Miriam E. Tucker

WASHINGTON — Graves' ophthalmopathy is uncommon in the first year after ablative radioiodine therapy, Julie E. Hallanger-Johnson, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Graves' ophthalmopathy (GO) affects up to 30% of patients with Graves' disease, with severe effects in 3%–5%.

The influence of radioiodine on the development of GO is not clear and is considered a controversial area. Randomized data of good quality are not available, and no reliable clinical or laboratory predictors of the development of GO following radioiodine therapy have been identified, although tobacco use has been suggested as a possible risk factor, said Dr. Hallanger-Johnson of the Mayo Clinic, Rochester, Minn., and her associates.

At the clinic, radioiodine therapy is the first choice of treatment for hyperthyroid adult Graves' patients, regardless of the presence or severity of ophthalmopathy.

For the study, the investigators reviewed the charts of 592 such patients who had received their first radioiodine therapy between 1990 and 1993. Most of the patients were women (76.9%), and the group had a mean age of 49 years. The majority (63.2%) had a history of smoking, 45.7% were current smokers, and 19.9% had taken antithyroid medication before being referred to Mayo.

GO was present prior to radioiodine therapy in 18% (105) of the patients, comprising 21% of the smokers and 14% of the nonsmokers. Those with GO at baseline had significantly higher levels of thyroid-stimulating immunoglobulin (TSI). They also were more likely to have been taking antithyroid medication (36% vs. 16%), suggesting that referring physicians were under the impression that radioiodine therapy might have adverse effects on GO, the investigators noted.

The rate of new-onset GO was 5% in the first year after radioiodine therapy, rising to 20% at 10 years. Patient survival free of GO was 95% at 1 year, 86% at 3 years, 86% at 5 years, and 81% at 10 years.

Development of new GO was not related to gender, smoking status, serum thyroxine values, thyroid weight, age, or need for a second dose of radioactive iodine, but was marginally related to higher levels of TSI.

The purported adverse effects of radioiodine therapy and the increase in TSH receptor antibodies typically occur in the first few months after radioiodine therapy. The fact that new cases of GO occurred in just 5% in the first year, with the rate remaining steady for the first 3 years, makes it unlikely that radioiodine therapy has an adverse effect on patients who do not already have GO at baseline, Dr. Hallanger-Johnson and her associates noted.

WASHINGTON — Graves' ophthalmopathy is uncommon in the first year after ablative radioiodine therapy, Julie E. Hallanger-Johnson, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Graves' ophthalmopathy (GO) affects up to 30% of patients with Graves' disease, with severe effects in 3%–5%.

The influence of radioiodine on the development of GO is not clear and is considered a controversial area. Randomized data of good quality are not available, and no reliable clinical or laboratory predictors of the development of GO following radioiodine therapy have been identified, although tobacco use has been suggested as a possible risk factor, said Dr. Hallanger-Johnson of the Mayo Clinic, Rochester, Minn., and her associates.

At the clinic, radioiodine therapy is the first choice of treatment for hyperthyroid adult Graves' patients, regardless of the presence or severity of ophthalmopathy.

For the study, the investigators reviewed the charts of 592 such patients who had received their first radioiodine therapy between 1990 and 1993. Most of the patients were women (76.9%), and the group had a mean age of 49 years. The majority (63.2%) had a history of smoking, 45.7% were current smokers, and 19.9% had taken antithyroid medication before being referred to Mayo.

GO was present prior to radioiodine therapy in 18% (105) of the patients, comprising 21% of the smokers and 14% of the nonsmokers. Those with GO at baseline had significantly higher levels of thyroid-stimulating immunoglobulin (TSI). They also were more likely to have been taking antithyroid medication (36% vs. 16%), suggesting that referring physicians were under the impression that radioiodine therapy might have adverse effects on GO, the investigators noted.

The rate of new-onset GO was 5% in the first year after radioiodine therapy, rising to 20% at 10 years. Patient survival free of GO was 95% at 1 year, 86% at 3 years, 86% at 5 years, and 81% at 10 years.

Development of new GO was not related to gender, smoking status, serum thyroxine values, thyroid weight, age, or need for a second dose of radioactive iodine, but was marginally related to higher levels of TSI.

The purported adverse effects of radioiodine therapy and the increase in TSH receptor antibodies typically occur in the first few months after radioiodine therapy. The fact that new cases of GO occurred in just 5% in the first year, with the rate remaining steady for the first 3 years, makes it unlikely that radioiodine therapy has an adverse effect on patients who do not already have GO at baseline, Dr. Hallanger-Johnson and her associates noted.

WASHINGTON — Graves' ophthalmopathy is uncommon in the first year after ablative radioiodine therapy, Julie E. Hallanger-Johnson, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Graves' ophthalmopathy (GO) affects up to 30% of patients with Graves' disease, with severe effects in 3%–5%.

The influence of radioiodine on the development of GO is not clear and is considered a controversial area. Randomized data of good quality are not available, and no reliable clinical or laboratory predictors of the development of GO following radioiodine therapy have been identified, although tobacco use has been suggested as a possible risk factor, said Dr. Hallanger-Johnson of the Mayo Clinic, Rochester, Minn., and her associates.

At the clinic, radioiodine therapy is the first choice of treatment for hyperthyroid adult Graves' patients, regardless of the presence or severity of ophthalmopathy.

For the study, the investigators reviewed the charts of 592 such patients who had received their first radioiodine therapy between 1990 and 1993. Most of the patients were women (76.9%), and the group had a mean age of 49 years. The majority (63.2%) had a history of smoking, 45.7% were current smokers, and 19.9% had taken antithyroid medication before being referred to Mayo.

GO was present prior to radioiodine therapy in 18% (105) of the patients, comprising 21% of the smokers and 14% of the nonsmokers. Those with GO at baseline had significantly higher levels of thyroid-stimulating immunoglobulin (TSI). They also were more likely to have been taking antithyroid medication (36% vs. 16%), suggesting that referring physicians were under the impression that radioiodine therapy might have adverse effects on GO, the investigators noted.

The rate of new-onset GO was 5% in the first year after radioiodine therapy, rising to 20% at 10 years. Patient survival free of GO was 95% at 1 year, 86% at 3 years, 86% at 5 years, and 81% at 10 years.

Development of new GO was not related to gender, smoking status, serum thyroxine values, thyroid weight, age, or need for a second dose of radioactive iodine, but was marginally related to higher levels of TSI.

The purported adverse effects of radioiodine therapy and the increase in TSH receptor antibodies typically occur in the first few months after radioiodine therapy. The fact that new cases of GO occurred in just 5% in the first year, with the rate remaining steady for the first 3 years, makes it unlikely that radioiodine therapy has an adverse effect on patients who do not already have GO at baseline, Dr. Hallanger-Johnson and her associates noted.

WASHINGTON — Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive “coping skills” training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms are not known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training—also known as stress reduction, stress management, or a host of other names—reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president.

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different. After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time. Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months. Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall—when a patient is reminded of a previous anger-inducing situation—also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

Further evidence supporting that notion came from another study from the same group, in which Dr. Williams was a coinvestigator. A group of 108 patients with type 2 diabetes was randomized to undergo a five-session group diabetes education program with or without a stress management training program similar to LifeSkills. Hemoglobin A_1c levels didn't differ in the first 6 months, but after 12 months there was a small yet significant difference (7.2% vs. 7.7%) between those who received stress management and the controls (Diabetes Care 2002;25:30–4). These data suggest that it may take some time before the impact of stress management is reflected in certain biological markers, he noted.

WASHINGTON — Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive “coping skills” training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms are not known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training—also known as stress reduction, stress management, or a host of other names—reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president.

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different. After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time. Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months. Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall—when a patient is reminded of a previous anger-inducing situation—also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

Further evidence supporting that notion came from another study from the same group, in which Dr. Williams was a coinvestigator. A group of 108 patients with type 2 diabetes was randomized to undergo a five-session group diabetes education program with or without a stress management training program similar to LifeSkills. Hemoglobin A_1c levels didn't differ in the first 6 months, but after 12 months there was a small yet significant difference (7.2% vs. 7.7%) between those who received stress management and the controls (Diabetes Care 2002;25:30–4). These data suggest that it may take some time before the impact of stress management is reflected in certain biological markers, he noted.

WASHINGTON — Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive “coping skills” training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms are not known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training—also known as stress reduction, stress management, or a host of other names—reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president.

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different. After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time. Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months. Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall—when a patient is reminded of a previous anger-inducing situation—also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

Further evidence supporting that notion came from another study from the same group, in which Dr. Williams was a coinvestigator. A group of 108 patients with type 2 diabetes was randomized to undergo a five-session group diabetes education program with or without a stress management training program similar to LifeSkills. Hemoglobin A_1c levels didn't differ in the first 6 months, but after 12 months there was a small yet significant difference (7.2% vs. 7.7%) between those who received stress management and the controls (Diabetes Care 2002;25:30–4). These data suggest that it may take some time before the impact of stress management is reflected in certain biological markers, he noted.

WASHINGTON — A high-quality carbohydrate diet is associated with reduced levels of C-reactive protein, Emily B. Levitan reported at conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

The finding, from the Women's Health Study, suggests that diets characterized by a high intake of soluble fiber and a low glycemic index appear to reduce inflammation, and therefore might reduce the risk of cardiovascular disease and type 2 diabetes. Previous smaller studies have linked dietary carbohydrates with inflammation, as measured by a high-sensitivity C-reactive protein (hsCRP) level, said Ms. Levitan, a medical student at Harvard Medical School, Boston.

The first large, cross-sectional study examining both fiber intake and dietary glycemic burden involved 15,033 of the Women's Health Study participants who filled out food frequency questionnaires, provided a baseline blood sample, and were not users of postmenopausal hormones. They were divided into quintiles for each of five measurements of carbohydrate quality: glycemic index (the degree to which an average gram of carbohydrate increases blood glucose, compared with white bread); glycemic load (a measure of both glycemic index and carbohydrate quantity); total fiber consumed; insoluble fiber intake; and soluble fiber intake.

After adjustment for age, body mass index, smoking, and various other medical and dietary factors, geometric mean plasma concentration of hsCRP was significantly associated with dietary glycemic index. Soluble fiber intake was inversely related to hsCRP.

There was no linear relationship between hsCRP level and either dietary glycemic load or insoluble fiber intake. The relationship with total fiber consumed was also significant, largely because of the influence of soluble fiber, she said.

WASHINGTON — A high-quality carbohydrate diet is associated with reduced levels of C-reactive protein, Emily B. Levitan reported at conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

The finding, from the Women's Health Study, suggests that diets characterized by a high intake of soluble fiber and a low glycemic index appear to reduce inflammation, and therefore might reduce the risk of cardiovascular disease and type 2 diabetes. Previous smaller studies have linked dietary carbohydrates with inflammation, as measured by a high-sensitivity C-reactive protein (hsCRP) level, said Ms. Levitan, a medical student at Harvard Medical School, Boston.

The first large, cross-sectional study examining both fiber intake and dietary glycemic burden involved 15,033 of the Women's Health Study participants who filled out food frequency questionnaires, provided a baseline blood sample, and were not users of postmenopausal hormones. They were divided into quintiles for each of five measurements of carbohydrate quality: glycemic index (the degree to which an average gram of carbohydrate increases blood glucose, compared with white bread); glycemic load (a measure of both glycemic index and carbohydrate quantity); total fiber consumed; insoluble fiber intake; and soluble fiber intake.

After adjustment for age, body mass index, smoking, and various other medical and dietary factors, geometric mean plasma concentration of hsCRP was significantly associated with dietary glycemic index. Soluble fiber intake was inversely related to hsCRP.

There was no linear relationship between hsCRP level and either dietary glycemic load or insoluble fiber intake. The relationship with total fiber consumed was also significant, largely because of the influence of soluble fiber, she said.

WASHINGTON — A high-quality carbohydrate diet is associated with reduced levels of C-reactive protein, Emily B. Levitan reported at conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

The finding, from the Women's Health Study, suggests that diets characterized by a high intake of soluble fiber and a low glycemic index appear to reduce inflammation, and therefore might reduce the risk of cardiovascular disease and type 2 diabetes. Previous smaller studies have linked dietary carbohydrates with inflammation, as measured by a high-sensitivity C-reactive protein (hsCRP) level, said Ms. Levitan, a medical student at Harvard Medical School, Boston.

The first large, cross-sectional study examining both fiber intake and dietary glycemic burden involved 15,033 of the Women's Health Study participants who filled out food frequency questionnaires, provided a baseline blood sample, and were not users of postmenopausal hormones. They were divided into quintiles for each of five measurements of carbohydrate quality: glycemic index (the degree to which an average gram of carbohydrate increases blood glucose, compared with white bread); glycemic load (a measure of both glycemic index and carbohydrate quantity); total fiber consumed; insoluble fiber intake; and soluble fiber intake.

After adjustment for age, body mass index, smoking, and various other medical and dietary factors, geometric mean plasma concentration of hsCRP was significantly associated with dietary glycemic index. Soluble fiber intake was inversely related to hsCRP.

There was no linear relationship between hsCRP level and either dietary glycemic load or insoluble fiber intake. The relationship with total fiber consumed was also significant, largely because of the influence of soluble fiber, she said.

WASHINGTON – Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive coping skills training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms aren't known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training–also known as stress reduction, stress management, or a host of other names–reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president. (See box.)

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different.

After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time.

Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure (SBP) fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months.

Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall–that is, the increase that occurs when a patient is reminded of a previous anger-inducing situation–also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

How to Cope With Negative Thoughts

The LifeSkills program starts by teaching patients how to be aware of their negative thoughts and feelings so they can evaluate them objectively and learn to manage them appropriately, Virginia P. Williams, Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

LifeSkills is taught through face-to-face workshops, a video plus workbook, and the Web (

www.williamslifeskills.com

The training focuses on core skills, including awareness of thoughts and feelings, evaluation and management of negative thoughts and feelings, deflection strategies, problem solving, assertion and saying “no,” communication and empathy, and being positive.

Patients keep a log of their thoughts and feelings, the times of day they occur, and what triggered them. This helps them evaluate whether their thoughts are appropriate given the facts. That process, in turn, facilitates deciding whether the correct course of action is to try to change a situation or change one's negative reaction to it. “Patients can't change the fact that they have diabetes, but they can change the way they manage it,” he said.

Patients are taught to use the mnemonic “I AM WORTH IT” to ask: Is the matter Important? Are negative thoughts/feelings Appropriate? Is the situation Modifiable? And, balancing the needs of myself and others, is it Worth It? If the answer to all four questions is “yes,” action skills to change the situation include problem solving, assertion, and saying “no.” If the answer to any of the questions is “no,” then “deflection skills” such as distraction, thought stopping, and relaxation/meditation are the next step.

Among the “action skills” is a systematic approach to problem-solving: Define the problem, generate alternatives through brainstorming, make a decision, implement the decision, evaluate the outcome, and revisit other options if needed. Assertion is another often-needed skill, in which patients are taught to ask others to change their behavior, to listen to them–or importantly, for people with chronic illness–to ask the physician for more information.

If “deflection” is the better course of action, relaxation exercises such as the one that Dr. Williams took the audience through may be in order: Picture a stop sign and say, “Stop” to yourself. Take three deep breaths, and say, “Relax” on each exhale. Inhale while clenching fists, then relax them on exhale. Inhale while clenching feet, then relax on exhale. Inhale while shrugging shoulders, then relax them on exhale. Inhale while tilting head to the right, then straighten on exhale. Inhale while tilting head to the left, then straighten on exhale. Finish with a “plain” inhale/exhale cycle.

WASHINGTON – Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive coping skills training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms aren't known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training–also known as stress reduction, stress management, or a host of other names–reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president. (See box.)

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different.

After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time.

Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure (SBP) fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months.

Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall–that is, the increase that occurs when a patient is reminded of a previous anger-inducing situation–also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

How to Cope With Negative Thoughts

The LifeSkills program starts by teaching patients how to be aware of their negative thoughts and feelings so they can evaluate them objectively and learn to manage them appropriately, Virginia P. Williams, Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

LifeSkills is taught through face-to-face workshops, a video plus workbook, and the Web (

www.williamslifeskills.com

The training focuses on core skills, including awareness of thoughts and feelings, evaluation and management of negative thoughts and feelings, deflection strategies, problem solving, assertion and saying “no,” communication and empathy, and being positive.

Patients keep a log of their thoughts and feelings, the times of day they occur, and what triggered them. This helps them evaluate whether their thoughts are appropriate given the facts. That process, in turn, facilitates deciding whether the correct course of action is to try to change a situation or change one's negative reaction to it. “Patients can't change the fact that they have diabetes, but they can change the way they manage it,” he said.

Patients are taught to use the mnemonic “I AM WORTH IT” to ask: Is the matter Important? Are negative thoughts/feelings Appropriate? Is the situation Modifiable? And, balancing the needs of myself and others, is it Worth It? If the answer to all four questions is “yes,” action skills to change the situation include problem solving, assertion, and saying “no.” If the answer to any of the questions is “no,” then “deflection skills” such as distraction, thought stopping, and relaxation/meditation are the next step.

Among the “action skills” is a systematic approach to problem-solving: Define the problem, generate alternatives through brainstorming, make a decision, implement the decision, evaluate the outcome, and revisit other options if needed. Assertion is another often-needed skill, in which patients are taught to ask others to change their behavior, to listen to them–or importantly, for people with chronic illness–to ask the physician for more information.

If “deflection” is the better course of action, relaxation exercises such as the one that Dr. Williams took the audience through may be in order: Picture a stop sign and say, “Stop” to yourself. Take three deep breaths, and say, “Relax” on each exhale. Inhale while clenching fists, then relax them on exhale. Inhale while clenching feet, then relax on exhale. Inhale while shrugging shoulders, then relax them on exhale. Inhale while tilting head to the right, then straighten on exhale. Inhale while tilting head to the left, then straighten on exhale. Finish with a “plain” inhale/exhale cycle.

WASHINGTON – Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive coping skills training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms aren't known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training–also known as stress reduction, stress management, or a host of other names–reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president. (See box.)

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different.

After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time.

Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure (SBP) fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months.

Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall–that is, the increase that occurs when a patient is reminded of a previous anger-inducing situation–also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

How to Cope With Negative Thoughts

The LifeSkills program starts by teaching patients how to be aware of their negative thoughts and feelings so they can evaluate them objectively and learn to manage them appropriately, Virginia P. Williams, Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

LifeSkills is taught through face-to-face workshops, a video plus workbook, and the Web (

www.williamslifeskills.com

The training focuses on core skills, including awareness of thoughts and feelings, evaluation and management of negative thoughts and feelings, deflection strategies, problem solving, assertion and saying “no,” communication and empathy, and being positive.

Patients keep a log of their thoughts and feelings, the times of day they occur, and what triggered them. This helps them evaluate whether their thoughts are appropriate given the facts. That process, in turn, facilitates deciding whether the correct course of action is to try to change a situation or change one's negative reaction to it. “Patients can't change the fact that they have diabetes, but they can change the way they manage it,” he said.

Patients are taught to use the mnemonic “I AM WORTH IT” to ask: Is the matter Important? Are negative thoughts/feelings Appropriate? Is the situation Modifiable? And, balancing the needs of myself and others, is it Worth It? If the answer to all four questions is “yes,” action skills to change the situation include problem solving, assertion, and saying “no.” If the answer to any of the questions is “no,” then “deflection skills” such as distraction, thought stopping, and relaxation/meditation are the next step.

Among the “action skills” is a systematic approach to problem-solving: Define the problem, generate alternatives through brainstorming, make a decision, implement the decision, evaluate the outcome, and revisit other options if needed. Assertion is another often-needed skill, in which patients are taught to ask others to change their behavior, to listen to them–or importantly, for people with chronic illness–to ask the physician for more information.

If “deflection” is the better course of action, relaxation exercises such as the one that Dr. Williams took the audience through may be in order: Picture a stop sign and say, “Stop” to yourself. Take three deep breaths, and say, “Relax” on each exhale. Inhale while clenching fists, then relax them on exhale. Inhale while clenching feet, then relax on exhale. Inhale while shrugging shoulders, then relax them on exhale. Inhale while tilting head to the right, then straighten on exhale. Inhale while tilting head to the left, then straighten on exhale. Finish with a “plain” inhale/exhale cycle.

WASHINGTON — The metabolic syndrome increases the risk for peripheral arterial disease as well as coronary artery disease, Andy Menke and his associates reported in a poster presented at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

The relationship between the metabolic syndrome and coronary artery disease is well established.

Now, data from 2,175 participants in the 1999–2002 National Health and Nutrition Examination Survey (NHANES) suggest that the association also extends to the peripheral arteries, and in a dose-response fashion—that is, the more metabolic syndrome components a person has, the greater the risk for peripheral arterial disease (PAD), said Mr. Menke, a doctoral student in the department of epidemiology at Tulane University, New Orleans.

A total of 827 participants had metabolic syndrome, defined as the presence of three or more of the following:

▸ Systolic blood pressure readings greater than or equal to 130 mm Hg, and/or diastolic blood pressure greater than or equal to 85 mm Hg, and/or the use of antihypertensive medication.

▸ Serum HDL cholesterol less than 40 mg/dL for men and less than 50 mg/dL for women.

▸ Serum triglyceride level greater than or equal to 150 mg/dL.

▸ Plasma glucose greater than or equal to 110 mg/dL and/or use of insulin or glucose-lowering medication.

▸ Abdominal obesity (waist circumference greater than 102 cm for men and greater than 88 cm for women).

Those with metabolic syndrome were significantly older, had a higher body mass index, and were more likely to have a low glomerular filtration rate.

The age-adjusted prevalence of PAD, defined as the average of the left and right ankle-brachial index being less than 0.9, was present in 5.3% of those with metabolic syndrome and in 3.2% of those without, a significant difference.

After adjustment for BMI, age, race/ethnicity, sex, high school education, physical inactivity, alcohol consumption, glomerular filtration rate, and current/former smoking, subjects with the metabolic syndrome were nearly three times more likely to have PAD than were those who did not.

Those with three metabolic syndrome components had an odds ratio of 1.68 for PAD, compared with subjects who had just one or two components, while the odds ratio for those with four or five components was 1.54.

Among the individual metabolic syndrome components, the subjects with elevated blood pressure had an odds ratio of 1.83 for PAD, compared with those who were normotensive, according to the investigators.

The conference was also sponsored by the National Heart, Lung, and Blood Institute.

WASHINGTON — The metabolic syndrome increases the risk for peripheral arterial disease as well as coronary artery disease, Andy Menke and his associates reported in a poster presented at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

The relationship between the metabolic syndrome and coronary artery disease is well established.

Now, data from 2,175 participants in the 1999–2002 National Health and Nutrition Examination Survey (NHANES) suggest that the association also extends to the peripheral arteries, and in a dose-response fashion—that is, the more metabolic syndrome components a person has, the greater the risk for peripheral arterial disease (PAD), said Mr. Menke, a doctoral student in the department of epidemiology at Tulane University, New Orleans.

A total of 827 participants had metabolic syndrome, defined as the presence of three or more of the following:

▸ Systolic blood pressure readings greater than or equal to 130 mm Hg, and/or diastolic blood pressure greater than or equal to 85 mm Hg, and/or the use of antihypertensive medication.

▸ Serum HDL cholesterol less than 40 mg/dL for men and less than 50 mg/dL for women.

▸ Serum triglyceride level greater than or equal to 150 mg/dL.

▸ Plasma glucose greater than or equal to 110 mg/dL and/or use of insulin or glucose-lowering medication.

▸ Abdominal obesity (waist circumference greater than 102 cm for men and greater than 88 cm for women).

Those with metabolic syndrome were significantly older, had a higher body mass index, and were more likely to have a low glomerular filtration rate.

The age-adjusted prevalence of PAD, defined as the average of the left and right ankle-brachial index being less than 0.9, was present in 5.3% of those with metabolic syndrome and in 3.2% of those without, a significant difference.

After adjustment for BMI, age, race/ethnicity, sex, high school education, physical inactivity, alcohol consumption, glomerular filtration rate, and current/former smoking, subjects with the metabolic syndrome were nearly three times more likely to have PAD than were those who did not.

Those with three metabolic syndrome components had an odds ratio of 1.68 for PAD, compared with subjects who had just one or two components, while the odds ratio for those with four or five components was 1.54.

Among the individual metabolic syndrome components, the subjects with elevated blood pressure had an odds ratio of 1.83 for PAD, compared with those who were normotensive, according to the investigators.

The conference was also sponsored by the National Heart, Lung, and Blood Institute.

WASHINGTON — The metabolic syndrome increases the risk for peripheral arterial disease as well as coronary artery disease, Andy Menke and his associates reported in a poster presented at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

The relationship between the metabolic syndrome and coronary artery disease is well established.

Now, data from 2,175 participants in the 1999–2002 National Health and Nutrition Examination Survey (NHANES) suggest that the association also extends to the peripheral arteries, and in a dose-response fashion—that is, the more metabolic syndrome components a person has, the greater the risk for peripheral arterial disease (PAD), said Mr. Menke, a doctoral student in the department of epidemiology at Tulane University, New Orleans.

A total of 827 participants had metabolic syndrome, defined as the presence of three or more of the following:

▸ Systolic blood pressure readings greater than or equal to 130 mm Hg, and/or diastolic blood pressure greater than or equal to 85 mm Hg, and/or the use of antihypertensive medication.

▸ Serum HDL cholesterol less than 40 mg/dL for men and less than 50 mg/dL for women.

▸ Serum triglyceride level greater than or equal to 150 mg/dL.

▸ Plasma glucose greater than or equal to 110 mg/dL and/or use of insulin or glucose-lowering medication.

▸ Abdominal obesity (waist circumference greater than 102 cm for men and greater than 88 cm for women).

Those with metabolic syndrome were significantly older, had a higher body mass index, and were more likely to have a low glomerular filtration rate.

The age-adjusted prevalence of PAD, defined as the average of the left and right ankle-brachial index being less than 0.9, was present in 5.3% of those with metabolic syndrome and in 3.2% of those without, a significant difference.

After adjustment for BMI, age, race/ethnicity, sex, high school education, physical inactivity, alcohol consumption, glomerular filtration rate, and current/former smoking, subjects with the metabolic syndrome were nearly three times more likely to have PAD than were those who did not.

Those with three metabolic syndrome components had an odds ratio of 1.68 for PAD, compared with subjects who had just one or two components, while the odds ratio for those with four or five components was 1.54.

Among the individual metabolic syndrome components, the subjects with elevated blood pressure had an odds ratio of 1.83 for PAD, compared with those who were normotensive, according to the investigators.

The conference was also sponsored by the National Heart, Lung, and Blood Institute.

WASHINGTON — Add chronic kidney disease to the list of problems linked with obesity.

That's the conclusion from data presented by Rebecca P. Gelber, M.D., at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

Diabetes and hypertension, as well as increasing age, have been established previously as risk factors for chronic kidney disease, whereas obesity is a primary risk factor for both diabetes and hypertension. But new data from the prospective Physicians' Health Study are the first to independently link body mass index (BMI) with the development of chronic kidney disease, said Dr. Gelber of Harvard Medical School and the Massachusetts Veterans Epidemiology Research and Information Center, Boston.

Blood samples were available at 14-year follow-up for 11,104 initially healthy male study participants (mean age 53 years). At baseline, about 38% of the subjects were overweight (BMI of 25–29.9 kg/m

As expected, the overweight and obese men were more likely during the study period to have hypertension, diabetes, or cardiovascular events. They were also more likely to smoke, reported less alcohol consumption, were less physically active, and were more likely to report a family history of MI.

At follow-up, chronic kidney disease—defined as an estimated glomerular filtration rate (GFR) of less than 60 mL/min per 1.73 m

Higher baseline BMI was consistently associated with increased risk for chronic kidney disease. Compared with participants in the lowest quintile of BMI (less than 22.7), the odds ratio for those in the highest quintile (greater than 26.6) was 1.42.

After adjustment for potential baseline confounders (age, alcohol consumption, exercise, smoking, and parental history of MI) as well as potential mediators of the association between BMI and chronic kidney disease (hypertension, diabetes, cholesterol, and cardiovascular disease), the relationship was attenuated but still significant, with an odds ratio of 1.24, Dr. Gelber reported at the meeting, also sponsored by the National Heart, Lung, and Blood Institute.

The association between BMI and chronic kidney disease remained significant, to a similar degree, when subjects were divided into normal, overweight, and obese BMI categories, when the definition of chronic kidney disease was narrowed to GFR less than 50, and when the men who were obese at baseline were excluded.

These findings support previous data suggesting that similar predisposing factors underlie both chronic kidney disease and CVD, Dr. Gelber noted.

WASHINGTON — Add chronic kidney disease to the list of problems linked with obesity.

That's the conclusion from data presented by Rebecca P. Gelber, M.D., at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

Diabetes and hypertension, as well as increasing age, have been established previously as risk factors for chronic kidney disease, whereas obesity is a primary risk factor for both diabetes and hypertension. But new data from the prospective Physicians' Health Study are the first to independently link body mass index (BMI) with the development of chronic kidney disease, said Dr. Gelber of Harvard Medical School and the Massachusetts Veterans Epidemiology Research and Information Center, Boston.

Blood samples were available at 14-year follow-up for 11,104 initially healthy male study participants (mean age 53 years). At baseline, about 38% of the subjects were overweight (BMI of 25–29.9 kg/m

As expected, the overweight and obese men were more likely during the study period to have hypertension, diabetes, or cardiovascular events. They were also more likely to smoke, reported less alcohol consumption, were less physically active, and were more likely to report a family history of MI.

At follow-up, chronic kidney disease—defined as an estimated glomerular filtration rate (GFR) of less than 60 mL/min per 1.73 m

Higher baseline BMI was consistently associated with increased risk for chronic kidney disease. Compared with participants in the lowest quintile of BMI (less than 22.7), the odds ratio for those in the highest quintile (greater than 26.6) was 1.42.

After adjustment for potential baseline confounders (age, alcohol consumption, exercise, smoking, and parental history of MI) as well as potential mediators of the association between BMI and chronic kidney disease (hypertension, diabetes, cholesterol, and cardiovascular disease), the relationship was attenuated but still significant, with an odds ratio of 1.24, Dr. Gelber reported at the meeting, also sponsored by the National Heart, Lung, and Blood Institute.

The association between BMI and chronic kidney disease remained significant, to a similar degree, when subjects were divided into normal, overweight, and obese BMI categories, when the definition of chronic kidney disease was narrowed to GFR less than 50, and when the men who were obese at baseline were excluded.

These findings support previous data suggesting that similar predisposing factors underlie both chronic kidney disease and CVD, Dr. Gelber noted.

WASHINGTON — Add chronic kidney disease to the list of problems linked with obesity.

That's the conclusion from data presented by Rebecca P. Gelber, M.D., at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association.

Diabetes and hypertension, as well as increasing age, have been established previously as risk factors for chronic kidney disease, whereas obesity is a primary risk factor for both diabetes and hypertension. But new data from the prospective Physicians' Health Study are the first to independently link body mass index (BMI) with the development of chronic kidney disease, said Dr. Gelber of Harvard Medical School and the Massachusetts Veterans Epidemiology Research and Information Center, Boston.

Blood samples were available at 14-year follow-up for 11,104 initially healthy male study participants (mean age 53 years). At baseline, about 38% of the subjects were overweight (BMI of 25–29.9 kg/m

As expected, the overweight and obese men were more likely during the study period to have hypertension, diabetes, or cardiovascular events. They were also more likely to smoke, reported less alcohol consumption, were less physically active, and were more likely to report a family history of MI.

At follow-up, chronic kidney disease—defined as an estimated glomerular filtration rate (GFR) of less than 60 mL/min per 1.73 m

Higher baseline BMI was consistently associated with increased risk for chronic kidney disease. Compared with participants in the lowest quintile of BMI (less than 22.7), the odds ratio for those in the highest quintile (greater than 26.6) was 1.42.

After adjustment for potential baseline confounders (age, alcohol consumption, exercise, smoking, and parental history of MI) as well as potential mediators of the association between BMI and chronic kidney disease (hypertension, diabetes, cholesterol, and cardiovascular disease), the relationship was attenuated but still significant, with an odds ratio of 1.24, Dr. Gelber reported at the meeting, also sponsored by the National Heart, Lung, and Blood Institute.

The association between BMI and chronic kidney disease remained significant, to a similar degree, when subjects were divided into normal, overweight, and obese BMI categories, when the definition of chronic kidney disease was narrowed to GFR less than 50, and when the men who were obese at baseline were excluded.

These findings support previous data suggesting that similar predisposing factors underlie both chronic kidney disease and CVD, Dr. Gelber noted.

WASHINGTON — Some of the botanical agents that are widely used among diabetic patients may have benefit—but more data are needed, Laura Shane-McWhorter, Pharm.D., said at the annual meeting of the American Association of Diabetes Educators.

Regardless of whether these unregulated products are beneficial, clinicians need to stay educated on the topic, since “this is something that all of us get asked about at one point or another,” said Dr. Shane-McWhorter, a certified diabetes educator and a professor at the University of Utah in Salt Lake City.

It's important to make sure patients aren't substituting complementary/alternative therapies for prescribed medications—cases of diabetic ketoacidosis have been reported among some who have, she said.

In addition, patients need to know that combining glucose-lowering botanicals with prescription diabetes medications may increase the risk of hypoglycemia.

The following are among the most popular of the more than 100 complementary/alternative therapies used to treat diabetes, Dr. Shane-McWhorter said.

Cinnamon

This everyday spice has received lots of attention lately. Its active ingredient, the polyphenolic polymer hydroxychalcone, is believed to enhance insulin action by increasing glucose uptake and glycogen synthesis. Side effects are limited mostly to the very rare topical allergic reaction.

But, like the others, it carries the theoretical potential for an additive hypoglycemic effect if combined with an insulin secretagogue.

In a randomized trial, 60 patients with type 2 diabetes were given 1, 3, or 6 grams of cinnamon four times daily or placebo. At 40 days, fasting blood glucose (FBG) had dropped from 209 to 157 mg/dL with 1 g cinnamon, from 205 to 169 mg/dL with 3 g, and from 234 to 166 mg/dL with 6 g. All changes were statistically significant compared with placebo, and the effect was still seen 20 days after cinnamon was stopped. Total cholesterol, triglycerides, and LDL cholesterol also dropped in the cinnamon groups (Diabetes Care 2003;26:3215–8).

The data are at least good enough to support a recommendation that patients use ½ to 1 teaspoon of ground cinnamon per day on cereal or other foods, she advised.

Gymnema sylvestre

From the Indian word “gurmar,” meaning “sugar-destroyer,” Gymnema sylvestre is thought to block both the craving for sweets and intestinal glucose absorption, increase cell permeability to insulin, and stimulate β-cell number and function.

Hypoglycemia has been reported with this agent when combined with insulin secretagogues.

In two small studies, 400 mg/day of Gymnema sylvestre leaves significantly reduced hemoglobin A_1c values in both type 1 (from 12.8% to 8.2% at 26–30 months) and type 2 diabetic patients (from 11.9% to 8.5% at 20 months). The 27 type 1 patients were able to reduce their insulin doses by a mean of 15 units, while 5 of the 22 patients with type 2 diabetes were able to discontinue sulfonylureas (J. Ethnopharmacol. 1990;30:281–94).

However, these authors did not report randomization or blinding, and there was a high dropout rate among the type 1 patients. More human research using a standardized version of Gymnema sylvestre is now being conducted in the United States by the Omaha-based company Informulab Naturals (

www.informulab.com

Other diabetes medications may need to be adjusted for patients who choose to use Gymnema sylvestre, and it should not be used in patients already on combination therapy, Dr. Shane-McWhorter advised.

Fenugreek

Used for many years to promote lactation, fenugreek (Trigonella foenumgraecum) contains a variety of ingredients including saponins, alkaloids, coumarins, and glycosides. Its mechanism of action is thought to be related to its high fiber content. It delays gastric emptying and inhibits carbohydrate absorption, and may also stimulate insulin secretion. It has also been used to treat hyperlipidemia and constipation, in addition to diabetes.

Side effects include gastrointestinal hypersensitivity and topical allergies. It also may stimulate uterine contractions. Fenugreek should be used with care in peanut-allergic patients, since it belongs to the same plant family. Fenugreek may interact with other anticoagulants (including Ginkgo biloba and ginger), interfere with the effects of steroids and hormones, and/or potentiate the effects of monoamine oxide inhibitors, she said.

In a study of 25 patients newly diagnosed with type 2 diabetes, 12 received 1 g/day of hydroalcoholic extract of fenugreek seeds, while the other 13 received placebo. The differences in FBG and 2-hour postprandial glucose were not significant at 2 months. However, the area under the curve for both blood glucose and insulin levels were lower in the fenugreek patients, who also showed significant improvements in both serum triglycerides and HDL cholesterol compared with placebo (J. Assoc. Physicians India 2001;49:1057–61).

Fenugreek may be appropriate for certain individuals, but it may be dangerous for women of childbearing age, Dr. Shane-McWhorter stressed.

Bitter Melon

This pickle-like vegetable from Southeast Asia and South America contains the hypoglycemics momordin and charantin, the alkaloid momordicine, and polypeptide P. It is thought to promote glucose uptake and glycogen synthesis.

It has a long list of reported side effects, including diarrhea, possible spontaneous abortion, and favism (acute hemolytic anemia) in individuals with hereditary glucose-6-phosphate dehydrogenase deficiency. Interactions have been reported with sulfonylureas and may occur with potassium depleters.

The largest study done with bitter melon (Momordica charantia) involved 100 patients with type 2 diabetes who ingested an aqueous suspension of the vegetable pulp after measurement of their fasting plasma glucose, which averaged 160 mg/dL. At 1 hour, glucose had dropped to 131 mg/dL. Following a 75-gram oral glucose load, mean glucose levels dropped to 222 mg/dL, compared with a mean of 257 mg/dL measured the previous day (Bangladesh Med. Res. Counc. Bull. 1999;25:11–3).

This agent should also be used with caution in women of childbearing age and should not be used during pregnancy, due to the risk for bleeding or contractions.

Ginseng

Both the American and Asian versions of ginseng are in the steroid family of ginsenosides, which have various hormonal and central nervous system effects. Depending on which ginsenosides they contain (Rg1 vs. Rb1), they can either increase or decrease blood pressure and CNS activity.

Reported side effects include the “ginseng abuse syndrome,” characterized by hypertension, anxiety, and insomnia. Ginseng has also induced postmenopausal vaginal bleeding, and it interacts significantly with a long list of drugs including warfarin, diuretics, β-blockers, antipsychotics, antidepressants, and opiates.

In one randomized, controlled, multicenter trial, 36 patients with type 2 diabetes were given 100–200 mg ginseng or placebo daily for 8 weeks. Results included improvements in mood and psychomotor performance, as well as lower A_1c and FBG levels (Diabetes Care 1995;18:1373–5).

American ginseng appears to lower glucose better than does the Asian type, but few studies have been done in diabetic patients. Of concern are data from a U.S. analysis of 25 different commercial preparations of ginseng in which the actual quantities varied from 12% to 137% of what was indicated on the bottle (Am. J. Clin. Nutr. 2001;73:1101–6).

Patients who choose to take ginseng should do so within 2 hours of a meal to avoid hypoglycemia. To avoid hormone-like effects, some have suggested taking a 2 week holiday every 2–3 weeks, or limiting its use to 3 months, Dr. Shane-McWhorter said.

Aloe

A member of the lily family, aloe's dried leaf juice was once used as a laxative ingredient, but that was stopped because it sometimes led to electrolyte depletion and intractable diarrhea. The gel component, however, is still used as a topical wound treatment and internally for diabetes. Its mechanism is thought to be related to its high fiber content.

In one single-blind, placebo-controlled study, FBG dropped from 250 to 142 mg/dL in 40 patients newly diagnosed with type 2 diabetes who took one tablespoon of aloe gel twice daily for 42 days, while FBG increased in the placebo group, from 251 to 257 mg/dL. Triglycerides also dropped in the aloe group, but there was no change in total cholesterol. (Phytomedicine 1996;3:241–3).

In another study of 40 patients already taking the sulfonylurea glibencamide, 20 were also given aloe for 42 days. Again, aloe reduced FBG from 288 to 148 mg/dL compared with 289 to 290 mg/dL with glibenclamide alone (Phytomedicine 1996;3:245–8).

Although the data on aloe at this time are too limited to support its use as a treatment for diabetes, it is one of the most popular alternative diabetes remedies among Hispanic patients. If they choose to use it, the dosage is 50–200 mg/day of the leaf gel, not the cathartic (leaf juice) form.

Nopal

The fiber in this member of the cactus family is thought to decrease glucose absorption and possibly increase insulin sensitivity. Also known as “prickly pear,” it's usually eaten cooked, and is also used to treat hyperlipidemia and to prevent hangovers. Side effects include increased stools and abdominal fullness, as well as possible additive hypoglycemia with secretagogues.

In one study, 16 patients with type 2 diabetes were assigned to broiled nopal (Opuntia streptacantha Lemaire), 10 to water, and 6 to broiled zucchini. At 2 hours, mean glucose dropped from 222 to 198 mg/dL and to 183 mg/dL by 3 hours (Diabetes Care 1988;11:63–6). In another study by the same group, nopal combined with sulfonylurea produced a 41-mg/dL drop in glucose at 3 hours, versus no change in those given water (Diabetes Care 1990;13:455–6).

Nopal's main effect appears to be on postprandial glucose. Like aloe, it is also extremely popular among Hispanic diabetic patients, and since it is relatively benign and may have some benefit, it may play a role in diabetes management. Dosage is 500 g/day of broiled or fresh stems from the immature plant, she said.

Finally, Dr. Shane-McWhorter shared her way of responding to a patient who is reluctant to start on conventional diabetes medication and expresses a preference for a more “natural” approach.

“I tell them there's a product that comes from a chemical class called biguanides which is derived from the botanical Galega officinalis, also known as goat's rue. It's called metformin.”

WASHINGTON — Some of the botanical agents that are widely used among diabetic patients may have benefit—but more data are needed, Laura Shane-McWhorter, Pharm.D., said at the annual meeting of the American Association of Diabetes Educators.

Regardless of whether these unregulated products are beneficial, clinicians need to stay educated on the topic, since “this is something that all of us get asked about at one point or another,” said Dr. Shane-McWhorter, a certified diabetes educator and a professor at the University of Utah in Salt Lake City.

It's important to make sure patients aren't substituting complementary/alternative therapies for prescribed medications—cases of diabetic ketoacidosis have been reported among some who have, she said.

In addition, patients need to know that combining glucose-lowering botanicals with prescription diabetes medications may increase the risk of hypoglycemia.

The following are among the most popular of the more than 100 complementary/alternative therapies used to treat diabetes, Dr. Shane-McWhorter said.

Cinnamon

This everyday spice has received lots of attention lately. Its active ingredient, the polyphenolic polymer hydroxychalcone, is believed to enhance insulin action by increasing glucose uptake and glycogen synthesis. Side effects are limited mostly to the very rare topical allergic reaction.

But, like the others, it carries the theoretical potential for an additive hypoglycemic effect if combined with an insulin secretagogue.

In a randomized trial, 60 patients with type 2 diabetes were given 1, 3, or 6 grams of cinnamon four times daily or placebo. At 40 days, fasting blood glucose (FBG) had dropped from 209 to 157 mg/dL with 1 g cinnamon, from 205 to 169 mg/dL with 3 g, and from 234 to 166 mg/dL with 6 g. All changes were statistically significant compared with placebo, and the effect was still seen 20 days after cinnamon was stopped. Total cholesterol, triglycerides, and LDL cholesterol also dropped in the cinnamon groups (Diabetes Care 2003;26:3215–8).

The data are at least good enough to support a recommendation that patients use ½ to 1 teaspoon of ground cinnamon per day on cereal or other foods, she advised.

Gymnema sylvestre

From the Indian word “gurmar,” meaning “sugar-destroyer,” Gymnema sylvestre is thought to block both the craving for sweets and intestinal glucose absorption, increase cell permeability to insulin, and stimulate β-cell number and function.

Hypoglycemia has been reported with this agent when combined with insulin secretagogues.

In two small studies, 400 mg/day of Gymnema sylvestre leaves significantly reduced hemoglobin A_1c values in both type 1 (from 12.8% to 8.2% at 26–30 months) and type 2 diabetic patients (from 11.9% to 8.5% at 20 months). The 27 type 1 patients were able to reduce their insulin doses by a mean of 15 units, while 5 of the 22 patients with type 2 diabetes were able to discontinue sulfonylureas (J. Ethnopharmacol. 1990;30:281–94).

However, these authors did not report randomization or blinding, and there was a high dropout rate among the type 1 patients. More human research using a standardized version of Gymnema sylvestre is now being conducted in the United States by the Omaha-based company Informulab Naturals (

www.informulab.com

Other diabetes medications may need to be adjusted for patients who choose to use Gymnema sylvestre, and it should not be used in patients already on combination therapy, Dr. Shane-McWhorter advised.

Fenugreek

Used for many years to promote lactation, fenugreek (Trigonella foenumgraecum) contains a variety of ingredients including saponins, alkaloids, coumarins, and glycosides. Its mechanism of action is thought to be related to its high fiber content. It delays gastric emptying and inhibits carbohydrate absorption, and may also stimulate insulin secretion. It has also been used to treat hyperlipidemia and constipation, in addition to diabetes.

Side effects include gastrointestinal hypersensitivity and topical allergies. It also may stimulate uterine contractions. Fenugreek should be used with care in peanut-allergic patients, since it belongs to the same plant family. Fenugreek may interact with other anticoagulants (including Ginkgo biloba and ginger), interfere with the effects of steroids and hormones, and/or potentiate the effects of monoamine oxide inhibitors, she said.

In a study of 25 patients newly diagnosed with type 2 diabetes, 12 received 1 g/day of hydroalcoholic extract of fenugreek seeds, while the other 13 received placebo. The differences in FBG and 2-hour postprandial glucose were not significant at 2 months. However, the area under the curve for both blood glucose and insulin levels were lower in the fenugreek patients, who also showed significant improvements in both serum triglycerides and HDL cholesterol compared with placebo (J. Assoc. Physicians India 2001;49:1057–61).

Fenugreek may be appropriate for certain individuals, but it may be dangerous for women of childbearing age, Dr. Shane-McWhorter stressed.

Bitter Melon

This pickle-like vegetable from Southeast Asia and South America contains the hypoglycemics momordin and charantin, the alkaloid momordicine, and polypeptide P. It is thought to promote glucose uptake and glycogen synthesis.

It has a long list of reported side effects, including diarrhea, possible spontaneous abortion, and favism (acute hemolytic anemia) in individuals with hereditary glucose-6-phosphate dehydrogenase deficiency. Interactions have been reported with sulfonylureas and may occur with potassium depleters.

The largest study done with bitter melon (Momordica charantia) involved 100 patients with type 2 diabetes who ingested an aqueous suspension of the vegetable pulp after measurement of their fasting plasma glucose, which averaged 160 mg/dL. At 1 hour, glucose had dropped to 131 mg/dL. Following a 75-gram oral glucose load, mean glucose levels dropped to 222 mg/dL, compared with a mean of 257 mg/dL measured the previous day (Bangladesh Med. Res. Counc. Bull. 1999;25:11–3).

This agent should also be used with caution in women of childbearing age and should not be used during pregnancy, due to the risk for bleeding or contractions.

Ginseng

Both the American and Asian versions of ginseng are in the steroid family of ginsenosides, which have various hormonal and central nervous system effects. Depending on which ginsenosides they contain (Rg1 vs. Rb1), they can either increase or decrease blood pressure and CNS activity.

Reported side effects include the “ginseng abuse syndrome,” characterized by hypertension, anxiety, and insomnia. Ginseng has also induced postmenopausal vaginal bleeding, and it interacts significantly with a long list of drugs including warfarin, diuretics, β-blockers, antipsychotics, antidepressants, and opiates.

In one randomized, controlled, multicenter trial, 36 patients with type 2 diabetes were given 100–200 mg ginseng or placebo daily for 8 weeks. Results included improvements in mood and psychomotor performance, as well as lower A_1c and FBG levels (Diabetes Care 1995;18:1373–5).

American ginseng appears to lower glucose better than does the Asian type, but few studies have been done in diabetic patients. Of concern are data from a U.S. analysis of 25 different commercial preparations of ginseng in which the actual quantities varied from 12% to 137% of what was indicated on the bottle (Am. J. Clin. Nutr. 2001;73:1101–6).

Patients who choose to take ginseng should do so within 2 hours of a meal to avoid hypoglycemia. To avoid hormone-like effects, some have suggested taking a 2 week holiday every 2–3 weeks, or limiting its use to 3 months, Dr. Shane-McWhorter said.

Aloe

A member of the lily family, aloe's dried leaf juice was once used as a laxative ingredient, but that was stopped because it sometimes led to electrolyte depletion and intractable diarrhea. The gel component, however, is still used as a topical wound treatment and internally for diabetes. Its mechanism is thought to be related to its high fiber content.

In one single-blind, placebo-controlled study, FBG dropped from 250 to 142 mg/dL in 40 patients newly diagnosed with type 2 diabetes who took one tablespoon of aloe gel twice daily for 42 days, while FBG increased in the placebo group, from 251 to 257 mg/dL. Triglycerides also dropped in the aloe group, but there was no change in total cholesterol. (Phytomedicine 1996;3:241–3).

In another study of 40 patients already taking the sulfonylurea glibencamide, 20 were also given aloe for 42 days. Again, aloe reduced FBG from 288 to 148 mg/dL compared with 289 to 290 mg/dL with glibenclamide alone (Phytomedicine 1996;3:245–8).

Although the data on aloe at this time are too limited to support its use as a treatment for diabetes, it is one of the most popular alternative diabetes remedies among Hispanic patients. If they choose to use it, the dosage is 50–200 mg/day of the leaf gel, not the cathartic (leaf juice) form.

Nopal

The fiber in this member of the cactus family is thought to decrease glucose absorption and possibly increase insulin sensitivity. Also known as “prickly pear,” it's usually eaten cooked, and is also used to treat hyperlipidemia and to prevent hangovers. Side effects include increased stools and abdominal fullness, as well as possible additive hypoglycemia with secretagogues.

In one study, 16 patients with type 2 diabetes were assigned to broiled nopal (Opuntia streptacantha Lemaire), 10 to water, and 6 to broiled zucchini. At 2 hours, mean glucose dropped from 222 to 198 mg/dL and to 183 mg/dL by 3 hours (Diabetes Care 1988;11:63–6). In another study by the same group, nopal combined with sulfonylurea produced a 41-mg/dL drop in glucose at 3 hours, versus no change in those given water (Diabetes Care 1990;13:455–6).

Nopal's main effect appears to be on postprandial glucose. Like aloe, it is also extremely popular among Hispanic diabetic patients, and since it is relatively benign and may have some benefit, it may play a role in diabetes management. Dosage is 500 g/day of broiled or fresh stems from the immature plant, she said.

Finally, Dr. Shane-McWhorter shared her way of responding to a patient who is reluctant to start on conventional diabetes medication and expresses a preference for a more “natural” approach.

“I tell them there's a product that comes from a chemical class called biguanides which is derived from the botanical Galega officinalis, also known as goat's rue. It's called metformin.”

WASHINGTON — Some of the botanical agents that are widely used among diabetic patients may have benefit—but more data are needed, Laura Shane-McWhorter, Pharm.D., said at the annual meeting of the American Association of Diabetes Educators.

Regardless of whether these unregulated products are beneficial, clinicians need to stay educated on the topic, since “this is something that all of us get asked about at one point or another,” said Dr. Shane-McWhorter, a certified diabetes educator and a professor at the University of Utah in Salt Lake City.

It's important to make sure patients aren't substituting complementary/alternative therapies for prescribed medications—cases of diabetic ketoacidosis have been reported among some who have, she said.

In addition, patients need to know that combining glucose-lowering botanicals with prescription diabetes medications may increase the risk of hypoglycemia.

The following are among the most popular of the more than 100 complementary/alternative therapies used to treat diabetes, Dr. Shane-McWhorter said.

Cinnamon

This everyday spice has received lots of attention lately. Its active ingredient, the polyphenolic polymer hydroxychalcone, is believed to enhance insulin action by increasing glucose uptake and glycogen synthesis. Side effects are limited mostly to the very rare topical allergic reaction.

But, like the others, it carries the theoretical potential for an additive hypoglycemic effect if combined with an insulin secretagogue.

In a randomized trial, 60 patients with type 2 diabetes were given 1, 3, or 6 grams of cinnamon four times daily or placebo. At 40 days, fasting blood glucose (FBG) had dropped from 209 to 157 mg/dL with 1 g cinnamon, from 205 to 169 mg/dL with 3 g, and from 234 to 166 mg/dL with 6 g. All changes were statistically significant compared with placebo, and the effect was still seen 20 days after cinnamon was stopped. Total cholesterol, triglycerides, and LDL cholesterol also dropped in the cinnamon groups (Diabetes Care 2003;26:3215–8).

The data are at least good enough to support a recommendation that patients use ½ to 1 teaspoon of ground cinnamon per day on cereal or other foods, she advised.

Gymnema sylvestre

From the Indian word “gurmar,” meaning “sugar-destroyer,” Gymnema sylvestre is thought to block both the craving for sweets and intestinal glucose absorption, increase cell permeability to insulin, and stimulate β-cell number and function.

Hypoglycemia has been reported with this agent when combined with insulin secretagogues.

In two small studies, 400 mg/day of Gymnema sylvestre leaves significantly reduced hemoglobin A_1c values in both type 1 (from 12.8% to 8.2% at 26–30 months) and type 2 diabetic patients (from 11.9% to 8.5% at 20 months). The 27 type 1 patients were able to reduce their insulin doses by a mean of 15 units, while 5 of the 22 patients with type 2 diabetes were able to discontinue sulfonylureas (J. Ethnopharmacol. 1990;30:281–94).

However, these authors did not report randomization or blinding, and there was a high dropout rate among the type 1 patients. More human research using a standardized version of Gymnema sylvestre is now being conducted in the United States by the Omaha-based company Informulab Naturals (

www.informulab.com

Other diabetes medications may need to be adjusted for patients who choose to use Gymnema sylvestre, and it should not be used in patients already on combination therapy, Dr. Shane-McWhorter advised.

Fenugreek

Used for many years to promote lactation, fenugreek (Trigonella foenumgraecum) contains a variety of ingredients including saponins, alkaloids, coumarins, and glycosides. Its mechanism of action is thought to be related to its high fiber content. It delays gastric emptying and inhibits carbohydrate absorption, and may also stimulate insulin secretion. It has also been used to treat hyperlipidemia and constipation, in addition to diabetes.

Side effects include gastrointestinal hypersensitivity and topical allergies. It also may stimulate uterine contractions. Fenugreek should be used with care in peanut-allergic patients, since it belongs to the same plant family. Fenugreek may interact with other anticoagulants (including Ginkgo biloba and ginger), interfere with the effects of steroids and hormones, and/or potentiate the effects of monoamine oxide inhibitors, she said.

In a study of 25 patients newly diagnosed with type 2 diabetes, 12 received 1 g/day of hydroalcoholic extract of fenugreek seeds, while the other 13 received placebo. The differences in FBG and 2-hour postprandial glucose were not significant at 2 months. However, the area under the curve for both blood glucose and insulin levels were lower in the fenugreek patients, who also showed significant improvements in both serum triglycerides and HDL cholesterol compared with placebo (J. Assoc. Physicians India 2001;49:1057–61).

Fenugreek may be appropriate for certain individuals, but it may be dangerous for women of childbearing age, Dr. Shane-McWhorter stressed.

Bitter Melon

This pickle-like vegetable from Southeast Asia and South America contains the hypoglycemics momordin and charantin, the alkaloid momordicine, and polypeptide P. It is thought to promote glucose uptake and glycogen synthesis.

It has a long list of reported side effects, including diarrhea, possible spontaneous abortion, and favism (acute hemolytic anemia) in individuals with hereditary glucose-6-phosphate dehydrogenase deficiency. Interactions have been reported with sulfonylureas and may occur with potassium depleters.

The largest study done with bitter melon (Momordica charantia) involved 100 patients with type 2 diabetes who ingested an aqueous suspension of the vegetable pulp after measurement of their fasting plasma glucose, which averaged 160 mg/dL. At 1 hour, glucose had dropped to 131 mg/dL. Following a 75-gram oral glucose load, mean glucose levels dropped to 222 mg/dL, compared with a mean of 257 mg/dL measured the previous day (Bangladesh Med. Res. Counc. Bull. 1999;25:11–3).

This agent should also be used with caution in women of childbearing age and should not be used during pregnancy, due to the risk for bleeding or contractions.

Ginseng

Both the American and Asian versions of ginseng are in the steroid family of ginsenosides, which have various hormonal and central nervous system effects. Depending on which ginsenosides they contain (Rg1 vs. Rb1), they can either increase or decrease blood pressure and CNS activity.

Reported side effects include the “ginseng abuse syndrome,” characterized by hypertension, anxiety, and insomnia. Ginseng has also induced postmenopausal vaginal bleeding, and it interacts significantly with a long list of drugs including warfarin, diuretics, β-blockers, antipsychotics, antidepressants, and opiates.

In one randomized, controlled, multicenter trial, 36 patients with type 2 diabetes were given 100–200 mg ginseng or placebo daily for 8 weeks. Results included improvements in mood and psychomotor performance, as well as lower A_1c and FBG levels (Diabetes Care 1995;18:1373–5).

American ginseng appears to lower glucose better than does the Asian type, but few studies have been done in diabetic patients. Of concern are data from a U.S. analysis of 25 different commercial preparations of ginseng in which the actual quantities varied from 12% to 137% of what was indicated on the bottle (Am. J. Clin. Nutr. 2001;73:1101–6).

Patients who choose to take ginseng should do so within 2 hours of a meal to avoid hypoglycemia. To avoid hormone-like effects, some have suggested taking a 2 week holiday every 2–3 weeks, or limiting its use to 3 months, Dr. Shane-McWhorter said.

Aloe

A member of the lily family, aloe's dried leaf juice was once used as a laxative ingredient, but that was stopped because it sometimes led to electrolyte depletion and intractable diarrhea. The gel component, however, is still used as a topical wound treatment and internally for diabetes. Its mechanism is thought to be related to its high fiber content.

In one single-blind, placebo-controlled study, FBG dropped from 250 to 142 mg/dL in 40 patients newly diagnosed with type 2 diabetes who took one tablespoon of aloe gel twice daily for 42 days, while FBG increased in the placebo group, from 251 to 257 mg/dL. Triglycerides also dropped in the aloe group, but there was no change in total cholesterol. (Phytomedicine 1996;3:241–3).

In another study of 40 patients already taking the sulfonylurea glibencamide, 20 were also given aloe for 42 days. Again, aloe reduced FBG from 288 to 148 mg/dL compared with 289 to 290 mg/dL with glibenclamide alone (Phytomedicine 1996;3:245–8).

Although the data on aloe at this time are too limited to support its use as a treatment for diabetes, it is one of the most popular alternative diabetes remedies among Hispanic patients. If they choose to use it, the dosage is 50–200 mg/day of the leaf gel, not the cathartic (leaf juice) form.

Nopal

The fiber in this member of the cactus family is thought to decrease glucose absorption and possibly increase insulin sensitivity. Also known as “prickly pear,” it's usually eaten cooked, and is also used to treat hyperlipidemia and to prevent hangovers. Side effects include increased stools and abdominal fullness, as well as possible additive hypoglycemia with secretagogues.

In one study, 16 patients with type 2 diabetes were assigned to broiled nopal (Opuntia streptacantha Lemaire), 10 to water, and 6 to broiled zucchini. At 2 hours, mean glucose dropped from 222 to 198 mg/dL and to 183 mg/dL by 3 hours (Diabetes Care 1988;11:63–6). In another study by the same group, nopal combined with sulfonylurea produced a 41-mg/dL drop in glucose at 3 hours, versus no change in those given water (Diabetes Care 1990;13:455–6).

Nopal's main effect appears to be on postprandial glucose. Like aloe, it is also extremely popular among Hispanic diabetic patients, and since it is relatively benign and may have some benefit, it may play a role in diabetes management. Dosage is 500 g/day of broiled or fresh stems from the immature plant, she said.

Finally, Dr. Shane-McWhorter shared her way of responding to a patient who is reluctant to start on conventional diabetes medication and expresses a preference for a more “natural” approach.

“I tell them there's a product that comes from a chemical class called biguanides which is derived from the botanical Galega officinalis, also known as goat's rue. It's called metformin.”

WASHINGTON — Two nonbotanical complementary therapies may benefit diabetic patients, Laura Shane-McWhorter, Pharm.D., said at the annual meeting of the American Association of Diabetes Educators.

Data are accumulating to support the use of alpha-lipoic acid in the treatment of diabetic neuropathy, and chromium as an adjunct to glucose- and lipid-lowering medications, said Dr. Shane-McWhorter, who is both a pharmacist and a certified diabetes educator at the University of Utah, Salt Lake City.

▸ Alpha-lipoic acid. This is a natural coenzyme found in the body; it is involved in energy production and has been used in Germany for decades as standard therapy for neuropathy. It is thought to reduce oxidative stress caused by increased blood glucose, the process believed to underlie many of the microvascular and neuropathic complications of diabetes.

Side effects include mild and dose-related gastrointestinal disturbances and possible hypoglycemia when used with sulfonylureas.

Alpha-lipoic acid (ALA) has a large body of data from well-conducted studies behind it. A recent metaanalysis of four large, randomized, double-blind, placebo-controlled, parallel-group trials investigated the efficacy and safety of 600 mg of ALA given intravenously daily (except weekends) for 3 weeks to a total of 716 diabetic patients with symptomatic polyneuropathy. The data also included 542 patients who received placebo (Diabet Med. 2004;21:114–21).

After 3 weeks, the relative difference in favor of ALA over placebo was 24% in total symptom score (pain, burning, paresthesia, numbness) and 16% for the neuropathy impairment score of the lower limbs. Overall responder rates were 53% in patients treated with ALA compared with 37% with placebo, a significant difference. The rates of adverse events did not differ between the groups.

Long-term trials will be necessary to determine whether ALA merely alleviates symptoms of diabetic neuropathy or actually slows its progression. “This is a product that definitely warrants some close attention,” Dr. Shane-McWhorter said.

▸ Chromium. This metal has become quite popular recently. Its trivalent form appears to work as an insulin sensitizer by increasing the number of insulin receptors in addition to other activities at the cellular level. There is also a suggestion that the use of chromium in combination with biotin may increase its efficacy. It has been used to improve lipids, to induce weight loss, and—by athletes—for its ergogenic effects.

Side effects include case reports of renal toxicity, psychiatric problems, and rhabdomyolysis, but only at extremely high doses. Chromium could potentially cause hypoglycemia when used with other glucose-lowering agents. Its use in combination with other chromium-containing herbs, such as horsetail or cascara, could lead to chromium toxicity. Moreover, high doses of vitamin C and nonsteroidal anti-inflammatory agents can increase the absorption of chromium, whereas H₂-blockers and proton-pump inhibitors may decrease it, Dr. Shane-McWhorter said.

In a widely quoted study, 155 subjects with type 2 diabetes received either 200 mcg or 1,000 mcg (1 mg) of chromium picolinate per day, along with their regular diabetes medications. At 4 months, hemoglobin A_1c had declined by 2.8% among the patients taking 1,000 mcg and by 1.9% for those taking 200 mcg, compared with a reduction of only 0.5% for those on placebo (Diabetes 1997;46:1786–91).

This study was done in an area of China known to be deficient in chromium, which raises the question of whether supplementation works only in individuals who are chromium deficient—which many diabetic patients are, she noted.

One problem with answering that question is that there is no standardized way of measuring body stores of chromium. However, toenails appear to be a particularly sensitive area. In one recent study, toenail chromium concentration was inversely associated with the risk of a first myocardial infarction in men (Am. J. Epidemiol. 2005;162:157–64).

Although chromium appears to be a promising agent for diabetic patients, its long-term effects are not known, she cautioned.

WASHINGTON — Two nonbotanical complementary therapies may benefit diabetic patients, Laura Shane-McWhorter, Pharm.D., said at the annual meeting of the American Association of Diabetes Educators.

Data are accumulating to support the use of alpha-lipoic acid in the treatment of diabetic neuropathy, and chromium as an adjunct to glucose- and lipid-lowering medications, said Dr. Shane-McWhorter, who is both a pharmacist and a certified diabetes educator at the University of Utah, Salt Lake City.

▸ Alpha-lipoic acid. This is a natural coenzyme found in the body; it is involved in energy production and has been used in Germany for decades as standard therapy for neuropathy. It is thought to reduce oxidative stress caused by increased blood glucose, the process believed to underlie many of the microvascular and neuropathic complications of diabetes.

Side effects include mild and dose-related gastrointestinal disturbances and possible hypoglycemia when used with sulfonylureas.

Alpha-lipoic acid (ALA) has a large body of data from well-conducted studies behind it. A recent metaanalysis of four large, randomized, double-blind, placebo-controlled, parallel-group trials investigated the efficacy and safety of 600 mg of ALA given intravenously daily (except weekends) for 3 weeks to a total of 716 diabetic patients with symptomatic polyneuropathy. The data also included 542 patients who received placebo (Diabet Med. 2004;21:114–21).

After 3 weeks, the relative difference in favor of ALA over placebo was 24% in total symptom score (pain, burning, paresthesia, numbness) and 16% for the neuropathy impairment score of the lower limbs. Overall responder rates were 53% in patients treated with ALA compared with 37% with placebo, a significant difference. The rates of adverse events did not differ between the groups.

Long-term trials will be necessary to determine whether ALA merely alleviates symptoms of diabetic neuropathy or actually slows its progression. “This is a product that definitely warrants some close attention,” Dr. Shane-McWhorter said.

▸ Chromium. This metal has become quite popular recently. Its trivalent form appears to work as an insulin sensitizer by increasing the number of insulin receptors in addition to other activities at the cellular level. There is also a suggestion that the use of chromium in combination with biotin may increase its efficacy. It has been used to improve lipids, to induce weight loss, and—by athletes—for its ergogenic effects.

Side effects include case reports of renal toxicity, psychiatric problems, and rhabdomyolysis, but only at extremely high doses. Chromium could potentially cause hypoglycemia when used with other glucose-lowering agents. Its use in combination with other chromium-containing herbs, such as horsetail or cascara, could lead to chromium toxicity. Moreover, high doses of vitamin C and nonsteroidal anti-inflammatory agents can increase the absorption of chromium, whereas H₂-blockers and proton-pump inhibitors may decrease it, Dr. Shane-McWhorter said.

In a widely quoted study, 155 subjects with type 2 diabetes received either 200 mcg or 1,000 mcg (1 mg) of chromium picolinate per day, along with their regular diabetes medications. At 4 months, hemoglobin A_1c had declined by 2.8% among the patients taking 1,000 mcg and by 1.9% for those taking 200 mcg, compared with a reduction of only 0.5% for those on placebo (Diabetes 1997;46:1786–91).

This study was done in an area of China known to be deficient in chromium, which raises the question of whether supplementation works only in individuals who are chromium deficient—which many diabetic patients are, she noted.

One problem with answering that question is that there is no standardized way of measuring body stores of chromium. However, toenails appear to be a particularly sensitive area. In one recent study, toenail chromium concentration was inversely associated with the risk of a first myocardial infarction in men (Am. J. Epidemiol. 2005;162:157–64).

Although chromium appears to be a promising agent for diabetic patients, its long-term effects are not known, she cautioned.

WASHINGTON — Two nonbotanical complementary therapies may benefit diabetic patients, Laura Shane-McWhorter, Pharm.D., said at the annual meeting of the American Association of Diabetes Educators.

Data are accumulating to support the use of alpha-lipoic acid in the treatment of diabetic neuropathy, and chromium as an adjunct to glucose- and lipid-lowering medications, said Dr. Shane-McWhorter, who is both a pharmacist and a certified diabetes educator at the University of Utah, Salt Lake City.

▸ Alpha-lipoic acid. This is a natural coenzyme found in the body; it is involved in energy production and has been used in Germany for decades as standard therapy for neuropathy. It is thought to reduce oxidative stress caused by increased blood glucose, the process believed to underlie many of the microvascular and neuropathic complications of diabetes.

Side effects include mild and dose-related gastrointestinal disturbances and possible hypoglycemia when used with sulfonylureas.

Alpha-lipoic acid (ALA) has a large body of data from well-conducted studies behind it. A recent metaanalysis of four large, randomized, double-blind, placebo-controlled, parallel-group trials investigated the efficacy and safety of 600 mg of ALA given intravenously daily (except weekends) for 3 weeks to a total of 716 diabetic patients with symptomatic polyneuropathy. The data also included 542 patients who received placebo (Diabet Med. 2004;21:114–21).

After 3 weeks, the relative difference in favor of ALA over placebo was 24% in total symptom score (pain, burning, paresthesia, numbness) and 16% for the neuropathy impairment score of the lower limbs. Overall responder rates were 53% in patients treated with ALA compared with 37% with placebo, a significant difference. The rates of adverse events did not differ between the groups.

Long-term trials will be necessary to determine whether ALA merely alleviates symptoms of diabetic neuropathy or actually slows its progression. “This is a product that definitely warrants some close attention,” Dr. Shane-McWhorter said.

▸ Chromium. This metal has become quite popular recently. Its trivalent form appears to work as an insulin sensitizer by increasing the number of insulin receptors in addition to other activities at the cellular level. There is also a suggestion that the use of chromium in combination with biotin may increase its efficacy. It has been used to improve lipids, to induce weight loss, and—by athletes—for its ergogenic effects.

Side effects include case reports of renal toxicity, psychiatric problems, and rhabdomyolysis, but only at extremely high doses. Chromium could potentially cause hypoglycemia when used with other glucose-lowering agents. Its use in combination with other chromium-containing herbs, such as horsetail or cascara, could lead to chromium toxicity. Moreover, high doses of vitamin C and nonsteroidal anti-inflammatory agents can increase the absorption of chromium, whereas H₂-blockers and proton-pump inhibitors may decrease it, Dr. Shane-McWhorter said.

In a widely quoted study, 155 subjects with type 2 diabetes received either 200 mcg or 1,000 mcg (1 mg) of chromium picolinate per day, along with their regular diabetes medications. At 4 months, hemoglobin A_1c had declined by 2.8% among the patients taking 1,000 mcg and by 1.9% for those taking 200 mcg, compared with a reduction of only 0.5% for those on placebo (Diabetes 1997;46:1786–91).

This study was done in an area of China known to be deficient in chromium, which raises the question of whether supplementation works only in individuals who are chromium deficient—which many diabetic patients are, she noted.

One problem with answering that question is that there is no standardized way of measuring body stores of chromium. However, toenails appear to be a particularly sensitive area. In one recent study, toenail chromium concentration was inversely associated with the risk of a first myocardial infarction in men (Am. J. Epidemiol. 2005;162:157–64).

Although chromium appears to be a promising agent for diabetic patients, its long-term effects are not known, she cautioned.

Hispanic women and those who receive prenatal care at a hospital or clinic were less likely to be screened for group B streptococcus in North Carolina during 2002–2003, the Centers for Disease Control and Prevention reported.

In 2002, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists jointly recommended universal prenatal screening for vaginal and rectal group B streptococcus (GBS) colonization at 35–37 weeks' gestation. The same year, the CDC began analyzing GBS screening rates in the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based monthly mail/telephone survey of randomly selected women in the state who have recently delivered a live-born infant.

The data comprise responses from 3,027 women who were included in the sample. In 2002, 70% reported having been tested for GBS during their most recent pregnancy, 11% said they had not been tested, and 19% did not know whether they had been tested. In 2003, those proportions were 74%, 8%, and 18%, respectively, the CDC reported (MMWR 2005:54:700–3).

Among the women who knew their GBS status, the factors significantly associated with lack of prenatal screening on multivariate analysis were Hispanic ethnicity, receipt of prenatal care primarily at a hospital clinic or health department (versus private physician/HMO), and lack of prenatal HIV testing. Those same factors also were associated with lack of knowledge of GBS screening on multivariate analysis, along with black race, other race, and Medicaid payment of delivery.

The incidence of invasive perinatal GBS disease in the United States declined 34% from 2002 to 2003, following the universal screening recommendation. Further efforts to reduce disparities in prenatal GBS screening among minority populations will be needed for continued progress, the CDC said.

Hispanic women and those who receive prenatal care at a hospital or clinic were less likely to be screened for group B streptococcus in North Carolina during 2002–2003, the Centers for Disease Control and Prevention reported.

In 2002, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists jointly recommended universal prenatal screening for vaginal and rectal group B streptococcus (GBS) colonization at 35–37 weeks' gestation. The same year, the CDC began analyzing GBS screening rates in the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based monthly mail/telephone survey of randomly selected women in the state who have recently delivered a live-born infant.

The data comprise responses from 3,027 women who were included in the sample. In 2002, 70% reported having been tested for GBS during their most recent pregnancy, 11% said they had not been tested, and 19% did not know whether they had been tested. In 2003, those proportions were 74%, 8%, and 18%, respectively, the CDC reported (MMWR 2005:54:700–3).

Among the women who knew their GBS status, the factors significantly associated with lack of prenatal screening on multivariate analysis were Hispanic ethnicity, receipt of prenatal care primarily at a hospital clinic or health department (versus private physician/HMO), and lack of prenatal HIV testing. Those same factors also were associated with lack of knowledge of GBS screening on multivariate analysis, along with black race, other race, and Medicaid payment of delivery.

The incidence of invasive perinatal GBS disease in the United States declined 34% from 2002 to 2003, following the universal screening recommendation. Further efforts to reduce disparities in prenatal GBS screening among minority populations will be needed for continued progress, the CDC said.

Hispanic women and those who receive prenatal care at a hospital or clinic were less likely to be screened for group B streptococcus in North Carolina during 2002–2003, the Centers for Disease Control and Prevention reported.

In 2002, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists jointly recommended universal prenatal screening for vaginal and rectal group B streptococcus (GBS) colonization at 35–37 weeks' gestation. The same year, the CDC began analyzing GBS screening rates in the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based monthly mail/telephone survey of randomly selected women in the state who have recently delivered a live-born infant.

The data comprise responses from 3,027 women who were included in the sample. In 2002, 70% reported having been tested for GBS during their most recent pregnancy, 11% said they had not been tested, and 19% did not know whether they had been tested. In 2003, those proportions were 74%, 8%, and 18%, respectively, the CDC reported (MMWR 2005:54:700–3).

Among the women who knew their GBS status, the factors significantly associated with lack of prenatal screening on multivariate analysis were Hispanic ethnicity, receipt of prenatal care primarily at a hospital clinic or health department (versus private physician/HMO), and lack of prenatal HIV testing. Those same factors also were associated with lack of knowledge of GBS screening on multivariate analysis, along with black race, other race, and Medicaid payment of delivery.

The incidence of invasive perinatal GBS disease in the United States declined 34% from 2002 to 2003, following the universal screening recommendation. Further efforts to reduce disparities in prenatal GBS screening among minority populations will be needed for continued progress, the CDC said.

WASHINGTON — Endocrinologists and rheumatologists are the most aggressive specialists when it comes to the screening, diagnosis, and treatment of osteoporosis, Tiffany Karas, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Of 122 physicians who responded to an electronic survey, there were 27 geriatricians, 25 endocrinologists, 23 obstetrician/gynecologists, 20 rheumatologists, 19 primary care physicians, and 8 orthopedic surgeons.

In screening for osteoporosis, 94% of the entire group said they would order a dual-energy x-ray absorptiometry (DXA) scan for a patient with two or more risk factors, said Dr. Karas and her associates, of Loyola University Medical Center, Maywood, Ill.

The risk factors most likely to prompt DXA scanning were height loss (93%), chronic prednisone use (89%), and menopause (86.6%). Among the risk factors least likely to prompt DXA were low testosterone (60%) and vertebral deformities (74%) in an elderly male patient. In general, all physicians surveyed were much less likely to order DXA for men with indications than for women. “This is one area where continuing education about osteoporosis may improve patient care,” the investigators noted.

Endocrinologists and rheumatologists were more likely to order DXA given any risk factor or patient scenario than were the other specialties, while orthopedic surgeons were the least likely. Rheumatologists were the most likely to initiate treatment in patients, followed by endocrinologists, geriatricians, primary care physicians, and ob.gyns.

Alendronate and risedronate were deemed the most efficacious treatments by more than 98% of all physicians, while calcium/vitamin D and calcitonin were thought to be the least efficacious.

Overall, patients were more likely to be screened, diagnosed, and treated for osteoporosis by female physicians who had been in practice for more than 6 years and who had practiced in urban, academic settings, Dr. Karas and her associates reported.

WASHINGTON — Endocrinologists and rheumatologists are the most aggressive specialists when it comes to the screening, diagnosis, and treatment of osteoporosis, Tiffany Karas, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Of 122 physicians who responded to an electronic survey, there were 27 geriatricians, 25 endocrinologists, 23 obstetrician/gynecologists, 20 rheumatologists, 19 primary care physicians, and 8 orthopedic surgeons.

In screening for osteoporosis, 94% of the entire group said they would order a dual-energy x-ray absorptiometry (DXA) scan for a patient with two or more risk factors, said Dr. Karas and her associates, of Loyola University Medical Center, Maywood, Ill.

The risk factors most likely to prompt DXA scanning were height loss (93%), chronic prednisone use (89%), and menopause (86.6%). Among the risk factors least likely to prompt DXA were low testosterone (60%) and vertebral deformities (74%) in an elderly male patient. In general, all physicians surveyed were much less likely to order DXA for men with indications than for women. “This is one area where continuing education about osteoporosis may improve patient care,” the investigators noted.

Endocrinologists and rheumatologists were more likely to order DXA given any risk factor or patient scenario than were the other specialties, while orthopedic surgeons were the least likely. Rheumatologists were the most likely to initiate treatment in patients, followed by endocrinologists, geriatricians, primary care physicians, and ob.gyns.

Alendronate and risedronate were deemed the most efficacious treatments by more than 98% of all physicians, while calcium/vitamin D and calcitonin were thought to be the least efficacious.

Overall, patients were more likely to be screened, diagnosed, and treated for osteoporosis by female physicians who had been in practice for more than 6 years and who had practiced in urban, academic settings, Dr. Karas and her associates reported.

WASHINGTON — Endocrinologists and rheumatologists are the most aggressive specialists when it comes to the screening, diagnosis, and treatment of osteoporosis, Tiffany Karas, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Of 122 physicians who responded to an electronic survey, there were 27 geriatricians, 25 endocrinologists, 23 obstetrician/gynecologists, 20 rheumatologists, 19 primary care physicians, and 8 orthopedic surgeons.

In screening for osteoporosis, 94% of the entire group said they would order a dual-energy x-ray absorptiometry (DXA) scan for a patient with two or more risk factors, said Dr. Karas and her associates, of Loyola University Medical Center, Maywood, Ill.

The risk factors most likely to prompt DXA scanning were height loss (93%), chronic prednisone use (89%), and menopause (86.6%). Among the risk factors least likely to prompt DXA were low testosterone (60%) and vertebral deformities (74%) in an elderly male patient. In general, all physicians surveyed were much less likely to order DXA for men with indications than for women. “This is one area where continuing education about osteoporosis may improve patient care,” the investigators noted.

Endocrinologists and rheumatologists were more likely to order DXA given any risk factor or patient scenario than were the other specialties, while orthopedic surgeons were the least likely. Rheumatologists were the most likely to initiate treatment in patients, followed by endocrinologists, geriatricians, primary care physicians, and ob.gyns.

Alendronate and risedronate were deemed the most efficacious treatments by more than 98% of all physicians, while calcium/vitamin D and calcitonin were thought to be the least efficacious.

Overall, patients were more likely to be screened, diagnosed, and treated for osteoporosis by female physicians who had been in practice for more than 6 years and who had practiced in urban, academic settings, Dr. Karas and her associates reported.