White rice or brown rice?

White Rice, Brown Rice, and Risk of Type 2 Diabetes in US Men and Women
Qi Sun, MD, ScD; Donna Spiegelman, ScD; Rob M. van Dam, PhD; Michelle D. Holmes, MD, DrPH; Vasanti S. Malik, MSc; Walter C. Willett, MD, DrPH; Frank B. Hu, MD, PhD
Arch Intern Med. 2010;170(11):961-969

In this large scale epidemiological study of diet, lifestyle practices, and disease status among 39 765 men and 157 463 women, higher intake of white rice (> 4 servings per week vs < 1 per month) was associated with a higher risk of type 2 diabetes: pooled relative risk 1.17 (95% confidence interval 1.02 to 1.36).

The authors conclude with the recommendation that most carbohydrate intake should come from whole grains rather than refined grains to help prevent type 2 diabetes.

Vitamin D Deficiency In The Obese Patient Awaiting Bariatric Surgery

 Vitamin D insufficiency prior to bariatric surgery: risk factors and a pilot treatment study

In a population where severe obesity is becoming increasingly prevalent, bariatric surgery is being employed more often.  This study assessed the vitamin D status of such patients and looked at other influential factors as well as evaluating the efficacy of 2 preoperative vitamin D repletion regimens.

Obesity and the risk of pancreatic cancer

Body Mass Index and Risk, Age of Onset, and Survival in Patients With Pancreatic Cancer. Donghui Li; Jeffrey S. Morris; Jun Liu; Manal M. Hassan; R. Sue Day; Melissa L. Bondy; James L. Abbruzzese. JAMA 2009;301(24):2553-2562

This case-control study by Li and colleagues adds pancreatic cancer to the growing list of cancers,  including of the colon, kidney,  oesophagus, breast (in post-menopausal women) and endometrium, that  are now recognised to be associated with obesity. The study included 841 patients with pancreatic adenocarcinoma and 754 healthy individuals frequency matched by age, race, and sex. Overweight or obesity during early adulthood was associated with a greater risk of pancreatic cancer and a younger age of disease onset. Obesity at an older age was associated with a lower overall survival in patients with pancreatic cancer.

Diabetic retinopathy, but not nephropathy, benefits from angiotensin receptor blocking

A very interesting study which explores the role of angiotensin receptor blocking treatment in preventing diabetic nephropathy in normotensive and normoalbuminuric patients. The benefits of early introduction of ACEI/ARB treatment in slowing progression of nephropathy in albuminuric patients has already been established but the investigators of this study conclude that such treatment has no benefit in preventing biopsy  proven nephropathy in normoalbuminuric patients.

Renal and Retinal Effects of Enalapril and Losartan in Type 1 Diabetes. Michael Mauer, M.D., Bernard Zinman, M.D., Robert Gardiner, M.D., Samy Suissa, Ph.D., Alan Sinaiko, M.D., Trudy Strand, R.N., Keith Drummond, M.D., Sandra Donnelly, M.D., Paul Goodyer, M.D., Marie Claire Gubler, M.D., and Ronald Klein, M.D., M.P.H. N Engl J Med 2009 361: 40-51

Background Nephropathy and retinopathy remain important complications of type 1 diabetes. It is unclear whether their progression is slowed by early administration of drugs that block the renin–angiotensin system.
Methods We conducted a multicenter, controlled trial involving 285 normotensive patients with type 1 diabetes and normoalbuminuria and who were randomly assigned to receive losartan (100 mg daily), enalapril (20 mg daily), or placebo and followed for 5 years. The primary end point was a change in the fraction of glomerular volume occupied by mesangium in kidney-biopsy specimens. The retinopathy end point was a progression on a retinopathy severity scale of two steps or more. Intention-to-treat analysis was performed with the use of linear regression and logistic-regression models.
Results A total of 90% and 82% of patients had complete renal-biopsy and retinopathy data, respectively. Change in mesangial fractional volume per glomerulus over the 5-year period did not differ significantly between the placebo group (0.016 units) and the enalapril group (0.005, P=0.38) or the losartan group (0.026, P=0.26), nor were there significant treatment benefits for other biopsy-assessed renal structural variables. The 5-year cumulative incidence of microalbuminuria was 6% in the placebo group; the incidence was higher with losartan (17%, P=0.01 by the log-rank test) but not with enalapril (4%, P=0.96 by the log-rank test). As compared with placebo, the odds of retinopathy progression by two steps or more was reduced by 65% with enalapril (odds ratio, 0.35; 95% confidence interval [CI], 0.14 to 0.85) and by 70% with losartan (odds ratio, 0.30; 95% CI, 0.12 to 0.73), independently of changes in blood pressure. There were three biopsy-related serious adverse events that completely resolved. Chronic cough occurred in 12 patients receiving enalapril, 6 receiving losartan, and 4 receiving placebo.
Conclusions Early blockade of the renin–angiotensin system in patients with type 1 diabetes did not slow nephropathy progression but slowed the progression of retinopathy.

You are what you don’t eat

Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. Sacks et al. N Engl J Med 2009;360:859-873

What is your favourite weight-loss diet? Low fat or high fat? Average protein or high protein? Low carb or high carb? Sacks and colleagues set out to answer these much debated questions in this large, long term, population-based trial and report that macronutrient composition made little difference. Although there were few drop-outs and treatment was intensive, the study was marred by a blurring of participants’ diets over time so in the end macronutrient differences between groups were less clear than originally envisaged. Nevertheless, they conclude that reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize. At the risk of stating the obvious, I think the chief take-home message is that a calorie is a calorie, regardless of whether it came from a KitKat or a celery stick: reduce your total calorie-intake and you lose weight. So, yes, you are what you don’t eat… in calories!

Intensive versus conventional glucose control in critically ill patients

Intensive versus Conventional Glucose Control in Critically Ill Patients. The NICE-SUGAR Study Investigators. N Engl J Med 2009; 360:1283-1297


Background: The optimal target range for blood glucose in critically ill patients remains unclear.

Methods: Within 24 hours after admission to an intensive care unit (ICU), adults who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter (4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter (10.0 mmol or less per liter). We defined the primary end point as death from any cause within 90 days after randomization.

Results: Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients, respectively. The two groups had similar characteristics at baseline. A total of 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14; 95% confidence interval, 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between operative (surgical) patients and nonoperative (medical) patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycemia (blood glucose level <40 mg per deciliter [2.2 mmol per liter]) was reported in 206 of 3016 patients (6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39).

Conclusions: In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter.

TOPDOC Diabetes National Study

The TOPDOC Diabetes national study is a UK-wide survey of foundation doctors and specialist trainees from all specialties looking at their confidence levels in the management of diabetes. The study is funded by the Association of British Clinical Diabetologists and follows from a national pilot that showed  a lack of confidence in managing aspects of diabetes care, including the management of diabetes emergencies.

All details are available at www.topdocdiabetes.org and the survey takes only 5 minutes to complete.


What is TOPDOC Diabetes?

TOPDOC Diabetes Study (Trainees Own Perception of Delivery Of Care in Diabetes) is a national study of confidence levels amongst trainee doctors in the management of diabetes.

Who is it for?

The study is aimed at foundation and specialty trainees in all specialties.

How can I take part in the study?

It only takes 5 minutes to answer the online survey at www.topdocdiabetes.org

What do you get in return?

Your details will be entered into a draw with a number of prizes (iTunes vouchers, travel grants and more!). TOPDOC results will also help us design training modules for you.