Yes folks, I’ve now launched the membership site, with information, a community forum and structured learning programmes for people with diabetes and their families.

Check it out right now at www.diabetesdietdoctor.com.

A new report, The Link Between Local Food Environments and Obesity and Diabetes, just published by the California Center for Public Health Advocacy (CCPHA), has summarised and confirmed the results of the 2005 California Health Interview Survey (CHIS).

It shows a clear link between High Retail Food Environment Index (RFEI) scores and the amount of both obesity and Type 2 diabetes in a neighbourhood.

The RFEI is made by dividing the total number of fast-food restaurants and convenience stores by the total number of grocery stores and local produce vendors in the area, so reflects the proportion of people eating diets with less fruit and vegetables.

The average Californian has easy access to four times as many fast-food restaurants and convenience stores as grocery stores and produce vendors.

Obesity rates are 20 percent higher for Californians with RFEIs of five and above compared to those with RFEIs below three.

Diabetes rates are 23 percent higher for Californians with RFEIs of five and above compared to those with RFEIs below three.

Nearly half of Californians have three times as many fast food outlets as fresh food outlets near them.

Pretty shocking eh?

Although some people have contested results like this in the past, it seems fairly clear to me that high carbohydrate, high trans-fats diets are a sure-fire recipe for putting on weight. and developing diabetes.
DESIGNED FOR DISEASE: The Link Between Local Food Environments and Obesity and Diabetes. The California Center for Public Health Advocacy, PolicyLink and The UCLA Center for Health Policy. 2008.

One of the conclusions reached from The Efficacy of Self-MONitoring in newly diagnosed Type 2 diabetes (ESMON) study recently published online by the British Medical Journal (BMJ) was that the group allocated to more intensive self monitoring scored significantly higher for depression than the control group. This has also been found in other studies of self monitoring.

Well, maybe so, but in this study, just as in all the others, the approach to self monitoring was such that no real improvements in control were achieved. It’s no good getting people to do the tests without putting the appropriate amount of effort into making sure that they know what to do with the results. In this study, the triallists did give some thought to this, but still certainly not enough.

Because of this, there was no overall improvement in control as assessed by the HbA1C levels. My guess is that the patients were just disappointed in their lack of improvement. And I don’t blame them.

Self monitoring, putting the patients in real control of their condition, has the potential to transform their lives by giving them confidence and hope, and offering real benefits in terms of preventing or even reversing the progress of their condition. Some people figure out how to do it on their own. An awful lot more could do it if properly trained.

BMJ, doi: 10.1136/bmj.39534.571644.BE (published 17 April 2008)

In an international study of 839 obese patients with Type 2 diabetes, rimonabant produced significant wieght loss, a reduction in waist size and an increase in HDL (”good”) cholesterol levels, but did not lead to any significant change in percentage atheroma volume. There was a small effect on total atheroma volume, but this was not clinically significant. The drug was associated with a high level of psychiatric side effects, as it has done in previous trials, and it has now been withdrawn in the US for this reason.

Weight loss in diabetes remains problematic, but the answer still seems to lie in cutting energy intake, particularly of carbohydrates, and taking more exercise.

Nissen et al. JAMA. 2008;299(13):1547-1560. Published online April 1, 2008 (doi:10.1001/jama.299.13.1547).

A Study published recently in the Journal of the American Medical Association in patients with type 2 diabetes and coronary artery disease, treatment with Actos (pioglitazone) resulted in a significantly lower rate of progression of coronary atherosclerosis compared with glimepiride. The changes were small, however, and the variability of the results wide.

The results have been challenged by other researchers, and although this is interesting, it does not seem to me that this is likely to represent any sort of breakthrough. The studies are continuing though, and may help us understand the mechanisms of heart disease in diabetes rather better.

Nissen et al. JAMA. 2008;299(13):1561-1573. Published online March 31, 2008 (doi:10.1001/jama.299.13.1561).

More and more genetic variants of diabetes such as MODY are being recognised all the time, and these are extremely important, because they open up new possibilities for early diagnosis and treatment. In particular, these advances make it clear that diabetes can no longer simply be divided into Type 1 and Type 2, and that we need to address treatment of the individual patient rather than attempt to force people into diagnostic pidgeonholes that they may not really fit.

TW

Following the recent stopping of the Intensive control arm of the ACCORD study of  patients with Type 2 diabetes because of an excess of deaths in this group, the investigators in the Australian ADVANCE study ran a preliminary analysis of their data, and found no increase in deaths in their Intensive control patients. This will come as a relief to any of you who were worried that tight control might actually be bad for you. There are some differences between the studies - the ADVANCE patients did not already have the same degree of cardiovascular risk factors as those in ACCORD, and the US patients were even more intensively treated with insulin.

So the message as far as I’m concerned still is - go for good control.

TW

Interesting commentary in the Journal of the American Medical Association recently about how abnormal fat metabolism is the root cause of Type 2 diabetes. The author suggests that accumulation of fats in body cells causes insulin resistance and therefore Type 2 diabetes. The fats, he says get deposited in body cells because people eat too much, and he’s probably right, but he doesn’t address the question of what sort of eating too much is particularly bad for you. The current view seems to be that excess calories make you fat, and that since dietary fat contains 9 kcal per gram, this is worse than carbohydrate, which has about 4 kcal per gram, but in fact, what really cause fat to be laid down in cells is insulin, and this is only produced when you take in carbohydrate. So, the theory may be right, but the detail, as always is vital to the message.

 The report is by Unger, JAMA, March 12 2008, Vol 299, No 10, 1185-7.