Diabetes Education

It is generally assumed that those who receive diabetes education will continue to act well after receiving information. Women who are contemplating pregnancy who have pregestational diabetes have an unusual focus on how to take care of their diabetes, but does it last?

Those who had attended an intensive diabetes management program in pregnancy were interviewed to see if long-term benefits from an intensive diabetes management program during pregnancy persisted. Diabetes Care 29:526-530, 2006

In the long term, retention of some of these behaviors of diabetes management and knowledge were noted. However, this was not reflected in an improved A1C level after 5 plus years.

Education is a life long adventure.

L-Arginine Rebuttal

A recent article came out condemning l-arginine as causing death after heart attacks. This is the time you need it most of all and my personal experience in my office is that l-arginine has stopped heart attack and stroke so that for my patients, only 0.05% visit the cardiologists for anything at all each year.

This is my rebuttal to the article.

Response to JAMA 1/4/06 Vol 295, No.1, 58-64,
L-arginine therapy in Acute Myocardial Infarction

There are over 40,000 articles which are generally positive on the use of l-arginine to reverse arterial lining (endothelium) elasticity, atherosclerosis, homocysteine and viral damage. How did these authors come to opposite conclusions to these prior studies?

* They started with smaller amounts of l-arginine, 3 gm rather than the 5 grams thought to be the therapeutic amount.
* They reduced the 3 gm to lower amounts if the patients had “side effects” symptoms. They did not state who and how much.
* The source of l-arginine is from a company whose product I do not know.

Patient management had other curious notes.
* Elasticity did not change on treatment. Most research note that this reflects insufficient l-arginine given to the patient.
* Diabetes was “well controlled” – meaningless in the hands of cardiologists unless there are HbA1c etc to prove control.
* Plasma l-arginine changed to less on treatment – how little were they taking? At what times and how often was it decreased in those who died?

This is cardiologists’ research. If treatment does not change elasticity/vascular stiffness like it did for all the references the authors quote shouldn't investigators change the treatment to more l-arginine?
* They quoted 6 articles in the introduction that said l-arginine improved vascular elasticity. Why not follow these articles protocol? This study set out to show endothelial integrity (effect on heart attack) not arterial elasticity.
* Why do a study that didn't achieve the basic starting point and then pronounce l-arginine is dangerous.
* How long did the patients have diabetes? What were other co-morbid states? HbA1c values? What treatments were used for those with diabetes? How well were they controlled during the study? Were the cardiologists attentive to the diabetes care?
* Were the Cardiologists who reviewed this paper aware of the prior science of l-arginine?

There are all sorts of bad science with “significant outcomes” that get published and quoted over the years even though the study design is seriously flawed. Put this publication on the list to join,
* The University Group Diabetes Project – Diabetes – 1970 – don't give all the Orinase in a maximum dose at one time.
* The Effect of Monochromatic Infrared Energy on Sensation in Patients With Diabetic Peripheral Neuropathy Diabetes Care 28:2896-2900, 2005 – don't use subjective measurement of neuropathy when it can be quantitated with FDA approved testing.
* Two New England Journal of Medicine March 16, 2006 stating folic acid and B vitamins a useless to present heart disease – don't recognize that elevated homocysteine is due to an underlying metabolic disorder that needs correction as well as control with folic acid and vitamin Bs.

It’s hard to understand that science does not always agree on any one situation. As doctors, it is up to us to understand the perspective that any science brings and give you the meaning of how to go forward in your life. The people who died all had diabetes. After all, it’s your time.

The Byetta Story

People with diabetes 2 have beta cell dysfunction, the cells that make and release insulin, and a decreased beta cell mass due to apoptosis – death of beta cells. This has highlighted the role of incretin hormones GIP and GLP-1 in beta cell function, growth and development.

The incretins are peptide hormones secreted by specific cells located in the small intestine in response to food intake. In the pancreas, incretin hormones act to increase glucose-dependent insulin secretion from beta cells and are essential for maintaining after meal glucose control.

There are observations to be noted in people with diabetes 2 before any diagnosis of an abnormal glucose is made. The disorder begins far sooner than the abnormal glucose indicates.

• The rapid release of insulin is completely absent at the time of diagnosis of diabetes 2.
• Total beta cell function and mass is half normal at time of diagnosis.

The remainder of the natural history of diabetes 2 is now well understood.

• Total beta cells, beta cell mass in people with diabetes 2, decreases linearly for the first 10 years if no intervention occurs.
• L-arginine still produces insulin response during this time.
• Glyburide and other sulfonylureas also produce a normal insulin response.

Apoptosis occurs at an increased rate in this stage of diabetes 2. There are treatments used to treat the high glucose that can decrease the life of the beta cell. These medications include the following.

• Starlix, Prandin and Glyburide
Byetta, fondly referred to as “lizard spit”, seems to reverse all of these negative diabetes 2 processes and treatments quite handily. It is quite similar to GLP-1 having been altered slightly to be able to patent the molecule. There are other unique features that make it quite safe. It acts to,
• Increase first phase insulin response
• Increase late phase and total insulin production.
• It inhibits glucagon release
• It lowers its power as glucose goes to normal thus decreasing the chance of hypoglycemia.

Additionally it increases important regulation of beta cell gene expression for the following.

• Glukinase – aids release of glycogen from liver
• Insulin production
• Glucose transporters – decreasing insulin resistance

Finally, Byetta will increase beta cell mass through replication of beta cell and decreased apoptosis.

It appears that Byetta will reverse the natural decline of the Islands of Langerhans where the beta cells reside and add a few more things that give the reversal a “soft landing” that makes it quite safe. The decrease in apoptosis and increase in beta cell mass mark this product as an exceptional advance in the care of patients with diabetes 2. We now are using Byetta in many people with type 1 with very good preliminary results.

This doesn’t even take into consideration the intangibles such as decreased fatigue, increased muscle strength and diminished abdominal fat patients love perhaps most of all.

It’s your time.

Vitamin D, or Vitamin D Hormone?

Vitamin D deficiency is common in the United States and worldwide. It is known to be important in bone mineral metabolism but now we have information that it does much more.

Vitamins are generally known to be responsible for a single disease and appropriate supplementation should correct the disease. A hormone goes to distant tissues and makes multiple metabolic improvements. That‘s vitamin D’s job.

Your levels of vitamin D should be much higher than previously thought. Certainly much higher than noted on the milk carton or vitamin pills in the local drug store. Here is the story for today.

Eight hundred to a thousand IU is needed in general but as we age we need much more. I like liquid formulations best because as you age D is more difficult to absorb. It is probably best to consume that thousand IU daily for consistency in improving all the things Vitamin D will do for you.

For example hip fracture drops 23% and other non-vertebral fractures drop 26%. We know about retarding bone loss as we age but did you that it works on the muscles as well? Lower extremity strength and improved walking were shown in several studies in older people. The risk of falling is improved 22%. It’s nice to have less muscle pain, walk a little faster and get out of a chair quicker than the other seniors. Arthritis is decreased in severity as well.

Many cancers are also significantly diminished in occurrence by increasing vitamin D. These include cancers of the colon, breast, and prostate. Other metabolic disorders include type 1 diabetes, hypertension, cardiovascular disease, possibly type 2 diabetes and multiple sclerosis.

Vitamin D is a potent modulator of activated T and B-lymphocytes, the workhorses of the immune system. Animal models show prevention of rheumatoid arthritis, and Crohn’s Disease of the bowel. Research has shown marked improvement in psoriasis as well.

If that isn’t enough, it is generally noted that there is a distinct improvement in well being and energy, often in the first week. All these improvements were reported in Endocrine News, a publication of the Endocrine Society in the August/September issue 2005 beginning on page 10.

It’s remarkable what you can do for yourself when you couple reliable information about health into action for your life. It’s not just good it’s thrilling. It’s the way life is supposed to be.

It’s your time.

Inflammation Explanation

Today, treatment of gum disease is no longer just in the mouth. Inflammation was thought to be isolated to tissue such as gums, and arteries and did not interact with one another. Now it is clear that inflammatory mediators released in different tissues in the mouth can accelerate low-grade inflammation in distant tissues such as in arteries. Gum disease will rapidly increase hardening of the arteries.

Sustained inflammatory activity is a characteristic feature of atherosclerosis (cholesterol) and arteriosclerosis (hard and brittle) artery disease. Cholesterol deposited in plaques in artery walls increases inflammation that weakens the arterial wall and the inner lining, the endothelium. Inflammation is also a determinant of plaque vulnerability, plaques that rupture then causes heart attack and stroke.

You can measure your risk of these two processes, treat to reverse your risk and confirm the return to normal. CRP (hs) is a blood test that measures the process of inflammation. Secondly, the CVProfiler, a noninvasive test done similar to the standard blood pressure, measures the state of hardness of the arteries. The CRP(hs) measures the process of atherosclerosis. The CVProfiler measures arterial elasticity, which is treated in a different way.

Cardiovascular health depends on total metabolic health. Vitamin D is now known to contribute to vascular health. People need more than the minimum daily requirement established 70 years ago. Homocysteine, a normal amino acid in the body, should be low. Treat to normal will give both health and energy. More than coping, reversing.

There are tests to monitor the risks.
• Blood level of hs-CRP
• Cholesterol (VAP)
• CVProfilor or OMRON HEM 9000 AI
• 25-OH Vitamin D, 1-25 OH-Vitamin D
• Homocysteine

It's your time! Dr. Joe

References

Saremi, A. et al. Diabetes Care 28: 27-32, 2005

Geerts, S. et. al., Further evidence of the Association Between Periodontal Conditions and Coronary Artery Disease. Journal of Periodontology 2004, Vol 75, No. 9 Pages 1274 1280.

Libby P. Vascular Biology of Atherosclerosis: Overview and State of the Art. Am J Cardiology 2003:91 (suppl)) 3A-6a.

Grey, E.: et al. Small but not Large Artery Compliance Predicts Cardiovascular Events. Am J of Hypertension 13 (2) No. B059, 2000.

Boushey et al, A Quantitative Assessment of Plasma Homocysteine as a Risk Factor for Vascular Disease. JAMA 1995; 274: 1049-57.

Vitamin D: What’s Enough, Science News, October 16, 2004 Vol. 166.

J. Joseph Prendergast has been a practicing physician for over 30 years. He is Board Certified in Internal Medicine as well as Endocrinology and Metabolism. Dr. Prendergast has published nearly 40 medical articles in well-known publications such as the Journal of the American Medical Association, The New England Journal of Medicine and Diabetes Care. In 1986, Dr. Prendergast formed a single specialty endocrinology practice, Endocrine Metabolic Medical Center and a non-profit research foundation, The Pacific Medical Research Foundation. For more information: Visit the EMMC web site & sign up for Dr. Joe’s free newsletter. My story, “Dr. Joe, The Uncommon Doctor” tells what this has meant to me so far.

The Nitric Oxide Pathway

I first learned of the nitric oxide pathway through friends’ work in the cardiovascular system and the possibility of reversing cardiovascular disease. For them the exciting part was rapid promotions through the academic systems to Chairman of the Department of Medicine in one major University and Director of Cardiovascular Research at yet another.

For me, and my friendship with them, it was a wonderful moment to share with them as they achieved their life’s dream of academic success. For me personally it was the beginning of the use of l-arginine to reverse my personal struggle with cardiovascular disease and continue a long productive career in metabolic medicine. This all culminated in the awarding of the Nobel Prize in Medicine in 1998, which recognized the huge potential for health the understanding of the Nitric Oxide (NO) Pathway affords.

My story, “Dr. Joe, The Uncommon Doctor” www.theuncommondoctor.com tells what this has meant to me so far. I say so far because I will tell you the broadening scope of the power of this pathway and what it means to us all for the future.

Anti-aging is on everyone’s tongue this year as the prime excitement from new research. The reversal of the arterial damage of cardiovascular disease is now recognized as reversal of the aging artery. What else might this involve?

Nothing is firm enough to know for sure but 85 review articles have been published in the last 7 years on the reversal of the following disorders.
• Cardiovascular disease
• Cardiomyopathies
• Age in general
• Hypertension of aging
• Saving the heart and kidney in disease
• Anti-inflammatory therapy
• Reversal of insulin resistance
• Erectile dysfunction in diabetes
• Heart failure
• Brain ageing

All sorts of therapies are being explored that influence the Nitric Oxide Pathway but the use of l-arginine as a “novel therapy” is being tested in virtually all of these.

I used l-arginine years ago when I was at UCSF to see if it would stimulate growth hormone when given by mouth. It did not. This is good because that means it will only make the eyes better in diabetes, not worse. When given by mouth it will likely help all these conditions.

Most likely, as some of the investigators are trying, we will just have to take a lot more to get all the good aspects of improving the Nitric Oxide Pathway.