Just in time for the holidays —
I know that during the holidays I spend more time with my family watching TV and we all enjoy watching cooking programs such as Top Chef. Before Thanksgiving every year, I watch Thanksgiving episodes with my daughter and together we plan the Thanksgiving menu. Our Thanksgiving ritual would not be complete without watching Alton Brown’s method for preparing turkey...
Cooking shows have come to dominate today's TV schedules as they try to promote healthy and innovative home cooking for the masses. But it turns out these programs could be doing more harm than good.
New research reveals TV viewers are more likely to eat unhealthy, calorie-rich snacks if they are watching a cooking show than a nature program! In a report on their findings, published in the journal Appetite, the researchers reported that "TV watching has been associated with overeating and obesity.”
Scientists believe food-related programs may affect eating behavior by triggering the desire for fatty, sugary foods. TV viewing generally has previously been associated with poor eating habits, but in this study psychologists at Hobart and William Smith Colleges, wanted to see what effect cooking programs specifically had on the taste buds.
They recruited 80 adults and split them into two groups. Half were told to watch a cooking show and the other half a nature program. Each person was given three bowls containing chocolate covered sweets, cheese curls or carrots. Researchers found that people watching the cooking shows got through substantially larger amounts of chocolate sweets than the nature show viewers, who were more likely to eat the raw carrots...
How popular food-related shows affect eating behavior has not been examined, but this latest research suggests adults may be just as much at risk from programs which, ironically, set out to promote healthy eating as regular TV watching which has been shown in many previous studies to cause weight increase. Watching TV an hour a day can increase a child's dietary intake by 167 calories and add more than a 10 pounds to their weight over a year, especially as children tend to eat snacks, sweets and fast foods which they see advertised most frequently on the screen.
Seems like I will be watching the National Geographic channel as well as football games this holiday season...
Happy Holidays to you all,
Miriam Rotman MD
Physicians have long noticed that though obesity is connected to diabetes there are plenty of obese people who never develop diabetes. That observation has recently been studied and vindicated.
According to a study that followed up 732 obese individuals for a median of 7 years recently published in JAMA (Sept. 19 issue of the Journal of the American Medical Association), excess visceral fat and insulin resistance, but not general adiposity, are both independently associated with incident prediabetes and type 2 diabetes mellitus.
"Although increased body mass index (BMI) is associated with diabetes at the population level, it does not adequately discriminate diabetes risk among obese individuals. Indeed, many obese persons appear resistant to the development of metabolic disease," the authors write.
Participants in the study, which followed 732 obese people for an average of 7 years, who later developed diabetes- were more likely than those who remained diabetes-free to have a family history of diabetes, suffer from hypertension and have an abnormally high waist circumference. BMI (Body Mass Index), which is in general use to measure obesity, was not found to be associated with higher risk.
This study validates previous studies that have shown that abdominal visceral fat specifically increases insulin resistance and raises the risk for the development of diabetes.
By recognizing that direct causes of increased risk, we enable direct targeting of those causes. In this case obviously both weight reduction and physical exercise aimed at reducing waist circumference, would both be extremely beneficial at reducing the risk of developing diabetes in high risk obese patients.
The discovery that stomach ulcers were actually caused not by diet and or stress but by bacteria led to a paradigm shift in the evaluation and treatment of ulcers and a Nobel prize to the researchers Marshall and Warren. H.pylori not only causes inflammation that may lead to eventual stomach ulceration but the inflammation can also lead to stomach carcinomas and lymphomas.
H.pylori is usually acquired in childhood and in developing countries can be found in more than 80% of the population over 20. This bacteria usually causes complaints of nausea, vomiting, stomach pain and other very common gastro-intestinal complaints.
In this issue of the monthly "Diabetes Care", a group of Latinos from Sacramento CA aged over 60 with no known Diabetes were followed for a decade. At the onset of the study all participants were also checked for various viral diseases (such as Herpes and Varicella) as well as blood markers for infection such as C-Reactive Protein (CRP). During the follow up, 144 patients developed Diabetes. Diabetes was found to be twice as likely to develop in patients that were positive for H.pylori. This relationship that was not found with any other virus or blood marker.
The association between the development of Diabetes and H.pylori has been previously reported but the studies all were small and had limitations. What stands out in this study is that more than 90% of the population studied were positive for H.pylori so there were very few individuals that were negative. This made it difficult to compare the negative for H.pylori group with the positive group.
Another drawback for this study was the testing method. There are 2 major ways to test for H. pylori - Fidelis utilizes the Exalenz BreathID® test which is the most precise method of testing and distinguishes between current and previous infections. In this study serology (blood markers) were used which are unable to distinguish between previous and current infection and so we don't know which of the positive patients actually had an active infection with H.pylori.
It is too early to advocate treatment of H.pylori to reduce the incidence of Diabetes but this relationship is certainly very interesting and we are waiting for a future major study that will guide the way to the best treatment options for patients.
In the mean time if you are suffering from any gastro-intestinal complaints, it might be time to discuss this with your physician. The test can be performed using the BreathID® technology, an advanced new H.Pylori diagnostics test, right in your doctor’s office, with immediate results. It is simple, non-invasive and highly accurate.
There are many ads on TV today that are reaching you about Peripheral Arterial Disease (PAD), so I thought that it was important, in light of current guidelines, to talk about this:
PAD is a narrowing of the peripheral arteries, most commonly in the arteries of the pelvis and legs. PAD is similar to Coronary Artery Disease (CAD) and carotid artery disease. All three of these conditions are caused by narrowed and blocked arteries in various critical regions of the body.
Atherosclerosis is a disease in which plaque builds up in the wall of an artery. PAD is usually caused by atherosclerosis in the peripheral arteries (or outer regions away from the heart). Plaque is made up of deposits of fats, cholesterol and other substances. Plaque formations can grow large enough to significantly reduce the blood's flow through an artery. When a plaque formation becomes brittle or inflamed, it may rupture, triggering a blood clot to form. A clot may either further narrow the artery, or completely block it.
If the blockage remains in the peripheral arteries, it can cause pain, changes in skin color, sores or ulcers and difficulty walking. Total loss of circulation to the legs and feet can cause gangrene and loss of a limb.
If the blockage occurs in a coronary artery, it can cause a heart attack. Heart attacks happen when an area of the heart tissue dies from lack of blood flow. When it occurs in a carotid artery, it can cause a stroke.
It's important to learn the facts about PAD. As with any disease, the more you understand, the more likely you'll be able to help your healthcare professional make an early diagnosis and start treatment. PAD has common symptoms, but many people with PAD never have any symptoms at all.
The most common symptom of PAD is painful muscle cramping in the hips, thighs or calves when walking, climbing stairs or exercising.
Symptoms of severe PAD include:
- Leg pain that does not go away when you stop exercising
- Foot or toe wounds that won't heal or heal very slowly
- A marked decrease in the temperature of your lower leg or foot particularly compared to the other leg or to the rest of your body
Understanding leg pain
Many people dismiss leg pain as a normal sign of aging. You may think it's arthritis, sciatica or just "stiffness" from getting older. For an accurate diagnosis consider the source of your pain- PAD leg pain occurs in the muscles, not the joints.
Those with diabetes might confuse PAD pain with a neuropathy, a common diabetic symptom that is a burning or painful discomfort of the feet or thighs. If you're having any kind of recurring pain, talk to your healthcare professional and describe the pain as accurately as you can. If you have any of the risk factors for PAD, you should ask your healthcare professional about PAD even if you aren't having symptoms.
PAD diagnosis begins with a physical examination. Your healthcare provider will check for weak pulses in the legs and the physical examination may include the following:
- Ankle-Brachial Index (ABI): a painless exam that compares the blood pressure in your feet to the blood pressure in your arms to determine how well your blood is flowing. This inexpensive test, using a FloChec™ ABI device, takes only a few minutes and can be performed by your healthcare professional as part of a routine exam. Normally, the ankle pressure is at least 90 percent of the arm pressure, but with severe narrowing it may be less than 50 percent.
If an ABI reveals an abnormal ratio between the blood pressure of the ankle and arm, you may need more testing. Your doctor may recommend one of these other tests.
- Doppler and Ultrasound (Duplex) imaging: a non-invasive method that visualizes the artery with sound waves and measures the blood flow in an artery to indicate the presence of a blockage.
- Computed Tomographic Angiography (CT): a non-invasive test that can show the arteries in your abdomen, pelvis and legs. This test is particularly useful in patients with pacemakers or stents.
- Magnetic Resonance Angiography (MRA): a non-invasive test that gives information similar to that of a CT without using X-rays.
- Angiography: (generally reserved for use in conjunction with vascular
treatment procedures) During an angiogram, a contrast agent is injected into
the artery and X-rays are taken to show blood flow, arteries in the legs and to
pinpoint any blockages that may be present.
Learn more about peripheral angiogram.
As stated earlier, PAD often goes undiagnosed. Untreated PAD can be dangerous because it can lead to painful symptoms, loss of a leg, increased risk of Coronary Artery Disease and carotid atherosclerosis. Because people with PAD have this increased risk for heart attack and stroke, the American Heart Association encourages people at risk to discuss PAD with their healthcare professional to ensure early diagnosis and treatment
Quick Facts about PAD (summary)
The most common symptoms of PAD are cramping, pain or tiredness in the leg or hip muscles while walking or climbing stairs. Typically, this pain goes away with rest and returns when you walk again.
- Many people mistake the symptoms of PAD for something else.
- PAD often goes undiagnosed by healthcare professionals.
- People with PAD have four to five times more risk of heart attack or stroke.
- Left untreated, PAD can lead to gangrene and amputation.
Added risks for PAD
- If you smoke, you have an especially high risk for PAD.
- If you have diabetes, you have an especially high risk for PAD.
- People with high blood pressure or high cholesterol are at risk for PAD.
The good news for PAD patients
- PAD is easily diagnosed in a simple, painless way starting with an ABI which your physician can do in the office setting using a FloChec™ ABI device.
- You can take control by leading a heart-healthy lifestyle and following the recommendations of your healthcare professional.
- Most cases of PAD can be managed with lifestyle changes and medication.
Is PAD dangerous or life threatening?
Yes, PAD is dangerous because these blockages can restrict circulation to the limbs and organs. Without adequate blood flow, the kidneys, legs, arms and feet suffer damage. Left untreated, the tissue can die or harbor infection such as gangrene.
Does PAD cause additional health problems?
PAD may be the first warning sign of atherosclerosis– chronic fatty deposit build-ups throughout your arteries. The whole circulatory system, including your heart and brain, are at risk when arteries are blocked and narrowed. Fatty deposits also increase the risk for vascular inflammation and blood clots that can block the blood supply and cause tissue death.
Aggressive control of blood sugar levels in type 1 and type 2 diabetes may reduce the risk for diabetic neuropathy
Diabetic neuropathy affects nearly 10% of patients with diabetes at diagnosis, and 40% to 50% of patients after 10 years. Yet no systematic reviews have assessed the role of enhanced glucose control in preventing neuropathy.
In this current analysis, Dr. Callaghan and colleagues searched several databases for randomized controlled trials of enhanced glucose control in diabetes mellitus.
A meta-analysis of 2 studies (from the Diabetes Control and Complications Trial) that reported incidence of clinical neuropathy in 1228 participants with type 1 diabetes indicated a significantly reduced risk of developing clinical neuropathy in those patients with enhanced glucose control. Intensive control also resulted in favorable secondary outcomes in studies of both type 1 and type 2 diabetes.
Unfortunately, the incidence of hypoglycemic events and other serious adverse events, such as brain injury, was significantly higher with intensive glucose control in both types of diabetes.
The authors add that in type 2 diabetes mellitus, enhanced glucose control was associated with a reduced incidence of neuropathy, but the trend was not statistically significant (P = 0.06).
The authors note that the conclusions of the current review are heavily dependent on a limited number of trials. In type 1 diabetes, the Diabetes Control and Complications Trial accounted for 97.4% of the evidence, and in type 2 diabetes, the conclusions depended heavily on the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, published in 2010, which accounted for 70.6% of the evidence.
"In both types of diabetes there is a need for further research to discover the optimal target level which will reduce the development of neuropathy without increasing the risk of death, weight gain, hypoglycemia, and other adverse events," Dr. Callaghan and colleagues suggest.
The bottom line for all diabetic patients is that though we know that enhanced glucose control can prevent neuropathy, it is not known how strict that control should be. The take away is that the closer you monitor your blood glucose levels and keep them normal, the more likely it is that you will prevent neuropathy and all the complications arising from it.
* Brian C. Callaghan, MD, assistant professor from the Department of Neurology at the University of Michigan in Ann Arbor, and colleagues.
The researchers reported the results of their systematic review in the June issue of The Cochrane Library
It seems that what we all knew to be bad for us is actually bad for us... In a 39-day experiment with healthy volunteers, shortened sleep time and varying bedtimes -- meant to mimic shift work -- led to impaired glucose regulation and metabolism, according to Orfeu Buxton, PhD, of Brigham and Women's Hospital in Boston, and colleagues.
"Since night workers often have a hard time sleeping during the day, they can face both circadian disruption working at night and insufficient sleep during the day," Buxton said in a statement. "The evidence is clear that getting enough sleep is important for health, and that sleep should be at night for best effect."
The combination of not enough sleep and circadian rhythm disruption caused a marked decrease in insulin secretion in response to the meal, the researchers reported. The combination of not enough sleep and circadian rhythm disruption caused a marked decrease in insulin secretion in response to the meal, the researchers reported.
In other words impaired sleep led to problems in sugar metabolism and could increase the risk of obesity and of developing diabetes!
So, make sure that you get enough sleep on a regular basis and let me misqoute a famous saying,
Early to bed and rested when you rise,
Will make you healthy, happy and wise!
Have a restful summer,
Miriam Rotman MD
By Dr. Miriam Rotman
This week's blog is for physicians -
For patients with diabetes, increased poly(ADP-ribose) (PAR) immunoreactivity, reduced abundance of type 1 procollagen, and impaired skin structure correlate with foot complications, according to a study published online June 29 in Diabetes Care.
Abd A. Tahrani, M.D., from the University of Birmingham in the United Kingdom, and colleagues examined whether high-risk patients exhibit skin structural and metabolic deficits that predispose to foot complications. Participants included nine control patients with diabetes, 16 patients with diabetic peripheral neuropathy (DPN) alone, 21 with recurrent diabetic foot ulceration (DFU), and 14 controls without diabetes. Intra-epidermal nerve fiber density (IENFD), structural analysis, type 1 procollagen abundance, tissue degrading matrix metalloproteinases (MMPs), and PAR immunoreactivity were measured using skin punch biopsies from the upper and lower leg skin.
The researchers found that diabetes and DPN decreased IENFD, with no difference noted between the neuropathic groups. In neuropathic subjects, especially in the DFU group, skin structural deficit scores were increased. Compared with controls without diabetes, individuals with DFUs had reduced abundance of type 1 procollagen. Activation of MMP-1 and MMP-2 was seen with diabetes. Compared with other DPN patients, those with DFU had increased PAR immunoreactivity.
"In conclusion, increased PAR polymerase, reduced type 1 procollagen, and impaired skin structure are associated with the development of foot complications in diabetes and may constitute novel biomarkers to identify patients at maximal risk," the authors write. "Therapies aimed at improving skin quality also warrant consideration as an approach to reduce DFU."
Wonderful free resource from the American Diabetes Association for Physicians -
The Where Do I Begin? booklet is the first
step to helping patients get the information they need at diagnosis. You can
order free copies of Where Do I Begin? and give this great resource to your
newly diagnosed patients. Encourage patients to take the next step and enroll
in the free program to get ongoing information and support over their first
year living with type 2 diabetes.
To order free copies, visit diabetes.org/atdx.
By Dr. Miriam Rotman
65,700 people with diabetes in the United States underwent one or more lower-extremity amputations in 2006, accounting to more than 60% of non-traumatic amputation in the country.
Diabetes is the leading cause of amputation of the lower limbs. It is clear that though as many as 50% of these amputations might be prevented through simple but effective foot care practices, patients (and their health care providers) are not doing enough to avoid amputations and the tremendous human and economic costs that this brings upon the patients. In the analysis of nearly 7,500 patients, presented at the (ADA) 63rd Scientific Sessions, both primary care physicians and endocrinologists failed to diagnose non-severe neuropathy in about 2/3 of cases. When it comes to severe neuropathy, about 1/4 endocrinologists and 1/3 primary care physicians miss the diagnosis.
People who have diabetes are vulnerable to nerve and vascular damage that can result in loss of protective sensation in the feet, poor circulation, and poor healing of foot ulcers. All of these conditions contribute to the high amputation rate in people with diabetes. The absence of nerve and vascular symptoms, however, does not mean that a patient’s feet are not at risk.
Risk of ulceration cannot be assessed without careful physical and neurological examination of the patient’s bare feet. Most physicians are not aware of the importance in asking the patient about neurological signs and symptoms – such as burning, tingling, numbness which all indicate neurological damage. The Semmes-Weinstein monofilament identified persons at increased risk of foot ulceration with a sensitivity of 66%-91% and a specificity of only 34%- 86%. The patient’s health-care providers suspected neuropathy when the patient was complaining of pain, burning and tingling but missed the diagnosis in most cases when the patient was suffering from numbness (lack of sensation).
Nerve conduction studies are generally considered the criterion standard for diagnosing peripheral neuropathy with a high degree of sensitivity (>85%) and specificity (85%-95%) and are optimal when used to evaluate diabetic patients with signs(pain, burning, numbness) and symptoms (loss of sensation, hypersensitivity, motor abnormalities) of neurological damage that might be suffering from other clinical diagnoses.
Good foot care, therefore, is an essential part of diabetes management – for patients as well as for health care providers, but unfortunately it is often overlooked.
A study of provider practices (below) found that clinicians were highly likely to prescribe preventive foot care behaviors when they were aware of a patient’s high risk for limb amputation as evidenced by prior history of foot ulcer. Clinician awareness of two other major risk factors (peripheral neuropathy or peripheral vascular disease), however, did not increase preventive care practices. The study’s authors concluded that physicians and patients need periodic reminders to identify patients in all high risk categories for ulcer or amputation as well as recognize the high risk group defined by moderate-severe peripheral neuropathy.
The key elements of preventive care include:
- Annual examination of the feet by health care providers and referral for NCV when appropriate
- Subsequent examination of high risk feet at each patient visit
- Patient education
- Careful glucose management
Based upon – “A Health Care Provider’s Guide to Preventing Diabetes Foot Problems” Published jointly by the National Institute of Diabetes and Digestive and Kidney Diseases and the US Dept. of HHS, November 2000
My name is Miriam Rotman, M.D., a Medical Director for Fidelis Diagnostics. I have been happily employed by Fidelis for the past 6 years, involved primarily in my favorite field – medical education, as well as many other endeavors (such as this blog).
Background: I grew up in Israel, where I went to Medical school and did both my residency and fellowship in primary practice. After moving to the States, I became involved with Fidelis at an early stage and have greatly enjoyed my time in the company both professionally and personally.
Fidelis has conceived this blog as a way of continuously updating for the public and the Fidelis community on the most current medical information as well as a forum for you to share views, ask questions, be more informed about your medical test and better educated.
We hope that if you have any question regarding an upcoming test, you post it on the blog and I promise to answer it as soon as possible. If I feel that the community will benefit from the question and answer, I might post it on the blog (anonymously of-course).
I hope you are as excited about this endeavor as I am,
Waiting to hear from you,
Miriam Rotman, M.D., Medical Director
TV Watching and Weight Gain
The connection between abdominal fat and diabetes
The link between diabetes and oral health
Stomach Bugs and Diabetes: Astounding relationship or just confounding?
Important facts about Peripheral Arteries Disease (PAD)
Aggressive control of blood sugar levels in type 1 and type 2 diabetes may reduce the risk for diabetic neuropathy
Lack of Sleep May Raise Risk of Diabetes
Correlates of Diabetic Foot Complications Identified
The Importance of Annual Feet Examination in Diabetic Care