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18 Search Results for ""type 2 diabetes""

  • What Happens Between Visits? What Happens Between Visits?

    • From: bgottlieb
    • Description:

      I definitely judge books by their covers, or the cover may at least inspire me to take a second look. The same is true for articles in medical journals.  I'm inclined to skip over titles with lots of capital letters or numbers, or with words that have more than 12 letters.  I'm drawn to titles that speak to me, that use words that I can pronounce, spell, and use in a conversation. When I saw the title "What happens between visits?  Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes," I had to read on.

      My health center is in the process of developing a medical home model for delivering care. The medical home is built on the notion that the care that takes place in the office is only a fraction of the care that a patient needs in order to achieve the best outcomes in both disease management and overall well-being. This is particularly true for diabetes and other chronic diseases that require multiple complex decisions and interventions on the part of the patient every day.

      Sarkar and colleagues studied low income, ethnically diverse patients with poorly controlled type 2 diabetes—not fully representative of all diabetic patients, but certainly representative of my patients.   The study used subjects enrolled in the Automated Telephone Self-Management  (ATSM) arm of a larger project (Improving Diabetes Efforts Across Language and Literacy [IDEALL]). The ATSM intervention involved education and self-management support for patients through weekly interactive, automated telephone calls that were reviewed by a nurse care manager. The nurse case manager would then call patients back whose responses to the automated call met call-back criteria, such as failing to exercise at least once in the past week or a blood glucose reading of less than 60. Records were reviewed to identify adverse or potential adverse outcomes. The events were characterized according to self-management domain, including medication use, diet adherence, symptom recognition, glucose monitoring, diabetic foot care, and appointment adherence. Based on the characteristics of these outcomes, the events were categorized according to contributing causes: systems issues, impaired patient-clinician communication, patient contributions and primary care clinician contributions.

      A total of 264 events were confirmed, including 111 adverse events and 153 potential adverse events. Of the 111 patients in this arm, 96 (86%) experienced at least one event. The most common self-management domain involved medication use which accounted for 59% of the adverse events and 65% of the potential adverse events. Diet adherence, glucose monitoring and symptom recognition were also common.

      Only 20% of events had a single contributing cause. The majority of events involved multiple contributing causes: 40% had 2 contributing causes, 37% 3 or 4 causes, and in 3% of cases a cause could not be determined. Patient factors contributed to 77% of the events and systems to 69% of events. Of interest to me is that primary care clinician factors contributed to only 6% of events.

      Much of the patient safety literature focuses on in-patient care. While there are certain lessons and principles that can be applied to ambulatory settings, there are important differences. As complex as the in-patient setting is, patient contributions to safety and errors are more controllable than they are in the outpatient setting. Patients spend a brief time in the clinic and then return home to remember and interpret their instructions, administer their medications, prepare food, exercise (or not), go to the pharmacy which may make their own errors, and see other providers who may make conflicting recommendations or prescribe treatments that interfere with existing medications. Patients may experience symptoms which they fail to report or misinterpret. They may run out of medications, double up on some medications and decide to stop others. They may make self-management decisions based on unproven, untrustworthy information, fears, or unfounded beliefs. As their providers, we may or may not learn about any of these behaviors and choices. We may learn about them well after the fact, when harm has been done.

      Clearly, our 15-minute visits are too often centered on the provider's agenda and are not designed for optimal communication. There are particular communication challenges with patients such as those in the study who, like my patients, have low health literacy, are poorly educated, and speak little or no English.

      Accurate and effective communication of health information is problematic in any setting, and every patient group has its own challenges.  Management of chronic illnesses is complex, with multiple decision points and contingencies. Most people, even those who are highly educated, are anxious in a health care setting and thus are not taking in information clearly. And, like most of what you are taught, you don't really learn it, don't even really know what your questions are, until you try to do it and integrate it into your life.

      The authors call for "patient-level self-management support and patient-centered communication." Our medical home will have to incorporate multiple channels of communication and information flow. We need to know how our patients are taking their medications, what they are eating, and how they are implementing our sliding scales and dietary plans—in real time as much as possible. Beyond that, we need to have channels for coaching and encouraging physical activity, healthy eating, medication adherence, and other health-promoting behaviors.

      Physicians will likely play a critical, but small role in these on-going activities.  In this study, technology backed by medical personnel provided channels for a two-way flow of information. Computer and web-based technology can continue to be exploited to promote health and wellness, although it will be a while before my patients benefit from this. However, even my patients have cell phones and are savvy about their extended applications. Automated text messages, phone messages, phone alarms at medication times—all of this and more can support most of our patients' ability to manage their diabetes.


      1. Sarkar U, Handley M, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qual Saf Health Care. 2010;19:223-228.
      2. Sarkar U, Handley M, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. J Gen Intern Med 2008; 23:459-65.

      Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.

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  • Cancer and Diabetes Cancer and Diabetes

    • From: bgottlieb
    • Description:

      Since the beginning of the year I have diagnosed 8 new cases of breast cancer. All of these women have diabetes except for the 34-year-old, although even she has a related state of insulin resistance -polycystic ovarian syndrome. Clearly, since I work in a health center that serves large numbers of minorities, I can expect to have a high prevalence of diabetes in my patient population…not to mention working almost anywhere in the 21st century, in an epidemic of obesity. Are there simply independently high rates of both diabetes and cancer? Or, is there a relationship between cancer and diabetes?

      Sitting at the top of my neglected must-read pile was an article that posed this question in a more rigorous manner and provided me with some food for thought.1 In December 2009 the American Diabetes Association (ADA) and the American Cancer Society (ACS) convened a consensus development conference to address this relationship. The writing group was charged with developing a consensus report to address the following questions:

      1. Is there a meaningful association between diabetes and cancer incidence or prognosis?
      2. What risk factors are common to both diabetes and cancer?
      3. What are possible biologic links between diabetes and cancer risk?
      4. Do diabetes treatments influence the risk of cancer or cancer prognosis?

      While the report does not represent the official position of either the ADA or the ACS, it is based on a series of presentations by experts during the December 2009 gathering, as well as a review of the evidence. It is a useful synthesis of what is known and what questions remain.

      As for the association between diabetes and cancer, the authors point out that after several decades of conflicting evidence, it appears that “cancer and diabetes are diagnosed within the same individual more frequently than would be expected by chance, even after adjusting for age.” The relative risk of cancer associated with diabetes, primarily type 2, varies by site from > 2-fold for liver, pancreas, and endometrium, to 1.2-1.5-fold for colorectal, breast, and bladder. There is no apparent association between type 2 diabetes and lung cancer; for kidney cancer and non-Hodgkin’s lymphoma, the data is inconclusive.  The association between type 1 diabetes and cancer has not been well-studied, and it appears that diabetes is associated with a lower risk of only prostate cancer.

      The effect of diabetes on cancer mortality is difficult to establish, since diabetes is associated with excess age-adjusted mortality with or without a cancer diagnosis. Of relevance to my patients, the authors refer to a study that indicates that 5-year mortality from breast cancer was increased among those with co-existing diabetes compared to those without (hazard ratio 1.39).2

      Cancer and diabetes share many risk factors: age, race/ethnicity, obesity, diet, physical activity, and tobacco. Apart from childhood cancers, the incidence of the majority of cancers increases with age, with highest rates among those aged 55 and older. Although increasingly prevalent among children and adolescents, the incidence of type 2 diabetes also increases with age, with highest rates among those aged 60 and older.

      In the United States, cancer incidence and mortality are greater among African Americans compared to all other groups. In the United States, type 2 diabetes incidence, morbidity, and mortality are greatest among all non-white groups compared to non-Hispanic whites. In both cancer and diabetes, race and ethnicity likely reflect a combination of socially determined risks, including environmental, socioeconomic, and behavioral factors in combination genetic factors.

      Overweight and obesity are both associated with multiple cancers compared to body mass index less than 25—including postmenopausal breast cancer, colorectal, endometrial, pancreatic, and adenocarcinoma of the esophagus, kidney, gallbladder, and liver. Obesity seems to increase mortality for some cancers, including prostate. An intriguing phenomenon is the association of weight gain during adulthood with the development of certain cancers such as breast cancer. This is relevant to my patients, since Latina women tend to gain and retain weight with each pregnancy.

      If weight loss was associated with reduced risk, the causal relationship between obesity and disease incidence and outcome would be strengthened. The association between weight loss and reduced incidence of and morbidity from type 2 diabetes is clear. The impact of weight loss on cancer is difficult to establish because a large amount of weight loss is needed to observe an effect, and large weight loss can also be a result of cancer.  Several studies demonstrate that women who underwent bariatric surgery had lower rates of cancer, primarily because of substantially reduced risk of breast and endometrial cancer. To date, comparable studies in men do not demonstrate an effect in lowering cancer risk.3

      There is overlap in the type of diet that seems to be associated with lower risk for cancer and lower risk for diabetes, including those that are low in red and processed meat, high in vegetables, fruits, whole grains. However, like most of what we believe about nutrition, the evidence is largely based on observational studies, with relatively few randomized, controlled clinical trials to support the claims.

      Both observational and randomized clinical trials support the role of physical activity in preventing and controlling type 2 diabetes. Observational studies support the role of physical activity in preventing certain cancers, namely colon, and postmenopausal breast and endometrial cancers, but clinical trials are lacking.

      The association between tobacco exposure and cancers is well-established, including trachea, bronchus, lung, larynx, upper digestive tract, bladder, kidney, pancreas, leukemia, liver, stomach, and cervix. Tobacco is also a risk factor for the development of type 2 diabetes and for accelerating its adverse consequences.

      Even moderate alcohol increases the risk of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colon, rectum, and breast. Similarly, excess consumption is a risk factor for diabetes. However moderate consumption may be protective.

      The authors explore several potential links between diabetes and cancer, including hyperinsulinemia, hyperglycemia, and chronic inflammation. Insulin may stimulate all cell growth and proliferation, including that of neoplastic cells, and hyperinsulinemia may promote carcinogenesis through several pathways. In vitro and human studies suggest a role for insulin and insulin receptors in breast cancer risk and outcome. Insulin receptors have been identified in various cancers, including breast cancer cells, and may be a marker for specific cell phenotypes. However, as with inflammatory cytokines and circulating hyperglycemia, the relationship between circulating insulin, the density of insulin receptors at the cellular level, and other growth factors is complex and not yet clarified.

      What about diabetes treatments? There is intriguing evidence that metformin inhibits cell proliferation, including tumor cells. The authors cite in vivo and human studies that suggest that metformin may be associated with a reduced risk for cancer as well as reduced cancer mortality. On the other hand, there is some evidence that exogenous insulin and insulin analogs may be associated with an increased risk of cancer. However, the evidence is inconclusive and requires further study. Observational studies have had multiple confounders, and RCTs were designed to look at cardiovascular outcomes and were not powered to evaluate the more rare cancer outcomes.

      What did I learn from this review? It does seem that there are plausible links between type 2 diabetes and certain cancers, and that the two broad categories of disease may share multiple risk factors. There are intriguing, plausible but inconclusive studies that define the potential causal pathways between diabetes and neoplastic processes, as well as between specific diabetes medications and neoplasia. The authors conclude, and I agree, that “many research questions remain.”

      In the United States and worldwide, cancer follows cardiovascular disease as the second leading cause of death. For Latinos, diabetes is a major contributor to cardiovascular morbidity and mortality. However, at least among my patients, emotional truth trumps epidemiologic truth. My patients fear cancer. Especially breast cancer.  The good news and the bad news is that there is considerable overlap among the major risk factors for cancer as well as cardiovascular disease and diabetes. The bad news first: Since obesity and physical inactivity are epidemic, and tobacco and alcohol use are prevalent, I will probably see a lot of cancer and diabetes, separately and together, disproportionately so among my socio-economically vulnerable patients.  Now the good news: The majority of these risk factors are modifiable, even if the evidence base for how to do so is less solid. I can use my patients’ intrinsic motivation to prevent cancer—not a bad motivation, after all—to reduce their risk for a whole group of killers.


      1. Giovannucci E, Harlan DM, Acher MC, et al, Diabetes and cancer: A consensus report. CA Cancer J Clin. 2010; 60:207-221.
      2. Lipscombe LL, Goodwin PJ, Zinman B, McLaughlin KR, Hux JE. The impact of diabetes on survival following breast cancer. Breast Cancer Res Treat. 2008;109: 389-395.
      3. Renehan AG. Bariatric surgery, weight reduction and cancer prevention. Lancet Oncol. 2009;10:640-641.

      Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.

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  • Diabetes, Obesity, and Governm Diabetes, Obesity, and Government

    • From: RichardReeceMD
    • Description:

      Obesity and its stepchild, type 2 diabetes, have replaced smoking as the leading health hazards. Yet despite government and public health pleadings to eat less, move more, lose weight, the obesity and diabetes epidemics are on a tear.

      Here is how the Wall Street Journal Health Blog assesses the situation:

      “Editors of the Lancet didn’t mince words when they weighed in on the epidemic of type 2 diabetes — they said the fact that the mostly preventable disease has become so prevalent is “a public health humiliation.”

      “Medicine might be winning the battle of glucose control, but it is losing the war against diabetes,” the authors write."

      “ ‘Lifestyle interventions’ is another name for efforts to convince people to lose or maintain weight, eat a more healthful diet and get more physical activity. When people do make changes, good things can happen - even a 7% weight loss can produce much as a 58% improvement in the risk of progressing from prediabetes to diabetes.”

      “It’s not like the diet and exercise message hasn’t been broadcast loud and clear, especially in the United States and other western countries, but public-health entreaties don’t always work. Most adults aren’t supposed to eat more than a teaspoon of salt per day, for example, but a CDC study released yesterday says only 10% of us do that. And other CDC statistics released recently show that in 2009, 29% of Americans were obese. “

      Hapless Government

      Why is government so hapless in persuading people to change for their own good?

      I suspect the answer lies in complexity of human society and its desire for personal freedom.

      In his classic The Road to Serfdom (1944), conservative economist Friedrich Hayek wrote that the economy and society are too complicated for centralized government to control and intervene at marketplace or lifestyle levels. That is why the economic stimulus package of February 2009 has failed to raise employment and why the health bill is unlikely to change patients’ lifestyles.

      Hayek contended political freedom and economic freedom are inextricably linked. In a centrally planned economy, the state infringes on what we do, what we enjoy, and where we live. When the state has the final say on the economy, we need permission of the state to act, speak and write. Economic control becomes political control.

      The problem with political control is that it attracts people who relish running the lives of others. Further, powerful politicians take care of their friends first and the people second.

      Americans are suffering from top-down overkill. President Obama has expanded federal control of health care. By doing so, he has left fewer resources for the rest of us to direct through our own decisions. In a a free modern society, we cooperate with others to produce the goods and services we enjoy, all without top-down direction.

      This holds true in everything that makes life worthwhile —when we sing and when we dance, when we play and when we pray. Leaving us free to join with others as we see fit—in our work and in our play—is the road to true and lasting prosperity.


      Katherine Hobson, “ ‘Type 2 Diabetes Epidemic Called a ‘Public Health Humiliation’” Wall Street Journal Health Blog,, June 25, 2010.

      Russ Roberts, "Friedrich Hayek Is Making a Comeback , “ Wall Street Journal, June 28, 2010.

      Richard L. Reece, MD, graduate of Duke Medical School, is a pathologist (which he defines as a doctor who knows everything but it may be too late), editor-in-chief of Physician Practice Options, and author of Voices of Health Reform (2005), Innovation-Driven Health Care (2007), Obama, Doctors, and Health Reform (2009), and over 1200 blogs on www.medinnovationblog.blogspot.com. He invites you to visit and comment on his blogs.

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  • Why Is There So Much Vitamin B Why Is There So Much Vitamin B12 Deficiency?

    • From: bgottlieb
    • Description:

      Is it my imagination, or does it seem like every other patient has vitamin B12 deficiency? Is it because my patients, unlike myself, are getting older? Are there other factors to consider?

      As humans age the risk of developing a vitamin B12 deficiency increases. Andres et al, report that more than 20% of adults 65 and older are deficient in this nutrient.1 I have been taught to attribute this to poor absorption due to factors in the stomach, the small intestine, or both. We are all familiar with the consequences of B12 deficiency to the hematologic and neurologic systems; every medical student memorizes the pathways that lead to macrocytosis, neuropathies, and spinal cord degeneration. There is increasing evidence that B12 is a key piece of other common pathophysiologic puzzles including atherosclerosis and dementia.2 Vitamin B12 deficiency contributes to common psychiatric disorders including PTSD, panic disorder, depression, and obsessive compulsive disorders.3,4 Vitamin B12 is involved in the humoral immune response, and low levels have been associated with an impaired response to pneumococcal vaccine.5

      It does seem that B12 deficiency is at least in part a phenomenon of “normal aging.” There are age-related changes in the stomach that reduce the availability of intrinsic factor. One might also argue that age alone can change the motility of the intestines, thereby altering the microflora, leading to poor absorption through the intestinal wall.

      However, the high prevalence of this nutritional deficiency among younger individuals suggests that there are other factors. For example, Mclean et al found high rates of vitamin B12 deficiency among Kenyan school children6; others have documented high rates of vitamin B12 deficiency throughout Africa and Asia, and among immigrant and refugee populations in the developed world who come from areas where this deficiency is endemic.7-9

      Clearly diets that are deficient in animal-based foods--either because of religious or cultural beliefs or poverty--are known to be associated with vitamin B12 deficiency. Worldwide, several common infections are also associated with vitamin B12 deficiency. Chronic infection with Helicobacter pylori can lead to gastric atrophy, reduction of parietal cells and intrinsic factor, and impaired absorption of vitamin B12.10 Intestinal parasites, including Giardia lamblia can lead to chronic malabsorption of many nutrients, including vitamin B12.7 These infections are unfortunately more common in parts of the developing world where diets are marginal in animal-based foods, thus increasing the vulnerability of these populations to vitamin B12 deficiency.

      Some of the things we do as physicians contribute to the problem. There has been recent attention to the association between vitamin B12 deficiency and commonly prescribed medications, including H2 antagonists, proton pump inhibitors (PPIs), and now metformin.11-15 When I think about how many prescriptions I write in a day for H2-blockers and PPIs, and the epidemic of obesity and diabetes, I have to reckon with the likelihood that I will be responsible for vitamin B12 deficiency (or already have been) for a significant number of patients.

      Sturtzel et al call attention to a more obscure possibility in their compelling, although small study, of frail elderly patients in a geriatric home.16 Patients were randomized to an intervention group that received 5.2 g/d of oat bran mixed into their food, and a control group. Both groups were fed the standard diet of the facility, were followed clinically for constipation, and treated with laxatives as indicated. Baseline laxative use and serum vitamin B12 and B6, and folic acid were the same. After 12 weeks, vitamin B6 and folic acid levels were unchanged. However, laxative use was reduced by 59% in the intervention group and only 8% in the control group, a difference that was statistically significant (P<.001). Vitamin B12 levels decreased significantly in the control group (P<.05), but showed no significant decrease in the intervention group (P<.05). The authors point out that physicians often treat constipation in the elderly without regard to potential consequences to the microflora of the intestines. Selecting a regimen for preventing constipation, or a treatment that does not alter the microflora, may preserve normal levels of vitamin B12 in this vulnerable population.


      Although the consequences of B12 deficiency can be permanent, in many cases they are reversible over time. Many of the medication-induced causes of B12 deficiency are also reversible over time. It is up to us to have a heightened awareness of the possibility of B12 deficiency--to identify it early and treat before consequences develop.

      Equally important is to prevent its development in the first place. Here is my “note to self”:

      •    Ask a good dietary history. This is especially true of vulnerable groups--the elderly, immigrants, and refugees, the poor. (Also women of childbearing age, which is a whole discussion unto itself.)
      •    Test for H pylori—particularly among patients who come from areas of the world where this infection is endemic. Think about H pylori when a patient has vitamin B12 deficiency.
      •    Think about intestinal parasites, and test when appropriate. If a patient seems to have been infected chronically, consider checking a B12 level.
      •    Monitor B12 levels regularly when patients take H2 antagonists, PPIs, and metformin for extended periods of time.
      •    Since short term use of H2 antagonists and PPIs does not seem to cause B12 deficiency, use these medications carefully and for the shortest amount of time.
      •    Remember that preventing constipation is better than treating it once it develops.
      •    Remember that all medications can have consequences, particularly if they are used on a regular basis. Consider the mechanism of action of commonly used medications such as laxatives. Choose medications that are least likely to alter the body’s fragile microsystems, especially among the frail elderly.
      •    Finally, review all medications regularly, and discontinue them when they are no longer indicated.


      1. Andres E, Affenberger S, Vinzio S, et al. Food-cobalamin malabsorption  in elderly patients: clinical manifestations and treatment. Am J Med. 2005; 118:1154-1159.
      2. Seshadri S, Beiser A, Selhub C,  et al. Plasma homocysteine as a risk factor for dementia and Alzheimer’s disease. N Engl J Med. 2002;346:476-483.
      3. Guzelcan Y, van Loon P. Vitamin B12 status in patients of Turkish and Dutch descent with depression: a comparative cross-sectional study. Ann Gen Psychiatry. 2009; 8:18.
      4. Coppen A, Bolander-Gouaille C. Treatment of depression: time to consider folic acid and vitamin B12. J Psychopharmacol. 2005;19:59-65.
      5. Fata F, Herzlich B, Shiffman G, et al. Impaired antibody responses to pneumococcal polysaccharide in elderly patients with low serum vitamin B12 levels. Ann Intern Med. 1996;124:299-304.
      6. McLean E, Allen L, Neumann C, et al. Low plasma vitamin B-12 in Kenyan school children is highly prevalent and improved by supplemental animal source foods. J Nutr. 2007; 137:676-682.
      7. Stabler S, Allen R. Vitamin B12 deficiency as a world-wide problem. Annu Rev Nutr. 2004;24:299-326.
      8. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010;29(1):87-99.
      9. Benson J, Maldari T, Turnbull T. Vitamin B12 deficiency: why refugee patients are at high risk. Australian Family Physician. 2010;39(4): 215-217.
      10. Kaptan K, Beyan C, Ural A, et al. Helicobacter pylori: is it a novel causative agent in vitamin B12 deficiency? Arch Int Med. 2000;160:1349-1353.
      11. Ruscin JM, Page RL, Valuck RJ. Vitamin B (12) deficiency associated with histamine (2)-receptor antagonists and a proton-pump inhibitor. Ann Pharmacother. 2002:36(5):812-816.
      12. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010; 29(1):87-99.
      13. Valuck RJ, Tuscin JM. A case-control study on adverse effects: H-2 blocker or proton pump inhibitor use and risk of vitamin B12 deficiency in older adults. J Clin Epidemiol. 2004;57(4):422-428.
      14. Ting R, Sceto C, Chan M, et al. Risk factor of vitamin B12 deficiency in patients receiving metformin. Arch Int Med. 2006;166:1975-1979.
      15. deJager J, Kooy A, Lehert P, et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomized placebo controlled trial. BMJ. 2010;340:c 2181.
      16. Sturtzel B, Dietrich A, Wagner K-H et al. The status of vitamins B6, B12, folate, and of homocysteine in geriatric home residents receiving laxatives or dietary fiber. The Journal of Health, Nutrition & Aging. 2010;14:219-223.

      Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.

      [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]


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  • Suboxone: A Bad Few Weeks Suboxone: A Bad Few Weeks

    • From: bgottlieb
    • Description:

      I have only a handful of patients who take Suboxone (naloxone HCl/buprenorphine HCl). I never intended this to become a large part of my practice, and it hasn’t. I did the special training required to prescribe this type of medication because I believe that the scope of primary care practice, especially for those of us who practice in “safety net” settings, should be as broad as possible in order to serve our patients and community. Substance abuse is a huge problem in all communities. Even the wealthy and well-insured do not get the best of services. Certainly the patients in my community suffer disproportionately from poor quality and lack of integration of services, and because the supply falls so far short of the demand. Plus, honestly, after more than a quarter of a century of practice, I wanted to feel like I, too, could learn something entirely new.

      My first patients have been stars. They had been in methadone maintenance programs, several of them for a number of years. They had done well in terms of their substance use – stopped using, stopped craving, but hated the way they felt. The lethargy, constipation, swelling were bad enough. What was worse was the feeling that they were still drugged. They still didn’t feel like themselves.

      Their transition to Suboxone was easy. Thankfully. They were my first patients, and I was geared up for something dramatic to happen in the office. No drama. I just followed the instructions for transitioning from methadone to Suboxone in my training, and my patients were all set within a few days. They felt better almost instantly.

      Of these first patients, all have been able to continue to work. Their family lives have improved, and they remain, after several years, substance free. Those who had chronic diseases (diabetes, primarily) have shown improvement. I believe that this is largely because their lethargy has lifted. They are more motivated. They experienced breakthroughs in those all important and seemingly recalcitrant behaviors—they exercise more, eat better, smoke less, take their medications more consistently, and approach life with a more positive outlook. Maybe it is just more years of sobriety. Perhaps. I think it is the change of drugs as well.

      Here is my favorite story. Mr X was 51 when he began to use Suboxone. He had heard that people felt better taking this medication and was tired of the fatigue and drugged feeling he experienced with methadone. His weight didn’t go below 426 lb, and having diabetes (HbA1c in the double digits) didn’t help. But he could not motivate himself to do much about these problems except take the medications he was prescribed.

      Once he began taking Suboxone and stopped methadone, his transformation was amazing. He started walking—at first in his neighborhood, and then after losing about 25 lb, he joined a gym. Despite chronic knee, hip, and back pain, he began to walk on the treadmill for 2 to 3 h/d. The pain decreased! He lost more weight. And more weight. After the first year, he had lost 80 lb. After 2 years, 110 lb, and as of now, after 3 ½ years he has lost an astonishing 150 lb. We celebrated when he could be weighed on a regular office scale. We have eliminated some medications for diabetes, BP, pain, and depression. Svelte he is not. But he has achieved what few people can, even with bariatric surgery, and he is so proud of himself.

      However, this has been a bad few weeks for Suboxone. Despite the contracts we have in place, the monitoring, the urine tests, the requirement that patients attend drug treatment programs and mental health counseling, I have had a run of unexpected events: Several patients relapsed on heroin and required higher levels of care than we can provide in our health center; several relapsed on other substances—found in the urine but not admitted to in our visits; information from reliable family sources that the patient has been using on the side; patients hiding “clean” urines on their bodies and providing those during our random toxic screens. Like many primary care sites, we do not have supervised urine checks.

      I can accept relapse. I accept the axiom that relapse is part of the disease of addiction. It is the dishonesty that wears me down.

      I do realize that dishonesty, in this sense, is also part of the disease of addiction. The craving, the drugs, for some people, under some circumstances, simply cannot be resisted, and they will resort to behaviors that involve lying, distortion, manipulation… and worse. Why is my reaction to this different than, for example, when an obese patient who has gained another 10 lb since his visit a month ago tells me that he “really doesn’t eat a thing, Dr. Gottlieb”? Or an asthmatic patient who hasn’t asked for a refill for her chronic medications in over a year insists that she is doing exactly what I tell her?… or any number of scenarios in which the patient’s report does not match observable reality? Is it because of the illegality of substances? Is it because my DEA and special license are involved in the case of drug addiction, whereas the DEA would not take note if I prescribed one albuterol inhaler more or less?

      Perhaps my frustration is that the overall program we have for treating drug addicted patients in outpatient settings is simply not enough. I realize that what we have at my health center is exceptional: right down the hall, within the same system of care, connected through a common electronic record and care giver meetings, is a mental health department with counselors, psychiatrists, psychologists, social workers, specialists in addictions. Not only that, they are bilingual (English and Spanish-speaking), and, for the most part, bicultural as well.

      But we don’t have the personnel to supervise urine toxic screens. We don’t have outreach workers, people who can help patients with their many concrete social service needs, which, if met, might reduce some of the stress in their lives. And because demand for all mental health services, including addictions, exceeds supply, we cannot quickly and seamlessly step up care as our patients experience the inevitable ups and downs in their sobriety. In that sense, it is not parallel to the asthmatic patient who has not taken her medications. I can simply see her today, tomorrow, and the next day to get her back on track or send her to the emergency room if that is what is needed.

      So—I have to take a deep breath. I have to take an honest look and review and sharpen my own clinical skills, instincts, and practices. I have to look at the policies and systems our health center has in place to make sure they are adequate and appropriate to care for people for whom sobriety is not well established. And I have to remind myself why I wanted to expand my skills to treat patients with addictions as part of my self-definition as a primary care physician.

      Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.

       [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]

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    • 4 years ago
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  • AACE/ACE Consensus Statement o AACE/ACE Consensus Statement on Diabetes Treatment: One practitioner’s gratitude

    • From: bgottlieb
    • Description:

      This will be a simple expression of gratitude. I have never been so happy to read a medical document as I was to read the recent AACE/ACE Consensus Statement on the treatment and control of type 2 diabetes.1 [abstract]

      This 19-page document provides solid, practical, and simple guidelines for the evaluation and treatment of type 2 diabetes--a no-frills approach to this complex and prevalent disease. The panel consists of experts in the management of diabetes. They reviewed the available literature and established underlying principles for their recommendations and target levels for treatment endpoints. However, given the relative lack of randomized controlled clinical trials that evaluate combinations of medications, they also based recommendations on their extensive clinical experience, attempting to achieve consensus as much as possible.

      The authors make their underlying principles transparent and remain true to these principles:

      • Avoid hypoglycemia (the key guiding principle)
      • Lifestyle (diet and exercise) activities are the cornerstone of all treatment programs and should be encouraged at every opportunity
      • Fasting and postprandial control are treatment endpoints
      • Maximize safety and efficacy (safety and efficacy are valued over cost, since cost of medications is only a small part of the cost of care of type 2 diabetes)
      • Minimize weight gain
      • Consider all FDA-approved medication classes
      • Maximize simplicity of treatment regimens as much as possible
      • Anticipate the degree of patient adherence, and modify treatments appropriately
      • Consider cost of treatment to the individual and society (medications, monitoring, and the cost of complications)

      The treatment algorithm provides a useful guide to both the expert and the generalist. By focusing on the level of HbA1c and the expected lowering by particular drug classes, the provider knows what to expect and can provide realistic guidance to the patient as well. The recommendations include an aggressive, yet safe pace for lowering the HbA1c by monitoring every 2 to 3 months and stepping up treatment as indicated.

      The report is comprehensive. The provider is reminded to reinforce lifestyle changes at sentinel moments of treatment, such as when a new drug class is introduced. Similarly, the provider is reminded to reinforce the full range of risk reduction interventions: tobacco cessation, use of aspirin, ACE inhibitors or angiotensin receptor blockers, and statins. In addition, there is a brief review of the pharmacology of each class of drug and a practical guide to drug-drug interactions.

      Why am I so grateful? Not a clinical session goes by that I don’t have to face some sort of decision about diabetes treatment. However, the decision, the circumstances, the nuances are different for each patient. While the authors caution the practitioner to individualize treatment, this document provides a solid jumping-off point. I always tell my students that diabetes is a low-tech disease. What I mean by this is that diabetes is related to the most basic activities of life--what you eat and how much you eat, your exercise and physical activity, and the many social and economic factors that have an impact on these basic activities. Therefore, sadly, even with 8 major categories of medications and research and development seeking new and better pharmacologic pathways to exploit, the solutions to diabetes are, ultimately, low-tech solutions: lifestyle changes and treatment that is safe, effective, and sustainable. I now feel that I have a handle on how to achieve that low-tech objective with my diabetic patients.


      1. Rodbard HW, Jellinger PS, Davidson JA et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocrine Practice. 2009;14:540-559.

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    • 5 years ago
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  • Mediterranean Diet: Benefits i Mediterranean Diet: Benefits in Early Type 2 Diabetes

    • From: bgottlieb
    • Description:

      It is rare that a study on prevention translates into a message that I can easily apply to my practice. Most behavior changes are difficult, even in the face of very convincing evidence. Not only is it difficult to change any well-established behavior, but in many cases we are asking our patients to substitute a behavior that is less rewarding.

      Certainly that is the case with dietary changes. Many of the foods we have learned to love over a lifetime—comfort foods, convenience foods—turn out to be bad for us. Many of the commercially advertised successful weight loss diets are highly restrictive, or, at least for the tastes of my patients, too weird and unappealing. So—I was delighted to learn that a randomized trial of a Mediterranean-style diet [subscription required] had a favorable impact on cardiovascular risk factors and delayed the need for glucose-lowering medications among newly diagnosed type 2 diabetics.1

      In Naples, Italy (what better place to conduct a trial for a food-based intervention?), 215 untreated, newly diagnosed type 2 diabetics were randomly assigned to 1 of 2 study diets. Participants were overweight (BMI >25 kg/m2), sedentary, not pregnant or lactating, not taking steroids, and not participating in a weight reduction program.

      The Mediterranean diet was rich in vegetables and whole grains. Poultry and fish were favored over red meat. Calories were restricted to 1500 and 1800 kcal/d for women and men, respectively. Based on observation [subscription required] of Mediterranean diets that were associated with weight loss and cardiovascular risk reduction, participants were instructed to limit calories from complex carbohydrates to not more than 50% of their daily calories.2 The primary source of additional fat was olive oil--30-50 g/d.

      The comparison diet was a low-fat diet rich in whole grains, with restricted added fats, sweets, and high-fat snacks. Calorie restrictions were identical to the Mediterranean diet. Participants were instructed to limit calories from fat to 30%, with no more than 10% of calories from saturated fat.

      All participants received the same “dose” of nutritional advice and were asked to maintain a diary of food intake, recording portion sizes and weights. All also received instruction on increasing physical activity, with a goal of 175 minutes of moderate-intensity physical activity per week. Physical activity was also recorded in a diary.

      Participants were followed over a 4-year period. The primary endpoint was time to introduction of antihyperglycemic agents according to American Diabetes Association (ADA) guidelines. Additional outcomes included changes in weight, glycemic markers, lipid levels, BP, and use of medications following ADA guidelines.

      After 18 months, there was a statistically significant difference in the need for antihyperglycemic medications (12% of subjects in the Mediterranean diet arm compared to 24% of subjects following the low-fat diet). At the end of the trial, need for medication increased in both groups, but remained statistically different in the same direction (44% compared to 70%).

      Participants in both groups lost weight, but those in the Mediterranean diet group lost more--a 2-kg difference. However, the differences in weight loss lost statistical significance by the end of the trial.

      Participants in both groups experienced decreases in HbA1c, but the reductions were statistically significantly greater in the Mediterranean diet group throughout the trial. Additional markers of glycemic control (fasting plasma glucose, insulin sensitivity, and adiponectin levels) also favored the Mediterranean diet group.

      The Mediterranean diet group also experienced statistically significant increases in HDL and decreases in triglycerides. BP levels decreased in both groups--initially more quickly in the Mediterranean diet group. But the differences attenuated in the later years of the trial.

      While acknowledging certain limitations of their study, the authors end their discussion with the following statement, “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.”

      I would agree. And now I can tell my patients to eat like they eat in Italy. What could be bad about that?

      1. Esposito K, Maiorino MI, Ciotola M, et al. Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: A randomized trial. Ann Int Med. 2009;151:306-314.
      2. Esposito K, Ciotola M, Giugliano D. Low-carbohydrate diet and coronary heart disease in women [Letter]. N Engl J Med. 2007; 356:750; author reply 750-752.

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  • Motivational Interviewing: A P Motivational Interviewing: A Primary Care Physician’s Thoughts

    • From: bgottlieb
    • Description:

      Several months ago, I participated in training on brief intervention approaches used in counseling patients who are engaged in substance abuse. The trainer focused on techniques based on motivational interviewing (MI). She described and demonstrated approaches that were a refreshing change from the confrontational, authoritarian, and—let’s be honest—generally ineffective strategies that we often use with patients, emphasizing instead a patient-centered approach.

      She encouraged us to listen closely for our patient’s core values and motivations for behavior change and to work with these, rather than imposing our own reasons for why he or she should cut down on drinking, stop smoking marijuana on a daily basis, etc. She taught us about the ruler: How important is it for you right now, on a scale from 0 to 10, to make this change? How confident are you right now, on a scale from 0 to 10, that you could make this change? She then provided some sample patient scenarios and led us in role playing exercises, allowing us to practice responding to a patient’s self-rating. “You rated yourself 3 on the confidence scale. Why did you say 3 rather than 0? What would it take for you to get to a 4 or a 5?”

      Ordinarily I am not a fan of a cookbook approach to interpersonal interactions. I have always felt that such approaches contradict the “medicine as art” philosophy that I have always embraced. However, something clicked: This approach resonated with many of the principles of patient-physician communication that I have learned and taught over the years. While straightforward and systematic, the approach seemed to offer the promise of communicating effectively with patients, and of succeeding in a most difficult area of patient care—lifestyle and behavior change. Moreover, I have been impressed that despite the “cookbook” tools, the rulers, the charts, the scripted responses and prompts, MI promotes a very individualized approach to patients. If anything, the tools allow the clinician to appreciate the nuances, the subtleties involved in behavior change.

      I began to think about the techniques and their theoretical underpinnings and realized that they could be applied to nearly every patient encounter. “Take this medication 3 times a day.” ”Check your fingersticks twice a day.” “Lose weight.” “Eat more vegetables, fewer chips.” “Find the time to exercise.” “Do more of this, less of that…” In one form or another, most of what we do as clinicians is about motivation, behavior modification, or full-scale change. And there is strong evidence that our standard techniques—even when motivated by compassion and concern, do not yield the results we hope to achieve. In fact, by maintaining a stance that is in opposition to the patient, imposing our own agenda and reasons for change, we often inadvertently reinforce the patient’s own pessimism and resistance to change. The harder we push, the more our patients hear their own internal voice that says “NO. I won’t change. I can’t change.” Or they tune us out, and at the same time tune out their own inner voice for change.

      MI draws from many theoretical currents in psychological and social theories of behavior change. It is based on the belief that change is possible and that ambivalence about change is natural and universal. People are aware that they must change and are engaged in an internal dialogue: I want to change—I don’t want to change. I can change—I can’t change. At its core, MI is a method for working with this ambivalence. Through MI techniques the clinician learns to recognize and reinforce “change talk”—the positive side of the internal dialogue. MI practitioners Rollnick, Miller, and Butler describe the “spirit” of MI as collaborative (patient and provider work together, keeping the patient’s agenda at the center), evocative (eliciting the patient’s goals, values, aspirations and dreams), and honoring patient autonomy (recognizing that ultimately, it is the patient who will decide when, how and how much to change).1

      Further, MI identifies 4 guiding principles: R—resist the righting reflex and abandon the notion that you know best, that it’s your responsibility to “fix” the patient; U—understand and explore the patient’s own motivations; L—listen with empathy; and E—empower the patient, encouraging hope and optimism = R-U-L-E.

      With training and practice, clinicians can learn to internalize the spirit and guiding principles of MI and begin to develop and refine a new style of being an empathetic guide, rather than a director, for interacting with patients. Patient and clinician collaborate on the agenda (“What shall we focus on today?”). The clinician requests the patient’s permission to address specific issues or to provide information (“Do you mind if I tell you a little about successes other patients have had in losing weight?”). Rather than lecturing the patient, the clinician listens closely to capture the patient’s values and motivators and reflects back to the patient (“I gather that it is important for you to feel healthy and strong.”).

      MI techniques have been used to address the full range of medical and public health problems, including substance abuse, medication adherence, smoking cessation, weight loss, and physical inactivity. It shouldn’t be surprising that there is a growing body of literature that supports the use of MI in the management of chronic diseases, including diabetes.

      West, et al, report a study of weight loss in which 217 overweight diabetic women were randomized to an intervention involving MI and usual care. The group receiving MI lost significantly more weight than the control group at 6 months. The effect was maintained at 18 months.2

      Motivational interviewing was found to improve glycemic control, reduce fears of hypoglycemia and improve perception of living with diabetes in a small study of adolescents with juvenile onset diabetes.3

      In their review of MI in the care and treatment of diabetes, Welch and colleagues caution that many of the studies are small, lack control groups, and may lack fidelity to a defined MI intervention.4 However, they conclude that the studies are promising and supportive of the application of MI techniques. Clearly larger and more carefully designed studies are needed to guide practice.

      In the meantime, I will continue to educate myself in the techniques of MI and will incorporate them into my work with all patients as part of my personal quest for continuous improvement in the art of medicine.


      1. Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: Helping patients change behavior. New York, NY: Guildford Press; 2007.

      2. West DS, DiLillo V, Bursac Z, et al. Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care. May 2007 30:1081-1087. doi:10.2337/dc06-1966.

      3. Channon S, Smith VJ, Gregory JW. A pilot study of motivational interviewing in adolescents with diabetes. Archives of Disease in Childhood. 2003;88:680-683. doi:10.1136/adc.88.8.680.

      4. Welch G, Rose G, Ernst D. Motivational interviewing and diabetes: What is it, how is it used, and does it work? Diabetes Spectrum. 2006;19(1):5-11. doi: 10.2337/diaspect.19.1.5.

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  • Diabetes, Work, and Unemployme Diabetes, Work, and Unemployment

    • From: bgottlieb
    • Description:

      One cannot read the paper or listen to the news without hearing about the economic crisis and its impact on individuals and families. Layoffs, job insecurity, and shrinking opportunities affect all strata and sectors of the population. My patients are largely recent immigrants, poorly educated and non-English-speaking. Most came to the US to work, and they do work. They work at conventional

    • 5 years ago
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    • Forum: Patient Car...
  • Which is better: Good rules or Which is better: Good rules or expertise?

    • From: StevenMerahnMD
    • Description:

      We’ve all heard a lot about evidence-based medicine (EBM); the problem is that humans just don’t always fit predetermined categories. According to the Centers for Medicaid and Medicare Services, 50% of people older than 65 have at least 3 coexisting chronic diseases; 20% have 5 or more.

      Taking liberties with the work of Dr Cynthia Boyd at Johns Hopkins (JAMA 2005: 294:716-24), let’s, for example, look at a hypothetical 79-year-old woman with COPD, type 2 diabetes, hypertension, osteoarthritis, and osteoporosis. If we were to follow clinical practice guidelines for treating this woman, she would be taking 19 different doses of 12 different medications that would have 10 different possibilities for significant drug-drug or drug-disease interactions. What would you recommend for this patient? Where is the EBM to help determine how to minimize costs and adverse interactions while ensuring the patient’s health?

      In recognition of clinicians’ need for data on comparisons of different treatment options, the Obama Administration has committed over $1 billion to establish a Center for Comparative Effectiveness Research (CCER). Comparative effectiveness research seeks to provide information on the relative strengths and weakness of various therapeutic interventions for specific sets of patients. It evaluates similar treatments, such as competing drugs, and examines different approaches, such as surgery and drug therapy. The Center is intended to centralize such research in an effort to provide clinicians and patients with valid decision-making information, yielding improved performance (and reduced waste).

      To be truly effective, applying EBM has to be about more than just using the best research evidence; it also has to embrace the practical realities of human beings solving human problems. In 1996, Dr. David Sackett and his colleagues (BMJ 1996; 312:71-72) made a very practical suggestion for defining EBM from the perspective of evidence-based practice: integrating the best research evidence with clinical expertise and patient values.

      So, returning to Dr Boyd’s hypothetical patient, how would you resolve the issues? But more importantly, what would be the criteria to evaluate the quality of your resolution? I hope that the vision for the CCER is twofold:

      • Not only to provide the background material for the ongoing process of shared decision making between provider and patient

      • But also to focus on the value of the health care professionals’ critical thinking and clinical skills that we bring to bear when we review the evidence and incorporate what we know of the patient’s life, values, and priorities.


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    • 5 years ago
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  • Diabetes, Work, and Unemployme Diabetes, Work, and Unemployment

    • From: bgottlieb
    • Description:

      One cannot read the paper or listen to the news without hearing about the economic crisis and its impact on individuals and families. Layoffs, job insecurity, and shrinking opportunities affect all strata and sectors of the population. My patients are largely recent immigrants, poorly educated and non-English-speaking. Most came to the US to work, and they do work. They work at conventional jobs and in the “underground” economy. Many work several jobs. They do what they have to do to survive, to participate in the American dream, and to support their families back home.

      My patients have been particularly hard hit. The few that had been able to finance a home are losing them; families are doubling up in apartments in order to pay the rent. Financial worries come up at every visit: loss of health insurance, the high cost of medications, fear of losing a job, uncertainty about the future and sadness about not being able to finance an education for college-age children and provide them with the opportunities that they did not have….these conversations supersede any discussion of HbA1c and LDL levels.

      Consistent with national trends, the prevalence of diabetes among my patients is high and increasing. It is striking younger adults, earlier in their working lives. And we know that so much of diabetic control comes down to economics – lifestyle – being able to afford healthy foods, find the time and facilities for physical activity, and having access to medications and medical care. What is and will be the impact of the economic downturn on diabetic patients?

      The most obvious is access to care. In a health system in which insurance is linked to employment, what will happen when people lose their jobs, when remaining job opportunities lack benefits, COBRA runs out, and the health safety net becomes overwhelmed?

      Unfortunately, we know the answers to these questions. The solutions lie in the realm of economic policies that will turn the economy around, and social policies that will address health care access and the strength of the safety net.

      Beyond this, what is known about the relationship between unemployment, disability, and diabetes?

      In 1989, Robinson et al reported on a study comparing diabetic and nondiabetic patients in Great Britain.1 In a random sample of adults aged 17 to 65, 22% of male diabetics were unemployed compared to 8% of nondiabetics, and 12% of females were unemployed compared to 5% of their nondiabetic counterparts (P<.001). The gap for those who were just entering the job market was particularly disturbing: Among 16-2-year-olds, 14% of diabetics were unemployed compared to 7% of their nondiabetic counterparts.

      Analyzing additional findings from the same study, the authors report that diabetics have more difficulties obtaining and maintaining employment than their counterparts who have illnesses other than diabetes.2 Compared to 2% of those with other illnesses, 13% of diabetics reported difficulty obtaining employment. And 9% of diabetics reported that they had to change jobs due to their diabetes, compared to 2% of those with non-diabetes illnesses. Similarly 7% of diabetics reported that they lost their job due to diabetes, compared to 2% of controls with other illnesses. Reports of sick days (any sick-related work absence) were similar among diabetics and nondiabetics (49% vs. 45%). Absence of more than 20 days in the past 12 months was more common among diabetics than those with other illnesses (29% vs. 16%)(all P values <.001). Shift work may present a particular challenge to diabetic patients: 18% of diabetic shift-workers reported problems with work, compared to 8% of non-diabetic shift-workers (P=.045).

      What is causing these problems with work? Von Korff and colleagues conducted a cohort study among 1642 members of an HMO in California in order to examine this question.3 Excluding retirees and self-defined homemakers, the authors defined 3 indicators of work disability: unable to work or being unemployed, missing 5 or more days of work in the previous 30 days, and severe difficulty with work-related tasks.

      They found that 19% had significant work-related disability, including 12% unemployed, 7% missed 5 or more days of work in the past month, and 4% reported severe difficulty with work-related tasks. Depression, chronic disease morbidity, and symptoms related to diabetes were associated with all 3 indicators of disability. Complications of diabetes predicted unemployment and work disability. Obesity and sedentary lifestyle did not.

      Depression was found to be a particular risk factor for work-related disability. More than 50% of those who were depressed and had 3 or more complications from diabetes were unemployed. Among those who had significant work-related disability, 50% met criteria for major or minor depression. Based on these findings, the authors concluded that providers needed to consider physical and psychological impairments among diabetic patients in order to manage and prevent work-related disability.

      What would this actually mean? What specific factors should I pay attention to?

      Detaille and colleagues undertook a qualitative study of patients with 3 types of chronic illnesses in order to begin to define what employees need in order to cope with their medical problems at work.4 The authors conducted a qualitative study of patients in the Netherlands with rheumatoid arthritis, diabetes mellitus, and hearing loss. The study included 23 patients with diabetes, men and women, representing a range of ages, educational levels, employment types, and years with diabetes. Both type 1 and 2 diabetics were represented, and 87% were insulin-dependent.

      Using a technique known as concept-mapping, patients were asked “What does a person with (specific illness) need to be able to keep on working?” Data analysis revealed clusters of topics that were consistently brought up by participants. In order of priority, diabetic patients mentioned:

      • Self-acceptance of and ability to cope with illness, accept the illness, and try to live as normally as possible
      • The need for information about technical devices and ways to receive financial aid or insurance in order to finance the purchase of these devices
      • Having colleagues’ and managements’ knowledge about diabetes and knowledge of how to react in case the individual becomes sick at work
      • Adaptations at work which might include stable work demands and work load, flexibility of work hours, ability to monitor blood glucose at work
      • Ability to control diabetes at work – including stable lunch hour
      • Support and understanding by colleagues and management, protection from job discrimination at work
      • Support from health professionals, including appropriate education about prevention and management of complications; cognizant of work demands in developing treatment regimen; health professionals at work who know how to react when there are complications
      • Adequate benefits and protections at work.

      While the authors consider their work to be preliminary, they suggest that the topics can serve as a guide for health providers. As diabetes increasingly becomes a disease of people in the beginning or middle stages of their working lives and as work-related pressures and uncertainties mount for patients of all economic strata, health providers must be mindful of the impact of diabetes on work, and help our patients meet the challenges they face in the work place.


      1. Robinson N, Yateman NA, Protopapa LE, Bush L. Unemployment and diabetes. Diabet Med. 1989;6(9):797-803.
      2. Robinson N, Yateman NA, Protopapa LE, Bush L. Employment problems and diabetes. Diabet Med. 1990;7(1):16-22.
      3. Von Korff M, Katon W, Lin EHB, Simon G, et al. Work disability among individuals with diabetes. Diabetes Care. 2005;28:1326-1332.
      4. Detaille SI, Haafkens JA, van Dijk FJH. What employees with rheumatoid arthritis, diabetes mellitus and hearing loss need to cope at work. Scand J Work Environ Health. 2003;29(2):134-142.

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  • Home Visit Home Visit

    • From: bgottlieb
    • Description:

      When I began practicing in my community health center in the early 1980s, I spent one session each week visiting patients in their homes. Even though most of them lived within walking distance of the health center, these individuals were too old, too sick, or too unwilling to make their way to my office.

      This type of care could never survive in today’s cost-conscious climate. Each visit took a very long time, and much of what I did could not be summed up in a standard S-O-A-P note. I cleaned the kitchen drawers of my patient, who had not left her 3rd floor walk up for 17 years, after a mouse leaped out at me from the silverware drawer when I searched for a scissors. I organized and put away Easter bunnies, Christmas lights, Valentine’s hearts, and St. Patrick’s Day shamrocks because the same patient, who virtually never left this one room which was festooned with a full year of holiday decorations, was becoming disoriented. I shared tea and special cookies, learned treasured family recipes, and paged through photographs of generations of family members. Even the most generous billing codes could not assign value to these and other services I provided over the 5 wonderful years of this program.

      In 2009, I care for patients who have chosen to die at home, and occasionally bring students to patients’ homes so they will appreciate what you don’t learn about patients in an office or hospital setting. But for the most part, this particular patient care experience is likely to remain part of my cherished past.

      Except for Mrs. E.

      Mrs. E lives exactly 5 blocks from my health center and 7 blocks from my home. She has type 2 diabetes and nearly every complication described in the textbooks. Every indicator of diabetic care and control is out of control and has been for many years. For the past year, she has boycotted all efforts to reach out to her. She says that she is simply too ill to come and see me. Despite the fact that she is not quite my age, she has the body of my elders—having had a series of strokes, heart attacks, and chronic infections. She has every reason to be tired and discouraged. Although she has had home nursing care for short periods, she is too young, and doesn’t have quite the urgency of medical need to qualify for long-term nursing care in her home. She is too poor to pay for private care and too cantankerous to receive consistent, willing care from her children, whose own lives are far from easy.

      I decided that I was going to visit her at home. She lives in relatively new garden-style public housing. My first impression, as I rang the bell and she opened the door, was of a home that was more cheerful and inviting than I had anticipated. The windows are large and allow a decent amount of light to fill the main living area. The furnishings are sparse, but well kept, and decorated with multi-colored hand-crocheted items—her own creations, I later learned. My eye caught site of an empty donut box—the size that would hold a dozen. Sitting regally on top of the donut box was her glucometer. On the coffee table was what looked to be a torn wrapper from a candy bar. On closer inspection, I saw that it was also a record of her finger stick readings for the past few weeks carefully arranged into 3 neat columns on the inside part of the wrapper—date, time, and blood sugar reading.

      I quickly settled for a limited agenda for this first visit. Being a guest in her home, I hoped to leave with an open invitation to return. I commented on the beautiful sunlight, admired her doilies, looked at her few family photographs, and agreed to the “5-cent” tour of her apartment. I asked if I could see her medications—and found a number of discrepancies between what I thought she was taking and what she was actually taking, and a few duplicates, disguised by generic names. I reviewed her finger stick record and appreciated its thoroughness, if not its actual results. We made a plan to make corrections in her medications. I gave her a calendar that the health center prints each year for patients, and we circled the date of my next visit.

      This is not a plan for all of the difficult-to-control diabetic patients of the world—or even in my own patient panel. I do spend some of my time working on plans and programs that are more realistic for larger numbers of patients. But this home visit and the visits to come are my own way of acknowledging that sometimes you can’t accomplish anything until you try to see the world through your patients’ eyes, at least a little bit.

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  • Type 2 Diabetes and Black Hist Type 2 Diabetes and Black History Month

    • From: bgottlieb
    • Description:

      The Story

      We all have patients like this. Mrs B is 58 years old. She has had type 2 diabetes for at least 20 years. I say ‘at least’ because she was diagnosed with diabetes when she resumed semi-regular primary care 20 years ago, after a decade without medical care following the birth of her second child. She had gestational diabetes with both pregnancies.

      I see her 3 to 4 times a year. She works 2 jobs and has been forced to move several times in the past few years because her income has not kept pace with rising rents in her neighborhood. At most of her visits, she has run out of one or another of her medications, or she is only taking some of her medications because she hasn’t been able to afford all the co-payments. Many weeks she chooses between insulin and gas for her car. Her gas tank’s needs usually prevail, because she would otherwise not get to work and things would be even worse.

      Needless to say, my pay-for-performance ratings are a little skewed now that I am held to actual outcomes, rather than my good faith efforts to bring her HgA1c, BP, and LDL to goal. But clearly, the true detrimental effects of her poor diabetic control are experienced by her, in the form of advancing kidney disease and retinopathy and the heart attack that is waiting to happen.

      It feels appropriate, as Black History Month approaches, and in the days and weeks following Martin Luther King’s birthday and the historic inauguration of our country’s first African American president, to mention that Mrs B is African American and to think about how being African American affects her diabetes.

      Like many of my African American patients, she has roots in the South. Her family came North following World War II. But the extended family reunites each summer, temporarily erasing the diaspora with plates and tables of comfort food, whose recipes were passed down from fore-grandmothers rather than the ADA. Slow and fast food--lots of it--her only indulgence. Mrs B has never smoked, drank alcohol or used illicit substances. She is devoutly religious, a pillar of her church and a member of her choir. She has even on several occasions been moved to song in my office, her deep alto muting the cries of babies getting shots, the phones, the beepers …to save my soul? …to show me a healing power beyond the pills and needles that I offer up? This is primary care at its unpredictable best.


      Genetics? Lifestyle? Stress?

      African Americans worldwide and in the United States have higher rates of type 2 diabetes than Caucasians. According to data from NHANES, a nationally representative sample of nutritional and other health practices and outcomes, African Americans were found to have higher rates of type 2 diabetes compared to Caucasians, with a relative risk (RR) of 2.1 for females and 1.6 for males.1 After adjusting for age, body mass index (BMI), various measures of lean weight and body fat, education and physical activity, African Americans remained at higher risk, but only at lower levels of BMI. As BMI increased, the risk differential between African Americans approached zero (for men, RR at BMI 25 = 1.5 and at BMI 30 = 1.0; for women, RR at BMI 25 = 1.6 and at BMI 30 = 1.

      Reiner, et al, studied the genetic characteristics of 810 self-identified African American subjects in order to characterize their genetic heterogeneity and investigate the interplay of these factors with socioeconomic factors related to cardiovascular risk and aging.2 They found a tremendous genetic variety among African Americans, with clustering of certain genetic markers. Blood glucose correlated with African ancestry. However, there was no simple correlation between BP, lipids, C-reactive protein, or carotid wall thickness with specific genetic backgrounds. The authors concluded that in order to understand the roots of chronic conditions such as diabetes and cardiovascular disease in African Americans, future studies will have to assess the complex interplay between genetic admixture and socioeconomic factors.

      Moody-Ayers and colleagues explored the extent to which African American patients age 50 and older with type 2 diabetes had been exposed to racism.3 Using the McNeilly Perceived Racism Scale, the authors determined that 95.2% of participants reported at least some exposure to societal racism, either at work or in another public arena.4 Men had higher scores than women, and interestingly, those with higher household incomes had higher scores than those with lower household incomes. Although the authors did not correlate exposure to racism with health outcomes, 55% of the participants rated their health as fair/poor--much higher than is typical of patients of the same age. Clearly further studies will be needed to assess the specific impact, if any, of racism on diabetic care and outcomes. But the authors make an excellent point: whether there is an effect, it is important for us as providers to be aware of experiences and exposures that our patients have.

      Others have begun to unravel the physiologic pathways that connect racism with poor health. Harrell et al describe physiologic responses to encounters with racial discrimination that are related to control of blood pressure and other mediating processes that lead to diabetes and cardiovascular disease.5 In their study, not acknowledging the encounter as racist seemed to be more strongly associated with these adverse physiologic effects.

      Geronimus, in her sentinel work on weathering, in which she integrates the impact of environmental exposures over a lifetime on health and well-being with physiologic pathways that mediate illness and disease, provides us with a starting framework for understanding how poverty, stress, the social environment, might cause type 2 diabetes--with or without a specific genetic vulnerability.6 She describes the factors of poverty that are associated with poor health outcomes, including diabetes: "material hardships, psychosocial conditions of acute and chronic stress, overburdened and disrupted social support and toxic environmental exposures … less access to information, services and technologies … increased tendency to engage in some unhealthy behaviors, [and] depression." 

      All of this rings true with what I know about Mrs B. She does not discuss race or racism with me. She has told me, over the years, about incidents of maltreatment by landlords, employers, people in the health care system, gas station attendants, store clerks that may have many dimensions--but certainly race is one. She is more likely to attribute her circumstances to being poor and to undifferentiated "trials" of life.

      While she may discuss race and racism with others, it is important that she and I, patient and physician, share a full and coherent narrative about her life and health. As her physician, I have a responsibility to keep an eye on the "high end" of medical science. It’s too late for revelations from the plethora of genetic studies to prevent her from getting type 2 diabetes. However, genetic studies may ultimately shed light on best choices of medications and other interventions as her disease unfolds.

      As a physician-public health practitioner, I do need to be aware of the circumstances that shape her illness and well-being. On the positive side--I need to follow studies of church-based interventions in the care and management of diabetes as an adjunct to what I can offer in my health center.7 I need to help her bring her great-grandmothers’ recipes in line with ADA recommendations. And I need to find ways to provide concrete, as well as emotional and spiritual support for the stresses and challenges that she experiences in her life in general and in her ability to cope with and manage her diabetes.



      1. Lipton RB, Liao Y, Cao G, Cooper RS, McGee D. Determinants of incident non-insulin-dependent diabetes mellitus among blacks and whites in a national sample: The NHANES I Epidemiologic Follow-up Study. Am J Epidemiol. 1993;138:826-839.

      2. Reiner AP, Ziv E, Lind DL, Nievergelt CM, Schork NJ, et al. Population structure, admixture, and aging-related phenotypes in African American adults: the Cardiovascular Health Study. Am J Hum Genet. 2005;76:463-477.

      3. Moody-Ayers SY, Stewart AL, Covinsky KE, Inouye SK. Prevalence and correlates of perceived societal racism in older African-American adults with type 2 diabetes mellitus. J Am Geriatr Soc. 2005;53:2202-2208.

      4. McNeilly MD, Anderson NB, Armstead CA, Clark R et al. The perceived racism scale: a multidimensional assessment of the experience of white racism among African Americans. Ethn Dis.  1996; 6(1-2):154-166.

      5. Harrell JP, Hall S, Taliaferro J. Physiological responses to racism and discrimination: an assessment of the evidence. Am J Public Health. 2003;93:243-248.

      6. Geronimus AT, Hicken , Keene D, Bound J. “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health. 2006:96(5):826-833.

      7. Samuel-Hodge CD, Keyserling TC, France R, Ingram AF et al. A church-based diabetes self-management education program for African Americans with type 2 diabetes. Prev Chronic Dis. 2006;3(3):A93.

    • Blog post
    • 5 years ago
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  • Gestational Diabetes – My Resp Gestational Diabetes – My Responsibility as a Primary Care Physician

    • From: bgottlieb
    • Description:

      Gestational diabetes (GDM) affects up to 14% of pregnancies, or 135,000 women per year in the United States.1 GDM is a major risk factor for the development of type 2 diabetes in the adult population. However, care and follow-up of women who have been diagnosed with GDM falls into a “no-man’s land” of care. While the American Diabetes Association recommends that women with GDM undergo testing 6 to 8 weeks postpartum, and every 3 years subsequently, recommendations from the American College of Obstetricians and Gynecologists and other policy-making bodies are less specific.1,2

      Attendance at postpartum visits is significantly lower than for antenatal care for a variety of reasons, including competing pressures on the mother of a newborn, lack of preparation and clear expectations for care, and, at times, loss of comprehensive insurance coverage following a delivery. Moreover, no HEDIS or other monitoring bodies measure adherence to postpartum follow-up for GDM (nor for any other aspect of postpartum care). The gap between obstetric and primary care is one of many gaps in the care of reproductive-age women. Hence, primary care providers may not even be aware of their patients’ antenatal care and complications, including those that require follow-up, such as GDM.

      What is the significance of GDM? Are women falling through the cracks? What is my responsibility as a primary care physician?

      A 2002 literature review examined the association between GDM and subsequent development of type 2 diabetes mellitus.3 Twenty-eight studies were examined, and results were adjusted according to retesting rates and length of follow-up. Cumulative incidence of type 2 diabetes following the index pregnancy ranged from 2.6% to 70%. There appears to be a steep rise in incidence in the first 5 years after delivery. Rates then appear to plateau after approximately 10 years.

      Regression analyses allowed the authors to assess the potential impact of additional factors on the subsequent development of type 2 diabetes. While associations were found in some studies between type 2 diabetes and factors such as prepregnancy and postpregnancy body mass index and extreme parity (> 5), an elevated fasting glucose level during pregnancy was most consistently and powerfully associated with future risk of type 2 diabetes. Family history and weight gain following delivery, 2 factors commonly assumed to be associated with type 2 diabetes, were not significantly associated in any study.

      In a finely tuned prospective cohort study of the association between glucose metabolism during pregnancy and future risk of a spectrum of glucose intolerance, including diabetes, 487 pregnant women underwent a 2 stage screening for GDM (glucose challenge test GCT – followed by a diagnostic oral glucose tolerance test – OGTT).4 Women were stratified into 4 groups at baseline. The groups were then retested 3 months postpartum, and results were once again stratified according to degree of glucose intolerance.

      Of the 487 women who were tested at baseline, 137 had GDM, 91 had gestational impaired glucose tolerance (GIGT), 166 had abnormal GCT and normal OGTT, and 93 had normal GCT and normal OGTT. Postpartum, the prevalence of glucose intolerance (both prediabetes and diabetes) increased across all groups from normal GCT and OGTT (3.2%), to abnormal GCT and normal OGTT (10.2%), to GIGT (16.5%), to GDM (32.8%). (Ptrend <.0001). In addition, all 3 categories of abnormal glucose tolerance in pregnancy independently predicted postpartum glucose intolerance: abnormal GCT and normal OGTT, OR 3.6; GIGT, OR 5.7; GDM, OR 14.3. The authors concluded that all degrees of abnormal glucose tolerance during pregnancy, including those that do not meet the diagnostic threshold for GDM, predict postpartum glucose intolerance.

      Are women getting the follow-up they need? If a recent study is any indication, they are not.5 Retrospective chart reviews were conducted among several obstetric practices in an urban setting in order to measure screening practices following GDM. The authors used both a “strict” definition--that an obstetrician-gynecologist ordered the ADA-recommended DM screening tests 5 to12 weeks following delivery—and a “broad” definition, which included either the strict definition or referral to a primary care physician for such testing. Of 2617 women tested, 90 had GDM and postpartum follow-up. Twenty percent (18/90) received screening according to the strict definition, and 33.3% (30/90) according to the broader definition.

      Differences in screening rates were noted according to the type of practice. A high-risk maternal and fetal medicine practice provided ADA-recommended screening for 14 of 17 patients and met the broader criteria for an additional 2, for a total of 94.1% of patients appropriately screened. In contrast, a generalist obstetric practice provided screening for 2 of 50 patients according to strict criteria and an additional 7 by broader criteria, for a total of 9 of 50 or 18% appropriately screened. Rates for a residents’ ambulatory clinic were 2 of 23 and 3 additional, respectively, for a total of 5 of 23 or 21.7%.

      In a retrospective cohort study, follow-up rates for 846 patients who were diagnosed between 2002 to 2008 were measured and stratified by maternal race, parity, and education, yielding disappointingly low rates of follow-up for GDM (overall follow-up rate was 29.6%).6 The highest rates were seen among Asian women (42%) – well below 50%. Latina patients had the lowest rates of 14%. Women aged 35 and older were 1.8 times more likely to receive follow-up than women younger than 35, as were nulliparous women (OR 1.76) and women with 2 or more years of college.

      As a primary care provider, I am always searching for any and all opportunities to identify risks and to intervene where possible. GDM and impaired glucose tolerance identified during pregnancy is a potential threat to women’s reproductive health as well as a marker of risk for chronic disease.

      Reproductive health. Poorly controlled GDM is a well-known risk for poor outcomes of pregnancy, including maternal complications, higher rates of perinatal mortality, and fetal congenital abnormalities. Excellent glycemic control in the months preceding and throughout pregnancy reduce these risks significantly.7

      Chronic illnesses. It was previously believed that GDM represented an acquired and reversible defect. However, it is now understood that the defect is chronic and precedes pregnancy but may become manifest during the physiologic stress of pregnancy. Indeed, GDM and type 2 diabetes have identical dual defects of insulin resistance and inability of the pancreatic beta cells to compensate for this resistance.8 Whether or not all or only a fraction of women with impaired glucose tolerance during pregnancy will ultimately develop diabetes, we know that glucose intolerance is part of a syndrome of related cardiovascular risks.

      A population-based retrospective cohort study, using hospital data and registries in Ontario, Canada, sought to determine whether women with GDM have an increased risk of cardiovascular disease (CVD) following the index pregnancy.9 The study matched 8,191 women with a history of GDM and a live birth between 1994-1997 with 10 women (a total of 81,262) who did not have GDM. Cardiovascular events included hospitalization for acute MI, coronary artery bypass or angioplasty, stroke, or carotid endarterectomy.

      After a mean follow-up period of 11.5 years, type 2 diabetes developed in 2,214 (27%) of the women with GDM and 2,596 (3.2%) of the women without GDM. The hazard ratio for cardiovascular events was 1.71 (95% CI 1.08-2.69). After adjustment for the presence of subsequent diagnosis of type 2 diabetes, the ratio decreased to 1.13 (95% CI 0.67-1.89). The study did not control for additional cardiovascular risk factors because this data was not available. However, the authors point out that insulin resistance is “associated with a clustering of risk factors that are in the causal pathway to CVD. Therefore, women with GDM likely have very different risk factor profiles than those without GDM, and adjusting for these differences might obscure a clinically important association between GDM and CVD.” The authors conclude that their study is consistent with others that determined that GDM is a risk for cardiovascular disease in women.10

      For women of childbearing age, pregnancy may be the equivalent of a stress test for insulin resistance, type 2 diabetes, and, by extension, risk for cardiovascular disease. Although there are no extensive, controlled trials of interventions to reduce the conversion of GDM to type 2 diabetes, the success of lifestyle and/or medications in preventing or delaying type 2 diabetes in patients with impaired glucose tolerance is encouraging and provides plausible rationale for interventions in the case of GDM.11

      So – as a primary care physician I do have a role to play.

      Preconception/interconception. I have to be certain that my female patients of childbearing age are properly educated about the impact of gestational diabetes and impaired glucose tolerance on future pregnancies and on their risk for chronic disease. This includes helping them reduce their risk through lifestyle modifications that are effective with type 2 diabetes – physical activity, dietary changes, and maintaining or achieving an optimal weight.

      Postpartum. At minimum, I will make certain that patients with GDM are screened according to ADA guidelines for type 2 diabetes. However, an even more cautious approach might be indicated. Women with particularly elevated fasting blood glucose readings during pregnancy might be at higher risk for subsequent type 2 diabetes, and perhaps require more frequent testing.3 Furthermore, it might be prudent to follow up those with sub-threshold glucose intolerance.4 At a minimum, anyone demonstrating any degree of impaired glucose tolerance should be offered the prevention activities listed above. And, hopefully, researchers in the field will develop the science and the evidence base that will provide finely tuned guidelines for screening and effective risk-reduction interventions.

      1.  American Diabetes Association: Gestational diabetes mellitus. Diabetes Care. 2000;23(suppl.1):577-579.
      2. American College of Obstetricians and Gynecologists Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol. 2001;98(3):525-538.
      3. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: A systematic review. Diabetes Care. 2002;25(10):1862-1868.
      4. Retnakaran R, Qi Y, Sermer M, et al. Glucose intolerance in pregnancy and future risk of pre-diabetes or diabetes. Diabetes Care. 2008;31(10):2026-2031.
      5. Almario CV, Ecker T, Moroz LA, et al. Obstetricians seldom provide postpartum diabetes screening for women with gestational diabetes. Am J Obstet Gynecol. 2008;198(5):528.e1-e5.
      6. Stasenko M, Cheng YW, McLean T, et al. Postpartum follow-up rates for gestational diabetes mellitus patients:789. Am J Obstet Gynecol. 199(6) supplement SA, 5223, 2008.
      7. Yang J, Cummings EA, O’Connell C, et al. Fetal and neonatal outcomes of diabetic pregnancies. Obstet Gynecol. 2006;108:644-650.
      8. Buchanan TA, Xiang AH. Gestational diabetes mellitus. J Clin Invest. 2005;115:485-491.
      9. Shah BR, Retnakaran R, Booth GL. Increased risk of cardiovascular disease in young women following gestational diabetes mellitus. Diabetes Care. 2008;31(8); 1668-1669.
      10. Carr DB, Utzschneider KM, Hull RL, et al. the American Diabetes Association GENNID Study Group. Gestational diabetes mellitus increases the risk of cardiovascular disease in women with a family history of type 2 diabetes. Diabetes Care. 2006;29:2078-2083.
      11. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.

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    • 5 years ago
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  • Are traumatic experiences a ri Are traumatic experiences a risk factor for chronic diseases?

    • From: bgottlieb
    • Description:

      Several days ago I returned from the first part of a training program on trauma and recovery offered by the Harvard Program on Refugee Trauma. This program continues online for the next 6 months. You may see references to this material in my forthcoming blogs as I continue to learn and digest the complex implications of trauma and torture on individuals and populations.

      Today’s discussion will begin with a question that I have had for many years treating my clinic patients. Are traumatic experiences a risk factor for chronic diseases? Is it simple misfortune that the patients who have suffered, by any measure, the worst experiences (rape, beatings, witness to violence, loss of family members, death threats) also have, by coincidence alone, seemingly higher rates and worse outcomes from diabetes, cardiovascular disease, cancer? Is life that unfair? Why is it that the same patients, who have demonstrated the profound courage not only to survive unspeakable circumstances, but to begin new lives and provide a foundation of strength, optimism, and resilience for their families, are so often themselves defeated by new enemies in the form of chronic diseases?

      Project 1 Billion is an international initiative established by Ministries of Health from post-conflict countries, the United Nations and other donor agencies.1 Project 1 Billion seeks international recognition and response to the urgent needs of the more than 1 billion people who are living with the impact of torture and other forms of trauma from manmade and natural disasters.

      One might ask what the role of a primary care physician is in the face of these large political crises. Apart from the responsibility that we all have, as citizens of the world, to respond to the suffering of our fellow citizens, the global crises of the world enters our offices, whether we are aware of this or not. Dr. Richard Mollica, a psychiatrist who has taken care of thousands of torture survivors over the past quarter of a century, describes a familiar scenario.2

      “A middle-aged Cambodian woman had had an excellent relationship with her American doctor for 9 years, but he had no idea that she had been tortured. He had had only partial success in controlling her type 2 diabetes. After attending a training session on treating the effects of terrorism after the events of September 11, 2001, the doctor asked the patient for the first time whether she had undergone extreme violence or torture. She revealed that 2 of her children had died of starvation in Cambodia, her husband had been taken away violently and disappeared, and she had been sexually violated under the Khmer Rouge. More recently, in the United States, her remaining daughter had been nearly fatally stabbed by a gang that burglarized her home. Since September 11, the patient had taken to barricading herself in her house, leaving only to see her doctor.”

      This type of biography is shared by many patients who walk through the doors of primary care. I have former “boat people,” survivors of political violence in El Salvador and Guatemala, Eritrean and Somali refugees who have been diagnosed with diabetes at unusually young ages, and whose diabetes is poorly controlled. In what way do their traumatic earlier lives and the ongoing struggles with racism, poverty, and loss of family and social support contribute to their burden of chronic disease?

      The link between trauma, mental health, and diabetes was corroborated by Goodwin and Davidson in an epidemiologic study.3 Using the National Co-morbidity Survey, a national probability sample of noninstitutionalized individuals aged 15 to 54, the authors investigated the association between diabetes and post-traumatic stress disorder (PTSD). After adjusting for sociodemographic characteristics and co-morbid mental disorders, diabetes was found to be significantly associated with PTSD (OR = 2.3). While neither the mechanism for the association nor the direction of causality could be determined from cross-sectional data, there are plausible physiologic explanations that link early life trauma, PTSD, and diabetes through the hypothalamic-pituitary-adrenal axis (HPA). Heim, et al. document HPA and autonomic nervous system hyperreactivity in their study that compares physiologic measures of women with a history of childhood abuse with counterparts without a history of childhood abuse.4 The former group was found to have a 6-fold greater ACTH response to stress than their age-matched counterparts.

      What, if anything, can be done? Are our patients permanently captive to the mental and physical effects of trauma? Heim, et al conclude that their findings “suggest potential utility of [CRF receptor antagonists] for the prevention and treatment of psychopathological conditions related to early-life stress.”4 Mollica continues in his description of the Cambodian woman, that the physician explored the effects of her traumas, diagnosed major depression, which he then treated with medication and counseling. Eventually, the diabetes came under control as well.

      Was this due to improved motivation and compliance? Were there additional physiologic factors? In the case of this specific patient, we can’t be sure. Studies are ongoing to elucidate the mind-body connection, the specific pathways that connect trauma to depression, PTSD and other mental health outcomes, and these outcomes to chronic diseases. Project 1 Billion established an ambitious Mental Health Action Plan to align international policies, programs, and standards and guidelines for clinical care to improve the health and well-being of traumatized individuals and populations.1

      What does this mean for the practicing clinician? As clinicians, we must always be aware of underlying social factors as well as best clinical practices for screening and treatment. In the same way that we must be aware of the social policies that influence the location of recreational facilities, affordable health-promoting foods in order to treat and prevent diabetes, we must also be aware of the prevalence of mass violence. From a clinical standpoint, Mollica advocates practices that can be easily implemented. The first step is awareness. A patient’s history of immigration or refugee status may provide clues to the possibility of torture or other forms of trauma. A simple, direct question, “Have you experienced extreme violence or trauma?” may open the door to further discussion.2 We will then be in a position to recommend appropriate therapeutic interventions which may result in improved outcomes for our patients’ mental health and well-being, as well as for their chronic illnesses including diabetes.


      1. Project 1 Billion, accessed at: http://www.hno.harvard.edu/press/pressdoc/supplements/mentalhealth.pdf.
      2. Mollica, RF. Surviving torture. N Engl J Med. 2004;351(1):5-7.
      3. Goodwin RD, Davidson JR. Self-reported diabetes and posttraumatic stress disorder among adults in the community. Prev Med. 2005;40:570-574.
      4. Heim C, Newport DJ, Heit S, Graham YP, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA. 2000; 284:592-597.
    • Blog post
    • 6 years ago
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  • Diabetes in the "real world:" Diabetes in the "real world:" A primary care physician's experience this week

    • From: bgottlieb
    • Description:

      I probably spend as much time as most primary care providers thinking about diabetes. Although the estimated prevalence in the United States is 4%, on any given day in my office, 30%-40% of my patients are either being treated for diabetes or had it during pregnancy. Another 30%-40% have multiple risks to develop the disease. It is rare for diabetes to be absent from the conversation!

      Parallel to the deluge of patients is the deluge of literature, new drugs, new indications for old drugs, clinical trials, and meta-analyses resulting in clinical guidelines, strict targets for LDL, BP and glycosylated hemoglobin. Much of the treatment literature centers on pharmaceuticals—to achieve glycemic control and to prevent complications of diabetes. Diabetes care has a hefty price tag—$132 billion per year.1

      This cost is driven in large part by treating diabetes complications and by use of an ever-expanding pool of pharmaceuticals. Indeed, the new millennium has brought a virtual explosion in diabetes medications—new classes of medications exploiting a range of metabolic pathways, new combinations of medications, and new formulations and delivery systems for traditional medications such as insulin. Between 2001 and 2007, drug expenditures for diabetes increased by 87% from $6.7 billion to $12.5 billion.1 Patients are on more complex regimens with more drugs and more costly drugs.

      Like most primary care providers, I try to do the best by my patients. I see them as often as they need to be seen, monitor everything I am supposed to monitor, prescribe medications according to the latest guidelines, cheer for them when they do “the right thing,” and try to stop them, or at least reduce the harm, when they do “the wrong thing.” My electronic medical record provides me with flags, clinical prompts, and helpful hints. The insurance companies and my hospital monitor me. They cheer when I do the right thing and chastise me when I don’t, or when my efforts fail to meet targets. But I can’t help from feeling that despite all of this, I am hitting very wide of the mark.

      Mrs A is 70 years old. She has had type 2 diabetes for 17 years. She also has hypertension, hyperlipidemia, and mild obesity. Since she was diagnosed with diabetes, she has dutifully taken all prescribed medications. Her only lapses occurred every few years when her insurance company suddenly changed the statin-of-choice, and her LDL would skyrocket from 80 to 180 while we straightened out her prescriptions. She takes her ACE inhibitor, her daily aspirin, her metformin, her glipizide, and her pioglitazone. Her HbA1c has been a proud and steady 6.0, her BP always at target. With a great deal of effort and after a lot of convincing, she stopped smoking and never looked back.

      The only things she/we didn’t do were things that I don’t have in my prescription pad. She is a widow; lives on a low fixed income; eats a meat, potatoes, and pasta diet—never one for fruits and vegetables. She never had the time or money to take care of her teeth. And she is not one for exercise, either. The senior stretch program at her senior housing was cut several years ago, and no one walks in her neighborhood.

      Last month she had a heart attack. She was fortunate. The MI was not complicated, and stents successfully opened her 2 blocked coronary arteries. She is now dutifully taking a beta blocker and clopidogrel.

      Where did we go wrong? According to a meta-analysis conducted by Selvin, et al, metformin—which she took—is associated with modest protection against cardiovascular morbidity and mortality.2 On the other hand, rosiglitazone is possibly associated with an increased cardiovascular risk. Is pioglitazone the same? Would the nonstatistically significant risk become significant in a carefully constructed, adequately powered clinical trial or would it be exonerated? Would a clinical trial have any relevance to Mrs A, who would undoubtedly have been excluded from most clinical trials?

      Did we aim for the correct HbA1c target? Was our proud achievement of 6.0 too misguided? If we believe the ACCORD trial, that target might have increased her risk.3 Should we now aim for 7.0? Should I stop the pioglitazone? If we have to add something else, should it be insulin? New or old? A whole new world of glucagon-like peptide 1 compounds has arrived.4 Would exenatide be the drug for her? Can we apply the findings from a clinical trial to Mrs A, or to any patient, who will take a medication for years rather than months, with all of her other medications and co-morbidities?

      After reviewing 40 clinical trials exploring the relationship between oral diabetes medications and cardiovascular outcomes, Selvin and co-authors concluded that “Larger, long-term studies taken to hard end points and better reporting of cardiovascular events in short-term studies will be required to draw firm conclusions about major clinical benefits and risks related to oral diabetes agents.”2 Okay—I can agree with that.

      I also agree with the conclusion of Alexander, et al, “Whether increased treatment costs are balanced by improved outcomes associated with these changes cannot be evaluated in the absence of data comparing effectiveness and cost-effectiveness across treatment classes. Our findings suggest the importance of generating new comparative data and coupling this information with clinical and formulary guidelines that contribute to constraining costs, maximizing glycemic control, and minimizing diabetes-related morbidity and mortality.”1 I would certainly be happier with better, longitudinal and comparative data, including reliable safety data of the drugs I prescribe. But how much would this cost, and how long would it take to conduct these trials?

      Therefore, I also agree with Dr David Nathan in the editorial that accompanies the Selvin, et al meta-analysis, when he writes “Increasing the size and duration of controlled clinical trials to provide adequate statistical power to detect relatively infrequent events would potentially bankrupt the pharmaceutical industry that supports most of the trials and delay the development of new drugs.”5 He adds “In the meantime, there are well-established and safe treatments that, if used aggressively, can improve the long-term health of patients with type 2 diabetes.”5

      Does he mean standard medications? Or maybe all of this attention on medications has distracted us from the full range of preventive and therapeutic strategies. Maybe the true measure of success, preventing clinical endpoints such as heart attacks, is only partly about the medications and must also consider the factors I haven’t been addressing. Some clinical trials factor in lifestyle, others hold lifestyle factors constant. But most clinical trials focus on medications.

      What would have happened if in addition to getting Mrs A to take her medications and stop smoking, I had also succeeded in getting Mrs A the dental care she needed, to walk 30 to 45 min every day, lose 25 lb, eat fresh fruits and vegetables every day? Would I have prevented her heart attack without even knowing it? Shouldn’t I be held accountable for the “therapeutic inertia” of failing to successfully address lifestyle and behaviors as much as I am for failing to achieve an LDL of less than 100?

      I should be. But I need to know what to do. I need guidelines and strategies that are based on evidence derived from trials that are as carefully designed and appropriately translated as pharmaceutical trials. I need trials that are carried out in real-world settings such as mine, with patients like Mrs A. I need trials that combine pharmaceutical and lifestyle interventions as part of the total picture of primary and secondary prevention, because that is what we do, or at least that is what we should be doing, in the real world.

      1. Alexander GC, Sehgal NL, Moloney RM, Stafford RS. National trends in treatment of type 2 diabetes mellitus, 1994-2007. Arch Intern Med. 2008;168(19):2088-2094.

      2. Selvin E, Bolen S, Yeh H-C, et al. Cardiovascular outcomes in trials of oral diabetes medications, a systematic review. Arch Intern Med. 2008;168(19):2070-2080.

      3. Action to Control Cardiovascular Risk in Diabetes Study Group: Gerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-2559.

      4. Drucker DJ, Buse JB, Kendall DM, et al. Exenatide once weekly versus twice daily for the treatment of type 2 diabetes: a randomized, open-label, non-inferiority study. Lancet. 2008;372:1240-1250.

      5. Nathan DM. Editorial: Glycemic management of type 2 diabetes, how tight is right and how to get there. Arch Intern Med. 2008;168(19):2064-2066.

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    • 6 years ago
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  • Health care reform, primary c Health care reform, primary care, diabetes and group visits

    • From: bgottlieb
    • Description:

      The State of Massachusetts, where I practice, instituted a plan for nearly universal access to care through a combination of expanded public insurance, firmer employer mandates and incentives, and penalties for consumers. Although still somewhat early to evaluate the overall impact of the program on access and health outcomes, it is clear that more people who would have otherwise slipped through the cracks are entering—or staying—in the health care system.

      As a primary care physician working in a community health center, I welcome and applaud these advances toward universal coverage. However, at 8 o’clock on a Monday evening, after I have seen 30 patients, spoken to another 30 on the telephone, e-mailed a handful, and (most likely) left as many or more patients dissatisfied because they didn’t get what they wanted from the health care system or from their primary care provider…. I have to wonder what exactly we are going to do as demand increasingly outstrips supply for the likes of me, the point of entry into the system.

      My health center serves a largely Latino community. We see new and second-generation immigrants from Central and South America and the Caribbean. Like other Latino communities, ours is disproportionately affected by obesity and overweight and type 2 diabetes, with higher rates of consequences compared to non-Hispanic populations. So—easily half of Monday’s 30 patients already have diabetes. In my “15-minute” visit, we greet one another and catch up, review old and new problems, conduct a physical exam, attend to routine screenings and prevention activities, make sure that the patient’s medications match up with what I believe s/he is taking, rewrite prescriptions, and schedule appropriate follow-up and specialty appointments.

      This assumes that everything else is going well. In most cases we must first wade through life’s stresses: violence in the community and sometimes at home, shaky employment, rising food and fuel costs, the mortgage that might be lost, the child who is doing poorly in school. If we’re lucky, we will have a few minutes to discuss diabetes, check in on fingersticks, and go over when physical activity might be able to be fit into the two jobs and family responsibilities. I am held to the same standards as all providers—to keep LDL below 100, diastolic BP below 80 and HbA1c below 7, even when I have had to spend more time figuring out how my patients will be able to afford the co-payments on their 7 daily medications than I have had to spend on the more direct aspects of disease management.

      So – what is my solution?

      I have been intrigued by the concept of group visits. We have had short-term grant funding over the years to develop demonstration projects for the care of Latino diabetic patients. We have shown that a series of group visits with a bicultural/bilingual health educator and nutritionist led to improvements in many markers of care and outcomes—including lowered HbA1c, compliance with yearly influenza vaccines, and visits to the ophthalmologist. Funding comes and goes, along with the extra staff that comes with it.

      There has been a resurgence of interest in physician-directed group visits to address not only the growing burden of chronic illness but also the resource and efficiency constraints of the current primary care practice environment. Jaber et al conducted a literature review of group visit articles from 1974 to 2004 found in PubMed and MedLine databases. Although the group visits were not restricted to diabetes, most focused on specific chronic diseases, and diabetes was well-represented among the studies. They presented findings from reports that included an evaluative component.

      Although a variety of models and diseases were represented, group visits tended to be disease-specific and were often associated with brief one-on-one visits with a physician or nurse at the time of the group meeting. The size of the group, frequency of meetings, degree of structure of the agenda, and composition (consistent membership vs variable) varied. However, most groups included multiple components in the course of a single meeting: education, motivational discussions, group problem solving, and modeling of desired behaviors.

      The authors systematically summarized the current state of the art, and, based on each study’s individual evaluation, created a summary evaluation of group visits for chronic diseases according to standard indicators of quality, satisfaction, efficiency, and clinical outcomes. Acknowledging the limitations of combining studies that were designed differently, that measured a variety of outcomes, and that addressed a range of chronic diseases, the authors found that group visits were associated with improved patient and physician satisfaction; reduced utilization of health resources in the form of emergency room visits, specialty evaluations, and hospitalizations; improvement in quality of care—most easily measured for diabetes care by improvements in HbA1c, urine microalbumin testing and receipt of preventive services; improvement in health promoting behaviors, self-care and self-efficacy; and improvement in quality of life.

      Studies did not consistently demonstrate reductions in overall cost of care nor consistent improvements in activities of daily living (ADLs) and depression scores. However, studies suggest that these outcomes may differ for certain subsets of patients; those who are high utilizers of resources at baseline may demonstrate a measurable reduction in cost of care, while average utilizers may not. Similarly, the measures chosen for ADLs and depression may not have been the best match for the populations studied.

      However, even the most conservative interpretation of their summary findings led the authors to conclude that “Group visits are a promising approach to chronic care management for the motivated patient. They provide a mechanism for providing time for education combined with medical care in a manner that at least maintains productivity and revenue. The combination of individual medical attention and group education, if well-designed, has the potential to address multiple aspects of patient care in a personalized, tailored fashion but may only be applicable to motivated patients who are willing to invest extra time in their care. Thus, the group visit model is a useful adjuvant to the chronic care model.”

      Applicable to motivated patients. A loaded concept. I don’t doubt that my patients would prefer to be healthy than not. But are they motivated in the sense that the authors intend? Or do their complex lives and multiple barriers to self-care impede their ability to express the motivation that I know they have to be as healthy as they can. I have seen my patients make good use of group visits, albeit groups that employed a different model. Will they, can they, make good use of the physician-led chronic disease group visit model? What would they need and want from group visits?

      I believe that all providers, no matter where they work, no matter who their patients are, must ask the same question if they are considering group visits. The authors propose a series of considerations for those of us planning to implement group visits, including structure of visits; processes to be employed for education, motivation, and changing behavior; the content of the visits, including involvement by multi-disciplinary team members; and the evaluative component, including appropriate tools to measure all anticipated outcomes.

      The authors remind us that the gold standard for evaluating group visits would be the randomized controlled clinical trial. I hope that such trials are carried out. And I hope they include patients such as mine. But I believe most of us cannot wait for the randomized clinical trials to take place. I certainly can’t. Not if I have too many days like last Monday. I, and I suspect many of us, will have to draw from what we know so far, make our plans, use the resources, and select our patients in the real-world settings in which we work. Hopefully, we can find a way to share our successes and problem-solving strategies, much as we hope our patients will in our group visit sessions.

    • Blog post
    • 6 years ago
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  • Diabetes...it's in the water?? Diabetes...it's in the water???

    • From: bgottlieb
    • Description:

      You can’t open a medical journal, read a newspaper or a tabloid in the supermarket check-out line without being confronted with headlines and dire predictions about the dual pandemics of obesity and type 2 diabetes. Studies run the gamut from sub-cellular and genetic mechanisms to individual lifestyle to public policy. And, no surprise, considering that in the US alone, direct and indirect costs of diabetes are estimated to be $174 billion each year. 1 While there are many studies that evaluate the association between the physical environment and type 2 diabetes, relatively few studies examine the potential role of exposure to environmental toxins.

      Navas-Acien and her co-authors re-focus our attention to an association that was suggested more than 50 years ago, but has received relatively little attention—that exposure to arsenic is a possible risk factor for type 2 diabetes. 2,3 The authors used data available from the2003-2004 National Health and Nutrition Examination Survey (NHANES) to measure the association between urine arsenic concentrations and type 2 diabetes. After adjusting for possible confounding exposure to organic arsenic compounds contained in dietary seafood that are not believed to carry this risk, the authors found that those with highest urinary levels of arsenic had more than a 3-fold risk of having type 2 diabetes compared to those with the lowest levels.

      Although limited in the usual ways that cross-sectional studies are limited, this study raises important concerns. Previous studies found an association between high levels of arsenic exposure and type 2 diabetes. The urinary markers in this study are felt to reflect low to moderate levels of exposure to arsenic, presumably from drinking water and dietary sources. NHANES is designed to be a representative sample of the US population. This study is about all of us. In their editorial commentary, Kile and Christiani point out that arsenic is a common pollutant in drinking water in the US and affects millions throughout the world. 4,5

      Type 2 diabetes is a multifactor disorder. While its web of interacting mechanisms have not been fully described, it is undoubtedly one of the best models for the complex interaction of genetic factors, individual behavior and the environment. Animal models suggest that arsenic acts on at least several of these levels. When I look not only at the high and growing prevalence of diabetes, but its disparities in incidence and outcome, I wonder if arsenic, or perhaps other environmental exposures, are playing a role in this aspect of the pandemic. Navas-Acien et al point out that 8% of the public water supply in the US may have arsenic levels above the EPA’s standard of 10 micrograms/liter, and another 39% have measurable levels that might be significant, given the difficulty in establishing threshold and “safe” levels of such toxic substances. 6 The authors focused on the association between type 2 diabetes and urinary arsenic levels among all groups, ages and genders. Included in the data, however, are statistically significant differences in urinary arsenic levels among non-whites in the sample – suggesting greater exposure.

      Much has been made of the possibility that non-whites may have a “genetic predisposition” to type 2 diabetes. Indeed, prevalence data in the US and throughout the world support this notion. But with a disease process as complex as type 2 diabetes, disparities are likely to arise from the interaction of multiple factors. We all need safe drinking water. The scientific foundation and social policies that support this right are critical. However, the importance of safe water may be even greater for some. Are the poor more likely to have unsafe drinking water? Are they less able to afford ultra-filtered bottled water? If so, then socio-economic disadvantage may lead to greater exposure to environmental toxins that adversely affect health through genetic and other pathways. The environment may have a differential effect, magnifying genetic and other risks on individuals and groups with particular vulnerabilities.

      1. American Diabetes Association. Economic costs of diabetes in the US in 2007. Diabetes Care. 2008; 31(3): 596-615.

      2. Stolzer BL, Miller G, White WA, Zuckerbrod M. Postarsenical obstructive jaundice complicated by zanthomatosis and diabetes mellitus. Am J Med. 1950;9(1):124-132.

      3. Navas-Acien A, Silbergeld EK, Pastor-Barriuso, Guallar E. Arsenic exposure and prevalence of type 2 diabetes in US adults. JAMA;300(7):814-822.

      4. Kile ML, Christiani DC. Environmental arsenic exposure and diabetes. JAMA. 2008;300(7):845-846.

      5. Smith AH, Lopipero PA, Bates MN, Stenimaus CM. Public health – arsenic epidemiology and drinking water standards. Science. 2002;296(5576):2145-2146.

      6. Focazio MJ, Welch AH, Watkins SA, Helsel DR, Horn MA. A retrospective analysis on the occurrence of arsenic in ground-water resources of the United States and limitations in drinking-water-supply-characterizations. Reston, VA: US Geological Survey; 2000. Water-Resources Investigations Report 99-4279.


    • Blog post
    • 6 years ago
    • Views: 549
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