Tuesday, 29 March 2011

White rice. brown rice. diabetes on the rise!

Rice is a staple around the world. In far east and most of Asia, rice is the major grain that is consumed. In the US, rice consumption is growing too. 20 billion pounds of rice is produced each year by farmers in Arkansas, California, Louisiana, Texas, Missouri and Mississippi1. Most of the rice produced in the US grown for local use and Americans consume about 25 pounds of rice each year1.

The incidence of diabetes varies in different parts of the world because of lifestyle factors. Diet is a big part of pathogenesis of diabetes and we know from population studies that high fat, high calorie diet can cause the metabolism to be diabetogenic.

In the United States, there are 23.6 million people (7.8% of the population) with diabetes with 90% of them being type 2 diabetic. With prevalence rates doubling between 1990 and 2005, CDC has characterized the increase as an epidemic2.

Does eating rice in any form cause diabetes to worsen? Or cause diabetes to develop in those predisposed? To answer this unusual question Qi Sun and colleagues conducted a trial to correlate white and brown rice consumption in relation to type 2 diabetes risk. This was published in nov 2010 issue of Archives of Int. Medicine.

Close to 40,000 males and 150,000 females (medical professionals, nursing staff) were studied prospectively for development of diabetes. People who ate five or more servings of white rice per week were associated with 17% higher incidence of diabetes as compared to one serving per month.

People who ate 2 servings of brown rice per week had 11% less incidence of diabetes as compared to people eating brown rice once a month.

The study design also allowed looking at effect of other whole grain. Bran in- take reduced incidence by a big amount, but germ intake did not affect the diabetes development as much.

Take home message, “substitute refined grains to whole, keep your blood sugar at goal!”

1. USA rice federation. http://www.usarice.com/doclib/157/3366.pdf
2. http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2
3. White Rice, Brown Rice, and Risk of Type 2 Diabetes in US Men and Women. Qi Sun, MD et al. Arch Intern Med. 2010;170(11):961-969

Saturday, 26 March 2011

Clinical trial of Pre-Diabetes treatment, ACT NOW

What IS pre-diabetes?

Pre-diabetes is defined as a condition where fasting blood sugar of the patient is between 100-125 mg/dl (according to the American diabetes association) or between 110-125 mg/dl (according to world health organization). If you have been diagnosed with pre-diabetes, click here.

Why is it important to identify patients with pre-diabetes?
For the simple reason, that a lot of pre-diabetics who do not achieve control on their sugars end up becoming full blown diabetics. They are at double risk for developing heart attack. what would happen if we treat someone who has pre-diabetes with medication? Does it help prevent diabetes and the dreaded complications?

In the most current issue of New England journal of medicine the medical group lead by Dr. DeFronzo and Dr. Tripathy attempt to answer just that question. Pioglitazone for Diabetes Prevention in Impaired Glucose Tolerance uses the drug pioglitazone (ACTOS) to treat about 600 patients with pre-diabetes. (ACT NOW trial)

Does treatment of pre-diabetes with Actos prevent full-blown diabetes?

Yes. At the end of 4 years, the time to develop diabetes was much lower in patients who received the drug. By 2.4 years, fifty patients in non-treatment group developed diabetes while fifteen in treatment group did so. In addition, at the end of 3 years the Hba1c was 2.5 points lower in treated group. ACTOS reduced the incidence of diabetes irrespective of age, sex or race. (equal opportunity treater?!)

This is result is not surprising; diabetes is defined biochemically by amount of sugar in your blood. By preventing the rise in sugar levels in blood, the diabetes is bound to be delayed.

Does treatment of pre-diabetes with Actos affect blood pressure or cholesterol?

There was no change in blood pressures between the two groups. HDL (good cholesterol) increased and triglycerides decreased in the treated groups.

So where does this study fit in?

Pre-diabetes is an important medical burden. The complications of diabetes have already have started in the pre-diabetic stage and thus intervention in this step will reduce them. The authors mention that similar trials with Metformin (GLUCOPHAGE) reduced the risk of conversion to diabetes by 31%, with thiazolidinediones (GLIPIZIDE, GLYBURIDE etc) down to 60% and with just life style modifications (good diet, weight loss, exercise) down to 58%. The ACTOS (pioglitazone) trial reduced it by 72%. 

Weight gain and edema (swelling and fluid retention) were the biggest side effects of the drug in the treatment group (205 patient versus 128 in non treated) and even lead to some patients dropping out. There is NO answer yet as to whether the increased weight and edema would lead to more heart disease.

Things to do if you have been diagnosed with pre-diabetes

So, now that you have been diagnosed with pre-diabetes what do you do? 

Make A checklist!

  1. Talk to your family doctor about it
  2. Monitoring of fasting sugars at least every 6 months
  3. Check Hba1c every 6 months
  4. Check urine protein (micro albumin) every year, this alerts to kidney damage
  5. If you also have high cholesterol use ‘statins’ (LIPITOR, PRAVACHOL, ZOCOR)
  6. If you have high BP, prefer to use an ACE inhibitor (lisinopril, benazepril etc)
  7. Get eye exams every year for retinopathy (blindness in diabetes can be prevented)
  8. Aggressive life changes (weight loss, cardio, low fat high fiber diet can reduce your risk of diabetes progression by 58%, see above and without side effects of drugs!)
  9. FDA has not approved any diabetic medicines at this time for treatment of pre-diabetes. ACT NOW (actos) trial results are up.

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