News to Empower You!

By Dace Trence, MD, FACE

What a lot of information has come out since the last EmPower issue this summer! Reports from completed diabetes studies, news about diabetes medication’s previously unrecognized benefits, and medication potential side-effects contains news to keep us healthier and live longer! And all of it exciting…

Type 2 Diabetes, Diet, Exercise and Heart Disease

Results reported from the Look AHEAD (Action for Health in Diabetes) study suggested that diet and exercise did not decrease the risk for heart disease in study participants with type 2 diabetes mellitus. How could this be? The study was large, with over 5,100 total participants that had a previous diagnosis of diabetes mellitus type 2 (the diabetes that results from a combination of insulin not working normally and less insulin production over time.) Study participants were randomly assigned to either a control group or an intensive lifestyle group. The intensive lifestyle group focused on decreased calorie intake with a goal to lose weight. Also, increased exercise was part of the intervention program. The goal was to achieve and maintain at least a seven percent weight loss. The outcomes to be measured related to cardiovascular disease – death from heart disease, or having a heart attack, a stroke, or being hospitalized for angina. Everyone received diabetes education and support. And the study was planned to include up to 13.5 years of observation and intervention, but was stopped 2 years early. So what happened? There were no outcome differences between the two groups!

Looking at the data, weight loss was greater in the intensive lifestyle group, and although the difference remained through to the end of the study, there was a bit of weight regained in the intensive lifestyle group. Hemoglobin A1c (a measure of diabetes blood sugar control) measures showed greater improvement in the intervention group, as did systolic blood pressure (the top value in blood pressure determinations) and HDLcholesterol (the heart protective cholesterol). The control group did show greater LDL-cholesterol reduction, but this came from more medication use, specifically statin medication. The control group also required more insulin and blood pressure medication. The average cost for medication for the control group was $2,500 per person more than for the lifestyle group. There were also more hospitalization costs in the control group. So why no difference in cardiovascular disease outcomes?

The answer might relate to several issues. The study participants on average had had their diabetes only five years -- a relatively short period of time. It can take many years to develop heart disease associated with diabetes; some feel that it may take up to 15 years of diabetes, so the study just might not have been long enough. Also, more weight loss might be needed to see any difference between the groups. And medications needed for blood pressure control as well as cholesterol control could be (and were) started in any individual needing them...and we know that these can independently lower the risk for cardiovascular disease.

So, if you have diabetes, should you ignore your doctor’s advice to be choosey with your calorie intake and forget that business about exercising? Absolutely not! The participants in the lifestyle group reported feeling better, walking better, and they showed less kidney disease. Reasons enough to listen to your diabetes team and bypass that large piece of pumpkin pie with whipped cream.

TAKE HOME MESSAGE: If you have diabetes, continue to pay attention to what and how much you chose to eat, and stay physically active!

Metformin and Its Effects On Dementia

Another piece of confusing news is about metformin and its possible effects on your thinking and reasoning (cognitive) capacity. Results reported at the Alzheimer’s Association International Conference this year suggested that metformin decreased the risk for developing dementia, as compared to other oral diabetes drugs. The study was retrospective (reviewing information that had already been collected). Researchers at Kaiser- Permanente reviewed the charts of just under 15,000 people with diabetes mellitus type 2, who were at least 55 years or older, and who were just on a single blood sugar-lowering drug for treatment of their diabetes. Metformin users had a 20 percent lower risk for the development of any dementia when compared to those on a sulfonylurea (such as glyburide) and a 23 percent lower risk when compared to thiazolidenediones (such as rosiglitazone). If the diabetes had been present for a shorter known period -- less than 3 years -- the metformin users had a 40 percent decreased risk of dementia as compared to the sulfonylurea group. If the diabetes was present for at least 10 years, the risk was 19 percent lower for the metformin users as compared to the sulfonylurea users. That metformin could have protective power is not entirely surprising – it is a medication that decreases the body’s resistance to insulin, and many feel that insulin resistance plays a role in the development of Alzheimer’s disease. Metformin might have a direct or indirect effect on nerves themselves – not only being protective of damage to the nerve, but perhaps supporting new nerve growth or new nerve connection development.

Thus, somewhat surprising was the report that came out even more recently that metformin could be associated with worsening cognitive ability! As reported by Australian researchers, testing was done on study participants who had either type 2 diabetes (total of 104) or impaired glucose tolerance (total of 22), a form of prediabetes. Overall, those with diabetes or pre-diabetes had worse cognitive performance than those who did not have diabetes. But among those with diabetes, even worse cognitive performance was associated with metformin use. So why the difference from the previous study? Patients tested were recruited from a memory disorders clinic, so cognitive changes could have been present prior to or after metformin was started. Also, the length of time individuals were on metformin was not mentioned, or whether metformin was the only blood sugar-lowering drug being taken by study participants, all leaving the reader with many more questions than answers.

TAKE HOME MESSAGE: If you are taking metformin, do not stop!

Finally, a report that having adequate vitamin D could be associated with less functional limitations as we age came out this summer from researchers in Amsterdam.The study was called the Longitudinal Aging Study. Differences between those with adequate levels of vitamin D and inadequate levels were seen within three years of observation for those 65-88, but took six years for those 55-65 years old. Among functions that were tested were activities such as walking up and down 15 stairs without resting, dressing and undressing without assistance, sitting down and standing up from a chair without assistance, and walking outside for five minutes without resting. Any difficulty with an activity was defined as a limitation. Functions were asked about by self- reported questionnaire, not directly observed by the researchers themselves.

TAKE HOME MESSAGE: Adequate vitamin D level can be associated with better daily function!