Fasting shown to reduce risk of diabetes, heart disease, cancer and other diseases.

Mice that fast periodically are healthier, metabolically speaking. To explore whether fasting can help people as well, Min Wei et al. studied participants who either consumed a fasting-mimicking diet for five days each month for three months or maintained their normal diet for three months and then switched to the fasting schedule. A post hoc analysis replicated these results and also showed that fasting decreased BMI, glucose, triglycerides, cholesterol, and C-reactive protein (a marker for inflammation). These effects were generally larger in the subjects who were at greater risk of disease at the start of the study. A larger study is needed to replicate these results, but they raise the possibility that fasting may be a practical road to a healthy metabolic system.

Calorie restriction or changes in dietary composition can enhance healthy aging, but the inability of most subjects to adhere to chronic and extreme diets, as well as potentially adverse effects, limits their application. They randomized 100 generally healthy participants from the United States into two study arms and tested the effects of a fasting-mimicking diet (FMD)—low in calories, sugars, and protein but high in unsaturated fats—on markers/risk factors associated with aging and age-related diseases.

Participants were separated into two groups, a control group eating a normal diet and a group placed on the three-month cycle of a fasting-mimicking diet. The fasting-mimicking diet had participants eat food supplied by L-Nutra designed to imitate a water-only fast consisting of 750 to 1,100 calories a day during the five-day fasting period each month.

Then they compared subjects who followed the three months of an unrestricted diet to subjects who consumed the FMD for five consecutive days per month for three months. Three FMD cycles reduced body weight, trunk, and total body fat; lowered blood pressure; and decreased insulin-like growth factor 1 (IGF-1). No serious adverse effects were reported. After three months, control diet subjects were crossed over to the FMD program, resulting in a total of 71 subjects completing three FMD cycles. A post hoc analysis of subjects from both FMD arms showed that body mass index, blood pressure, fasting glucose, IGF-1, triglycerides, total and low-density lipoprotein cholesterol, and C-reactive protein were more beneficially affected in participants at risk for disease than in subjects who were not at risk. Thus, cycles of a 5-day FMD are safe, feasible, and effective in reducing markers/risk factors for aging and age-related diseases. Larger studies in patients with diagnosed diseases or selected on the basis of risk factors are warranted to confirm the effect of the FMD on disease prevention and treatment.

Results showed a reduction of cardiovascular risk factors including blood pressure, signs of inflammation, fasting glucose and reduced levels of the metabolism hormone IGF-1 in 71 of the trial participants, who also lost weight and inches around their waist, reducing their risk of cancer, diabetes, heart disease and other diseases. More specific results showed that participants on the fasting-mimicking diet lost an average of 6 pounds and 1 to 2 inches around their waist. Their systolic blood pressure dropped by 4.5 mmHg, their diastolic blood pressure dropped by 3.1 mmHg and their IGF-1 levels dropped between 21.7 ng/ml and 46.2 ng/ml.

Valter Longo, director of the USC Longevity Institute, professor of biological sciences for USC Davis and Dornsife and co-author of the study said in a press release, “This study provides evidence that people can experience significant health benefits through a periodic, fasting-mimicking diet that is designed to act on the aging process….Prior studies have indicated a range of health benefits in mice, but this is the first randomized clinical trial with enough participants to demonstrate that the diet is feasible, effective and safe for humans. Larger FDA studies are necessary to confirm its effects on disease prevention and treatment.”

“After the first group completed their three months on the fasting diet, participants were moved over to the control group to see if they also would experience similar results,” Longo said. “We saw similar outcomes, which provides further evidence that a fasting-mimicking diet has effects on many metabolic and disease markers. Our mouse studies using a similar fasting-mimicking diet indicate that these beneficial effects are caused by multi-system regeneration and rejuvenation in the body at the cellular and organ levels. Our participants retained those effects, even when they returned to their normal daily eating habits.”

Practice Pearls:

• Results showed a reduction of cardiovascular risk factors, including blood pressure, signs of inflammation, fasting glucose and reduced levels of the metabolism hormone IGF-1.
• Beneficial effects are caused by multi-system regeneration and rejuvenation in the body at the cellular and organ levels.
• Larger FDA studies are necessary to confirm its effects on disease prevention and treatment.

Reference:

The study was published in the journal Science Translational Medicine. Feb 15, 2017, Vol. 9, Issue 377 DOI: 10.1126/scitranslmed.aai8700

For more information plus a video interview on intermittent fasting from Dr. Mark Mattson, see: http://www.diabetesincontrol.com/mattson-1-what-is-intermittent-fasting

Recent survey finds support for keeping parts of it intact, even among those who want it repealed.

If the Affordable Care Act was repealed the first day the new president takes office, then 30 million people would lose their insurance and a huge burden would be placed on those with prior existing health conditions.

A recent survey’s findings come as leaders in the Republican-controlled Congress make plans to repeal the law, also known as Obamacare, when President-elect Donald Trump takes office. It was promised that it would be on of the first things he does as president.

The survey found virtually no support for keeping the law as is. But nearly 4 in 5 physicians who answered the survey want at least some aspects of it preserved, whether as part of the current law or in a new one.

The survey was conducted in late November and includes responses from 687 physicians and 835 consumers of a medical online newsletter.  Of those:

• Nearly half (49%) of the consumers and 43% of physicians believe the law should be kept, but improvements should be made.
• 31% of consumers and 36% of physicians believe the law should be repealed, but some aspects of it should be used in a replacement law.
• 19% of consumers and 18% of physicians believe the law should be repealed and replaced with a new one.
• Only 2% of the consumers and 3% of physicians believe Obamacare should be kept as is.

The finding is consistent with other recent polls that have found less enthusiasm for a total repeal of the law. A Kaiser Health Tracking Poll released on December 1 found that 1 in 4 Americans wanted a full repeal. It also noted that the number of Republicans who want the law repealed had dropped from 69% to 52%. A HealthDay/Harris poll found that 28% of Americans supported a full repeal.

“In the past, when people might have been asked if they were for or against the ACA, it was almost a free pass; with President Obama in the White House, there was no way it was going away. Now, where there’s a very real threat it will be repealed, people are saying, ‘Hey, wait a minute. What are we losing in the process?’ ”

The survey also found broad support for specific aspects of Obamacare that physicians and consumers say should be required of all healthcare plans. They include the following:

• Coverage of mental health services: 95% of consumers, 91% of physicians
• Coverage of preventive services, such as mammograms and colonoscopies, with no copayment: 92% of consumers, 78% of physicians
• Women’s health coverage, such as birth control and maternity benefits: 87% of consumers, 80% of physicians
• Coverage for young adults up to age 26 under a parent’s plan: 82% of consumers, 88% of physicians
• No lifetime maximum benefits on health insurance coverage: 82% of consumers, 82% of physicians
• The majority of respondents had a high level of support for women’s health coverage
• 77% of both consumers and doctors felt that the federal government should provide an option allowing people to purchase government-administered health coverage, also known as a “public option.”

Even among the consumers who say they support a full repeal of the ACA, an overwhelming majority still support some of its provisions:

• 89% believe all healthcare plans should provide coverage of mental health services.
• 85% believe all healthcare plans should cover preventive services with no copayment.
• 77% believe healthcare plans should have no lifetime maximum benefits on coverage.
• 76% believe all healthcare plans should provide women’s health coverage.

In addition, 66% of those supporting a repeal say they believe it’s important to have affordable healthcare coverage for everyone, and 63% support a “public option.”

According to the survey, if the ACA is fully repealed, physicians and consumers paint a different picture of what they believe will happen.

Among doctors:

• 47% believe their patients’ costs will increase.
• 57% believe their patients’ benefits will decrease.

Among consumers:

• 45% say they believe their costs will stay the same.
• 58% believe their benefits will remain the same.

Asked about their biggest healthcare priority for the next president and Congress, physicians and consumers were split.

Physicians listed their priorities as follows:

• Cuts in healthcare premiums (41%)
• Universal healthcare coverage (31%)
• Lower drug prices (21%)

Consumers, however, had a different top priority:

• Universal healthcare coverage (34%)
• Cuts in healthcare premiums (34%)
• Lower drug prices (24%)

Practice Pearls:

• The majority of those covered under ACA want the cost to come down and keep some of the benefits.
• Prior existing conditions is one of the major items that should be kept.
• Mental health services, coverage of preventive services at no cost, and lower drug prices round out the most important elements that people want to continue with.

Center on Health Insurance Reforms, Health Policy Institute, Georgetown University; Kaiser Family Foundation; HealthDay/Harris poll.

What does it mean when we say we need to focus on the total or whole patient?

It comes down to focusing on the things that affect the patient’s ability to self-manage their diabetes so they can have a normal life while improving their quality of life, which can include the psychological, financial, and social circumstances in their lives.

The ADA’s 2017 142-page document, “Standards of Care” published December 15th in a supplement to Diabetes Care also addresses the antibody screening of asymptomatic first-degree relatives of patients with type 1 diabetes to help prevent DKA, including the use of a standard number to determine hypoglycemia and using empagliflozin or liraglutide in patients with type 2 diabetes to help prevent cardiovascular disease, and also monitoring patients for B12 deficiency when taking metformin.

The standards also contain new advice or updates related to gestational diabetes follow-up, inclusion of sleep assessment in diabetes management, use of fat and protein in insulin-dosing calculations, interruption of sitting every 30 minutes with short exercise bouts, and consideration for use of metabolic (formerly bariatric) surgery down to body mass index 30 kg/m2.

ADA Chief Scientific and Medical Officer Robert E Ratner, MD, added that, “The ADA is the only group that revises practice guidelines annually. The new changes also 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. Plus, there is a new chapter on Promoting Health and Reducing Disparities in Populations,” which 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 in his press conference.

“We need to keep reminding ourselves as medical professionals that we’re not just managing glucose, we are managing a human being who’s just trying to live a normal life.”

This also includes 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.

We also need to realize that 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.

The standards now also recommend that first-degree relatives of people with type 1 diabetes be screened for islet autoantibodies. Closer monitoring is advised for those relatives who are positive for two or more antibodies on two separate occasions, since they have a greater than 95% probability of developing type 1 diabetes.  By identifying individuals at the stage of persistent positive antibodies, we have the research opportunity to intervene and prevent the progression, but more important, we know who’s at risk and can begin therapy before DKA. “This is a huge and fundamental change in our understanding of T1D,” Ratner said.

Another new recommendation, initially published in a separate position statement on November 21, calls for “serious, clinically significant” hypoglycemia to be officially defined as a value less than 54 mg/dL (< 3.0 mmol/L), with a “glucose-alert value” designating need for action set at 70 mg/dL (3.9 mmol/L) or lower. Symptoms have been removed from the definition.  Actually having definite numbers to define hypoglycemia will make it much more standardized.

The new guidelines can recognize the fact that a lot of people have hypoglycemic unawareness. “If you have a confirmed value of 50, that’s serious hypoglycemia even without symptoms. What we’re saying is individuals and their caregivers should strive to never have a glucose value less than 54.”  The 70-mg/dL value is not considered hypoglycemia, but rather a level suggesting that a therapeutic adjustment be made, such as adjusting insulin dose, eating, or suspending the patient’s insulin pump.  “Our therapeutics aren’t that good, so we need a buffer zone between a potentially dangerous level and where we’re going to intervene,” Dr Ratner explained.

Also included in the pharmacologic chapter is a new evidence-based recommendation to consider periodic measurement of vitamin B12 levels in patients on long-term metformin use and use supplementation as needed, following reports regarding an association between metformin use and vitamin B12 deficiency.

And, in light of the overall emphasis on real-life circumstances, for the first time this year the standards provide median cost information for glucose-lowering medications, including insulins.

Practice Pearls:

• First-degree relatives of those with type 1 diabetes need to be tested for antibodies and watched more closely.
• Using empagliflozin or liraglutide in patients with type 2 diabetes can help in preventing cardiovascular disease.
• We need to focus on the things that affect the patient’s ability to self-manage their diabetes so they can have a normal life.

Diabetes Care. Published online December 15, 2016. Standards of Care

Diabetes patients tend to overestimate complications risk, treatment benefits.

Researchers in the United Kingdom have developed a validated risk assessment equation to show the 10-year risk of blindness and lower limb amputation in diabetes patients. Microvascular and macrovascular complications are common in diabetes patients; risk factors included hyperglycemia and hypertension. Controlling these risk factors reduces the risk of these complications.

Data was collected via a prospective cohort study from general practitioners in England from 1998 to 2014. Development of the equations used data from over 400,000 diabetes patients, whereas validation used almost 350,000 diabetes patients. Data came from the UK QResearch database. Validation was carried out using that database as well as the Clinical Practice Research Datalink (CPRD) database.

The researchers looked at two outcomes: lower limb amputation and blindness. Blindness included one or both eyes, registered blindness, and severe visual impairment. They used a plethora of predictor variables, including ethnicity, presence of other disease states, age, body mass index, smoking status, length of diabetes diagnosis, and measures of glycemic control.

The algorithms are based on variables that patients are likely to know or that are routinely recorded in general practice computer systems. They can be used to identify patients at high risk for prevention or further assessment. Limitations include lack of formally adjudicated outcomes, information bias, and missing data.

These new algorithms calculate the absolute risk of developing these complications over a 10-year period in patients with diabetes, taking account of their individual risk factors.

The developed equations have C statistics values of at least 0.73, indicating good discrimination and calibration. These equations can help patients and providers concretely assess the risk of these life-changing complications. An accurate picture of the risk can help patients and providers make important clinical care decisions in the management of the disease state.

The algorithms are designed to provide better and more accurate information for patients and doctors on the absolute risks of blindness and amputation, to inform management decisions. Patients with diabetes tend to overestimate their risk of complications and also overestimate the benefits of treatment. For example, in one study, patients believed that they were 1.5 times more likely to become blind and 13 times more likely to have a lower leg amputation than estimates of absolute risk based on the DCCT trial.  Some people may argue that overestimating the risk of complications might result in patients being more likely to take intensive treatment. However, from a holistic and ethical point of view, more accurate individualized information on the risk of complications may help patients to make more informed decisions about the balance of risks and benefits of treatment options reflecting their own values and choices. Overestimation of the risk of complications might lead to increased levels of anxiety and depression, which could negatively affect quality of life. This is especially important as patients with diabetes are more likely than the general population to experience anxiety and depression.

For clinicians, complications could enable screening programs to be tailored to an individual’s level of risk and support the more rational use of scarce resources. For example, blindness can be prevented by screening for and treatment of retinopathy. Patients at high risk of blindness might need retinal screening more often than once a year. Those at higher risk of amputation might benefit from a proactive targeted program to prevent lower extremity amputation (including more frequent checks, tailored patient education, specially designed protective footwear, and early reporting of foot injuries), as this has been shown to substantially reduce the risk of emergency admissions, use of antibiotics, foot operations, and lower limb amputation compared with usual practice. Better information on the absolute risk of individual complications could also prompt more intensive treatment of modifiable risk factors—such as lowering of (HbA1c) and tighter blood pressure control—which are generally considered to reduce the risk of microvascular complications such as blindness.

See what your risk factors are. QDiabetes® (Amputation and blindness) equations.

Practice Pearls:

• Researchers in the UK have developed algorithms to test the 10-year risk of blindness and lower limb amputation in diabetes patients.
• Data came from hundreds of thousands of primary care patients.
• The equations can be used to help patients and providers make better clinical decisions about care.

Hippisley-cox J, Coupland C. “Development and validation of risk prediction equations to estimate future risk of blindness and lower limb amputation in patients with diabetes: cohort study.” BMJ. 2015;351:h5441.

Study cites pantries as beneficial point of intervention for low-income population.

Diabetes patients who live at a low-income level typically lack the education and nutrition to control their condition. One of the risk factors for poor diabetes control is food insecurity, which can lead to hunger due to the inability to afford healthy food. To help offset this issue, food pantries can serve as a place of provision to fight against hunger.

A pilot study by UC San Francisco and Feeding America was initiated to determine whether healthy food could help low-income people to better control their diabetes. Researchers conducted this study by tracking 687 food pantry clients who had diabetes in California, Texas and Ohio from February 2012 to March 2014.

Food banks and pantries involved in this study delivered healthy food consistently to people with the diet-sensitive disorder. There were four components included in the intervention: screening for diabetes, the provision of diabetes-appropriate food, helping clients to find primary care providers, and providing diabetes education and support. Over 80 percent of participants were satisfied with the diabetes food, eating all or most of it.

The results showed better glycemic control and good medication adherence in participants. HbA1c improved from 9.52 percent to 9.04 percent, which could lower patients’ risk of diabetes complications.

Policy makers should consider ways to leverage food bank assets, said the study authors, when designing public health interventions for people with diet-sensitive chronic diseases such as diabetes.

“The healthy food that a food bank can provide is a cornerstone of good diabetes management.” said first author Hilary Seligman. Good food provided in food banks definitely could improve public health.

Practice Pearls:

• A pilot study of low-income diabetes patients with food insecurity showed the patients are likely to better control their glycemic level by receiving healthier food through food banks.
• The results showed better glycemic control and good medication adherence in participants.
• Food banks not only could help people fight for hunger, but could also improve public health by providing healthy food.

H. K. Seligman, C. Lyles, M. B. Marshall, K. Prendergast, M. C. Smith, A. Headings, G. Bradshaw, S. Rosenmoss, E. Waxman. “A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic Control Among Clients In Three States. Health Affairs.” 2015; 34 (11).