Barriers to Diabetes Care
US family physicians, who care for about 90% of the nation's diabetics, face a difficult battle adjusting medications and monitoring patients for kidney disease, peripheral neuropathy, leg ulcers, and diabetic retinopathy during brief office visits. Education about nutrition and self-care help people with diabetes avoid these serious complications. Unfortunately, the health system in the US is set up to deal with acute rather than chronic disease and does not support preventive measures. Patients without insurance and/or with low incomes face an added challenge. Even if they understand the importance of monitoring blood sugar levels and seeing their physician, low-income diabetics cannot afford it. As one family physician told J.B. Brown and colleagues, "Diabetes is a fairly expensive illness. The testing, the medication, the diet and the frequency of visits."

During the late 1990s, four New York City hospitals set up "boot camps" for diabetics. At these education centers, diabetics learned about the consequences of uncontrolled diabetes, how to check their blood sugar levels accurately, and how to use nutrition to keep those levels more stable; they also began an exercise program. Specialists in endocrinology and ophthalmology monitored patients for disease progression. Within seven years, three of the four centers had closed because they were losing too much money. The fourth one at Columbia University Medical Center relies on generous donors to stay open.

US insurance companies are unwilling to reimburse centers and patients for preventive care. Insurers gamble that diabetic enrollees will have moved on to another provider before complications that require an amputation or kidney dialysis arise. People tend to change health insurers an average of every six years. Why spend money to prevent complications that the company may not have to pay for in the future? In addition, insurance companies do not want to offer services that attract diabetics. By offering preventive care and access to endocrinologists, insurers would be attracting more people with an expensive chronic illness.

Hospitals have their own bias against low-tech preventive care. Dr. Diana K. Berger told The New York Times, "‘If a hospital charges, and can get reimbursed by insurance, $50,000 for a bariatric surgery [that helps control diabetes and] that takes just 40 minutes…or it can get reimbursed $20 for the same amount of time spent with a nutritionist, where do you think priorities will be?"

Dr. Gerald Bernstein, who directed the diabetic center at Beth Israel Medical Center, believes that the US needs to restructure its reimbursement system if it hopes to deal with diabetes: "Until we address the financing and the reimbursement structure, this disease is going to rage out of control." Canadian diabetics and their family physicians have access to more options. Canada's universal health care supports family physicians' use of in-home services and diabetes education centers to help monitor and educate patients.

Brown JB, Harris SB, Webster-Bogaert S, et al. The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus. Family Practice. 2002;19(4):344-349. Available at http://fampra.oxfordjournals.org/cgi/reprint/19/4/344. Accessed February 8, 2007.

Urbina I. In the treatment of diabetes, success often does not pay. The New York Times. January 11, 2006. Available at: www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html. Accessed January 30, 2006. (Free access, but you must log in to access article.)

Zgibor JC, Songer TJ. External barriers to diabetes care: Addressing personal and health systems issues. Diabetes Spectrum 2001;14(1):23-28. Available at: http://spectrum.diabetesjournal.org/cgi/reprint/14/1/23. Accessed February 8, 2007.
(April 2007: Try this link instead: http://spectrum.diabetesjournals.org/cgi/content/full/14/1/23)

Metabolic Syndrome
Metabolic syndrome, also known as Syndrome X and insulin resistance syndrome, is the label for a group of measurements, associated with cardiovascular disease and diabetes. The defining factors, at this time, are high blood pressure (greater than 130/85 mm Hg), high fasting glucose levels (more than 110 mg/dL), high triglyceride levels (greater than 150 mg/dL), low HDL cholesterol (men – less than 40 mg/dL; women – less than 50 mg/dL), and too much abdominal fat (waist circumference greater than 40 inches for men and greater than 35 inches for women). Measuring around the abdomen (parallel to the floor and at the level of the iliac crest) at the end of a normal expiration provides a better indication of metabolic syndrome than body mass index. People with three or more of these factors meet the present criteria for metabolic syndrome.

By bringing these measurements back to more normal levels, people with metabolic syndrome may reduce their risk of developing heart disease, stroke, and diabetes. Physical activity – as little as 30 minutes of moderate exercise, five days/week – and a good diet are the front line for prevention and treatment. A key point in diet recommendations is to reduce the intake of simple sugars and high glycemic carbohydrates that cause a fast rise in blood sugar. High fructose corn syrup, found in many processed foods, may be especially problematic. T. Nakagawa and colleagues at the University of Florida showed that fructose, and not dextrose, increased blood insulin, triglycerides, and uric acid levels in rats. The researchers say that uric acid inhibits nitric oxide bioavailability: "Insulin requires nitric oxide to stimulate glucose uptake."

In a 2005 joint statement, the American Diabetes Association and the European Association for the Study of Diabetes questioned the value of labeling patients with the term "metabolic syndrome." Authors of the paper found "no solid evidence" that "any of the metabolic syndrome health factors contribute more together than they do individually. In other words, the whole is not greater than the sum of its parts….Each of the health factors mentioned above put people at risk for heart disease and should be treated as such, but the combination of these factors should not be considered, or treated as, a separate disease."

American Diabetes Association. Is the metabolic syndrome really a syndrome? Available at: www.diabetes.org. Accessed February 7, 2007.

Gaulte J. ADA statement-metabolic syndrome not a useful concept any longer. Available at: http://mdredux.blogspot.com/2005/08/ada-statement-metabolic-syndrome-not.html. Accessed February 7, 2007.

Getting tough with metabolic syndrome. Available at: www.postgradmed.com/issues/2004/01_04/metabolic_foldout.pdf. (257KB .pdf) Accessed February 7, 2007.

Holt S. Natural approaches to the metabolic syndrome, syndrome x. Available at: www.power-surge.com/educate/holt_syndromex.htm. Accessed on February 7, 2007.

The metabolic syndrome. JAMA. February 15, 2006; 295 (7):850. Available at: http://jama.ama-assn.org/cgi/reprint/295/7/850. Accessed February 7, 2007.

Nakagawa T, Hu H, Zharikov S, et al. A causal role for uric acid in fructose-induced metabolic syndrome (Abstract). Am J Physiol Renal Physiol. 2006 Mar;290(3):F625-31. Available at: www.ncbi.nlm.nih.gov/entrez/. Accessed February 7, 2007.

Dietary Supplement and Nonprescription Drug Consumer Protection Act
On December 22, 2006, President Bush signed into law the Dietary Supplement and Nonprescription Drug Consumer Protection Act (Public Law No: 109-462). This law requires each nonprescription drug and dietary supplement, sold in the US, to have the manufacturer's or retailer's domestic address or phone number on its label, so that consumers can report serious adverse events that occur while taking the substance. A serious adverse event is defined as a life-threatening event that results in death, inpatient hospitalization, a persistent or significant disability or incapacity, a congenital anomaly or birth defect, or a circumstance that requires medical or surgical intervention to prevent one of these outcomes.

Companies are responsible for submitting reports of a serious adverse effect to the Secretary of Health and Human Services within 15 business days. They must also submit subsequent, related medical information, received within one year of the event. The Secretary is responsible for developing systems that consolidate duplicate reports and medical information concerning an event into one report. Companies are required to keep records pertaining to each reported adverse event for six years and to allow inspection by Department of Health and Human Services employees. "The submission of any adverse event report…shall not be construed as an admission that the nonprescription drug [or dietary supplement] involved cause or contributed to the adverse event," according to the new law.

A bill to amend the Federal Food, Drug, and Cosmetic Act with respect to serious adverse event reporting for dietary supplements and nonprescription drugs, and for other purposes. Available at http://thomas.loc.gov/cgi-bin/bdquery/z?d109:SN03546:@@@L?summ2=m&. Accessed February 7, 2007.

Television Watching & Diabetes
Physical activity decreases the risk of metabolic syndrome and type 2 diabetes, so it makes sense that sitting for extended periods increases the risk. Studies, however, indicate that television watching is one sedentary behavior that is particularly negative. Television watching takes up a significant portion of daily life in the US. A 1997 Nielsen Media Research survey reported that men watched about 29 hours of television each week and women watched 34 hours.

A prospective cohort study of women in the Nurses' Health Study found a link between TV watching, obesity, and diabetes. With each additional two hours of TV watching per day, the risk of obesity rose 23% and the risk of diabetes increased 14%. In contrast, sitting at work for the same time increment was associated with just a five-percent increased risk of obesity and a seven-percent increase in diabetes. Every two-hour increment of standing or walking around the home was associated with a nine-percent reduction in obesity and a 12% reduction in diabetes. Frank B. Hu and Harvard colleagues say, "We estimated that in our cohort, 30% (95% CI, 24-36%) of new cases of obesity and 43% (95% CI, 32-52%) of new cases of diabetes could be prevented by adopting a relatively active lifestyle [less than ten hours/week of TV watching, and 30 minutes/day or more of brisk walking]."

A French cross-sectional analysis of 1902 men and 1932 women, 50 to 69 years old, found that the frequency of most signs of metabolic syndrome increased as time spent watching a TV screen or a computer screen increased. Sandrine Bertrais and colleagues attributed this association to the decrease in physical activity among men; if they are watching TV, they are not moving. Women, however, showed a positive association between metabolic syndrome and time spent watching a screen, independent of physical activity levels. The researchers also found no correlation between time spent reading and the frequency of metabolic syndrome components in either gender.

At least three factors may account for the observed positive association between TV watching and obesity-diabetes risk. First, TV watching typically displaces physical activity and thereby reduces energy expenditure. A study involving 486 adult residents of low-income housing linked each hour of TV watching to 144 fewer steps each day: "Average daily television viewing was associated with reductions in total pedometer-determined physical activity levels (approximately 520 steps per day)." Second, TV watching (and, perhaps, computer use?) lowers the metabolic rate more than other sedentary activities such as reading, writing, sewing, playing board games, and driving a car. Third, food advertising encourages increased calorie intake and consumption of high-glycemic, nutrient-poor foods.

Bennett GG, Wolin KY, Viswanath K, et al. Television viewing and pedometer-determine physical activity among multiethnic residents of low-income housing (Abstract). American Journal of Public Health. September 2006;96(9):1681-1685. Available at: www.ajph.org/cgi/content/abstract/96/9/1681. Accessed February 7, 2007.

Bertrais S, Beyeme-Ondoua JP, Czernichow S, et al. Sedentary behaviors, physical activity, and metabolic syndrome in middle-aged French subjects. Obesity Research (Abstract). 13:936-944 (2005). Available at: www.obesityresearch.org/cgi/content/abstract/13/5/936. Accessed February 7, 2007.

Hu FB, Li TY, Colditz GA, et al. Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA. April 9, 2003; 289(14):1785-1791. Available at: www.jama.com. Accessed December 26, 2006.

Wiecha JL, Peterson KE, Ludwig DS, et al. When children eat what they watch (Abstract). Archives of Pediatrics & Adolescent Medicine. April 2006; 160(4); 436-442. Available at: http://archpedi.ama-assn.org/cgi/content/abstract/160/4/436. Accessed February 7, 2007.

Iron Intake, Meat, and Type 2 Diabetes
Consumption of heme iron found in animal products, particularly red meat, is associated with increased insulin resistance and diabetes risk in men and women. Unlike iron found in dried fruit, kelp, some whole grains, and brewer's yeast, heme iron from red meat, fish, and poultry is highly bioavailable and readily stored in the body. Epidemiological studies, cited by Swapnil Rajpathak and colleagues at Harvard Medical School, have associated high iron stores with an increased risk of cardiovascular disease, metabolic syndrome, gestational diabetes, and type 2 diabetes. Different hypotheses have been proposed for this relationship. Increased oxidative stress due to iron's action as a catalyst in the formation of hydroxyl radicals is one possible factor. Also, high iron levels may slow the liver's extraction of insulin from the bloodstream. A third explanation is that iron deposits in pancreatic b-cells may hamper insulin secretion.

A prospective cohort study, conducted within the Nurses' Health Study, reported "no association between total, dietary, supplemental, or non-heme iron intake and the risk of diabetes" among women. Heme iron, however, showed a statistically significant association with diabetes risk. Rajpathak and colleagues reported that relative risk increased as consumption increased, after controlling for age, body mass index (BMI), and other risk factors. The group of women who consumed the most meat increased their risk of diabetes by 28%. When not controlling for other diabetic risk factors, the group of women who ate 2.25 mg or more of meat a day had a 52% greater risk of developing diabetes than the group who ate less than .75 mg of meat per day. Another study by Harvard researchers found that women who eat bacon, hot dogs, and sausage frequently have a greater risk of developing diabetes than meat-eaters who stick to beef, lamb, and/or pork.

A third Harvard study looked at the relationship of iron intake and diabetes among men. As in the women's study, total iron intake was not associated with type 2 diabetes. This study, however, found that only heme iron from red meat was associated with an increased risk: "…the association may have been confounded by other components of red meat intake because heme-iron intake from sources other than red meat (e.g., fish, chicken, and egg) was not associated with the risk of type 2 diabetes."

A 2001 study involving 30 lacto-ovo vegetarians and 30 meat-eaters reported a correlation between insulin resistance and body iron stores, as measured by serum ferritin concentrations. The vegetarians had eaten eggs but no meat within the previous five years. Meat-eaters had eaten animal muscle at least once a day for five years before the study. All sixty participants were lean, glucose-tolerant, and had normal blood pressure. Nancy W. Hua and co-authors reported, "Lacto-ovo vegetarians were more insulin-sensitive than meat-eaters, with a steady-state plasma glucose (mmol/l) of 4.1 (95% CI 3.5, 5.0) v. 6.9 (95% CI 5.2, 7.5) for meat-eaters (P=0.0028)." Six of the male meat-eaters also underwent phlebotomy to lower their blood iron concentration range to that of the vegetarian group. Steady-state plasma glucose concentrations were 41% lower after phlebotomy (P=0.0008), "indicating enhancement of insulin-stimulated glucose disposal following Fe depletion."

Hua NW, Stoohs RA, Facchini FS. Low iron status and enhanced insulin sensitivity in lacto-ovo vegetarians. British Journal of Nutrition. 2001;86:515-519.

Jiang R, Ma J, Ascherio A, et al. Dietary iron intake and blood donations in relation to risk of type 2 diabetes in men: A prospective cohort study. American Journal of Clinical Nutrition. 2004;79:70-75. Available at: www.ajcn.org/cgi/reprint/79/1/70. Accessed February 8, 2007.

Rajpathak S, Ma J, Manson J, et al. Iron intake and the risk of type 2 diabetes in women. Diabetes Care. June 2006;29(6):1370-1376. Available at: www.hu.usp.br/plotufo/testo%20MCM%205882%2012%2009%.2006.pdf. Accessed February 8, 2007.
(April 2007: Try this link: http://care.diabetesjournals.org/cgi/reprint/29/6/1370.pdf 88KB .pdf)

Schulze MB, Manson JE, Willett WC, Hu FB. Processed meat intake and incidence of type 2 diabetes in younger and middle-aged women.(Abstract) Diabetologia. November 2003. Available at: www.springerlink.com/content/5m0a47bn3y3tmvd7/. Accessed February 8, 2007.

Maitake SX-Fraction
Since 1994, researchers have been studying a compound, SX-fraction, found in the maitake mushroom (Grifola frondosa). This oligosaccharide-bound protein enhances cells' sensitivity to insulin. Insulin helps transport glucose into cells. When cells resist insulin, blood glucose levels rise, stimulating the pancreas to produce more insulin. This insulin resistance is a sign of prediabetes and of metabolic syndrome (Syndrome X). Maitake is also a source of a protein-bound, beta-glucan compound, called D-fraction. This compound does not affect insulin resistance, but it does boost the immune system by increasing the activity of natural killer cells, macrophages, cytotoxic T cells, interleukin 1 and 2, and tumor necrosis factor.

SX-Fraction™, a highly purified form of maitake mushroom powder produced by Maitake Products, Inc., arrived on the market in 2003. This product is designed for people with type 2 diabetes and metabolic syndrome. Both the Food and Drug Administration (FDA) and research authorized by the Japanese government agree that maitake is safe for humans. Clinical data on SX-fraction's effectiveness is still being gathered.

People who are taking medication for diabetes need to be aware that SX-Fraction "can make [that] medicine dangerously potent," according to Mark Kaylor, PhD, and Ken Babal, CN. Blood sugar levels need to be carefully monitored. Suggested protocol for diabetes is two to three tablets of SX-Fraction, three times a daily within 30 minutes after a meal. It may take two or more months of supplementation before the full therapeutic effect takes hold. When the effect has stabilized, users are advised to reduce to a maintenance dose of one or two tablets, three times a day.

Kaylor M, Babal K. Syndrome X and SX-Fraction. Orem, Utah: Woodland Publishing; 2003.

Hyperbaric Oxygen Therapy for Diabetic Wounds
In April 2003, Medicare added serious diabetic ulcers that had failed to heal within a month (using standard treatment) to its list of approved uses for hyperbaric oxygen therapy (HBOT). During HBOT, patients breathe 100% oxygen while in a pressurized treatment chamber. Studies since 1967 indicate that HBOT improves oxygenation to tissue throughout the body and increases bactericidal activity, particularly against anaerobic bacteria. HBOT also promotes wound healing by boosting the number of fibroblasts (undifferentiated cells in connective tissue) and encouraging collagen synthesis and the formation of epithelial tissue and new blood vessels. Other approved uses for HBOT include air or gas embolism, carbon monoxide poisoning, cyanide poisoning, smoke inhalation, gas gangrene, decompression sickness, intracranial abscess, and thermal burns.

Diabetic foot ulcers affect up to 25% of all people with diabetes, according to A.R. Berendt. Peripheral neuropathy, poor circulation, and impaired local immunity contribute to the development of these difficult-to-heal wounds. Limb amputation often results. Clinical use indicates that HBOT speeds healing and prevents amputation. Most of the support for HBOT stems from clinical use rather than from randomized trials. Since the oxygen treatment is not patentable, no one is interested in paying for large randomized studies. Dr. Ted Sosiak, secretary of the Ontario Medical Association's committee on hyperbaric medicine, says that HBOT resolves diabetic ulcers "about 75 per cent [sic] of the time." He also told The Globe and Mail that hyperbaric therapy is more cost-effective than amputation: "Amputation in Canada, using the CDA's own figures, costs about $74,000," he said, "while an average course of HBOT treatment – 30 or 40 are usually needed to fully heal a diabetic ulcer – costs between $8,000 and $12,000."

HBOT has a few risks and contraindications. The most common adverse effect is a progressive, reversible myopia. Seizures have also occurred. "The only absolute contraindication to HBO," according to Gill and Bell, "is an untreated tension pneumothorax, and this must be excluded before treatment. Relative contraindications include impaired pressure equalization and cardiac disease."

Berendt AR. Counterpoint: Hyperbaric oxygen for diabetic foot wounds is not effective (abstract). Clinical Infectious Diseases. 2006; 43:193-198. Available at: www.journals.uchicago.edu. Accessed February 8, 2007.

Blatchford C. Diabetics are losing legs unnecessarily. The Globe and Mail. March 26, 2005. Available at: www.theglobeandmail.com/servlet/story/RTGAM.20050325.wxdiab26/ BNStory/National/?pageRequested=all. Accessed March 27, 2005.
(April 2007: Article availalbe at no charge at http://www.uhms.org/PRESSURE/May%20June%2005/mj05-PG6.htm )

Gill AL, Bell CNA. Hyperbaric oxygen: Its uses, mechanisms of action and outcomes. Q J Med. 2004; 97:385-395. Available at: http://qjmed.oxfordjournals.org/cgi/reprint/97/7/385. Accessed February 8, 2007.

"Prescribing Happiness"
An article by Paul J. Hershberger, PhD, in Family Medicine (October 2005) urges family practitioners to make use of techniques from the field of positive psychology. Positive psychology is the study of happiness, life satisfaction, finding meaning in life, character strengths, and the development of these attributes. Hershberger writes, "Because happiness is associated with multiple benefits, including better health, it behooves family physicians to become familiar with and incorporate positive psychology into their practices." Positive emotions also promote cognitive flexibility and creativity – helpful qualities for navigating the many decisions that we make each day.

The techniques in Hershberger's article are amazingly simple. "Three Good Things," a gratitude exercise, involves writing down three positive occurrences from the day's happenings each night. For each occurrence, participants write an answer to the question "why did this occur?" A preliminary study by Martin Seligman and others indicates that just one week of doing this exercise was associated with greater happiness and less depression up to three months later. This exercise may help alter the glass-is-half-empty perspective of people who fix their attention on problems and worries.

A second technique called "Capitalization" appears to improve social/work environments, build morale, and increase satisfaction in a relationship. S.L. Gable says that telling about a positive event increases the positive emotions (and corresponding neurotransmitters) associated with the event. The more a positive event is retold, the greater the positive affect and satisfaction. Responding to someone's good news is equally important. Using an "active and constructive" response style that includes enthusiasm and an invitation to share more about the event increases social support and is associated with more satisfaction and less conflict in the relationship.

"Satisficing" is a third technique. Our culture programs us to acquire the newest and the best. Since new products and new information arise every day, a focus on getting the best sets us up for second-guessing and dissatisfaction with whatever we buy. Trying to decide what is "the best" can be time-consuming and wearing, emotionally and energetically. Satisficing involves determining a criteria for "good enough." Practitioners can encourage people who seem driven to acquire "the best" to opt for "good enough" in an upcoming decision and then ask them about the experience afterwards. Hershberger points out that physicians often choose to satisfice when they prescribe an older, less expensive medication that is "good enough," instead of the newest or most expensive.

A fourth technique encourages people to pay attention to what they tell themselves when a negative event occurs. These self-messages can foster pessimism by seeing that single failure or negative event as an statement of what always happens and will never change. A learned optimistic explanatory style "attributes negative outcomes to factors that are temporary and specific, rather than to factors that are persistent and pervasive." Hershberger uses the example of a medical student whose patient has a negative outcome. Instead of seeing the event as evidence of being a bad doctor, the student is encouraged to identify temporary and specific factors that contributed to the situation. It becomes a learning experience instead of ground for pessimism and self-defeat. Hershberger says that "an optimistic explanatory style…is associated with better mental and physical health, academic achievement, athletic performance, and performance in many career domains."

Hershberger PJ. Prescribing happiness: Positive psychology and family medicine. Family Medicine. October 2005;37(9):630-634. Available at: www.stfm.org/fmhub/fm2005/October/Paul630.pdf. (144 KB .pdf) Accessed February 7, 2007.

Ritter M. Don't worry, be happy. Researchers seek routes to happier life. Available at: www.azdailysun.com/articles/2006/11/24/news/national/20061124_us_news_35.prt. Accessed November 27, 2006.

Diabetes and the Mentally Ill
The high rate of diabetes among the mentally ill is challenging psychiatrists to pay more attention to their patients' physical health. In addition to dietary and lifestyle factors that contribute to the surge of diabetes among the general population, people with mental illness are also subject to the effects of atypical anti-psychotic drugs. These drugs contribute to diabetes by altering glucose metabolism and promoting weight gain. "Sort of a cruel irony in this," said [Dr. Jeffrey Lieberman of Columbia University in a New York Times article], "is that all of the drugs do it to some degree, but the ones that have the most effect cause the most weight gain and metabolic side effects. There's increasing discomfort that these are driving up deaths and lowering quality of life."

All too often, psychiatrists are the only medical doctors that mentally ill patients see. Because of the serious consequences of diabetes and obesity, some psychiatrists are screening patients for diabetes before choosing drugs. A few are weighing patients and checking blood sugar levels as part of their patients' regular appointments. Most psychiatrists, however, do not feel qualified or equipped to deal with diabetes. Dr. Donna Ames Wirshing, a staff psychiatrist at the West Los Angeles Veterans Administration Medical Center, and her husband, Dr. William Wirshing, are exploring the use of nutrition and exercise coaches to help mentally ill patients. Psychiatrists can also adapt their treatment in ways that acknowledge their patients' physical as well as mental conditions. Instead of having patients sit in a chair or lie on a couch during their sessions, psychiatrists can have patients (and, perhaps, themselves) use an exercise bike; or doctor and patient take a walk around the block together while the patient talks.

Kleinfield NR. In diabetes, one more burden for the mentally ill. The New York Times. June 12, 2006: A1, A17.