December 17, 2016

Type 2 Diabetes from Statins

I am somewhat surprised, but appreciative that Om Ganda, M.D., Director of the Lipid Clinic at Joslin Diabetes Center is not trying to hide the fact that statins have the side effect of causing type 2 diabetes.

He does seem to be blunting the side effect, and is saying that it may be the higher doses causing problems. If you’re like nearly one-third of Americans over age 40, you probably take a statin. These cholesterol-lowering drugs are used for reducing risk of stroke and heart attack. They work by lowering the amount of LDL cholesterol, the so-called “bad cholesterol” in the blood. Statins also reduce inflammation around plaque in the blood vessels.

Despite their benefits, some people stop taking them because of side effects. The latest example, which is shown in numerous studies suggest that taking statins could increase the risk of developing type 2 diabetes. “Nobody expected it,” says Dr. Ganda.

In response to this mounting evidence, Dr. Ganda carried out a comprehensive review of all available evidence examining the association between statins and type 2 diabetes. The new review showed largely consistent results across 33 randomized controlled trials and observational studies.

“There does seem to be a slight, but significant increase in the risk of new-onset diabetes in patients on statin therapy,” says Dr. Ganda.

Of the 33 studies included in the review, one study found that taking statins was linked to a 25 percent higher risk of diabetes. However, the other studies revealed either no increase or a much smaller increase (2 to 10 percent) with various statins.

Dr. Ganda says that it’s important to note that the increased risk is over and above the risk people already have, because diabetes and prediabetes are so common today.

The review also showed that the highest risks are associated with the most intensive statin therapy. It appears that those on high-dose statins, which have a greater effect at lowering cholesterol, are more likely to develop diabetes than those on moderate-dose statins.

“The risk of diabetes is dependent on the dose of the statin – that is, how strong it is — and the correlation seems to be significant,” says Dr. Ganda. “But still, more intensive therapy is indicated because of all the evidence that we have, particularly in patients who already have cardiovascular disease.”

The reason behind the statin-induced diabetes remains unclear. “The cumulative evidence does show that most people who get diabetes on statins already have prediabetes or features of metabolic syndrome, he explains. “This means that starting statin therapy just ushers it in.

What to Think About - If you’re concerned about preventing diabetes from happening, adopting a healthier lifestyle is the first step. If you’ve been diagnosed with prediabetes and have to go on statin therapy, talk to your doctor about doing whatever is necessary to control or reverse your prediabetes. In general, that means staying active, eating a heart-healthy diet and controlling your weight.

“People should be educated about their choices,” says Dr. Ganda. “The results from this review provides yet another reason for people to monitor their diet and get regular exercise.”

Should You Avoid Statins? Despite the slight increase in diabetes risk from using statin drugs, this alone is not enough to avoid taking them, Dr. Ganda points out. “It’s important for people with diabetes not to stop initial statin therapy, because it lowers the risk of cardiovascular disease.”

Instead, he explains, statin therapy should be intensified in order to get LDL as low as possible. As we get older, our LDL cholesterol usually rises, probably due to an increase in body fat. This harmful cholesterol is what produces atherosclerosis, the buildup of plaque in the inner linings of arteries that restricts blood flow. The goal should be an LDL level below 100, closer to 70 if you have heart disease “This benchmark is stricter than it used to be because many trials have shown that the lower you get LDL cholesterol the better,” he says.

When these studies first came out some experts said that statins should not be used in the diabetes population, but that is the wrong approach, he adds. “There is no reason to avoid statins out of fear of developing diabetes. And those who do develop diabetes on statin therapy are still protected against cardiovascular disease, even after developing diabetes.”

In addition, please read this article which says in one sentence the following - “The association of statins with the risk for incident diabetes is less well understood, but in an earlier study, previous meta-analysis of 13 clinical trials of statins featuring a total of 91,140 patients suggests that the risk for diabetes associated with these medications is real.”

December 16, 2016

Clinical Trial Results Not Published

Apparently, the United States isn't the only place that clinical trials never are published. January 6,2012, I blogged about NIH-funded trials not being published. Now Canada is having the same problem and it is among universities and research hospitals where they are having the biggest problems.

The CBC of Canada reports that every year, thousands of its citizens sign up to participate in clinical trials. Like the U.S., the results of many of these trials never are published.

And new online tool aims to put pressure on some of the companies and institutions behind the problem. TrialsTracker maintains a list of all the trials registered on the world's leading clinical trials database and tracks how many of them are updated with results.

Amid pharmaceutical companies and research bodies from around the world on, maintained by the U.S. National Institutes of Health, nine Canadian universities and institutions rank in the top 100 organizations with the greatest proportion of registered trials without results.

"It's well documented that academic trialists routinely fail to share results," says Ben Goldacre, who was part of the team from the University of Oxford that developed TrialsTracker. "Often they think, misguidedly, that a 'negative' result is uninteresting — when, in fact, it is extremely useful."

The University of Toronto's David Henry says "publication bias," as it's called, is robbing the medical community and patients of important information.

"We've been deceived about the truth about treatments that we've used widely over a long period, in very large numbers of individuals, because of the selective publication of results that are favorable to the product," says Henry, a professor of health systems data at U of T's Institute for Health Policy Management and Evaluation.

But Henry adds that publication bias isn't the only reason results aren't being made public. He says many institutions haven't made it a priority.

"If you leave it to the trialists, they've often moved on to the next trial," he says. "At the end of the day, I don't think they give enough weight to it."

Please consider reading the full article here, as I only covered part of the full article.

December 15, 2016

Elderly Often Have Dehydration Problems

Dehydration in the elderly can be difficult for many doctors to correctly diagnose.
Often doctors become confused because of urinary tract infections (UTIs) and prescribe antibiotics heavily which can then lead to real UTI.

Dehydration means the body doesn’t have as much fluid within the cells and blood vessels as it should. Yes, the body can gain fluid through what we eat and drink. The body loses fluid by urination, sweating, and a host of other bodily functions. When we lose more fluid than we take in, we become dehydrated.

When a person starts to become dehydrated, the body is designed to signal thirst to the brain. Then the kidneys are supposed to start concentrating the urine to lessen the water loss in urine. However, as we age, the body's mechanisms that are meant to protect us from dehydration lose the ability to perform efficiently. The elderly often develop reduced thirst signals and become unable to concentrate their urine.

Other factors that put older adults at risk include:
  1. Chronic problems with urinary continence, which can make older adults reluctant to drink a lot of fluids
  2. Memory problems, which can cause older adults to forget to drink often, or forget to ask others for something to drink
  3. Mobility problems, which can make it harder for older adults to get something to drink
  4. Living in nursing homes, because access to fluids often depends on the availability and attentiveness of staff
  5. Swallowing difficulties
Dehydration can also be brought on by an acute illness or other event. Vomiting, diarrhea, fever, and infection are all problems that can cause people to lose a lot of fluid and become dehydrated. The elderly are more likely to be taking medications that increase the risk of dehydration, such as diuretic medications, which are often prescribed to treat high blood pressure or heart failure.

In the elderly, the most accurate way to diagnose dehydration is through laboratory testing of the blood. Dehydration generally causes abnormal laboratory results such as:
  1. Elevated plasma serum osmolality: this measurement relates to how concentrated certain particles are in the blood plasma
  2. Elevated creatinine and blood urea nitrogen: these tests relate to kidney function
  3. Electrolyte imbalances, such as abnormal levels of blood sodium
  4. Low urine sodium concentration (unless the person is on diuretics)
Doctors often sub-classify dehydration based on whether blood sodium levels are high, normal, or low.

Dehydration can also cause increased concentration of the urine — this is measured as the “specific gravity” on a dipstick urine test. However, this is not an accurate way to test for dehydration in older adults, since we tend to lose the ability to concentrate urine as we get older.

Physical signs of dehydration may include:
  • dry mouth and/or dry skin in the armpit
  • high heart rate (usually over 100 beats per minute)
  • low systolic blood pressure
  • dizziness
  • weakness
  • delirium (new or worse-than-usual confusion)
  • sunken eyes
  • less frequent urination
  • dark-colored urine
But as noted above: the presence or absence of these physical signs are not reliable ways to detect dehydration. The physical symptoms above can easily be caused by health problems other than dehydration.

So if you are concerned about clinically significant dehydration, or about the symptoms above, blood tests results may be needed. A medical evaluation for possible dehydration should also include an interview and a physical examination.

Please read the entire blog here and it explains much more about dehydration.

December 14, 2016

Eye Care for PWD

Yes, I used PWD for people or person with diabetes in the title and I am trying to use more acronyms to help people learn them and recognize them when other people use them in articles, blogs, or on social media. I have received emails asking the meaning of a few acronyms.

Yes, I have blogged about eye diseases and diabetes before, but I still receive emails asking if they should take eye diseases seriously. I always answer with the three blogs from January 21 to 23, 2014 and add this to their reading from January 4, 2014 and this blog from January 1, 2016.

I will always write about the same topics that I have written about before when I receive emails asking questions about a topic. I realize that new readers find my blogs and have questions.

To keep your vision sharp, you’ll want to take great care of your health so you can avoid problems related to diabetes. Over time, high blood sugar can damage the tiny blood vessels in your eyes. That can lead to a condition called diabetic retinopathy. High blood sugar can also lead to cataracts and glaucoma, which happen earlier and more often when you have diabetes.

Use these seven tips to take charge of your disease and protect your eyes:
  1. Schedule appointments with your eye doctor at least once a year so she can spot any problem early and treat it. During your exam, your eye doctor will use special drops to widen (dilate) your pupils and check the blood vessels in your eyes for early signs of damage.
  2. Keep your blood sugar under control. If you do that, you can slow any damage to the tiny blood vessels in your eyes. Several times a year, you should have an A1c blood test. It shows your blood sugar levels over the past 3 months. Your result should be around 6.5% or less.
  3. High blood pressure alone can lead to eye disease, so keep it in check. If you have high blood pressure and diabetes, you need to be even more careful about your health. Ask your doctor to check your blood pressure at every visit. For most people with diabetes, it should be less than 140/80.
  4. Check on your cholesterol levels. All it takes is a blood test to find out how much “bad” LDL and “good” HDL cholesterol you have. Too much LDL is linked to blood vessel damage.
  5. Eat for wellness. Go for fruits, vegetables, and lean protein. If that’s a big change for you, you can get ideas and encouragement from a nutritionist. You can also ask your doctor’s advice about when you should eat and how much is OK if you take insulin.
  6. If you smoke, quit. Lighting up causes problems with your blood vessels, which makes you more likely to end up with eye trouble. It’s not easy to kick the habit, so don’t hesitate to ask your doctor for help. Alternatively, go to a support group or quit-smoking program.
  7. Move more, if you have no medical limitations. Exercise can have a big influence on blood sugar. If you use insulin or medication to lower your blood sugar, ask your doctor when you should check your levels before and during your workouts. Also ask what type of workout you should do.

There are more ideas and if you have them, do not be afraid to use them as well.

December 13, 2016

Mildly Excessive Body Iron Increases Risk of Type 2

I am thankful that The University of Eastern Finland developed this study and that Science Daily printed their information. Several of the post menopausal women in our support group were also happy when I sent them the link to this as they had been having several conversations with different doctors lately about anemia and this gave them another concern, but as Brenda told me, this is good to know. She sent the link to her daughter, as she wanted to let her know about this study.

Even mildly elevated body iron contributes to the prevalence and incidence of type 2 diabetes, according to research from the University of Eastern Finland. Excess body iron accumulation is a known risk factor of type 2 diabetes in hereditary hemochromatosis, but the results presented by Dr Alex O. Aregbesola in his doctoral thesis show that elevated iron is a risk factor in the general population as well, already at high levels within the normal range.

In addition, a gender difference was observed in the risk and prevalence of type 2 diabetes, to some extent due to different body iron accumulation between men and women. Men had 61% higher prevalence and 46% increased risk of developing type 2 diabetes when compared to women. At comparable age groups, men were found to accumulate more iron than women do, and iron explained about two-fifths and one-fifth of the gender difference in type 2 diabetes prevalence and incidence respectively.

Moderate iron stores are safer than depletion toward iron deficiency and possible anemia.

Body iron predicted the risk of type 2 diabetes. There was a slight variation in the risk of type 2 diabetes over a wide range of serum ferritin (sF) concentrations that reflect body iron stores, with a marked increase in the risk observed at high normal range of sF concentrations in men (>185 µg/L). However, iron depletion toward deficiency as reflected by serum-soluble transferrin receptor concentrations did not offer protection against type 2 diabetes; rather, there was a U-shaped type of association between iron stores and the risk of type 2 diabetes which showed that the risk was lowest on moderate levels.

"Hence, a safe range of body iron stores in men with regard to the risk of type 2 diabetes may be 30-200 µg/L of serum ferritin," Dr Aregbesola says. The association between body iron and impaired glucose metabolism was strongest among people in prediabetes states.

Abnormalities in glucose metabolism and type 2 diabetes are on the increase globally, and the prevalence of diabetes among adults is estimated at 642 million by 2040. Reduced quality of life and increased mortality due to type 2 diabetes and its complications are of great concern. Preventive measures targeted at established risk factors of type 2 diabetes, such as excess body weight or obesity, physical inactivity and poor nutrition need further exploration. This may be a key and signifies the need for further studies.

Unhealthy dietary habits associated with the surge of type 2 diabetes include excess dietary intake of iron and unregulated iron supplement use. Iron is a micronutrient that is required in the formation of some essential body proteins and enzymes, like hemoglobin, cytochromes and peroxidase. However, it is harmful when stored in excess in the body. It promotes the release of free radicals that damage the secretory capacity of beta cells of pancreas to produce insulin. It also decreases insulin sensitivity in peripheral tissues and organs involved in glucose metabolism.

The doctoral thesis is based on studies where the main aim was to examine the associations between body iron stores and glucose homeostasis and type 2 diabetes among middle-aged men and women representing the general population and living in the eastern part of Finland. The thesis investigated the risk of type 2 diabetes over a wide range of body iron stores, as well as whether iron depletion toward mild iron deficiency offers protection against type 2 diabetes risk. The types of associations between body iron stores and glucose homeostasis were examined in the three glycemic states ‒ normoglycemia, prediabetes and type 2 diabetes, using markers of insulin resistance and beta cell function. Gender differences and the contribution of body iron accumulation to any gender difference in type 2 diabetes were also investigated.

"This study provides a new body of evidence that mildly elevated body iron is an important risk factor of glucose metabolism derangement, which contributes to the increase in the prevalence and incidence of type 2 diabetes," Dr Aregbesola concludes.

December 12, 2016

Am I to Blame for My Diabetes?

This is a topic that just won't go away, especially when doctors blame them for their diabetes. Jason called Max and I to come to his house last evening as he had a fellow that was blaming himself for his diabetes. We both arrived and when introduced, we could understand why Jason had chosen us. The fellow was definitely overweight, but not obese.

Jason asked Max to explain how he handled his diagnosis of diabetes. Max said self-blame was easy because he was obese. He said his doctor had not blamed him and actually wanted to help him. Next Jason asked me the same question. I said that self-blame was on my mind, but since I knew many relatives had type 2 diabetes and my brother had type 2 diabetes, self-blame did not last long.

I added that my biggest problem was moving out of the past and living in the now took several months. I fortunately, at the time, had a neighbor that was a nurse and she would call occasionally to inquire how I was changing my food plan and telling me to keep a positive attitude. This really helped and caused me to do a lot of research and find books I could really rely on to help me.

Next, I asked the fellow why he was blaming himself. Albert said because his doctor had blamed him for developing diabetes. He then added that he had a sister with type 2 diabetes and several other relatives with type 2. Albert then thanked me for reminding him of this and now he would be able to move on and stop blaming himself.

Albert then asked me what I was talking about when I said moving out of the past and living in the now. Max stated that many of us experience this. We deny our diabetes or accept it but still try to live like we had been living, figuring that the medication will meet our needs. I said this is accurate and you can add fear of the unknown future when you are told little about what you need to do to manage diabetes.

Albert said that should not affect me as my doctor has been giving me a lot to read on the Internet and book titles. Jason asked why he had not mentioned
much of this earlier. Albert said he wanted to hear what we were thinking. He admitted this was part of his way of learning what others had to say about diabetes. Jason then told him to start with what he has learned before meeting his two friends. Albert said he had learned about the low-carbohydrate, high fat
(LCHF) food plan and managing his diabetes with insulin. That by following this his insulin needs would be considerable less than following the ADA food plan or the recommendations of the registered dietitians.

We all agreed he was on the right plan and if his doctor had him on insulin, we needed the name of his doctor with the advice he had received. Jason said he would let us know later, but he felt satisfied that Albert's self-blame would stop shortly.

December 11, 2016

Our December Meeting

December 10 was our last meeting of the year. Brenda had her daughter present the topic of dehydration for the elderly. Allison started by stating she was not a doctor and as such she may not cover everything and may not be able to answer some questions.

She asked for a show of hands of how many may be concerned about becoming dehydrated. All hands went up and she said she hoped what she had prepared would help. Next she asked how many had read Bob's blog of the current week on this. Most of the hands went up and then she asked how many had read the link he had in the blog. Several hands were lowered. Allison said Bob has many blogs on dehydration and I will mention a few of these at the end.

Dehydration has medical consequences and these depend on the severity of dehydration and how long it has been developing or been in existence. In the elderly, weakness and dizziness can provoke falls. And in people with Alzheimer’s or other forms of dementia, even mild dehydration can cause noticeable worsening in confusion or thinking skills.

Dehydration often causes the kidneys to become inefficient, and in severe cases may even cause acute kidney failure.

The consequences of frequent mild dehydration. meaning dehydration that would show up as abnormal laboratory tests but otherwise doesn’t cause obvious symptoms, are less clear.

Chronic mild dehydration can make constipation worse. Another health problem that has been consistently associated with low daily water intake is kidney stones.

A review on fluid intake and urinary system diseases concluded that it’s plausible that dehydration increases the risk of urinary tract infections, but this is not definitely proven.

Talking about urinary tract infections (UTIs), if you are concerned about frequent bacteria in the urine, you should make sure this reflects real UTIs and not simply a sign of the elderly person’s bladder being colonized with bacteria.

This is a very common condition known as asymptomatic bacteriuria, and incorrectly diagnosing this as a UTI can lead to pointless overtreatment with antibiotics.

The treatment of dehydration depends on:
  • Whether the dehydration appears to be mild, moderate, or severe
  • What type of electrolyte imbalances (such as high/low levels of sodium and potassium) appear on laboratory testing
  • If known, the cause of the dehydration

Mild dehydration can usually be treated by having the person take more fluids by mouth. Generally, it’s best to have the person drink something with some electrolytes, such as a commercial rehydration solution, a sports drink, juice, or even bouillon. But in most cases, even drinking water or tea will help.

Moderate dehydration is often treated with intravenous hydration in urgent care, the emergency room, or even the hospital. Some nursing homes can also treat dehydration a subcutaneous infusion, which means providing fluid through a small IV needle placed into the skin of the belly or thigh. This is called hypodermoclysis, and this is actually safer and more comfortable for seniors than traditional IV hydration.

Severe dehydration may require additional intervention to support the kidneys, and sometimes even requires short-term dialysis.

Experts generally recommend that older adults consume at least 1.7 liters of fluid per 24 hours. This corresponds to 57.5 fluid ounces, or 7.1 cups. Clinical research hasn’t compared different fluids to each other to determine which fluid is the best to treat dehydration.

As to whether certain fluids are dehydrating, probably the main fluid to be concerned about in this respect is alcohol, which exerts a definite diuretic effect on people.

The effect of caffeine on causing people to lose excess water is debatable. Technically caffeine is a weak diuretic. But studies suggest that people who are used to drinking coffee don’t experience much diuretic effect.

Now, caffeine may worsen overactive bladder symptoms, so there may be other reasons to be careful about fluids containing caffeine. However, coffee and tea are not proven to be particularly dehydrating in people who drink them regularly.

The safest approach would still be to drink decaffeinated drinks. But if an elderly person particularly loves her morning cup of (caffeinated) coffee, I’d say to consider accommodating her if at all possible.

Bob has written about hydration myths here and here and these can be important. If you are having leg cramps read about the causes here. Then please read about the 14 forgotten caused of dehydration. The last blog you should consider is about low blood pressure.

Then Allison opened the discussion for questions and answers and this lasted for longer than she had expected and finally asked if another meeting would help. Yes, was the answer and Brenda suggested the May 2017 meeting and this was agreed.

Brenda asked for cleanup and Allison came to thank me for all the material I had in my blogs to help her with the discussion.