Beneficial Effect of Weight Loss on Obstructive Sleep Apnea in Patients with Diabetes

From Archives of Internal Medicine article

Participation in an intensive lifestyle intervention leading to weight loss is associated with improvements in obstructive sleep apnea among patients with diabetes, reports Archives of Internal Medicine.
Researchers studied some 260 overweight older patients (mean age, 61) with type 2 diabetes and obstructive sleep apnea (average apnea-hypopnea index, 23 events per hour) for 1 year. Patients were randomized either to an intensive lifestyle intervention using restricted caloric intake and moderate exercise, or to a series of three group sessions focusing on diet, exercise, and social support.
By year's end, intensive-intervention patients had lost significantly more weight and showed a significant improvement in sleep apnea, compared with controls. In the control group, patients showed a worsening in their sleep apnea, despite maintaining stable weight. The greatest improvements in the apnea-hypopnea index were among patients with the highest initial values and the greatest weight loss.

Why we eat too much, and how to get control

By Rachel Grumman (CNN.com)

We all know we're supposed to eat healthy portions. So why is it that a rough day at the office or even just the smell of chocolate-chip cookies can cause us to throw our best intentions out the window?

If you overeat, think about what triggered your overindulgence so you can do better next time.

We tapped the nation's leading experts for the unexpected reasons why so many of us overdo it -- so you can break the cycle and prevent an unwanted pile-on of pounds.

You're not getting enough sleep

Missing out on your zzz's not only puts you in a mental fog, it also triggers a constellation of actual metabolic changes that may lead to weight gain. A lack of shut-eye harms your waistline because it affects two important hormones that control appetite and satiety--leptin and ghrelin--says Kristen L. Knutson, Ph.D., a research associate specializing in sleep and health at the University of Chicago's Department of Medicine. Health.com: Potential side effects of sleeping pills

According to a study published in the Annals of Internal Medicine, people who slept only four hours a night for two nights had an 18 percent decrease in leptin (a hormone that signals the brain that the body has had enough to eat) and a 28 percent increase in ghrelin (a hormone that triggers hunger), compared with those who got more rest. The result: Sleep-deprived study volunteers reported a 24 percent boost in appetite. Short sleep can also impair glucose metabolism and over time set the stage for type 2 diabetes, Knutson notes.

How to get control:

When we're exhausted, we hunger for just about everything in sight, especially if it's sugary or high in carbs. That may be because these foods give us both an energy boost and comfort (since lack of sleep is a stressor), Knutson says. To quell the urge for fattening foods and still get the energy kick you need, reach for a combination of complex carbs and protein.

"If you're feeling tired, you want carbs. But go for high-fiber carbs for long-lasting energy," says Keri Gans, R.D., a spokeswoman for the American Dietetic Association (ADA). "Fiber burns slower than simple sugars, and adding in some protein keeps you satisfied longer."

At breakfast, have whole-wheat toast with egg whites or a high-fiber cereal with fruit and a yogurt. And for a food-free way to perk up during the day, take a 10-minute walk outside. You also can prevent uncontrollable cravings in the first place by prioritizing a good night's sleep -- get seven to nine hours a night in a slumber-friendly bedroom (one that's as dark and quiet as possible and reserved for shut-eye and sex only).

A final tip: If you're plagued by sleep problems, ask your doctor for a referral to a sleep specialist. Health.com: Ways to eliminate bedroom distractions and get sleep

You're sabotaged by stress

Constant stress causes your body to pump out high doses of hormones, like cortisol, that over time can boost your appetite and lead you to overeat. "Cortisol and insulin shift our preferences toward comfort foods--high-fat, high-sugar, or high-salt foods," says Elissa Epel, Ph.D., an associate professor at the University of California, San Francisco (UCSF), Department of Psychiatry and a leader of the UCSF Center on Obesity Assessment, Study, and Treatment. Health.com: Feeling stressed? Why you may feel it in your gut

Fat cells also produce cortisol, so if you're overweight and stressed, you're getting a double-whammy in terms of exposure. Overweight women gained weight when faced with common stressors such as job demands, having a tough time paying bills, and family-relationship strains, according to a study published in the American Journal of Epidemiology.

Cortisol, together with insulin, also causes your body to store more visceral fat, which is a risk factor for heart attack and stroke, Epel notes. What's more, stress makes it harder to stick with a healthy eating plan. "It's a reason why people go off diets," notes Marci Gluck, Ph.D., a clinical research psychologist at the Obesity and Diabetes Clinical Research Section of the National Institutes of Health in Phoenix, Arizona. Folks who normally restrict their eating, tend to overeat in response to stress.

How to get control:

Sure, real-life pressures can put you in nonstop-nibble mode. But working stress-reduction techniques into your busy days can really help. Yoga, meditation, and deep-breathing exercises are powerful tools that keep tension in check. And spending 20 minutes doing progressive muscle relaxation--alternately tensing and relaxing muscle groups--significantly lessens stress, anxiety, and cortisol, according to a study published in the International Journal of Obesity and Related Metabolic Disorders. Health.com: How to grocery shop on a diet

Exercise will also do the trick. "Try dancing to your favorite tunes, running in place, playing a sport, or taking a simple walk," says Elisa Zied, R.D., an ADA spokeswoman and author of "Nutrition at Your Fingertips." When you're feeling edgy, make a habit of turning to these activities rather than diving into your candy stash. If you're feeling completely overwhelmed by stress, talk to a counselor who specializes in stress management.

You've got fatty foods (literally) on the brain

We're hardwired to hunger for fatty, sugary, salty foods because, back when our ancestors were foraging for every meal, palatable eats meant extra energy and a leg-up on survival, says Dr. David A. Kessler, former commissioner of the Food and Drug Administration (FDA) and author of "The End of Overeating: Taking Control of the Insatiable American Appetite."

So it's not just a lack of willpower that's tripping you up, but rather your outdated survival mode. In fact, when you eat fat-rich foods, your brain not only gets a signal that your body is satisfied but also forms long-term memories of the experience, according to new research published in the Proceedings of the National Academy of Sciences. What once helped early humans survive is now giving us ever-expanding waistlines.

Adding to the challenge to control overeating, the mere sight of food can cue up a craving. "[Cravings] are based on past learning and memories as well as the sight or smell of food, time of day, or location," Kessler says. "You'll walk down the street and start thinking about chocolate-covered pretzels because you've had them before on the same street."

Health Library

• MayoClinic.com: Whole grains -- Hearty options for a healthy diet

How to get control:

Avoid eating your favorite treat if you're in a particular mood, if it's a certain time of day, or if you're in a specific place; this will prevent you from creating a triggering link between those feelings or locations and that treat, Kessler says. And since the smell and sight of fatty, sugary foods is pure temptation, try to keep yourself from passing the bakery or ice cream shop you can't resist.

Also, pay attention to what you're thinking when temptation strikes. "Once the brain is activated [by a craving], having that inner dialogue of, 'No, I shouldn't have that,' only increases the wanting," Kessler notes. Instead, focus on something you want more than that slice of cheesecake--from being healthier for your kids to feeling less winded when you walk to work--to help override the urge. Health.com: Surprising myths about excess weight

If logic is out the window, indulge in healthier versions of your favorites such as low-fat frozen yogurt with almonds when you crave a sundae or a calcium-rich glass of nonfat chocolate milk when you need a chocolate fix.

You Pigged Out -- Now What?

• Forgive yourself. "Having one overindulgent meal should not derail you from your healthful eating habits, while being too negative will make you more likely to throw up your hands in despair and overindulge at the next meal or several meals for days to come," Elisa Zied, R.D., says.

• Give yourself a do-over. Immediately start with lean protein, veggies, whole grains, and fruit, and drink plenty of water, Zied suggests.

• Learn from it. Think about what triggered your overindulgence--not to punish yourself, but to choose smarter next time. "If you keep a food journal, you might see you ended up pigging out because you waited too long to eat," Keri Gans, R.D., says.

• Add on exercise. To feel in control again, simply tack on a few extra minutes to your regular walk, gym routine, etc. At the same time, "try not to think of exercise as a punishment for overindulging," Zied says. If you do, you'll grow to dread the gym.

Disseminated viral warts

Today I saw a 24 y/o patient complaining of warts. He had them for over 10 years now. His right arm was almost completely covered in them; both hands were also badly affected. He has no history of previous illness (besides the warts), takes no medications, denies any illicit drug use or sexual promiscuity. 

If it were just a few warts then it would be a simple case.  But since they’re so many, and so widespread, the suspicion for a possible complication of something else pops up. For example HIV, Syphilis, or a rare condition that causes warts to grow out of proportion like that.

I ordered a syphilis test and a HIV test to confirm. The next step, after receiving the results, would be a dermatologist referral. The problem in treating this is that they're too many. Usually they can be burned, frozen or treated with podophyllin. This would be extremely difficult for various reasons: 1) to be burned you need localized anesthesia...in this case he would need MANY injections or a complete arm blockade and I don't think that is feasible for this. 2) Freezing them would also be very painful and lengthy. 3) Podophyllin is applied in small drops to each wart and can cause irritation, contact dermatitis, and in some rare cases nausea, vomiting, diarrhea, seizures and coma. Imagine the risk in treating so many warts. 

The following picture is not from the patient, but his are similar, just a lot more.

The following picture is from a somewhat similar disease called Epidermodysplasia Verruciformis: (EV) is an extremely rare disorder of warts, the pathogenesis of which is poorly elucidated. Individuals with EV have a severe and apparently congenital susceptibility to infection with HPV that may be inherited in an autosomal recessive fashion. EV is clinically characterized by widespread warts that appear in childhood— typically flat warts as well as lesions that are scaly, red/brown macules— which do not revert and often develop into skin cancers. The HPV strains specific to the scaly (scary!) warts that characterize EV are HPV-5 and HPV-8.

The following is a link to a video of a man with this disease.

Video of EV patient

63% of Physicians Favor Public Option

By Emily P. Walker, Washington Correspondent, MedPage Today
Published: September 14, 2009

  

WASHINGTON -- A solid majority of physicians favor creating a new public insurance option that would operate alongside existing private plans, according to a survey published online in the New England Journal of Medicine.
About 63% of doctors, across a smattering of specialties and in various geographic regions, support a public insurance option. That figure is in line with national consumer polls that have shown the majority of Americans support a public plan.
While most physicians' groups have voiced a collective opinion on the issue, the opinions of individual doctors are less clear.
"Given the enormity of the current effort to reform healthcare and its potential effect on the future of generations of Americans, policymakers need to hear the views on the whole range of physicians on the key elements of reform," wrote Salomeh Keyhani, MD, and Alex Federman, MD, MPH, from the Mount Sinai School of Medicine in New York.
To examine individual perceptions, Keyhani and Federman collected data from 2,130 physicians from the American Medical Association's Masterfile and stratifed the responses of those doctors into four groups: primary care doctors, medical specialists, surgical specialists, and other specialties.
Physicians were asked which options they most support: a public option only; private options only; or a mixture of private and public insurance options.
The majority of physicians (63%) said they support a mixture of public and private plans -- a cornerstone of the plan President Barrack Obama outlined in his recent address to Congress.
Meanwhile, 27% of respondents said they favored offering private insurance plans only, but creating subsidies to help low-income people afford insurance.
Just 10% favored a healthcare system in which a public, government-run plan was the only insurance option, which would mean private insurance companies would no longer exist in their current form.
Primary care physicians were the most likely to support a public option, while those in fields with less patient contact, such as radiologists and anesthesiologists, were less likely to support a public option, although 57% of those specialists still supported a public option.
Doctors who own their own practices were less likely than non-owners to support a public plan (58% versus 67%; P<0.001).
Physicians who are paid salary only tended to support adding a new public plan more than physicians who are paid through billing insurance companies or the government (69% versus 59%; P<0.001).
Support of the public plan was fairly universal across geographic regions as well, but the biggest majority of support came from those practicing in the Northeast (70%).
Among AMA members, about 62% of respondents supported the public plan.
"Support of the public and private options was consistent across a wide range of physicians, including those from the traditionally conservative southern regions of the United States, those with a financial stake in their practice, and members of the AMA, despite that group's history of opposition to reform efforts" the article's authors concluded.
The AMA -- which has fought past reform efforts, including the creation of another public program, Medicare -- has offered its support for legislation in the House, which would create a public option. The data from the new survey suggest that view is consistent with individual AMA member views.
The plan outlined by the Senate Finance Committee does not contain a public insurance option. It would set up state-by-state cooperatives, which would allow patients to pool together to purchase insurance, and to have an ownership stake in their insurance plan.
There are no plans in Congress that would establish a single-payer system.
The study authors point out several limitations to their survey, including a low response rate of just 43%, however, they add there were no significant differences between the characteristics of responders and non-responders.
The study authors reported no relevant conflicts of interest.
In a second Perspective, also published Monday online in NEJM, researchers sought to gauge physicians' personal attitudes about healthcare reform.
For that survey, researchers led by Ryan Anteil of the Mayo Medical School mailed an eight-page questionnaire about moral and ethical beliefs in medical practice. Physicians were asked to respond to how much they agreed with the following statements:

• "Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligation as a physician."
• "Every physician is professionally obligated to care for the uninsured and the underinsured."
• "I would favor limiting reimbursement for expensive drugs and procedures that would help expand access to basic healthcare for those currently lacking such care."

The survey also asked for physicians' moral perceptions on using cost-effectiveness data to determine which treatments are offered to patients.
Of the 991 returned surveys (a response rate of 51%), 78% of respondents said that addressing societal health policy issues is in the scope of professional obligation of a physician.
About 73% said physicians are obligated to care for the uninsured and underinsured.
Most respondents (67%) said they would favor limiting reimbursements for expensive treatments to expand access. Not surprisingly, surgeons and sub-specialists were more likely to oppose cutting payment for pricey procedures than were primary care doctors.
A little more than half (54%) said they were morally opposed to using cost-effectiveness as a factor in deciding which treatments a patient should receive.
As would be expected, there were differences between physicians who described themselves as "conservative" or "liberal" on social issues.
Liberals agreed more strongly that doctors have an obligation to address societal issues, and that physicians are obligated to care for the uninsured and underinsured, and that cutting reimbursements for expensive procedures should help pay for reform.
Conservatives, however, tended to object more strongly than liberals to using cost-effectiveness data in making clinical decisions.
The authors say the data suggest that efforts to mobilize physicians can increase their sense of professional responsibility, but "also that such efforts may encounter considerable opposition from some quarters of the profession, particular to elements of reform that impinge on physicians' decision-making autonomy or threaten to reduce reimbursement for the costly interventions they provide."
The study authors reported no potential conflicts of interest.

Deep Vein Thrombosis vs. Cellulitis

Today I saw a 68 year old male, with history of Diabetes and Hypertension who was complaining of right calf edema, pain and erythema since he woke up this morning. He refers he “thinks he got bitten by something”.

The picture here is not from the patient himself.

                                                     This is what his varicose veins look like.

Around the center area of the calf there is a round spot, about 3.5” in diameter, which was erythematous and tender. This was present only on one leg.

The patient denies fever or recent trauma. He had a positive

Homans sign

* Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight has been a time-honored sign of DVT. However, Homans sign is neither sensitive nor specific: it is present in less than one third of patients with confirmed DVT, and is found in more than 50% of patients without DVT.

The patient had to be sent to the ER for a possible Deep Vein Thrombosis. Also, it could be a Cellulitis. The patient’s history of varicosities suggest circulatory problems, so correlating one with the other I though it more prudent to have him get an ultrasound to discard or diagnose Deep Vein Thrombosis at the ER. I should get the results in the next few days.

FDA Panel Votes to Approve Second HPV Vaccine

By Michael J. Himowitz, Deputy Managing Editor; Emily P. Walker, Washington Correspondent
Published: September 09, 2009

 

WASHINGTON -- An FDA advisory panel today voted to recommend approval of GlaxoSmithKline's Cervarix vaccine for use against the two strains of human papillomavirus (HPV) that cause 70% of cervical cancers.
In a separate action, the Vaccines and Related Biologics Committee recommended that the agency okay Merck's application to extend the use of its HPV vaccine, Gardasil, against genital warts in males ages 9 through 26.
The panel's near unanimous vote Wednesday on the use of Cervarix against HPV types 16 and 18 in females ages 15 to 26 makes it likely that the FDA will ultimately approve the first competitor to Gardasil, which has been used for three years in girls and women from 9 to 26 years of age to ward off four strains of HPV.
The FDA is not bound by the recommendations of its panel of outside experts, but usually follows the committee's advice.
The panel voted 12-1 that the manufacturer had demonstrated the effectiveness of Cervarix and 11-1 that it had demonstrated safety.
However, members of the panel pressed for strong aftermarket follow-up after discussing data that showed a somewhat higher rate of miscarriages around the time of vaccination and a small number of neurological problems.
Cervarix has already been approved in 98 countries.
FDA staff documents discussed by the committee indicated that Cervarix is effective in preventing genital dysplasias associated with HPV 16 and/or 18 in women ages 15 to 25 who are naive to those HPV types.
The FDA staff also noted that Cervarix might be effective in reducing genital dysplasias related to HPV 31, but that didn't come up in the vote.
The FDA conclusions are based on findings from the already-reported PATRICIA trial -- short for PApilloma TRial against Cancer in young Adults -- which enrolled more than 18,000 women in 14 countries.
The primary endpoint was vaccine efficacy against cervical intraepithelial neoplasia associated with HPV 16 or HPV 18 in women who were not infected with either at baseline.
At the final analysis, 60 cases of cervical intraepithelial neoplasia were confirmed, of which 33 contained DNA from nonvaccine oncogenic HPV types as well as HPV 16 or HPV 18.
Of those, four were in the vaccine group and 56 in the control group, the researchers found, for a vaccine efficacy rate of 93%.
Many women in the study were infected with nonvaccine oncogenic strains of HPV, and in a post hoc analysis, the researchers estimated a cross-protective efficacy that could represent between 11% and 16% additional protection against cervical cancer.
In considering Merck's request to extend Gardasil's approval to males, the committee voted 7-0 that data support the vaccine's effectiveness in preventing genital warts caused by HPV types 6 and 11. The vote was 7-1 on the safety of the vaccine. FDA staff papers likewise favored the endorsement.
HPV in males can produce skin warts, genital warts, penile intraepithelial neoplasia, penile cancer, anal intraepithelial neoplasia, anal cancer, oropharyngeal cancer, and recurrent respiratory papillomatosis, but Merck's current application is just for the prevention of genital warts.
Genital warts are the most common presenting complaint in both males and females with HPV. About 1% of the entire U.S. sexually active population is estimated to have genital warts. About 200 per 100,000 males are newly diagnosed with genital warts each year, according to the FDA.
Most genital warts are caused by genital infection with HPV, particularly types 6 and 11 which are found in 70% to 100% of lesions.
The sponsor is seeking approval based on a phase III study of 4,065 boys and men who were randomized to receive the three-dose Gardasil vaccine or placebo.
Each patient underwent a genitourinary exam, had specimens collected for HPV, and underwent a lesion biopsy if indicated at months 7, 12, 18, 24, 30, and 36. Sera were collected for immunogenicity at screening and at months 7, 24, and 36.
Although the primary endpoint of the study was external genital lesions -- including penile, perianal, and perineal intraepithelial neoplasia (PIN), as well as genital warts -- the data showed that most lesions were actually warts and that there were very few cases of PIN, so Merck and the FDA agreed to focus the application only on genital warts.
The vaccine offered a nearly 90% protection against genital warts. In the vaccine group, three out of 1,397 patients became infected with HPV, and in the control group, 28 patients out of 1,408 became infected over the course of the study.
"Data submitted ... demonstrate that Gardasil is efficacious in the prevention of genital warts caused by HPV 6 and 11 in males 16 to 26 years of age," concluded staff from FDA's Center for Biologics Evaluation and Research.
The vaccine was more effective in those between the ages of 15 and 20 than in those 21 to 27 (94% versus 85%). Efficacy didn't appear to decrease as number of sexual partners increased.
Gardasil efficacy was greater in men who have sex with women than in men who have sex with men (92% versus 79%).
Among those with preexisting HPV infections, the vaccine was markedly less effective.
Merck also submitted results from a study to demonstrate the noninferiority of antibody responses among younger females to older females (and to extrapolate those findings to males), and a study to demonstrate that the vaccine has a similar antibody response in males and females.
FDA staffers said Gardasil was found to be safe, and no deaths that occurred during the study were attributed to the vaccine.
According to the briefing documents, a "comprehensive discussion of prevention and treatment of HPV in males would also include estimates of the impact on transmission to females," but Merck's data was not that far-reaching.

Novartis Says Swine Flu Vaccine Works Quickly

By Michael Smith, North American Correspondent, MedPage Today
Published: September 03, 2009

A vaccine against the H1N1 pandemic flu was safe and immunogenic within two weeks after a single dose, according to the Swiss drugmaker Novartis AG.

The vaccine, developed using a cell-culture method, is the second to show single dose immunogenicity, after China's Sinovac Biotech reported similar results Aug. 31.

The Sinovac drug, to be given in a 15-microgram dose without adjuvant, was approved today by the Chinese State Food and Drug Administration. The vaccine, dubbed Panflu, is approved for people ages 3 to 60, according to the Chinese official news agency Xinhua.

The Novartis vaccine, dubbed Celtura, was tested for safety and immunogenicity in a 100-volunteer study run by the University of Leicester and University Hospitals of Leicester in England.

In the trial, the vaccine -- boosted with the adjuvant MF-59 -- was given in one or two doses of 7.5 micrograms each, the company said in a statement.

Serum antibody responses were highest among volunteers who got two doses but a single dose also yielded responses deemed to be protective against the flu.

Specifically, hemagglutination-inhibition titers reached 1:40 or higher in 80% of those getting a single dose and more than 90% of those getting two doses.

Additional clinical trials sponsored by Novartis -- intended to include more than 6,000 adults and children -- are already under way, the company said.

"The pilot trial results are encouraging," according to Andrin Oswald, MD, chief executive officer of Novartis Vaccines and Diagnostics.

"The study suggests that while two doses seem to provide better protection, one dose of our adjuvanted Celtura vaccine may be sufficient to protect adults against the swine flu," he said in a statement.

The vaccine against the seasonal flu usually elicits an immune response with a single shot, because of lingering immunity from previous exposures both to vaccines and seasonal strains.

But health officials have been concerned that few people have any immunity to the pandemic H1N1 strain, so that two doses would be required to obtain any protection.

Given the short time available to produce the vaccine, such a requirement might mean a shortfall in available drug.

New Delayed-Release Prednisone Relieves RA Symptoms

By John Gever, Senior Editor, MedPage Today
Published: September 02, 2009


Low doses of an investigational, delayed-release version of prednisone relieved rheumatoid arthritis symptoms in a pivotal phase III trial, paving the way for a U.S. marketing application, the product's manufacturer said.
The oral drug, tradenamed Lodotra, is formulated to begin rapid release of prednisone about four hours after swallowing. Its manufacturer, Swiss-based Nitec Pharma, said that when the drug is taken at bedtime, the release coincides with nocturnal spikes in proinflammatory cytokines, maximizing the steroid's effectiveness.
The newly completed U.S. study compared 5 mg of Lodotra once nightly with placebo in a randomized trial involving 350 rheumatoid arthritis patients with inadequate responses to disease-modifying drugs. Conventional prednisone is commonly given in doses of 10 to 20 mg.
Some 49% of the Lodotra group achieved ACR 20 responses (20% reduction in symptoms according to American College of Rheumatology criteria), compared with 29% of those taking placebo, the company announced in a press release.
The drug also led to a mean 44% reduction in morning stiffness, compared with 21% in the placebo group. Both differences were highly significant (P<0.001), according to Nitec.
An earlier European trial tested Lodotra against regular prednisone at an average dose of 6 mg. The delayed-release formulation significantly shortened the duration of morning stiffness and led to greater reductions in interleukin-6 levels, Nitec said. ACR 20 responses and other standard measures of symptom reduction were similar.
On the basis of these studies, Nitec said it plans to request FDA approval of the drug for treating rheumatoid arthritis. It was approved in Germany earlier this year.
Nitec is also sponsoring a phase II study of the drug in severe asthma and is planning a trial in polymyalgia rheumatica.

Mediterranean Diet Reduces Need for Diabetes Drugs

By Chris Emery, Contributing Writer, MedPage Today
Published: August 31, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner   

Action Points 
Explain to interested patients that research shows that a Mediterranean diet may reduce the need for antihyperglycemic drugs for type 2 diabetes.


Note that the study provides evidence that lifestyle interventions can be effective at treating type 2 diabetes, according to the authors.
The so-called Mediterranean diet -- rich in nuts, whole grains, fruits, and vegetables -- reduces the likelihood that patients recently diagnosed with type 2 diabetes will need antihyperglycemic drug treatment, a new study found.
Among diabetics who followed a Mediterranean-style diet, only 44% required antihyperglycemic drug therapy, compared with 70% of patients who followed a standard low-fat diet (95% CI -31.1% to -20.1%, P<0.001), according to a report in the Sept. 1 Archives of Internal Medicine.

Patients on the Mediterranean-style diet also lost more weight and experienced greater improvements in blood sugar control and coronary risk measures than those on the low-fat diet.

"Compared with a low-fat diet, a low-carbohydrate, a Mediterranean-style diet led to more favorable changes in glycemic control and coronary risk factors and delayed the need for antihyperglycemic drug therapy in overweight patients with newly diagnosed type 2 diabetes," Dario Giugliano, MD, PhD, of the Second University of Naples, and colleagues wrote.

Despite these findings, the authors suggested that drug therapy would still be a primary weapon in the battle against type 2 diabetes as the number of cases grows to 380 million cases worldwide by 2025, according to estimates cited in the paper.

"Lifestyle intervention studies have demonstrated large reductions in risk for type 2 diabetes that remain after lifestyle counseling is stopped," the authors wrote. "Despite this beneficial effect, the American Diabetes Association recommends that patients with newly diagnosed type 2 diabetes be treated with pharmacotherapy as well as lifestyle changes."

"Lifestyle changes are often inadequate because patients do not lose weight or regain weight or their diabetes worsens independent of weight," they continued.

"Pharmacotherapy also often fails with time, and some drugs have associated cardiovascular and other risks. For those reasons, lifestyle changes proven to be more effective than what is typically recommended would be welcome."

To investigate the difference between two lifestyle therapies, a low-fat diet and a Mediterranean diet, Giugliano and colleagues conducted a randomized trial between January 2004 and September 2008 at the Diabetes Clinic of the Azienda Ospedaliera Universitaria at the Second University of Naples.

The participants were 215 overweight people (BMI greater than 25 kg/m2) between the ages of 30 and 75 who were newly diagnosed with type 2 diabetes, had never been treated with antihyperglycemic drugs, and had hemoglobin A1c (HbA1c) levels less than 11%.

Half were put on a Mediterranean-style diet that was rich in vegetables and whole grains. Most red meat was replaced with poultry and fish. Women were restricted to 1,500 kilocalories per day and men were restricted to 1,800 kilocalories per day, with the goal of no more than 50% of calories from complex carbohydrates. The diet had no less than 30% of daily calories from fat.

The other half of the patients were put on a low-fat diet based on American Heart Association guidelines. The diet was rich in whole grains while it restricted fats, sweets, and high-fat snacks. Women and men were likewise restricted to 1,500 and 1,800 kilocalories per day, respectively. But unlike the Mediterranean diet group, they were restricted to no more than 30% of calories from fat and no more than 10% of calories from saturated fat.

The participants received dietary advice from nutritionists and dietitians during monthly sessions for the first year, and every other month thereafter for the duration of the four year study. The patients kept diaries to record their food intake, which the researchers used, along with counseling session attendance records, to assess their adherence to the diet.

This may have limited the accuracy of the assessment of the patient's adherence to the diets, since the researchers did not directly assess what the patients ate, the authors noted.

Another limitation was that both patients and providers knew to which diet the patients were assigned. Thus, doctors who prescribed diabetes medications to patients knew which diet the patients were on, which could have introduced bias.

"Nevertheless, we believe our findings suggest that people with newly diagnosed type 2 diabetes who use a low carbohydrate [Mediterranean] diet can lower their HbA1c levels and delay the need for antihyperglycemic drug therapy compared with use of a low-fat diet," the authors wrote.

"Perhaps most important, the findings reinforce the message that benefits of lifestyle interventions should not be overlooked despite the drug-intensive style of medicine fueled by the current medical literature."