Back ground
The risk of developing cardiovascular disease is two 2 to 3 times higher in people with Type 2 diabetes!
Cardiovascular disease is the #1 cause of death and disability in people with Diabetes !
Question
"Will lowering my blood sugar more help me prevent a heart attack "
Yes____ No____ Maybe____ I don't know____
This question was discussed in a recent CME ( Continuing Medical Education course ) in MedScape
An Update on Glycemic Control and Cardiovascular Disease in Diabetes CME
Robert S. Rosenson, MD, FACC Faculty and Disclosures
CME Released: 06/29/2012; Valid for credit through 06/29/2013
Classic studies
Type 1 diabetes
DCCT demonstrated the benefits of achieving an A1c level of 7 in patients with type 1 diabetes with a significant reduction in the risk for developing eye , nerve and kidney damage but no significant reduction in the risk for heart disease. A followup study , EDIC , completed 17 years later on the same group of patients found a 42% relative risk reduction for any cardiovascular event in the intensive treatment group even though the A1c settled to an average of about 8 shortly after the original study was completed in both groups.
Type 2 Diabetes
UKPDS - This study also demonstrate a significant reduction in the risk for developing eye , nerve and kidney damage in the intensive treatment group , with a A1c of 7 , compared to the control group. There was also a non- significant 14% reduction in the risk of developing cardiovascular disease in the intensive treatment group treated with sulfonylyureas and /or insulin. A sub-group , treated with metformin , did show a significant reduction of 39% in the risk of developing heart disease. Another sub-group of older by 5 years , more overweight with higher sugars did not show the benefit from taking metformin.
comment- I recall one curve on a slide from the UKPDS study that suggested that achieving an A1c
below 7 and closer to 6 would demonstrate a reduction in the risk for developing
cardiovascular disease . A study done years later called the ACCORD study failed to answer
the question.
ACCORD study
This study evaluated the vascular outcome comparing patients treated to achieve an A1c of <6 to a control group. The study was discontinued early due excess mortality in the intensive treatment group.
There was also a significant increase in the risk of severe hypoglycemia in the intensive treatment group. Subsequent analysis of the data uncovered some interesting findings .
*The excess mortality seemed to occur in the patients struggling to achieve an A1c of less than 6 and
not in the patients easily achieving an A1c of <6 .
* The A1c was the strongest predictor of mortality with most of the increased risk occurring in patients
with a A1c > 7 in both groups
ADVANCE study ( type 2 diabetes )
This study compared intensive treatment , A1c goal of 6.5 , to standard treatment over 5 years.
Mean A1c in the Hypoglycemia
intensive treatment group - 6.5 2.7%
control group - 7.3 1.5%
Results
Glucose control did not significantly reduce the risk of heart disease
Intensive treatment did increase the risk of hypoglycemia
intensive treatment did reduce the risk of developing kidney disease
VADT study
Compared A1c levels of 6.9 in the intensive treatment group vs 8.4 in the control group and found no difference in the the risk for developing heart disease. However a subsequent analysis of the data revealed that patient with Diabetes of less than 15 years duration seemed to have a significant benefit from intensive treatment.
What does this mean to you and I in our every day dealing with diabetes ?
Any comments ?
My thoughts tomorrow.
Have fun , Be smart , just doing your best may be a good thing
David Calder,MD
Thank you for great support
Rachel garcia
MONDAY, JANUARY 30, 2012
Omega -3 - fatty acids and Heart Disease
We know that Omega 3 fatty Acids , EPA and DHA, in Fish Oil reduce triglyceride levels but do they reduce the risk of having heart disease.
There is one study done in Japan, Jelis Study (Japan EPA Lipid intervention Study) reported in Lancet 2007;369: 1090-8
This study was included 18,000 patients with and without heart disease with total cholesterol of 251 mg/dl (6.5 mmol/L ) and LDL of 171 ( 4.4 mmol/L ) and randomized to a low dose statin alone or a statin plus 1.8 grams of EPA purified from omega - 3- fatty acids in fish oil and followed for an average of 4.6 years.
Results ;
Statin only group --- ------------ 3.5% had a major coronary event
Statin plus 1.8 grams of EPA -- 2.8% had a major coronary event
A 19% relative risk reduction in the group receiving 1.8 gms of EPA
There was a followup analysis of this study reported in Artherosclerosis 2009 may:204(1):233.
This analysis looked at people in the Jelis study with elevated Triglycerides > 150 mg/dl and
HDL < 40 mg/dl. In this higher risk group, EPA treatment resulted in a 53% relative risk reduction.
There is another planned study - REDUCE IT ( Reduction of Cardiovascular Events with EPA intervention trial ) that will specifically look at the effects of Triglyceride reduction and cardiovascular risk. Hopefully this study , to be completed in 6 years ,will provide us with a more definitive answer .
For now , Omega 3 fatty acids , are still my first choice.
Have fun , Be Smart and Defeat Diabetes
David Calder,MD
Click on the link below to learn more about ," Fixing The 9 " and preventing heart disease.
Diabetes Office Visits- Helps You Prevent Heart Disease
SATURDAY, FEBRUARY 4, 2012
Shopping for Omega -3 Fatty Acids can be confusing
HINT- Save 45.6 seconds of your day by just reading the bold print
Shopping for Omega- 3- Acids can sometimes be confusing. I was in a store yesterday that had at least 6 different brands of Omega -3 - fatty acids on their shelves.
My wife has elevated triglycerides and takes 4 to 5 grams of " Omega -3- FA" /day and I have normal triglycerides and take close to 2 gms/day. The American Heart Association recommends 1 gm/day for someone without elevated triglycerides or heart disease. I have attached a copy of the American Heart Association recommendations below. The Jelis study , that we discussed on Jan. 30 , found a 19% relative risk reduction for a cardiovascular event by taking 1.8 gms of purified EPA for people with and without known heart disease or triglyceride problems.
I feel like a well informed consumer and had a simple goal of finding the smallest capsule with the highest amount of Omega -3 Fatty acids. My wife and I spent about 20 minutes reading labels using our calculator to find the pill that best met our goals. I have 3 different bottle setting in front of me now.
# 1 1200 mg of natural fish oil concentrate with 684 mg Omega -3 -Fatty acids
smaller print EPA 410 mg
DHA 274 m
Total amount /capsule--------- 684
# 2 Fish oil 1400mg/980 omega-3
smaller print EPA 647 mg
DHA 253 mg
other *****
Total amount /capsule---------- 900 mg
# 3 Cod Liver Oil high in EPA and DHA / Omega - 3 - Fatty acid 1100 mg
smaller print EPA 400 mg
DHA 500 mg
Other *****
Total amount per teaspoon 900 mg
I am not sure which omega -3 fatty acid is named "other ". I personally prefer to use EPA and DHA because they have been shown to be effective. We chose #2 because it had a little more Mg / capsule than #1 and also had more EPA and less "other" than #3.
I plan to take 2 capsules /day and my wife will take 5 capsules /day. We have lipid panels scheduled for next month.
What is in that "Other " category ? What is alpha linolenic acid ? Find out tomorrow.
Happy shopping,
David Calder, MD
My friend , a fellow blogger and founder of 1 diseaseworldvoice.org and Laffing at Life is shopping for Omega 3's today and may have a comment about his experience.
AMERICAN HEART ASSOCIATION RECOMMENDATIONS
Fish is a good source of protein and, unlike fatty meat products, it’s not high in saturated fat. Fish is also a good source of omega-3 fatty acids. Omega-3 fatty acids benefit the heart of healthy people and those at high risk of — or who have — cardiovascular disease. Research has shown that omega-3 fatty acids decrease risk of arrhythmias (abnormal heartbeats), which can lead to sudden cardiac death. Omega-3 fatty acids also decrease triglyceride levels, slow the growth rate of atherosclerotic plaque and lower blood pressure (slightly).
Benefits vs. Risks of Eating Fish
Top 10 Fish and Shellfish in the United States Based on Consumption
Fish with the Highest Levels of Mercury (about 1 ppm)
(grams per 3-oz. serving)
(grams per 3-oz. serving)
MONDAY, FEBRUARY 6, 2012
The 'Other" Omega -3- Fatty acids
Three of those have received the most attention as being beneficial to our health. These include Alpha- Linolenic Acid (ALA), EPA and DHA.
I did not see ALA ( alpha - linolenic acid) listed as a primary ingredient on the packages I looked at , so it must fall into the "other" category.
ALA cannot be over looked because it is the parent fatty acid to EPA and DHA.
Alpha -linolenic acid is found in vegetables such as rape seed used to produce canola oil, flax seed, walnuts, TOFU , spinach, Romaine lettuce ,soybeans, turnip greens, brussels sprouts, raspberries green beans and others. I generally think of the sources of ALA as Beans, Greens and Nuts.
Our bodies can convert Alpha- Linolenic Acid to EPA and DHA,however;
This conversion process is not efficient so we tend to delegate this job to fatty cold water fish , such as Sardines , salmon , Cod , Tuna ,Herring ,shrimp and scollops .
In summary eating greens,beans,nuts (especially walnuts) and cold water fish is not a bad idea. It reminds me of something called the Mediterranean diet.
Have fun eat healthy and defeat diabetes
David Calder,MD