June 28 – Orlando — The editorial staff of Medical Economics brings you daily coverage of breaking news, the latest research findings, and reports of interest to the readers of Medical Economics, Drug Topics, Formulary, and Contemporary OB/GYN.

Our five-day coverage of this year’s American Diabetes Association’s 70th Scientific Sessions includes the results of major clinical trials and ongoing news and information of interest to clinicians who treat type 1 and 2 diabetes.

Elizabeth Selvin, PhD

Boyd E Metzger, MD

Gestational diabetes and obesity, either separately or in combination (known as diabesity) are strongly associated with an increased frequency of delivering a high birth weight child, said Boyd E Metzger, MD.
          The finding comes from an analysis of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, which was designed to find the level of glucose tolerance, short of diabetes, that is associated with risk of adverse outcome.
          The study included 23,316 pregnant women who underwent 75-g oral glucose tolerance testing at 24 to 32 weeks’ gestation and whose glucose levels were blinded to caregivers. The main study, published in 2008, found continuous, independent associations of measures of maternal glycemia and body mass index (BMI) at the 75-g oral glucose tolerance test with predefined perinatal outcomes (increased birth weight and increased cord-blood serum C-peptide levels).
          For the present analysis, the relative contributions of gestational diabetes and maternal obesity to risk of macrosomia (birth weight of 4,000 g or greater) were examined.
          Maternal BMI was classified as nonobese or obese by modification of the 2009 Institute of Medicine recommendations.
          The observed number of cases of macrosomia in the nonobese group with gestational diabetes was 286, compared to an expected number of 186, for an excess number of 100 cases.
          “Obesity was associated with a 2-fold higher frequency of macrosomia” whether or not the women had gestational diabetes, said Metzger, professor of metabolism and nutrition, division of endocrinology, metabolism, and molecular medicine, Northwestern University, Chicago. Among the obese group, the excess number of cases of macrosomia was 154 in the group without gestational diabetes (151 expected, 305 observed) and 126 in the group with gestational diabetes (63 expected, 189 observed).
          In the 380 total instances of excess macrosomia, gestational diabetes only was present in 26%, gestational diabetes plus obesity was present in 33%, and obesity only was present in 41%.
          In 2009, a task force of the International Association of Diabetes and Pregnancy Study Groups recommended that the diagnosis of gestational diabetes be made when 1 or more of the following thresholds is met or exceeded: fasting plasma glucose of 92 mg/dL (5.1 mmol/L); 1-hour plasma glucose of 180 mg/dL (10 mmol/L); 2-hour plasma glucose of 153 mg/dL (8.5 mmol/L). These proposed diagnostic criteria are based on their predictive value for adverse pregnancy outcomes from the original HAPO study.

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Lawrence de Koning, PhD

Dietary choices can have a discernable effect on the risk of developing type 2 diabetes. That conclusion is based on analysis of men in the Health Professionals Follow-Up Study (HPFS), which followed 41,212 men for up to 20 years.
         “It is important to replace red and processed meats with other choices, chicken and fish and especially vegetable protein sources,” said Lawrence de Koning, PhD, postdoctoral fellow, Harvard School of Public Health, Boston. “The data show us that vegetable-based protein does not elevate the risk of diabetes and may very well be protective.”
          It has long been recognized that low-carbohydrate diets appear to be protective for cardiovascular and other diseases. Low-carbohydrate diets are also frequently used for weight loss. But the relationship between low-carbohydrate diets and type 2 diabetes risk is less clear, de Koning said.
          Researchers analyzed food consumption reports submitted every 4 years by the HPFS participants and the occurrence of type 2 diabetes to assess dietary risk factors. Food questionnaire responses were used to score 3 low-carbohydrate diets: high-total protein/fat, high-animal protein/fat, and high-vegetable protein/fat.
          There were 2,761 cases of type 2 disease reported during the follow-up period. Hazard ratios (HRs) were calculated after adjusting for age, smoking, physical activity, body-mass index, coffee and alcohol use, family history of diabetes, and total energy. The high-animal protein/fat diet carried the highest risk for type 2 diabetes (HR, 1.41; P<.0001), followed by the high-total protein/fat diet (HR, 1.32; P <.0001), and the high-vegetable protein/fat diet (HR, 0.93; P=.44).
          The high-total protein/fat diet lost its type 2 diabetes risk after adjusting for animal protein and fat. The HR associated with the high-animal protein/fat diet was reduced to 1.19 (P=.01) after adjusting for red and processed meats, but there was no change in risk after adjusting for poultry or fish.
          “The risk relationship with red and processed meats is linear,” de Koning said. “At low levels of intake, you might have a low level of risk that can be offset by some other protective factor such as more exercise.”
          Results of the HPFS analysis suggest that the key to reducing type 2 diabetes risk is to follow a prudent diet that is high in whole grains, moderate in alcohol, and low in red and processed meats, sodium, and sugar-sweetened beverages.

Julie Miller Jones, PhD, CNS, LN

Fructose is the sugar consumers love to hate. It gets the blame for obesity, metabolic syndrome, and a variety of dietary ills.
         “Fructose has become the new trans fat,” said Julie Miller Jones, PhD, CNS, LN, professor emeritus, St Catherine University, St Paul, Minnesota. “Consumers are trying to avoid it, especially in the form of high-fructose corn syrup. That’s an unfortunate name because the fructose concentration isn’t high.”
          High-fructose corn syrup contains 42% to 55% fructose, Jones told a Sunday-morning symposium, Dietary Sweeteners Containing Fructose—Effects on Metabolism and Impact in the Food Supply. That is similar to many common fruits and vegetables and lower than the 66% fructose found in apples and pears. Agave, often marketed as a natural sweetener, contains 85% fructose.
          The problem, Jones continued, is too much sugar and too many calories. “You can get a $0.69 Big Gulp that delivers 800 calories and not a single nutrient,” she said. “A calorie is a calorie, whether it comes from glucose or fructose or a jelly donut.”

Kimber Stanhope, PhD

          Excess dietary sugar is associated with increased body weight, lipids, blood pressure, and insulin resistance, continued Kimber Stanhope, PhD, associate project scientist in molecular biosciences, University of California, Davis. Excess fructose is associated with distinct metabolic effects.
          Recent human studies have found that fructose is associated with increased visceral fat, whereas glucose is associated with increased subcutaneous fat. Fructose also decreases insulin and leptin and elevates triglycerides compared with glucose. Both sugars produce similar weight gains.
          “A calorie is not just a calorie when it comes to metabolic syndrome risk factors,” Stanhope said.

Michele Doucette, PhD, RN

          Weight gain and obesity are the overriding concerns when it comes to type 2 diabetes, noted Michele Doucette, PhD, RN, assistant professor of family medicine, University of Colorado, Denver. Don’t eliminate fructose; reduce the total caloric intake.
          The risk for type 2 diabetes is 2 to 7 times higher in obese persons compared with normal-weight persons and 20 times higher when body mass index exceeds 35.
          “What is important is the total amount of calories, not the source, in terms of weight gain,” Doucette said. “What is really driving the obesity epidemic is energy balance.” Obesity is the result of multiple factors, including genetics, food consumption, activity level, food access and availability, urbanization, and more, she continued. Portion size is an obvious problem.
          The 7-ounce cup of coffee with milk and 85 calories has morphed into a 16-ounce giant that is mostly milk and delivers 480 calories. The 12-ounce soda, 160 calories, has largely been replaced by the 20-ounce, 240-calorie version.
          “We are eating too much of too many foods that are energy rich and nutrient poor,” Doucette said. The remedy, she added, is to help patients eat more wisely so that they consume fewer calories and increase their activity level.

Shane Sweet, MA

Exercise research has found that boosting patients’ self-determination is an effective way to improve their motivation to exercise. The results were presented during an oral presentation, Practical Issues in Diabetes and Exercise on Sunday afternoon.
         “The number one reason people give for not exercising is lack of motivation and interest,” said exercise motivation researcher Shane Sweet, MA, doctoral candidate at the University of Ontario, Ottawa, Canada. “Increasing their sense of self-determination increases motivation, which results in better adherence to exercise, medications, glucose, and A_1c.”
          Increasing self-determination means helping patients realize that they have choices. Once patients recognize that they have control over those choices, they tend to make the right ones.
          “We all have an inborn tendency to prefer well being,” Sweet explained. “We all want to feel comfortable in our skins. If you can help them [patients] recognize that they have choices about exercise, help them build confidence and competence in exercise activities, and help them relate better to exercise, they are going to feel more motivated.”
          The key is to behave in a warm and caring manner using motivational interviewing and expressing empathy.
          “You want to help the patient discover choices,” Sweet explained. “It gives a greater sense of control and less sense of pressure.”
          The next step is to build confidence and competence by helping the patient identify the expected outcome and set realistic goals. Using more frequent, easier-to-achieve goals instills confidence. It is also important to build skills and coping strategies. That may mean helping patients learn an exercise skill or realize that minor aches and pains are normal.
          Controlling language—phrases such as “you must,” “you should,” or “you ought to”—are probably counterproductive.

Guillame Charpentier, MD

Clinical reporting and coaching systems can significantly reduce hemoglobin A_1c levels without increasing the costs of care. The good news came from Guillaume Charpentier, MD, Center Hospitalier Régional Gilles de Corbeil, Corbeil, France, during a Sunday symposium, New Technologies for Diabetes Education.
          There are 3 broad models for telecare, Charpentier said. The most basic is a downward model, with automated phone messages and calls from a diabetes specialist to the patient. The second adds data transmission, either by modem or, more recently, by cell phone, with feedback by phone, text message, or Web page. The last model adds decision-support software for both clinician and patient.
          Early downward models showed some success, Charpentier noted, with one type 1 diabetes trial showing a 1.1% A_1c reduction over 6 months.
          Early decision-support systems showed marginal results. IDEATeL (Informatics for Diabetes Education and Telemedicine), a telemedicine system tested in New York State, showed a 0.18% A_1c drop over 5 years but added $8,000 per patient to care costs.
          More recently, Charpentier developed DIABEO, a smart phone-based system with an electronic diary, a patient-specific bolus calculator, and mealtime dose calculations based on glucose trends. A trial comparing standard care to DIABEO with weekly phone consults showed a 0.9% reduction in A_1c over 3 months. There was no increase in physician time, Charpentier reported, and a sharp decline in hypoglycemic events.
          “This system is free to all patients with diabetes in France,” Charpentier said. “We have adapted it to all of the popular smart phones, and we expect it to be fully reimbursed by the national health plan in the very near future.”
          The system has also been adapted for type 2 diabetes. New features include automatic basal dose adjustments, coaching for food and activity based on recent blood glucose results, and food selection advice. Early results show a steady decline in A_1c, Charpentier said, with more mature data due in 2011.

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