dimanche 1 décembre 2013

SPEND A MORNING WITH AN ENDOCRINOLOGIST AND READ WITH HIM

Eleven articles arrived on a peer reviewed Diabetes and Metabolism Journal this morning.
What was very interesting to note was that the authors were not from the usual developed countries but were from China, Brazil, Argentina, Egypt, and Panama.
The character of the research in the papers are also different, they are all of immediate importance and relevance to those countries, rather than obscure research of future value. The latter research is very important too, but in countries where there are limited resources for research and health care, it is better to be practical rather than theoretical.
Most physicians licensed in any part of the world engage in clinical practice rather than research but the small numbers who do engage in scientific or clinical research is important indeed.
While scientific research would delve into molecular and genetic metabolism, to give an example, the clinical research usually can shed light upon the social aspects of illness and suffering and also allows a non medical view of the situation. It is difficult for an anthropologist or psychologist to look into a scientific paper detailing the c230 allele in a population but it can certainly comment from a cultural point of view on the relationship with Body weight and Waist circumference in a particular population and whether or not it is increasing or decreasing.
Let me see the offerings this morning in the Diabetes and Metabolism Journal. I will list them in the order I read them

Abdominal obesity, Insulin Resistance and oxidized Low Density Lipoproteins in Latino Adolescents.
In this Mexican adolescent population, Insulin Resistance and abdominal adiposity were related with Oxidized LDL that may lead to their increased cardiovascular risk.
It would be of interest to the American Indians, since Mexicans have a high degree of American Indian Blood.
The Question in my mind, as pertaining to the American Indian, Why did and how did they become Insulin Resistant?

Prevalence, sociodemographic distribution, treatment and control of Diabetes Mellitus in Panama.
There are no surprises here, one in ten adults had Diabetes, more so if you are poor and black, Surprisingly (not so much since I have visited these indigenous groups) the Native Indian groups had lesser amount of Diabetes burden. The middle class is catching on, with the ones earning around 600 dollars a month having just about the highest levels of Diabetes. More than half the people who had diabetes were not controlled, a figure not so different from the USA, and also not something to be self-congratulatory for the Panamanian Doctors who have failed in the appropriate treatment of Diabetes.


Metabolic syndrome and the early detection of impaired glucose tolerance among professionals living in Beijing, China: a cross sectional study
Of the 928 eligible urban professionals in the study, nearly one in four had glucose intolerance. Their risk of diabetes was higher if they had higher end waist circumferences.
Oh Poor China! Rapid increases in economic wealth have created more McDo, more Pizza Hut and more metabolic syndrome among professionals!


I also received a letter from Indonesia this morning to say that in that booming economy, the diabetes rates are also booming from 12 per cent nationally to up to 30 per cent in Jakarta! Is this the prize of one becoming well off?

The next one was also of interest, it was from Brasil.
Ability of body mass Index to predict abnormal waist circumference
There is always some controversy regarding what is better, Body Mass Index, which is calculated by weight in kg divided by height in meters squared and expressed as a number. It varies according to race. But people in the field know that waist circumference is an excellent indicator of underlying metabolic abnormality, but very seldom measured unless you are doing surveys in schools or public health education in communities. Very seldom your doctor would measure that in his office.

So it is good to know what are the cut off points for BMI at which we should use caution?
The most accurate BMI cut off point for abnormal Waist Circumference WC was 27.1kg/m2 for men and 26.8 kg/m2 for women (using WC of greater than 102 cm in men and 88 cm in women) and for most of the people in this world, especially in Asia, a BMI of 24.7 kg/m2 for men and 24.9 kg/m2 predicts abnormal WC (greater than 80 cm for women and 90 cm for men).
So keep in mind that people living in South America, Middle East, Asia and the immigrants from those countries to the West, if a man or a woman has a BMI of 25 kg/m2 she or he can be expected to have already metabolic dysfunction and that it would be the best time to begin intensive counselling.
Thanks for that article from Minais Gerais in Brasil.

Next one was once again from Beijing, China.
Insulin resistance determined by Homeostasis Model assessment HOMA and associations with Metabolic syndrome among Chinese children and teenagers.
I am involved in the prevention of obesity among Native American Children and know how important it is to identify and intervene at the earliest stage possible.
The horror of the article is that one in four school children in the Beijing area, had obesity or manifestations of Metabolic Syndrome and they were 6-18 years of age. Higher the Insulin resistance greater the risk of Metabolic syndrome and future metabolic diseases! Que horror! But it is no different from what is happening in USA UK Australia and China has the honour of achieving this dubious honour within the last ten years!


Another article from Rio de Janeiro, implicating that Sucrose added diet, which was of the same macronutrient value, increased the CRP, inflammatory marker in type 1 patients.
Here it is one step for Quality versus Quantity. If you had just calculated the Quantity of Sugar there would have been no difference, but if you had calculated the quality of Sugar as Sucrose, you see the difference.
This reinforces my long held belief that it is the Quality of Food that matters much more than Quantity as well as the carbs/protein/fat content in it.


I decided to read next the pharmacological article:
Comparative efficacy of glimepiride and metformin in monotherapy of type 2 diabetes mellitus: Meta=analysis of randomized controlled trials
All the authors were Chinese and attached to the University of Macau, in Macau, China.
I am not fond of such studies, which tries to prove one drug is better than the other. First of all when you are working in a poor country such as Cambodia, you want the most efficient drug at the cheapest price and for that you cannot beat Metformin and I am not interested that Glimepiride is as effective as Metformin, without mentioning that it is at least three times as expensive!


On to the next one, this time from Egypt.
Curcumin has been touted as a good hypoglycaemic agent, but does it improve pancreatic islet cell regeneration?
In diabetic rats, one could definitely see the anti diabetic action and enhanced pancreatic islets regeneration, in this article. It is something to be encouraged since curcumin is found amply in nature and could easily be incorporated into a cuisine and diet. It is the major ingredient of south Asian Turmeric powder and thus gives the yellow colour and member of the Ginger family. It has been known to have anti-inflammatory properties.


The next article was a population-based study, again from China. And I realized that in China it is easy to have large population studies so that they can ascertain the prevalence of cardiac autonomic neuropathy, something we in the west very seldom talk about.
So what is this Cardiac Autonomic Neuropathy or CAN? And what is its significance in China?
It seems it is a significant problem in China, not only among patients with Diabetes but other segments of the population, such as the Elderly or Hypertensive patients as well as those with Metabolic Syndrome or
Musculoskeletal disorders. I was amazed to learn that in patients with Diabetes in China, CAN can be found in 1/3 to 2/3 of the patients! Certainly surprising, we don't find it, is it because we are not looking for it? Also they were able to get nearly 3000 people so that they can test for CAN as well as Metabolic Syndrome on them! Just in one city.. It does help to have a large population.
The main finding of the study is that Metabolic Syndrome and Resting Heart Rate is strongly correlated with Cardiac Autonomic Neuropathy. It is an interesting finding in that, as we already know, cardiovascular disease begins even before diabetes is diagnosed in the early glucose intolerant state.
There is something else that reminds us, people who exercise regularly have lower Heart Rates, they also have less Metabolic Syndrome!
So take your pulse now, put on the running shoes, off you go!


The article from Buenos Aires was about Proliferative Retinopathy and neovascularization of the anterior segment of the female type 2 diabetic rats, the conclusion already present in the title of the article, yes, they do get proliferative retinopathy in places they normally get if fed High Fat Diet!
Of course High Fat Diet for the rat varies differently and depending upon the quality of the High Fat diet, one can see Insulin resistance in various different tissues. In an article published in the American Journal of Physiology in 1998, Canadian researchers were able to show that insulin dependent glucose uptake in the Adipocytes were lowered only when the high fat diet contained high levels of N6 Fatty Acids!  Something for us to remember since most of the cooking oils in the market, especially in Asia, are high in omega 6 rather than the omega 3 fatty acids!

Last of the articles for today was from Belgium but the lead author had a nice maghrebien Jewish name, Benhalima. The article said, without any great surprises that the screening practices varied widely in the Flemish part of Belgium and that only 1 in 4 centres are implementing the International Screening Strategy.


So, dear friends, this was my reading for this morning. I enjoyed also visiting in my mind the various places the authors came from, most of which I had travelled to with the exception of Shanghai and El Kahira.  I have conservatively calculated that a practising physician, if he is achieve anything like competency in what is happening in the medical world, especially if he is a specialist physician, has to read at least two hours per day.
Being an anthropologist, where reading is integral, in addition to being a specialist physician, you can imagine how fruitful an intuition I had gained as an adolescent!
LIFE SHOULD BE LONG PERIODS OF HOLIDAYS INTERSPERSED WITH INTERVALS OF WORK
Successful medical practice should be many long hours of reading and discussing, interrupted by hours of seeing patients and looking after them!