March 10, 2018 : Issue #928

• How is Cardiovascular Health Related to Duration of Diabetes and Prediabetes?
• American College of Physicians Recommending Controversial Increase in A1c of 7% to 8%
• Eating Disorders Negative Effect on Glycemic Control
• Are We Doing a Better Job of Detecting Diabetes?
• Newfound Benefit of Ezetimibe in DM
• Metformin During Gestational Diabetes Increases Risk of Childhood Obesity
• Exclusive: Dr. Jamie Uribarri on the Health Effects of AGEs in Diet

I recently converted one of my aero road bikes from a 22-speed to a single speed, which means I only have one gear. I can still get up to 27 mph on a sprint, but instead of pedaling at 80 revolutions a minute, I am forced to pedal at 123 revolutions. According to my coach, this extra work builds stamina and strength, which will come in handy when I attempt to do the Hincapie mountain climb in Chattanooga later this spring. This is 80 miles and 5,500 feet of climbing and my goal is not to have to get off the bike and walk at all.

The reason I mention this is to drive home a point about a recent recommendation the American College of Physicians has shared concerning A1c goals. It seems that they feel an A1c of 7 to 8 is okay to strive for. Why they would do that, knowing the thousands of studies that have been done showing the value of getting A1c’s below 7, is beyond my comprehension and would be equivalent to my coach telling me quit trying to climb the whole ride and just get off and walk.

Are they making this recommendation because that way they will look like they are doing a better job getting to target, regardless of the outcome for the patient?

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We can make a difference!

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Dave Joffe

Editor-in-chief

The American College of Physicians (ACP) said doctors can tell patients to aim for a glycosylated hemoglobin, or HbA1C, level between 7 percent and 8 percent, rather than the traditional 6.5 percent to 7 percent. Plus, clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%. (See article 2)

Do you agree A1c should be between 7% and 8%?

Follow the link to see what your colleagues think.

See article 2.

Gout is a tricky diagnosis to make. Rarely is it made via the gold standard technique of synovial aspiration and polarized light microscopy. The vast majority of diagnoses are clinical. A primary care and rheumatologist team of Dutch researchers led by Hein Janssens derived and published a clinical decision rule in 2010. This app brings that decision rule to primary care physicians, rheumatologists, and acute care (ER/urgent-care) clinicians everywhere.

Dr. Jaime Uribarri is a physician and clinical investigator. He was born in Chile and received his medical degree from the University of Chile School of Medicine. He did all his postgraduate training in the United States. He has been in The Icahn School of Medicine at Mount Sinai, NYC, since 1990, where he is currently Professor of Medicine and Director of the Renal Clinic and the Home Dialysis Program at the Mount Sinai Hospital.

A patient that you haven’t seen for several years comes to your clinic for a wellness check-up. Since her last visit, she has gained about 15 pounds (5’6”, BMI 27 kg/m2). Her stage 1 hypertension is controlled with hydrochlorothiazide. As you discuss her weight gain, you learn that she doesn’t get more than 30 minutes a week of physical activity. You decide it would be best to check her A1C. Which of the following information from her history leads you to screen her for type 2 diabetes?

A. Her youngest child weighed 8.5 pounds at birth.
B. Two of her cousins have type 2 diabetes.
C. She just celebrated her 41st birthday.
D. She has a history of hypertension.

Follow the link for the answer.

Cardiovascular disease is the reason for increased risk of death, when a patient is diagnosed with T2DM at an earlier age. This information comes from a published study in Diabetologia on Feb. 22, 2018. The study examined the effect of age at diagnosis of type 2 diabetes on the risk of all-cause and cause-specific mortality over 15 years.

Data was taken from 744,000 patients with T2DM who were registered on the National Diabetes Services Scheme in Australia between 1997 and 2011. The researchers found that there were 115,363 deaths during 7.20 million person-years of follow-up. The rates of all-cause and cancer mortality declined and CVD mortality was constant during the first 1.8 years after diabetes diagnosis. There was an exponential increase in all mortality rates with age. The median age at diagnosis was 58.6 years (IQR 49.4–67.9). All mortality rates increased exponentially with age. An earlier diagnosis of type 2 diabetes (longer duration of disease) was associated with a higher risk of all-cause mortality, primarily driven by CVD mortality. A 10-year earlier diagnosis (equivalent to 10 years’ longer duration of diabetes) was associated with a 1.2–1.3 times increased risk of all-cause mortality and about 1.6 times increased risk of CVD mortality. The effects were similar in men and women. For mortality due to cancer (all cancers and colorectal and lung cancers), we found that earlier diagnosis of type 2 diabetes was associated with lower mortality compared with diagnosis at an older age. Earlier diagnosis of type 2 diabetes correlated with increased risk of all-cause mortality, mainly driven by CVD mortality. There was a correlation for a 10-year earlier diagnosis of diabetes with a 1.2- to 1.3-times increased risk of all-cause mortality and about a 1.6-times increased risk of CVD mortality. Similar effects were seen in men and women. Earlier diagnosis of type 2 diabetes correlated with lower mortality due to cancer compared with diagnosis at an older age. The findings suggest that younger-onset type 2 diabetes increases mortality risk, and that this is mainly through earlier CVD mortality. From the results of the study it is believed that any efforts to delay the onset of type 2 diabetes might, therefore, reduce mortality.  As we are seeing an increase of diagnosis of T2DM at a much earlier age, then from the results of this study we will most likely see a greater number of deaths at an earlier age.  Diabetologia Feb., 22nd, 2018

Study finds disease duration in middle age to be independently related to development of subclinical atherosclerosis and cardiac dysfunction later in life.

Organization says adults with type 2 diabetes can aim for an easier-to-achieve blood sugar target than what’s been used to guide treatment in the past.

An attempt to improve diet quality in youth with type 1 yields less than promising results.

While detection of type 2 diabetes for specific subgroups in the population has slightly increased, overall detection rates remain low among US adults.

When added to statin therapy in patients with diabetes, ezetimibe provides greater cardiovascular protection than what is seen in individuals without diabetes.

Long-term impact of intrauterine exposure to medication on the offspring remains unclear.

Quote of the Week!

“Only I can change my life. No one can do it for me.”

…Carol Burnett

Diabetes in Control gratefully acknowledges the assistance of the following pharmacy doctoral candidates in the preparation of this week’s newsletter:

Lamija Zimic, Doctor of Pharmacy Candidate 2018, USF College of Pharmacy

Adrianna Jackson, Doctor of Pharmacy Candidate 2018, LECOM College of Pharmacy

Your Friends in Diabetes Care
Steve and Dave
Diabetes In Control
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