Registration underway. St. Charles Hospital, 200 Belle Terre Road, Port Jefferson will offer a 24-class free diabetes prevention program (DPP) in St. Luke’s lecture room, 2nd floor, from March 4 to Dec. 2 from 6 p.m. to 7:30 p.m. This program provides trained lifestyle coaching, CDC approved curriculum, and group support during the course of the year. Classes will be held weekly from March 4 to June 17, bi-monthly from July 8 to Aug. 26 and then monthly from Sept. 9 to Dec. 2.
If you have prediabetes, you can take control and reduce your risk of developing diabetes. Pre-registration is required. To register or for more information, please email [email protected] or call 631-474–6797.
Diabetes complications can include permanent vision loss
By David Dunaief, M.D.
Dr. David Dunaief
Diabetic retinopathy (DR) is the leading cause of blindness among U.S. adults, ages 20 to 74 years old (1). As the name implies, it’s a follow-on to diabetes, and it occurs when the blood vessels that feed the light-sensitive tissue at the back of your eye become damaged. It can progress to blurred vision and blindness, typically affecting both eyes.
As of 2023, only about 66 percent of adults with diabetes had a recommended annual eye screening (2). Why is this important? Because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss with treatments that target its early stages.
A consequence of DR can be diabetic macular edema (DME) (3). With DME, swelling of the macula, which is an oval spot in the central portion of the retina, can cause significant vision loss. Those with the longest duration of diabetes have the greatest risk for DME.
Unfortunately, the symptoms of vision loss often don’t occur until the later stages of the disorder, after it’s too late to reverse the damage.
How do you treat diabetic macular edema?
DME treatments often include eye injections of anti-VEGF medications, either alone or alongside laser treatments. They work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF) (4). These can slow the progression of DME or reverse it (4).
The results from a randomized controlled trial showed that eye injections with ranibizumab (Lucentis) in conjunction with laser treatments, whether laser treatments were given promptly or delayed for at least 24 weeks, were effective in treating DME (5).
Other treatments can include NSAID and/or steroid drops that attempt to reduce swelling of the macula.
Can you reduce DME risk by treating diabetes?
Unfortunately, medications that treat type 2 diabetes do not lower your risk of DME. The THIN trial, a retrospective study, found that a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (6). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This persisted through the 10 years of follow-up. In addition to DME occurrence, the FDA warns of other significant side effects from these drugs.
To make matters worse, of the 103,000 diabetes patients reviewed, those who received both thiazolidinediones and insulin had an even greater incidence of DME. It was unclear whether the findings were caused by the drugs or by the severity of the diabetes, itself.
This contradicts a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (7). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).
What does this ultimately mean? Both studies had weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (8). There are additional studies underway to clarify these results.
Can glucose control and diet change the equation?
The risk of progression of DR was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (9). Unfortunately, medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. However, an inference can be made: a nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (10, 11).
If you have diabetes, the best way to avoid DR and DME is to maintain effective control of your sugars. It is also crucial that you have a yearly eye exam by an ophthalmologist. This will help detect issues early, before permanent vision loss occurs. If you are taking the oral diabetes class thiazolidinediones, this is especially important.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
Award-winning TV host, comedian, actress and author Sherri Shepherd is at increased risk for pneumococcal pneumonia and invasive pneumococcal disease (IPD) because she has diabetes. She doesn’t want to let it stop her from taking her shot on – or off – the stage. That’s why Sherri is partnering with Pfizer to share her diabetes story and help raise awareness about the importance of getting vaccinated.
Q: Sherri, there’s no doubt that you’re a superstar in more than one arena. What has helped contribute to your success over the years?
I learned early on that you need to run toward the thing that scares you because that’s where you can really thrive. And let me tell you, starting out in comedy and TV can be scary. But I put in the time practicing jokes on the bus, spending time on the road, working late hours behind the scenes, and it all led me to where I was supposed to be. And now, I get to take my shot at doing what I love every day.
Q: I’m sure you faced some challenges to get where you are today. What was one of the biggest you’ve faced?
I think the biggest one for me is more of a personal one. I have diabetes, so over the years I’ve had to learn how to keep my health in check. For me, I prioritize eating right, keeping active, talking with my doctor regularly, and getting vaccinated to help prevent pneumococcal pneumonia and IPD. It took a lot to get here so I don’t want to be held back from doing what I love.
Q: Tell me more about pneumococcal pneumonia and IPD. Are they serious?
Absolutely. Pneumococcal pneumonia is a potentially serious bacterial lung disease that can disrupt your life for weeks. In more severe cases, it can put you in the hospital and even be life-threatening. The same bacteria that cause pneumococcal pneumonia can also cause invasive pneumococcal disease, or IPD, which includes blood infection and meningitis.
Q: That does sound serious. Who is at greater risk?
People like me who are 19 or older with certain underlying medical conditions like diabetes, asthma or COPD. In fact, people 19-64 living with diabetes are at over 5x higher risk for pneumococcal pneumonia and up to 4.8x higher risk for IPD, compared with healthy adults the same age. People 65 or older are also at increased risk, even if they’re healthy.
Q: What advice would you give to people about protecting themselves against pneumococcal pneumonia and IPD?
Getting vaccinated is one of the best ways to help protect yourself. And vaccination is available all year round, so I encourage everyone to talk to their doctor or pharmacist to see if a pneumococcal vaccination is right for them. They can also visit VaxAssist.com to book an appointment online today.
Q: Thanks, Sherri. Is there anything else people should know about pneumococcal pneumonia and IPD?
People assume you can only get pneumococcal pneumonia and IPD during flu season or in the winter, but you can get it any time of year. And even if you’ve already been vaccinated against pneumococcal pneumonia before, your doctor may still recommend another vaccination for further protection. I love hosting my show and doing comedy, but I don’t joke around when it comes to pneumococcal pneumonia and IPD – and you shouldn’t either. Go talk to your doctor or pharmacist about getting vaccinated, so you can also keep taking your shot at whatever it is you love to do. (BPT)
The holiday season is a joyous time of year, but it can also throw your wellness routines out of alignment. Doctors advise prioritizing healthy choices during this period, so you can start 2025 on the right foot.
“Everyone’s holiday wish is to be happy, health and safe, but the season is often a time for overindulgence in food and drink, increased stress and exposure to respiratory illness,” says Bruce A. Scott, M.D., president of the American Medical Association (AMA).
The AMA recommends taking these steps during the holidays:
1. Vaccines are a safe and remarkably effective defense from a number of serious respiratory viruses that circulate in the fall and winter. To protect yourself and your family, get up to date on your vaccines, including the annual flu shot, as well as the updated COVID-19 vaccine for everyone 6 months and older. Vaccines are also available to protect older adults from severe RSV. Tools to protect infants during RSV season include maternal vaccination as well as the monoclonal antibody immunization. If you have questions, speak with your physician and review trusted resources, including getvaccineanswers.org.
2. Watch what you eat. Pay particular attention to labels and avoid processed foods as much as you can, especially those with added sodium and sugar. Consider having a healthy snack before the big meal or offer to bring a healthier dish for the holiday spread. Drink water instead of sugar-sweetened beverages, and eat nutritious, whole foods like fresh fruits and vegetables alongside richer holiday fare.
3. Stick to your exercise schedule and prioritize physical activity during this busy time of year. A good rule of thumb for adults is at least 150 minutes a week of moderate-intensity activity, or 75 minutes a week of vigorous-intensity activity. Brisk walks, bike rides, hikes and even family-friendly sports like basketball and touch football are good for heart health.
4. Use time with relatives to find out whether your family has a history of type 2 diabetes or cardiovascular disease, and whether other family members have been told they have prediabetes. With this information, you can better understand your risk and take charge of your health.
5. Prioritize your mental health. Factors like holiday spending and navigating time with extended family can bring on extra seasonal stress. You can help manage stress by getting sufficient sleep, exercising and seeking help from a mental health professional when you need it.
6. Make smart choices and plan ahead if you’re driving. In December 2021 alone, 1,013 Americans died in alcohol impaired-driving crashes. Do not drive under any circumstances if you intend to drink. And if you are the designated driver, make a 100% commitment to sobriety.
7. Be prepared when traveling. Whether you’re flying or taking a road trip, you might be tempted to grab convenient, unhealthy food for the journey. Consider packing your own snacks, such as fresh fruits and vegetables or small portions of dried fruits and nuts.
8. Get New Year’s resolutions started early. Speak with your doctor or health care professional about quitting tobacco and nicotine use, and declare your home and car smoke-free to eliminate secondhand smoke exposure.
“The holiday season is a wonderful time to reconnect with family and friends – it’s also a chance to reconnect with your physical and mental health,” says Dr. Scott. (StatePoint)
Foot ulcers develop in about 15% of the 25 million Americans living with diabetes and are a top cause of hospitalization. These ulcers can lead to serious complications, such as infection and amputation. According to foot and ankle surgeons, there are steps you can take to prevent complications and keep your feet healthy, as well as breakthrough treatments that are saving limbs, restoring mobility and improving lives.
“The majority of lower-extremity amputations are preceded by a reoccurring foot sore or an ulcer that won’t heal,” says John S. Steinberg, DPM, FACFAS, a board-certified foot and ankle surgeon and a Fellow Member and Past President of the American College of Foot and Ankle Surgeons (ACFAS). “Patients do best when they take charge of their foot health with the help of a foot and ankle surgeon.”
The surgeon members of ACFAS are sharing some important insights into preventing foot ulcers associated with diabetes and treating them if they do occur.
Make these precautions part of your foot care routine:
• Inspect feet daily using a flashlight and mirror to see the bottoms of your feet.
• Moisturize dry, cracking feet to prevent sores. Use powder to control moisture that can result in blisters.
• To prevent injury, wear protective, well-fitting shoes and socks at all times, even in the house. Change socks daily and more often if your feet get wet or sweaty. Avoid socks with holes or seams. Sometimes diabetic shoes are prescribed to avoid pressure and rubbing on the feet.
• Get regular foot exams from a foot and ankle surgeon, which can reduce amputation risk by 45-85%. The surgeon can also screen feet for loss of protective sensation.
• Manage your diabetes. Out-of-control blood sugar levels can lead to nerve cell damage, making it harder to detect foot problems.
Look for telltale signs that an ulcer may be developing:
• Swelling. The foot or ankle may look puffy or engorged and larger than the other.
• Temperature. Cold feet might mean a circulatory issue, whereas hot feet might mean infection.
• Color changes. Redness and even other colors might appear before an ulcer forms.
• Calluses. If a callus changes colors or develops dark, “dried blood” colored spots, it may be time to have a foot and ankle surgeon offer a proper diagnosis.
Ask your foot and ankle surgeon about innovative treatments:
If you do experience a non-healing ulcer, talk to your foot and ankle surgeon right away about innovative technologies that stimulate healing.
Groundbreaking approaches include stem cell therapy, the use of bioengineered skin substitutes to accelerate growth of healthy skin, and negative pressure wound therapy (NPWT) to promote healing and enable healthy, new tissue to grow. Today, foot and ankle surgeons rarely do a skin graft without NPWT. Skin grafting for foot ulcers has also advanced. Surgeons now use advanced reconstructive surgery and grafting techniques to promote wound healing and decrease wound recurrence.
The success rate of these advanced therapies is high, providing substantial improvement over treatments of the not-too-distant past, when doctors would clean and bandage the wound and hope for the best.
“Thanks to the many advances in diabetic foot care, patients today are having simpler surgeries, avoiding amputations, and getting back to everyday life sooner than ever before,” says Dr. Steinberg.
For more information or to find a foot and ankle surgeon near you, visit FootHealthFacts.org, the patient education website of the American College of Foot and Ankle Surgeons. (StatePoint)
As many in the type 1 diabetes community can attest, it can be difficult at first to understand the purpose of screening or the subsequent tests before and following a type 1 diabetes diagnosis, and what the results can mean for you or a loved one.
To help alleviate any uncertainties around which screening or test to take (and why), it’s time to bring it back to basics. Below are the “ABCs” of some of the screenings and tests (e.g., Autoantibody Screening, Blood Glucose Test, and A1C Test) that are currently available for type 1 diabetes, with the goal of empowering people of all ages with the tools and information necessary to advocate for their health when they are speaking to their doctor. It’s important to note that while a blood glucose test and an A1C test are crucial to the diagnosis, monitoring, and management of type 1 diabetes, an autoantibody test is the only test that can confirm your risk of developing the disease.
Autoantibody Screening
Autoantibody screening is a blood test that can detect whether someone is at risk for developing type 1 diabetes. The blood test looks for type 1 diabetes-related autoantibodies, which are proteins that appear in the blood in the early stages of the disease before there are noticeable symptoms, which tend to occur when type 1 diabetes has already progressed to a later stage after weeks, months, or even years.
When it comes to detecting type 1 diabetes early, knowledge is power. As a nurse who lives with type 1 diabetes herself, Grace Cochran could not agree more: “Having insights into whether you are at risk of developing type 1 diabetes is incredibly important. Early information can give you more time to educate yourself and your family about the disease and prepare for what will eventually come,” Cochran shared.
“People may think ‘ignorance is bliss’ when it comes to a future type 1 diabetes diagnosis, but as someone who not only received an unexpected diagnosis that required a hospital stay myself but also as a nurse who cares for people who might be in a similar situation, I can tell you that it’s 100% worth it to get screened,” Cochran continued.
The1Pledge.com has useful information about the importance of early screening and detection and how to start a conversation with your doctor. By the time someone is in the later stage of disease, complications of untreated type 1 diabetes can lead to an emergency room visit and hospital stay, as they did for Cochran, and lifelong insulin dependence begins – which brings up the “B” of the ABCs.
Blood Glucose Test
A blood glucose test not only confirms a type 1 diabetes diagnosis, but also helps people living with type 1 diabetes regularly monitor their disease. Doing so is important, as it gives a person insights into whether their blood glucose or sugar levels are within a normal range. Many factors can impact blood glucose levels, such as food, activity level, stress, illness, and certain medications and dehydration.
“There are a lot of tools these days that can help make routinely monitoring blood glucose levels easier and more convenient,” Cochran said. “For example, a doctor can test a person’s blood glucose levels, and many people living with type 1 diabetes also use devices to self-monitor their blood glucose levels throughout each day because this condition requires 24/7 care and attention. In addition to working with my care team, I’ve learned tips and tricks since I was first diagnosed 17 years ago to manage my glucose levels – but I, of course, still monitor my blood glucose levels multiple times a day, every day.”
Indeed, finding the right care team is incredibly important for people living with type 1 diabetes. For instance, an endocrinologist, a specialist who cares for people with diabetes, can work with someone living with type 1 diabetes and help them maintain normal blood glucose levels. Not only that, but they can also measure how someone is managing their disease over time, leading to the “C.”
A1C Test
An A1C test, which is also referred to as an “estimated average glucose,” can be used to show average blood sugar levels over two to three months. For people with type 1 diabetes, an A1C test can provide an overview of blood glucose management over a set period of time and help them, along with their endocrinologist, understand if any adjustments need to be made in the way they are managing their disease.
ABC Recap
It’s important to understand the role of screening before a type 1 diabetes diagnosis and the tests that are used following a diagnosis to monitor the disease and guide appropriate management. You can learn more about how to get screened early for type 1 diabetes and what to expect after screening by talking to your doctor. (BPT)
Our understanding of type 2 diabetes management is continually evolving. With this, we need to retire some older guidance. Here, we review a few common myths and the research that debunks them.
Myth: Fruit should be limited or avoided.
Fact: Diabetes patients are often advised to limit fruit in any form — whether whole, juiced, or dried — because it can raise your sugars. This is only partly true.
Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. This includes dates, raisins, and apple juice, which are often added to “no sugar” foods to sweeten them. The same does not hold true for whole fruit, whether fresh or frozen. Studies have shown that patients with diabetes don’t experience sugar level spikes, whether they limit whole fruits or consume an abundance (1). In a different study, whole fruit was even shown to reduce the risk of type 2 diabetes (2).
In yet another study, researchers considered the impacts of different types of whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load, actually lowered these levels. The only fruit tested that seemed to have a mildly negative impact on sugars was cantaloupe.
Whole fruit is not synonymous with sugar. One reason for the beneficial effect is the fruits’ flavonoids, or plant micronutrients, but another is their fiber.
Myth: All carbohydrates raise your sugars.
Fact: Fiber is one type of carbohydrate that has distinct benefits. It is important for reducing risk for an array of diseases and for improving their outcomes. This is also true for type 2 diabetes.
Two very large prospective observational studies, the Nurses’ Health Study (NHS) and NHS II, showed that plant fiber helped reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a direct relationship between the amount of metabolites and the reduction in diabetes risk: the more they consumed and the more metabolites in their urine, the lower the risk. The authors encourage patients to eat more of a plant-based diet to get this benefit.
Foods with lignans include cruciferous vegetables, such as broccoli and cauliflower; an assortment of fruits and whole grains; flaxseed; and sesame seeds (5). The researchers could not determine which plants contributed the greatest benefit; however, they believe antioxidant activity drives this effect.
Myth: You should you avoid soy when you have diabetes.
Fact: In diabetes patients with nephropathy (kidney damage or disease), soy consumption was associated with kidney function improvements (6). There were significant reductions in urinary creatinine levels and proteinuria (protein in the urine), both signs that the kidneys are beginning to function better.
This was a four-year, small, randomized control trial with 41 participants. The control group’s diet comprised 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s diet consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.
This is very important, since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism and low iodine levels should be cautious about soy consumption; some studies suggest it might interfere with synthetic thyroid medications’ effectiveness (8).
Myth: Bariatric surgery is a good alternative to lifestyle changes.
Fact: Bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of 16 randomized control trials and observational studies, the procedure led to better results than conventional medicines over a 17-month follow-up period for HbA1C (three-month blood glucose), fasting blood glucose and weight loss (9). During this period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.
However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in diabetes remission, and many regained weight. Thus, even with bariatric surgery, altering diet and exercise are critical to maintaining long-term benefits.
We still have a lot to learn with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. Emphasizing a plant-based diet focused on whole fruits, vegetables, beans and legumes can improve your outcomes. If you choose a medical approach, bariatric surgery is a viable option, but you still need to make significant lifestyle changes to sustain its benefits.
References:
(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Thyroid. 2006 Mar;16(3):249-58. (9) Obes Surg. 2014;24:437-455.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
If you have diabetes, you are at high risk of vascular complications that can be life-altering. Among these are macrovascular complications, like coronary artery disease and stroke, and microvascular effects, such as diabetic nephropathy and retinopathy.
Here, we will talk about diabetic retinopathy (DR), the number one cause of blindness among U.S. adults, ages 20 to 74 years old (1). Diabetic retinopathy is when the blood vessels that feed the light-sensitive tissue at the back of your eye are damaged, and it can progress to blurred vision and blindness.
As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (2). Why does this matter? Because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss.
Over time, DR can lead to diabetic macular edema (DME). Its signature is swelling caused by fluid accumulating in the macula (3). An oval spot in the central portion of the retina, the macula is sensitive to light. When fluid builds up from leaking blood vessels, it can cause significant vision loss.
Those with the longest duration of diabetes have the greatest risk of DME. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent damage (2).
In a cross-sectional study using NHANES data, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (4). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.
Unfortunately, the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse the damage.
What are treatment options for Diabetic Macular Edema?
While DME has traditionally been treated with lasers, injections of anti-VEGF medications may be more effective. These eye injections work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (5). The results from a randomized controlled trial showed that eye injections with ranibizumab (Lucentis) in conjunction with laser treatments, whether laser treatments were given promptly or delayed for at least 24 weeks, were equally effective in treating DME (6). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).
Do diabetes treatments reduce risk of Diabetic Macular Edema?
You would think that using medications to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (7). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. Note that DME is not the only side effect of these drugs. There are important FDA warnings for other significant issues.
To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.
This contradicts a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (8). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).
What does this ultimately mean? Both studies had weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (9). There are additional studies underway to clarify these results.
Can glucose control and dietimprove outcomes?
The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (10). Unfortunately, medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. However, an inference can be made: a nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (11, 12).
If you have diabetes, the best way to avoid diabetic retinopathy and DME is to maintain good control of your sugars. Also, it is imperative that you have a yearly eye exam by an ophthalmologist, so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. If you are taking the oral diabetes class thiazolidinediones, this is especially important.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
Sugar control and regular eye exams are your best defense
By David Dunaief, M.D.
Dr. David Dunaief
We talk a lot in the medical community about the vascular consequences of diabetes, and rightly so. If you have diabetes, you are at high risk of vascular complications that can be life-altering. Among these are macrovascular complications, like coronary artery disease and stroke, and microvascular effects, such as diabetic nephropathy and retinopathy.
Here, we will discuss diabetic retinopathy (DR), the number one cause of blindness among U.S. adults, ages 20 to 74 years old (1). Diabetic retinopathy (DR) is when the blood vessels that feed the light-sensitive tissue at the back of your eye are damaged, and it can progress to blurred vision and blindness.
As of 2019, only about 60 percent of people with diabetes had a recommended annual screening for DR (2). Why does this matter? Because the earlier you catch it, the more likely you will be able to prevent or limit permanent vision loss.
Over time, DR can lead to diabetic macular edema (DME). Its signature is swelling caused by fluid accumulating in the macula (3). An oval spot in the central portion of the retina, the macula is sensitive to light. When fluid builds up from leaking blood vessels, it can cause vision loss.
Those with the longest duration of diabetes have the greatest risk of DME. Unfortunately, many patients are diagnosed with DME after it has already caused vision loss. If not treated early, patients can experience permanent damage (2).
In a cross-sectional study using NHANES data, among patients with DME, only 45 percent were told by a physician that diabetes had affected their eyes (4). Approximately 46 percent of patients reported that they had not been to a diabetic nurse educator, nutritionist or dietician in more than a year — or never.
Unfortunately, the symptoms of vision loss don’t necessarily occur until the latter stages of the disorder, often after it’s too late to reverse the damage.
Treatment options
While DME has traditionally been treated with lasers, injections of anti-VEGF medications may be more effective. These eye injections work by inhibiting overproduction of a protein called vascular endothelial growth factor (VEGF), which contributes to DR and DME (5).
The results from a randomized controlled trial showed that eye injections with ranibizumab (Lucentis) in conjunction with laser treatments, whether laser treatments were given promptly or delayed for at least 24 weeks, were equally effective in treating DME (6). Other anti-VEGF drugs include aflibercept (Eylea) and bevacizumab (Avastin).
Risk from diabetes treatments
You would think that using medications to treat type 2 diabetes would prevent DME from occurring as well. However, in the THIN trial, a retrospective study, a class of diabetes drugs, thiazolidinediones, which includes Avandia and Actos, actually increased the occurrence of DME compared to those who did not use these oral medications (7). Those receiving these drugs had a 1.3 percent incidence of DME at year one, whereas those who did not had a 0.2 percent incidence. This incidence was persistent through the 10 years of follow-up. Note that DME is not the only side effect of these drugs. There are important FDA warnings for other significant issues.
To make matters worse, those who received both thiazolidinediones and insulin had an even greater incidence of DME. There were 103,000 diabetes patients reviewed in this trial. It was unclear whether the drugs, because they were second-line treatments, or the severity of the diabetes itself may have caused these findings.
This is in contrast to a previous ACCORD eye sub-study, a cross-sectional analysis, which did not show an association between thiazolidinediones and DME (8). This study involved review of 3,473 participants who had photographs taken of the fundus (the back of the eye).
What does this ultimately mean? Both studies had weaknesses. It was not clear how long the patients had been using the thiazolidinediones in either study or whether their sugars were controlled and to what degree. The researchers were also unable to control for all other possible confounding factors (9). There are additional studies underway to clarify these results.
Glucose control and diet
The risk of progression of diabetic retinopathy was significantly lower with intensive blood sugar controls using medications, one of the few positive highlights of the ACCORD trial (10). Unfortunately, medication-induced intensive blood sugar control also resulted in increased mortality and no significant change in cardiovascular events. However, an inference can be made: a nutrient-dense, plant-based diet that intensively controls blood sugar is likely to decrease the risk of diabetic retinopathy and further vision complications (11, 12).
If you have diabetes, the best way to avoid diabetic retinopathy and DME is to maintain good control of your sugars. Also, it is imperative that you have a yearly eye exam by an ophthalmologist so that diabetic retinopathy is detected as early as possible, before permanent vision loss occurs. If you are taking the oral diabetes class thiazolidinediones, this is especially important.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.
In some patients, small amounts of wine may reduce cardiovascular risks
By David Dunaief, M.D.
Dr. David Dunaief
Our understanding of diabetes — its risks and treatment paradigms — is continually evolving and improving. This is good news, since the current rate of diabetes among the U.S. adult population is 13 percent, while another estimated 88 million U.S. adults have prediabetes (1).
What is prediabetes? Typically, it’s when fasting glucose levels (HbA1C) sit in the 5.7 and 6.4 percent range.
With diabetes comes a host of other health complications, including increased heart attack risk. However, cardiovascular risk and its severity may not equally affect men and women. In two trials, women with type 2 diabetes had greater cardiovascular risk than men. In one retrospective study, women with diabetes were hospitalized due to heart attacks at a higher rate than men, although both had substantial risk increases, 162 percent and 96 percent, respectively (2).
What might reduce our risks for diabetes or its complications? Fortunately, we have options. These include diet improvements, timing of blood pressure medications, and, oddly, modest wine consumption.
Diet bests metformin fordiabetes prevention
All too often in the medical community, we are guilty of reaching for drugs and either overlooking lifestyle modifications or expecting that patients will fail with them. This is a disservice; lifestyle changes may be more effective in preventing this disease.
In a head-to-head comparison study, diet plus exercise outperformed metformin for diabetes prevention (3). This study was performed over 15 years of duration in 2,776 participants who were at high risk for diabetes because they were overweight or obese and had elevated sugars.
There were three groups in the study: one received a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; one took metformin 875 mg twice a day; and one was a placebo group. Diet and exercise reduced diabetes risk by 27 percent, while metformin reduced it by 18 percent over the placebo, both reaching statistical significance. Note that, while these are impressive results that speak to the use of lifestyle modification and to metformin, the diet they used was not an optimal diabetes diet.
Blood pressure medications’ timing
Interestingly, taking blood pressure medications at night has an odd benefit, lowering the risk of diabetes (4). In a study, there was a 57 percent reduction in the risk of developing diabetes in those who took blood pressure medications at night rather than in the morning.
It seems that controlling sleep-time blood pressure is more predictive of diabetes risk than morning blood pressure or 48-hour ambulatory blood pressure. This study had a long duration of almost six years with about 2,000 participants.
Researchers used three blood pressure medications in the trial: ACE inhibitors, angiotensin receptor blockers (ARBs) and beta blockers.
The first two have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, these had the most powerful effect on preventing diabetes. Furthermore, when sleep systolic (top number) blood pressure was elevated one standard deviation above the mean, there was a 30 percent increased risk of type 2 diabetes.
Interestingly, the RAAS-blocking drugs are the same drugs that protect kidney function when patients have diabetes.
Can wine help?
Diabetes patients are often warned to limit or eliminate alcohol. A significant part of the reasoning relates to how the body metabolizes alcohol and sugars. So, the results of a study that showed small amounts of wine could have benefits in reducing diabetes-associated complications among those whose sugars were well-controlled sent ripples throughout the medical community.
The CASCADE trial, a randomized controlled trial, shows wine may have heart benefits in well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (5).
Patients were randomized into three groups, each receiving a drink with dinner nightly. One group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank the red wine saw a significant increase in their “good cholesterol” HDL levels, an increase in apolipoprotein A1 (the primary component in HDL) and a decrease in the ratio of total cholesterol-to-HDL levels compared to the water-drinking control arm. In other words, there were significant beneficial cardiometabolic changes.
White wine also had beneficial cardiometabolic effects, but not as great as red wine. However, white wine did improve glycemic (sugar) control significantly compared to water, whereas red wine did not. Also, slow metabolizers of alcohol in a combined red and white wine group analysis had better glycemic control than those who drank water. This study had a two-year duration and involved 224 patients. All participants were instructed to follow a Mediterranean-type diet.
Does this mean diabetes patients should start drinking wine? Not necessarily. This was a small study, and participants were well-controlled type 2 diabetes patients who generally were nondrinkers.
We need to reverse the trend toward higher diabetes prevalence. The good news is that we’re continuing to learn what lowers diabetes risk and, for those with Type 2 diabetes, what can improve cardiovascular risks.
References:
(1) cdc.gov. (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online Sept. 11, 2015. (4) Diabetologia. Online Sept. 23, 2015. (5) Ann Intern Med. 2015;163(8):569-579.
Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.
