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Archive - 09 - 2007

For Some Diabetics, Burden of Care Rivals Complications of Disease

Posted by dlife on Fri, Sep 28, 07, 02:23 PM 0 Comment

September 28, 2007 (University of Chicago) - Many patients with diabetes say that the inconvenience and discomfort of constant therapeutic vigilance, particularly multiple daily insulin injections, has as much impact on their quality of life as the burden of intermediate complications, researchers from the University of Chicago report in the October 2007, issue of Diabetes Care.A typical diabetes patient takes many medications each day, including two or three different pills to control blood sugar levels, one or two to lower cholesterol, two or more to reduce blood pressure, a daily aspirin to prevent blood clots, plus diet and exercise. As the disease progresses, the drugs increase, often including insulin shots."The people who care for patients with a chronic disease like diabetes think about that disease and about preventing long-term complications," said study author Elbert Huang, MD, assistant professor of medicine at the University of Chicago. "The people who have a chronic disease think about their immediate lives, which includes the day-to-day costs and inconvenience of a multi-drug regimen. The consequences are often poor compliance, which means long-term complications, which will then require more medications."Despite growing reliance on such complex multi-drug regimens, large proportions of patients with type-2 diabetes continue to have poorly controlled glucose (20%), blood pressure (33%) and cholesterol (40%)."This tells us that we need to find better, more convenient ways to treat chronic illness," Huang said. "It is hard to convince some patients to invest their time and effort now in rigorous adherence to a complex regimen with no immediate reward, just the promise of better health years from now," Huang said."This certainly rings true to me," agreed diabetes specialist Louis Philipson, MD, PhD, professor of medicine at the University of Chicago, who was not part of the research team. "Some patients, if you judge by their behavior, would rather be well on the road to future blindness, kidney failure or amputations then work hard now at their diabetes."Huang and colleagues conducted hour-long face-to-face interviews with a multiethnic sample of 701 adult, type-2 diabetes patients attending Chicago area clinics between May 2004 and May 2006. They asked patients to rank the benefits of various treatments and the daily quality-of-life burdens of diabetes-associated complications. Patients were asked to express their preferences in a series of trade-offs. The surveyors asked, for example: would you rather have six years of life in perfect health, or ten years with an amputation?As expected, patients were most distressed by end-stage complications, especially kidney failure, a major stroke or blindness. They were slightly less concerned about amputations or diabetic retina damage, and still less about angina, diabetic nerve or kidney damage.Patients also disliked intensive treatments, especially intensive glucose control, with multiple daily insulin injections, and what the authors called comprehensive diabetes care, which was intensive glucose control plus other medications. On average, patients ranked the burden of comprehensive diabetes care and intensive glucose control as equal to the burden of angina, diabetic nerve damage or kidney damage.Patients varied widely in how they ranked treatments and complications. Those who had experience with a specific medication or complication saw them as having less of an impact on quality of life than those without such direct experience.But many patients found both complications and treatment onerous. Between 12 and 50 percent were willing to give up 8 of 10 years of life in perfect health to avoid life with complications. More surprising, between 10 and 18 percent of patients were willing to give up 8 of 10 years of healthy life to avoid life with treatments.The existing burden of treatment may even increase when results from the ongoing ACCORD trial are announced in 2010, said Huang. "This trial may produce evidence for even greater use of medications to try to prevent complications," he said"Our study results show that taking multiple medications on a routine basis represents a significant burden for many patients," the authors conclude. "Quality of life related to treatments will be likely to improve if we can simplify or modify current treatments through treatment innovations."Until specialists find ways to do that, Philipson added, "physicians need to be able to spend more time with patients." This includes finding ways to bill appropriately for phone- and web-based interactions. "We also need more ancillary services like psychiatric social workers and diabetes educators to meet with patients," he added. "That could save the health care system a ton of money, even without developing new drugs or treatments. But we have to do that as well."The Centers for Disease Control and Prevention, the National Institute of Aging, the National Institute of Diabetes and Digestive and Kidney Disease, and the Chicago Center of Excellence in Health Promotion Economics funded the research. Additional authors were Sydney Brown, Bernard Ewigman, Edward Foley and David Meltzer of the University of Chicago.

Glycemic Index Values are Variable

Posted by dlife on Thu, Sep 27, 07, 11:58 AM 0 Comment

September 27, 2007 (Newswise) In work investigating the reproducibility of glycemic index values, researchers at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University (USDA HNRCA) have reported that multiple glycemic index value determinations (measure of the rate of glucose absorption into the bloodstream) using a simple test food, white bread, resulted in a relatively high level of inter-individual (among different individuals), and intra-individual (within the same individual) variability. Further studies will focus on better defining the magnitude and the sources of the variability. The intent is to better understand how glycemic index relates to chronic disease risk in a wide range of individuals.Alice Lichtenstein, DSc, corresponding author and director of the Cardiovascular Nutrition Laboratory at the USDA HNRCA and colleagues assessed 14 study participants glycemic response to 50 grams of carbohydrate in the form of white bread (test food) and glucose dissolved in water (control food) on different days. This experiment was repeated three times with each individual.Using glucose as the control food, previous studies indicate that white bread has a glycemic index of about 70, says Lichtenstein, who is also the Gershoff professor of nutrition science and policy at the Friedman School of Nutrition Science and Policy at Tufts. In our study the combined average was 71, virtually identical to the published value. However, quite strikingly, individual values ranged from 44 to 132. What is critical is to determine why there is such a wide range of responses among individuals.In addition, within the same individual, test values varied by as much as 42 percent. These results show that perhaps using glycemic index for groups is a reasonable indicator to predict chronic disease risk, but there is still considerable uncertainty when applying glycemic index to individuals, explains Lichtenstein.Glycemic index is a scale applied to foods based on how quickly the glucose in foods is absorbed into the blood stream, relative to pure glucose. Some nutrition professionals use the glycemic index as a tool for people trying to control blood sugar, such as those with diabetes. Others use the mean glycemic index of diets to predict chronic disease risk in large groups of people. Potential confounding factors, such as the fiber or fat content of the food, are not directly factored into the calculations.There are many factors that can influence the glycemic index of a food, says Lichtenstein. For example, a piece of white bread may have a high glycemic index but, if a person eats a slice of turkey and cheese with that bread, the effect of the multiple foods may result in a different glycemic index than if that person had eaten the white bread alone. Since most food is consumed as combinations during meals and snacks, there is a need to assess the significance of using glycemic index values determined on individual foods for food mixtures. Similarly, it is important to know whether the food consumed prior to a meal or snack alters subsequent glycemic response.It is possible that we need to develop better research tools and more stringent applications for glycemic index determinations, she says. Larger studies of diverse populations are needed to determine why inter-individual, and particularly intra-individual, glycemic index values are so variable. If we can identify the source of the variability, it will allow for more insight into the applications of the glycemic index as a tool for both researchers and in public health messages.Lichtenstein and colleagues have received a five-year grant from the National Institute of Diabetes and Digestive and Kidney Diseases to further their understanding of the glycemic index and its utilities. The current study was supported by the U.S. Department of Agricultures Agricultural Research Service.Vega-Lopez S, Ausman LM, Griffith JL, Lichtenstein AH. Diabetes Care. 2007 (June); 30 (6): 1412-1417. Interindividual Variability and Intra-Individual Reproducibility of Glycemic Index Values for Commercial White Bread.The Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University is the only independent school of nutrition in the United States. The schools eight centers, which focus on questions relating to famine, hunger, poverty, and communications, are renowned for the application of scientific research to national and international policy. For two decades, the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University has studied the relationship between good nutrition and good health in aging populations. Tufts research scientists work with federal agencies to establish the USDA Dietary Guidelines, the Dietary Reference Intakes, and other significant public policies.

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