome. Children with type 2 diabetes are at an accelerated risk for the long-term complications of diabetes, including heart disease, stroke, kidney disease and nerve damage.

cells) may actually produce extra glucose and fat to attempt to supply the rest of the body with

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Picture

Type 2 Diabetes in Kids and Adolescents:

revention®

How do you treat type 2 diabetes? First, we want to prevent the disease. Daily exercise for 60 minutes, decreasing obesity, eating healthy foods with the right portion size is a good first step. Treatment of type 2 diabetes takes multiple steps working together: • Develop a total treatment plan with your endocrinologist. • Educate the child/adolescent and the entire family. • Involve your school, faith-based organizations, neighbors and community. • Learn healthy food choices, proper portion sizes and develop an eating plan. • Exercise every day; we breathe and eat every day, so it’s time to exercise every day. • Check blood glucose levels, write them down and discuss with your doctor. • Set a good example as a parent. You have to also perform all of these tasks daily. • Take medication as prescribed, if needed. Compliance is important. • Aggressive management of possible associated problems is a key, including elevated blood pressure, cholesterol and fat levels. • Continue daily working on overall health goals.

Thanks and good luck! Work as a team with your endocrinologist. A. Jay Cohen, MD, FACE A. Jay Cohen, MD, FACE, is the Medical Director at The Endocrine Clinic, P.C. He is also Clinical Assistant Professor in the Department of Family Medicine at the University of Tennessee and Clinical Associate Professor in the Department of Pharmacology at the University of Tennessee; Director of the Diabetes Advisory Panel at St. Francis Hospital; and a consultant in endocrinology at St. Jude Children’s Research Hospital. He is actively engaged in numerous phase 2 and 3 endocrine clinical research studies in areas such as inhaled insulins, new type 1 and 2 diabetes agents, novel osteoporosis agents, new androgen therapies, and long acting growth hormones. He is a primary investigator into humanized anti-CD3 monoclonal antibodies to potentially cure type 1 diabetes.

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Type 1 Diabetes Mellitus

What is it? How do you Manage It? By George Grunberger, MD, FACP, FACE

ou sit in your new diabetes doctor’s waiting room. Your name is called and you are ushered into the examination room. The doctor walks in and before he sits down he asks you: “What type of diabetes do you have?” Panic sweeps you; first question and I flunked already! You manage a meek: “How many types are there? I didn’t realize there is more than one.” No one has asked you that question before.

years before the job of destroying those insulin-producing cells is done, it is quite unusual to see type 1 diabetes in infants or very young kids. The other confusing thing is that, thanks to our current lifestyle, people with type 1 diabetes tend not to be skinny any longer. Add to it that because of childhood obesity and physical inactivity we now see many kids being diagnosed with type 2 diabetes, thus blurring the distinction between the diabetes types even more. Type 1 diabetes does not tend to “run in the families” as much as type 2 does even though there are specific genes identified with giving you the increased chance of coming down with type 1 diabetes. However, it is clear your genes alone don’t result in the disease. The unanswered question is what else happens that triggers the onslaught which kills off those insulin-making cells? It has been noticed that the frequency of type 1 diabetes has increased everywhere in the world over the past 100 years. What is it in the environment which might trigger that autoimmune attack in those genetically predisposed individuals? There have been many speculations (you have probably heard of different viruses, cow’s milk, possibly some pollutants or toxic substances in the air) but no definite answers are in. The problem is that even though we could predict type 1 diabetes years before it happens (just by drawing blood for those darn antibodies and measuring how much insulin people make after being given sugar) we can’t screen the entire population every year (imagine how much that would cost!). And since you need to destroy probably as many as 90 percent of those pancreatic cells to see blood sugar go up into the diabetic range, by the time the diagnosis is made it is too late to prevent it.

The doctor tries to reassure you that this is not the first time he sees a patient who didn’t know. So, you try to relax and listen to his explanation. There are actually several types of diabetes mellitus. The three most common ones in the U.S. are so-called type 1, type 2 and gestational diabetes. The last one is easy, that is diabetes diagnosed during pregnancy. All types of diabetes are diagnosed the same way: glucose (“sugar”) levels in the blood are high (over 126 mg/dl in the fasting state and/or over 200 mg/dl two hours after you eat or drink the “Glucola” in the lab; it is recommended these numbers are obtained on two separate days before the diagnosis is made). So, what is the difference between types 1 and 2? Type 1 diabetes is a so-called autoimmune condition. That means your own body produces antibodies against parts of the only cells which can make insulin in humans (that is beta cells of the pancreatic islets of Langerhans), eventually destroying them. As a consequence, patients with type 1 diabetes need to administer insulin for the rest of their lives (people cannot live without insulin, so important is the hormone for many functions of your cells and tissues).

So, we are stuck (literally) treating type 1 diabetes after it wipes out most of the beta cells; and, the patients then need to take insulin for the rest of their lives. So, the management of type 1 diabetes typically revolves about figuring out the best way to deliver insulin so that glucose (and A1c) levels are as close to normal as possible while minimizing the number of hypoglycemic (low sugar) reactions. Anyone who has tried it will testify how difficult that tightrope walk is. Clearly, educating the patient about the importance of the right diet, physical activity, stress management, proper techniques for checking the blood glucose levels and insulin injection technique, etc. has to be placed on top of the agenda since the tasks can get overwhelming and no one can expect the newly diagnosed patient to know those things right off the bat. The family and community support is essential for successful overall management of this lifelong condition.

Type 2 diabetes, by the way, is that condition in which persons cannot make sufficient amounts of insulin and on top of it the insulin they do manage to make does not do a very good job taking care of things, resulting in high blood glucose levels. There are perhaps twenty times as many people with type 2 than with type 1 diabetes in our country. Back to type 1 diabetes. A long time ago, it used to be called “juvenile-onset” diabetes because it was thought that it affected only children and adolescents. We know better now. Type 1 diabetes can occur at any age; it’s just that it tends to be more aggressive (there are more antibodies destroying those beta cells quicker) in young people. Also, since it might take five to eight

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Type 1 Diabetes Mellitus Even though every type of insulin will lower blood glucose levels (that is its job after all) in the 21st Century, there are essentially two ways offered to patients with type 1 diabetes: multiple daily insulin injections or continuous insulin infusion by an insulin pump. In both cases, the idea is to copy Mother Nature as closely as possible. In a healthy individual, those beta cells in the pancreas make about half of the insulin continuously— 24 hours a day, 7 days a week, and the other 50 percent come in short bursts to appropriately cover your meals so blood glucose levels always stay normal.

Continued

The recent advance has come from using continuous glucose sensors, which give the user real-time information not only about glucose levels but also directions of changes in glucose numbers, history, and can sound alarms for very high or very low readings. Those sensors are placed on the skin and again plastic tubing is inserted under the skin to provide the information. What about the cure for type 1 diabetes? While many scientists have been working on it for decades, currently, there is none available. The closest we have come is to use pancreas transplant (either whole from a cadaver or a part from a living relative donor) or pancreatic islet cell transplant (in which only the insulin producing cells are injected and they settle around the liver where they start producing insulin normally). Both types of transplants require use of anti-rejection medications by the recipients to avoid rejection of those foreign cells.

For the multiple insulin shot routine, the “base” is covered by one of two insulin “analogs” (made by changing the structure of human insulin to behave differently), insulin glargine or detemir. Their job is to make sure blood glucose is OK overnight and before each meal. The remaining insulin is provided by mealtime injections of “rapid-acting” analogs (there are three on the U.S. market, insulin LisPro, aspart, and glulisine). Patients usually take as much as needed to “cover” their meals. Most are taught to count carbohydrate content of the meal and match that with the quick-acting insulin (for example, take one unit for every starch exchange or 15 grams of carbohydrate). Insulin pumps provide insulin only in the rapid acting variety. They are worn externally (much as your favorite PDA or cell phone) and push insulin under your skin through a skinny plastic tube all the time. The user programs the pump so it delivers about half as a “basal” rate (that rate varies according to the need), and the remainder gets activated by a push of a button to give bursts (“bolus”) of insulin again to cover the meal. Patients usually change the infusion site every three days. Much progress has been made into making insulin delivery as painless and convenient as possible but it still takes an injection through the skin. Other ways to deliver insulin (into the lungs, through the nose, inhaling into the mouth, skin patches, etc.) have been tried but to date none of them has been judged to be as reliable.

As you can see tremendous progress has been made in dealing with type 1 diabetes, but we still have a ways to go…

Insulin Treatment Options for Diabetes

George Grunberger, MD, FACP, FACE George Grunberger, MD, FACP, FACE, is chairman of the Grunberger Diabetes Institute in Bloomfield Hills, Michigan, and a Clinical Professor of Internal Medicine and Molecular Medicine & Genetics, Wayne State University School of Medicine in Detroit, Michigan. Dr. Grunberger has published over a hundred original peer-reviewed manuscripts, in addition to review articles, abstracts, book chapters, and letters to journals. His research interests have spanned the spectrum of subjects related to diabetes and its complications, from very basic studies on molecular underpinning of insulin action and insulin resistance to clinical research studies on many aspects of diabetes and its management.

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Ordinary People,

Extraordinary Journeys

Tarin Jackson

Basic Training

By Sarah Senn

n high school, everyone wants to fit in and no one wants to stick out. So how do you cope as a teenager when your doctor tells you that you have type 1 diabetes? Just ask Tarin Jackson. At age 14, Tarin was diagnosed with type 1 diabetes. Before her diagnosis, she was feeling exhausted and abnormally thirsty. Her vision was blurry and she had to urinate frequently. Convinced that she had diabetes, Tarin persuaded her parents to take her to the doctor. Tarin’s blood glucose level was extremely high at 870, and she had to be hospitalized immediately.

for using exercise along with proper diet and insulin use to prevent “diabulimia,” a condition whose name combines diabetes and bulimia in which insulin doses are omitted or reduced in order to lose weight. Now at 31, Tarin works as a pharmaceutical representative promoting diabetes treatment and sharing her success story with others. Tarin speaks with healthcare professionals about the challenges of control and exercise for people with type 1 diabetes. She also leads and attends support groups for people with diabetes. Despite her busy lifestyle, Tarin makes time to work out everyday, as well as track her blood glucose levels at least six to eight times a day.

As a freshman in high school, Tarin was very active in school sports. She was on her high school’s soccer, ski and track teams, and also competed in gymnastics. Tarin often had to travel to out-of-state meets and tournaments. After she was diagnosed, Tarin wondered if she would still be able to play sports. While her doctors warned her that this disease was “difficult enough to manage” without playing in competitive sports, Tarin was determined to stay active. She monitored her blood glucose levels frequently and worked hard to maintain her weight. With the help of her physician, she was able to devise a treatment plan that still allowed her to remain active in sports throughout high school.

In addition to all of her other activities, Tarin recently launched a business. After spending years trying to find a diabetes supply case that would fit her needs, she created her own brand of couture bags which she designed with diabetes patients like herself in mind. You can learn more about the bags at www.sugapak.com. Although, she is a prime example of a patient with diabetes who can maintain a healthy weight, reach healthy A1c levels, and live a happy and healthy lifestyle, Tarin admits that it’s not always easy living with diabetes. She explains, “When I get overwhelmed, I have to remind myself to bring it back to the basics.”

Tarin’s transition into the college years was somewhat more difficult. The laidback lifestyle of the college environment created new challenges. With a new schedule and less opportunities to be involved with sports, Tarin found it more difficult to manage her diabetes. She gained weight, her A1c levels rose, and she had to take more insulin. It was Tarin’s father who finally gave her the expression of “tough love” she needed to get her condition back under control.

Tarin has some advice for people with type 1 diabetes:

“My dad said, ‘If you do not take control over your diabetes, it is going to eat you up and spit you out!’” Tarin recalls. “It was then that I realized that things needed to change.” In order to get her diabetes management back on track, Tarin started exercising daily and began testing her blood glucose levels frequently.

• Be active. Exercise is important. • Find a support group or other people you can talk to about your condition.

After college, Tarin’s passion for exercise, which she describes as “the extra prescription that helped me to get where I am now,” led her to becoming a personal trainer. Her experience as a trainer heightened her already keen awareness of the concerns that many young women, especially those with type 1 diabetes, have about their body image. She prides herself as a role model

• And most importantly, never go anywhere without your diabetes supplies.

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Putting Your ‘Disaster Plan’ into Action

- One Doctor’s Story

By Lois Jovanovič, MD, FACE

lthough living in Santa Barbara is heaven on earth, over the last two decades vicious wildfires throughout the state have served as a painful reminder that we need to be prepared in the face of disaster. Just in the last two years, fires have started within minutes and spread in a few hours to wide areas of Santa Barbara County. After the Zaca fire in 2007 destroyed over 220,000 acres of land, our office, the Sansum Diabetes Research Institute, adopted the American Association of Clinical Endocrinologists’ (AACE) Diabetes Disaster Plan. The AACE “Diabetes Disaster Plan” is a checklist of 17 essential items to help patients prepare in case of an emergency.

On November 13, 2008, at 6:18 p.m., a fire started in the hills above Montecito, a neighboring village immediately south of Santa Barbara. The hilltop was ablaze, and the fire could be seen moving quickly down the hills into the city. The winds were hot and ferocious, and thus the fire spread within minutes into Santa Barbara. The residents were called by reverse 911 to immediately evacuate. The message was “You have less than 10 minutes to leave your home. If you have diabetes, take your insulin and needles.” By 7:00 p.m., the city was two-thirds evacuated into the high school gymnasium in a school north of Santa Barbara. The city was without electricity for 36 hours, but we had a sufficient insulin supply, thanks to the preparation and warnings by police and fire crews to be prepared! The AACE disaster plan brought sunshine to our community despite the loss of over 200 homes.

We modified our plan to include a reverse 911 phone call message to patients’ homes that were in danger, to identify the Santa Barbara locations for meeting points, essential medicines to have packed, ready and checked for expiration dates on a monthly basis, and the statement in every plan- “If you have diabetes, take your insulin and needles with you.”

Here’s a sample of the checklist of activities that you can do to make sure you’re prepared when disaster strikes:

Santa Barbara is actually a very small county of only 425,000 people, but we estimate that there are 14,000 people with diabetes. Our shops and drug stores close at 7:00 p.m. and the city hospital does not have a public pharmacy. If 2,000 people in Santa Barbara were dependent on insulin for life support daily, the insulin supply in the hospital would not be sufficient to treat everyone.

• List of all medical conditions and prior surgeries. • List of all your health care professionals with their contact information. • Wear shoes at all times and examine your feet often for infection.

Therefore, we also adopted a list of medicines that are essential for life support if not taken daily. The question is not how to maintain health or steady state serum concentrations of drug levels. If there is limited or no access to medications, the question is survival. Insulin is essential for life if one has type 1 diabetes mellitus and serious complications can occur if without insulin for longer than 24 hours.

• At least a three-day supply of bottled water. To Download entire checklist go to www.powerofprevention.com

Lois Jovanovič, MD, FACE Lois Jovanovič, MD, FACE, is CEO and Chief Scientific Officer of Sansum Diabetes Research Institute; Clinical Professor of Medicine, University of Southern California, Keck School of Medicine; and Adjunct Professor of Biomolecular Science and Engineering and Chemical Engineering at the University of California, Santa Barbara. Dr. Jovanovič has published over 490 articles in the fields of diabetes, metabolism, nutrition, obstetrics and gynecology, perinatology and engineering.

The American College of Endocrinology would like to thank Eli Lilly for their generous support of the Diabetes Disaster Plan.

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Richard F. Spark MD, FACE

Testosterone and Men’s Health -New Insights

oday’s man, especially the mature man, is under assault. Each night as he tunes into the evening news or his favorite TV sports event he cannot escape the relentless attack on his masculinity. One after another prime time advertisers remind him that he is no longer as young as he once was- he spends too much time in the bathroom trying to urinate and too little time in the bedroom having sex. He is encouraged to “Speak with your doctor.” But which doctor should he speak to about these problems? Both urination and the ability to have sexual intercourse require normal male genital function. In the past, his Urologist, someone familiar with male genital anatomy, may have been consulted to help him cope with these problems. Today, however, he might want to chat with his Endocrinologist who has a better understanding of the male sexual chemistry needed to allow a man to urinate effortlessly and acquire and maintain penile erections firm enough to allow him to have and enjoy sexual intercourse. One hormone (testosterone) plays a critical role in man’s problems with urination and sexual function as he ages. With advancing years, the testosterone made in a man’s testicles enters his blood stream and then penetrates his prostate gland. There, under the influence of an enzyme (5-alpha reductase), testosterone is transformed into another hormone dihydrotestosterone (DHT) and it is the increasing level of intraprostatic DHT that is the culprit responsible for the age-related increase in the size of a man’s prostate. His prostate gland is anatomically positioned right next to his urethra (the tube in the penis through which man urinates). Pressure from the bulging prostate on the urethra causes a blockade impeding the flow of urine, making it difficult for a man to release all the urine stored in his bladder. He is left with a sensation of fullness, as well as a need to urinate more often. Years ago, prostate surgery to whittle down the size of the prostate was the only way to alleviate pressure on the bladder so that urine could flow more freely.

Now that we know that the hormone DHT is directly responsible for prostate growth, there are other options. Some men have low DHT levels because they are born without the enzyme needed to transform testosterone to DHT. These men have tiny prostate glands that never enlarge. To mimic this experiment of nature, medications (finasteride (Proscar) and dutasteride (Avodart)) have been developed. These medications block the conversion of testosterone to DHT and short-circuit the stimulus to prostate growth. Treatment with either medication brings about a decline in the amount of DHT stored in the prostate. As DHT levels within the prostate decline, the prostate becomes smaller and no longer impinges on the urethra allowing men to urinate more freely.

Testosterone and Sexual Function in Young and Not-So-Young Men There is a moment in every man’s life, coinciding with the teenage surge in testosterone release into his blood stream, when he wakes every morning with an erection and quite suddenly starts to experience sexual feelings. The morning erections are due to a diversion of blood flow into specialized spongy tissue in his penis called corpora cavernosae. As the pressure within these areas increases, his penis swells and then becomes rigid enabling him to have sexual intercourse. As a young man, the flow of blood into his penis is free and uninterrupted so that he can experience an erection without difficulty. His interest in sex (libido) is, however, testosterone dependent. As long as blood flows freely in his body, he can experience erections; and, as long as his testicles churn out a full quotient of testosterone, interest in sex is sustained. Unfortunately, over time as a man gets older he may acquire new habits and problems that disrupt both his natural sexual energy and sexual potency. For instance, he may not always eat properly, exercises less, starts to put on weight, becomes addicted to smoking cigarettes, and could be prone to the

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development of diabetes and high cholesterol levels. These are behaviors that individually and collectively start damaging blood vessels in his body limiting the flow of blood to his vital organs. If blood flow through his coronary arteries is diminished, he has chest pain (angina), whereas leg cramps (claudication) are the natural consequence of diminished blood flow to his lower extremities. An inability to acquire or maintain an erection is inevitable if blood flow to the penis is compromised.

his emotional health and possibly his longevity as well. Recent studies indicate that when men experience depression all do not respond equally to antidepressant medication. Some men, especially those with low testosterone levels, remain depressed until testosterone treatment is added to their antidepressant medication.

Fortunately, there are now three different medications sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) to help with this problem. All increase blood flow to the erectile chamber of the penis and improve a man’s chance of acquiring and maintaining an erection in response to sexual stimulation. They were thought to be the only medication men with erectile dysfunction would need to become sexually potent again. Unfortunately, none of these medications are always effective for all men. Some men fail to benefit from these medications because in addition to low blood flow they also have low serum testosterone levels. In the original studies of sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) men with low testosterone levels were not allowed to participate. We now know why. It turns out that an enzyme within the penis nitric oxide synthetase (NOS) must be present in ample amounts for all of these erection enhancers to work. Men with low testosterone levels have low NOS levels and that is why they do not have erections after using sildenafil (Viagra), vardenafil (Levitra) or tadalafil (Cialis). Testosterone treatment normalizes testosterone levels; and, once this occurs, men can once again experience erections when they use either sildenafil (Viagra), vardenafil (Levitra) or tadalafil (Cialis). Not only is the maintenance of a normal testosterone level vital for a man’s sexual health, it now appears to be critical for

Surprisingly, there are other risks for men with testosterone deficiency. Men with low testosterone levels do not live as long as men with normal testosterone levels. In one study, 794 men had serum testosterone levels measured and then followed for 11.8 years. Those with the lowest serum testosterone level (241 ng/dl)* were more likely to have died during those 11.8 years than age-matched men with normal testosterone levels.

Testosterone and Longevity

Testosterone and the Annual Physical Today, men show up for their annual physical and can expect to have measurements of height, weight, blood pressure, A1c to check for diabetes (one out of every three men with age-related diabetes have low testosterone levels), as well as a cholesterol screen. Considering the importance of testosterone in man’s sexual, and emotional health, as well as his longevity, perhaps it is now time for serum testosterone measurements to be included as part of the routine annual physical for all men. *(280-800 ng/dl is the normal male testosterone range.) This article is concurrently being published in Review of Endocrinology

Richard Spark, MD, FACE Richard Spark, MD, FACE, received his undergraduate training at Yale and his medical degree from Case Western Reserve University School of Medicine where he was elected to Alpha Omega Alpha. His research papers have been published in several major medical journals. Dr. Spark is co-author of the recently published AACE Clinical Practice Guidelines on Hypogonadism and Erectile Dysfunction. Dr. Spark has written three books on men’s health and has also written for articles that have appeared in the New York Times Sunday Magazine and the New Republic. He and his wife have been married for 48 years and they have four wonderful children, one grandson and twin granddaughters.

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Endocrine Notes

1. 2. 3.

Ask the Expert featuring Paul S. Jellinger, MD, MACE

Do herbs like red yeast rice help to lower the cholesterol? Red yeast rice does lower cholesterol to a modest degree although these products may vary in their composition. Some may contain statins, which are the same drugs available by prescription to lower cholesterol, or derivatives of statins. Statin side effects, although uncommon and generally not severe, may sometimes be seen with red yeast rice usage. Although red yeast rice lowers cholesterol, unlike statins there are no clinical trials showing that it reduces heart attacks or strokes.

Why do some obese individuals not get complications like diabetes and heart disease while others do? Good question. Obese individuals with “insulin resistance” or “metabolic syndrome” are the persons particularly predisposed to developing diabetes and heart disease. That represents 75 to 80 percent of obese persons. Metabolic syndrome consists of abnormal lipids, high blood pressure, elevated blood sugar and weight gain around the waist. There are some “healthy” obese, but the majority of obese individuals are at risk.

Some people have said that eating cinnamon can lower blood glucose levels. Is this true? Cinnamon has very mild blood sugar lowering properties and may be minimally effective in early diabetes. It should never be used as therapy by itself for clearly elevated blood sugars. Its overall effectiveness remains questionable.

What is A1c, and how is it different from testing blood glucose?

HbA1c or “A1c” is not a blood glucose (sugar) measurement. It measure a protein found in the red blood cell that is formed in proportion to the blood glucose level. Since the red blood cell lives in our bodies for approximately 120 days, the A1C measurement reflects the average level of blood sugar control over the past two to three months. Measurement of a single blood glucose reflects just one point in time, while the A1c much more accurately reflects long-term control over the previous 60-90 days. The A1c is considered the “gold standard” in assessing control of diabetes, while an individual blood glucose level may be important in making immediate adjustments to diabetes medications or daily routines. Non-diabetic individuals have an A1c level of <6.0 percent but mostly in the low 5.0 range. Persons with poorly controlled diabetes will have an A1c >8.0 percent. AACE and the American College of Endocrinology believes that for many but not all persons with diabetes, an appropriate A1c goal is <6.5 percent. Your individual goal should be discussed with your endocrinologist or other diabetes specialist.

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Endocrine Notes

Breaking News T

he results of a study called the NICE-SUGAR study were recently released in the New England Journal of Medicine. Some have interpreted the study to mean that tight glucose (blood sugar) control for hospitalized patients can actually have a negative impact. Several months earlier, results of the ACCORD study were released, which also brought into question the value of tight glucose control, this time in the outpatient setting.

The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) caution against letting these studies swing the pendulum of glucose control too far in the other direction where providers in hospitals are complacent about uncontrolled hyperglycemia. However, recognizing the importance of glycemic control across the continuum of care, AACE and the ADA joined forces to develop an updated consensus statement on inpatient glycemic management. After a thorough analysis of all the data from clinical published trials, including the NICE-SUGAR study, AACE and the ADA believe that patients with elevations in blood glucose should continue to be treated, but to less intensive blood glucose targets. The Associations recommend revised glucose targets of 140-180 mg/dL.

The updated recommendations can be found on the AACE Web Site at www.aace.com.

What is Gestational diabetes? This common condition refers to an inability to “handle” food properly, as a result of the hormones of pregnancy working against the normal effect of insulin, and allowing the sugar in the blood to rise to dangerous levels. It occurs more commonly in women with a family history of diabetes, as well as women from certain ethnic groups, and is worsened by obesity. Often it can be treated by careful diet alone; but, in many cases, treatment with insulin injections will be necessary to protect the baby from the bad effects of the mom’s high blood sugar. These include high birth weights and the need for Cesarean sections, as well as low blood sugar in the baby at birth (hypoglycemia), which can cause seizures. Expectant mothers may be asked to check their own blood sugars after meals with a finger-prick to make sure that therapy is working correctly. Gestational diabetes is also a strong predictor of type 2 diabetes later in life. This gives a woman a “heads-up” to engage in healthy eating, regular exercise and keeping her weight in the normal range, since all of these things have been shown to actually prevent or delay the onset of diabetes and all of its complications.

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