Diabetes and Poor Diet; Non-Surgical Sciatica Treatment
TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include diabetes and poor diet, treating sciatica, beverages and diabetes, and cord blood analysis and obesity.
0:43 Beverage consumption, mortality and type 2 diabetes
1:41 Sugar sweetened beverage consumption
2:40 Contain anti-inflammatories
3:01 Type 2 diabetes and suboptimal diet
4:02 Drilled down to certain factors
5:02 More education related to greater risk
6:02 Prevent diabetes with diet
6:52 Surgical versus nonsurgical treatment of sciatica
7:53 Leg pain result no significant difference
8:51 Waiting for a year may not be helpful
9:31 Methylation of DNA in umbilical cord blood
10:32 Can predict obesity with patterns
11:30 Analysis when child is born?
Elizabeth: How much of type 2 diabetes can be parked at the door of a bad diet?
Rick: Can beverage consumption affect mortality in people with diabetes?
Elizabeth: If we take a look at methylation of DNA from cord blood, can we predict which infants will become obese?
Rick: And in individuals with sciatica, is surgery or non-surgical treatment best?
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I’m going to toss the ball to you. Which of yours would you like to start with?
Rick: Let’s start with this idea that beverage consumption could potentially affect mortality in people with type 2 diabetes. In 2021, about 537 million adults worldwide had diabetes and that’s projected to go up to almost 800 million by 2045. Some of the conditions associated with that are cardiometabolic or cardiovascular issues and premature death. We know that sugar-sweetened beverages in the normal population is associated with some adverse health outcomes. The question that these investigators tried to answer was, does beverage consumption actually affect mortality in people with type 2 diabetes?
They used 2 large databases, over 15,000 men and women either enrolled in the Nurses’ or Physicians’ Health Study, starting back in the 1980s and followed for over 20 years — individuals that had type 2 diabetes — and they gave regular accounts of what their diet and what their beverage consumption was.
During an average of about 18½ years of follow-up, about half the individuals died. Those that drink sugar-sweetened beverages, it increased their mortality by about 20%. Individuals that had artificial-sweetened beverages or fruit juice, mortality was not increased at all.
Parenthetically, if you drank coffee, tea, plain water or low-fat milk, you had a lower mortality. If you happen to start with sugar-sweetened beverages and switch to those, it lowered your risk of dying by about 20%. Or if you started drinking a small amount of coffee and increased that, it lowers your mortality by about 15% or 20% as well.
Elizabeth: Let’s just mention that that’s in The BMJ. While we’re talking about coffee, of course, we have pretty substantial information already about the purported health benefits of coffee and this seems to add more to that.
Rick: Absolutely. In the general population, it’s been shown to be helpful. This is the first study that’s looked at a large number of individuals with diabetes. This would indicate that, in fact, coffee, tea, even low-fat milk can be helpful. There is some biologic plausibility these drinks contains things that are anti-inflammatory. We know that inflammation plays an important role.
Elizabeth: One of the things that I find rather astonishing about this is the magnitude of the risk in sugar-sweetened beverages.
Rick: Your mortality was increased about 20% with sugar-sweetened beverages. Conversely, drinking coffee, tea, or water lowered your risk by about 12% to 20%, as well.
Elizabeth: Since we’re talking about diabetes, let’s turn to Nature Medicine. This is a modeling study that’s looking at incident type 2 diabetes that’s attributed to a suboptimal diet in 184 countries. This global burden of what they call diet-attributable type 2 diabetes is not really understood very well, so they created this risk assessment model. As I said, they looked at 184 countries in 1990 and then again in 2018.
In 2018, suboptimal intake of 11 dietary factors that they identified were associated with 14.1 million incident type 2 diabetes cases — about 70% of new cases globally. The largest burden of these was attributable to insufficient whole grain intake, excess refined rice and wheat intake, and excess processed meat intake. They were able to drill down among these factors and say, “This is what we can directly or mostly attribute this to.”
They did look at different regions of the world and they also looked at men versus women. They found that this diet-attributable type 2 diabetes, that proportion of the diet was generally more impactful in men than it was in women, inversely correlated with age. In many parts of the world, this diet issue and type 2 diabetes was associated with more educated individuals, which I found a really interesting factor. They’re trying to give us places that we can intervene to try to help with this and actually make those very tailored for specific areas in the world.
Rick: Okay. In the U.S., it sounds like some of these things had a higher incidence in a more educated population or in developed countries. We know that developed countries also have more processed food, for example.
Elizabeth: I’m still astonished by this notion that if you’re more educated, that you end up at greater risk of consuming a suboptimal diet.
Rick: I think there are a lot of, I want to say, convenience foods that we have that aren’t available in other countries — fast food, processed food. Individuals that work very hard and don’t take time to cook properly or eat properly, in my opinion, that accounts for a large portion of it.
Elizabeth: See, I disagree with you. I disagree with you because when I reflect on my own diet, and certainly we can rest on this notion that we between us have a rather high degree of education, I do not consume all of those foods. I assiduously avoid those foods. I’m still stuck in this place of, “Really?” If you’re more educated and you’re paying attention, you’ve got to know that ultra-processed foods are not a good choice.
Rick: Yeah. I think it has to do less with what you know and more with how you practice. The take-home for our listeners is we talked about the fact that if you have diabetes, what you drink can influence your overall health. If you want to prevent diabetes, you can actually play an important role not only with exercise and a good diet, but specific foods to both ingest and to avoid as well.
Elizabeth: There is specific identification. They have six harmful dietary factors that are jointly responsible for the majority of this risk. Those include refined rice and wheat, processed meats, unprocessed red meats, sugar-sweetened beverages, potatoes, and fruit juice. I think that when we reflect on the global burden of the production of these foods, it’s also a good choice environmentally to back away from these things as the majority of someone’s consumption.
Rick: I totally agree. The short-term and long-term health consequences, not just individually but also globally as well, what we’re doing with our climate.
Elizabeth, I’m going to switch gears. Let’s look at The BMJ. This is an analysis that looked at surgical versus non-surgical treatment for sciatica. Sciatica, by the way, is a fairly common condition. The lifetime prevalence is up to 43%. In approximately about 90% of the cases, it is due to a herniated disk that compresses the nerve root. That nerve root compression or inflammation is what causes the pain. Although the prognosis is usually pretty favorable, about 20% to 30% of patients still experience pain after a year.
The treatments for that are either surgical or non-surgical. The non-surgical thing could be things like a steroid injection, physical therapy, non-steroidal anti-inflammatory medications. Obviously, the surgery usually involves a discectomy. Is one any better than the other?
The authors looked at all the randomized controlled trials that compared any surgical treatment with any non-surgical treatment. Some of these people had short-term sciatica. Some had long-term sciatica. Twenty-four different trials that had enrolled over 1,711 participants.
When they looked at just leg pain, there was a moderate effect at the immediate term. But over this long term, there was really no significant difference between sciatica treated surgically and that treated non-surgically. Unfortunately, the evidence was considered to be very low to low certainty. When they looked at disability, there was a short-term effect, but long term, that is, even up to the course of a year, there is really no significant difference.
Current recommendations are try to treat it non-surgically first. If it’s not successful, then you can resort to surgical treatment. Truth of the matter is, if you just wait around for a year, even treating it without surgery you’ll get a very similar effect. But those that really want an immediate benefit, they said surgery is your option.
Elizabeth: I’m wondering how long it’s going to take for analyses like this to inform insurance claims relative to surgery for this particular condition and for them to start denying surgery when they know that the outcomes are going to be the same in a year if we just wait.
Rick: For many individuals, waiting for a year isn’t a very suitable option. If you’re disabled and you can’t work, whether the insurance company is saying, “Well, you know what? Just wait around for a year” — that’s just not very attractive to many individuals.
Elizabeth: It may not be, but I’m suspecting that it’s probably going to be something that’s on the horizon. I would also just remind you, gosh, how many surgical interventions have we talked about where, when we compare longer-term outcomes versus the immediate impact of surgery, we find that in a year from that time or 5 years from that time we’re in the same place? It’s a lot of them.
Rick: It is. The other thing that this study didn’t address was really the cost-benefit analysis.
Elizabeth: Finally, let’s turn to The Lancet. This is very unique, I thought, and I’m not sure that you’ve heard much about this before either. This is looking at DNA methylation. We’ve heard lots and lots about that in the last decade or so I would say. But in this case, they’re looking at umbilical cord blood and they’re associating it with body mass index trajectories from birth to adolescence.
They take a look at this methylation at birth and then they follow these people until they are 18 years of age. Then they looked at let’s look at this pattern of methylation. Can we predict based on this who is going to end up developing obesity over the long haul?
They identified 4 distinct patterns of this body mass index trajectory: a normal weight, early overweight or obesity, late overweight or obesity, and then normal to very late overweight or obesity. Sure enough, when they take a look at these methylation patterns, they were able to determine ones that were associated with the ultimate development of obesity at these different time points. We could be looking at cord blood and saying, “You know what? You’re at risk for developing obesity. Why don’t we intervene early and see if we can prevent it?”
Rick: With DNA methylation, it doesn’t alter the DNA sequence. It just alters which genes are actually expressed. There are things that can affect DNA methylation: environmental things, carcinogens or alcohol, tobacco, exercise, and diet. This study shows that these cord DNA methylations — these are things that affect the mother and fetal life. There must be some exposures that causes these DNA methylation changes. This gene expression starts very young and predisposes the child to obesity. I think this is fascinating.
Elizabeth: Absolutely. I mean, I can foresee a day where this kind of analysis is going to be done when a child is born. They do attribute these changes in these methylation patterns to prenatal nutritional differences, maternal nutritional differences, and metabolic programming. We know already that some of that is probably related to stress or maternal cigarette smoking, or inactivity, or whatever. Trying to identify all of those factors so that intervention is possible, I think, is also practical.
Rick: It would be interesting to know at some point that a precise assessment of what they’re potentially likely to face during their teenage years and to target prevention to prevent things like diabetes or obesity in this particular case. I look forward to seeing how we can use this information in the future.
Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.
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