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

Lowering blood pressure and cholesterol simultaneously can sharply reduce heart attacks and strokes

An inexpensive combination of a cholesterol-lowering drug and one to reduce blood pressure can reduce the incidence of heart attacks and strokes by as much as 60%, but getting patients to begin the regimen and then to stay on it is an extremely difficult task, Kaiser Permanente researchers reported today. Giving the drugs to nearly 70,000 people with cardiovascular disease or diabetes prevented an estimated 1,271 heart attacks and strokes in one year, Dr. James Dudl of the Kaiser Permanente Care Management Institute and his colleagues reported in the American Journal of Managed Care.

The inspiration for the study came from the Archimedes Model, a sophisticated computer simulation of the human body that predicted that lowering blood pressure and cholesterol simultaneously in those at the highest risk for cardiovascular problems could reduce the incidence by 71%. But such a study had never been carried out in the real world before.

The Kaiser team chose two generic drugs, cholesterol-lowering lovastatin and blood-pressure-reducing lisinopril, and offered them to 170,000 members of their managed care programs in Northern and Southern California who suffered from heart disease or diabetes. Some of the patients were already taking one of the drugs, but none of those selected were taking both. About 75% of them were also taking daily aspirin, but the researchers did not include aspirin in the protocol because they had no way to monitor usage.

They began the program in 2004 and nearly 70,000 patients agreed to participate. The team monitored compliance for two years by checking on whether and how often patients refilled their prescriptions, then monitored health effects in the third year through the patients' health records. Some 47,268 patients had what the team termed "low exposure" to the drugs, taking them less than half the time. Their risk of hospitalization for heart attack or stroke was lowered by 15 events per 1,000 person-years, and an estimated 726 events were prevented.  An additional 21,292 patients had "high exposure" to the drugs, taking them more than half the time. Their risk was reduced by 26 events per 1,000 person-years, preventing an estimated 545 events.

"What was fairly amazing to me was that we got such a good drop in heart attack and strokes" despite the low adherence, Dudl said. "The issue now is how to increase adherence." The primary reasons for non-adherence, he noted, were things like, "I don't know why I was taking the drugs," "I forgot to refill the prescription," and "I worry about side effects." Those are issues "that have to be addressed with each patient, one by one." Kaiser now has a follow-up program focused on adherence, he said.

"We made it the simplest regimen we could," he added, with a standardized dose of each drug for everyone. "Can you imagine how difficult it would have been" if it were a more complicated regimen or physicians had to schedule multiple visits to adjust dosages for each patient. "It's a great example of how difficult it is for people to understand and do something that is beneficial to them."

-- Thomas H. Maugh II

WIC program gets its first overhaul -- to include fresh produce

There is rejoicing today at agencies that work with recipients of food vouchers through the Women, Infants and Children program.

"We're in seventh heaven," said Laurie True, executive director of the Cal WIC Assn., based in Sacramento.

Starting Thursday, WIC recipients -- more than 8 million of them -- will be able to use vouchers to buy fresh fruit and vegetables, under a program revision that has been years in the making.

"We're extremely excited," said Pina Hernandez, outreach manager for the Public Health Foundation Enterprises WIC Program, which provides WIC services to 316,000 people in Los Angeles and Orange counties.

"It's a much-needed change," said Elizabeth Pivonka, president of the Produce for Better Health Foundation, a nonprofit behind a national public health initiative to get people to eat more fruit and vegetables.

"That's the one food group consumers are eating so little of," she said.

When WIC was devised more than 30 years ago, hunger and vitamin deficencies were problems, and the WIC foods reflected that -- eggs, cheese, protein, milk, juice. Today, of course, obesity is the top food-related health problem.

WIC also provides education to recipients, and Pivonka said the emphasis on the reasons people need fruit and vegetables might help families develop good eating habits. And for families who might have felt that fresh produce was too expensive, the targeted funds will "give them permission to eat fruits and vegetables," she said.

The provision is $6 a month for children, $8 for pregnant women and mothers of children 5 and under, or $10 for mothers who are exclusively breast-feeding.

"Is it sufficient? No, but it's just a supplemental program," Pivonka said.

-- Mary MacVean

Treat mild diabetes in pregnancy, study suggests

Even women with mild gestational diabetes should receive treatment to improve the health of both mother and baby, according to a federally funded study that should help resolve a longstanding controversy in obstetrics.

Rates of gestational diabetes have been increasing as more U.S. women enter pregnancy overweight. Moderate-to-severe cases of the condition are always treated, but there has been uncertainty among doctors on whether women with mild increases in blood-sugar levels warrant additional care.

"Healthcare providers do not wish to overtreat women or unnecessarily alarm them, nor do they wish to impose extra costs, including self-glucose monitoring," said Dr. Mark Landon, lead investigator and interim chair of obstetrics and gynecology at Ohio State University Medical Center.

The study, published in the New England Journal of Medicine, assigned 958 women with mild gestational diabetes, who were between 24 and 31 weeks’ pregnant, to receive either diabetes treatment or no treatment. The women who received treatment were counseled on diet and glucose monitoring and, if necessary, received insulin.

 Most of the babies in both arms of the study were born at normal weights. However, in the treatment group, 7.1% of infants were too large — defined as at or above the 90th percentile — compared with 14.5% in the untreated group. Babies in the treated group were less likely to be born via Cesarean section or to suffer trauma at birth.

Women in the treated group gained less weight during pregnancy, had fewer preterm births and fewer cases of preeclampsia, a sudden increase in blood pressure. The study was conducted at 14 sites and funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

-- Shari Roan

Photo: Los Angeles Times

Diabetics are hitting the snooze button on their nutritional wake-up alarm

You'd think being diagnosed with a chronic condition would be a wake-up call for most people.

That doesn't seem to be the case with those who have Type 2 diabetes. The disease, which influences how the body metabolizes glucose, can cause fatigue, dehydration, and as it progresses, hardening of the arteries, leading to heart attack and stroke. While medication is often prescribed for the disease, diet and exercise play key roles in controlling it. Yet many people haven't exactly adhered to that message.

A new study shows that people with Type 2 diabetes consume far too much fat and sodium and far too few fruits, vegetables, dairy products and grains. Researchers examined surveys measuring food and nutrient intake completed by 2,757 participants in the Look AHEAD trial, which is analyzing the effects of a lifestyle intervention versus diabetes support and education for long-term cardiovascular health.

Survey results revealed that a hefty 93% of participants got more than the recommended percentage of daily calories from fat, 85% topped the recommendations for saturated fat, and 92% got too much sodium. Overall, diets provided 44% of calories from carbohydrates, 40% from fat, and 17% from protein. Diets also lagged behind in the recommended amounts of fruits, vegetables, dairy and grains.

Although one might assume that those who had been dealing with the disease for a longer time might have better diets, that wasn't the case. In the study, the authors wrote, "All of these participants would benefit from counseling to encourage consumption of high fiber, low-fat grains, low-fat dairy, and guidance to select leaner cuts of meat. In addition, counseling to reduce consumption of discretionary calories would improve the likelihood of meeting fat and cholesterol intake guidelines and improve the overall quality of foods consumed."

The study appears in the August issue of the Journal of the American Dietetic Assn.

-- Jeannine Stein

Photo credit: Spencer Weiner / Los Angeles Times

Some blood-glucose test results could be wrong, FDA says

If you've been using glucose test strips to monitor your blood-sugar levels, check the label and check your other medications. The Food and Drug Administration warned today that some of the strips could be inaccurate if people are taking medications that contain sugars other than glucose.

Some strips. Not all. The advisory targets those strips known as GDH-PQQ (for glucose dehydrogenase pyrroloquinoline quinone). Other types are fine. So for heaven's sake, don't simply stop testing your blood glucose.

In fact, most of the targeted strips are used in healthcare centers, but even so... this is something of which diabetics -- and their healthcare providers and caregivers -- should be aware.

Diabetics undergoing dialysis or who have recently had surgery are among those most likely to be affected. The FDA said in its warning that the strips can react with other types of sugars and produce a falsely high result. The patient could then take too much insulin. And as diabetics know, this could lead to low blood sugar, coma or death.

Here's the FDA warning about the products from Roche, Abbott, Home Diagnostics, Smiths Medical and Insulet Labs.  

Here's the agency's advice for patients, which lists details about the specific products.

And here's an AP story with additional context.

-- Tami Dennis

Photo: Insulin is necessary. But too much can be fatal.

Credit: Los Angeles Times

Another cure for Type 1 diabetes ... in mice

Scientists have been searching for a way to cure Type 1 diabetes by regenerating the insulin-producing beta cells in the pancreas that are lost in the disease. Without them, the body is unable to metabolize sugar, forcing patients to compensate by injecting themselves with insulin several times a day.

One popular strategy has been to try to get embryonic stem cells or induced pluripotent stem cells -- which can theoretically become any type of human cell -- to grow into the beta cells that diabetes patients need. Last year researchers from Harvard University took a huge shortcut and transformed normal pancreas cells into the coveted beta cells by activating a trio of dormant genes.

Today a team of European and American researchers report that pancreatic cells in diabetic mice could be reprogrammed into beta cells by turning on just one gene, called Pax4.

The scientists gave the mice a drug called streptozotocin that killed off their beta cells while preserving other types of pancreatic cells. Then they activated the Pax4 gene, which does most of its work during fetal development.

They found that the gene converted so-called alpha cells -- which normally made a hormone called glucagon -- into beta cells that made insulin. Beta cell levels were eight times higher in treated mice than in untreated control subjects, according to the study being published in Friday’s edition of the journal Cell.

For some reason that the researchers don’t yet understand, the therapy worked best on mice that were less than one month old. For them, the treatment completely counteracted the symptoms of Type 1 diabetes.

In fact, it may have worked too well, leaving the mice with a shortage of alpha cells. Before this approach can be tried in humans, scientists will need to figure out a safe way to turn on the Pax4 gene -- and then find a way to shut it off.

“A lot of 'ifs' remain before we will know whether it could be taken to the clinic,” said the study’s lead author, Patrick Collombat, a researcher at the Max Planck Institute for Biophysical Chemistry in Germany. But for Type 1 diabetes patients who are currently treated with daily insulin injections, he said in a statement, this much is clear: “We need a better treatment. We need to find a way to regenerate beta cells.”

-- Karen Kaplan

Photo: Cellular reprogramming methods may make insulin shots like this one obsolete. Credit: Christine Cotter / Los Angeles Times

At risk of diabetes? Probably. Find out how much...

The "probably" is a reference to the fact that two-thirds of adults in the United States are overweight or obese. That statistic has become so common it's failing to shock. (Here are the numbers from the National Center for Health Statistics.)

But the numbers themselves -- and their inability to dismay -- bode ill. They're national statistics, but the risk of Type 2 diabetes, stroke and heart disease is personal.

From a WebMD roundup of the risk factors for diabetes, specifically Type 2: "Research at the Harvard School of Public Health showed that the single best predictor of type 2 diabetes is being obese or overweight."

Here's more information from the National Diabetes Information Clearinghouse on the risks for Type 2 diabetes. And here's a wealth of diabetes information from Medline Plus.

In short, if you're overweight, you're increasing your chances of developing a devastating disease that affects almost every part of the body. An online tool from the American Diabetes Assn. helps you assess that risk -- taking into account much more than weight. Unlike many online assessment tools that allow you to plug in only the barest of details, this one -- called My Health Advisor -- spends a bit of time inquiring about your personal health history and other factors. Then it offers up a personal assessment chart, based on research into those risk factors. (A related tool, My Food Advisor, can help you chart carbohydrate intake and other ways to improve your diet.)

Give it a try. The results take the theoretical and make it personal.

And in case you missed this week's drumbeat of obesity-related news, here's a refresher:

Growing obesity swells healthcare costs

Sebelius offers solutions to high cost of obesity

Tough love for fat people: Tax their food to pay for healthcare

And ... Lace up your sneakers and grab a hankie -- 'The Biggest Loser' is having a casting call

-- Tami Dennis

Photo: It doesn't have to be this way.

Credit: Bob Chamberlin / Los Angeles Times

 

Dialysis patients at risk from 'enhanced' meats

Although lawmakers and consumer advocates have been fussing about publication of nutrient contents for fast foods and restaurant meals, a potentially bigger threat to health may lie in poorly labeled meats and poultry in the local supermarket. Many such products that are "enhanced" with water and other additives -- think the "plumped" chickens so disparaged in the clever Foster Farms ads -- contain levels of phosphorus and potassium that can be hazardous to dialysis patients and others with kidney disease, researchers reported online in the Clinical Journal of the American Society of Nephrology.

The healthy kidney regulates blood levels of phosphorus and potassium, but the diseased kidney is typically unable to do so. High levels of either can lead to death. Dialysis removes them, but consuming extra quantities of them can make the process more difficult.

Dr. Richard A. Sherman and Dr. Ojas Mehta of the University of Medicine and Dentistry of New Jersey randomly purchased uncooked meat and poultry from supermarkets, then tested them blindly for potassium and phosphorus concentrations. They found that that products labeled as "enhanced" had an average phosphate concentration 28% higher than that of additive-free products, and some had 100% more. Additive-free products all contained less than 387 milligrams of potassium per 100 grams of protein, and five of the 25 products with additives contained at least 692 mg per 100 grams. Though many of the enhanced products reported the presence of the additives on the labeling, eight of the 25 did not. The authors called for full labeling of the products, which is not required under federal rules.

The study was funded by grants from Dialysis Clinics Inc. and Genzyme.

-- Thomas H. Maugh II

Diabetes drug Avandia comes under new criticism

The diabetes drug rosiglitazone, already under fire because it has been found to increase the risk of heart attacks, can also produce liver failure and death in some patients, researchers from the activist group Public Citizen said this week.

They wrote in the journal Pharmacoepidemiology and Drug Safety that a review of adverse events reported to the Food and Drug Administration found 11 deaths due to liver toxicity between 1997 and 2006 associated with the drug, which is sold under the brand name Avandia. The group had petitioned the FDA in October to ban the drug because of the heart risks, and they renewed their call for action.

"Because of low reporting rates to the [FDA] database, the 11 cases likely represent a small fraction of the patients who developed liver failure because of the drug," said Dr. James Floyd of Public Citizen. He estimated that 1 in every 44,000 patients who take the drug develops liver failure.

Previous studies have shown that Avandia increases the risk of heart attack by about 40%, doubles the risk of heart failure and bone fractures, and increases the risk of anemia and vision loss from macular edema, a swelling of the retina caused by the accumulation of fluids in the eye, according to Public Citizen. Reports of the drug's risk have sharply reduced prescriptions for it: They dropped from a peak of about 13.2 million in 2006 to 3.1 million in 2008. That means that 8,500 prescriptions for the drug are still filled every day.

The group also found 10 deaths from liver failure associated with the related drug pioglitazone, sold under the brand name Actos. That drug has not been linked to heart attacks, but is associated with an increased risk of heart failure, Floyd said. Public Citizen estimated 1 case of liver failure for every 52,000 patients taking it.

The manufacturers of both drugs contend that no scientific study has linked them to liver toxicity. Public Citizen, however, recommends that patients should stick to older and safer -- and, not incidentally, cheaper -- medications like metformin (Glucophage) and glipizide (Glucotrol).

-- Thomas H. Maugh II