Program Aids Diabetes, Depression Care

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Treating diabetes and depression in a coordinated way can help to improve both, new research suggests. The study included 180 people with both conditions. They were randomly assigned to receive either usual care or an integrated program of care. People in the second group received extra help. A care manager worked with them to help them keep track of and remember to take their medicines. The care manager also provided education about their conditions and other services to improve care. The program lasted 12 weeks. In the usual-care group, more than 3 out of 10 had improvements in blood sugar and depression symptoms. Among those who got extra care, 6 out of 10 improved. The journal Annals of Family Medicine published the study. HealthDay News wrote about it January 20.
What Is the Doctor’s Reaction?
Depression and diabetes are two of the most common chronic (long-lasting) diseases in the United States. And they often occur together. About 25% of people with diabetes are depressed. That’s nearly twice the rate among people without diabetes.
The exact reason for the link between diabetes and depression is unknown. It’s likely there are multiple reasons. People with diabetes might feel depressed by the diagnosis. They also can feel overwhelmed by the effort it takes to manage this disease. And many experts believe they are connected by a biologic link.
Having both depression and diabetes greatly increases the risk of early death. The main reason is the higher rate of heart attacks and blood vessel diseases in people with both conditions.
People with depression are less likely to keep their blood sugar under good control. Unhealthy behaviors linked to heart disease seem to be especially common in people with both depression and diabetes. They are more likely than others to smoke, eat an unhealthy diet and get little exercise. They also tend not to take their medicines regularly for high blood pressure and high cholesterol. Both of these conditions increase the risk of heart disease risk
Until recently, doctors have focused more on treating the diabetes. They have given less attention to the depression. Why?

  • Past studies have suggested that depression does not respond as well to treatment when a person has other chronic diseases.
  • Some of the medicines used for depression can raise blood sugars.
  • Doctors know they can lower blood sugar quickly and effectively with lifestyle choices and medicines. Depression is more challenging to treat.

But findings of a new study suggest a different approach. The study appears in the January/February issue of the journal Annals of Family Medicine. Blood sugar control and depression symptoms improved when both conditions were treated in a coordinated way.
What Changes Can I Make Now?
Diagnosing diabetes is straightforward — a blood test shows a high blood sugar. There is no simple test for depression. It is diagnosed based on symptoms.
Feeling sad is only one of the symptoms of depression. Some people with depression would even deny sadness. Other important symptoms include:

  • Little interest or pleasure in things you used to enjoy
  • Sleep problems:
    • Trouble falling asleep
    • Waking up early and not being able to fall back to sleep
    • Sleeping too much
  • Feeling tired, with no energy
  • Poor appetite or overeating
  • Feeling bad about yourself, feeling that you are a failure or have let people down
  • Trouble concentrating
  • Thinking that you would be better off dead or considering hurting yourself in some way

If you have both diabetes and depression, don’t wait to treat the depression. Don’t think that you need to get your blood sugar well controlled first. Once your blood sugar is in the safe range, getting treatment for depression will make taking care of your diabetes easier.
Treating the depression can help you to adopt better eating habits and get more exercise. This could mean lower blood sugar, perhaps with fewer medicines or at least lower doses.
What Can I Expect Looking to the Future?
You can expect scientists to discover a genetic basis for the link between depression and diabetes. This will lead to better treatments for both diseases.
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Parents' Role in Weight Control Assessed

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A new report calls for more research to find the best ways for parents and other caregivers to fight obesity in children. The American Heart Association issued the statement. It reviewed studies that took different approaches. Some of these have been linked to better results. They include changing behaviors as a family, setting clear goals, keeping track of progress and keeping healthy foods in the home. About 17% of the studies found that kids lost more weight when parents were involved in treatment. Some studies also found that a role for parents also helped kids to keep weight off longer. But in other studies family involvement did not make a difference. The study authors said research has not focused enough on the roles of culture, family relationships and parenting styles, among other things. The journal Circulation published the study. HealthDay News wrote about it January 23.
What Is the Doctor’s Reaction?
As a pediatrician and a parent, it seems plain old obvious to me that anything we do to fight the childhood obesity epidemic needs to involve parents and other adult caregivers. After all, they are the ones who:

  • Shop
  • Pack lunches
  • Cook meals
  • Take kids to McDonald’s
  • Sign them up for soccer
  • Buy video games and televisions
  • Make decisions about how much time kids spend in front of them

Basically, there is nothing I can do as a pediatrician that doesn’t involve a parent or caregiver.
So I was pretty excited about a new scientific statement from the American Heart Association (AHA). It’s called "Evaluating Parents and Adult Caregivers as Agents of Change for Treating Obese Children."
The first part of the statement goes through the core behavior change strategies for obese youth. The AHA says these strategies are "grounded in strong theoretical models." They include:

  • Choosing specific habits or behaviors that should change
  • Writing down or keeping track of a target behavior such as what children eat or how much they exercise
  • Setting goals
  • Limiting temptations
  • Offering support for good behavior (such as rewarding kids for making good food choices)
  • Using self-efficacy and self-management skills (learning willpower!)

The authors talk about ways that parents and adult caregivers can implement these strategies. Again, it seemed somewhat obvious to me that involving all caregivers is necessary for any of these strategies to work.
But in the second section, when they reviewed studies on the effect of parent and other caregiver involvement, do you know what they found?
It wasn’t at all clear that caregivers made a difference in treating child obesity.
To be fair, some studies did show that it made a difference. Also, most of the studies only kept track of kids and families for a few months. This may not have been long enough to show real results. But nevertheless, it was discouraging.
So what is going on? Maybe parents and caregivers really don’t make a difference — but that’s hard to believe. Maybe that’s not the explanation. Maybe parents need more education and support to be effective. Or — and this is the most likely explanation — maybe our overall efforts to treat childhood obesity just aren’t effective.
The last section of the statement discussed possible areas of research. For example, what is the role of family relationships when it comes to childhood obesity? What is the role of genetics, or culture? What are the best changes to make in the home environment? What are the best parenting practices if we want to keep kids at a healthy weight?
The parent, the child and the environment each play an important role in childhood obesity, the authors say. We need to understand each one separately before we can understand how they work together.
That’s the central problem here. There’s no obvious solution for the treatment of childhood obesity. If there were, we’d have had it fixed by now. It may be obvious that parents and caregivers need to be involved. But the best way to involve them is far from obvious — and they aren’t the only solution.
What Changes Can I Make Now?
If you are a parent or caregiver of a child, you should:

  • Know your child’s body mass index, or BMI, and know if it’s healthy. Your doctor is your best resource. The U.S. Centers for Disease Control and Prevention (CDC) website has a great BMI calculator for kids. It also includes lots of useful information about healthy eating and exercise.
  • Know your own BMI. Overweight parents are more likely to have overweight kids. The reasons involve genes and also family lifestyle habits. Which leads me to…
  • Take a long, hard, honest look at your family’s lifestyle. Do you exercise? How much is the TV on? Is there soda in the fridge? Are your habits as healthy as they could be?

What Can I Expect Looking to the Future?
As I have said many times in news reviews related to childhood obesity, unless we make some real changes what we can expect is more overweight kids. And those kids are far more likely to grow into overweight adults. This will bring a future load of medical, emotional, social and financial problems.
This scientific statement helps us understand how parents and caregivers might be able to help fight child obesity. And it also points out what we need to study if we are going to make them really helpful. That’s just the kind of information we need if we are going to save our children’s future.
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Women May Need Fewer Bone Tests

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Older women at low risk of osteoporosis may need to get bone density tests only every 15 years, new research suggests. The study included 5,000 women. They were part of a large, long-term health study. When the study began, they were at least 67 years old. A bone mineral density test at that time showed that none had osteoporosis. Some did have osteopenia. They had below-normal bone density, but not as low as in osteoporosis. During the next 15 years, only 1% of those with normal bone density developed osteoporosis. But the number was 62% for those with advanced osteopenia. Women who had normal bone density or mild osteopenia were found to be low-risk. Researchers concluded that most could wait 15 years for another test. Some might need the tests more often if other factors increased their risk. Women with moderate osteopenia should repeat the test in 5 years, researchers said. Those with advanced osteopenia should get the test every year. The New England Journal of Medicine published the study. The Associated Press wrote about it January 19.
What Is the Doctor’s Reaction?
Most screening tests are not a one-time thing. Even if your test results are perfectly normal, you’re probably going to be told to have the test again in a while.
For example, if you have a mammogram, it’s likely you’ll need another in a year or two. If you have a colonoscopy, they’ll probably tell you to have another in 10 years. The same is true for cholesterol tests, prostate cancer screening and Pap smears. And if the results are abnormal, you’re probably in for even more frequent tests.
What about the bone mineral density (BMD) test? This is a test for osteoporosis. People with this condition have fragile bones that are prone to fracture. These fractures, especially hip fractures, can lead to loss of independence and even death. But osteoporosis often can be prevented. Effective treatments also exist. So the results of a bone mineral density test are important. It’s easy to understand why current guidelines recommend routine testing for women over age 65 and men age 75.
How often should the tests be repeated? According to the National Guideline Clearinghouse, "there is overall agreement that an interval of at least two years is appropriate" for repeat testing. In fact, the ideal number of years between tests is not clear.
The authors of a new study wondered whether doing frequent tests made sense. They asked a simple question: Can bone mineral density tests predict how long it will take for 10% of women to develop osteoporosis? If the answer is "yes," one can propose a rational standard for how often to do repeat testing.
The New England Journal of Medicine published the study. The researchers looked at records for nearly 5,000 women. Some of them had normal bone density when the study began. The rest had osteopenia, a condition in which bone density is low but not low enough to be considered osteoporosis. None of the women had any previous fractures related to osteoporosis. All were at least age 67.
This study found that women should schedule repeat bone mineral density tests based on the results from their last test:

  • Every 15 years if test results are normal or show mild osteopenia. Fewer than 1% of women with normal results and 5% of women with mild osteopenia developed osteoporosis within 15 years.
  • Every 5 years for women with moderate osteopenia
  • Yearly if a test reveals severe osteopenia

Women were divided into mild, moderate and severe osteopenia groups based on their test result (called the T score).
The results of this study have the potential to change how we screen for osteoporosis. After all, there’s little reason to order a test over and over if the result is unlikely to matter. And limiting tests that aren’t needed could provide enormous savings in wasted health care costs.
Still, it’s worth keeping in mind some cautions about this research.

  • Bone mineral density is not a perfect screening test. Some people develop "fragility fractures" even though their test result is normal or shows osteopenia.
  • Many doctors recommend treatment for a woman whose bone mineral density is falling fast, even if she doesn’t yet have osteoporosis. An example would be a woman who had mild osteopenia a few years ago and now has severe osteopenia. Waiting for osteoporosis to develop may be waiting too long.
  • For women with high risk of osteoporosis, bone density may change quickly. This study tried to account for factors that could affect bone mineral density. But other factors could have been missed. This could make the results less accurate.
  • This study did not include men. The ideal interval to repeat testing for men remains uncertain.

Still, if you’ve ever wondered whether you really needed that repeat bone test, this new study suggests you’re on to something.
What Changes Can I Make Now?
Talk to your doctor about any factors that may affect your personal risk of osteoporosis. Ask about what screening tests, if any, you should have. Review this new study with your doctor if you are having repeated bone mineral density tests.
Know the factors that increase the risk of osteoporosis. While family history is an important one, it cannot be changed. Other factors can be changed. They include:

  • Lack of exercise
  • Lack of calcium or vitamin D in the diet
  • Smoking
  • Drinking excess amounts of alcohol
  • Certain medicines, especially corticosteroids (but don’t change your medicines without the approval of your doctors)
  • An overactive thyroid (detectable by a simple blood test)

If your doctor recommends a medicine to prevent or treat osteoporosis, take it as prescribed. If you have side effects or other concerns about taking it, be sure to review this with your doctor.
What Can I Expect Looking to the Future?
Current guidelines recommend several screening tests for common, treatable conditions. However, it’s important to review them to be sure they make sense. This study is a good example. Bone mineral density tests are important. But, for many women, repeating them often may not be.
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