Talk:Diabetes/Archive 4

Diabetic Nutrition
''According to recent studies, chromium may prevent diabetes from occurring, and can help diabetics maintain optimal blood glucose levels when taken consistently. Says biochemist Richard Anderson, of USDA's Human Nutrition Research Center, "In almost every study where we gave chromium, we got better control of glucose with less insulin." Chromium is relatively inexpensive as a nutritional supplement.

Some studies suggest that one to six grams of cinnamon daily can lower blood sugar, and recent studies in Japan have shown that consumption of two teaspoons of apple cider vinegar before a meal can counteract the effects of white rice on blood glucose levels.'' Andreas 21:29, 7 February 2006 (UTC)

These claims have to be substantiated by sources. Only if it is generally accepted by the scientific community can they be incorporated in the article. As long as this is not a recommendation by the various professional associations, they does not belong into Diabetes management.

effects of white rice on blood glucose levels - this is against accepted knowledge: white rice is notg any different from any other variety of rice or other starch-containing foods. Andreas 21:29, 7 February 2006 (UTC)

Expansions to the section on history are possible
The section on the history of this condition begins, rather surprisingly, with reference to diabetes in modern times. References to a disease which could now be termed diabetes mellitus have been found in Egyptian papyri, and in ancient India, it was noticed that flies were attracted to the urine of diabetics. In the sixteenth century, Paracelsus believed, erroneously, that the urine of diabetics contained too much salt, an error later corrected by the seventeenth century physician Thomas Willis, who first discovered the it was not salt, but sugar in the urine of diabetics. By the end of the nineteenth centur, French physicians had distinguished beween "diabetes maigre" and "diabetes grande", a distinction between diabetes in underweight and overweight individuals which, albeit with qualification, can be considered the a forerunner of today's distinction between Type One and Type diabetes. Various forms of treatment were suggested for diabetes prior to 1921, including the low-carbohydrate, low-calorie diet advocated by Frederick Allen, which would at least extend the expectancy of insulin-dependent diabetics a few, if not many, years at a time when it was a fatal illness. All this information is typed in here because it has been omitted from the section on history, and I shall look forward to a medical historian's efforts to extend this section. A. Carl 19:33, 5 February 2006 (UTC)

I shall admit that I had not read the section on etymology when I typed the above, and having just read it, am of the opinion that some of it could go to the section on History. Even with such a transition, there is still surely much that more that could be said on the history of medicine insofar as it relates to diabetes than is contained within this article. A. Carl 19:39, 5 February 2006 (UTC)

Bouchardat and Lancereaux
The two French physicians I was thinking of were Bouchardat and Lancereaux. It was really Lancereaux who was the significant pioneer here, making, in 1870, a distinction between "diabetes maigre" and "diabetes gras" which can be taken as an early fore-runner of the modern distinction between Type One and Type Two diabetes. A. Carl 12:38, 6 February 2006 (UTC)

More information is needed in the section on glucose monitoring
I have just read the section on glucose monitoring, and was quite alarmed. This section states, firstly, that diabetics should check their blood sugar "from time to time", but I would have thought that checking at least once daily (preferably, two or three times a day for some diabetics) was to be recommended. Secondly, I was quite alarmed by the way this merely said that keeping blood sugars below 7 millimoles is to be encouraged. It did not mention that blood sugars should also be above 3 to prevent hypoglycemia. Any diabetic reading this could be forgiven for erroneously thinking that the lower his or her blood sugar is, the better, but surely proper management of diabetes does not involve keeping blood sugar low, but keeping it balanced. In neither this section nor, as far as I could see, was the effect of stress on diabetes management mentioned, but stress can lead to increase the risk of both overly high and overly low blood sugars in diabetics. Please could a more sound diabetologist or medical doctor update the section on glucose monitoring? A. Carl 20:17, 7 February 2006 (UTC)
 * You misunderstood: the HbA1c level should be below 7%. I removed the reference to this because it is misleading. The section actually should be shortened and readers referred to the article on Diabetes management, that has detailed information. In spite of warnings that Wikipedia should not be used as a substitute for professional health care, it is still important to avoid misleading information for the sake of the safety of the public. Andreas 21:21, 7 February 2006 (UTC)


 * Thank you for this. However, I still think that even to say  "HbA1c" should be below 7" could be misleading for people with diabetes, as if the HbA1c of a diabetic were below 5, it could be a sign that the diabetic has had frequent hypoglycemia. I applaud your statement that it is important to avoid misleading the public. Should not medical articles be headed by a logo as prominent as that which accompanies articles over which neutrality is disputed, accompanied by a statement that "This article should not be used as a substitute for medical healthcare"?A. Carl 22:25, 9 February 2006 (UTC)


 * AC,
 * Your suggestion that articles on medical topics should be written by medical folk, in an effort to avoid misleading the public is attractive. But... WP is a volunteer enterprise (I'm almost certain of this as I've been offered no payment for my work!!), some of whom are indeed specialists in the articles they edit. As such, it reflects divergences of opinion about controversial topics. My own bias is, I suspect, somewhat similar to yours in that I think there is a great deal of quackery in re diabetes and that such should not be present here. How a notional volunteer can make this distinction is not so clear. Appeal to authority (ie, "I'm a doctor and I say it's so, so there!") is less than satisfactory. And how can one be even sure so and so actually is a doctor. Several incidents have made clear that it's not so easy to tell even in person whilst practicing alongside Dr Bozo the fake.
 * WP has essentially made a bet that multiple eyes (and editors) will converge on something reasonable and useful. So far, it's done shockingly well, at the expense of the odd editor having to clean up the nonsense. I see no way to implement methods to improve quality (by what metric and who applies it?) without killing much o fthe volunteer effort. Basically a discussion that should go to a WP audience, not this talk page. See the Village Pump, for instance. Or you can start a project advocating such a change in WP policy. there are several, some more amusant than others.
 * Not sure how better to address this concern. ww 23:01, 20 March 2006 (UTC)

New external link
I wish to add the following article: A pilot study for Australia`s first clinical trial to evaluate the effectiveness of traditional Chinese exercises in preventing the growing problem of diabetes has produced startling results. http://www.acupuncture.com.au/research/article18.html

Then give us the citation to a published study instead of linkspam. Thanks. alteripse 12:38, 5 March 2006 (UTC)
 * When the study is published in a peer-reviewed journal it can be included either here or in the article on type 2 diabetes. Thatcher131 12:52, 5 March 2006 (UTC)

Add Gastroparesis to Complications?
How about adding gastroparesis to complications? Jack Daw 21:17, 11 March 2006 (UTC)


 * I think it's a good idea as it's a major problem when it happens. However, we've already got a large introductory article and explaining what's going on would take a goodly number of words. No idea how to solve that, save perhaps an article on diabetic complications with the details. But this risks the problem of ending up with an article which is mostly pointers to other articles. This is essentially pointless for an introductory article of first resort. ww 22:47, 20 March 2006 (UTC)

home blood glucose monitoring

 * The previous version re home blood glucose monitoring (HBGM) was very dogmatic in stating that it is required/beneficial. This has been hugely controversial in the last few years in the UK as it was realised that more was being spent on such supplies than on provision of diabetic services or the antihyperglycaemic drugs themselves. Some PCT health authorities tried to issue blanket bans on type 2 diabetic controlled on just diet or tablets alone from having home testing - this was of course highly contested by diabetes groups & their GPs and we now have a more balanced approach - see example of one patient leaflet still active from Sept 2004: East & North Herts PCT - Blood Glucose Test Strip.
 * The majority of type 2 on oral medication do not adjust their own medication dose on a day-to-day basis (unlike majority of diabetic on insulin). It is of course a separate issue as to whether they should be educated to do so, but the current "norm" in the UK is not so. Other than the instructive use of HBGM after an initial diagnosis (as they learn how various foods affect their sugar levels), it makes (generally) little difference to their overall control - mildly poor home readings are likely to be reflected in mildly raised HbA1c and (hopefuly) a small increase in medication dose (so what was the point all those sore finger tips?). Urine testing a couple times a week (daily if unwell) is, for many, sufficient to confirm that they are not running unacceptably high between their routine 6 monthly HbA1c blood tests. Most (but not all) are aware if they are becoming hypoglycaemic for which the correct action is to quickly take some sugary foods (rather than establishing that this occasion is at 2.5mmol vs 2.7mmol, 45mg/dl vs 49mg/dl in US units). Of course, type 2s on insulin should be encouraged to HBGM (some refuse), as should those who do not get warning symptoms of impeding hypoglycaemia. Finally there are always shift-workers who may need additional help in gauging their control. As a locum GP, I have sadly seen in several surgeries many patients dutifully self-testing once or twice daily for years with consistant unacceptable sugars of 10-15mmol (180-270mg/dl US) - their testing has been pointless (although obviously not their "fault") when they & their own regular GPs should long ago have increased oral medication or accepted need for a switch onto insulin.
 * The section is I agree now rather too long and might be better transfered across to the main artice on the topic (Diabetes management) - but I took quite a long time over sorting out the mess of 4 different reference styles in the article.
 * Type 1 or 2 applies to underlying mechanism of cause, not to how they are treated. Hence a type 2 who needs step up from diet to tablets to insulin, is still a type 2 (albeit now a "type 2 on insulin"). Similarly if a type 1 were ever to be particially treated by a pancreatic transplant and then maintain reasonable control through just dietary means, they still have type 1 diabetes. It is generally accepted that irrespective of type of diabetes, equal degrees of poor control have the same associated risks of retinopathy, neuropathy & nephrophathy. So a well controlled type 2 on tablets is at far lower risk than a poorly controlled type 1 on insulin, and in turn both are at less risk that an awfully controlled type 2 on diet alone. Other than the UK Health Department's obsessive requirement that GPs classify their diabetics as either type 1 or 2 (causing large administrative workload to update computer entries that may have used just a generic "Diabetes mellitus" code), it really makes little difference in the careful monitring for all diabetics and the increasing importance of addressing other risk factors (smoking, weight, exercise, BP, cholesterol). David Ruben Talk 00:44, 18 March 2006 (UTC)
 * DR,
 * Much of what you say reflects clinical experience and is certainly true. Most of it is the sort of thing large health care enterprises must be concerned about. It is too dogmatic and misleading for this article.
 * This article is not about clinical average treatments or cost effectiveness of such treatments or withholdings of same. It is about the disease (s). And it has been affirmatively shown that close, tight, glucose control does reduce long term complications to normal or near normal rates. That point formerly came through in re Type 2 (well, mostly) and does not now, having been complicated with clinical and insurance expense considerations, with specific references to UK programs and such. This material belongs in a section on practical monitoring considerations in re Type 2 in another article. Not here in this article of first reference for the Average Reader.
 * What the diabetic should do is one thing, and should be discussed here. It's simple, straightforward, dispells many a folk tale understanding, and is furthermore true. Practical considerations as listed currently obscure most of these virtues. ww 23:10, 20 March 2006 (UTC)
 * I've made a few phrasing changes in this section, but still think it's largely inappropriate at this length in this artice. ww 04:55, 29 March 2006 (UTC)

curing diabetes section
This has been revised and restored after the deletion just prior to this post. Some mention of this issue is appropriate in this article for seveal reasons. First, there is alot of quackery surrounding diabetes and some evaluation of the propsects for a cure would be useful to readers in avoiding being quacked. Second, an actual prospect of a cure is serious and several lab research schemes are underway. Third, the proposed schemes are themselves fasinating, if only enough to justify a few words. Fourth, though not currently in clinical practice, the subject is intersting in its own right. ww 04:55, 29 March 2006 (UTC)
 * I find the "quacked" argument very compelling. Rklawton 05:03, 29 March 2006 (UTC)

Intro
Recent edits removed the list of major complications from the intro. This left the article seeming to concentrate almost exclusively on sugar control. This may have been the approach in treating cases in the 1980's and early 1990's, but now is of almost secondary importance for those working in developed countries.

Of course there may be life-threatening presentation of typeI's or chronic ill health seen prior to type2 diagnosis. Likewise immediate ill health if hypo or hyperglycaemia. But with patient self-monitoring, modern drugs (oral & insulins) and HbA1 tests, reasonable control can be achieved. At this point the patient is not "unwell" from diabetes. Excessive attention to improving a "moderately controlled" to a "tightly controlled" patient generally does not then improve the patient's sense of immediate "wellness" (especially if treatment-related hypos start to occur). Of course tight control improves longterm outlook for microvascular disease, but what is most likely to kill a diabetic is the increased risk of macrovascular cardiovascular disease. So if the choice is "good" or "very good" control, it is probably more important to be addressing a patient's smoking, blood pressure & cholesterol. Certainly more of my time with those with diabetes is spent worrying over preventing MIs, renal failure & blindness, than the last decimal place of their sugar results. In the UK, the Quality Outcome Framework points (with associated income) awarded to General Practitioners for managing diabetes reflect the multiple of risk factors that must be monitored.

As a UK diabetes expert (a co-author of one of studies cited), once only half jokingly observed, in 20 years time diabetics might be more properly managed by cardiologists rather than endocrinologists obsessed with laboratory reports of sugar levels. His definition of diabetes, at a talk to GPs about the importance of addressing cardiovascular risks, was "Diabetes is a potentially terminal cardiovascular illness in patients who happen to have raised blood sugar levels".

The major complications of diabetes therefore I believe are so important as to deserve inclusion in the introduction to this article. David Ruben Talk 03:19, 15 April 2006 (UTC)


 * I was the editor who originally listed the major complications in the intro. Most type II diabetics do not die from HONC but from macro- and microvascular disease. That is intro material. I agree with David that this material should be reinserted. JFW | T@lk  22:07, 30 April 2006 (UTC)