U.S. Teen Diabetes Higher than Estimated

More teens in the U.S. have diabetes or prediabetes than previously thought.

Many also don't know they have this disease, a new study discovered. Nearly 1 percent of more than 2,6-- teens studied had diabetes, with almost one in three cases undiagnosed. Of the 2,600, almost 20 percent had prediabetes – in the range of 100 mg/dl to 125 mg/dl.

"These findings are important because diabetes in youth is associated with early onset of risk factors and complications," said lead researcher Andy Menke of Social & Scientific Systems in Silver Spring, Md. One prior study estimated the prevalence of diabetes in teens at about 0.34 percent, but the current study shows it's double that -- 0.8 percent.

The researchers couldn't distinguish between teens that had type 1 or type 2 diabetes. However, previous research among children and teens with diabetes found that 87 percent had type 1 diabetes, previously called juvenile diabetes.

While type 1 diabetes, an autoimmune disease, isn't preventable, type 2 is usually related to lifestyle factors. Type 2 is generally seen in adults, but experts say it's risen among younger people as obesity rates have soared.

Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City says, "It is alarming to see such a high incidence of [childhood] diabetes when it should be close to zero.” “The very high prevalence of prediabetes, diabetes and especially undiagnosed diabetes in adolescents is worrisome," he added. “The majority of those with prediabetes will develop diabetes if nothing is done to change their lifestyle,” Zonszein concluded.

African Americans and Hispanics were more likely than whites to have prediabetes or not know they had diabetes, the study found. There are effective treatments, but those treatments are not useful to people who have not been diagnosed. Untreated, diabetes can lead to heart disease, circulatory problems, vision loss, and amputation of feet and legs.

Classic symptoms include increased urination, increased thirst, weight loss (due to dehydration), and perhaps increased hunger and blurry vision. Previous studies have found that both type 1 and type 2 diabetes are increasing among adolescents.

According to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases, being overweight or obese is the main cause of type 2 diabetes. People at high risk can prevent or delay its onset by losing 5 percent to 7 percent of their weight, the agency says. Because type 2 is considered lifestyle-related, better education on reducing risk factors for type 2 and improved screening for adolescents at high risk is needed. The agency recommends at least 30 minutes of moderate-intensity physical activity five days a week, and reducing daily calorie consumption.

Of 62 teens with diabetes, 29 percent didn't know it. Prevalence of prediabetes was 18 percent, and more common in boys. Among the diabetic teens, nearly 5 percent of whites had not been diagnosed versus 50 percent of the African Americans and 40 percent of Hispanics.

Update on Those with Foot Problems

We now have seen all four that have serious foot problems. All four are off the SGLT2 Inhibitors, thankfully. They are now using insulin and doing much better.

The fellow with the infected cracked heel did have the start of gangrene, but the doctor operated and removed it. It will take several months for this to heal and he is on crutches for several months so that he can keep his weight off it. The doctor said the chances of success were good and it is now up to him to treat it and keep his appointments for the doctor to examine it weekly for at least two months. At that time, the doctor will reevaluate it and see him every two weeks and then possibly monthly.

When we had our meeting with them, all were thankful we had forced the issue and taken them directly to the emergency room. The fellow that had two foot ulcers is also using crutches and said he will be seeing his doctor every week for possibly two months and then the doctor will reevaluate and possibly change the frequency of checkups.

The other two are also using crutches and are also seeing their doctor every week for a month and then they will be reevaluated for longer times between appointments. Max and Barry were very happy that with how serious they had looked and now having them being able to get around with crutches, that the most serious threats were behind them. Jerry said that the fellow that thought he had LADA really had type 2 diabetes and the hospital confirmed this with the correct tests. He decided to stay on insulin because of the level of management he is achieving.

The five profusely thanked us and said they had learned a lot in the last week and now know how important caring for their feet is. Two said they will be adding a podiatrist to their diabetes team and the other three said they were changing doctors that would check their feet on a regular basis. All are planning to remain on insulin and three have submitted their papers to be seeing the Veteran Affairs doctors yet this year.

All five want to join our support group and we will recommend them at our new member meeting in October. We have decided as a support group to add members in the month of October and plan our meeting accordingly. Tim said he would schedule accordingly and have one or both nutritionists and our CDE available to do a presentation and answer questions.

We are discussing in groups and by email the idea of assessing dues in the amount of $15 split into three months. Many are in favor, but a few are against dues. This will be the subject for our September meeting and this is why we are talking about this now to find out where the opposition is and their reasons. Most of us feel the dues should go to speakers, but others have other ideas. Several of us feel we will lose some members if we have dues, but now we are discussing if this will be a good or bad thing.

The potential new members feel that the dues are reasonable and they feel we have earned it and that paying for speakers would be a good thing. Tim said that at present, all but one of the potential new members favor having dues.

Tim said that many of those opposing $15 dues would accept $10 dues and this is being discussed also.

'Gender' Needs to Be Part of Treatment

This is the first time I have seen this discussed by almost anyone specifically. This is coming from the Medical University of Vienna.

They declare that the international guidelines for the management of type 2 diabetes mellitus purport to observe factors such as age, social environment, the duration of the illness, or associated health complaints. The factor gender is not included. They state that this is becoming an ever-growing issue because men and women bear different risks and fall victim to and suffer from a different type of diabetes. This indicates that the treatment should be increasingly more gender-specific and thus personalized.

This is the most important realization of a review regarding the status of gender-specific differences authored to this holistic extent for the first time worldwide, to which the MedUni Vienna researchers Alexandra Kautzky-Willer and Jürgen Harreiter (both of the University or Internal Medicine II, Gender Medicine Unit) participated.

The review was published in Endocrine Reviews, the journal in endocrinology with the highest impact factor 21,059 by far. In addition, the article from the MedUni Vienna scientists was featured prominently on the cover of the journal.

The following is key. Other risk factors, genetic disposition, and biomarkers in women and men, the facts clearly speak for a gender-specific consideration and treatment of diabetes mellitus, which affects approximately 600,000 Austrians. From a biological aspect, men are principally at a higher risk of contracting diabetes mellitus; women are "protected" for a while due to the increased disbursement of the estrogen hormone until menopause causes a hormonal change and reduces this protection.

In most cases, the risk for men is increased because they have a greater amount of stomach fat and more liver fat and a lower sensitivity to insulin, even if they are not overweight. However, the lack of testosterone in men is a risk factor, whereby women with a greater amount of male sexual hormones are principally at a higher risk.

"In contrast, it was shown that the thigh fat, which is more frequent in women due to genetics and estrogen, can even have a protective effect. On the other hand, the stomach circumference in women has a better diabetes predictive power than in men," states Kautzky-Willer, diabetes expert and Austria's first professor for gender medicine. "In women, also psychosocial stress, stress on the job as well as lack of decision-making competency at high performance pressure or lack of sleep more frequently lead to diabetes than in men. This is often also intensified due to weight gain." On the other hand, men are more at risk of developing diabetes at a later point in life, if their mothers suffered malnutrition during pregnancy.

There are also gender-specific differences in the biomarkers, which can aid in the early detection of the diabetes risk: so are the protein Fetuin-A formed by the liver as well as Copeptin (a prohormone formed in the hypothalamus), and proneurotensin (a neurotransmitter) promising biomarkers in women, yet not in men. Here, the hormone Leptin, which sends chemical messages to cease eating and to harvest energy from the reservoirs, such as fat depots, is a strong biomarker.

Also environmental impacts as risk factors for diabetes. Also endocrine disruptors, meaning hormone-active substances, become increasingly important," emphasizes Jürgen Harreiter. Studies showed that synthetically manufactured substances such as Bisphenol A or Phatalate (softening agent), which are contained in many plastic items, are considered risk factors for diabetes - depending on age, also here there are different effects in men and women.

There are also regional differences: More and more women in Oceania, South and Central Asia, as well as the Middle East are contracting diabetes, whereas the illness concerns more and more men in more affluent areas of the Pacific-Asia region as well as in central Europe.

In the future, the mentioned gender-specific factors in case of diabetes are to be incorporated in the praxis (the practice) more than ever. Here, MedUni Vienna is playing a leading role throughout Europe, particularly with the internal network of researches at the University for internal medicine III with gynecology, the Excellence Centre for Hochfeld-MR, nephrology, the centre for Public Health but also with the Institute for the science of complex systems as well as strong international cooperation. ÖDG (Austrian Diabetes Society) with Kautzky-Willer as Deputy Chairperson and many MedUni Vienna scientists in leading positions, is worldwide the only one with gender-specific guidelines in their program.

Why Is the Best Diabetes Treatment Unavailable to Us?

Yes, diabetes education is by far the best treatment for diabetes, but why is this treatment so seldom taught to people with diabetes. This is a blog to answer a speech by Dr. Margaret Powers at ADA last month. Dr. Powers asked why access is so low. She is the current President of Health Care and Education at the American Diabetes Association and promotes diabetes self-management education, or DSME for diabetes patients.

Her speech could have been more effective if she would have declared that DSME was for people with type 1 diabetes. Then she could have correctly stated that only 7% of individuals with private insurance and 5% of those on Medicare receive this type of diabetes education. Those numbers are much lower than many would expect.

In her address, titled “If DSME Was a Pill, Would You Prescribe It?”, Dr. Powers argued that diabetes education is one of the best treatments available. She received a standing ovation from the packed ballroom, arguing that access to education must improve.

“Here are three highlights from her presentation:

1. If diabetes education were a medication, it would score highly across the official ADA/EASD diabetes management criteria: efficacy, hypoglycemia risk, weight loss, other side effects, and costs. Studies have shown diabetes education provides significant reductions in A1c and the risk of hypoglycemia, improves weight loss and other side effects, and is reimbursable by Medicare and most private insurers.

2. Diabetes education can increase healthcare savings. Dr. Powers pointed to one notable study (Health Care Use and Costs for Participants in a Diabetes Disease Management Program, United States, 2007-2008) that found the average annual hospital charges for 33,000 patients who received any education was 39% less than the yearly average for those who received no education.
3. Diabetes education provides psychological benefits that medications do not. Dr. Powers shared that education reduces diabetes distress and the often hidden emotional burdens that come with managing diabetes (see past diaTribe coverage on distress with insight from Dr. Bill Polonsky). Studies show diabetes education also improves quality of life, coping skills, knowledge, self-care behaviors, healthy food choices, and physical activity.”

The above is true, but much of this excludes people with type 2 diabetes. What Dr. Powers fails to talk about is lighting a fire under the members of the American Association of Diabetes Educators (AADE) and especially the insurance cartel to properly pay CDEs for their time if they actually teach education.

Many do little education and most use mandates, mantras, and dogma instead of education. Then when they also have a second title of registered dietitian, most of these dual titled CDEs switch to teaching nutrition and do no diabetes education. Our support groups knows this from first hand experience and they refuse to do any diabetes education when the insurance companies notify them that the session is for diabetes education only.

Most CDEs refuse to work with people with type 2 diabetes. Considering the numbers of CDEs that work full-time as CDEs, it is not surprising that there are so few CDEs available to work with people with type 2 diabetes.

Have You Been Checked for Diabetic Retinopathy?

Maybe I have been fortunate because at three months after diagnosis, I had an eye examination to establish a baseline for the condition of my eyes. Even though I had been diagnosed late, I had no indication of diabetic retinopathy. Because of my age, I have had an eye examination at least once a year since and when the cataracts started, it has been every six months.

I have now completed the cataract surgeries and I am still wearing glasses, but much less strong a prescription. I will be checked again in November because of other problems, which were caused by torn retina repairs in both eyes, but I still feel very fortunate with my eyesight.

The Australian study is somewhat of a disappointment as they state that general practitioners are waiting about three years before referring patients to have an eye examination done. If diabetes management is poor, a lot of damage can be done in three years. If diabetes management is good, then seldom will there be any damage, but I would not like to be in that situation.

An average delay of 3.1 years for an initial diabetes eye exam was found in a recent Australian study. The findings were published online in a letter to the editor in Clinical & Experimental Ophthalmology.

Brigitte M. Papa, MD, from the University of Melbourne in Australia, and colleagues examined current general practitioner (GP) management practices for diabetic retinopathy screening in a cross-sectional survey of 598 GPs in Victoria. The survey comprised 12 questions relating to diabetic retinopathy screening. Data were included from 198 responses to the survey, of which 175 were complete.

Overall, 53% of GPs reported that they referred newly diagnosed individuals for an eye check at the time of diagnosis; 23% referred patients at 1 year or more after initial diagnosis.

Ninety-seven percent of GPs reported referring patients with type 2 diabetes for diabetic retinopathy screening at least biennially. However, only 55% and 39% of GPs verified patient uptake of the first eye referral and confirmed receipt of a report from the eye health professional following the first eye assessment, respectively.

This study signals the need for better systems of care to support diabetic retinopathy screening and, ultimately, improve long-term visual outcomes for persons with diabetes.

The American Diabetes Association recommends an eye checkup every second year and this may be okay for some individuals, but people with diabetes should follow the directions of their eye care professional.

Several of our members are also now being considered for cataract surgery and it is surprising how many of the newer members have never followed through in having there eyes checked. A.J was really shocked as he remembers the endocrinologist telling him to have an eye checkup and a teeth checkup and the two of us talking about this on the way home.

A.J said he did not want a meeting this early, but felt that the first meeting in September should cover this topic and other things that needed to be done. We have covered taking care of our feet, but not the other points that need to be done after diagnosis. I agreed and said we needed to talk to Tim.

Suicide Risk Increases In Bariatric Surgery Patients

Using the search terms “suicide among bariatric surgery patients,” I found several articles on studies about the suicide risk increase in patients having bariatric surgery.

This study, published online October 7 in JAMA Surgery says - suicide attempts increase substantially in morbidly obese patients in the years following bariatric surgery, when the "honeymoon" period of substantial weight loss comes to an end.

Mental health has been discovered to be the main culprit during the 5 years preceding the surgery. Patients with morbid obesity are more likely to have mental health problems than the general population anyway, so we see a higher prevalence of mental illness diagnoses prior to bariatric surgery,"

Many patients do benefit from the surgery; a small proportion of patients may experience self-harm issues. We are suggesting is that they be referred back to the appropriate mental health professional after surgery so that any potential for self-harm can be dealt with.

Investigators carried out a population-based, self-matched longitudinal cohort analysis of patients living in the province of Ontario who underwent bariatric surgery. A total of 8815 patients underwent bariatric surgery during the 5-year enrollment period, almost all of whom underwent the Roux-en-Y gastric bypass procedure.

A total of 111 patients (1.3%) of the cohort had at least one self-harm emergency before or after surgery, including 11 patients who had emergencies in both periods ― 37 in the preoperative period, and 63 in the postoperative period. Most events were reported in women, in patients aged 35 years or older, and in those living in urban areas. Intentional self-poisoning by medication was the most common means of attempted suicide, accounting for 73% of all suicide attempts. Physical trauma accounted for about 21% of the events. Almost all events were considered of high triage urgency and resulted in hospitalization.

Most bariatric surgery programs do offer mental health consultations before the surgery to ensure that candidates are suited to undergo the procedure. They found in the current study, the period for mental health support may need to be considerably longer for some patients. Suicide attempt rates were distinctly accentuated in patients living in lower-income and rural areas.

The authors note "patients with a history of major depression similarly accounted for almost all events, suggesting that such patients also merit a comprehensive risk assessment."

In an accompanying editorial, Amir Ghaferi, MD, and Carol Lindsay-Westphal, PhD, Veterans Administration Healthcare System, Ann Arbor, Michigan, note, "the study has two important findings." First, the preoperative incidence of self-harm emergencies in patients undergoing bariatric surgery is twice that of the population in general and increases by an additional 50% in the postoperative period. Clearly there is significant room for improvement to identify ideal screening tools, protocols, and follow-up, they suggest.

"Secondly, most self-harm emergencies occur in the second and third postoperative years," they point out.

Most bariatric surgery programs focus on the first postoperative year, when most weight loss occurs. Given the findings of the current study, "data support the call for long-term follow-up in bariatric surgery, especially for patients with a history of major depressive disorder and/or self- harm."

Commenting on the study for Medscape Medical News, Sanjeev Sockalingam, MD, associate professor of psychiatry, University of Toronto, in Ontario, noted that most patients who come for bariatric surgery have a lifetime history of a formal psychiatric illness. Dr Sockalingam is also director of psychiatric assessment in a large-volume bariatric surgery program at the Toronto Western Hospital.

"What I think this signals is that obesity and mental health have a really close bidirectional relationship," Dr Sockalingam said. One thing the current study did not do is look at what happens to severely obese people who do not undergo bariatric surgery, which would have made for an interesting comparison, he added.

In a broader context, Dr Sockalingam believes the study clearly shows how important it is to screen patients not just before they undergo bariatric surgery but over the long term. "Having a history of psychiatric illness is not a reason not to undergo surgery," Dr Sockalingam said.

"It is really about making sure that people have appropriate support, that their mental health condition is appropriately managed and stable, and most importantly, that they have appropriate access and follow-up for their mental health as they go through their postoperative journey."

Since 2009, there has been a mandated 5-year follow-up period in bariatric centers in the province of Ontario. Dr Ghaferi reports receiving salary support from Blue Cross Blue Shield of Michigan as director of the Michigan Bariatric Surgery Collaborative. None of the other study authors nor Dr Sockalingam have disclosed any relevant financial relationships.

Quality of Life after Bariatric Surgery

Weight loss surgery is helping in the reduction of Type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, sexual dysfunction, and even the mortality rate.

Bariatric surgery is recommended by the National Institute of Health for Obese patients with a body mass index (BMI) of at least 40 or less obese patients with serious coexisting medical condition I and a BMI of at least 35. According to National Health and Nutrition Examination Survey, 34% of Americans have metabolic syndrome, with a waist circumference greater than or equal to 102cm (men) or 88cm (women); triglyceride greater than or equal to 150 mg/dl, HDL less than 40 mg/dl (men) or 50 mg/dl (women); hypertension greater than or equal to 130/85 mmHg; and fasting glucose greater than or equal to 100 mg/dl.

The purpose of this study is to determine whether surgical weight loss helps in the reduction of type 2 diabetes and decreases mortality rate. Numerous prior studies have demonstrated a connection between drastic surgical weight loss and an improvement in type 2 diabetes, as well as a decrease in mortality rate. The primary endpoint of bariatric surgery is weight loss. The overall percentage of excess weight loss (EWL) is 47-70%. A systematic review discovered EWL greater than 50 %. A meta-analysis study also concluded that adjustable gastric banding (AGB) is associated with less weight loss.

In another prospective observational study, 4,776 consecutive patients undergoing a bariatric surgery reported a low mortality rate of 0.3%. There are a number of complications associated with surgical weight loss surgery, about 70%, such as myocardial infarction and pulmonary embolism, which are the major causes of mortality. Those with higher mortality rate after bariatric surgery are patients with a higher BMI, males, older age, smokers and those with multiple comorbidities.

Observational and meta-analysis both demonstrate that bariatric surgery is effective in controlling type 2 diabetes, decreasing anti-diabetic drug usage and a high remission rates. Of the 135,246 subjects using meta-analysis, 78% had complete resolution with HbA1c less than 6.5%. However, factors like shorter duration of diabetes, greater weight loss, and former oral antidiabetic drug usage are some of the anticipating reasons of type 2 diabetes remission. For clinical outcome, a study performed by Brethauer et al performed between 2004 and 2007 had a mean estimated weight loss of 55% and a mean HbA1c, which decreased from 7.5±1.5% to 6.5±1.2%.

In another study organized at Cleveland clinic, 150 patients with T2DM were randomized to conventional medical therapy with HbA1c level of 7.5±1.8% in the medical therapy group. For the mortality rate, a meta-analysis of 44,022 subjects from eight trials demonstrated a reduced risk of global mortality with (OR =0.58, CI 0.49-0.63).

Another study was organized to determine whether bariatric surgery improves one’s sexual function. Patients undergoing this procedure fill gender relevant questionnaires, whereby their sexual performance is assessed. This is done before the surgery and 6-7 months after surgery. A statistical analysis test was done using SPSS 11.0 software. Continuous variables were compared using student t-test for independent samples. Of the 51 patients who underwent the surgery, 48 of them finished the second half after the 6-7 months post-surgery questionnaires. With a P less than 0.001, the results were statistically significant. Of the 43 women, 20 of them had a Female Sexual Function Index (FSFI) score of 24.66 before surgery, indicating a sexual dysfunction; but only 4 remained with dysfunction after post-surgery. This indicated a P less than 0.001. For the men, there was a baseline of 40.2 to 43.9, so they did not achieve statistical significance. This study shows that weight loss positively influences sexual function in the obese population. A limitation of this study included a low response by bariatric patients.

In conclusion, there have been a number of studies that have broadened our knowledge on the safety and efficacy of bariatric procedures and the effect on obesity, type 2 diabetes, and sexual dysfunction. The surgery therefore helps to improve one’s quality of life.