Beat it

Beat it

America: Time to Shake the Salt Habit?

Mar. 27, 2013 — The love affair between U.S. residents and salt is making us sick: high sodium intake increases blood pressure, and leads to higher rates of heart attack and strokes. Nonetheless, Americans continue to ingest far higher amounts of sodium than those recommended by physicians and national guidelines.
A balanced review of the relevant literature has been published in the March 27, 2013 edition of The New England Journal of Medicine. Theodore A. Kotchen, MD, professor of medicine (endocrinology), and associate dean for clinical research at the Medical College of Wisconsin, is the lead author of the article.
Dr. Kotchen cites correlations between blood pressure and salt intake in a number of different studies; typically, the causation between lowering salt intake and decreased levels of blood pressure occur in individuals who have been diagnosed with hypertension. Although not as pronounced, there is also a link between salt intake and blood pressure in non-hypertensive individuals. Additionally, recent studies have demonstrated that a reduced salt intake is associated with decreased cardiovascular disease and decreased mortality.
In national studies in Finland and Great Britain, instituting a national salt-reduction program led to decreased sodium intake. In Finland, the resulting decrease in systolic and diastolic blood pressures corresponded to a 75 -- 80 percent decrease in death due to stroke and coronary heart disease.
Nevertheless, not all investigators concur with population-based recommendations to lower salt intake, and the reasons for this position are reviewed.
"Salt is essential for life, but it has been difficult to distinguish salt need from salt preference," said Dr. Kotchen. "Given the medical evidence, it seems that recommendations for reducing levels of salt consumption in the general population would be justifiable at this time." However, in terms of safety, the lower limit of salt consumption has not been clearly identified. In certain patient groups, less rigorous targets for salt reduction may be appropriate.
Co-authors are Allen W. Cowley, Jr., PhD, James J. Smith and Catherine Welsh Smith Professor in Physiology, and Harry and Gertrude Hack Term Professor and chairman of Physiology, the Medical College of Wisconsin; Edward D. Frohlich, MD, Alton Ocshner Distinguished Scientist at the Ochsner Clinic Foundation in New Orleans, La.

Living with diabetes

Clark Vowell recognized the symptoms, but he didn’t want to face the reality. He thought of himself as a healthy 16-year-old kid — a little skinny, sure, but not one with a serious disease.

However, after a month of waiting, doctors confirmed Vowell’s fears: he had type 1 diabetes.

"I only thought diabetes came from eating too much sugar and bad food," Karen Vowell said, after her son Clark told her he might have diabetes. "He started losing weight and looked like a skeleton. We knew he wasn't a druggie."

Diabetes is a disease in which the body does not produce or properly use insulin, a hormone necessary to convert sugar, starches and other food into the energy needed for daily life.

Type 1 diabetes, or T1D, is an immune disorder in which the body attacks and destroys insulin-producing beta cells in the pancreas. In Type 2 diabetes (T2D), the body either does not produce enough insulin, or the cells ignore the insulin.

The symptoms Mrs. Vowell noticed in her son were those of T1D. While Type 2 diabetes can be prevented, controlled and even cured with a healthy diet and exercise, Clark’s condition is genetic and, for now, incurable.

Tuesday marked the 25th Annual American Diabetes Association Alert day, a reminder for the public to take a test to determine if they are at risk for developing diabetes. According to the American Diabetes Association (ADA), seven percent of the U.S. population is living with this disease.

The number of Americans with diabetes has continued to increase, according to the Center for Disease Control's most recent National Diabetes Fact Sheet. So has the number of Americans with prediabetes, a condition that increases their risk of T2D, heart disease and stroke.

"When you think diabetes and type one, you think some things are over," Mrs. Vowell said. "Buts it's just a different lifestyle – you don’t need to watch every little rock or crevice."

While Mrs. Vowell said she took awhile to understand this, Clark was proactive about living a normal life.

"If anyone could lead the way in this, it is Clark," Mrs. Vowell said. "From the beginning his learning curve was ahead of mine as he began to ask himself what to do to handle this disease."

Mrs. Vowell watched as her son learned how to check his sugar levels, watch how many starches he ate and take insulin. She said that for family members who have discovered their loved ones have diabetes, support is always important.

"Gauge the person's personality and play it to their strengths," she said. "Fortunately, Clark kind of did this on his own."

As many as three million Americans may have T1D, according to Juvenile Diabetes Research Foundation International, a research center looking for a cure for T1D. The Foundation also reported that each year more than 15,000 children and 15,000 adults are diagnosed with T1D in the U.S. Only five percent of diabetes diagnoses are a case of T1D, according to the American Diabetes Association (ADA).

Before Vowell finally went to the doctor, he suspected that he had diabetes thanks to WebMD. For a while, Vowell said he was constantly drinking water and going to the bathroom – a symptom of the disease, according to the ADA.

After a family ski trip, Vowell said he knew he couldn't wait any longer. He went to the doctor, and although the results were somewhat expected, Vowell said it was still scary.

Vowell stayed a few days in the hospital and immediately began to learn how to live life with diabetes. He said he soon realized that although he had many new responsibilities, life didn't have to turn completely upside down.

Vowell said you learn to check your blood sugar and how much insulin you need to take when eating a bagel compared to chips. As long as someone learns how their body will respond to certain foods, he said, there are hardly any limits.

"Ultimately, it’s an individual's responsibility to manage their diabetes, but you can take the good with the bad,” Vowell said.

After being diagnosed, Vowell discovered what he wanted to do with his life. Vowell said he wants to finish pharmacy school and help others manage their diabetes – maybe later even help research for a cure.

Until then, Vowell said he will continue to live life to the fullest – and use his diabetes to do so. A few years ago he completed the Tour De Cure, a 100-mile bicycle ride that raises money for the ADA. Though his blood sugar dropped once or twice, Vowell said he was completely in control of his diabetes.

During the summers, Vowell has also participated in camps for children diagnosed with diabetes, where he builds on his passion for helping people face diabetes head-on.

Vowell laughed as he talked about advising others to make diabetes a good thing, and said it might sound weird to some.

"I know not everyone who gets diabetes will be affected like I have, but those who get it do have to try to make a good out of this bad," Vowell said. "It's just my life now."

Carla Cox, a Certified Diabetes Expert, said someone diagnosed with T1D would learn that it is very livable but tedious. Life can be pretty normal but they have to remember to get insulin, check their blood sugars and count carbs when they eat, Cox said.

While this keeps someone with diabetes safe and well educated on what they consume, carb counting can have negative side effects, including eating disorders. “Someone can definitely begin to obsess about it,” Cox said, citing eating disorder rates as high as 14 percent of diabetics in some regions.

Cox said T1D can result from a combination of someone's genetic makeup and a circumstance that can make someone more vulnerable – such as a virus like the chicken pox.

A case of this can be seen with Grayson Mohr, a sophomore at the University of Montana. In 1998, Mohr was one of about 5,000 people in a three-week span to be diagnosed with T1D, he said. Doctors told the Mohr family that there had been so many diagnosed, they believed a virus had triggered it.

A few weeks before starting kindergarten Mohr and his family went on a camping trip. One afternoon, Mohr drank a water supply that was intended to last three days. His mom recognized the signs and took him to a diabetes clinic the next day. Soon after, the family confirmed he had T1D.

"A person from the diabetes clinic came over for dinner and to make sure we were doing okay," Mohr said. "I remember hiding under my parents' bed for like an hour and a half because I was scared to take my shots."

He was about five years old at the time.

With the help of his parents' goofy Band-Aids and reward system, Mohr said he adjusted to life as a diabetic pretty quickly.

Fifteen years later, living with diabetes still presents some problems.

Mohr said that just last week he woke up around 12:30 in the morning feeling sick and realized his insulin pump had run out. Mohr tried to walk upstairs to his roommates, but he vomited and had to wait until morning to get help.

Mohr said it had been about nine or ten hours since he had insulin in his system. This had happened several times in his life, but Mohr said that particular instance was beyond anything he had experienced before.

"I called in a roommate and said, this doesn't look okay, I was throwing up blood and I had never done that before – this one was a special occasion," Mohr said.

After taking a few days to recover, it was back to the life of a normal college student, Mohr said.

"I actually think I was incredibly lucky to get diabetes," Mohr said. "Just because I look around in the world and what people have sometimes – diabetes is pretty damn easy – at least I'd rather this than something else."


New Hope for Diabetes Sufferers?

According to a 2010 report from the Centers for Disease Control, 1 out of 3 adults in the United States could be diagnosed with diabetes by the year 2050.

 On March 5, researchers under the leadership of Dr. Camillo Ricordi at the Diabetes Research Institute at the University of Miami announced a medical breakthrough, a biologically-engineered organ that would mimic the pancreas in creating the precise amount of insulin the body would need at any given moment, thereby controlling the patient's blood sugar levels. Called the "BioHub," it was described as "the closest medical science has gotten to a cure" for Type 1 diabetes, the variety also known as juvenile diabetes because most patients develop it either during their childhood or teen years.

 In the mid-1980s, Ricordi invented a device that was capable of extracting islets, or the cells that produce insulin, from a donated, healthy pancreas. The cells could then be transplanted into the patient's liver. The body's immune system, however, would eventually kill the foreign cells. The only workaround was for the patient to take anti-rejection drugs, causing several side effects and potentially dangerous health issues for the patient.

 The solution Ricordi and his team devised was a mini organ, implanted under the skin, in which the islets are sheltered from the body and still capable of thriving and reproducing.

 The actual implant procedure requires minimal surgery, and patients should be able to go home the same day. And if for some reason the BioHub encounters a problem or doesn't work, it can be easily replaced.

 "The beauty of this is, if a patient rejects this, its such a small thing that they will just have a little scar," Ricordi said in an interview with Univision News' Aqui y Ahora show. "It's not dramatic like in the case of an organ transplant rejection."

 Before diabetes patients can start signing up for the surgery, however, they have to wait for the FDA to give the device its approval, a process that Ricordi explains could take five to seven years. Currently researchers at the DRI are about to start phase one of the clinical trials, and only those patients with a severe case of Type 1 diabetes will be eligible.

 Ricordi is reluctant to say he's come up with a cure for Type 1 diabetes, but he is optimistic. His dream is to one day do the same for patients with Type 2 diabetes, the version attributed to poor diet, obesity and hereditary predisposition that usually has its onset later in life.



How Diabetes Drug Delays Aging in Worms

Mar. 28, 2013 — A widely prescribed type 2 diabetes drug slows down the aging process by mimicking the effects of dieting, according to a study published today using worms to investigate how the drug works.
Following a calorie-restricted diet has been shown to improve health in later life and extend lifespan in a number of animals, ranging from the simple worm to rhesus monkeys. The type 2 diabetes drug metformin has been found to have similar effects in animals but until now it was not clear exactly how the drug delays the aging process.
Researchers supported by the Wellcome Trust and Medical Research Council looked at the effects of metformin on C. elegans worms that were grown in the presence of E. coli bacteria, a relationship similar to that which humans have with the 'healthy' bacteria in our gut. They found that the worms treated with metformin lived longer only when the E. coli strain they were cultured with was sensitive to the drug.
Dr Filipe Cabreiro from the Institute of Healthy aging at UCL, who led the research, explains: "Overall, treatment with metformin adds up to 6 days of life for the worm which is equivalent to around a third of its normal lifespan. It seems to work by altering metabolism in the bacteria that live in the worm, which in turn limits the nutrients that are available to the worm host and has a similar effect to restricting the diet."
Bacteria living in the gut have an important role in helping the host organism to digest and extract nutrition from food. Defects in gut bacteria have been linked to metabolic diseases such as obesity, diabetes, inflammatory bowel disease and cancer. It has also been suggested that gut bacteria may have an impact on the aging process, but this is the first study to suggest a mechanism for how this works.
The team used strains of E. coli with defects in genes that are linked to metabolism and tweaked the levels of nutrients available to tease out which metabolic pathways might be affected by the drug. They found that treatment with metformin disrupted the bacteria's ability to metabolise folate, a type of B-vitamin, and methionine, one of the building blocks of proteins. This limits the nutrients that are available to the worm and mimics the effects of dietary restriction to enable the worms to live longer.
However, when they added an excess of sugar to the diet, the team found that the life-extending effects of metformin were cancelled out. As the drug is used as a treatment for diabetes caused by elevated glucose levels in the blood, this finding is particular relevant for understanding how the drug works in people.
Professor David Gems, who directed the study, said: "We don't know from this study whether metformin has any effect on human aging. The more interesting finding is the suggestion that drugs that alter bacteria in the gut could give us a new way of treating or preventing metabolic diseases like obesity and diabetes."
Metformin is currently one of the most widely prescribed drugs and the findings should help to inform how it is used in patients



Financial toll of diabetes spreads beyond its sufferers

CORPUS CHRISTI, Texas - Jerry Madrigal's life is spent in medical offices.
What started as a small sore on the 49-year-old's foot has turned into a diabetes diagnosis and an endless series of pricey procedures and prescription medications.
No longer able to work, Madrigal, of Corpus Christi, Texas, lives on disability checks and his wife's part-time pay. He has no clue how much all of this costs; his medical bills are fully covered by government-funded Medicaid.
Diabetes' financial toll extends beyond those diagnosed, reaching into the pocketbooks of taxpayers and those with health insurance who pick up the tab for the uninsured or those on government-funded health care plans.
"I think that everybody bears the cost of diabetes and its complications resulting in disability, because much of that is paid for through our taxes," said Dr. Melissa Wilson, an endocrinologist who served on the Texas Diabetes Council.
The federal government estimated the total cost of diabetes at $51.3 billion in 2010. And diabetes often coincides with other health problems, such as stroke or kidney failure, making it difficult to pin down the exact cost of the disease.
Emergency room visits or conditions associated with diabetes, such as strokes and heart attacks, make the true costs of diabetes likely to be much higher.
And they continue to grow.
Nationwide, diabetes costs nearly tripled from $18.8 billion in 1996, according to the Agency for Healthcare Research and Quality. Medicare and Medicaid covered, on average, 42 percent, or $196 billion over 14 years, according to the agency.
That's enough to pay the wages of a quarter million teachers during the same time.
Still, while the costs of diabetes skyrocket, prevention has not kept pace.
Self-management classes, widely regarded as one of the best ways to prevent the onset of expensive complications, have failed to live up to their potential and often struggle to stay afloat as funding gets stripped away.
That leaves people like Madrigal dependent on the government. Without Medicaid, Madrigal doesn't know how he would afford the diabetes treatment to save his foot and keep him alive.
In the past year, he's had four surgeries, including the amputation of his big toe. His kidneys are failing. He needs dialysis three times a week until he can get a kidney transplant.
At his sickest, Madrigal took almost a dozen prescription pills a day.
Madrigal worked as a laborer for years. He earned $350 a week and didn't have health insurance.
Hospital social workers helped him enroll in the county's indigent care program. Funded by property tax dollars, the program covers health care for the county's poorest residents.
He stayed on that plan until he was able to enroll in Medicaid.
Madrigal's situation is common in Texas, where Medicaid and Medicare paid for two-thirds of the state's diabetes-related hospital stays in 2010, according to the state's health department.
And those stays aren't cheap.
Diabetes hospitalizations on average cost about the same as a new Lincoln MKS luxury sedan: $48,720, or 50 percent more than hospitalizations not related to diabetes, according to state reports released in April 2012.
That's because people with uncontrolled diabetes are more prone to infections and have a tougher time fighting them, Wilson said. A spike in blood glucose levels, even temporarily, can paralyze white blood cells for up to two weeks, compromising a person's immune system, she said.
People with diabetes also face hefty indirect costs, such as reduced productivity and increased absenteeism from work.
A January 2012 in Health Affairs found that people with diabetes have harder times finding and keeping jobs and earn far less over their lifetimes than people without diabetes.
Tricare, which provides health benefits for military personnel and retirees and their families, spent $76.5 million on diabetes care in Texas alone in 2011. That's up 14 percent from 2007, adjusted for inflation.
Pharmacy costs made up 44 percent, or $33.7 million in 2011, according to Tricare's reports.
For Madrigal, it's too late to prevent some of the debilitating long-term complications of diabetes, but he's doing all he can -- closely monitoring his diet, exercising on the stationary bike in his living room and following doctor's orders. He's lost 45 pounds. At his last checkup, his blood sugar had dropped to prediabetic levels.

Quantity of Sugar in Food Supply Linked to Diabetes Rates

For years, scientists have said “not exactly.” Eating too much of any food, including sugar, can cause you to gain weight; it’s the resulting obesity that predisposes people to Type 2 diabetes, according to the prevailing theory.
But now the results of a large epidemiological study conducted at UC San Francisco suggest that sugar may also have a direct, independent link to diabetes.
Researchers examined data on global sugar availability and diabetes rates from 175 countries over the past decade. After accounting for obesity and a large array of other factors, the researchers found that increased sugar in a population’s food supply was linked to higher Type 2 diabetes rates, independent of obesity rates. Their study was published Feb. 27 in PLOS ONE.
The study provides the first large-scale, population-based evidence for the idea that not all calories are equal from a diabetes-risk standpoint.
“It was quite a surprise,” said Sanjay Basu, MD, PhD, an assistant professor of medicine at the Stanford Prevention Research Center and the study’s lead author. The research was conducted while Basu was a medical resident at UCSF and working with Robert Lustig, MD, a pediatric endocrinologist at UCSF Benioff Children’s Hospital and the paper’s senior author.
“We’re not diminishing the importance of obesity at all, but these data suggest that at a population level there are additional factors that contribute to diabetes risk besides obesity and total calorie intake, and that sugar appears to play a prominent role.”
Specifically, more sugar was correlated with more diabetes: For every additional 150 calories of sugar available per person per day, the prevalence of diabetes in the population rose 1 percent, even after controlling for obesity, physical activity, other types of calories and a number of economic and social variables. A 12-ounce can of soda contains about 150 calories of sugar. In contrast, an additional 150 calories of any type caused only a 0.1 percent increase in the population’s diabetes rate.
Population Exposure to Excess Sugar
Not only was sugar availability correlated to diabetes risk, but the longer a population was exposed to excess sugar, the higher its diabetes rate after controlling for obesity and other factors. In addition, diabetes rates dropped over time when sugar availability dropped, independent of changes to consumption of other calories and physical activity or obesity rates.
“Epidemiology cannot directly prove causation,” said Lustig. “But in medicine, we rely on the postulates of Sir Austin Bradford Hill to examine associations to infer causation, as we did with smoking. You expose the subject to an agent, you get a disease; you take the agent away, the disease gets better; you re-expose and the disease gets worse again. This study satisfies those criteria, and places sugar front and center.”

The findings do not prove that sugar causes diabetes, Basu emphasized, but do provide real-world support for the body of previous laboratory and experimental trials that suggest sugar affects the liver and pancreas in ways that other types of foods or obesity do not. “We really put the data through a wringer in order to test it out,” Basu said.
The study used food-supply data from the United Nations Food and Agricultural Organization to estimate the availability of different foods in the 175 countries examined, as well as estimates from the International Diabetes Foundation on the prevalence of diabetes among 20- to 79-year-olds.
The researchers employed new statistical methods derived from econometrics to control for factors that could provide alternate explanations for an apparent link between sugar and diabetes, including overweight and obesity; many non-sugar components of the food supply, such as fiber, fruit, meat, cereals and oils; total calories available per day; sedentary behavior; rates of economic development; household income; urbanization of the population; tobacco and alcohol use; and percentage of the population age 65 or older, since age is also associated with diabetes risk.
 “As far as I know, this is the first paper that has had data on the relationship of sugar consumption to diabetes,” said Marion Nestle, PhD, a professor of nutrition, food studies and public health at New York University who was not involved in the study. “This has been a source of controversy forever. It’s been very, very difficult to separate sugar from the calories it provides. This work is carefully done, it’s interesting and it deserves attention.
The fact that the paper used data obtained over time is an important strength, Basu said. “Point-in-time studies are susceptible to all kinds of reverse causality,” he said. “For instance, people who are already diabetic or obese might eat more sugars due to food cravings.”
The researchers had to rely on food-availability data for this study instead of consumption data because no large-scale international databases exist to measure food consumption directly. Basu said follow-up studies are needed to examine possible links between diabetes and specific sugar sources, such as high-fructose corn syrup or sucrose, and also to evaluate the influence of specific foods, such as soft drinks or processed foods.
Another important future step, he said, is to conduct randomized clinical trials that could affirm a cause-and-effect connection between sugar consumption and diabetes. Although it would be unethical to feed people large amounts of sugar to try to induce diabetes, scientists could put participants of a study on a low-sugar diet to see if it reduces diabetes risk.
Basu was cautious about possible policy implications of his work, stating that more evidence is needed before enacting widespread policies to lower sugar consumption.
However, Nestle pointed out that the findings add to many other studies that suggest people should cut back on their sugar intake.
“How much circumstantial evidence do you need before you take action?” she said. “At this point we have enough circumstantial evidence to advise people to keep their sugar a lot lower than it normally is.”

Availability of sugar influences rate of diabetes, study says

 Researchers studying 175 countries find that a 150-calorie daily increase in the availability of sugar raises the prevalence of Type 2 diabetes by 1.1%.

In a finding certain to put new pressure on the purveyors of sugary foods and drinks, a worldwide analysis shows that regardless of its effect on obesity, the ebb and flow of sugar in a country's diet strongly influences the diabetes rate there.
The new study provides compelling evidence that obesity isn't driving the worldwide pandemic of Type 2 diabetes as much as the rising consumption of sugar — largely in the form of sweetened sodas, experts said.
Increases in sugar intake account for a third of new cases of diabetes in the United States and a quarter of cases worldwide, according to calculations published Wednesday in the journal PLOS ONE. In the 175 countries studied, a 150-calorie daily increase in the availability of sugar — about the equivalent of a can of Coke or Pepsi — raises the prevalence of Type 2 diabetes by 1.1%, a research team from Stanford University and UC San Francisco found.
Dr. Walter Willett, a nutritionist and epidemiologist at the Harvard School of Public Health, said the results almost certainly underestimated the role of added sugar in the development of diabetes, since the data didn't distinguish between sugar that comes from fresh fruit and sugar that is concentrated in junk foods and sodas with no other nutrients.
The results make clear that sugar consumption "is fueling the global epidemic of diabetes," and that reducing that consumption is an essential step in controlling the rise of the disorder, said Willett, who was not involved in the study.
Over the last half-century, the increasing availability of sugar has made 62 new calories available every day to each man, woman and child on Earth. Most of that extra sugar has been produced in the last decade, as the U.S., China and other countries have vastly expanded their production of sweetener for the world market.
The result has been a global rise in the number of people who are overweight or obese, with an estimated 1.4 billion adults over 20 falling into one of those categories, according to the World Health Organization. Type 2 diabetes was once a disease of affluence, but it now affects an estimated 312 million people in rich and poor countries alike; WHO estimates that diabetes deaths — largely due to cardiovascular disease — will increase by two-thirds to about 5.7 million by the year 2030.
Whether sugar consumption or obesity is the biggest factor in diabetes is an unresolved question with important implications for public health policy. If obesity is the primary cause, measures that boost exercise and reduce intake of any kind of calories should drive down diabetes rates. If sugar is responsible, the emphasis should shift to reducing the amount of the sweetener consumed in food and drinks.
Plenty of research implicates sugar-sweetened beverages as playing an outsized role in weight gain. For instance, studies that tracked people for up to 20 years have found that with each daily serving of soda a person consumes, the risk of developing diabetes rises by 15% to 25%, Willett said. A 12-ounce serving of Coca-Cola contains 140 calories, primarily from sugar, and the equivalent serving of Pepsi has 150 calories.
The beverage industry, which generates billions of dollars in worldwide sales of such products, has mounted a spirited defense against measures aimed at reducing soda consumption, including so-called soda taxes and limits on the size of fountain drinks that can be sold in snack bars and concession stands.
Dr. Robert Lustig, an expert on sugar metabolism and senior author of the new study, said that in light of its findings, soda manufacturers can no longer reasonably argue that calories from their products are no more dangerous than calories from any other source.
The study tracked changes in diabetes rates, sugar availability and a host of other social and health factors in 175 countries between 2000 to 2010. The researchers used data on sugar availability instead of sugar consumption because the U.N.'s Food and Agricultural Organization consistently tracks market availability of sugar and several other categories of food. The U.N. does not distinguish among various forms of sugar, including table sugar and high-fructose corn syrup.
The researchers found that in countries where the incidence of diabetes went up, the availability of sugar had increased earlier and in roughly the same proportion. By establishing a dose-response relationship, the study allows researchers to infer that high doses of sugar causes diabetes.
The direct relationship held up even when the researchers considered sugar's role in weight gain and obesity's role in diabetes. In countries where average calorie intake was relatively low, obesity was rare and physical activity was common, people were more likely to develop diabetes if availability of sugar was high. The analysis explains why diabetes rates have dropped in countries like New Zealand, Iceland and Pakistan despite surging obesity and why the disease is on the rise in places like the Philippines, Romania, Bangladesh and Sri Lanka even though few people there are obese.
"This is as good as medicine gets in terms of proving causation," said Lustig, a pediatric endocrinologist at UCSF who has long warned of the health dangers of sugary drinks, including fresh juice. The study should mark "a tipping point" in the public debate over the regulation of sugar-sweetened soft drinks, he added.
The American Beverage Assn. took issue with Lustig's claims.
"This study does not show — or even attempt to show — that consuming sugar causes diabetes," the trade group said in a statement. "The study's conclusions on sugar and diabetes should be viewed cautiously given that the underlying model failed to consider the potential impact of solid fats — such as butter, cheese and lard — or factor for family history."
 In a statement, the Sugar Assn. faulted the study for failing to separate the effects of "natural sugar" and high-fructose corn syrup.

Study finds diabetes does not increase risk of total knee surgical complication

 PASADENA, Calif., Feb. 27, 2013 – Patients with diabetes who undergo total knee replacement surgery do not have increased risk of surgical complications compared to those patients without diabetes, according to a Kaiser Permanente study published today in The Journal of Bone and Joint Surgery.
Researchers studied the electronic health records of more than 40,000 patients who had a first-time knee replacement from January 1, 2001 through December 31, 2009. Of the patients studied, 12.5 percent had controlled diabetes, 6.2 percent had uncontrolled diabetes and 81.3 percent did not have diabetes. In contrast to the findings of previous studies, researchers on this study found those with controlled and uncontrolled diabetes who underwent a total knee replacement were at no increased risk of complications such as follow-up surgery (also known as revision arthroplasty), deep infection, or blood clots in the legs or lungs, when compared to patients without diabetes.
"We are fortunate to do our research in a real-world setting that helps us to find real-world solutions for our patients," said Annette L. Adams, PhD, MPH, of the Kaiser Permanente Southern California Department of Research & Evaluation. "This current study suggests that patients with diabetes who have higher glucose levels may not be at greater risk of poor surgical outcomes. This finding will help physicians and their patients with diabetes make better informed decisions about total knee replacement as an option."
Adams also noted that one of the elements that differentiated this study from previous research was that the Kaiser Permanente patients with diabetes had better glycemic control than previous study populations. "We have good quality of care, and good chronic disease management," Adams said, "and in this setting, glycemic control had little impact on the outcome of total knee replacement surgery."
The study also found that among the approximately 28 percent of patients who did experience adverse outcomes in the year after surgery, 27.1 percent were rehospitalized for any reason, 1.1 percent underwent follow-up surgery, 1 percent had a heart attack, 0.7 percent developed a deep infection while 0.5 percent had blood clots in the legs and lungs within the first 90 days after surgery.
"While this study puts us one step closer to understanding diabetes-related complications associated with surgical procedures, more research is needed to determine what aspects of diabetes are associated with adverse outcomes," said Robert Namba, MD, Department of Orthopedic Surgery at Kaiser Permanente Southern California. "It is important to note that patients with diabetes remain at high risk of a number of poor health outcomes affecting many organ systems and clinicians should continue to review all available information about the overall health and stability of these vulnerable patients."
The study was sponsored by Kaiser Permanente's Center for Effectiveness and Safety Research, The Center facilitates inter-regional research conducted by the research programs in each of Kaiser Permanente's eight regions (Colorado, Georgia, Hawaii, Mid-Atlantic States, Northern California, Northwest, Ohio, and Southern California). Through investments in infrastructure and specific projects, the center takes advantage of Kaiser Permanente's talented research teams, rich data assets, and integrated delivery system to contribute to the knowledge base in comparative effectiveness and safety.
"This work illustrates how Kaiser Permanente is realizing the promise of a learning healthcare organization," said Elizabeth McGlynn, PhD, director of the Center for Effectiveness and Safety Research. "We are bringing together our clinical leaders and the Kaiser Permanente research community to answer questions that are critical for ensuring high-quality patient care."
The study was conducted using the Kaiser Permanente Total Joint Replacement Registry, which now has more than 160,000 total joint arthroplasty procedures registered. Since its inception in 2001, Kaiser Permanente's registry has helped health care providers identify clinical best practices, evaluate and monitor patient outcomes and risk factors associated with revision surgeries, and assess the clinical effectiveness of implants. Developed in association with Kaiser Permanente's surgeons, the registry's data is collected prospectively through standardized documentation by surgeons and supplemented by the organization's electronic health records.
Kaiser Permanente's implant registries, which include the Total Joint Replacement Registry, recently won the 2012 annual John M. Eisenberg Patient Safety and Quality Award, sponsored by The National Quality Forum and The Joint Commission. These registries are models of integration across medical centers in nine states and they represent strong partnerships among health plan administration, hospitals, and physician medical groups united to improve the quality of care for patients.
Other study authors included: Jean Q. Wang, MS, Kaiser Permanente Southern California Department of Research & Evaluation; Elizabeth W. Paxton, MA, Surgical Outcomes and Analysis, Southern California Permanente Medical Group Clinical Analysis; Eric S. Johnson, PhD, Kaiser Permanente Northwest Center for Health Research; Elizabeth A. Bayliss, MD, MSPH, Kaiser Permanente Colorado Institute for Health Research; Assiamira Ferrara, MD, PhD, Kaiser Permanente Northern California Division of Research; Cynthia Nakasato, MD, Kaiser Permanente Hawaii Center for Health Research; and, Stefano A. Bini, MD, Department of Orthopedic Surgery, Kaiser Permanente Northern California.
About the Kaiser Permanente Southern California Department of Research & Evaluation
The Department of Research & Evaluation conducts high-quality, innovative research into disease etiology, prevention, treatment and care delivery. Investigators conduct epidemiology, health sciences and behavioral research as well as clinical trials. Areas of interest include diabetes and obesity, cancer, HIV/AIDS, cardiovascular disease, aging and cognition, pregnancy outcomes, women's and children's health, quality and safety, and pharmacoepidemiology. Located in Pasadena, Calif., the department focuses on translating research to practice quickly to benefit the health and lives of Kaiser Permanente Southern California members and the general population. Visit

Sitting less may reduce diabetes risk

How long have you been sitting today? Here's one more reason that you should get up and move around once in a while.
A new study in the journal Diabetologia suggests that reducing your sitting time is more important in lowering your risk of diabetes than exercise. This is just the latest in a string of research suggesting that moving around helps your health. But the new results should not replace standard recommendations for exercise, and more research is required to understand the reasons for the findings, said lead study author Joseph Henson.
"It looks as if just sitting for long periods of time has a real negative impact upon overall health," Henson said.
A chronic illness, diabetes reflects a problem in the body with the hormone insulin, which regulates blood sugar. The condition happens when the body can't use the insulin that it produces effectively, or when the pancreas doesn't produce enough of the hormone.
Henson, of the Diabetes Research Unit at the University of Leicester, wanted to explore this topic because of the increasing prevalence of diabetes worldwide. Nearly 350 million people around the globe have diabetes, according to the World Health Organization, and deaths from diabetes are expected to increase by two-thirds between 2008 and 2030.
"The increase in diabetes has been due to the fact that people have generally just gotten larger," Henson said. So as obesity has increased so has the prevalence of diabetes."
The trend is obvious in the United States. The number of people with diagnosed diabetes went from 5.6 million to 20.9 million from 1980 to 2010, according to the Centers for Disease Control and Prevention. This disease is also a huge driver of health care costs in the U.S., according to the American Diabetes Association.
This study looked specifically at people at risk of type II diabetes in the United Kingdom. Participants came from two diabetes prevention programs.
Researchers put accelerometers on 878 patients to see how much they moved or didn't move, monitoring when they took breaks from sitting down. They wore these devices on their hips for at least seven consecutive days, during waking hours, the study said.
The study found that sedentary time was associated with worse outcomes in "bad" HDL cholesterol, 2 h glucose and triacylglycerol, which are all indicators of metabolic and cardiovascular health.
Perhaps surprisingly, time spent sitting - not time spent exercising - was the factor most strongly associated with health outcomes examined in the study. Why? Henson said there may be a specific enzyme that responds differently when people are sitting, compared to when they exercise, but more research is needed.
Data from the study suggests that reducing time sitting by 90 minutes during the course of the day significantly lowers the risk of diabetes, Henson said.
This was not a controlled study, meaning the study authors did not deliberately prescribe a group a certain amount of physical activity and compare outcomes with another group who sat the whole time. A rigorous experimental design is necessary to more conclusively draw connections between behaviors and disease risk.
As has been demonstrated in other studies, taking breaks from sitting appears to be associated with better health indicators.
The participants in this study were already at risk for diabetes, so in a person who does not have a predetermined risk, "trying to move for 5 minutes every hour seems right," Henson said.

Sugar In Diet Linked To Type 2 Diabetes Rates, Study Finds

 Dr. Robert Lustig is the anti-sugar man. In his popular YouTube lecture, "Sugar: The Bitter Truth,", a subsequent profile in the New York Times Magazine and his best-selling book, Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity and Disease he explains how the sweeteners in our food contribute to metabolic disorders associated with obesity.
But Lustig believes we shouldn't associate these illnesses only with a high body mass index (BMI). In a new study published in PLoS One, Lustig of the University of California, San Francisco, and Dr. Sanjay Basu of Stanford University set out to show that the availability of added sugar in the human diet may have a direct effect on Type 2 diabetes rates, independent of obesity levels, calorie intakes and many other related factors.
"Obesity costs us zero dollars and causes zero deaths," Lustig told HuffPost. "Chronic metabolic disease, which is associated with obesity but may have additional or different causes, costs us $192 billion per year."
Marion Nestle, a professor of nutrition, food studies and public health at New York University, agrees with that sentiment to a degree. "Obesity is a risk factor, not a disease," said Nestle, who was familiar with Lustig's paper but did not contribute to it. "But there is a very clear correlation between diabetes and obesity -- anyone can see it."
Lustig points to research that shows that as many as 40 percent of people who are at a healthy weight, as defined by their BMI score, have some aspect of metabolic dysfunction, such as hypertension, high cholesterol or Type 2 diabetes. On the flip side, 20 percent of obese people do not have any associated metabolic condition. He holds diets with an excess of sugar, or lack thereof, responsible for this discrepancies.
His study tried to isolate the direct effect of sugar in the diet on countries' rates of Type 2 diabetes. It found that every 150-calorie increase from a sugar source -- cane sugar, high fructose corn syrup and other sweeteners-- correlated with a 1.1 percent increase in the Type 2 diabetes rate over a 10-year period, from 2000 to 2010. In other words, the more sugar in the food supply, the more cases of Type 2 diabetes were diagnosed.
While sugar availability has been trending up worldwide, a handful of countries (including Bangladesh, South Korea, Albania and Nigeria) have seen declines, thanks to changes in trade agreements, Basu explained in an email. Those countries provided the researchers with a real-world experiment into whether Type 2 diabetes rates would decline in response to reduced sugar. They found that diabetes rates did, in fact, decline in those instances.
"It's totally plausible," said Dr. David Katz, founding director of Yale University's Prevention Research Center. "A direct link between sugar and diabetes stands to reason, and the food industry uses variations on sugar as additives to enhance the palatability of food -- to make it tastier and irresistible, while downgrading its quality."

"But sugar isn't the only problem," Katz added, saying that starches and other high-glycemic-index foods can be just as harmful to health.
Lustig, Basu and their team analyzed food supply data from the United Nations Food and Agricultural Organization for 175 countries to determine how much sugar was available. They controlled for certain other aspects of the diet, such as fiber, oils, cereals and meats. When they also controlled for the countries' gross domestic product, obesity levels and quality of diabetes surveillance, they found that as sugar availability rose, so too did the prevalence of Type 2 diabetes. One limitation of the study is that the researchers were unable to control for all aspects of diet, including refined flour and starches.
While Lustig sees sugar as a menace unto itself -- causing fatty deposits around the liver that contribute to insulin resistance and fostering dysfunction of the pancreas that stalls insulin production -- many other medical experts, including Katz, believe that a high glycemic diet -- whether from sugars, starches or many other processed and high-calorie sources -- can cause the same damage.
"It shouldn't surprise anyone that eating a lot of sugar is bad for your health," said Nestle. "Obesity is correlated with diabetes and calories have to do with diabetes, but it's difficult to separate calories from sugars. It's also quite possible that people who eat sugar take in more calories and are fatter."
Katz noted that since sugar makes food more palatable, people are apt to eat more of a sugary food, increasing their overall calorie load and contributing to obesity.
"Looking at their data, for every increase in BMI, there is a greater associated rise in diabetes rate than there is for the same increment of added sugar," Katz said. In other words, obesity had a stronger relationship with Type 2 diabetes than sugar consumption did.
"There is really no doubt that obesity is a statistical risk factor for diabetes; our study was not designed to rebut that idea at all," explained Basu to HuffPost. "Rather, it was designed to investigate an additional possibility that the availability of sugars may also have an independent role in diabetes, even aside from contributing to weight or total calories consumed. This could explain some puzzling findings about why diabetes rates among some populations have escalated independent of changes in obesity rates."
The researchers said they hoped their study would help inspire policies that deal with added sugar as a public health threat. The National Health and Medical Research Council of Australia, for instance, released a recommendation this month to limit the amount of added sugar in the daily diet.
"It's really important in this area of research not to cherry-pick individual pieces of research, and that's why I'm emphasizing the 55,000 pieces of research we looked at in the last 10 years," said professor Warwick Anderson of the Australian council. "I just want to emphasize that we've looked at the totality of evidence."
 The U.S. Department of Agriculture does not have a specific, numbers-based recommendation for added sugars, but Dr. Robert Post, director of the USDA's Center for Nutrition Policy and Promotion, told HuffPost that if an individual followed the department's MyPlate guidelines, his or her intake of added sugars would be about 5 to 15 percent of total calories.
One thing that nutrition experts do agree on is that sugar from processed foods is a major problem.
"Frankly, this is a product of willful engineering of the food supply," said Katz. "Overall nutritional quality is the problem."

FDA reviewing new diabetes drugs due to pancreatic disease risk

WASHINGTON A group of new diabetes drugs is under investigation because it may increase the risk of pancreatic problems, including pancreatitis and cancer.
The Food and Drug Administration said Thursday samples of pancreas tissue taken from a small number of patients showed inflammation and cellular changes that often precede cancer. Academic researchers took the samples from diabetes patients who were taking the new medications, after they died from various causes.
Details of the research have not yet been published, but the agency said in an online statement it is seeking more information.
While the FDA has issued previous alerts about the pancreatitis risk, the agency had not notified the public about pre-cancerous cell changes seen with the drugs.
For now, regulators say they are still investigating the issue.
"FDA has not concluded these drugs may cause or contribute to the development of pancreatic cancer," the agency said in an online statement. "At this time, patients should continue to take their medicine as directed until they talk to their health care professional."
The drugs under review come from a wave of recently approved diabetes medications, including Merck's Januvia and Janumet, Novo Nordisk's Victoza and Bristol-Myers Squibb's Byetta and Bydureon, among others. All the drugs mimic natural hormones that the body usually produces to spur insulin production after a meal.
GLP-1 mimickers like Victoza, Byetta and Bydureon are injected anywhere from twice a day to once a week. They allow the body to produce more insulin to lower blood sugar after a meal. Almost 1 million Americans take drugs these types of drugs.
DPP-4 inhibitors, taken by 1.6 million Americans, are pills taken once or twice a day to stimulate insulin production and limit the release of a hormone that raises blood sugar levels. Januvia and Janumet fall into this category.
The FDA previously added information about cases of pancreatitis, some of them fatal, to the labels of Byetta in 2007, and Januvia and Janumet in 2009. Janumet combines the drug with metformin, a decades-old drug commonly prescribed for diabetes. The two drugs brought in a total of about $5.75 billion last year, making them Merck's biggest franchise.
Citi Investment Research analyst Andrew Baum told investors the investigation would likely have "minimal impact" on drug sales. Similar investigations in recent years have not resulted in safety restrictions, he says.
"We believe that the likely worst case for the market incumbents is that the FDA could add additional warnings about increased risk of pancreas-related adverse events" Baum stated in a research note.
People with Type 2 diabetes are unable to properly break down carbohydrates, either because their bodies do not produce enough insulin or because they've become resistant to the hormone, which controls blood sugar levels. These patients are at higher risk for heart attacks, kidney problems, blindness and other serious complications.
Many diabetics require multiple drugs with different mechanisms of action to control their blood sugar levels.
With more than 25 million people living with diabetes in the U.S., some of the world's biggest drugmakers have launched new treatments in recent years, though safety questions have emerged.
A recent study of insurance records found that use of those drugs could double the risk of developing acute pancreatitis, according to the FDA.
The pancreas produces various hormones, including insulin, that help the body break down sugar. Pancreatitis causes an inflammation of the organ and can lead to fatal complications, including difficulty breathing and kidney failure.

5 million more people living with diabetes

By Jacque Wilson and Sophia Dengo, CNN
 (CNN) -- Dr. John Anderson isn't surprised by the rapidly growing cost of diabetes in America. New research from the American Diabetes Association shows the total cost of diabetes was $245 billion in 2012 -- a 41% increase from the $174 billion spent in 2007.
"I know of no other disease that's increasing at (about) 8% per year," said Anderson, president of medicine and science for the American Diabetes Association. "That to me isn't surprising, it's troubling."
What is surprising, Anderson said, is that the increased price isn't due to rising health care costs. It's due instead to the "sheer number" of Americans who have diabetes.
"Medication costs have gone up, but overall they haven't gone up significantly," said Matt Petersen, the American Diabetes Association's managing director of medical information and professional engagement. "We have more people with diagnosed diabetes. A lot more of them. That's the burden we face."
An estimated 22.3 million people were living with type 1 or type 2 diabetes in 2012, according to the new report, up from 17.5 million in 2007.
The growing population is due to several factors, Petersen said. Diabetes prevalence increases with age, so the aging baby boomer population is attributing to rising costs. The obesity epidemic also plays a role. Being overweight or obese is a risk factor for type 2 diabetes, according to the Centers for Disease Control and Prevention.
Unfortunately, not all risk factors can be controlled, Petersen said. African-Americans, American Indians and Asian-Americans are all at a greater risk of developing diabetes than Caucasians, leading researchers to believe there is a genetic link.\
"People fundamentally can't do anything about susceptibility," he said.
Diabetes can cause serious health problems such as heart disease, kidney failure and blindness, according to the CDC. If it's not kept under control, diabetes also can cause infections that may lead to leg or foot amputations.
Approximately 246,000 deaths were attributed to diabetes in 2012, according to the American Diabetes Association's report.
There is good news, Petersen said. Although our diabetes costs are growing, we're spending the dollars effectively.
"We're picking it up earlier and caring for it better," he said. "We're getting the right value for our money."
Anderson and the association hope to continue to spread awareness about diabetes. Addressing the disease on the front end, before it leads to serious complications, will help lower overall costs, he said.
"That's a great way of preventing the growth of this epidemic."