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Quit Smoking Magic Summary


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Lifestyle Modifications Smoking Cessation And Exercise

Much of the work documenting the impact of smoking on health does not discuss results on subsets of subjects with diabetes, suggesting that the identified risks are at least equivalent to those found in the general population. Other studies of individuals with diabetes consistently report a heightened risk of morbidity and premature death associated with the development of macrovascular complications among smokers. Although smokers have repeatedly heard of the pulmonary effects of smoking, the cardiovascular burden of diabetes, especially in combination with smoking, has not been communicated effectively to either people with diabetes or health care providers. Despite demonstrated efficacy of smoking cessation counseling, only about 50 of patients with diabetes are advised to quit smoking by their health care providers (12). Treatment characteristics that have been identified as critical to -o achieving cessation include counseling by multiple health care providers, use of individual...

Protein Restriction Lipid Control and Smoking Cessation

Who had a more liberal protein intake in diabetic nephropathy (200). More recent studies have also confirmed these observations (201). Measures to correct dyslipidemia, either dietary or pharmacotherapeutic, have also been associated with improved outcome in diabetic nephropathy (201,202). Smoking cessation may provide an additive protection from the risk of development of diabetic nephropathy (203,204). Thus, every attempt should be made to encourage patients with diabetes to stop smoking.

Smoking cessation

Cigarette smoking is the single most important risk factor for the development of PAD. Continued smoking is associated with a greater likelihood of developing Smoking cessation Exercise, smoking cessation, drugs (e.g. cilostazol and pentoxifylline), angioplasty, vascular surgery for severe symptoms Behavioural therapy, nicotine replacement therapy, bupropion Aspirin, clopidogrel, warfarin (if in atrial fibrillation) Insulin, sulphonylurea, metformin, glitazones Glitazones, metformin Statins, fibrate disabling claudication, limb-threatening ischaemia, amputation and the need for surgical intervention (Jonason and Ringqvist, 1985 Hirsch etal., 1997). In addition, patency rates and survival are much lower among patients who smoke following a revascularisation procedure (Ameli etal., 1989). Unlike the increased cancer risk from smoking and the adverse effects on lung function that persist for many years after a long-term smoker gives up cigarettes, the excess risk of cardiovascular...

Stop smoking

People with diabetes who smoke have at least the same risk of morbidity and mortality as non-diabetics who smoke, and probably greater. Diabetics who smoke have about four times the risk of dying from a cardiovascular disease as those who do not. Vigorous efforts should be made to discourage young people with diabetes from starting smoking. Smokers should be given considerable help and support to stop. As nicotine may alter the rate of insulin absorption, glucose should be monitored after stopping. The insulin dose may need to be adjusted. Nicotine patches can be used by people with diabetes but care should be taken by those with cardiovascular disease. Avoid patches in those with renal failure. Bupropion can also be used in people with diabetes but not in those with renal failure. Monitor blood pressure.

Recent Developments

2 A very significant predisposition to AMD associated with modifiable risk factors is emerging thus, smoking appears to be a potent risk factor with smokers being around twice as likely to develop AMD.7 There is also a strong association with obesity,4 and this may relate to the pro-oxidant state that exists in obese subjects.

Exogenous Sources of Advanced Glycoxidation End Products

Tobacco smoke is another exogenous source of AGE. Tobacco curing is essentially a Maillard browning reaction, as tobacco is processed in the presence of reducing sugars. Combustion of these adducts during smoking gives rise to reactive, toxic AGE formation (39). Total serum AGE, or AGE-apolipoprotein (apo)-B levels have been found to be significantly higher in cigarette smokers than in nonsmokers. Smokers and especially diabetic smokers have high AGE levels in their arteries and ocular lenses (40).

The Transtheoretical Model Of Behaviour Change

Model Trans Theoretical Change

Prochaska and DiClemente54 investigated the process of change in an observational study that followed smokers who were attempting to stop independently. They observed that individuals went through a number of discernible stages in the change process, which led to the Transtheoretical Model of Change (Figure 5.2). Six stages of readiness were described precontemplation, contemplation, determination, action, maintenance and relapse. Each stage represents an amalgamation of attitudes, intentions and behaviours55. This model has subsequently been used to describe the process of change in a wide variety of behaviours, such as exercise52, smoking56, healthy eating57 and diabetes self-management58.

Trials examining glycemic targets

The VADT (Veterans Affairs Diabetes Trial) started in December of 2000 with the goal of enrolling 1700 men and women 41 years of age or older with HbA1c level of 7.5 or higher despite therapy with oral agents or insulin. Volunteers are randomized to an intensive or standard treatment program and followed for 5 to 7 years formajor CV events (MI, stroke, new or worsening congestive heart failure CHF , amputation for ischemic diabetic gangrene, invasive intervention for coronary or peripheral arterial disease, and CV death). The study is designed to have 86 power to detect a 21 relative reduction in major CV events. In the intensive arm, the goal is to achieve an HbA1c level of 6 or less by sequential addition and titration of metformin, rosiglitazone, or evening intermediate NPH insulin or long-acting insulin glargine to achieve near-normal fasting glucose levels, and subsequent morning or multiple daily injections of short-acting insulins or other therapies as needed (eg, glimepiride...

The Brenner Hypothesis

The mechanism by which glomerular number is reduced is uncertain but exogenous factors acting on the fetus may be important. Vitamin A and its derivatives play a role in nephrogenesis 37 and vitamin A deficiency is associated with renal abnormalities 38 and reduced glomerular number 39 . Low circulating levels of Vitamin A occur in women who smoke, abuse alcohol or adopt extreme weight reducing diets 40, 41 . Whether this reduction in Vitamin A levels is sufficient to reduce glomerular number is uncertain. Maternal smoking reduces birth weight 42 and in Manalich's study 33 maternal smoking status was a stronger determinant of glomerular number than birth weight itself.

Factors affecting insulin absorption

These are myriad and tend to be forgotten when the patient and diabetes adviser are poring over the blood glucose diary. The size of the insulin depot and the amount of fat surrounding the depot affects absorption. The rate of entry into the blood stream is determined by the circulation through and from the injection site. Thus cold or other stimuli causing vasoconstriction such as nicotine or drugs will reduce absorption, as will shock from whatever cause. Heat will increase absorption as will increased blood flow to an exercising muscle under the injection site. Human insulin may be absorbed more rapidly than porcine insulin.

Wet Gangrene Of The Hallux

Superficial Femoral Artery Stenosis

A 72-year-old male patient with type 2 diabetes diagnosed at the age of 60 years and being treated with insulin, attended the outpatient diabetic foot clinic because of pain in his right hallux. His diabetes control was poor (HBA1c 8.7 ). He had hypertension and background retinopathy in both eyes. He was an ex-smoker. The patient had

Alternative Views And Future Directions

Current guidelines for the general care of patients with diabetes emphasize lower than usual blood pressure goals (typically 130 80 mm Hg), smoking cessation, and the best possible glycemic control 7 . Hence, within the armamentarium for treating early renal disease, the finding of microalbuminuria leads only to the addition of an ACEI or ARB to the recommended regimen. (Other issues such as low protein diets, phosphate control, and anemia management are in the province of more established renal insufficiency) Furthermore, since these drugs are generally well tolerated, some have proposed treating all diabetics, or at least those at higher risk, with an ACEI and forgoing screening for albuminuria altogether. One economic analysis concluded that for type 2 diabetics over 50 years, this was a cost saving strategy 42 . Another model also held that such an approach for high-risk patients with type 1 diabetes was cheaper 43 . Of course, identification of the higher risk subgroup is at...

Wet Gangrene Of The Toes

Superficial Femoral Artery And Angiogram

A 54-year-old male patient with type 2 diabetes diagnosed at the age of 49 years was admitted to the Vascular Surgery Department because of wet gangrene involving the toes of his left foot. He had been treated with sulfonylurea over the previous 8 years which had led to acceptable diabetes control (HBA1c 7.5 ). The patient was an ex-smoker. During the last 10 years he had also suffered from hypertension which had been treated with an angiotensin converting enzyme inhibitor and a diuretic. He had typical intermittent claudication with

Prevention of Progression at the Macroalbuminuria Stage

Improved glycemic control on the progression of overt nephropathy may become evident when combined with stricter control of hypertension (a target blood pressure of 135 80 or less) (207). Similarly, in the UKPDS, attenuation of nephropathy was most pronounced in the subgroup with tight glycemic and blood pressure control (209). Tight glycemic control in overt diabetic nephropathy may also benefit other microvascular complications. ACE inhibitors and or AT-1 blockers are the agents of choice for blood pressure control in patients with diabetic nephropathy and macroalbuminuria because these agents clearly retard the progression of renal disease (193,197). Dyslipi-demia (202) and, as noted earlier, smoking may also contribute to renal injury in diabetes. Thus, despite the lack of definite evidence on the role of hyperglycemia in the progress of overt nephropathy to ESRD, current recommendations are that strict glycemic control should be part of a comprehensive regimen that includes...

Biguanides Metformin Case Study

A 40 year old man with a family history of DM comes to the Diabetes Clinic for the second time, three months after his first visit. At the first visit he had been diagnosed as having Type 2 DM, which had manifested after intense family problems, with typical symptoms (polyuria and polydipsia) and balanoposthi-tis. At that time the patient weighed 102 kg (224.9 lb) and had a body mass index of 33.6 kg m2. He had an office job, sitting for long hours, and smoked roughly 30 cigarettes a day. He drank 2-3 glasses of beer 2-3 times per week. His arterial blood pressure was 140 80 mmHg, his glycosylated haemoglobin (HbA1c) 10 percent (normal values 4.8-6.2 percent) and his fasting blood After a review of his diet and his general health condition, metformin was recommended at a dose of 850 mg with lunch. Furthermore, a statin was prescribed. The importance of smoking cessation was pointed out to him.

Intermittent claudication

The mainstay of treatment for intermittent claudication is smoking cessation and regular exercise. A meta-analysis of randomised controlled trials of physical exercise has shown that regular exercise improves walking distance, but the walking programme should be supervised and involve 30 min per session, at least three times per week for 6 months (Gardner and Poehlman, 1995). The mechanism for the benefit may be derived from improved cardiovascular fitness, increased production of nitric oxide and or modification of cardiovascular risk factors. In the exercise programme, patients should be told to 'walk through the pain' rather than to stop at the point when the pain begins since this helps to increase the collateral blood supply. Raising the heel of the shoe by 1 cm will also increase the walking distance by reducing the workload on calf muscles. Bicycle riding is probably less beneficial because it exercises the thigh muscles and not the calf muscles.

Predictors Of Mortality

Verona Diabetes Study

Recognition of the predictors of mortality is the first step in planning an intervention aimed at reducing mortality. Predictors can be divided into unmodifiable and modifiable factors. The former include age, gender and family history the latter include cigarette smoking, high blood pressure, high blood glucose, elevated total and low-density lipoprotein cholesterol, obesity, diabetes treatment, model of diabetes care and so on. For the purpose of this review it is more useful to classify these predictors into the classic, which are shared by both the diabetic and non-diabetic population, and the diabetes-specific, which are specifically correlated with the disease, its natural history, treatment and complications (Table 8.3). of subjects belonging to the 'young-old' age group (60-70 years), while negative studies recruited subjects aged 70 and over. In a Finnish study, smoking, high systolic blood pressure and low HDL cholesterol predicted cardiovascular events among elderly...

Macrovascular Complications Protecting Your Heart

CAD is found in the arteries of people with T1DM who die of other causes as young as age 20 or even younger, and it's extensive in older people with T1DM who die of other causes. However, it's not found in everyone. Those folks with T1DM who don't have other risk factors, such as uncontrolled high blood pressure, cigarette smoking, a sedentary lifestyle, and high cholesterol levels, rarely have problems with coronary artery disease. A family history of coronary artery disease is another risk factor and one that you can do nothing about, but its effect is minimized when the other risk factors are avoided or controlled.

How To Cure Buminuria

Other ways of reducing cardiovascular risk Smoking cessation Smoking in a person with diabetes is particularly harmful. It not only increases the already raised risk of macrovascular disease, but it also increases microvascular complications, particularly nephropathy and retinopathy. Patients with diabetes who smoke should be actively targeted for smoking cessation interventions.

Mechanisms Underlying Endothelial Dysfunction in Diabetes

Two conditions leading to uncoupling of eNOS have been described. These include BH4 (eNOS co-factor) deficiency and intracellular L-arginine (eNOS substrate) depletion (77). In conditions of BH4 deficiency, eNOS remains in an uncoupled state and preferentially produces superoxide rather than NO. NO in turn is thought to be a superoxide scavenger. Superoxide product peroxynitrite has been shown to rapidly oxidize the active eNOS cofactor BH4 to inactive dihydrobiopterin (BH2) (80). In addition, uncoupled eNOS and L-arginine depletion is characteristically found in conditions where high oxidative stress is encountered, as observed in patients with diabetes (77), hypercholesterolemia (81), and in chronic smokers (82). Thus, hyperglycemia-induced uncoupling of eNOS leads to increased formation of ROS resulting in increased oxidative stress, which has been shown to be a strong stimulus for PKC activation (see Fig. 3).

The Natural History Of The Diabetic Foot

The foot with extensive necrosis cannot be saved and comes to major amputation. Every diabetic patient can be placed into one of these stages, which demand appropriate multidisciplinary management, addressing various aspects of wound, microbiological, mechanical, vascular, metabolic and educational care. Metabolic management is similar for all stages. Thus, tight control of blood glucose is extremely important to preserve neurological function and treatment of blood pressure and lipids to maintain cardiovascular function. Advice should be given to stop smoking.

Epidemiology Of Dyslipidemia In Type Diabetes

Of the 347 978 men screened for participation in the multiple risk factor intervention trial (MRFIT) (15), 5163 were identified as having diabetes through reporting of medication. In the 12-year follow-up of this cohort, the absolute risk of cardiovascular death was increased threefold in patients with diabetes after adjustment for age, race, income, serum cholesterol, systolic blood pressure and cigarette smoking. With increasing serum cholesterol cardiovascular deaths increased both in men with and without diabetes however, for given cholesterol level, men with diabetes had a two- to three-fold excess risk of cardiovascular disease. This was also true for two other major risk factors, cigarette smoking and hypertension, and for the three factors combined. These findings supported the notion that in diabetes rigorous intervention to control risk factors, including cholesterol levels, is needed.

Risk factors for coronary heart disease CHD the role of oxidative stress

Endothelial Dysfunction Diabetic Foot

Different stage in a chronic inflammatory process in the artery. The lesions of atherosclerosis represent a series of highly specific cellular and molecular responses that can be described as an inflammatory disease. Possible causes of endothelial dysfunction leading to atherosclerosis include hypercholesterol-aemia, hypertension, diabetes mellitus, cigarette smoking, elevated plasma homocysteine concentrations, infectious microrganisms and ageing. Framingham's studies have shown how each factor and combination of these factors are associated with atherosclerotic diseases.9 All these factors can be associated with oxidative stress.10-15 The beneficial effect of alpha-tocopherol and ascorbic acid is mediated by their antioxidant actions in preventing atherosclerosis. On the other hand, the effect of alpha-tocopherol could also be mediated by its antiplatelet and anti-coagulant actions, which would prevent the thrombotic consequences of atherosclerosis.16'17 Cigarette smoking,...

Counseling and Preconception Care Recommendations to Reduce Maternal and Fetal Risks of Preexisting Diabetes What Are

Counsel on smoking cessation strategies and set this as a preconception goal, if applicable Obtain a baseline measure of urine albumin excretion Counsel on the risks of preeclampsia and preterm delivery Counsel on the risk of progressive renal disease Counsel on maternal fertility, and if applicable, PCOS Obtain baseline TSH, if no previous one available Subsequent hyperglycemic visits Evaluation of and counseling on insulin dosing to improve glycemic control MNT for improving glycemic control Reinforcement of smoking cessation if applicable Initial euglycemic visit Smoking is an important risk factor not only for macrovascular disease but also for intrauterine growth retardation. Smoking cessation should be urged for all women in the preconception period. Recommendations. Exercise echocardiograms may be considered for women with diabetes over the age of 35. Duration of diabetes, presence of diabetes complications, and other CAD risk factors should be included in this decision....

Feckless patient with endstage renal failure

Stub Toe Nail

Fig. 6.10 This patch of necrosis developed on the apex of the 1st toe of a patient in end-stage renal failure treated by renal transplantation. Her pedal pulses were palpable. The patch of necrosis began as a small crack in the nail sulcus and spread very slowly to involve most of the toe, which was amputated because of severe pain. She smoked 25 cigarettes a day.

Prevention Of Type Diabetes

Post-challenge) Low insulin secretion Insulin resistance syndrome (low HDL-C, high triglycerides, hypertension, fibrinolytic defects, glucose intolerance) Low magnesium level Low chromium level High plasma non-esterified fatty acids Low sex hormone binding globulin Low physical activity Cigarette smoking

How often should BP be measured in diabetic patients What is the recommended method of followup

The measurement should be performed both in a sitting and standing position (after at least 1 minute of standing) in order to exclude potential orthostatic hypotension - i.e., fall of systolic BP by 20 mmHg and or of diastolic by 10 mmHg - which is not that infrequent in diabetic patients (the coexistence of supine hypertension with orthostatic hypotension is a difficult therapeutic problem that can require modification of the pharmaceutical regimen). The patient should rest quietly for at least 10 minutes before the measurement, should not have consumed alcohol, caffeine or nicotine for the previous half an hour and the room temperature should be normal. The BP should ideally be measured at least three times (with intervals of 1-2 min) and the mean of the last two measure- ments used for its recording. It is essential that the cuff deflation be performed slowly, at a rate of 2 mmHg per second during BP measurement.

Hyperinsulinemia and Insulin Resistance Linked to Colorectal Cancer

At the Department of General Surgical Science, Gumma University, Gumma, Japan 46 , patients suffering from colorectal cancer but never diagnosed for diabetes, were tested for glucose tolerance. Serum glucose and insulin levels were found to be higher in cancer patients than in controls. The authors concluded that hyperinsu-linemia may be one of the causes of colorectal cancer and should be controlled to prevent recurrence of colorectal cancer even after curative resection. Mechanistically, hyperinsulinemia has been associated with insulin resistance, increased levels of growth factors, including IGF-1, and alterations in NF-kB and peroxisome prolifera-tor-activated receptor signaling, which may promote colon cancer through their effects on colonocyte kinetics. The insulin resistance colon cancer hypothesis, stating that insulin resistance may be associated with the development of colorectal cancer, represents a significant advance in colon cancer, as it emphasized the potential for...

Modifiable Risk Factors

Hu et al. (39) published results from the Nurses' Heath Study including 84,941 female nurses followed from 1980 to 1996, and who were free of diagnosed cardiovascular disease and diabetes at baseline. During the 16 years follow-up 3300 new cases of type 2 diabetes were diagnosed. As shown in Figure 4 obesity was the single most important predictor of diabetes. Women whose body mass index was at least 35.0 km m2 had almost 40-fold risk of becoming diabetic compared to women whose body mass index was < 23.0 kg m2. Weekly exercised at least 7h wk reduced the risk of type 2 diabetes by 39 compared to women who exercise < 0.5h wk. Smoking of > 14 cigarettes day increased the diabetes risk by 39 , but alcohol intake > 10 g day reduced the risk by 41 . The study also indicated that a diet high in cereal fiber and polysaturated fat and low in saturated and trans fats and glycemic load reduced the risk of developing diabetes. A combination of several lifestyle factors, including low...

What are the risk factors for the development of DM

For Type 2 DM, epidemiologic studies as well as data from its pathophysiology and natural history, have shown various factors that are related to an increased frequency of its appearance. These factors are age > 45 years, obesity (BMI > 25 kg m2), family history of DM, a sedentary life-style, certain racial groups and nationalities (African Americans or Hispanics, Native Americans, Pacific Islanders, etc.), history of gestational DM or birth of a child > 4 kg (8.8 lb), history of hypertension or dyslipidaemia and the polycystic ovary syndrome. Also, a low birth weight and cigarette smoking have been associated epidemiologically with the risk of developing DM. However, the most powerful association has been found with the presence of Impaired Fasting Glucose (IFG) and or Impaired Glucose Tolerance (IGT). IFG is defined as the presence of fasting plasma glucose levels between 110-125 mg dl 6.1-6.9 mmol L for Europe 100-125 mg dl 5.6-6.9 mmol L for America), and IGT is the presence...

Course Of Nephropathy During Pregnancy

Maternal anemia results from both decreased erythropoietin production by damaged kidneys and the physiologic hemodilution of pregnancy. The degree of anemia is related to the severity of nephropathy as reflected in lower creatinine clearance and is not usually associated with abnormal iron studies 95 . Exogenous erythropoietin can be used to treat anemia unresponsive to iron and folate replacement 194-197 . Asymptomatic bacteriuria is more common in diabetic than non-diabetic women, leading to a greater risk of UTI 198-201 , but there is controversy over screening and treatment outside of pregnancy 202,203 . During pregnancy screening and preventive treatment of women with hypertension or DN is justified due to the deleterious effects of pyelonephritis 95 . Although paradoxically PET in the third trimester may be less common in non-diabetic women who smoke cigarettes 175,177,204 , smoking should be strongly discouraged in diabetic women due to impaired

Peripheral Arterial Disease

Peripheral arterial disease continues to be underdiagnosed. In one comprehensive review (19), 6979 patients either older than 70 years, or 50-69 years old with a history of cigarette smoking or diabetes, were evaluated. Only 49 of the patients with a prior diagnosis of peripheral arterial disease were identified by the physicians treating them and 45 of patients diagnosed with peripheral arterial disease in this study had gone previously undetected. Smoking is the most powerful modifiable risk factor for peripheral disease intermittent claudication is three times more common in smokers than nonsmokers. The severity of the disease increases with the number of cigarettes smoked. Cessation of smoking has been reported to cause significant reductions in rest pain, MI, cardiac deaths, and overall 10-year survival (36). Stop smoking

What Else Might Help

The sun long enough to get sunburned. Smokers develop a particular type of facial wrinkling, which is related to their premature aging in general. Approximately fifteen minutes of sun exposure daily are sufficient for the body to make large amounts of vitamin D, but not enough to result in sunburn (for most individuals). Longer sun exposure should be accompanied by the use of sunscreen or UV-blocking clothing.

Depression And Diabetes

Depression may also be of concern in individuals with diabetes because of its association with health risk behaviors and medical morbidity. The health risk behaviors with which depression is associated include cigarette smoking, overeating, physical inactivity and obesity. The adverse effects of which are amplified in those with comorbid diabetes. Whatever the mechanism that accounts for the comorbidity of depression and diabetes, depression has also been associated with an increased risk of diabetes-related medical complications, including sexual dysfunction, retinopathy, nephropathy, heart disease, and stroke (82, 108). Because of the reciprocal relationship between depression and metabolic control, attention to both mood disturbances and to diabetes management may be necessary in order to prevent or delay the progression of diabetes complications.

Other intervention studies

In another Italian intervention study 122 non-insulin-treated type 2 diabetes patients, half of them women, were randomized into two groups (Trento et al., 2002). In the intervention group, patients were divided into small groups including nine or ten patients. Educational sessions were held every 3 months including topics about meal planning, burden of overweight, smoking cessation, and physical exercise. In the control group, patients continued individual consultation. After 4-year follow-up, statistically significant decrease in body weight was found in the intervention group (2.5 kg, P < 0.001) but not in the control group (weight decrease 0.9 kg, NS). Also, fasting blood glucose was measured, but it did not show statistically significant change in either of these groups. Weight reduction in the control and the intervention groups in the above three obesity intervention studies are given in Figure 5.2.

Methodological Issues in Gene Profiling With Kidney Tissue

To date, the feasibility of finding diagnostic and outcome predictor biomarker genes of human diseases based on gene expression profiling have been demonstrated for various malignancies, including acute leukemia (6), breast cancer (6), and lung cancer (7). In comparison with studies on tumor material, the application of micro-array studies to human DN poses different challenges (8). Highly sensitive and

Clinical studies on renin angiotensin aldosterone system inhibition and outcomes of new onset diabetes

To inhibit the contractile response to AI endothelial-dependent dilation was improved with quinaprilat, but not with enalaprilat enalaprilat significantly potentiated bradykinin-mediated femoral vasodilation increased coronary artery dilation increased endothelial function in smokers and those with elevated LDL cholesterol only quinapril significantly improved endothelial function

Patients Unsuitable For Strict Control

In practice, however, there are patients in whom attempts to achieve a near normal glycated haemoglobin are not appropriate (Box 8.2). Patients with advanced complications, especially retinopathy, have not been shown to benefit and a sudden improvement in glycaemic control may cause acceleration in severity of pre-proliferative or early proliferative retinopathy (Hanssen et al., 1986). Although some authorities claim that this should not be a contraindication to improving glycaemic control (Chantelau and Kohner, 1997), as yet there is no real evidence for benefit in advanced cases and the retinopathy should be treated appropriately before glycaemic control is intensified. Similarly, in patients with established renal impairment and severe macrovascular disease, attempts to treat elevated blood pressure and plasma lipids and to encourage patients to stop smoking may be more beneficial than targeting glycaemic control alone. As intensive insulin therapy is aimed at achieving benefit...

Which medicines are used in the treatment of diabetic dyslipidaemia

A 67 year old woman with a history of DM and hypertension for the last 15 years, obesity (BMI 31 kg m2), presents at the Diabetes Clinic for a regular visit. She reports that she has smoked 10 cigarettes a day for 35 years. Recent laboratory examinations show total cholesterol 300 mg dl (7.76 mmol L), triglycerides 685 mg dl (7.74 mmol L), HDL-cholesterol 34 mg dl (0.88 mmol L) and LDL-cholesterol 129 mg dl (3.34 mmol L). Her renal and hepatic functions are normal and the blood sugar is at a relatively good level, with HbA1c 7.4 percent. The patient reports that her mother, who also suffered from DM, had died at the age of 72 years from a myocardial infarction and she expresses concerns for her own prospects. What you would advise this patient at this visit

How is the action of inhaled insulin influenced by smoking

Chronic smoking accelerates the onset of action of inhaled insulin and causes a higher insulin concentration in smokers' blood compared to non-smokers. This is due to the increased permeability of the alveolar-capillary barrier of smokers. The absorption of insulin from smokers' lungs is influenced by the time between the last smoke and the inhalation of insulin (also by the transdermal use of nicotine), rendering the action of inhaled insulin unpredictable to a large extent. For this reason the use of inhaled insulin should not be recommended in smokers with DM. Moreover, certain writers express scepticism because the action of insulin on the IGF (insulin-like growth factor) receptors of the alveoli can have a carcinogenic action, especially when smoking that predisposes to cancer of the lungs coexists. The larger studies of treatment with inhaled insulin were careful to exclude smokers therefore there are in sufficient data with regard to this matter. Evidence from small studies in...

Peripheral Vascular Disease

Advice for any stable claudicant with no evidence of tissue loss is to 'stop smoking and keep walking'. There is considerable evidence that in order to be effective the patient should walk to the point of claudi-cating and even some distance with claudication. It is believed that this might encourage the proliferation of collateral circulation (Hiatt et al 1990).

What are the physical consequences

People with diabetes have a higher risk of developing certain health problems, or complications, and this risk is particularly high for people who are overweight, who smoke or who are not physically active. However, it is important to remember that you will not inevitably develop complications simply because you have diabetes. Careful research has shown that the better your blood glucose control, the less likely you are to experience complications. Knowing this helps many people to work harder at controlling their diabetes when they're tempted to let things slide a little. Along with good diabetic control, giving up (or not starting) smoking can reduce your chances of developing complications. Smoking and diabetes definitely do not mix. All of the possible complications are more common in people who smoke, and anyone who has already developed any of the associated problems should stop smoking

Unique Characteristics Of Coronary Artery Disease In The Diabetic Population

These patients often lack other traditional coronary artery disease risk factors such as hypercholesterolemia, hypertension, tobacco use, and family history of premature coronary artery disease. In contrast, type 2 diabetes patients typically have several cardiovascular risk factors and present in the fifth or sixth decade of life, or later (26).

Do functional foods reach the populations at risk

Several surveys have shown that a higher socioeconomic status is associated with a healthier diet, that is, a diet closer to the recommendations.10'45 Consumers with a low or middle socioeconomic status would therefore benefit most from functional foods. It has been suggested that functional foods would appeal most to healthy, well-educated and rich consumers, but this does not appear to be true in a Dutch survey among 1183 consumers aged 19-91 years, determinants of functional food use depended on the type of food.46 Stanol-enriched margarines were consumed most by smokers and consumers with a poorer subjective health. A Finnish study, however, showed a higher consumption of such margarines in consumers with higher socioeconomic status.47 Differences in marketing strategies can possibly account for these differences.

Introduction oxidative stress and cardiovascular disease

The literature reviewed below strongly suggests that oxidative stress plays a key role in the etiology of cardiovascular disease. Oxidative stress is a physiological condition in which pro-oxidant factors outweigh antioxidant defences. Accordingly, the role of oxidative stress in promoting cardiovascular disease and the roles of fat-soluble antioxidant nutrients in potentially protecting from this disease process will be discussed in some detail. Oxidative stress is likely to occur during inflammatory processes, during exercise and from cigarette smoking. The evidence presented below also suggests that vitamin D plays an important and significant role in preventing cardiovascular disease but it is very unlikely that this effect is related to its potential role as an antioxidant.

Conclusion and future trends reconciling the evidence

Clinical characteristics of patients with low antioxidant status have not been defined and should be studied in the near future. So far, clinical trials with antioxidants included patients without evaluating either oxidative stress or antioxidant status and such indiscriminate enrolment could perhaps account for the negative results of antioxidant trials recently emphasized by meta-analysis.68 A recent report by Meagher et al.69 is highly relevant to this discussion. They fed normal subjects doses of vitamin E ranging from 200 to 2000 mg day for 8 weeks. The highest dose increased plasma vitamin E levels 5-fold, but urinary excretion of isoprostanes and 4-hydroxynonenal (breakdown products of fatty acid auto-oxidation) was unaffected. The results suggest that in normally nourished subjects, additional vitamin E will not necessarily confer any additional antioxidant protection. Earlier studies in cigarette smokers, in contrast, did show a vitamin E effect on plasma isoprostane levels,...

Treatment of hypertension

Beta-blockers have traditionally been considered a relative contraindication in patients with intermittent claudication. However, many controlled studies have found that beta-blockers do not adversely affect walking capacity or symptoms of intermittent claudication (Radack and Deck, 1991). It is therefore thought that beta-blockers can be used safely in this group of patients particularly if strong indication exists, such as previous myocardial infarction, heart failure or resistant hypertension. Similarly, when considering treatments that block the renin-angiotensin system, the risk of underlying renovascular disease should always be considered in patients with PAD, treatment-resistant hypertension and mild renal impairment, especially smokers.

Bypass Angioplasty Revascularisation Investigation BARI

By contrast with the BARI randomised patients, in the BARI registry survival with PTCA and CABG was similar (Alderman etal., 1997b Detre etal., 1999). Registry patients had a better risk profile, including less heart failure and cigarette smoking. Compared with CABG-treated registry patients, PTCA-treated registry patients had a lower prevalence of three-vessel CHD and proximal and ostial left anterior descending

Getting Well After Cancer

The ravages of cancer must be healed once the malignancy has been stopped. This is where carcinogens play a role. The lung lesions will not heal unless cigarette smoking, freon, asbestos, and fiberglass exposure is stopped. Carcinogens were thought to be the cause of cancer. Actually, they drew the cancer to the organ. Nickel draws cancer to the prostate. Barium found in lipstick draws cancer to the breast. And so on.

Eye liner and Eyebrow Pencil

Get a pure charcoal pencil (black only) at an art supply store. Try several on yourself (bring a small mirror) in the store to see what hardness suits you. You may need to wet it with water or a vitamin E perle first. Don't put any chemicals on your eyelids, since this penetrates into your eye. To check this out for yourself, close your eye tightly and then dab lemon juice on your eyelid. It will soon burn Everything that is put on skin penetrates. Otherwise the nicotine patch and estrogen patch wouldn't work. Not even soap belongs on your eyelids Charcoal pencils are cheap. Get yourself half a dozen different kinds so you can do different things.

Prevention and reduction of cardiovascular risk

Diabetic smokers have a similarly increased risk of cardiovascular disease to non-diabetics. Overweight, hypertensive diabetic women who are taking oral contraceptives are at especially high risk of cardiovascular complications. Studies have also shown that smokers were more likely to have nephropathy and retinopathy than non-smokers.

Fisoprostanes and overweight and obesity

A role for oxidant stress in the development and progression of atherosclerosis has been hypothesized for more than two decades.27-29 In recent years, however, the quantification of F2-IsoPs has allowed investigators to explore, for the first time, the extent to which humans undergo enhanced oxidant stress under patho-physiological situations associated with the development of atherosclerotic cardiovascular disease. These studies have found that increased levels of plasma and or urinary F2-IsoPs are associated with most of the risk factors for atherosclerosis, including hypercholesterolemia,30 diabetes mellitus,31-33 hyperhomocys-teinemia,34 and chronic cigarette smoking.35-37 This suggests that certain populations at risk for the disease are under increased oxidant stress.

When should the treatment of hypertension in diabetic patients begin and in what way How long will the treatment last

Since hypertension in the diabetic individual is defined as the presence of BP levels > 130 80 mmHg, it is obvious that the therapeutic approach should begin when its values exceed these limits. Initially, for blood pressure levels of 130-139 80-89 mmHg, it is advisable for the first approach to be non-pharmaceutical, and to try to reduce the BP with lifestyle modification measures. These include an effort of body weight reduction in obese patients (with diet and exercise), reduction of salt and alcohol consumption, and smoking cessation. Weight loss is the most efficient of these measures, as regards the success of BP reduction (a loss of 10kg body weight usually produces a BP fall by 5-20mmHg). A reduction of dietary caloric consumption is very important, with fat restriction, mainly saturated animal fat, being the basic factor. Salt should be limited to less than 6g per day. Alcoholic beverages should also not exceed 2-3 glasses of wine (or equivalent alcohol quantity in other...

Prevention Or Delay Of Type Diabetes

Intensive therapy (median HbAlc level achieved of 6.4 ) or standard therapy (median HbAlc level achieved of 7 ). After a median follow-up of 5 years, compared to the standard-therapy group those in the intensive-therapy group achieved a reduction in the incidence of nephropathy (5.2 vs. 4.1 ), although severe hypoglycemia was more common (1.5 vs. 2.7 ). There were no differences in overall mortality (9.6 vs. 8.9 ), cardiovascular mortality (5.2 vs. 4.5 ), or major macrovascular events (10.6 vs. 10 ). Finally, patients in the Veterans Affairs Diabetes Trial (VADT) (n 1,792) had a mean age of 60.4 years at entry and 11.5 years of diabetes duration. Ninety-seven percent were men and 40 had prior macrovascular events and a baseline mean HbA1c level of 9.4 (50). They were assigned to receive intensive therapy (median HbA1c level achieved of 6.9 ) or standard therapy (median HbA1c level achieved of 8.4 ). After a median follow-up of 6 years, there was no significant difference in the rate...

What other sexual disturbances apart from erectile dysfunction can occur

The doctor ought to discuss with the patient the need for smoking cessation and the need for aggressive control of the metabolic disturbances. He ought to reassure the patient regarding the unfavourable effect of blood pressure medicines 'on his problem'. He should add an antiplatelet agent (aspirin or clopidogrel) to the patients regimen.

Basic theoretical concepts

In this concept, the initial step is considered dysfunction of the endothelium, the innermost layer of the vasculature, by local disturbances of blood flow, along with metabolic and humoral risk factors (e.g. hyperglycemia, dyslipidemia, cigarette smoking, inflammation). These alterations of the endothelium perpetuate a series of events that culminate in the development of an atherosclerotic plaque.

Diabetes and pregnancy

The importance of GDM to the mother is that it identifies her as having a metabolic susceptibility for the subsequent development of type 2 diabetes. There is a variable rate of progression to diabetes, with up to 50 of women from ethnic minority groups progressing to diabetes within 5 years of a GDM pregnancy, although this is lower in Caucasian women. There is also an increased risk of cardiovascular disease and such women need to be advised about the benefit of weight loss, exercise and smoking cessation. All

Supporting evidence is of classes A C RuwwiC

Cardiovascular and Cerebrovascular Disease - Treatment includes control of cardiovascular risk factors (HTN, hyperlipidemia and smoking cessation) and ASA use. Patients with CAD may be treated medically or surgically. Consider referring patients with known CAD to cardiology and patients with known carotid disease to surgery. CHF is also common in patients with diabetes. Caution should be used when prescribing spironolactone and eplerenone to people with diabetes, especially in combination with ACE inhibitors. Close monitoring of potassium and renal function is necessary. See the Blood Pressure Control algorithm. For patients with type 2 diabetes mellitus, thiazide diuretics in the treatment of hypertension can reduce cardiovascular events, particularly heart failure. Conclusion Grade I See Conclusion Grading Worksheet - Appendix F - Annotations 24, 30D (Thiazide Diuretics) (ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group, The, 2002 Wing, 2003)

Prospective observational epidemiological studies

In the case of physical activity, people who engage in greater amounts of activity may themselves select other healthy behaviors which are incompletely measured and adjusted for (e.g. less cigarette smoking or altered diet). There may also be a genetic component to physical activity, either based on spontaneous activity100 or clustering of other genetic factors which facilitate activity101. Analyses of twin studies have shown contradictory results concerning asso

Other Dietary Factors And Smoking

Several micronutrients, most notably chromium, zinc, magnesium and vitamin E, have been implicated in the pathogenesis of Type 2 diabetes and or been shown to be associated with improved glycaemic control. However, no epidemiological studies have provided convincing support for the role of any of these nutrients in the aetiology of the disease. There is perhaps rather more support for the suggestion that vitamin D deficiency may be important. Vitamin D deficiency impairs insulin release followed, if prolonged, by impairment of insulin secretion and reduction of glucose tolerance which progresses to irreversible diabetes. Asians living in East London have a reduction in insulin secretion associated with vitamin D deficiency which is improved after treatment with vitamin D (49). There has been much recent interest in the observation that babies with a low birthweight and infants with a low weight at one year are at increased risk of developing IGT and Type 2 diabetes later in life. The...

Nitric oxide and the development of atherosclerosis

All the major cardiovascular risk factors (including hypertension, high levels of low-density lipoprotein LDL cholesterol, tobacco use, and hyperhomocysteinemia) are associated with decreased endothelium-dependent vasodilation prior to the development of clinically apparent vascular disease. This would suggest that the endothelial damage is implicated in the development of atherosclerosis (35).

Use of FLabeled Fluoro DeoxyDGlucose as Diagnostic Tool

By now, FDG-PET has become the method of choice for the staging and restaging of many of the most common cancers, including lymphoma, lung cancer, breast cancer, and colorectal cancer. FDG-PET has also become extremely valuable in monitoring the response to therapeutic drugs in many cancers. New PET agents, such as fluorothymidine and acetate, have also shown promise in the evaluation of response to therapy and in the staging of prostate cancer 57 .

Dietary antioxidants and the prevention of CHD evidence from clinical trials

While most epidemiological studies have demonstrated that dietary intake of vitamin E is inversely related to coronary heart complications, supplementation studies gave conflicting results. Clinical trials with antioxidants have been done in patients with or without previous history of cardiovascular disease (Table 5.2). Surrogate endpoints, such as analysis of atherosclerosis progression, or 'hard' endpoints, such as vascular death and MI, have been used to evaluate the clinical benefits of antioxidant vitamins. The Alpha-Tocopherol-Beta-Carotene-Cancer (ATBC)52 prevention study was a randomized, double-blind, placebo-controlled primary-prevention trial to determine whether daily supplementation with alpha-tocopherol, beta-carotene or both reduced the incidence of lung cancer and other cancers. A total of 29 133 male smokers, 50-69 years of age, were randomly assigned to one of four regimens alpha-tocopherol (50 mg per day) alone, beta-carotene (20 mg per day) alone, both...

Emboli and palpable pulses

The toe became necrotic but was not amputated. At first it was believed that the necrosis was full thickness and that the toe would autoamputate through the interpha-langeal joint, but the necrosis was more superficial than first thought. The toe was treated conservatively with outpatient debridement by the podiatrists and systemic antibiotics and aspirin, and healed in 1 year. He continued to smoke heavily despite being referred to the smoking cessation clinic.

Multifactorial intervention

Eighty patients were randomly assigned to receive conventional treatment and 80 to receive intensive treatment, with a stepwise implementation of behavioural modification and pharmacological therapy that targeted hyperglycaemia, dyslipidaemia and microalbuminuria, along with secondary prevention of cardiovascular disease with aspirin. The goal of dietary intervention was a total daily intake of fat < 30 of the daily energy intake. Light-to-moderate exercise for at least 30min 3-5 times weekly was recommended. Smoking cessation was encouraged. All patients were prescribed an ACE inhibitor or angiotensin II receptor antagonist, and a daily vitamin-mineral supplementation. All patients received aspirin therapy, if not contraindicated. Hypoglycaemic agents were introduced if a patient was unable to maintain glycosylated haemoglobin A1c values below 6.5 . If a patient had hypertension, thiazides, calcium channel blockers and beta-blockers were added as needed on ACE inhibitor (or...

No of antihypertensive agents Trial Target BP mm Hg

Measured was mortality from all causes, from CV disease, from ischemic heart disease, and from other causes. Men with known diabetes had increased mortality from all causes, CV disease, and ischemic disease (RRs, 2.2, 3.3, and 4.2, respectively P < 0.001 independent of age and other risk factors) compared with men without known diabetes. The increased risk of death among men with diabetes was largely explained by the hemoglobin A1c (HbA1c) concentration. HbA1c was related to subsequent all-cause, CV, and ischemic heart disease mortality throughout the study population the lowest rates were seen in those with HbA1c concentrations below 5 . An increase of 1 in HbA1c was associated with a 28 (P < 0.002) increase in risk of death independent of age, blood pressure, serum cholesterol, body mass index, and cigarette smoking. This effect remained (RR, 1.46 P 0.05 adjusted for age and risk factors) after men with known diabetes, a HbA1c concentration greater than 7 , or a history of...

Niddm And Ambulatory Bp

We have compared ambulatory BP in 16 normoalbuminuric smokers and non-smokers without hypertension. Systolic BP was slightly higher (3mmHg day time, 5 mmHg night time) in smokers, but this failed to reach statistical significance 68 . In a larger study encompassing 24 normoalbuminuric smokers and non-smokers diastolic day and night BP was significantly higher (3.9 and 3.5 mmHg respectively) in smokers. In addition a dose response relationship was demonstrated 69 . Notably, this effect of smoking in diabetic individuals contrast the well known finding of a lower night BP in non-diabetic smokers 68,70 . Smoking does not affect the night day ratio of BP in diabetes 68,69,71 .

Insulin Resistance And Hyperinsulinemia

Fifty percent of the variability in insulin action may be attributed to differences in lifestyle for example obesity, physical inactivity and cigarette smoking all increase the degree of insulin resistance. The other 50 of the variability is likely to be related to genetic differences. In addition, it is now clear that hypergly-caemia itself may produce insulin resistance a phenomenon known as glucotoxicity (DeFronzo et al 1992). Insulin resistance is common in individuals with Type 2 diabetes mellitus, and this phenomenon is implicated as a major factor in the development of overt hyperglycaemia. In the Insulin Resistance and Atherosclerosis Study (IRAS), Haffner and coworkers (1997) reported that insulin resistance was present in 85 of subjects with diabetes. Insulin resistance may also be found in conditions that are not necessarily associated with glucose intolerance (Table 14.2). (Ferrannini 2000). DeFronzo and Ferrannini (1991) have shown that patients with Type 2 diabetes,...

Smoking and Inflammation

Virtually everyone who smokes (or chews) tobacco products knows that they are hazardous to health. In addition to increasing the risk of lung cancer, tobacco smoke boosts the risk of many other types of cancer, emphysema, and coronary artery disease. Smoking significantly elevates levels of C-reactive protein (CRP), a powerful promoter of inflammation. Even after a person stops smoking, his or her CRP levels remain higher than normal for years. If you don't smoke, don't start. And if you do, try to break the habit.

Calcium and Vitamin D

Women with preexisting diabetes may not have optimal levels of copper, magnesium, zinc, vitamin C, and vitamin E therefore, a prenatal vitamin and mineral supplement may be needed. Women who smoke, abuse alcohol, and have a suboptimal nutrient intake may also benefit from taking a prenatal supplement.

The use of functional foods to meet dietary guidelines

Foods enriched with fibres and vitamins can be an alternative to fruits and vegetables, but only to a certain point. For example, different dietary fibres have different effects on CVD risk water-soluble dietary fibres such as pectin and guar gum appear to have stronger effects than insoluble fibres such as wheat bran.24,25 Thus, a mixture of various dietary fibres such as found naturally in fruits and vegetables appears to be necessary for a protective effect on CVD. Also, adding vitamins to foods to compensate for low fruit and vegetable intakes might not have the expected effects. For example, beta-carotene was widely believed to reduce cancer risk in smokers, because intake of carotene-rich foods was associated with less cancer, as were high levels of carotene in blood. However, it was found that carotene supplements increased risk of lung cancer in smokers.26 27 Large clinical trials of antioxidants have also had disappointing outcomes.28 Moreover, several other bioactive...

CVD Morbidity and Mortality in Diabetic Women The Evidence

Well-designed population-based studies have shown an increased risk for fatal and nonfatal CVD among women with DM. Analysis of data from the Framingham Heart Study and the Framingham Offspring Study evaluated the gender-specific effect of DM and established CHD on subsequent mortality in adults. Risk for CHD was adjusted for age, hypertension (HTN), cholesterol levels, tobacco use, and body mass index (BMI). The increased risk ratios for death from CHD were 2.1 in men with diabetes only, and 4.2 in men with CHD only, compared with nondiabetic men without CHD. The diabetes-related increased ratio for CHD death was 3.8 in women with diabetes and 1.9 in women with CHD. Thus, these data indicate that men with established CHD have higher risk for CHD mortality than diabetic men. In contrast, in women the presence of DM was associated with a greater risk than established CHD for subsequent CHD mortality (10). The Rancho Bernardo Study reported the 14-year gender-specific effects of DM2 on...

Diabetes and Its Relationship to Pancreatic Carcinoma

A hospital-based case-control study revealed that cigarette smoking, family history of PC, heavy alcohol consumption (> 60 ml ethanol day) and diabetes mellitus are significant risk factors for PC. The significant synergy between these risk factors suggests a common pathway for carcinogenesis of the pancreas 58 .

Dietary strategies to prevent the development of heart disease

Most investigators agree that atherosclerosis is a chronic low-grade inflammation disease.29 Pro-inflammatory factors (free radicals produced by cigarette smoking, hyperhomocysteinaemia, diabetes, peroxidised lipids, hypertension, elevated and modified blood lipids) contribute to injure the vascular endothelium, which results in alterations of its antiatherosclerotic and antithrombotic properties. This is thought to be a major step in the initiation and formation of arterial fibrostenotic lesions.29 From a clinical point of view, however, an essential distinction should be made between unstable, lipid-rich and leucocyte-rich lesions and stable, acellular fibrotic lesions poor in lipids, as the propensity of these two types of lesion to rupture into the lumen of the artery, whatever the degree of stenosis and lumen obstruction, is totally different.

Supporting evidence is of class A

Peripheral vascular disease in combination with peripheral neuropathy places patients with diabetes at increased risk for nontraumatic amputations of the lower extremity. Peripheral vascular disease may be slowed by smoking cessation and treatment of hypertension and dyslipidemia. (See Annotation 11b, Start or Intensify Statin Dose and the Blood Pressure Control algorithm). Aggressive daily foot care, inspection of the feet at every office visit, early treatment of foot infections, treatment of callus, use of moisturizing lotion and proper footwear may forestall problems, including amputation. Vascular surgery may also prevent amputation in some patients with established severe peripheral vascular disease. Treatment includes glycemic, blood pressure and lipid control, as well as smoking cessation, which may slow the progression. Proper high-risk foot management is necessary to prevent ulceration and amputation. Consider referral of patients with claudication and or absent pedal pulses...

Treatment of CVD Risk Factors in Diabetic Women Are We Achieving the Goals

In contrast, a meta-analysis of 16 studies showed that the relative increased cardiovascular risk seen in diabetic women was no longer significant after adjustment for HTN, total cholesterol, and tobacco use (23). Nevertheless, most available data suggest that increased CVD morbidity and mortality in diabetic women is related to a less than ideal control of modifiable CVD risk factors.

Therapeutic implications

Lifestyle modifications including implementation of a regular exercise program, reduction of obesity through dietary measures, and avoidance or cessation of cigarette smoking should be implemented to reduce the intensity of a prothrombotic state and the progression of macrovascular disease. Vitamin B6 (1.7 mg per day) and folic acid (400 g of dietary or 200 g of supplemental folic acid per day) in recommended daily allowance (RDA) doses appear to be appropriate particularly because elevated homocysteine (139)

Nonpharmacological Treatment Of Hypertension In Diabetic Patients

The goal of treating hypertension in patients with diabetes mellitus is to prevent associated morbidity and mortality. Lifestyle modification, including weight management, diet, salt reduction, moderation of alcohol intake, increased physical activity and smoking cessation are the cornerstones of therapy. Weight loss in overweight individuals can improve control of both hypertension and diabetes mellitus. Many studies have shown that even modest reduction of body weight can improve BP and glycemic control. Reduction in weight may be associated with BP reductions because of reduction of insulin levels, sympathetic nervous system activity, and vascular resistance.

Nutrients That Can Help

N-acetylcysteine (NAC) is sometimes used by physicians to break up mucus in the lungs. Used on a long-term basis, NAC may help protect lung cells. A number of other antioxidants also might be helpful. Studies of smokers and beta-carotene have shown contradictory effects, but a modest intake of this carotene (10,000 IU or 6 mg) in combination with other antioxidants, such as vitamins E and C, is likely to be helpful. There appears to be a threshold of benefits from beta-carotene in smokers, so the above dosage should not be exceeded.

Chronic Heart Failure

A low-salt diet (usually 2 g) with carbohydrate content tailored to the severity of diabetes is appropriate. It is rarely necessary to restrict salt to such a degree that the patient's diet is unpalatable nor is it ordinarily necessary to restrict water intake. Unless there is active and potentially dangerous demand ischemia or exercise-induced arrhythmias, physical activity need not be curtailed other than as dictated by symptoms. Indeed, regular aerobic exercise should be encouraged, and organized exercise conditioning programs may be beneficial. Such programs have not been convincingly shown to enhance cardiac function, but they increase exercise tolerance and have been reported to improve endothelial function. In diabetic patients, they offer the additional benefits of weight loss and enhanced control of blood glucose. Of course, smoking cessation is imperative. Smoking has specific, deleterious effects in heart failure because of vasoconstriction and reduced oxygen-carrying...

Using other medications and treatments

At the other end of the spectrum are drugs that make it even more difficult to control your blood glucose (or your child's). Alcohol and nicotine in cigarettes top the list, but there are a number of illegal drugs that also complicate diabetes management. Avoid these drugs at all costs. In Chapter 12, I explain how they make glucose control so difficult.

Management of hypertension

The role of sodium restriction is controversial. The INTERSALT Study showed that dietary sodium restriction can independently lower blood pressure and is additive with weight loss (Fagerberg et al., 1984). Studies have shown that moderate sodium restriction to 100 mmol (2300 mg) per day can reduce systolic pressure by 5 mmHg and diastolic pressure by 2-3 mmHg (Cutler et al., 1997). In addition, the response to antihypertensive therapy appears to be more effective in salt-restricted subjects. Physical activity, involving 30-45 min of brisk walking has been shown to lower blood pressure, as well as smoking cessation, and reduction of alcohol intake (Joint National Committee, 1997 Haire-Joshu et al., 1999 American Diabetes Association, 2002).

True Origins Of Viruses

It is a time of great change for this planet as pollution spreads from pole to pole. The growth of industrial activity, mining, chemical manufacturing, the food industry, and personal habits like smoking have spread new chemicals to every corner of the globe. The element polonium, which is radioactive and in tobacco smoke, is harmful to human lungs, but may not be harmful to a small lung parasite, like Pneumocystis carnii.

Good to Sell

However, as this is a worldwide epidemic, so should be the corresponding regulations WTO, WHO, FAO, and other international organizations should play an active part in solving the problem. Otherwise, it might just happen that countries with the means to implement effective controls will have healthy food, while developing countries with limited control mechanisms will be flooded with the junk food that cannot be sold elsewhere. This is similar to what occurred when developed countries issued restrictions on tobacco consumption, and tobacco companies increased their penetration in the rest of the world with China becoming the country with the largest smoking population (53).


One should, however, be careful regarding patients who may be at risk for renal arteriostenosis and therefore careful follow-up in such patients is needed. Patients who are generally arteriosclerotic should be followed even more carefully, including patients who are smokers (49). In my view it is not generally indicated to screen for renal arteriostenosis. If serum creatinine increases above about 20 during antihypertensive treatment, further investigations may be relevant.


Cigarette smoking is less common, or as common among type 2 diabetic patients and normoglycaemic individuals. Similar to non-diabetic subjects the risk of CAD in patients with type 2 diabetes depends on the number of cigarettes smoked (Laakso and Lehto, 1997). Smoking may act directly or adversely influence risk factors contributing to the development of CAD (Tsiara etal., 2003). Smoking can cause endothelial dysfunction, dyslipidaemia (low HDL-cholesterol, high total triglycerides) and impaired platelet function. Smoking also increases insulin resistance and induces changes in growth factors and adhesion molecules.


The endothelium secrets not only vasorelaxing agents, but also vasoconstricting agents. Thromboxane A2, is one of the best studied vasoconstrictors and it is the physiological counteracting mediator for NO. Both thromboxane A2 and its precursor, prostaglandin H2, are synthesized by both platelets and vessel wall tissues. Thus, it is obvious that the increased activation of platelets in diabetics (36) contributes to the formation of thromboxane A2 and prostaglandin H2 in this disease state (37). Other factors that may equally contribute to the increased platelet biosynthesis of thromboxane A2 include cigarette smoking (38), hypercholesterolemia (39), and homozygous homocystinuria (40). The rate of thromboxane A2 biosynthesis appears to reflect the influence of co-existing disorders like diabetes, hypertension, and dyslipidemia on platelet biochemistry and function (41). Thus, enhanced thromboxane A2 biosynthesis may represent a common link between these cardiovascular risk factors and...

Inhaled Insulin

INH, glycaemic control or adverse outcomes (allergic events, pulmonary side effects or hypoglycaemia) 36,37 . However, there are several potential problems to be overcome with patients who smoke and patients with impaired pulmonary function conditions that could affect the kinetics of INH. Previously, it has been demonstrated that smoking as well as chronic obstructive lung disease can increase pulmonary absorption of INH whereas asthma decreases it. Mild to moderate cough is seen with INH 34,36,37 . A major concern with INH is the potential for pulmonary toxicity because of the growth-promoting properties of insulin. Small decreases in lung function as judged by FEV1 and DLCO have been found to develop early in the treatment with INH but, however, it does not progress over 2 years. At present it can be concluded that INH offers an alternative non-invasive route for premeal insulin administration with glycaemic efficacy in T1DM 36,37 . INH should be a treatment option for people who...


Evaluation Study NMR Nuclear magnetic resonance NO Nitric oxide NTD Neural tube defects NRT Nicotine replacement therapy OAD Oral antidiabetic agent oGTT Oral glucose tolerance test OSA Obstructive sleep apnoea PAD Peripheral arterial disease PARP Poly-ADP-ribose polymerase PCI Percutaneous coronary intervention PCOS Polycystic ovarian syndrome PDE Phosphodiesterase PDGF Platelet-derived growth factor PEDF Pigment Epithelial-Derived Factor PEG Percutaneous endoscopic gastrostomy PKC Protein kinase C


It is increasingly recognized that smoking is not only a cardiovascular risk factor, but also a risk factor for development and progression of diabetic nephropathy 47-49 . Of note, even in the general population, smoking is associated with microalbuminuria and renal function abnormalities 50 . Smoking-induced increase of systemic blood pressure and or glomerular hyperfiltration (as documented in type 1 DM 51 ) could be a mechanism behind this. In line with this, a cross-sectional study at renal biopsy findings in type 2 diabetic patients showed that glomerular alterations -and not interstitial fibrosis- were associated with smoking 52 . Thus, smoking cessation is not only important to prevent malignancies and cardiovascular disease, but, in addition, it should also be part of any renoprotective regimen.


Obesity decreases longevity, a 7- to 8-year loss of lifespan in 40-year-old nonsmoker individuals and a 13- to 14-year less lifespan in smokers (25) when obesity occurred by 20 to 30 years of age there was a 22 reduction in longevity, 17 to 20 less lifespan (26). Thus it could be expected that the impact of obesity starting earlier in life, beginning during childhood, would be more dramatic and lifespan would be further impaired. In a study by Must et al., long-term morbidity and mortality of overweight adolescents were examined (27). They demonstrated that obesity in adolescent subjects was associated with an increased risk of mortality from all causes and disease-specific mortality among men, but not among women. The risk of morbidity from coronary heart disease and atherosclerosis was increased in both men and women who had been obese in adolescence. However, in a study by Freedman et al., childhood overweight was related to adverse risk factors among adults, but associations were...

Essential Eye Care

Although the final word is not in on the effects of excessive alcohol on eye disease in diabetes, is it worth risking your sight for another glass of wine Smoking has definitely been shown to raise the blood glucose in diabetes. Even at a late stage, you can stop the progression of the eye disease or reverse some of the damage if you stop smoking now.

Rate Of Progression

Blood pressure control may account, at least in part, for these differences. On the other hand, a small, retrospective study in London found that Indo-Asians with DN had a significantly higher rate of doubling of serum creatinine than whites or Afro-Caribbeans despite similarities in blood pressure, glycemic control, smoking behavior, baseline proteinuria, and use of ACE inhibitors (86), again suggesting that other genetic, socioeconomic, and environmental factors must be involved in the more rapid progression of DN in transitional and disadvantaged populations.

Exposure to Tobacco

In African Americans, exposure to cigaret smoke increases the risk of DN (65), but this finding has not been confirmed in other transitional and disadvantaged populations. Nevertheless, in the United States, members of transitional and disadvantaged populations are disproportionately inclined to substance abuse, including tobacco (66). Economic transition appears to increase the prevalence of cigaret smoking among Australian Aboriginals (67), and migration from rural to urban areas is associated with increased prevalence of tobacco abuse in China (68). Why economic transition is associated with increased prevalence of smoking is unclear. Tobacco abuse may cause smokers to feel more relaxed and in control (68) or may result from increased disposable income and increased access to cigarets in urban areas (72).

Clinical Trials

Framingham data (24) clearly showed that body mass index was directly associated with blood pressure, blood glucose, and total cholesterol. Therefore, nonpharmacological adjunctive treatment of dyslipidemia involves increased physical activity, smoking cessation, weight reduction, and dietary modification (reducing the intake of trans fatty acids, cholesterol, and saturated fat in the diet). 3. Adjuvant nutritional therapy, smoking cessation, and therapeutic lifestyle changes (including weight loss and exercise).


Lycopene, and lutein are varieties of carotenoids. Epidemiologic evidence suggests that serum carotenoids are potent antioxidants and may play a protective role in the development of chronic diseases including cancers, cardiovascular disease, and chronic inflammatory signaling 15 . Variations in insulin-mediated glucose disposal in healthy individuals have been found to be significantly related to plasma concentrations of lipid hydroperoxides and liposoluble antioxidant vitamins. Research has found that synthetic -carotene may increase the risk of lung cancer, prostate cancer, intracerebral hemorrhage, and cardiovascular and total mortality in people who smoke cigarettes or have a history of high-level exposure to asbestos 16 . Natural carotenoids from foods or supplementation have not been reported to have this effect.


In addition to hyperglycemia, individuals with T2D often have a constellation of other metabolic abnormalities which increase their CVD risk (60-64). Risk determinants of CVD include the presence or absence of coronary heart disease (CHD), other clinical forms of atherosclerotic disease, and the major risk factors high LDL cholesterol, cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD (defined as a relative with CHD younger than 65 years for women and 55

Treatment Strategy

There is little evidence that treatment of dyslipidemia will protect renal function and the few studies that do exist are conflicting. Obviously, treatment of hyperlipidemia is more important for the prevention of cardiac and vascular disease. However, with very advanced renal disease, statins are not effective (56), and the role of optimal glycemic control is still being discussed. Strict blood glucose control is hardly necessary (and very difficult) (57). Cigarette smoking is also considered a risk factor and all patients should be given advice regarding smoking cessation (49).

Some More Factors

Smoking is a factor that one would assume to be a real problem when it comes to exacerbating retinopathy. However, there is not as strong an association as one would think. The literature goes back and forth on the issue, and it is therefore not fully justified to include smoking with the above pantheon of clear-cut risk factors.7 However, smoking clearly worsens other problems, such as large-vessel disease and renal failure, and these in turn can exacerbate retinopathy. Besides, smoking can aggravate other ophthalmic problems such as cataracts and macular degeneration, so you should feel free to nag patients about their smoking, whether they have diabetes or not. The American Academy of Ophthalmology makes a nice handout on the subject of smoking and its effects on the eye. Unfortunately, large corporations have worked very hard to make it very difficult to stop smoking, so it is not clear how much success you may have with this one. Sometimes, though, patients will be more worried...

The Waiting Room

The focus on self-management can begin while the patient is in the waiting room. The patient's attention can be drawn to the importance of self-care activities by having various pamphlets, posters and notices placed in the waiting room. These might include notices from the hospital or clinic regarding diabetes education or information classes, support groups, as well as pamphlets on diet, exercise or smoking cessation.

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Quit Smoking Today

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