Tag Archives: diabetes

Do Medical Tattoos Need Guidelines?

Should medical tattoos be standardized? Should there be guidelines pertaining to their design, and where on the body they’re located? Should physicians prescribe tattoos to patients with hidden medical conditions? And if the answer to any of those questions is yes, should medical personnel be the ones doing the tattooing?

Photo by Miriam E. Tucker / Used with permission

Those were among the questions raised by Dr. Saleh Aldasouqi in a poster presentation and at a press briefing at the annual meeting of the American Association of Clinical Endocrinologists.

Some patients with diabetes and other hidden medical conditions are choosing to be permanently tattooed rather than wear a necklace or bracelet to alert emergency personnel of their conditions. This is particularly common among patients with type 1 diabetes, for whom low blood sugar can result in unconsciousness or odd behavior that can easily be mistaken for drunkenness.

“There are a lot of patients with diabetes who are getting tattoos. Just Google ‘medical tattoos’ or ‘diabetic tattoos’ and you’ll find a large number from around the world.  The problem is they’re not consulting their physicians. They could have high sugar, which can affect wound healing. …There are so many issues now being talked about with regard to medical tattooing,” noted Dr. Aldasouqi, an endocrinologist at Michigan State University, Lansing.

He believes these issues should be addressed by professional medical organizations, possibly including those pertaining to diabetes, dermatology, and emergency medicine.

As for tattoo location on the body,  the wrist would be the most logical place since first responders will always check there, he said.

So who should do the tattooing?  Tattoo parlors that are licensed under state or local laws are typically clean and use sterile equipment, and require customers to read and sign consent forms that address medical conditions and risks.  Of course, tattoo artists would need to be educated about any new standard.

But dermatologists or plastic surgeons could do it as well. “We’re not competing with tattoo artists, but at least we can collaborate with them by standardizing at their level, or make it a minor surgical procedure. In fact, this is being done to mark the skin for radiation therapy in cancer patients, and in reconstructive surgery after breast cancer. Some medical tattooing is already being done  by medical specialists. So, it’s open for discussion.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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More Docs Are Asking Patients to Exercise

Physicians are getting better at advising adults to exercise.

Photo courtesy National Cancer Institute/Bill Branson

In 2010, 32.4% of adults in the United States who had seen a physician or other health care professional in the past year had received a recommendation to begin or continue to do exercise or physical activity, up from 22.6% in 2000. At each time point, women were more likely than men to have been advised to exercise.

The findings, published this month as a National Center for Health Statistics Data Brief, come from the National Health Interview Surveys conducted in 2000, 2005, and 2010.

Between 2000 and 2010 the percentage of patients aged 85 and older who received a “get fit” recommendation from a physician nearly doubled from 15.3% to 28.9%. The percentage of patients aged 18-24 years receiving such a recommendation also increased during the same time period, but to a lesser extent (from 10.4% to 16.1%).

The report also found that the percentage of adults with hypertension, cardiovascular disease, cancer, and diabetes who received exercise advice from a physician increased between 2000 and 2010.

“Trends over the past 10 years suggest that the medical community is increasing its efforts to recommend participation in exercise and other physical activity that research has shown to be associated with substantial health benefits,” the report states. “Still, the prevalence of receiving this advice remains well below one-half of U.S. adults and varies substantially across population subgroups.” 

 — Doug Brunk (on Twitter@dougbrunk)

Photo courtesy National Cancer Institute Visuals Online

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A ‘Health Shock’ for Youth with Diabetes

While the financial impact of diabetes on the delivery of medicine and related health care is a popular area of research, the nonmedical implications for young adults “have gone virtually unexplored,” lead author Jason M. Fletcher, Ph.D.,  associate professor of public health at Yale University, declared in the January 2012 issue of Health Affairs.

Jason M. Fletcher, Ph.D./Photo courtesy Yale University

According to results from a study Dr. Fletcher conducted with his associate Michael R. Richards, a doctoral candidate at Yale, the nonmedical consequences of diabetes can occur early in life and are associated with certain adverse effects. For example, a person with diabetes can expect to earn significantly less income over his or her working life compared with one who does not have the disease. Diabetes patients also more likely to drop out of high school and less likely to attend college.

The study was based on a survey of nearly 15,000 youth in grades 7-12 who participated in the National Longitudinal Study of Adolescent Health in 1994 and 1995 and who completed follow-up surveys in 1996, 2001/2002, and in 2008, when most were about 30 years old (Health Aff. 2012; 31:27-34). The researchers found that the high school dropout rate among people with diabetes was 6% higher than the rate among people without the disease. In addition, people with diabetes were 8%-13% less likely to attend college compared to their peers without the disease. Interestingly, having a parent with diabetes lowered the chances of attending college by another 4%-6%.

Over a 40-year work lifetime, people with diabetes can expect to earn $160,000 less in wages compared with people who do not have the disease. The researchers termed the double-whammy of adverse impact on schooling and wages as a “health shock” to people with diabetes.

“These results highlight the urgency of attacking this growing health problem, as well as the need for measures such as in-school screening for whether diabetes’s impact on individual learning and performance begins before the classic manifestations of clinical diabetes appear,” the researchers concluded.

— Doug Brunk

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Moving Beyond the Hospital

Recently, officials at Hoag Memorial Hospital Presbyterian, a regional health care system in Orange County, Calif., decided to rebrand their 60-year-old institution. The not-for-profit health care system is now known simply as Hoag. They weren’t just going for brevity. They specifically wanted to drop the word “hospital.”

Dr. Richard Afable, Hoag’s president and CEO, recently spoke to a small meeting of hospitalists in Las Vegas and explained that the name change reflects a shift toward providing more services outside of the hospital. Hoag’s hospitals do a great job treating the acutely ill, he said, but the leadership wanted to reach out to people in the community before they got sick enough to make it to the hospital.

Dr. Richard Afable. Photo by Mary Ellen Schneider/ Elsevier Global Medical News.

So officials at Hoag have been working to offer more services related to conditions that either slightly touch the hospital or don’t touch it at all, Dr. Afable said. For example, the system has beefed up its offerings around diabetes care and now provides counseling on how to manage the disease and prevent complications. In the old days, they would have waited for someone to have a heart attack or lose a limb before taking care of them, Dr. Afable said. They also are developing community-based programs for breast cancer, a condition that today is treated primarily outside of the hospital.

And Dr. Afable advised hospitalists to consider following Hoag’s lead and look how they can be involved in care outside of the hospital. He noted the example of CareMore, a medical group and health plan based in California, which is being acquired by the health insurer Wellpoint, Inc. Under CareMore’s model, hospitalists not only care for patients while they are in the hospital, but also after they leave. Once a patient is stable, they are sent back to receive the rest of their care from their primary care physician. Since CareMore uses a capitation payment model, there aren’t concerns about which physician gets the payment for the post-discharge care. The model is food for thought for hospitalists as care becomes increasingly less hospital centric, Dr. Afable said.

— Mary Ellen Schneider

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Conflicts of Interest at the UN Noncommunicable Disease Summit? Bingo.

Just in advance of the United Nations High Level Meeting on the Prevention and Control of Non-communicable Disease, a coalition comprising more than 140 nongovernmental and public health organizations has called on the UN to restructure the way in which the food and beverage industry has been involved in the policy negotiations.   

Photo by Christian Cable / Wikimedia Commons

The Conflicts of Interest Coalition (COIC) describes itself as a group of “civil society organizations united by the common objective of safeguarding public health policy-making against commercial conflicts of interest through the development of a Code of Conduct and Ethical Framework for interactions with the private sector.” 

The COIC sent a Statement of Concern to the President of the United Nations General Assembly and the UN summit’s facilitators, decrying the lack of clarity regarding the role of the private sector in public policy-making in relation to the prevention and control of non-communicable diseases (NCDs).  

“Since the major causes of preventable death are driven by diseases related to tobacco, unhealthy diet, physical inactivity and alcohol drinking, we are concerned that many of the proposals to address NCDs call for ‘partnerships’ in these areas with no clarification of what this actually means. Public-private partnerships in these areas can counteract efforts to regulate harmful marketing practices,” the COIC wrote.

Calling industries “both part of the NCD problem and the solution,” the COIC believes industry should be involved in the implementation of policy but not its development. To that end, the group’s Statement offered two proposals:

First, a change in the nomenclature of nongovernmental organizations (NGOs) to distinguish between those that are industry-supported and those that are strictly civil society: “Business-interest-not-for profit organizations (BINGOs) and public interest nongovernmental organizations (PINGOs).

Second, a “code of conduct” that sets out a clear framework for interaction with the food and beverage industry and managing conflicts of interest, differentiating between policy development and implementation. 

“We ask for the UN to consider our comments and take them into account for the UN High Level Meeting in September,” the COIC wrote in the Statement, a version of which was published Sept. 16 online in The Lancet.  

Indeed, food industry lobbying is believed to have played a role in the removal of specific targets and indicators for reductions in salts, sugars, and saturated fats from earlier versions of the Political Declaration that will be voted on at the UN High-Level meeting, but it is probably too late to change that document since the vote is expected to take place Monday morning, according to Ann Keeling, chair of the Noncommunicable Disease Alliance (NCDA), the leading NGO that pushed for the Summit.

Ann Keeling photo courtesy of the International Diabetes Federation

However, she told me in an email, there will be time to address the conflict of interest issue in 2012, when the UN will be making decisions on both the establishment of partnerships as well as targets and indicators.

“The view of the NCDA is that the private sector, subject to ethical frameworks on conflict of interest, must be part of the solution, especially in implementation. We believe there should be a ‘triple partnership’ going forward – public/private/people with NGOs being the people and with far greater involvement from global to community level of people with NCDs.”

–Miriam E. Tucker (@MiriamETucker on Twitter)

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Chew on This!

Grandmothers the world over are the same when it comes to some things.

Sneaking candy behind mom’s back.

Big cuddly hugs.

Best. Cooking. Ever.

And advice about how to eat said cooking.

A slow eater. Credit: Håkan Svensson, Xauxa/ Wikimedia Commons

“Slow down! This isn’t a race you know! Chew each mouthful 100 times!”

Japanese grandmas are no different – and even the Japanese government has jumped on the chewing bandwagon, Dr. Masaaki Eto said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Eto described his study of 9 obese – but not diabetic -  subjects with a mean body mass index 27 k/m2 (in Japan, obesity begins at a BMI of 25 kg/m2). At baseline, the volunteers’ mean fasting plasma glucose was 99 mg/dL. They all ate the same 630-calorie meal on two separate days: bread, butter, a hard-boiled egg, steamed vegetables, a banana, and milk.

On day one, they had to finish it in 20 minutes, chewing each bite 5 times. On the second test day, they ate the same meal, also in 20 minutes, but chewed each mouthful 30 times.

Dr. Eto and his colleagues measured two satiety hormones – glucagon-like peptide (GKP-1) and peptide YY (PYY) before and after each meal.

The results will please grandmas worldwide.

Chewing each bite 30 times significantly increased the levels of both hormones over chewing 5 times, said Dr. Eto of Ohu University, Fukushima, Japan.

Among the 5-chew gulpers, plasma PYY increased from 36 pg/mL to 41 pg/mL – not a significant change. But the slow chewers had quite a different outcome. “The 30-times chewing group had a significant increase in plasma PYY,” Dr. Eto said. Their levels jumped from a mean of 36 pg/mL to 66 pg/mL.

The story was repeated with GLP-1. The fast-chewers did have an increase – although not significant (5 pmol/L to 17 pmol/L).  But the slow-chewers had much better results, increasing their GLP-1 from 5 pmol/L to a whopping 29 pmol/L.

“This is the first report that thorough chewing stimulates postprandial increases in the two hormones,” Dr. Eto said. “These hormones reduce appetite and food consumption, so thorough chewing may help obese subjects to lose weight.”

Besides, he said, Japanese grandmothers “since the old days” have advised kids to do a lot of chewing.  So much so, he added, that the Japanese government has issued a recommendation to  chew each bite of food 30 times – to help avert the country’s growing obesity problem. “That is why we picked 30 times chewing,” for the study, Dr. Eto said.

Some audience members weren’t completely convinced that the good results are related to the combination of chewing and food intake. One questioned whether the mechanics of chewing was key benefit, stimulating the vagusl nerve to release GLP-1. “For instance,” he asked, “what if the subjects chewed the food and then spat it out? What would the results be then?”

To which moderator Dr. Davide Carvalho replied, “I believe chewing and spitting out the food could be the best diet we could invent.”

—Michele G. Sullivan

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Optimism About UN Noncommunicable Disease Summit

The noncommunicable disease community is unlikely to get everything it was hoping for out of the United Nations High-Level Meeting on NCDs next week, but its leading spokesperson is upbeat nonetheless. “Even if nothing happens in New York, the fact that people are aware of diabetes and other noncommunicable diseases … that there will be a political declaration – a political statement – coming out of New York stating that diabetes and other NCDs are serious, is an achievement in itself,” International Diabetes Federation president Jean Claude Mbanya said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Jean Claude Mbanya / Photo by Miriam E. Tucker

The upcoming 5th edition of the IDF Diabetes Atlas, to be released on November 14th – World Diabetes Day – will include the data that there are 366 million people living with diabetes and 4.6 million deaths due to diabetes – one death every 7 seconds – at a cost of $465 billion spent on diabetes care. In contrast, the last IDF Diabetes Atlas, released in 2009, put the prevalence figure at 285 million. “The cost of not doing something about diabetes is more than the benefit,” said Dr. Mbanya, who noted that IDF is releasing those few figures in advance of the UN NCD summit because “We don’t want the world leaders to forget about diabetes, which is the tsunami of the 21st century.”

In the Political Declaration, which will probably not change during the UN meeting, member states have agreed to establishing NCD plans and policies that create partnerships, to reducing salts and sugars and eliminate industrially produced trans fats in all foods, to increase access to affordable, quality-assured medicines and technologies, to strengthen health care systems to include integration of NCD prevention and treatment, and to increase resources for NCDs. The document also contains an agreement to develop a comprehensive global monitoring framework for NCDs in 2012, and a set of voluntary global targets and indicators.

Items that IDF and the NCD Alliance had pushed for that didn’t make it into the Declaration because of opposition based primarily on budgetary concerns included the specific target of a 25% reduction of NCD deaths by 2025, and a requirement for monitoring. “We think we need targets and measurements. What gets measured is what gets done,” Dr. Mbanya commented.

But, the UN summit isn’t the last step. There will be another evaluation in 2014, just in advance of the scheduled 2015 revision of the Millennium Development Goals. Because many countries base funding decisions on the MDGs, inclusion of NCDs there would be another huge step forward, he said.

For now though, “just getting heads of states to hold a summit on NCDs is an achievement in itself. This will be only the second summit on health after [the 2001 summit on HIV/AIDS]. So, we have achieved something. We have attracted the world’s attention.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Can Crowdsourcing Speed Diabetes Drug Discovery?

When it comes to finding treatments and cures for complicated conditions such as diabetes, why not cast the widest net possible for new ideas? That’s the thinking behind the Juvenile Diabetes Research Foundation’s new collaboration with an organization called Innocentive to seek innovative proposals from the general public for a novel glucose-responsive insulin drug. The “Challenge,” which offers a $100,000 reward, is an example of crowdsourcing in drug discovery, a recent concept that has been gaining momentum.

manbeastextraordinaire (Jake Brown) / Wikimedia Commons

“Originally, crowdsourcing was defined as a mechanism by which specific problems are communicated to an unknown group of potential solvers in the form of an open call, usually via the Internet; the community (the “crowd”) is asked to provide solutions and the ‘winners’ are rewarded,” Dr. Monika Lessl and Dr. Khusssru Asadullah, of Global Drug Discovery Bayer Healthcare Pharmaceuticals, Berlin, wrote earlier this year in Nature Reviews/Drug Discovery.

Eli Lilly was the first company to introduce the crowdsourcing concept in drug discovery by establishing the InnoCentive platform in 2001. Now an independent organization, InnoCentive has a “solver” community of more than 200,000 experts from 20 countries. In Innocentive’s “Challenge Platform” model, intellectual property (IP) is transferred from the solver to the “seeker” in return for a financial reward. In contrast, with Bayer Healthcare’s Grants4Targets, IP remains fully with the applicants initially, and subsequent collaborative agreements are negotiated for promising agents. In yet another crowdsourcing model sponsored by the UK’s Medical Research Council, IP is jointly owned and revenue is split between the parties.

Drs. Lessl and Asadullah write that in order for drug discovery crowdsourcing to be successful, “it is critical that the questions or challenges to be addressed are suitable, precisely defined and clearly presented, and that what is expected from potential solvers and offered by the searching organizations is clearly communicated.” Indeed, the expectation is clearly spelled out for the JDRF/InnoCentive initiative: “What we need is a sophisticated insulin that will take the guesswork out of managing diabetes by working the same way insulin works in people without diabetes,” Aaron Kowalski, Ph.D., assistant vice president of Treatment Therapies at JDRF, said in a press statement.

This isn’t JDRF’s first support of research on glucose-responsive insulin. Back in 2008, JDRF formed a $1 million partnership with a company called SmartCells, Inc. to advance the preclinical development of a product called SmartInsulin. SmartCells has since been acquired by Merck, which is continuing the product’s development. As Dr. Kowalski told me, “JDRF remains interested and excited in the clinical development of SmartInsulin by Merck.”

Photo by Miriam E. Tucker

So why is JDRF now simultaneously crowdsourcing the concept? Again, it’s about that wide net. First, Dr. Kowalski said, there may be multiple innovative ways to design glucose-responsive insulins. Second, it’s possible that not all insulin-dependent diabetes patients would respond the same way to a single type of insulin. “Therefore, we aim to stimulate more approaches that we hope will provide multiple options to patients with diabetes.”

Third, because the approval process for new drugs is highly variable, “The more options that are available, the more likely it is that one of them will make its way through the regulatory process.” Bottom line: “Insulin-dependent diabetes remains an urgent, unmet medical need, and it is important for JDRF to take a multi-pronged approach to tackle this challenge.” By opening up the challenge to the entire world, crowdsourcing would seem to be the ultimate “multi-pronged” approach.

Anyone with a solution that fits the proposed criteria is eligible to enter the Challenge, which requires only a written proposal. Submissions will be accepted through November 9, 2011.

—Miriam E. Tucker (@MiriamETucker on Twitter)

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Engaging Diabetes Patients 24/7

It’s the conundrum of every clinician who cares for patients with diabetes: How do you keep them engaged and motivated in their self-care during the gaps between office visits? The findings of a study from an established multimedia company may point to one solution.

Launched in 2004 as the only national television show exclusively about diabetes, “dLife”  is also an interactive website/online community, a radio show, a mobile app, and a resource for diabetes educators. Now, the company has sponsored a study that demonstrated measurable benefit from a tailored, 24-hour online intervention for people with type 2 diabetes.

©nyul/fotolia.com

Commissioned by dLife with an unrestricted grant to the Geisinger Health System, the study — officially called Technology in Diabetes Engagement and Self-Care (TIDES) — enrolled 166 adult type 2 diabetes patients identified via electronic medical records at three of Geisinger’s primary care sites. They were randomized to usual care or that plus unlimited use of a tailored online portal containing weekly diabetes self-care topics, Q&A with experts, quizzes, recipes, diet assistance, videos of segments from the television show, and social networking forum. Motivational messages were displayed throughout.

Participants received weekly email newsletters highlighting the site’s features. The site was available 24/7, so patients could use it as often as they wanted on their own schedule.

Over 6 months, 76% of the 117 in the intervention group were “engaged” in the site, opening the emails/links, and/or taking the quizzes. At 6 months, those randomized to the site improved in 9 of 11 variables on the Diabetes Knowledge Questionnaire, compared with no change in the controls. Change in the score was significantly correlated with the degree of site usage, according to Geisinger’s Dr. Margaret Rukstalis, who presented the findings at the recent meeting of the American Association of Diabetes Educators.

Although there was no overall difference at 6 months in median change from baseline in hemoglobin A1c between the intervention group and controls, the difference was significant among those who experienced a drop in A1c, by 0.8 percentage points compared with just 0.3 for the controls.

Dr. Rukstalis said that she believes the intervention filled a gap in clinical care. “Given many rural persons with diabetes are often medically underserved with limited access and ability to attend traditional lifestyle interventions, TIDES demonstrates how multimedia engages persons with diabetes via email and web in their own lives.”

Miriam E. Tucker/Elsevier Global Medical News

The founder/CEO of dLife, Howard Steinberg, told me that the company plans to introduce the intervention to health plans, provider groups and employers, and that it will be available in various forms over time. Meanwhile, elements of TIDES are available right now at dLife.com.

According to Mr. Steinberg, “We plan on studying the impact TIDES will have on improving practice efficiency, as it is low cost and requires little or no time from them. Doctors can feel confident that dLife is evidence based, effective and engaging.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Noncommunicable Disease Alliance Fights to Retain Goals

The international noncommunicable disease movement has hit a snag. Negotiations have been delayed in drafting the official Political Declaration for the United Nations High-Level Meeting on the Prevention and Control of NCDs, scheduled for Sept. 19-20. The main issue, according to the NCD Alliance, a lobbying coalition of global NCD-related organizations, is that the United States, Canada, and the European Union are blocking proposals for the inclusion of the specific goal of cutting by 25% all preventable deaths from cancer, cardiovascular disease, diabetes, and chronic respiratory disease by 2025.

Arnaldo Pomodoro's "Sphere within Sphere" sculpture at UN Headquarters in New York/ Photo by Miriam E. Tucker

In a statement, the alliance said “The situation is urgent. Yet, it is reported that sound proposals for the draft Declaration to include time-bound commitments and targets are being systematically deleted, diluted and downgraded.” The alliance has sent a letter to UN Secretary-General Ban Ki-moon to express “grave concern at the current state of preparations” for the high-meeting, which is to be only the second-ever such UN meeting focusing on a global health issue. The first one, on HIV/AIDS in 2001, is credited with spurring global political, social, and financial action to address that problem.

According to the alliance, language about “action-oriented outcomes” is being replaced with “vague intentions” to “consider” and “work towards” NCD reduction goals, moves they deem “simply unacceptable.” Along with the 2025 goal, the letter reiterates previous demands that UN member states must develop a set of specific, evidence-based targets and global indicators, a clear time line for tackling the epidemic of the four major NCDs, and “a high-level collaborative initiative of government and UN agencies with civil society to stimulate and assess progress.”

In an interview with Reuters, NCD chair Ann Keeling said that money was the main sticking point, with wealthier nations reluctant to commit to paying for chronic disease care in poor countries at a time when even “rich” economies are in a downturn. Indeed, the sum is considerable, as NCDs now account for 63% of all deaths worldwide and half of all global disability, posing a serious threat to development in many lower-income nations. “The reason we called for a UN summit in the first place was to move toward a global action plan…The world is essentially sleepwalking into a sick future,” said Ms. Keeling, who is also chief executive officer of the International Diabetes Federation.

Negotiations on the Political Declaration are set to resume Sept. 1. In the meantime, the IDF has recently launched a postcard campaign urging President Obama to attend the high-level meeting, which is expected to draw heads of state from many UN member nations. The IDF has also organized a rally - with the support of several U.S.-based diabetes organizations and bloggers and other international NCD-related groups - to be held in New York City’s Central Park on Sunday, Sept. 18 to raise public awareness about the worldwide impact of NCDs.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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