The Cost of Diabetes Treatment

The staggering cost of treating diabetes and the number of diabetes-related programs highlight a need for a national diabetes coordinator to ensure results," Haza said. "We are spending as much on diabetes as we are on the entire Department of Education, but no one is leading the effort." A report by Medco Health Solutions Inc. issued last month found that the growing diabetes epidemic and more aggressive treatment could result in soaring costs to treat the disease over the next three years. An analysis of Medco's 2007 Drug Trend Report found that, by 2009, spending just on medicines to treat diabetes could soar 60 percent to 68 percent from 2006 levels. The sales of diabetes drugs in the United States reached $9.88 billion in 2005, according to data from IMS Health Inc. "Coordinating America's response to diabetes should be mandatory," said Lana Vukovljak, CEO of American Association of Diabetes Educators. "Over the next 30 years, diabetes is expected to claim the lives of 62 million Americans. Surely this health crisis warrants the appointment of a manager charged with aligning budgets and programs for diabetes at the federal level," Vukovljak said in a statement. Uncontrolled diabetes can result in a wide variety of serious health complications, including heart disease, stroke, vision loss, amputation of extremities and kidney disease. "Our findings suggest that there are many missed opportunities for the federal government to enhance its impact on diabetes prevention, detection, treatment and management of complications," Marsha Gold, who led Mathematica's research team, said in a statement.

Symptoms of Ovarian Cancer

In response to reports by patients with ovarian cancer of the symptoms they experienced, Dr. Goff and others have found that certain symptoms are much more frequent in women with ovarian cancer than in women in the general population. These symptoms include bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency. "The symptoms are not specific, and all of us have had 1 or more of these symptoms from time to time," Dr. Goff says. "What's different about the symptoms of ovarian cancer is that they are new symptoms, not symptoms you have had all your life; they occur regularly, either daily or every other day; and they persist more than several weeks." The consensus panel recommended that women who experience these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist, because prompt medical attention might allow diagnosis at the earliest possible stage of ovarian cancer, when prognosis is better. Because there is no effective screening test for ovarian cancer, symptom recognition and regular pelvic examinations are essential for early detection. "We are not 100% sure that identification of symptoms will lead to earlier detection of ovarian cancer, but because there is a potential for that, we need more research to see what effect implementing this statement will have on outcomes," Dr. Goff says. "Even in stage 1, which is associated with a 90% cure rate, women have these symptoms. If women are having these symptoms even in early stages, then with recognition of these symptoms, we may be able to diagnose ovarian cancer in early stages when chance of cure is 70% to 90%, as opposed to the 20% to 30% chance of cure in advanced stages." Although other symptoms are often reported by women with ovarian cancer, such as fatigue, indigestion, back pain, pain with intercourse, constipation, and menstrual irregularities, these symptoms are not as helpful in diagnosing ovarian cancer because they are found in equal frequency in women without ovarian cancer in the general population. A nationwide poll conducted by GCF in May 2007 revealed that women agree that it is important to know the symptoms of ovarian cancer, but 65% did not feel sufficiently informed. There is therefore a great need for information dissemination and education of women and healthcare providers. "By highlighting these symptoms and their potential association with ovarian cancer, more women may seek medical attention, especially if these symptoms persist over a few weeks," Dr. Barakat said. "Since ovarian cancer is much less common than other cancers, such as breast and lung cancer, patient education has lagged behind. Increasing public awareness could potentially lead to more patients being diagnosed with early-stage disease, and potentially lead to fewer deaths from ovarian cancer." Dr. Barakat also highlighted the need for additional research on laboratory screening tests. "One of the most important areas of research in this disease should be the development of novel biomarkers that can detect early ovarian cancer," he says. "Currently, the best test we have is a CA-125 blood test. This tumor marker is only elevated in 50% of patients with early ovarian cancer and has not been shown to be an effective screening tool in this disease." "Our goal is not to scare people, but to arm people with the knowledge that if these symptoms persist, they could be a sign of ovarian cancer or other serious condition," Dr. Goff concludes. "If ovarian cancer is suspected because of these symptoms and a suspicious mass is detected, it is very important for the woman to see a gynecologic oncologist. In that situation, if there is ovarian cancer, women are significantly more likely to have the right surgery and a higher chance of cure, so it could mean the difference between life and death."

FDA Site for Tweens - Reducing Obesity

Spot the Block Using the Nutrition Facts Label to Make Healthy Food Choices -- A Program for Tweens http://www.cfsan.fda.gov:80/~dms/spotov.html

New, Continuous 7-Day Blood Sugar Tracking

FDA Approves Continuous 7-Day Glucose Monitoring System The U.S. Food and Drug Administration today approved a device that measures glucose levels continuously for up to seven days in people with diabetes. While a standard fingerstick test records a person’s glucose level as a snapshot in time, the STS-7 Continuous Glucose Monitoring System (STS-7 System) measures glucose levels every five minutes throughout a seven-day period. This additional information can be used to detect trends and track patterns in glucose levels throughout the week that wouldn’t be captured by fingerstick measurements alone. However, diabetics must still rely on the fingerstick test to decide whether additional insulin is needed. “The STS-7 System supplements standard fingerstick meters and test strips, providing diabetics ages 18 and older with a way to see trends and track patterns,” said Daniel Schultz, M.D., director of FDA’s Center for Devices and Radiological Health. “It can help detect when glucose levels drop during the overnight hours, show when glucose levels rise between meals and suggest how exercise and diet might affect glucose levels.” The STS-7 System, manufactured by DexCom Inc. of San Diego, Calif., uses a disposable sensor placed just below the skin in the abdomen to measure the level of glucose in the fluid found in the body’s tissues (interstitial fluid). Sensor placement causes minimal discomfort and can easily be done by patients themselves. The sensor must be replaced weekly. An alarm can be programmed to sound if a patient’s glucose level reaches pre-set lows or pre-set highs. Diabetes is caused by the body’s inability to produce or use insulin, a hormone that unlocks the cells of the body, allowing glucose (sugar) to enter and fuel them. An estimated 20.8 million people in the United States—7 percent of the population—have diabetes. Most have type 2 diabetes, a condition in which the body does not properly use insulin. An estimated 5 percent to 10 percent of people with this chronic disease have type 1 diabetes, which results from the body's failure to produce insulin. People with type 1 diabetes must take insulin every day. Diabetes can lead to wide fluctuations in blood sugar levels. Over time, abnormally high levels of glucose can damage the small and large blood vessels, leading to diabetic blindness, kidney disease, amputations of limbs, stroke, and heart disease. While there is no known cure, studies have shown that patients who regularly monitor and regulate their blood glucose levels have lower incidences of complications associated with the disease. FDA’s approval of the STS-7 System was based on results of a study conducted by DexCom of 72 patients with diabetes at five clinical sites in the United States. The study demonstrated that the STS-7 System was safe and effective for detecting trends and tracking patterns in glucose levels in adults. A three-day version of the device, the STS Continuous Glucose Monitoring System, was approved in March 2006.

Calcium to Prevent Osteoporosis - Take More!

The totality of the evidence indicates that high calcium intake is important both for prevention and management of osteoporosis, and recent negative trials do not refute the much larger body of positive studies. The challenge is not to haggle over exactly how much is enough but, as the Surgeon General's report on osteoporosis put it, to recognize that current intake is far below optimal values. It is imperative to take action to augment calcium intake, both in the general population and particularly in persons being treated for osteoporosis. For many patients, calcium supplements are the most appropriate choice to ensure adequate intake. A number of different calcium compounds are used in supplements; the 2 main forms are calcium carbonate and calcium citrate. Although absorption of calcium citrate is similar to calcium carbonate, a calcium carbonate supplement contains 40% calcium vs the 21% found in calcium citrate.[52] Because formulations may contain different amounts of calcium, the number of tablets needed to obtain a recommended dose may vary. Figure 6 depicts the amount of calcium found in common compounds. Patients often erroneously believe that they are obtaining sufficient calcium through their diet. However, it is known that the median calcium intake in postmenopausal women in North America is substantially below existing recommendations.[11] Because milk and milk products provide the majority of dietary calcium in the United States, if a person is lactose-intolerant, a vegan (consuming no animal products), or avoids dairy products for other reasons, it may be especially challenging to obtain adequate amounts of calcium solely through diet.[50] In addition to being aware of the amount of dietary calcium they are ingesting, it is important that patients understand that absorption from foods can be affected by a number of factors, many of which have already been well described. These include age, vitamin D, pregnancy, and plant substances in the diet. Oxalates (found in chocolate and spinach) and phytate (found in whole grains) are among dietary substances that impair absorption. Therefore, 8 cups of spinach are needed to obtain the same amount of calcium obtained from an 8-ounce serving of milk or 1 cup of yogurt, which contain calcium in an easily absorbable form.[51] Vitamin D. Although vitamin D status has been discussed as a potential confounder of results in calcium studies, the importance of vitamin D in its own right must also be emphasized. It has long been recognized that vitamin D is important for calcium absorption, and recent studies have demonstrated that absorption efficiency increases with improving vitamin D status up to serum 25(OH)D levels of about 80 nmol/L (32 ng/mL).[43,44] Postmenopausal women, as reported in many studies, tend to have average serum 25(OH)D values ranging from 50 to 55 nmol/L (20 to 22 ng/mL)[43,45] and are therefore absorbing the calcium they ingest with reduced efficiency. Protein. As with vitamin D, protein plays an important role in its own right. Although North Americans are considered to consume generous amounts of protein it is also true that many fragile elderly individuals have low protein intake. If these same individuals are our osteoporosis patients, then they will probably not respond well to pharmacotherapy until their nutritional status is repaired. If deficient in calcium, vitamin D, and protein, many will be unresponsive to monotherapy, whether nutritional or pharmacologic. This is seen most obviously in patients with hip fracture, whose outcomes have been shown to improve dramatically with protein supplementation.[46] Exercise. Bones are designed to bear loads and to resist mechanical forces. Maintenance of adequate bone mass requires continued mechanical loading. Nutrition alone may slow the progress of disuse bone loss, but it will not block its full, ultimate expression. Optimal exercise regimens are uncertain, but impact loading appears to be more osteotrophic than, for example, weight lifting or swimming. In general, patients with osteoporosis need to maintain as vigorous an exercise program as is compatible with their bone fragility status. Good online sources of information for patients about calcium and or bone health include the National Institutes of Health, Office of Dietary Supplements;[51] American Osteoporosis Foundation;[54] and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.[53]

All About Sleeping Better

Insomnia: Once you and your doctor have ruled out any medical problems that may be causing your insomnia, you might try self-care methods. "Good sleep hygiene" refers to practices you can follow to help ensure adequate, quality sleep. For good sleep hygiene, try to do the following: Stick to a regular bedtime schedule. Get out of bed at the same time each morning, even if it's a weekend or holiday. Avoid napping during the day. Avoid stressful activities and vigorous exercise for two hours before going to bed. Before going to bed, try relaxation techniques, such as deep breathing, yoga, or meditation. Make sure your bedroom is dark, quiet, and cool. Use earplugs or eye shades if needed. Leave the bedroom if you can't sleep. Go into another room and read or do something relaxing and quiet. Exercise regularly. Avoid substances that contain caffeine (such as coffee, tea, soft drinks, or diet pills). Avoid alcohol and nicotine before bed. Snoring: If your snoring is light, try these self-care techniques: Sleep on your side. Avoid alcohol, and don't smoke. Avoid sleeping pills and other sedatives. Also, seek treatment for any allergies or nasal obstructions you may have. Sleep apnea: Weight loss can improve but may not adequately treat sleep apnea. Avoiding alcohol and sleeping pills can also help. You may want to talk to your doctor about a technique called continuous positive airway pressure (CPAP). With CPAP, each night you wear a mask that increases the air pressure inside your throat. This prevents your airway from becoming too narrow and may allow you to sleep without interruption. Except in very carefully selected cases, surgery does not adequately treat anything more than the mildest degrees of sleep apnea (though it may be more effective for troublesome snoring). A dental brace that holds your lower jaw forward during sleep is an increasingly available option for snoring and mild to moderate sleep apnea. Pregnancy and sleep: Pregnant women who experience insomnia during pregnancy may find relief by taking afternoon naps, drinking warm milk, or taking a warm (not hot) bath before bedtime. Exercise during the day should help too. Expectant mothers may find it more comfortable to sleep on their side, with pillows supporting their head, abdomen, and topside knee. Women who are pregnant should not take sleeping pills or herbal sleeping remedies without talking with their doctor first. Narcolepsy: Often, naps help relieve narcolepsy but cannot be relied on exclusively. Your doctor may prescribe stimulants (such as Ritalin or dextroamphetamine) to make you more alert. Antidepressants may be used to treat cataplexy (drop attacks) or sleep paralysis, if present. Restless leg syndrome: Cutting your caffeine intake may help. Other self-help measures may include a warm bath or relaxation exercises before bed. Hot or cold packs on your legs may provide relief. Several effective medications are available. Restless leg syndrome is a very treatable condition. Nightmares/night terrors: If your child has a nightmare or night terror, the best medicine is comfort. If the dreams reoccur frequently, talk with your child's doctor about the problem. Age: The lighter sleep patterns of older adults can sometimes lead to sleep problems. However, studies show that older adults who exercise and keep active sleep better than those who don't. Elderly people who don't sleep well at night may find afternoon naps helpful. However, excessive naps will disrupt sleep at night. Getting adequate light during the day, particularly in the morning, is important. Lifestyle: You'll sleep better if you have good sleep hygiene and avoid caffeine, alcohol, nicotine, and heavy meals before bed. Regular exercise can improve sleep, as long as the exercise is performed at least two hours before bedtime. Medication: If you think prescription or over-the-counter medication may be causing your sleep problems, talk with your doctor. You may need to have your medication dose adjusted or may need to take a different kind of medication. Depression and anxiety: If depression or anxiety is keeping you up for more than a few nights, talk to your doctor about treatment. Heart failure and lung problems: If you experience breathlessness when you lie down to sleep or awaken in the night feeling breathless, you should see your doctor. You could have problems with your heart or lungs.

Hearing Loss and Aides

Technological advances in hearing aids and HATS have expanded the range of options available to improve the success of a device use. Today's hearing aids differ significantly from their analog predecessors because the application of digital signal processing has permitted many adaptive and/or automatic features. In the past decade, hearing instrument technology has developed to the point that digital hearing aids now constitute nearly 90% of all hearing aid sales in the U.S.[21] This growth has permitted decreases in the cost of digital technology so that digital hearing aids now span the range from entry-level prices to high-end pricing, thus allowing all users the option of digital technology. Included in the benefits of digital hearing aids are improved sound quality; multiple listening programs for different listening environments; advanced noise reduction strategies; acoustic feedback reduction; compatibility with remote control options; and flexibility in manipulation of the frequency, compression, and gain ( Table 1 ). These developments allow the audiologist considerable flexibility in choosing appropriate technology for the varied needs of older adults. Such features as automatic function of the telecoil (a hearing aid component for use with the telephone or for coupling to HATS) and multiple programs ensure that even those with limited manual dexterity or cognitive impairments can wear a device that optimizes performance across a broad range of listening environments. It is no longer necessary to find the switch or remember to return to a listening program when the conversation has ended for effective telephone use. Difficulty understanding speech amid noise is a common complaint for hearing aid users. Directional microphone technology has advanced to optimize the directional responsiveness of the hearing aid microphone in order to reduce the level of noise when the noise source is from an angle that is behind or beside the hearing aid user. Automatic directional systems are intended to accurately switch between directional and omnidirectional modes, and this option is available even in the lower-priced entry-level digital devices.

New Cardiopulmonary Resuscitation Guidlines (CPR)

CPR consisting of chest compression plus mouth-to-mouth ventilation is a major element in the chain of survival for people with cardiac arrest. However, although bystander CPR improves the likelihood of survival, it is attempted in less than one third of patients who collapse, partly due to the reluctance of bystanders to undertake mouth-to-mouth ventilation. In CPR guidelines, according to the current authors, cardiac-only resuscitation by bystanders is recommended in dispatch-assisted resuscitation or if a rescuer is unwilling or unable to do mouth-to-mouth ventilation, but this technique is not generally known or taught to the public. One study has shown that cardiac-only resuscitation results in better survival without neurologic impairment.

Saline Nasal Irrigations for Chronic "Sinus" Symptoms

Nasal irrigation previously has been demonstrated to be an effective, safe, and well-tolerated means to treat frequent or chronic rhinosinusitis. The current authors reported results from a randomized controlled trial of 6 months of therapy with 2% saline nasal irrigation vs usual care in the December 2002 issue of the Journal of Family Practice. The authors found that the use of saline was associated with fewer sinus symptoms, improved sinus-related quality of life, and reduced use of antibiotics and nasal sprays. A follow-up study to this trial demonstrated that participants in the original randomized trial continued to use nasal irrigation as a successful modality to treat rhinosinusitis. Given the apparent clinical success of nasal irrigation for frequent or chronic rhinosinusitis, the authors sought to examine qualitative data regarding the everyday benefits and drawbacks of irrigation from study participants. Their results are summarized in the "Study Highlights." Study Highlights Participants from the researchers' primary study were invited to participate in structured 30-minute interviews to explore their experience with nasal irrigation for rhinosinusitis. Patients included in the original study had either 2 episodes of acute sinusitis or 1 episode of chronic sinusitis in the past year. In addition, participants reported a moderate-to-severe overall daily quality-of-life burden associated with rhinosinusitis. Participants randomized to receive nasal irrigation had an educational session that included lessons on rhinosinusitis and individual coaching on the practice of nasal irrigation. 28 of the original 35 subjects who received nasal irrigation agreed to participate in the interviews for the current study. Their clinical data were similar to the original cohort as a whole. 4 main content themes emerged from these interviews: Patients felt empowered in being able to access, monitor, and adjust treatment with nasal irrigation on their own. They were pleased to be less reliant on clinician visits and antibiotics. Patients were enthusiastic regarding the efficacy of nasal irrigation in reducing sinus symptoms and improving their quality of life. Many subjects reported improvement within the first or second use of nasal irrigation. Patients cited fear of having water in the nasal cavity, initial unpleasant sensation of water in the nasal cavity, having to learn how to perform nasal irrigation effectively, the time to perform nasal irrigation, and occasional mild adverse effects as potential barriers to the use of nasal irrigation. Adverse effects included saline drainage and nasal burning, but these events were not strong enough to stop the practice of nasal irrigation. Patients noted that the initial education session, particularly individual coaching on the practice of nasal irrigation, was effective in overcoming many of the barriers to the use of nasal irrigation. In addition, their experience at home with adjusting the schedule, salinity, and temperature of nasal irrigation allowed for effective and well-tolerated treatment. Pearls for Practice Nasal irrigation with saline solution has been demonstrated to improve symptoms of rhinosinusitis, sinus-related quality of life, and the use of other medications for rhinosinusitis. This treatment appears effective over the long term. The current study demonstrates that patients with frequent or chronic rhinosinusitis may have some initial trepidation regarding the use of saline nasal irrigation, but some coaching on how to use irrigation along with self-adjustment of therapy allowed patients to overcome potential barriers to treatment. Patients find the use of nasal irrigation empowering and effective.

DHEA In Older Men

Because blood levels of dehydroepiandrosterone (DHEA) and testosterone decline with age, some people believe that DHEA and testosterone supplementation can reverse the effects of aging. This hypothesis was examined in a double-blind, placebo-controlled, randomized trial that included 87 men and 57 women aged 60 or older. Baseline levels of DHEA-S (the sulfated form of DHEA) in both sexes, and baseline levels of bioavailable testosterone in men, were required to be below the 15th percentile for normal young adults. Men received a DHEA tablet (75 mg) daily, a transdermal testosterone patch (5 mg daily), or double placebo; women received a DHEA tablet (50 mg) or placebo. After about 2 years of follow-up, no differences were noted between the active-drug and placebo groups in physical performance (i.e., aerobic capacity and muscle strength) or in quality of life as measured on a validated questionnaire. In the active-drug groups, small increases in bone density were noted only at the femoral neck in men and at the distal radius in women. These changes were much smaller than those typically seen with bisphosphonate drugs. No significant adverse events occurred. Comment In this well-done randomized trial, supplementation with DHEA or low-dose testosterone conferred no obvious benefits to older adults. Based on these and previous results, the authors and an editorialist conclude that DHEA and testosterone should not be used as anti-aging supplements. The editorialist also believes that DHEA should be treated as a regulated drug and not as a dietary supplement. — Allan S. Brett, MD

Quinine Drugs Removed from Market

FDA Removes Unapproved Quinine Drugs From Market Yael Waknine Medscape Medical News 2006. © 2006 Medscape December 13, 2006 — The US Food and Drug Administration (FDA) has ordered the removal of unapproved drug products containing quinine, citing serious safety concerns and deaths associated with their use. The action is part of a larger effort to remove all unsafe, unapproved drugs from the market.Since 1969, the FDA received 665 reports of serious adverse events (including 93 fatalities) associated with quinine use, according to an alert sent yesterday from MedWatch, the FDA's safety information and adverse event reporting program. Serious adverse events have included cardiac arrhythmias, thrombocytopenia, and severe hypersensitivity reactions; potentially serious interactions with other drugs can also occur.The FDA notes that only one quinine product (Qualaquin, made by Mutual Pharmaceutical Company, Inc) is currently approved by the FDA. Although indicated only for the treatment of uncomplicated Plasmodium falciparum malaria, the drug is often prescribed to treat leg cramps and similar conditions despite drug label warnings advising that the risks associated with its use in this setting outweigh potential benefits.Unapproved quinine drug products are marketed without these drug label warnings, which increases the risk for their misuse and potential consumption of doses that have not been reviewed or approved by the FDA. Because of its narrow therapeutic index, quinine must be used carefully; dose modifications and/or close monitoring may be required for patients with hepatic or renal impairment. Under the FDA order, all manufacturing of these products must cease within 60 days. However, some previously shipped merchandise may remain on pharmacy shelves for a short time. Consumers have been advised to contact their healthcare provider with any questions or concerns regarding their use of unapproved quinine products.Adverse events potentially related to quinine therapy should be reported to the FDA's MedWatch reporting program by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.

New Research on Care/Prevention of Chronic Diseases

Introduction Chronic disease prevention and management were hot topics receiving daily attention at the 2006 American Academy of Family Physicians (AAFP) Scientific Assembly. A comprehensive evidence-based lifestyle management plan for cardiovascular disease prevention was offered by Steven Masley, MD, FAAFP.[1] Alvin Lin, MD, FAAFP, and Kay M. Nelsen, MD, discussed how "good is not good enough" in our current approach to chronic disease care and offered new, more rigorous targets for physicians and patients alike.[2] Evidence-Based Lifestyle Changes for Cardiovascular Disease Guidelines for patients and physicians from the American Heart Association (AHA), the American Diabetic Association (ADA) and other organizations advocate lifestyle change including diet, exercise, smoking cessation, and other behaviors to improve cardiovascular (CV) risk. The number of research studies which pinpoint and specify the rationale for making changes, and the risk reduction associated with each lifestyle change, has grown significantly. This body of literature empowers physicians to better counsel patients on prevention of adverse CV events, particularly stroke and myocardial infarction. Dr. Masley reviewed the mechanism for plaque formation and rupture as the basis for a paradigm switch from coronary procedures such as angioplasty to diet change. Despite data supporting prevention, the United States spent $200 billion on CV therapies in 1998 with only 6% expended on preventive strategies for patients.[3] Yet interventional cardiology was associated with a failure rate of 40%, preventing only 1 of 30-40 deaths, and improving only 1 of 30-40 CV events.[3] The procedures also carried the risks for loss of cognitive function, death, and stroke.[4] Indications for revascularization procedures should only be angina and restoration exercise capacity. Among risk factors identified for CV disease, the top 5 are: Cholesterol; Diabetes mellitus (DM); Smoking; Hypertension; and Obesity. Ethnic differences exist for each risk factor[5]; for example, obesity and hypercholesterolemia have a higher prevalence among blacks and Hispanics compared with Asians. Dr. Masley suggested that exercise treadmill testing is useful for predicting CV risk because exercise capacity is a powerful predictor of mortality.[6,7] Class I evidence for stress testing indicated for evaluation of includes: Known CV disease; Suspected angina; Diabetics embarking on an exercise program; and An occupation that affects public health. Measures of cardiac fitness include the 1-minute heart rate recovery and the blood pressure (BP) response. Plaque assessment using carotid intimal media thickness is another tool that can help track responses to lifestyle change or medication.[8] The following 10 lifestyle steps were described by Dr. Masley to reduce adverse CV events: Step 1: Reduce low-density lipoprotein (LDL) cholesterol using a combination of dietary measures such as adding soy and garlic,[9] switching from saturated and hydrogenated fats to unsaturated fats, increasing plant sources of omega-3 fats,[10] and increasing monounsaturated nut intake of walnuts, almonds, and pecans[11,12] before medications are considered. Step 2: Improve total cholesterol/high-density lipoprotein cholesterol (TC/HDL) and triglyceride/HDL cholesterol (TG/HDL) ratios to reverse the metabolic syndrome epidemic. Increasing HDL levels may be achieved with prolonged regular aerobic exercise of no less than 30-45 minutes daily[13] and moderate alcohol intake of 1-2 drinks daily.[14,15] A modest increase may be seen with garlic,[16] onion (3% to 5% improvement), and soy (up to 5% improvement)[17] intake. The type of carbohydrate eaten affects insulin levels and TC/HDL ratios, and glycemic load is more important than glycemic index.[18] Hence, a high-fiber intake of grains, beans, vegetables, and fruits has a beneficial effect, while consumption of fluffy whole wheat breads and potatoes can raise postprandial blood sugar levels. Step 3: Increase intake of beneficial foods. Follow diets, such as the Mediterranean or Japanese diet, high in vegetables and fruits, fiber, olive oil, and soy[19,20]; the emphasis should be on adding healthy -- rather than eliminating unhealthy -- foods. More specifically, soy isoflavones (from, for example, edamame beans) are associated with possible reduction of clot formation[21,22] and improved endothelial function.[23,24] Dark cocoa reduces clotting and is a potent antioxidant, thereby suppressing LDL oxidation and, possibly, lowering plaque formation.[25] Step 4: Change type of fat intake to nuts and olive and canola oils, but remain mindful of calories associated with high nut consumption. One handful of walnuts has 280 calories, but if eaten before a meal can help to induce satiety and reduce overall caloric intake.[26] Saturated fats should be avoided because of: Increased clot formation; Weight gain; and Increased LDL cholesterol. Trans fats in margarines and processed foods should be avoided and lean proteins (chicken and turkey) should be selected over red meats. Step 5: Reduce LDL oxidation by: Eating at least 5 servings of fruits and vegetables daily, especially the most colorful produce (like blueberries, pomegranates, and red and black beans)[27]; and Adding garlic[28] and spices,[29] particularly capsaicin and curcumin from chili and turmeric, respectively. Step 6: Decrease clotting and CV events using: Omega-3 fats; Garlic; Moderate alcohol; and A baby aspirin for primary and/or secondary prevention of CV and cerebrovascular events, if there are no contraindications. Fish and seafood (which should be eaten 2-3 times weekly) are excellent sources of omega-3 fats; Dr. Masley's first-choice recommendations are: Salmon; Trout; Sardines; Mussels; and Oysters, followed by: Shellfish; Mahi mahi; and Halibut. His choices reflect lower mercury levels of less than 2 ppm; intake of big-mouthed fish, such as yellow-tail tuna, increases exposure to higher mercury content. Flax, soy products, nuts, green leafy vegetables, canola oil, and fish oil supplements also contain omega-3 fats. The dosing of omega-3 depends on its indication: 300 mg daily for health maintenance; 3-4 g daily for hypertriglyceridemia; 2-4 g for anti-inflammatory purposes or for disc herniation; and 1-2 g for arrhythmias. Fish oil supplements should be selected on the basis of independent testing for heavy metals, low levels of lipid peroxides (they should not taste fishy or rancid), and dosed to minimize risk for bleeding and drug interactions. Step 7: Enhanced arterial function and BP is best achieved by 30-60 minutes of moderate activity for 6 days a week burning at least 2000 kcal weekly, and strength training 2-3 times weekly working at least 8-12 body parts and targeting blood pressure (BP) at 110/70 mm Hg (below pre-hypertensive levels).[30] Salt intake should be limited to less than 2400 mg daily, while calcium and magnesium should be maintained at 100 mg and 500 mg daily respectively. Step 8: Judicious use of supplements is advised because of variability in evidence for efficacy and the lack of standardized manufacturing guidelines. Dr. Masley recommended adequate intake of: Folic acid 400 mcg daily (diet plus supplement); Vitamin B6 -- 10-25 mg daily; Vitamin B12 -- 10-1000 mcg; and Phytosterols from plant foods. Evidence for using coenzyme Q10, hawthorne, and acetyl-L-carnitine is inconclusive and these are not currently recommended for cardiac health. Step 9: Stress management should directly address adequate sleep (at least 7 hours daily) and restful and relaxing activities such as meditation, yoga, and deep prayer. Step 10: Success at making lifestyle changes is linked to: Physician attention to patient beliefs; Limitations and goals; and Venues for offering intensive and effective lifestyle change in practice, including the group medical visit model specifically focused on CV targets, regular chart review, and documentation of patient progress. Management of Chronic Disease: When Is Good Not Good Enough? Drs. Lin and Nelsen discussed how chronic diseases are a major cause of disability in the United States, reviewing the major causes of death and morbidity[2]: Childhood obesity; Arthritis; Adult DM; Hypertension; and Hypercholesterolemia. They presented data that provide physicians with specific and more rigorous goals and endpoints for the control of DM, cholesterol, and BP. As Dr. Nelsen explained, global focus of organizations such as the World Health Organization, United Nations, and the World Bank continues to be on infectious rather than chronic diseases. Despite the change in chronic disease management from acute hospital admission to ambulatory care delivery, the use of information systems and team-based healthcare, the goals of continuity of care, service integration, and patient education provided through patient-centered care are far from being reached worldwide. The burden of chronic diseases continues to rise with 29 million deaths worldwide in 2002 from[31]: CV disease; Cancer; Chronic respiratory disease; and DM. According to an important trial, "a combination of personal and non-personal health interventions could lower the global incidence of CV events by as much as 50%.[32]" Government action to reduce salt content of processed foods is an example of a non-personal health intervention. Case in Point: Diabetes Mellitus Twenty-one million Americans were diagnosed with DM in 2005 and 10 million over 60 years have DM currently. Only 1 out of 5 Healthy People 2000 goals were met for the US population namely, a small 3% reduction in amputations from DM.[33,34] The goals related to DM that have not been met are reduction of: Disease incidence; Renal disease; and Blindness. Only one half of diabetics are taking proper medications.[35] Health disparities in DM management persist, and although 90% of patients with DM see physicians, they are not well monitored for: Hemoglobin A1c (HbA1c) levels; Self glucose testing; Annual urinary albumin screening; and Foot care. Health education occurs for less than 50%.[36] Data from a meta-analysis propose HbA1c goals as low as possible, suggesting that there is no threshold that is too low.[37] In one study, for every 1% drop in HbA1c there was a 21% decrease in all-cause mortality and adverse endpoints. Another study demonstrated a 28% increased risk for death for every 1% increase in HbA1c value, regardless of BP, cholesterol level, body mass index, and smoking status.[38] The Lower the Better Even in those without DM, lower HbA1c is associated with reduced CV and all-cause mortality. LDL cholesterol goals for DM have been well articulated by the AHA and the American College of Cardiologists with atheromatous regression and reduced CV mortality demonstrated at lower levels when LDL is lowered to 60 mg/dL.[39] Like HbA1c and LDL cholesterol in DM, BP control is now guided by the "lower is better" principle. Regardless of comorbidities including DM, lower levels of BP are associated with better outcomes of mortality and CV events. The risk for CV morbidity and mortality begins at a BP of 115/75 mm Hg, and for every increase in blood pressure of 20 mm Hg systolic or 10 mm Hg diastolic, the risk for CV events increases 2-fold.[40] Conversely, every 2-mm Hg drop in systolic BP translates into a 10% drop in stroke incidence and a 7% drop in CV events. Some data are slightly more hopeful, including a study showing that diabetes processes of care (such as eye and foot exams, measurement of microalbuminuria, diabetic education, and vaccinations) and intermediate outcomes (for example, HbA1c and LDL cholesterol) have improved nationally in the United States in the past decade.[41] This same trial, however, showed that: 2 in 5 persons with diabetes still have poor LDL cholesterol control; 1 in 3 persons still has poor BP control; and 1 in 5 persons still has poor glycemic control. Summary Drs. Lin and Nelsen concluded that physicians need to be more aggressive with all lifestyle strategies that lead to reduced HbA1c, LDL cholesterol, and BP in both diabetic and nondiabetic patients. For diabetic patients, target HbA1c should be as low as possible. For LDL cholesterol, diabetics should aim for levels below 70 mg/dL. Patients with hypertension should be controlled to levels at or below 115/75 mm Hg.