Diabetes Care Linked to PCP Volume

Primary care physicians (PCPs) with higher overall ambulatory volumes provided lower-quality care to patients with diabetes, whereas PCPs with higher diabetes-specific volume provided higher-quality care, a large cohort study suggests.

"Although a relationship between volume and quality has previously been demonstrated with procedural and hospital-based volumes, there has been less research demonstrating associations between outpatient volumes and quality of care in chronic disease management," the researchers write. "Our study provides evidence of such a relationship in the outpatient context."

Andrew Cheung, MD, from the Department of Medicine, McMaster University, Health Sciences Centre, Hamilton, Ontario, Canada, and colleagues reported their findings online December 13 in the Annals of Internal Medicine.

This is something that most of our support group members have discovered on their own. Many PCP's try to take our members off insulin and start them back on oral medications. Our members have learned when this happens, it is time to leave and not look back. Most of our insulin using members have found a doctor that they are satisfied with seeing and those on oral medications are always asking us questions about the doctor they should see, if and when they feel the need to move to insulin.

The researchers analyzed data from provincial healthcare administrative databases to examine the relationships between overall ambulatory volume and diabetes-specific volume for PCPs and quality of care among 1,018,647 patients with diabetes in Ontario, Canada.

They used six indicators to evaluate quality of care: eye examination, low-density lipoprotein (LDL) cholesterol testing, hemoglobin A1c testing, prescriptions for angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs), prescriptions for statins, and emergency department (ED) visits for hypoglycemia or hyperglycemia.

Patients of PCPs with the highest overall volume had lower rates of appropriate eye examination, hemoglobin A1c testing, and LDL cholesterol testing — findings that were indicative of lower quality of care. These patients were also less likely to fill prescriptions for ACEIs, ARBs, or statins compared with patients of physicians with the lowest overall volume.

These findings contrasted with those for patients of PCPs with higher diabetes-specific volume. Marginal rates of appropriate eye examinations, hemoglobin A1c testing, and LDL cholesterol testing were higher among these patients, as were rates of prescriptions for ACEIs or ARBs and statins.

In addition, marginal rates of ED visits for hypoglycemia and hyperglycemia were lower among patients of PCPs with increasing overall ambulatory volume, suggesting higher quality of care, but this trend was not statistically significant.

Rates of ED visits for hypoglycemia and hyperglycemia were also lower among patients of PCPs with higher diabetes-specific volume. Patients of PCPs with lower diabetes-specific volume were younger and were more likely to be referred to an internist or endocrinologist.

"Referral to a specialist substantially improved the likelihood that recommended process measures would be achieved; however, referred patients had 3 times the rate of ED visits," Kevin A. Peterson, MD, MPH, from the University of Minnesota, Minneapolis, explains in an accompanying editorial. "Clearly, better performance on process measures does not guarantee better clinical outcomes. The study also suggests an association between higher volume of patients with diabetes and better performance on diabetes process measures, although whether this association is causal remains unclear."

He continues, "Providing an isolated focus on a single disease-based performance measure tells only part of the story and can underestimate the effect of a PCP on the medical needs of a community. Pursuing modestly higher-quality care for substantially fewer people is not necessarily a step forward. The question remains of how many patients with and without diabetes should be empaneled with a PCP so that the dual goals of comprehensive, evidence-based primary care and a manageable physician workday can be achieved."

"These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care," the researchers conclude.

The authors and editorialist have disclosed no relevant financial relationships.

Unusual Actions of Some Diabetes Drugs

Scientists have found that some drugs from a group of anti-diabetic treatments may, in certain circumstances, act on glucagon receptors in the body, meaning that they could also potentially enable the release of sugar into the bloodstream.

Researchers behind the study say that while their results are speculative at this stage, they point to a lack of complete information about the potential impact of a group of treatments known as GLP-1 agonists, or incretin mimetics.

In particular, their survey found that one such treatment has the hitherto unrecognized potential to activate receptor sites for the hormone, glucagon. This can promote the release of sugars into the blood, which is a process that GLP-1 agonists are supposed to prevent.

The paper, which is published in TheJournal Of Biological Chemistry, stresses that these are only initial findings, and that more in-depth research will be needed before “definitive conclusions can be drawn” about the existing results.

The researchers also say that there is no evidence that existing GLP-1 agonists are in any way dangerous for patients, but they do call for a more comprehensive approach to testing new drugs of this type, before they are released on to the market.

The work was carried out by a team of researchers, led by academics from the University of Cambridge and the University of Warwick. Dr Graham Ladds, from the Department of Pharmacology and St John’s College, University of Cambridge, said: “What we have shown is that we need a more complete understanding of how anti-diabetic drugs interact with receptors in different parts of our bodies.”

“GLP-1 agonists clearly benefit many patients with Type 2 diabetes and there is no reason to presume that our findings outweigh those benefits. Nevertheless, we clearly lack a full picture of their potential impact. Understanding that picture, and being able to consider all the components of target cells for such treatments, is vital if we want to design drugs that have therapeutic benefits for diabetes patients, without any unwanted side effects.”

People affected by diabetes suffer from excessively high blood sugar levels and resulting complications, caused by the fact that their body does not produce enough insulin – the hormone that enables the uptake of sugar from food. According to the World Health Organization, about 347 million people worldwide have diabetes and it is likely to become the seventh leading cause of death in the world by the year 2030. Among adults, type 2 diabetes accounts for the vast majority of cases.

GLP-1 agonists are a group of injectable drugs, which are normally prescribed to patients who have not been able to bring their condition under control through lifestyle changes or with first-stage, tablet treatments.

They work by imitating the effects of a naturally-occurring hormone, called a Glucagon-like peptide (GLP-1). This regulates blood sugar levels both by stimulating the release of insulin, and also by inhibiting glucagon, another hormone which allows the liver to release stored sugar into the bloodstream.

In addition, both GLP-1 and GLP-1 agonists have a number of other potentially beneficial effects. These include telling the brain when a person is full, and clinical trials have shown that some GLP-1 agonists can promote weight loss.

Like other peptides, GLP-1 takes effect by binding to specific receptor sites in the cells of our bodies. GLP-1 agonists are synthetic molecules which are designed to bind to these receptors in the same way.

Building on previous research, however, the new study investigated the possibility that instead of activating these receptors, GLP-1, or treatments which mimic it, might bind to the receptor for glucagon instead. This belongs to the same general “family” of receptors, but activating it could cause an unwanted side-effect for people with diabetes because it can potentially enable the release of more sugar into the bloodstream.

Although a limited number of previous studies had suggested that this was not possible, the team’s lab-based tests discovered that in certain conditions, GLP-1 can bind to the glucagon receptor. Their initial experiments, carried out on yeast containing the receptor, found that it was activated not only by GLP-1, but also by a GLP-1 agonist, which was among three such drugs that the group tested. Further experiments were then carried out in a mammalian cell culture, with similar results.

The researchers found that the decisive element was another protein called a receptor activity-modifying protein (RAMP2). When RAMP2 was present, it prevented the peptides – including the diabetes treatments – from binding to the glucagon receptors. In its absence, however, binding became possible.

Little is currently known about RAMP2. Tests in mice have, however, shown that its levels vary in different parts of the body. In the liver, where glucagon receptors stimulate the release of sugar into the blood, levels of RAMP2 appear to be lower than in other parts of the body. As a result, it is possible that some GLP-1 agonists could activate these receptors and, potentially, promote the effects of glucagon, which they are supposed to inhibit.

“The work shows that, contrary to our previous assumptions, glucagon receptors can potentially be activated by anti-diabetic treatments,” Dr Ladds added. “To date, very little work has been done on RAMPs, but they clearly play an important part in the process of regulating blood sugar, which is core to helping people with diabetes. The study shows that there is a critical need to take this into account when designing new therapeutics.”

Saturated Fats May Be Healthy

A Norwegian study challenges the long-held idea that saturated fats are unhealthy

A new Norwegian diet intervention study (FATFUNC), performed by researchers at the KG Jebsen center for diabetes research at the University of Bergen, raises questions regarding the validity of a diet hypothesis that has dominated for more than half a century: that dietary fat and particularly saturated fat is unhealthy for most people.

The researchers found strikingly similar health effects of diets based on either lowly processed carbohydrates or fats. In the randomized controlled trial, 38 men with abdominal obesity followed a dietary pattern high in either carbohydrates or fat, of which about half was saturated. Fat mass in the abdominal region, liver and heart was measured with accurate analyses, along with a number of key risk factors for cardiovascular disease.

"The very high intake of total and saturated fat did not increase the calculated risk of cardiovascular diseases," says professor and cardiologist Ottar Nygård who contributed to the study.

"Participants on the very-high-fat diet also had substantial improvements in several important cardiometabolic risk factors, such as ectopic fat storage, blood pressure, blood lipids (triglycerides), insulin and blood sugar."

Both groups had similar intakes of energy, proteins, polyunsaturated fatty acids, the food types were the same and varied mainly in quantity, and intake of added sugar was minimized.

"We here looked at effects of total and saturated fat in the context of a healthy diet rich in fresh, lowly processed and nutritious foods, including high amounts of vegetables and rice instead of flour-based products," says PhD candidate Vivian Veum.

"The fat sources were also lowly processed, mainly butter, cream and cold-pressed oils."

Total energy intake was within the normal range. Even the participants who increased their energy intake during the study showed substantial reductions in fat stores and disease risk.

"Our findings indicate that the overriding principle of a healthy diet is not the quantity of fat or carbohydrates, but the quality of the foods we eat," says PhD candidate Johnny Laupsa-Borge.

Saturated fat increases the "good" cholesterol. Saturated fat has been thought to promote cardiovascular diseases by raising the "bad" LDL cholesterol in the blood. But even with a higher fat intake in the FATFUNC study compared to most comparable studies, the authors found no significant increase in LDL cholesterol.

Rather, the "good" cholesterol increased only on the very-high-fat diet.

"These results indicate that most healthy people probably tolerate a high intake of saturated fat well, as long as the fat quality is good and total energy intake is not too high. It may even be healthy," says Ottar Nygård.

"Future studies should examine which people or patients may need to limit their intake of saturated fat," assistant professor Simon Nitter Dankel points out, who led the study together with the director of the laboratory clinics, professor Gunnar Mellgren, at Haukeland university hospital in Bergen, Norway.

"But the alleged health risks of eating good-quality fats have been greatly exaggerated. It may be more important for public health to encourage reductions in processed flour-based products, highly processed fats and foods with added sugar," he says.

The Whole Patient Finally Considered

The American Diabetes Association's2017 Standards of Medical Care include a new focus on assessment of the social, psychological, and financial circumstances in patients' lives that affect their ability to self-manage their diabetes, with the emphasis being on helping those with the condition to live as normal lives as possible. This means caring for the whole patient and not just part of the situation that the patient encounters.

For 2017, the ADA advises assessment of nonmedical factors that influence patients' abilities to self-manage their diabetes, including issues around access to care, financial barriers, and food insecurity, along with psychological or psychiatric disorders.

A new chapter called "Promoting Health and Reducing Disparities in Populations" provides guidance for promoting patient-centered care aligned with the Chronic Care Model, team-based care, and referral to local community resources for further support.

"You need to be aware of issues that impact self-management.… It doesn't do the patient or clinician any good if the clinician writes a prescription for an expensive branded medication and the patient can't afford it," Dr Ratner noted.

New recommendations for psychosocial assessment and intervention were published in a separate document November 22 in Diabetes Care. We're not just managing glucose, we're managing a human being who's trying to live a normal life.

These include evaluation for symptoms of diabetes distress, depression, anxiety, and disordered eating and of cognitive capacities, using appropriate standardized tools at initial visits, periodic intervals, or if the patient experiences any changes that merit concern, with the inclusion of family members when appropriate. Any problems found should be addressed via follow-up visit or referral.

In particular, depression is extremely common in both type 1 and type 2 diabetes and doubles the cost of care if left untreated, Dr Ratner said. "The idea is that we're not just managing glucose, we're managing a human being who's trying to live a normal life, and it's hard.… Ultimately, the person with diabetes is their own primary caregiver, and we need to be able to support them in doing that very difficult job," he said.

This seems to be the first time that the ADA has advocated anything like this. I am not aware of anything in the last seven year, but this may have been partially advocated before and fallen out of practice.

This is a good practice and may have come at the right time.

Importance of Vitamin K

Vitamin K is a fat-soluble vitamin. Originally identified for its role in the process of blood clot formation ("K" is derived from the German word "koagulation"), vitamin K is essential for the functioning of several proteins involved in physiological processes that encompass, but are not limited to, the regulation of blood clotting (coagulation). Naturally, occurring forms of vitamin K include a number of vitamers known as vitamin K1 and vitamin K2. Vitamin K1 or phylloquinone is synthesized by plants and is the predominant form in the diet. Vitamin K2 includes a range of vitamin K forms collectively referred to as menaquinones. Most menaquinones are synthesized by human intestinal microbiota and found in fermented foods and in animal products. Menaquinones differ in length from 1 to 14 repeats of 5-carbon units in the side chain of the molecules. These forms of vitamin K are designated menaquinone-n (MK-n), where n stands for the number of 5-carbon units (MK-2 to MK-14). Widely used in animal husbandry, the synthetic compound known as menadione (vitamin K3) is a provitamin that needs to be converted to menaquinone-4 (MK-4) to be active.

Vitamin K functions as a cofactor for the enzyme, γ-glutamylcarboxylase (GGCX), which catalyzes the carboxylation of the amino acid glutamic acid (Glu) to γ-carboxyglutamic acid (Gla). Vitamin K-dependent γ-carboxylation that occurs only on specific glutamic acid residues in identified vitamin K-dependent proteins (VKDP) is critical for their ability to bind calcium.

Although vitamin K is a fat-soluble vitamin, the body stores very small amounts that are rapidly depleted without regular dietary intake. Perhaps because of its limited ability to store vitamin K, the body recycles it through a process called the vitamin K-epoxide cycle. The vitamin K cycle allows a small amount of vitamin K to be reused many times for protein carboxylation, thus decreasing the dietary requirement. Briefly, vitamin K hydroquinone (reduced form) is oxidized to vitamin K epoxide (oxidized form). The reaction enables γ-glutamylcarboxylase to carboxylate selective glutamic acid residues on vitamin K-dependent proteins. The recycling of vitamin K epoxide (oxidized form) to hydroquinone (reduced form) is carried out by two reactions that reduce vitamin K epoxide (KO) to vitamin K quinone and then to vitamin K hydroquinone (KH2). Additionally, the enzyme vitamin K oxidoreductase (VKOR) catalyzes the reduction of KO to vitamin K quinone and may be involved — as well as another yet-to-defined reductase — in the production of KH2 from vitamin K quinone. The anticoagulant drug warfarin acts as a vitamin K antagonist by inhibiting VKOR activity, hence preventing vitamin K recycling (see Coagulation).

The ability to bind calcium ions (Ca2+) is required for the activation of the several vitamin K-dependent clotting factors, or proteins, in the coagulation (clotting) cascade. The term, coagulation cascade, refers to a series of events, each dependent on the other, that stop bleeding through clot formation. Vitamin K-dependent γ-carboxylation of specific glutamic acid residues in those proteins makes it possible for them to bind calcium. Factors II (prothrombin), VII, IX, and X make up the core of the coagulation cascade. Protein Z appears to enhance the action of thrombin (the activated form of prothrombin) by promoting its association with phospholipids in cell membranes. Protein C and protein S are anticoagulant proteins that provide control and balance in the coagulation cascade; protein Z also has an anticoagulatory function. Control mechanisms for the coagulation cascade exist since uncontrolled clotting may be as life threatening as uncontrolled bleeding. Vitamin K-dependent coagulation factors are synthesized in the liver. Consequently, severe liver disease results in lower blood levels of vitamin K-dependent clotting factors and an increased risk for uncontrolled bleeding (hemorrhage).

In January 2001, the US Food and Nutrition Board (FNB) of the Institute of Medicine established the adequate intake (AI) level for vitamin K based on consumption levels in healthy individuals (Table 1). The AI for infants was based on estimated intake of vitamin K from breast milk (42).

Table 1. Adequate Intake (AI) for Vitamin K

Life Stage	Age	Males (μg/day)	Females (μg/day)
Infants	0-6 months	2.0	2.0
Infants	7-12 months	2.5	2.5
Children	1-3 years	30	30
Children	4-8 years	55	55
Children	9-13 years	60	60
Adolescents	14-18 years	75	75
Adults	19 years and older	120	90
Pregnancy	18 years and younger	-	75
Pregnancy	19 years and older	-	90
Breast-feeding	18 years and younger	-	75
Breast-feeding	19 years and older	-	90

Phylloquinone (vitamin K1) is the major dietary form of vitamin K in most diets. Green leafy vegetables and some plant oils (soybean, canola, olive, and cottonseed) are major contributors of dietary vitamin K. However, phylloquinone bioavailability from green vegetables is lower than in oil and supplements. Also, the phylloquinone content of green vegetables depends on their content in chlorophyll (green pigment), so that outer leaves have more phylloquinone than inner leaves. The efficiency of phylloquinone intestinal absorption varies among plant sources and is increased with the addition of a fat source to a meal. Finally, the hydrogenation of vegetable oils may decrease the absorption and biological effect of dietary phylloquinone. If you wish to check foods for their nutrient content, including phylloquinone, search the USDA food composition database. A number of phylloquinone-rich foods are listed in Table 2, with their content in phylloquinone expressed in micrograms (μg).

Table 2. Some Food Sources of Phylloquinone

Food	Serving	Phylloquinone (μg)
Kale, raw	1 cup (chopped)	472
Swiss chard, raw	1 cup	299
Parsley, raw	¼ cup	246
Broccoli, cooked	1 cup (chopped)	220
Spinach, raw	1 cup	145
Watercress, raw	1 cup (chopped)	85
Leaf lettuce (green), raw	1 cup (shredded)	46
Soybean oil	1 Tablespoon	25
Canola oil	1 Tablespoon	10
Olive oil	1 Tablespoon	8
Cottonseed oil	1 Tablespoon	3

Dietitians Being Called Out By Bloggers

More bloggers are becoming active in highlighting the faults of the different antics of dietitian organizations around the world. Most dietitian organization officers and staff are tools of Big Food and Big Beverage and in some countries, the dietitian members are the activists for the food and beverage companies.

Yes, I call them antics because they behave like the anointed and will not put up with any debate or discussion on the topic of dietetics. When there is discussion, they say that the patients do not understand and they must reteach them the importance of diet. They must follow their directions as to the number of carbohydrates they must consume and if they have diabetes, they inform the doctor that they need more medications or a higher dose of medications.

In some countries, they monitor what patients are told and expose other dietitians, doctors, and others and they are put on notice that the dietitian is no longer a dietitian. The doctor is often charged with not being authorized to practice nutrition and brought up on charges. Other people are charged with practicing nutrition without a license and this has happened in the State of North Carolina against Steve Cooksey. Fortunately, he was able to defeat the NC dietetic board.

This is one more reason we need to be watchful as the Academy of Nutrition and Dietetics (AND) is bringing more bills before more legislatures in more states to make them the only source of nutrition and dietary advice. Under the current president of the Certified Diabetes Educators, Hope Warshaw, who is also a registered dietitian, is also making more state legislatures receive bills to make the Registered Dietitians the only source of dietary advice. This makes two organizations pushing the same information at state legislatures.

Read this by Dr. Malcolm Kendrick about some of the other dietitian acts in other countries. Then read this by Eddie at Low Carb Diabetic for his take on dietitians. It could be very informative to follow these two bloggers for other activities of dietitians.

There are other bloggers that occasionally write about dietitians, myself included, but only when something is very obvious. Most are low carb bloggers and object to dietitians that push low fat and high carb diets.

Dietitian Controversy

Recently, November 21, Candice Choi of the Associated Press published a feature article on Kellogg's Breakfast Council of “independent experts”. These are industry efforts at corporate damage control. And in cases like these, public health always takes a bath.

At least this time, the Academy of Nutrition and Dietetics (AND) were caught with their hands in the money satchel. Yes, the AND continues to be in constant controversy and this time passing off food industry marketing as education. This is what the AND officers and headquarters staff are well qualified in doing and being caught while doing it.

What was not covered in the AP's article is any reaction from the members of AND. This makes Candice Choi's article less effective and makes me wonder if the members really care and maybe they support the actions of organization.

“Highlights:

• “On its website, Kellogg touted a distinguished-sounding “Breakfast Council” of “independent experts” who helped guide its nutritional efforts. Nowhere did it say this: The maker of Froot Loops and Frosted Flakes paid the experts and fed them talking points, according to a copy of a contract and emails obtained by The Associated Press.”

• “For Kellogg, the breakfast council — in existence between 2011 and this year — deftly blurred the lines between cereal promotion and impartial nutrition guidance. The company used the council to teach a continuing education class for dietitians, publish an academic paper on breakfast, and try to influence the government’s dietary guidelines.”

• “[Kellogg] told the AP it had been reviewing its nutrition work, and decided not to continue the council. The breakfast council page is no longer online.”

• “The breakfast council was also a way to patrol for naysayers. After an advocacy group issued a report criticizing sugary cereals, Sarah Woodside, a Kellogg employee, sent the council an email explaining why it was unfair and asked them to alert her if they noticed any discussions about it.”

• “Disclosures by the council could be confusing. When two of the experts taught a class for dietitians on the “science behind breakfast,” an introduction said they were members of Kellogg’s Breakfast Council, then said they had no conflicts of interest. It said Kellogg funded the class, but had no input into its content.”

• “Marion Nestle, a professor of nutrition at New York University, said health experts usually have good intentions when working with companies, and may not realize they’re being used for their credibility.”

• “One of the breakfast council’s most notable achievements was publishing a paper defining a “quality breakfast” in a nutrition journal. Kellogg touted the paper in its newsletter as being written by “our independent nutrition experts.” Dietitians could earn continuing education credits from the publisher for taking a quiz about the paper.”

• “Kellogg didn’t describe its own role in overseeing editing and providing feedback, such as asking for the removal of a line saying a recommendation that added sugar be limited to 25 percent of calories might be “too high.”