Doctors embrace bariatric surgery as effective treatment for diabetes

Fifty international scientific and medical experts have issued a "consensus statement" declaring that bariatric surgery should be considered a treatment option for patients with Type 2 diabetes, even if they are not extremely obese.

The new guidelines, published today online in the Annals of Surgery, urge surgeons performing bariatric surgery and healthcare insurers reimbursing for such treatment to relax criteria, adopted in 1991, that have restricted such surgery to patients with a body-mass index of 35 or more.

Reviewing more than a decade's worth of studies on weight-loss surgery and diabetes, clinicians and researchers backing the document have concluded that the improved metabolic function that is typical in diabetic patients who undergo bariatric surgery is not merely an incidental effect of weight loss. "Surgery is a specific treatment for diabetes...the effect on diabetes is a direct consequence of the new anatomy created by surgery," said lead author Dr. Francesco Rubino, director of the gastrointestinal metabolic surgery program at New York-Presbyterian Hospital/Weill Cornell Medical College.

The implications, added Rubino in an interview, "are enormous." For starters, that finding should drive a broadening of the patient population offered the option of gastric bypass surgery or less invasive procedures that reduce the capacity of the gastrointestinal tract. Rubino said that patients with Type 2 diabetes that is poorly managed by diet, exercise and medicine should now routinely be assessed as surgery candidates.

Some of those will likely be far less overweight than the bulk of patients who have had the surgery for weight loss. Rubino cited the example of diabetic patients of Asian descent, who rarely reach a BMI of 35 but who might benefit from bariatric surgery.

For the more than 20 million Americans -- and counting -- thought to have Type 2 diabetes, bariatric surgery may offer more than just another treatment option. Research shows that for many patients, diabetes abates dramatically and permanently with surgery. That, said Rubino, makes the possibility of a "cure"--a prospect not discussed until very recently--real for many patients who have been told that "living with diabetes" is the best they can do.

Beyond that, said Rubino, clinicians caring for these patients will need to optimize their pre- and post-operative care to serve a new objective: that of improving metabolic function. Currently, many bariatric surgery patients continue on diabetes medicines after their operation when that might not be optimal or even necessary.

Finally, the consensus finding should guide the search for drugs that can better treat Type 2 diabetes. Those should focus on how metabolic function is changed by an alteration of the gut's anatomy, and whether drugs could be developed or adapted to work in the same way, Rubino said.

-- Melissa Healy

Obesity and type 2 diabetes grow in tandem, along with the health risks, research finds

Escalating obesity rates are no secret in this country, but seeing the statistics is a sober reminder of the health risks of being severely overweight.

A study published last week in the Journal of Diabetes and its Complications provided some numbers on obesity and morbid obesity among diabetics and non-diabetics in the U.S., showing how weight has increased over the years. Researchers from Loyola University Medical Center in Illinois looked at data from the National Health and Examination Surveys from 1976 through 2006. They focused on body mass index, waist circumference and prevalence of obesity (a BMI of 30 or more) and morbid obesity (a BMI of 40 or more) for 4,162 men and women with type 2 diabetes, and 40,376 without.

Among adults with type 2 diabetes, over the 20 years average BMI increased 17%. Among nondiabetics it rose 11.5%. Total obesity among adults with diabetes increased by 58%, and among adults without diabetes it rose by 136%. Morbid obesity rose by 141% among diabetics and 345% among non-diabetics. All groups showed a significant growth in waist circumference.

The study also found that one out of five people with type 2 diabetes is morbidly obese, and among African Americans with type 2 diabetes, one out of three is obese.

Among the culprits for the rise in figures, say researchers, are the availability of inexpensive food, larger portions of food, and soda consumption.

In the study, the authors wrote, "The rapid rise of obesity among adults with type 2 diabetes has important implications for the future health of this population. Although cardiovascular risk among adults with type 2 diabetes remains high, obesity itself heightens risk of cardiovascular mortality, especially among women."

-Jeannine Stein

Photo credit: Rogelio V. Solis / Associated Press

Don't blame Starbucks: Cops may have poorer health due to night shifts

Midnight shift workers often find it hard to get enough quality sleep on a consistent basis. Police officers are not exempt, often working late shifts and overtime as part of their job.

A new study finds that their schedule may cause cops to develop metabolic syndrome, a cluster of symptoms including high blood pressure, insulin resistance and high trigylcerides that advance development of such conditions such as stroke, cardiovascular disease, and type 2 diabetes.

The research, published in the current issue of Archives of Environmental & Occupational Health, focused on 98 police offers who were part of the Buffalo Cardio-Metabolic Occupational Police Stress study, which began in 2003. The participants had their blood pressure checked, took a blood test and had their waist circumference measured. They also filled out a questionnaire focusing on lifestyle choices such as sleep habits, physical activity, and smoking and alcohol use.

Researchers discovered that in general, those on afternoon and midnight shifts were younger than those working during the day, and predominately male. Overall, 30% of the police officers on the night shift had metabolic syndrome. In the general population, that number was 21%, taken from the National Health and Nutritional Examination Survey. The younger officers on the night shift (average 36.5 years) also had higher rates of metabolic syndrome than age-matched men and women in the general population, who came in at 24%.

Waist circumference was larger and HDL "good" cholesterol levels were lower among night shift cops compared to the general population and to officers working day and evening shifts. Officers working nights who got less than six hours of sleep had higher averages of metabolic syndrome factors than day shift workers.

"One potential explanation for this unusual finding is that midnight shift officers were most likely to be sleep deprived because of difficulties associated with day sleeping," said John Violanti, the study's lead author, in a news release. The research associate professor at the University of Buffalo's department of social and preventive medicine added, "Sleep debt has been shown to have a harmful impact on carbohydrate metabolism and endocrine function, which could contribute to metabolic disorders."

In the study, the authors wrote, "Information gained through this study may be useful to aid further investigation of not only police officer health, but also the health of those in other first-responder occupations."

--Jeannine Stein

Photo credit: Allen J. Schaben / Los Angeles Times

Lifestyle changes may be the best way to delay diabetes

Lifestyle changes are the best way to stave off development of Type 2 diabetes, according to a 10-year followup of an innovative trial to prevent the disease in high-risk groups. The results are important because diabetes is a rapidly spreading epidemic in the United States. About 24 million Americans -- 1 in every 9  -- have diabetes, the vast majority of them Type 2, which develops during adulthood. An additional 57 million people have blood glucose levels that are higher than normal but that are not yet in the diabetic range, and it is this group that could benefit the most from interventions.

The original Diabetes Prevention Program trial involved 3,234 overweight or obese men and women, most of them from ethnic groups with an above-normal risk for diabetes. They were divided into three groups: one received intensive training on altering their lifestyle, the second received the diabetes medication metformin, and the third received a placebo. The lifestyle intervention involved reducing the amount of fat in their diet, exercising daily and losing 5% to 7% of their body weight. On average, those in this group exercised about 30 minutes per day and lost about 15 pounds, although they subsequently regained 10 pounds. Those in the metformin group lost 5 pounds, and those in the placebo group lost less than 2.

The study was halted prematurely in 2001 when it became clear that lifestyle intervention was most effective. Those in the lifestyle arm of the trial reduced their risk of diabetes by 58% compared with the placebo group, and those in the metformin group reduced risk by 31%.

The original group was offered the chance to participate in followup studies and 1,766 did, roughly a third from each of the trial arms. All were given training in lifestyle changes.

The study team, led by Dr. David M. Nathan of Massachusetts General Hospital, reported on the 10-year results this week in the journal Lancet. In the 10 years, participants in the original lifestyle-change group delayed the onset of diabetes by an average of four years compared with the placebo group, and those in the metformin group delayed it by an average of two years. "The benefits of intensive lifestyle changes were especially pronounced in the elderly," Nathan said. "People age 60 and older lowered their rate of developing diabetes in the next 10 years by about half."

About 5% to 6% of those in the lifestyle intervention group developed diabetes every year during the initial trial, a rate that remained constant over the follow-up period. About 8% of those in the metformin group and 11% of those in the placebo group developed diabetes each year during the original trial. Over the rest of the period, however -- apparently because of the added lifestyle training -- the latter two groups reduced their annual rate to the same range as those in the original lifestyle group.

In an editorial accompanying the report, Dr. Anoop Misra of Fortis Hospitals in New Delhi wrote that, "Prevention of diabetes is a long and winding road. There seems to be no shortcut, and a persistent and prolonged lifestyle intervention seems to be the most effective mode to travel on it."

-- Thomas H. Maugh II

Photo: Walking was the most common form of exercise in the lifestyle-change group. Credit: Robert Lachman/ Los Angeles Times

Newer antipsychotics linked to kids' weight gain; all but one linked to metabolic changes

Children and adolescents who started on any one of four psychiatric drugs known as "atypical antipsychotics" packed on a significant amount of weight, new research has found. And three of the four psychiatric medications under study came with metabolic side effects that will dramatically boost a child's likelihood of developing cardiovascular disease, according to a study published Tuesday in the Journal of the American Medical Assn.

Patients taking their first-ever course of drugs marketed as Abilify, Risperdal, Seroquel and Zyprexa experienced weight gains ranging from about 9.7 pounds for Abilify to 18.7 pounds for Zyprexa. (Seroquel users gained about 13.2 pounds and Risperdal users gained about 11.7 pounds over 12 weeks. A comparison group of children with a diagnosis of severe mental illness but who were not on the medications gained less than a half-pound in the course of the study.)

Young patients on Risperdal, Seroquel and Zyprexa all experienced a significant increase in their triglycerides, and those taking Zyprexa and Seroquel had a surge in their overall cholesterol readings. Those taking Abilify registered dramatic changes in body composition, but no metabolic changes that reached the level of statistical significance accepted by medical researchers.

Among the 205 patients who completed the study, it was rare for researchers to see metabolic syndrome or diabetes develop in the 12 weeks of treatment they observed. But they took note of two kinds of changes in subjects that were ominous: first, they noted significant changes in the children's fat mass and waist circumference measures--which predict the development of heart disease in the general population and metabolic syndrome in adults taking antipsychotic medicines; and second, they recorded significant changes in many of the children's triglycerides and in the ratios of triglycerides to HDL cholesterol--both considered a reliable predictor of insulin resistance to come.

The latest study is the largest to date focusing on young patients taking one of the new-generation antipsychotics for the first time. Its results were hailed as "timely and sobering" in an editorial accompanying the study's publication. It comes against a backdrop of rapidly expanding use of these drugs, and their growing use among children as young as 5. The Food and Drug Administration is currently considering whether it to accept the recommendation of a panel of outside experts and approve three of the four drugs for use by children diagnosed with schizophrenia and/or bipolar disorder.

JAMA's editorial suggests that such a step might be ill-advised.

"These results challenge the widespread use of atypical antipsychotic medications in youth," wrote University of Washington, Seattle, child psychiatrists Christopher K. Varley and Jon McClellan.

The commenting physicians warned that the change in children's cholesterol levels and insulin resistance readings observed after only 12 weeks of treatment "portends severe long-term metabolic and cardiovascular sequelae." While physicians expanded their use of the drugs because they were "widely touted as being more effective and safer" than older psychiatric drugs, that belief "should be reconsidered," Varley and McClellan wrote.

Several earlier studies of these antipsychotic medications have documented weight gain, changes in body composition and measures of metabolic function. But this study's findings are the most dramatic so far to come to light. The researchers suggested that earlier studies--many of them conducted under the sponsorship of drug makers--may have understated children's weight gain on the drugs by including many subjects who had taken earlier courses of antipsychotic medicine, and thus already had experienced drug-connected weight gain. For all the subjects followed in this study, this was the first time they had taken any drug classified as an antipsychotic medication. 

Scattered in academic medical centers across New York state, all the researchers were sponsored by grants from the National Institutes of Health.

-- Melissa Healy

Just because we didn't focus on pre-diabetes doesn't mean you shouldn't

Reader Barbara Kaplan of Los Angeles wasn't satisfied with today's special Health section on diabetes treatment. She writes:

"Although I applaud your efforts in heightening awareness of diabetes, especially type 2, it is unfortunate that you failed to mention pre-diabetes, which usually precedes a formal diagnosis of the disease. A fasting blood sugar of 126 or an A1C of 6.5 generally occur after months, years or even decades of readings that, albeit lower, but still can cause considerable damage to the body. If a person is aware of the fact that he or she is on the road to full-blown diabetes, early intervention can often prevent further deterioration. 
 
"Also, your emphasis on overweight and obesity could cause people of normal weight to ignore symptoms. There are many non-obese type 2 diabetics, and even more non-obese pre-diabetics. For example, I have been pre-diabetic for at least 5 or 6 years despite a BMI of 23. My A1C is 6.1, which is lower than the criteria you suggest but still too high.  I have never had a fasting blood sugar over 110, but that too is above normal. Fortunately, because of my family history, I periodically used a relative's meter to test myself and therefore caught my condition early. I now use Metformin to hopefully arrest progression.  However, my brother wasn't diagnosed until after his fasting levels rose above 126.  By that time he had neuropathy and other symptoms which were irreversible. I also know people who, by the time they were diagnosed, were ready for toe amputations and other drastic measures. Several of these folks were quite slender.
 
I hope you can publish an update to today's section in a future edition. Pre-diabetes is a potentially serious condition that can be controlled or even reversed."

Consider it done, Barbara. And because you've said it so well, we'll simply add these links to more information on pre-diabetes ...

- the American Diabetes Assn. The information includes risk factors for the condition, prevention tips, frequently asked questions about it and more.

- the Centers for Disease Control and Prevention. This site offers not just general facts, but useful specifics on tests, diagnostic values and screening values.

- the National Diabetes Information Clearinghouse. This overview includes a useful heads up about ongoing research, plus findings from the Diabetes Prevention Program.

-- Tami Dennis

Photo: Eat right, exercise ... it's good advice for everyone; and the naturally thin don't get a pass.

Credit: Anne Cusack / Los Angeles Times

Diabetes: What doctors know -- and what patients know

Doctors and researchers know that poorly controlled diabetes can lead to blindness, kidney damage, nerve damage and limb amputations and increase the risk of heart attacks and strokes. And they know how to monitor blood glucose, what patients should eat and which medications they should take.

The advice is not one-size-fits-all. There are tips specifically for ...

- teenagers, from the National Diabetes Education Program.

- men, from the American Diabetes Assn.

- women, from WomensHealth.gov.

- for older people, from the National Institute on Aging.

That's just for starters.  

The American Diabetes Assn. offers an excellent Ask the Expert section, with topic-specific advice from an optometrist, pharmacist, dietitian and dentist.

The site is truly a phenomenal resource. (There's even a risk test.) Even if you don't have diabetes, take some time to explore the information. There's something for almost everyone who wants to live a little more wisely -- and the information can shed light on the battles that millions of Americans face every day.

We too offer advice -- but mostly news and trends and profiles related primarily to Type 2 diabetes (because it's by far the most common), but also to Type 1 as well -- in this week's Health section devoted to diabetes.

But patients learn some lessons first-hand. And those are the lessons we want to know about... And that we want to share. Such as ...

How do you manage the intricacies of ordering off an unknown menu? ... Of feeling yourself become shaky in the middle of watching your kid's soccer game? ... Of transporting insulin on a three-week trip? ... Of reconciling your dietary restrictions with the food preferences of loved ones who have no such limitations? Of even trying to eat a simple meal when kidney failure is so close that almost all foods seem closed to you...?

If you have your own hard-won advice -- or aha! moment, we'd like to hear it.

-- Tami Dennis

Photo: A simple blood test actually isn't. The results can trigger a host of actions and reactions and then compensatory actions, all part of the effort to control glucose.

Credit: Los Angeles Times

Investigational drug may promote weight loss

A medication that is under review by the Food and Drug Administration for the treatment of Type 2 diabetes may also promote weight loss, according to a study published online today in the Lancet. The drug, liraglutide, was approved earlier this year in Europe for the treatment of diabetes. It is marketed under the brand name Victoza.

Liraglutide is an injected drug that stimulates the release of insulin when glucose levels become too high. It also helps curb appetite. In the new study, researchers in Denmark assigned 564 obese individuals to one of four liraglutide doses, a placebo or the weight-loss drug orlistat. All the participants followed a diet of about 500 less calories than they normally consumed. They also increased their physical activity levels.

After 20 weeks, those on liraglutide lost more weight than those on the placebo. Participants on the highest dose of liraglutide lost 15 pounds compared with 6 pounds on the placebo and 9 pounds on orlistat. Three-quarters of the subjects on the two highest doses of liraglutide lost 5% or more of their body weight. The medication also reduced blood pressure and symptoms of pre-diabetes.

Side effects were nausea and vomiting but no serious adverse events were reported. Patients did not seem to mind injecting the drug, the authors noted. However, longer studies are needed on the drug, said in an accompanying editorial by Dr. George A. Bray of the Pennington Biomedical Research Center at Louisiana State University.

"Whether long-term use of an injectable drug is palatable as a treatment for obesity is yet to be established," he said.

The FDA has also raised questions about whether the medication can cause thyroid tumors, said Dr. Mitchell Roslin, chief of obesity surgery at Lenox Hill Hospital in New York.

"As a weight loss drug, liraglutide faces many hurdles," Roslin said in a statement. But, "drugs that can control diabetes, without causing weight gain, have huge potential. Furthermore, this group of patients is used to injections of insulin and Byetta. For a primary obesity drug to require injections would require blockbuster data."

- Shari Roan 

Photo credit: Tim Sloan  /  AFP  /  Getty Images.

Recommendations for new school meal nutrition standards

The nutrition standards behind the National School Lunch Program and the School Breakfast Program have not been updated since 1995. Today, the federal Institute of Medicine is issuing a report recommending new standards, calling for more produce, more whole grains. And for the first time, a limit to calories.

Thirty million children eat school lunch, and 10 million eat school breakfast -- and the IOM panel says it hopes new standards will help those children develop good habits that they carry into adulthood. That, the panel says, should help curb obesity and other health problems associated with diet.

The panel's recommendations go to the U.S. Department of Agriculture for possible implementation. It was the USDA which requested the report.

The panel says new standards would cost money -- for food as well as for training and capital improvements. But it says food costs would go up by less than 10% for breakfast and 25% or less for lunches. The government now spends $8.7 billion a year in reimbursements for school meals to school districts.

The recommendations are meant to bring school food in line with the dietary guidelines the government issues for Americans. It seeks to have the amount of sodium in school meals reduced by more than half over the next decade.

Among its recommendations: that calories be limited, based on age level, for breakfast and lunch, and that the sodium level for a typical lunch be eventually reduced to 740 milligrams. It also sets out targets for weekly servings of fruits and vegetables, and it calls for more whole grains.

"It's about time," says Matthew Sharp of the California Food Policy Advocates and one of the people who testified before the panel. Meals, he says, should be nutritious and affordable and they also should "teach kids healthy habits" and expose them to a variety of foods.

-- Mary MacVean

Can your neighborhood make you sick?

Type 2 diabetes may not be contagious, but it certainly appears to be spreading. In 1958, the prevalence was 0.9%. By 2000 it had climbed to 4.4%, and it’s projected to hit 7.2% in 2050.

What accounts for this? Perhaps it’s the way residential neighborhoods have evolved to accommodate car rides to fast-food restaurants instead of walks to corner grocery stands.

A study being published today in the Archives of Internal Medicine calculates that people who live in neighborhoods that are conducive to physical activity and healthy eating have a 38% reduced risk of developing diabetes compared with people who don’t.

The study looked at 2,285 adults who lived in Baltimore, the Bronx in New York and Winston-Salem, N.C. As participants in the Multi-Ethnic Study of Atherosclerosis, they gave researchers information about where they lived, what they ate, their medical history and exercise habits. Over the five years of the study, 233 were diagnosed with Type 2 diabetes.

Drexel University epidemiologist Amy Auchincloss and colleagues studied the data to see what – if anything – set the diabetes patients apart from the rest of the volunteers. After controlling for factors like age, sex, income, family history, drinking and smoking, they found that people in the top 10% of neighborhoods for promoting healthy diets and physical activity were indeed less likely to become diabetic than people in the bottom 10%.

In some sense, the results aren’t terribly surprising, Dr. Mitchell H. Katz of the San Francisco Department of Public Health noted in an editorial accompanying the study. Diabetes rates were lower in the good old days before families could afford multiple cars and folks had to walk quite a bit to get to schools, stores and jobs. Home-cooked meals may have featured lots of butter, but they weren’t routinely served with a side of fries and refillable cup of soda. If there was a TV in the living room, channel surfers had to get up off the couch to change the station.

Correlation does not equal causation, of course. Perhaps people who value a healthy lifestyle choose to live in neighborhoods with bike trails and health food stores. Or maybe it’s simply that people who make more money can afford to shop at Whole Foods and visit the doctor for an annual checkup.

Doctors can’t do much about the genetic factors that might predispose someone to diabetes. But if public health experts identify ways to make neighborhoods healthier, we ought to give them a try, according to Katz.

“If we are to decrease the rates of type 2 diabetes, we need to change the environment in ways that make it easy for people to exercise and eat right as part of their daily routine,” he wrote. Some simple examples include: providing access to school playgrounds even after school is over for the day; widening sidewalks; painting bike lanes on roads; and establishing community gardens.

-- Karen Kaplan

Photo: Living by a farmers market is linked to a reduced risk of Type 2 diabetes. Photo credit: David Karp/For The Times