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Volume 8, Number 2 February 2005 - National Diabetes Education ...

THOMSON HEALTHCARERelease Date: January 2005Valid Until: June 2006This educational activity is a component ofthe National Diabetes Education Initiative ®(NDEI ® ) sponsored by Thomson ProfessionalPostgraduate Services ® (PPS), Secaucus,New Jersey.Issue No. 2, February 2005, is part of a12-part CME activity (January–December2005). Physicians who wish to receive CMEcredit for this educational activity should dothe following: (1) read each of the 12 monthlyissues in the series and retain them for futurereference; (2) review the original articles discussedin their entirety; and (3) after completingthe last issue of the year (December 2005),obtain the post-test to complete the CMEactivity. The post-test may be obtained fromwww.ndei.org or by calling 1 (800) 606-6106and requesting the post-test. You will receivethe post-test, registration, and evaluationforms by fax. To receive CME credit, the participantmust complete the 12-part series andpost-test and return the completed registrationand evaluation forms to: Thomson ProfessionalPostgraduate Services, Attn: CME Dept. T129,PO Box 1505, Secaucus, NJ 07096-1505(Fax: 1 [201] 430-1441).Applicants will receive a certificate of participationfrom PPS by return mail within6 to 8 weeks of the date of receipt of thecompleted evaluation/registration form.Learning ObjectivesAfter studying the literature presented inthis Clinical Insights in Diabetes series,participants will be able to:• Identify patients with type 2 diabetesand the metabolic syndrome• Select an appropriate therapeutic regimenfor patients with type 2 diabetesand the metabolic syndrome• Summarize risk factors for cardiovasculardisease in patients with type 2 diabetesand the metabolic syndromeThis CME activity is sponsored by ThomsonProfessional Postgraduate Services ® ,Secaucus, NJ.Thomson Professional Postgraduate Services ®is accredited by the Accreditation Council forContinuing Medical Education to providecontinuing medical education for physicians.Thomson Professional Postgraduate Services ®designates this educational activity for amaximum of 4 category 1 credits toward theAMA Physician’s Recognition Award. Eachphysician should claim only those credits thathe/she actually spent in the activity.This CME activity is supported by anunrestricted educational grant fromTakeda Pharmaceuticals North America, Inc.and Eli Lilly and Company.National Diabetes Education Initiative,NDEI, and Clinical Insights in Diabetes aretrademarks used herein under license.Copyright © 2005 ThomsonProfessional Postgraduate Services ® .All rights reserved.MAYER B. DAVIDSON, MD,* CO-EDITOR-IN-CHIEF; JAMES W. REED, MD, MACP, FACE, † REVIEWER;TERRENCE F. FAGAN, ‡ MANAGING EDITORChoice of Diet Plan Less Important ThanDiet AdherenceADiabetesVOLUME 8, NUMBER 2 • FEBRUARY 2005CLINICAL INSIGHTS INstudy of four popular diet plansshowed that diet adherence was moreeffective than the choice of diet for weightloss and heart disease risk reduction.Dansinger and colleagues enrolled agroup of 160 overweight or obese participants(mean body mass index [BMI]:35 kg/m 2 ; range, 27-42 kg/m 2 ) to a 1-yeartrial of the respective dietary componentsof the Atkins, Ornish, Weight Watchers,and Zone diets. The participants were aged22 to 72 years (mean[standard deviation, SD]age, 49 [11] years) withknown dyslipidemia,hypertension, or fastinghyperglycemia; baselinecharacteristics did notdiffer significantly betweengroups. Participantswere randomly assigned to theAtkins (low carbohydrate, n=40), Ornish(low-fat vegetarian, n=40), Weight Watchers(reduced calories, n=40), and Zone(nutrient balance, n=40) diets. Recommendationsregarding exercise, dietarysupplements, and external support werestandardized for all 4 groups.Outcome measures, assessed at 2, 6,and 12 months, were changes in baselinecardiovascular risk factors, changes inweight, and dietary adherence. Adherencewas based on participant self-reporting.Study dropout rates were high; 61 participants(38%) dropped out by 6 months, 67(42%) by 12 months. The most commonA strong association wasobserved between dietadherence and weightloss but not between diettype and weight lossreasons cited for dropping out of the studywere the assigned diet was too difficult tofollow or not yielding sufficient weight loss.With baseline values of those who discontinuedparticipation carried forward, all 4diets in the preliminary intent-to-treat analysisshowed modest statistically significantweight loss at 12 months. Mean (SD) weightloss was 2.1 (4.8) kg for Atkins (21 [53%] ofparticipants completed the study, P=0.009),3.3 (7.3) kg for Ornish (20 [50%] completed,P=0.007), 3.0 (4.9) kg forWeight Watchers (26 [65%]completed, P

CLINICAL INSIGHTS IN DIABETESChoice of Diet Plan Less Important Than Diet AdherenceContinuedC-reactive protein levels by approximately15% to 20% (P

CLINICAL INSIGHTS IN DIABETESReduced C-Reactive Protein Levels SignificantlyRelated to Reduced Rate of Atherosclerosis WithIntensive Statin TreatmentContinuedatherosclerosis than patients with reductionslower than the median (P=0.001). Aweak but significant association was foundbetween the reduction in LDL-C levels andthe reduction in CRP levels for the totalgroup of patients (r=0.13, P=0.005; N=502),but not in the pravastatin or atorvastatingroup alone, demonstrating that the CRPreductions are largely not associated withthe decrease in LDL-C levels.The authors concluded that intensivestatin treatment in patients with atherosclerosisreduces the progression of the diseaseand that the reduction is significantly relatedto greater reductions in the levels ofboth atherogenic LDL-C and CRP.Nissen SE et al. Statin therapy, LDL cholesterol,C-reactive protein, and coronary artery disease.N Engl J Med. 2005;352:29-38.Using anaggregate scoreof weightedcardiac riskfactors may bemore effectivethan countingthe number ofrisk factors.When to Screen for Occult CAD in AsymptomaticPatients With DiabetesType 2 diabetes is a recognized riskequivalent for coronary artery disease(CAD), and it is associated with a two- tofourfold increase in the risk of developingCAD. The 30-day mortality rate for apatient with diabetes increases by morethan 50% after a myocardial infarction(MI). Also, the risk of an MI in people withdiabetes but no previous MI is equivalentto those without diabetes but with a previousMI.Studies have found that occult CAD isfound among 20% of healthier asymptomaticpatients with diabetes and >50% inasymptomatic patients with more complicateddiabetes. The challenge, Di Carli andHachamovitch report, is to identify asymptomaticpatients with diabetes who haveoccult or silent CAD. A normal stress singlephotonemission computed tomography(SPECT) scan was associated with low CVDrisk in patients without diabetes, but wasnot the case in patients with diabetes. Inaddition, in the abnormal SPECT setting,the risk conferred by any abnormality isgreater in patients with diabetes thanthose without.American Diabetes Association (ADA)guidelines recommend screening for occultCAD in asymptomatic patients with diabeteswith an abnormal resting ECG or withevidence of carotid or peripheral occlusivearterial disease, and current evidence supportsthese recommendations. The data arenot as strong for the ADA recommendationto screen patients with suspicious symptomsof CAD, such as chest pain and fatigue,although dyspnea may suggest greater risk.ADA recommendations of testing patientswith greater than two cardiac risk factorshave been found to be no more effectivethan screening those with fewer than twofactors.The study’s authors suggest that usingan aggregate score of weighted risk factorsmay be more effective than counting thenumber of risk factors, and that othermarkers of autonomic functions such as theValsalva heart rate ratio should be considered.Another option may be testing foratherosclerotic burden with noninvasiveprocedures such as the use of a calciumscore threshold, intima-medial thicknessratios, or ankle-brachial indices, and thatfurther investigation of these strategies iswarranted.Di Carli MF and Hachamovitch R. Should we screenfor occult coronary artery disease among asymptomaticpatients with diabetes? J Am Coll Cardiol.2005;45:50-53.3

CLINICAL INSIGHTS IN DIABETESNDEI upcoming CME eventsNDEI MISSIONSTATEMENTNDEI is a multicomponenteducational program ontype 2 diabetes designed forendocrinologists, diabetologists,cardiologists, primarycare physicians, and otherhealthcare professionals involvedin the care and managementof patients withtype 2 diabetes and insulinresistance. NDEI programsaddress issues concerninginsulin resistance and type 2diabetes, from the epidemiologyand pathophysiology ofthe disease and its associatedcomplications to the therapeuticoptions for treatmentand prevention.• New on-demand CME program: “Integrating Metabolism, Inflammation,and CVD: Translating Emerging Science into Clinical Practice.” Explore thecurrent thinking on PPARs and PPAR agonists and earn free CME online atwww.ndei.org.• New on-demand CME program: “A Case-Based Approach to Type 2 Diabetesand the Metabolic Syndrome.” Log on to www.ndei.org to learn to identifytreatment targets and therapeutic options.• Log on for the free CME on-demand activity “Altering Clinical Outcomes inType 2 Diabetes and Metabolic Syndrome” at www.ndei.org. Delve intoinsulin resistance and macrovascular complications linked to CVD.For more information about upcoming NDEI CME activities, visit usat www.ndei.org or call 1 (800) 606-6106.Visit www.ppscme.org for information on other CME activities.Clinical Insights in Diabetes is co-edited by NDEI faculty members Mayer B.Davidson, MD, and Silvio E. Inzucchi, MD.Clinical Insights in Diabetes is available to you via email. If you would like toreceive future issues via email, please insert your email address and fax this pageback to 1 (800) 471-7716.Name: ______________________________________________________________________(Please print)Email Address: ______________________________________________________________If you have any friends or colleagues who would like to receive this newsletter viaemail, please fill in their information on the line below and fax this page to us at1 (800) 471-7716 so they can be added to our subscriber list.Name: ______________________________________________________________________Specialty: ___________________________________________________________________Email Address: ______________________________________________________________You have received this email because we believe it may be of interest to you. If youwould like your name to be removed from our mailing list, please choose from thefollowing:1) Reply to this email and place REMOVE in the subject line.2) Call 1 (800) 873-1362 and leave a message with your name and email addressindicating that you would like to be removed.Copyright © 2005 Thomson Professional Postgraduate Services ® . All rights reserved.EM-T129-PHYCMEem-0205-17.7K4

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