Comments on: Blind Men and The Diabetes Elephant http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/ Posts from an Insane Healthcare System Thu, 11 Mar 2010 02:55:07 +0000 http://wordpress.org/?v=abc hourly 1 By: Liana http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1056 Liana Fri, 20 Jun 2008 16:38:59 +0000 http://www.docgurley.com/?p=204#comment-1056 Thanks, Doc. In our health region, we get told off for ordering HbA1c for diagnosis... so I use it to monitor treatment, and also to decide when to start right away with meds instead of giving a 3 month trial of exercise and lifestyle. Maybe with this new study, they'll reconsider? I agree that the HbA1c is a lot easier... no fasting required. However, in the Canadian Diabetes clinical practice guidelines, they say that the lack of standardization with the HbA1c test makes it less useful for diagnosis, and they also mention that a FPG of 7.0 or OGTT of >/=11.1 are most predictive of microvascular damage (alas, no mention of macrovascular damage). Of course, the guidelines are from 2003 and updated guidelines are going to be released in the fall so who knows if they will change their tune? I'm eager to see what changes they recommend. Thanks, Doc.

In our health region, we get told off for ordering HbA1c for diagnosis… so I use it to monitor treatment, and also to decide when to start right away with meds instead of giving a 3 month trial of exercise and lifestyle. Maybe with this new study, they’ll reconsider?

I agree that the HbA1c is a lot easier… no fasting required. However, in the Canadian Diabetes clinical practice guidelines, they say that the lack of standardization with the HbA1c test makes it less useful for diagnosis, and they also mention that a FPG of 7.0 or OGTT of >/=11.1 are most predictive of microvascular damage (alas, no mention of macrovascular damage).

Of course, the guidelines are from 2003 and updated guidelines are going to be released in the fall so who knows if they will change their tune? I’m eager to see what changes they recommend.

]]> By: Doc Gurley http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1046 Doc Gurley Tue, 17 Jun 2008 23:24:48 +0000 http://www.docgurley.com/?p=204#comment-1046 The HgbA1C study was specifically designed to look at non-diabetics, but included some diabetics anyways. The authors state that in prior studies with diabetics "A1C levels have also been associated with mortality in patients with type 1 diabetes and nondiabetic chronic kidney disease and with incident cardiovascular disease." Of the 408 diabetics in this study, "Although mortality rate was also increased in participants with a previous diagnosis of diabetes, this was only partially explained by their increased A1C levels." - possibly due to smaller numbers. My Doc Gurley take on this question is that elevated HgbA1C is bad for everyone, but sneakier and previously-unrecognized as potentially lethal in non-diabetics. To answer your final question, the HgbA1C test is unique in that it is 1) much easier to do than either a 2 hour OGGT or fasting glucose (as this study proves, where HgbA1C was done as part of a hepatitis screening campaign) and 2) has unique properties in that it looks for elevated blood glucose levels averaged over the preceding three months. All other glucose tests just look at your blood "now" but don't say anything about your blood sugar over time. "Better" is a relative measure of a test- and in this case HgbA1C's much, much better at picking up what your body has been exposed to for the last three months. The HgbA1C study was specifically designed to look at non-diabetics, but included some diabetics anyways. The authors state that in prior studies with diabetics “A1C levels have also been associated with mortality in patients with type 1 diabetes and nondiabetic chronic kidney disease and with incident cardiovascular disease.” Of the 408 diabetics in this study, “Although mortality rate was also increased in participants with a previous diagnosis of diabetes, this was only partially explained by their increased A1C levels.” – possibly due to smaller numbers. My Doc Gurley take on this question is that elevated HgbA1C is bad for everyone, but sneakier and previously-unrecognized as potentially lethal in non-diabetics. To answer your final question, the HgbA1C test is unique in that it is 1) much easier to do than either a 2 hour OGGT or fasting glucose (as this study proves, where HgbA1C was done as part of a hepatitis screening campaign) and 2) has unique properties in that it looks for elevated blood glucose levels averaged over the preceding three months. All other glucose tests just look at your blood “now” but don’t say anything about your blood sugar over time. “Better” is a relative measure of a test- and in this case HgbA1C’s much, much better at picking up what your body has been exposed to for the last three months.

]]> By: Liana http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1045 Liana Tue, 17 Jun 2008 22:32:15 +0000 http://www.docgurley.com/?p=204#comment-1045 Hmm... interesting. I read the study, and what I got out of it was more so that a lot of people are running around out there with undiagnosed diabetes, and undiagnosed diabetes will kill you. Of note, 71% of the participants were Maori. Significantly more at risk of diabetes and metabolic syndrome than Caucasians for example. So it's not really clear to me how well this would apply to Caucasians since they weren't able to tease out other cardiovascular risk factors. Are there any studies that suggest that a HbA1c is better than, say, a 2 hour OGTT or fasting plasma glucose for diagnosing diabetes? Hmm… interesting. I read the study, and what I got out of it was more so that a lot of people are running around out there with undiagnosed diabetes, and undiagnosed diabetes will kill you.

Of note, 71% of the participants were Maori. Significantly more at risk of diabetes and metabolic syndrome than Caucasians for example. So it’s not really clear to me how well this would apply to Caucasians since they weren’t able to tease out other cardiovascular risk factors.

Are there any studies that suggest that a HbA1c is better than, say, a 2 hour OGTT or fasting plasma glucose for diagnosing diabetes?

]]> By: Michael Maison http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1044 Michael Maison Tue, 17 Jun 2008 02:52:30 +0000 http://www.docgurley.com/?p=204#comment-1044 You are right (as usual) Doc Gurley. Another "coup de grace" study on the subject of whole grain intake and diabetes/cardiovascular protective benefits: American Journal of Clinical Nutrition, Vol. 76, No. 2, 390-398, August. Whole-grain intake is favorably associated with metabolic risk factors for type 2 diabetes and cardiovascular disease in the Framingham Offspring Study1,2,3,4 Nicola , McKeown, James B Meigs, Simin Liu, Peter WF Wilson and Paul F Jacques. You are right (as usual) Doc Gurley. Another “coup de grace” study on the subject of whole grain intake and diabetes/cardiovascular protective benefits:

American Journal of Clinical Nutrition, Vol. 76, No. 2, 390-398, August. Whole-grain intake is favorably associated with metabolic risk factors for type 2 diabetes and cardiovascular disease in the Framingham Offspring Study1,2,3,4 Nicola , McKeown, James B Meigs, Simin Liu, Peter WF Wilson and Paul F Jacques.

]]> By: Doc Gurley http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1043 Doc Gurley Mon, 16 Jun 2008 20:14:20 +0000 http://www.docgurley.com/?p=204#comment-1043 Actually, Helen, the data strongly disagree with you. Below are a very few of the many studies that show that whole grains are associated with a reduced risk of type 2 diabetes and cardiovascular disease. Studies also overwhelmingly show that whole grains improve a sense of fullness (satiety) and help with weight loss because of it, as well as blunting spikes of elevated glucose throughout the day, even if only eaten at breakfast. No one who is diabetic should be eating massive amounts of carbs (whole or not) – but whole grains are an important part of a healthy diet for everyone. A few of the many studies: Nilsson AC, Ostman EM, Holst JJ, Björck IM. Including indigestible carbohydrates in the evening meal of healthy subjects improves glucose tolerance, lowers inflammatory markers, and increases satiety after a subsequent standardized breakfast. J Nutr. 2008 Apr;138(4):732-9. Priebe MG, van Binsbergen JJ, de Vos R, Vonk RJ. Whole grain foods for the prevention of type 2 diabetes mellitus. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD006061. Review. Kochar J, Djoussé L, Gaziano JM. Breakfast cereals and risk of type 2 diabetes in the Physicians' Health Study I. Obesity (Silver Spring). 2007 Dec;15(12):3039-44. Nilsson AC, Ostman EM, Granfeldt Y, Björck IM. Effect of cereal test breakfasts differing in glycemic index and content of indigestible carbohydrates on daylong glucose tolerance in healthy subjects. Am J Clin Nutr. 2008 Mar;87(3):645-54. Clark CA, Gardiner J, McBurney MI, Anderson S, Weatherspoon LJ, Henry DN, Hord NG. Effects of breakfast meal composition on second meal metabolic responses in adults with Type 2 diabetes mellitus. Eur J Clin Nutr. 2006 Sep;60(9):1122-9. Epub 2006 May 3. Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, Brand-Miller JC. Glycemic index, glycemic load, and chronic disease risk--a meta-analysis of observational studies. Am J Clin Nutr. 2008 Mar;87(3):627-37. Review. Krishnan S, Rosenberg L, Singer M, Hu FB, Djoussé L, Cupples LA, Palmer JR. Glycemic index, glycemic load, and cereal fiber intake and risk of type 2 diabetes in US black women. Arch Intern Med. 2007 Nov 26;167(21):2304-9. Actually, Helen, the data strongly disagree with you. Below are a very few of the many studies that show that whole grains are associated with a reduced risk of type 2 diabetes and cardiovascular disease. Studies also overwhelmingly show that whole grains improve a sense of fullness (satiety) and help with weight loss because of it, as well as blunting spikes of elevated glucose throughout the day, even if only eaten at breakfast. No one who is diabetic should be eating massive amounts of carbs (whole or not) – but whole grains are an important part of a healthy diet for everyone.
A few of the many studies:
Nilsson AC, Ostman EM, Holst JJ, Björck IM.
Including indigestible carbohydrates in the evening meal of healthy subjects improves glucose tolerance, lowers inflammatory markers, and increases satiety after a subsequent standardized breakfast.
J Nutr. 2008 Apr;138(4):732-9.

Priebe MG, van Binsbergen JJ, de Vos R, Vonk RJ.
Whole grain foods for the prevention of type 2 diabetes mellitus.
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD006061. Review.

Kochar J, Djoussé L, Gaziano JM.
Breakfast cereals and risk of type 2 diabetes in the Physicians’ Health Study I.
Obesity (Silver Spring). 2007 Dec;15(12):3039-44.

Nilsson AC, Ostman EM, Granfeldt Y, Björck IM.
Effect of cereal test breakfasts differing in glycemic index and content of indigestible carbohydrates on daylong glucose tolerance in healthy subjects.
Am J Clin Nutr. 2008 Mar;87(3):645-54.

Clark CA, Gardiner J, McBurney MI, Anderson S, Weatherspoon LJ, Henry DN, Hord NG.
Effects of breakfast meal composition on second meal metabolic responses in adults with Type 2 diabetes mellitus.
Eur J Clin Nutr. 2006 Sep;60(9):1122-9. Epub 2006 May 3.

Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, Brand-Miller JC.
Glycemic index, glycemic load, and chronic disease risk–a meta-analysis of observational studies.
Am J Clin Nutr. 2008 Mar;87(3):627-37. Review.

Krishnan S, Rosenberg L, Singer M, Hu FB, Djoussé L, Cupples LA, Palmer JR.
Glycemic index, glycemic load, and cereal fiber intake and risk of type 2 diabetes in US black women.
Arch Intern Med. 2007 Nov 26;167(21):2304-9.

]]> By: Helen Howes http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1042 Helen Howes Mon, 16 Jun 2008 19:08:24 +0000 http://www.docgurley.com/?p=204#comment-1042 Whole grains are not better for diabetic or pre-diabetic people. There is much evidence that the GI is less helpful than the GL for us too. No grains seems to be nearer the ideal... Exercise and weight loss definitely help, but the biggest risk factor (not addressed) is genetic - there is a strong familial connection, particularly if one's mother, father, or grandparent had the disease... Whole grains are not better for diabetic or pre-diabetic people. There is much evidence that the GI is less helpful than the GL for us too. No grains seems to be nearer the ideal… Exercise and weight loss definitely help, but the biggest risk factor (not addressed) is genetic – there is a strong familial connection, particularly if one’s mother, father, or grandparent had the disease…

]]> By: Doc Gurley http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1041 Doc Gurley Mon, 16 Jun 2008 15:33:11 +0000 http://www.docgurley.com/?p=204#comment-1041 I've put the specifics of the Finnish Risk Score (and some more links) into an addendum to the article. Hope that helps you reach the info. I’ve put the specifics of the Finnish Risk Score (and some more links) into an addendum to the article. Hope that helps you reach the info.

]]> By: Ian Furst http://www.docgurley.com/2008/06/14/blind-men-and-the-diabetes-elephant/comment-page-1/#comment-1040 Ian Furst Mon, 16 Jun 2008 12:58:33 +0000 http://www.docgurley.com/?p=204#comment-1040 Good post -- I tried to get to the Finnish score but it's password protected. Good post — I tried to get to the Finnish score but it’s password protected.

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