Talk:Diabetes/Archive 9

EDIT: Glandular vs. Organ Manipulation Comparisons

I have seen Kevin Trudeau's infomercials as far back as the early 1990's, dealing with improvement of memory. "Kevin, you discuss how with weight loss that the resetting of the Hypothalimus Gland can permanently keep weight loss in check. Can the same thing be said about Diabetes, meaning can the Pancreas insulin secretion ratio be reset properly to eliminate Diabetic onset, or that can't happen because the Pancreas does not have glandular characteristics for that to happen? I know the government makes it so you can't mention it on TV, or in an e-mail, but if it's in one of your books, could you give a reference page at least? My e-mail address is tonydpanico@yahoo.com . Take care of yourself, and keep up the good work!!!

In Type 1, by and large there is no insulin production, so no resetting of a ratio is possible. In Type 2, the body resets the ratio, in some sense as insulin production is largely a consequence of blood glucose level. However the insulin resistance (in about 2/3 of the peripheral tissues) that is characteristic of Type 2 is not much affected by any resetting of a ratio in the beta cells. As for "glandular characteristics" of the beta cells in the pancreas, well, this is opaque. I suspect this is an oddity of terminology peculiar to someone in the commercial supplement business (perhaps like the Kevin Trudeau yo mention?) and whatever it's meaning, it is not used in ordinary medicine / endocrinology. As for government prohibition of mentioning something on TV or in email, this is also opaque. And likely for similar reasons.

I would note though, that diabetes is currently not curable, though there is a promising and rather mysterious excision of a portion of the upper small bowel which seems to work for Type 2/ There is much research going on, and we are getting closer to understanding the underlying operation of normal tissue (and so to some extent of misbehaving diabetic tissues), so there is more hope than formerly. It is not unreasonable to expect something dramatic in this direction in the next decade or so. For the moment, standard treatements, properly adjusted to particular patent responses are by far the best option. Without doubt. Diabetes (any flavor) is dangerous and damaging and should not be treated by informercial based nostrums or any equivalent. There is no known treatment in any medical tradition which is better than the standard medical ones. I would caution against snake oil of any sort. No sensible person would treat a broken leg with patent medicine nostrums, and for exactly analogous reasons, one shouldn't treat diabetes similarly. ww (talk) 08:27, 26 November 2007 (UTC)

Transplant is a cure

The article says there is no "practical" cure, but then a few sentences later admits that some people can be considered "cured" due to a transplant. It should admit from the start that there is a cure: transplant, which has been used for years and works. Who is to say it isn't "practical"? Also, it says the only ones who can be considered "cured" are those with kidney-pancreas transplants. What is the reason why those with kidney-pancreas transplants are considered "cured", but not those (if any) with pancreas-only or islet-only transplants? At least this page should be consistent with itself. It says here Capital Health Edmonton Area Pancreas Transplantation that a transplanted pancreas is not considered a cure because it only lasts on average 8-10 years. Is this different if it's a kidney-pancreas transplant? --Coppertwig 16:36, 14 September 2007 (UTC)

I can only speculate as to the reasoning, but I presume the problem lies with the difficulty of getting transplants and the complications that can ensue afterwards. I don't think anyone would claim that we have a cure for heart disease because we can perform heart transplants. Additionally, I believe there is little understanding as to what may trigger another beta cell attack - for type 1 - and the risk of subsequent beta cell failure as a result of insulin-resistance-induced stress - for type 2 - is not removed.

As concerns kidney-pancreas versus pancreas only transplants, I don't think there is a difference in "curing" diabetes. The two usually just go together because transplants are reserved for patients with serious diabetic complications such as nephropathy which would necessitate a kidney transplant. If you are going to do one, may as well do two. AnthroGael 22:29, 9 November 2007 (UTC)

Safety of drugs

PMID 17638715 - safety of drugs is similar along the board. JFW | T@lk 21:04, 18 September 2007 (UTC)

MCOTW

Today, this article has become the medical collaboration of the week (WP:MCOTW). It will remain MCOTW for 2 weeks, until the beginning of October. It is presently in a reasonable state, so we should aim to get this article up to good article or featured status if at all possible.

Presently, we mainly need to trim things that are not needed, and maximise the quality of the content that we have. The "history" section is fairly good, although landmark trials on treatment may still need to be listed (I would list the DCCT, for instance). Trials on type 1 might not be generalisable to type 2, and the article needs to mention this. We need much more on social/political impact and quality of life. JFW | T@lk 11:16, 21 September 2007 (UTC)

Review

I'm working my way through the text. Please check any copyedits I do to ensure meaning isn't changed or important emphasis lost, etc. Here are some points I've noted as I'm reading:

• The article is seriously undercited. Often whole sections lack apparent sources.
• Some sources group types 1 and 2 as "idiopathic diabetes" and the remaining causes are "secondary diabetes". I'm familiar with the term idiopathic from epilepsy but don't know how useful it is here. I think it is useful to distinguish genetic mutations that predispose towards diabetes from genetic mutations that have their own syndromes that may have diabetes as one consequence.
• The type 1 paragraph of Genetics is rather hand-wavy and vague. For example, there is a difference between inheriting a disease and inheriting a predisposition towards a disease.
• The "Candidate genes" sentence of the type 2 paragraph of Genetics is incomprehensible. I know this is complex stuff, but someone needs to try to explain it in laymans terms. I don't want the complex terms removed (dumbing down) but rather that it is explained to me (briefly) what they are and why it is important wrt diabetes.
• Could the "Complications" section become "Prognosis" in keeping with MEDMOS.
• The top-level sections "Aging" and "Terminology" should IMO be eliminated. Some of the "Ageing" section could go under "Prognosis" and some under "Epidemiology". Some of "Terminology" could go to "History" and some to "Classification".
• As JFW says, the social impact/QoL stuff is lacking. Perhaps some of the charity websites can give pointers as to what sort of issues we should cover.

Colin°^Talk 22:36, 25 September 2007 (UTC)

Could surgery cure T2 diabetes?

I've added to the "cure" section with the details of a recent report in New Scientist magazine (c/w relevant citations) concerning how it's been found that removing the duodenum can result in a "cure" of T2 diabetes. ---- WebHamster 15:03, 26 September 2007 (UTC)

Unfortunately it is too early to judge the effect of GI surgery on non obese patients. Studies so far were carried out on only small number of patients and long term outcome is not clear. I think we would rather omit this at present or very brief at best. also note WP:PSTS, WP:MEDMOS--Countincr ^{( t@lk )} 16:54, 26 September 2007 (UTC)

It's accurate, it's factual, it's cited from 2 reliable sources. All valid reasons for inclusion, whereas WP:IDONTLIKEIT most certainly isn't a valid reason for exclusion. May I ask who the "we" is that you refer to? It certainly is not Original Reasearch, you won't see my name on the sources anywhere. Likewise it meets the requirements of MOS, or at least my original text did anyway. ---- WebHamster 18:05, 26 September 2007 (UTC)

By "we", he is referring to the perceived majority opinion of the Wikipedia community. This is not a "cure", but a prospective "potential cure", of which there are dozens being researched on at any given time, most of which will unfortunately go nowhere. The article simply doesn't have enough room for more than a brief mention of each, if that. Further, the New Scientist article represents the conclusion of a single group of people, not the opinion of the medical community at large. No one says you wrote it yourself, but when it's the speculative conclusion of a single source, that is about as close to WP:OR as one can get without picking up a pen. The speculation that other research teams are soon going to report on the subject is exciting, but not appropriate for Wikipedia. Per WP:MEDMOS the "reliable sources" bar for medical topics is much higher simply because medical subjects attract controversy and opponents even on the most basic and commonly held facts. Postscript: It is questionable that this should even be mentioned. New Scientist is not a peer-reviewed scientific journal. It is, according to its own publisher, an "after all, an ideas magazine. That means writing about hypotheses as well as theories"". Reswobslc 19:46, 27 September 2007 (UTC)

Whilst travelling around wiki-stalking and making further factual errors, please note the references given. The New Scientist is a highly respected UK scientific publication. Perhaps you should follow the DOI link to discover that the NS was reporting the findings of a group of medical experts, they weren't reporting their own findings. You are close to WP:ANI. ---- WebHamster 20:38, 27 September 2007 (UTC)

User:WebHamster has been posting references to New Scientist in unrelated articles all over Wikipedia (like here and here in just the last 24 hours). While New Scientist is certainly not the National Enquirer, it's still a reason to consider this a little more carefully. Reswobslc 22:27, 27 September 2007 (UTC)

"All over wikipedia"? You mean two articles? Two articles that are correctly cited and referenced to both the primary and secondary source? You really don't know what the New Scientist is do you? Or the fact that people subscribe to it, read it and recycle the knowledge gained? Although it doesn't suit your purposes, I'm afraid to say that the New Scientist is a reliable source and has been for many years. If I were you I'd be more concerned about the contents of your "contrib" list than about either the New Scientist or the text I contribute to Wikipedia. So are you going to explain clearly what you mean by "it's still a reason to consider this a little more carefully"? Is that an attack on my contributions or an attack on the veracity of New Scientist? ---- WebHamster 23:21, 27 September 2007 (UTC)

The New England Journal of Medicine, in the articles that I cited, refers to gastric bypass as a "cure" for diabetes. They had 2 case-controlled studies with hundreds of patients followed for 30 years. I thought it was provocative to say "cure", but you can't get a more reliable source than that, and according to their data, it did cure diabetes. (This is WP:OR and doesn't count for WP, but a friend of mine got a gastric bypass, and one of his main reasons for risking a 1% mortality at the time was that it would cure his diabetes -- and it did.)

The New Scientist article, which I also read but forgot about until I saw it again here, makes the important point that gastric bypass can cure diabetes even in subjects who aren't obese or even overweight. So it's not the weight loss that cures diabetes, it's something about the duodenum. The New Scientist is a secondary source, but you can always cite the primary source. However, WP (I can't find the link) encourages secondary sources, because people can misinterpret primary sources. Semi-popular news sources (if they do it right) state the results clearly, put it in perspective, and get a comment from scientists who weren't involved in the original research. However, I thought this particular cite was a little too long, which is why I cut it down. If I had more time I would have given a PMID link to the original articles. That should solve the secondary-source problem.

It's not wrong to read the New Scientist and stick in useful and relevant information from it in the appropriate WP articles. Nbauman 23:13, 27 September 2007 (UTC)

The New Scientist is a reliable source that meets Wikipedia's verification policy. I'd place it somewhere higher than many newspapers but lower than a typical peer-reviewed journal. However, its news reporting shares problems with most news sources in that the journalistic style does not lend itself to being a useful text for precisely and accurately sourcing medical facts in an encyclopaedia.

I firmly believe in WP's tagline "the free encyclopedia that anyone can edit." This means that anyone can add information if they have an adequate source and not expect it to be gratuitously removed. However, I also firmly believe in the note at the bottom of my edit window: "If you don't want your writing to be edited mercilessly ... do not submit it." Other editors will quite rightly seek out better sources (see WP:MEDRS for some guidelines) and based on those sources (or indeed the lack of them) may judge that the text needs to be changed or even removed. Justification for such a change/deletion should be supplied and I think Nbauman has done that. Even text sourced to an article in the highest quality journal might be removed if judged inappropriate.

There's also the saying "Extraordinary claims require extraordinary evidence." When speaking of a cure (or a long sought cause) for a disease, we have an additional requirement to use only the best quality sources. All news sources (including the news sections of respected journals) have a tendency to be over-confident in their reporting of such things. Since this is not WikiNews, we do not have to rush to print with the latest findings. If there is doubt, we can afford to wait until a thorough review has been performed and published. Colin°^Talk 11:58, 28 September 2007 (UTC)

2 articles in the NEJM, one of them a prospective controlled study with 4,000 subjects over 11 years average followup, confirmed by a retrospective cohort study with 16,000 subjects over 7 years average (and 550 subjects up to 18 years), plus an editorial, is extraordinary evidence. It's even more extraordinary evidence when supported by the proposed mechanism described in the article in Surgery for Obesity and Related Diseases, as cited in the New Scientist article.

If you can find a wp:rs to add any reasons to be skeptical of these claims, I would be happy to see you add them. There will probably be comments in the letters section of the NEJM. Nbauman 17:12, 28 September 2007 (UTC)

My comments were addressed towards Reswobslc's criticisms of WebHamster rather than your edits. I wanted to say that WebHamster didn't break any policies but we can probably do better than cite New Scientist when reporting on cures. I interpreted your edit summary "NEJM articles are much more important, with hundreds of patients over 30 years." and above discussion to mean you had added a NEJM citation. But I can't find citations for those "2 articles in NEJM" you mention. Are all those NEJM studies/editorials on the obese patients or the non-obese? If all we have wrt non-obese patients is a case-report on 2 patients, then I suspect it is too early to claim that a cure has been found. In fact, contrary to what I wrote above, the New Scientist article is less "over-confident" than the Wikipedia article. All it says is "Could type 2 diabetes be reversed using surgery" whereas we are claiming "surgeons have cured diabetes in non-obese diabetic patients with gastric bypass surgery". Colin°^Talk 18:10, 28 September 2007 (UTC)

Can I just point out that I didn't just quote the NS, but to offset the argument of "keen journalism" I also cited the original paper that they were reporting on. In my original text I used the term "cure" in quotes. I did so deliberately to point out that it was a quote from the report, not my conclusion of the report. This was lost in the rewrite. ---- WebHamster 19:28, 28 September 2007 (UTC)

I would like to add some more to Colin's argument. Improvement achieved in obese patients through bypass surgery does not necessarily imply that same can be achieved in non-obese patients. When weighing a claim from a study, several factors need to be considered other than those already discussed; such as what is the size of the study sample, is it randomised, is it blinded, is it a prospective study. Let me roughly calculate minimum number of subjects required to assess a new treatment for type 2 diabetes using this simple formula. DM2 has more than 100 million sufferers worldwide, as such minimum 384 subjects are required to be 95% confident that error margin would be less than 5% (standard confidence interval). Some large scale trials such as NEJM one did show long term good blood sugar control after bariatric surgery. But like NEJM study, they are done on obese patients. GI bypass surgery is an accepted form of treatment in patients whose BMI is more than 35. I am not aware of any large scale randomised study on non-obese patients. The study which new scientist reported (PMID 17386401) was done on only 2 patients. The Medscape article on this issue is highly recommended.--Countincr ^{( t@lk )} 20:26, 28 September 2007 (UTC)

What should also be noted for readers not familiar with the NS article is that emphasis wasn't totally on the team that are citing the result of 2 patients. What was lost in the rewrite of the paragraph I originally added is that there are additional studies going on in several disparate countries. The rewrite diluted this down to such an extent that it now looks like the report was solely about 1 small team with 5 patients, 2 of whom results are known about. I'm tempted to put the original text back in to enable it to show the larger picture. ---- WebHamster 20:59, 28 September 2007 (UTC)

The NS article says "According to Rubino [a surgeon at the Catholic University of Rome, Italy, who was involved in the study], duodenal exclusions in people with diabetes who are not morbidly obese have also been performed by groups in Mexico, Peru, Dominican Republic and India with similar outcomes, although the results have not been published. Clinical trials are now starting in some of these countries, as well as in China, Japan, the US, Italy and Belgium." In other words, this information is second-hand to NS (i.e., unverified) and unpublished, which makes it poor evidence. It goes on to say "it may be five years before we have a clear idea of exactly who should undergo surgery" and that the American Association of Clinical Endocrinologists is "studying the evidence, but has not yet reached a decision." If the use of surgery as a cure deserves mention, then the most we can say is that trials have begun and early results look promising. Colin°^Talk 21:47, 28 September 2007 (UTC)

Although I don't disagree with any of the above, I believe that leaving it in as a quote, and certainly the bit of the AACE would allow the reader to make their own mind up about the veracity of the claim. Obviously it would need to be put in such a way that demonstrates that it is indeed opinion of the scientists involved. As regards being second hand to NS, pretty much everything in this sort of publication is second hand, it's the nature of the beast. As to the paper being referred to, as I don't have access to the relevant subscriptions I am unable to say what it includes as conclusions to be drawn, assuming there are any in it. In merely mentioning that trials have begun and little else, I believe that to be next to useless as it gives no context. What trials? Why are the trials beginning? What are they going to achieve? Too little information is sometimes worse than bad information. The fact of the matter is that although this is early days there is a ground swell of hope that is proceeding in a particular direction based on factual, albeit minimal, information. The small consensus so far is that the NS article is reliable and there are reliable sources being reported, that alone should mean that it is mentioned. I believe that the current info should be expanded a little more to enable clarity of what is being claimed, as at the moment it appears to be making claims that are unsubstantiated. ---- WebHamster 22:56, 28 September 2007 (UTC)

The reason I deleted all that stuff from WebHamster's paragraph about ongoing research is that nothing in the New Scientist article indicated that they had any results (published, reported at meetings, or unpublished). You could say that duodenal exclusions have been performed on people who are not morbidly obese in unpublished studies, but I don't see how the list of specific countries contributes any further understanding. But the beginning of a clinical trial is important, because it shows that somebody is taking the idea seriously to proceed to the next step; I'd like to know who and where.

The New Scientist is not written for ignorant diabetes patients who are desperately searching for a cure; it's written for scientists and doctors who want interdisciplinary information that they don't get in their own specialist journals, for science and medical teachers and students, for policy makers (MPs and U.S. congressmen read and often write for the New Scientist), for professionals like lawyers and economists, and for people in the general public who have science literacy.

In this case we have 3 articles in the NEJM (which I now cited) which report that gastric bypass reduces death from diabetes by IIRC 95%, but they can't explain the mechanism. It's not weight loss because diabetes disappears in the first few weeks after surgery, long before weight is lost. Here the New Scientist is reporting new published research which suggests a mechanism -- there is something in the duodenum which affects diabetes. (That makes sense, if you've been following the work in Rockefeller University and elsewhere on the mechanisms of obesity and insulin metabolism.) This has been demonstrated in large numbers of animal studies and now with a few human surgeries. Early human trials always treat small numbers of people. Before you perform surgery on 300 people, you try it out on a half dozen people first. Since many surgeons want to try this in large-scale trials, it's important to report the results of the first few people. That's why the New Scientist story is so important.

I don't understand why we should wait for conclusions to be scientifically resolved before we write about them in Wikipedia. If we did that, we couldn't write about much medicine. Look in the Cochrane Collaboration and see how few treatments are resolved based on Level 1 evidence. Some of the biomedical articles in WP (for example all the cytokines and molecular cascades) would be of interest only to a graduate student or equivalent. Why shouldn't we include the latest evidence and hypotheses on diabetes?

A couple of generations ago, doctors were very patronizing toward patients. They said in effect, "Don't you worry your little head about all those details that are best left to doctors. Just let us figure out what's good for you and you follow our orders." Now we allow and indeed encourage patients to learn the basic biological mechanisms behind their disease, and that includes hypotheses which have strong but not conclusive evidence. Just because the American Association of Clinical Endocrinologists doesn't have a position paper doesn't mean we should keep that information away from WP readers who can't handle ambiguity.

This whole model of waiting for journal articles before you change medical practice is actually a myth. There was an article in the New York Times on 10 September which quoted Leonard Saltz, an investigator at Memorial Sloan Kettering, saying that he knows the literature in his area before it's published.

I think WP readers can handle ambiguity, some of them are highly educated, and the successful results of the first preliminary human surgeries belongs in an article on diabetes. Nbauman 04:13, 29 September 2007 (UTC)

I think we are comparing apples and oranges here. The NEJM studies and the NS article are not contradictory if anything they support each other's conclusions, but they are sufficiently different (i.e. obese vs non-obese) to warrant the inclusion of both. It was not my intention by including the article to make any commentary whatsoever on the NEJM, it was you who started comparing both. I still don't understand why. Additionally you keep saying that the NS article doesn't point to any published papers. Well of course it does, I cited the DOI reference to it. To answer the posed question about showing that different countries are involved. It goes to show that a lot of people are taking interest and acting on these findings. It gives additional support to its veracity. Not necessarily from a WP standpoint, but from a reader standpoint. I don't understand your statements about doctors patronising their patients by not giving them all the details, whilst at the same time you have pared down the NS paragraph so much as to do the very thing you are demonstrating is old school thinking. You removed all the details. As regards handling ambiguity "some" readers are indeed of the type you suggest, but "many" readers aren't. I'd even suggest that the "many" outnumber the "some". In any case, why should they have to handle the ambiguity? This is an encyclopaedia, it's supposed to be a place to come to allay any ambiguity, not to be given it. Now unless there are any objections from any of the regular editors over and above Nbauman's then I intend to replace my original wording. ---- WebHamster 11:15, 29 September 2007 (UTC)

WebHamster, I basically agree with you. Most of my post was responding to Countincr, Reswobslc and Colin. It's often difficult in these WP discussions to keep track of who said what (especially in a 25-line editing window).

I agree with you that the NEJM and NS articles support each other. But they are overlapping. Some of the subjects in the Swedish NEJM study were not obese but overweight (30>BMI>25). I think that the NS article adds important information (a possible mechanism) to the NEJM article even though it only refers to a few human subjects. I agree that the NS article points to published papers -- you cited the DOI reference and I added the journal citation and PMID number. My comments about doctors patronising patients was addressed not to you but (supporting you) to the argument that studies like this shouldn't be included in WP until they had been replicated in large studies. By "ambiguity," I meant the ambiguity that comes in early studies from only having a few subjects. The only way to allay that ambiguity is to repeat the studies with more subjects.

I've written a lot of medical articles, I've summarized a lot of journal articles and oral presentations, and I've even written a few stories for the New Scientist. The edits I made to your summary were the kind of cuts that medical editors always reserve to footnotes or to appendices.

NS has their own reasons for listing all the countries, but if you're trying to summarize the clinical results of these studies, there's no need to list the fact that the research has been done in Italy, Brazil, France, Mexico, Peru, Dominican Republic, India, China, Japan, US, and Belgium. Your important point gets lost in the catalog of countries. How does it help me to understand the fact or mechanism by which gastric bypass cures diabetes (or anything else) to know that some unnamed investigators in Mexico have unpublished results?

I cut out the reference to the American Association of Clinical Endocrinologists because, as news editors always say, you don't quote somebody saying they have no opinion. How does that help the reader to understand the mechanism? (The NS did that probably to show that they weren't just jumping into print with a provocative claim, but had checked it out with reliable sources.) Nbauman 17:49, 29 September 2007 (UTC)

Thanks, that does make the conversation clearer for me. Though I shouldn't waste too much time on explaining it for Reswobslc as he wasn't here to improve the article, only to save us from my apparent New Scientist fixation. ---- WebHamster 19:38, 29 September 2007 (UTC)

(unindent)Well I agree with WebHamster that you've cut out too much for the remainder to make much sense, though the original added text did contain unnecessary detail. Lets look at this section prior to recent changes:

Type 2 diabetes can be cured by gastric bypass surgery in 80-100% of obese patients, and in some non-obese patients, usually within days after surgery. This is not an effect of weight loss, since it occurs long before weight loss. After gastric bypass surgery for obesity, the death rate from all causes is reduced by up to 40%.

This mentions "and in some non-obese patients" and also the point that weight loss is not the reason. The paragraph discusses a potential cure in a passive way, neither explicitly mentioning specific surgeons or articles. The current text adds some more sources to the above, as well as the following short paragraph:

Other surgeons have cured diabetes in non-obese diabetic patients with gastric bypass surgery. The doctors believe that the duodenum is responsible for releasing a form of "molecular signal" that results in a cell's insulin resistance.

Why does this begin with "Other surgeons"? The text hasn't been discussing any surgeons. The remainder of that sentence actually adds no information that isn't contained in the first sentence of the preceding paragraph. The second sentence introduces "the doctors", whoever they might be. Our reader needs to know this is a "hypothesis" and one held currently by a small number of physicians (the NS attributes it solely to Francesco Rubino). Also, the lay reader needs an explanation of why "gastric bypass surgery" might alter how the duodenum releases the molecular signal (in other words, without reading up on it, it isn't clear to the reader that this bypass surgery actually involves removal of the upper small intestine, the duodenum). The reader has no idea if this is an established cure (it certainly isn't) or if it has been widely performed (it hasn't) or widely available (it isn't). Therefore, I propose removing the second paragraph altogether and leaving the following:

Type 2 diabetes can be cured by gastric bypass surgery in 80-100% of obese patients, and in some non-obese patients, usually within days after surgery. This is not an effect of weight loss, since it occurs long before weight loss. One hypothesis is that the duodenum (the upper part of the small intestine) releases an unknown molecular signal that may lead to insulin resistance; this is removed during the surgery. After gastric bypass surgery for obesity, the death rate from all causes is reduced by up to 40%.

This says all one needs to know at present. Colin°^Talk 18:50, 29 September 2007 (UTC)

Add in the citations to support the talked about assumptions and I'm all for that version. It's succinct and it does get over the important points. I agree that the NS report/published paper doesn't need to be mentioned in the text but I would prefer that it's there as a footnote purely for verification purposes. ---- WebHamster 19:38, 29 September 2007 (UTC)

Sure, I missed off the refs because they don't work well on talk pages. Colin°^Talk 22:19, 29 September 2007 (UTC)

Actually that's a little too succinct for me.

The reported cure of diabetes by gastric bypass surgery in obese patients is 80-100%, and the death rate from all causes is reduced by up to 40%, in well-designed studies of thousands of patients, published in the NEJM. There's very strong evidence for that.

The reported cure of non-obese patients was published in Surg Obes Relat Dis., a relatively obscure journal (not in the Brandon-Hill list), on 2 of 7 patients (it has no abstract in PubMed), or not published at all. There's weak preliminary evidence, although it's worth pursuing.

We should make sure that the claims made in the NEJM are referenced by the citation to NEJM, and the claims made in the NS are referenced by the citation to NS. The hypothesis that a signal from the duodenum is responsible should be referenced to Francesco Rubino in the NS, not the NEJM.

And he should have finally presented his results at that 8 September International Federation for the Surgery of Obesity meeting by now. What did he say? Nbauman 23:53, 29 September 2007 (UTC)

Some recent edits introduced some unnecessary doubt ("apparently cured") and possibly some original research wrt the hormone. I've revisited the various papers, and found another. The text has now been revised to stick closely to the sources and not introduce any personal speculation. The 40%-all-deaths factoid is really an aside in an article on diabetes. I've left it in but trimmed the sources from three to one, which is the one that supports the figures used. Finally, I've removed the Ray Kurzweil SPAM. Colin°^Talk 12:54, 1 October 2007 (UTC)

Why did you remove the Sjöström paper? That has an even better experimental design than Adams. Two studies that confirm each other are stronger evidence than one. Nbauman 23:30, 1 October 2007 (UTC)

Several reasons:

• Both studies, despite difference design, are large and convincing enough on their own.
• The text "gastric bypass surgery...has the benefit of reducing the death rate from all causes by up to 40%" is precisely supported by Adams. That study looked specifically at gastric bypass surgery and states "adjusted long-term mortality from any cause in the surgery group decreased by 40%, as compared with that in the control group" with a very high level of confidence. It was published in the NEJM, which, as you say, is a top journal.
• The Sjöström study did have a better experimental design but was looking at all forms of bariatric surgery (gastric bypass, vertical-banded gastroplasty, and banding) and was specifically interested in weight loss leading to decreased overall mortality. Caveat: I can only read the abstract so there may be specific figures for gastric bypass contained within the paper.
• This article is on diabetes, not obesity and this section is discussing gastric bypass surgery specifically since it appears that other forms of bariatric surgery do not have the same effect on type 2 diabetes. Therefore the Adams paper is a better choice and the Sjöström study, good though it may be, is a distraction. The NEJM editorial (such that I can read) appears to focus on intentional weight loss and mortality.

If you are particularly interested in the results from these papers, then I suspect there are other articles on WP that could use them. I think, as far as type 2 diabetes is concerned, we have said enough. Colin°^Talk 08:10, 2 October 2007 (UTC)

Complications section

This is more of a question that needs answering first and depending on the answer whether there's a need for some expansion in this section. The section lists the sequence involved in hypos. What makes me ask is that after reporting my own rather bad keto-acidosis event I asked if there was long term problems associated with it, the reply was no but "repeated hypos do far more damage". After my DNS told me this I didn't have time to ask her to expand on it. So my question is, is there indeed complications arising from frequent hypos, and if there is should that be included as an addition tot he hypo paragraph. I should point out that I'm not actually asking for medical advice, if I was I'd be down the diabetic centre instead :). I just thought that if it exists it may be a good idea to include it as most people know about diabetic coma but not so many about frequent attacks, me included. ---- WebHamster 17:44, 1 October 2007 (UTC)

There is some recent evidence that recurrent hypos don't cause increased mortality. In contrast, I can think of several ways in which DKA can lead to major complications (cerebral oedema in children, aspiration pneumonia, acute renal failure). JFW | T@lk 16:27, 7 October 2007 (UTC)

Chropmium, vanadium...

Gekritzl (talk · contribs) has added a "natural treatments" paragraph. I tried to tag it with {{POV-section}}, but the same user removed it. I will outline my problems here:

• All treatment is now in diabetes management. I think that whatever is left from this section should go there rather than remain part of the main article.
• GI and high-fibre diets should be moved to a section on diet, rather than be labeled "natural" (as if other diets are not natural)
• Chromium is of proven uselessness, and few diabetologists will support its use. I have provided a reference of a recent study that again deconstructs its role in diabetes, but I feel we should abandon this altogether. It was never hot to begin with.
• Vanadium has been shown to have some benefit in three studies, but I have never heard of its use and suspect that it is not part of the standard management of diabetes.

I would like to have some opinions, but I feel the section in its present form should be removed. JFW | T@lk 22:53, 20 October 2007 (UTC)

Concur. ww 04:00, 23 October 2007 (UTC)

Vanadium - at least 5 studies (I have added the citations). (User)(Talk)GeĸrίtzĿ._..•˚^˚ 23:05, 20 October 2007 (UTC)

I have no problem moving the section to the diabetes management article. (User)(Talk) GeĸrίtzĿ._..•˚^˚ 23:14, 20 October 2007 (UTC)

You need to split the "prevention" and the "treatment" part of your additions and move them to the relevant sections. We can't have a separate section just because you wrote it :-). JFW | T@lk 08:05, 21 October 2007 (UTC)

Screening section

This section needs an edit as it's fast becoming US-centric, e.g. African-American when Black people is more universal, e.g. we in the UK don't refer to black people as African-American. US political correctness is okay in the US, but not on Wikipedia. Another for example, in the US "Asian" is meant to represent Chinese, Japanese etc, whereas in the UK and Europe it represents Indian, Pakistani etc. There needs to be a more universal tone throughout the whole article, but especially that section. I would have done it unilaterally but in the interests of peace and harmony I'm pointing it out here first. ---- WebHamster 00:38, 5 October 2007 (UTC)

That language, including the use of "Asian", was from an article by a Dutch doctor in a British journal. Nbauman 23:12, 6 October 2007 (UTC)

Regardless, the terms mean different things to different people thereby confusing things in an article that's meant to clarify things for the reader. I left it as Southern Asian as that is specific, I just amended African-American to Afro-Caribbean and added clarity to Mestizo (like who the hell ever uses that term <g>) by using the Hispanic description. The article is already weighted towards the US viewpoint as it is, e.g. the mg/dl measurement coming first with the mmol/l measurement coming later in parentheses, when in fact mmol/l is the world standard and mg/dl only being used in the US. Just look on it as a small step to universalising the article. ---- WebHamster 23:52, 6 October 2007 (UTC)

No, that's wrong. You're misquoting the original source. "Mestizo" is not the same as "Hispanic." "African-American" is not the same as "Afro-Caribbean." These are specific population groups that are discussed in the medical literature and studied for diabetes and other purposes. Diabetes among Mestizos is different from diabetes among Hispanics. There is a codeine sensitivity that is common among Afro-Caribbeans that is not common among African-Americans. It's like changing "Irish" to "English."

I read U.S., U.K. and Canadian medical journals all the time, and I write for them. I interview U.K., Canadian and Australian doctors. I have to know exactly what these words mean. I've interviewed and written about doctors who did epidemiological studies of African-Americans. They're a completely different population from Afro-Caribbeans. You're not internationalizing it. You're just making it wrong. Nbauman 17:01, 7 October 2007 (UTC)

You're forgetting that you aren't writing for a medical journal, you're writing for the world in general. The medically qualified are more likely to write this article than read it. Joe Public the diabetic are the ones who are going to be reading it. You are splitting very fine genetic hairs. There is no such thing as an African-American outside a political correctness zone and there is certainly no physiological difference between a black man in the UK and a black man in the US, yet one is Afro-Caribbean and one is African-American? I'm sorry, but that's rubbish. They are just labels. You'll be telling us next that there's a difference between African-American and Negroid next. ---- WebHamster 17:18, 7 October 2007 (UTC)

The text should match the sources, word-for-word wrt population groups. If a term is ambiguous or used differently by different English readers, then it should be clarified either explicitly or via a suitable wikilink, taking great care not to change the meaning in the process. I agree that 'Mestizo' is not a commonly-heard term in the UK so many readers on this side of the pond wouldn't know what it was. By following the wikilink, you learn. The solution to quoting just US-centred parochial population group studies is to find other sources that cover Europe, Africa, etc. If Nbauman has access to the two sources we've used (+ 1 David Ruben quoted in the edit summary), could you ensure the ethnic groups match the sources? Colin°^Talk 18:34, 7 October 2007 (UTC)

It all depends on whether the sources turn the article in to "Diabetes in the US" which this article already looks like. It's already far too US-centric as it is. Diabetes is a world problem and as such the article should reflect that. Personally I'd bin the existing source and use a more universal one so as to avoid the issue totally. Not being an academic I don't have access to the relevant papers/publications, so I'm afraid it will need to be someone else who does it given that most of the info is behind educational logins. ---- WebHamster 18:55, 7 October 2007 (UTC)

WebHamster, the NEJM and BMJ said that celiac (or coeliac) disease is common among Celtic populations. Do you think it would make any difference if I internationalized it and said that celiac disease is common among Irish populations? Nbauman 17:56, 13 October 2007 (UTC)

And leave out the Welsh? ---- WebHamster 20:07, 13 October 2007 (UTC)

The Welsh, and the Celts, are as unfamiliar in the U.S. as the Mestizo are to you. If you asked Americans to identify the Celts the most common answer you would get would be a basketball team. Do you think it would make any difference if I changed the Celts, the Irish and the Welsh to "English" because most Americans couldn't tell the difference between them? Nbauman 18:49, 14 October 2007 (UTC)

I recommend you go to Boston and ask, though it is nice of you to volunteer to speak on behalf of most Americans. You are also forgetting that I didn't replace Mestizo, I expanded it so that people outside "Fortress America" could understand it without having to leave the page. Your suggestion above is to replace, not expand. Afro-Caribbean is understood worldwide. So it's up to you, what would you say is best, Clarity and '95%' accuracy, or 100% accuracy and lack of clarity? I vote the former, but that's just me. Oh yes, don't forget that the Scots are Celts too, so English would be totally wrong. You could always try British, but I think you underestimate your fellow countrymen... unless of course you're talking about Caitlin Upton. ---- WebHamster 22:08, 14 October 2007 (UTC)

I keep telling you that "African-American" and "Afro-Caribbean" are not the same population, for purposes of epidemiology, genetics, environment, and access to medical treatment. As I already said, there is a well-known dangerous genetic hypersensitivity of Afro-Caribbeans to codeine, which is not present in African-Americans. So just because someone finds a greater incidence of diabetes in African-Americans, that doesn't mean there is a greater incidence of diabetes in Afro-Caribbeans. It's all very well to internationalize (which is why I read the BMJ every week), but you can't make things up. Nbauman 23:21, 14 October 2007 (UTC)

We're not talking about codeine hypersensitivity though are we? we're talking about diabetes, and there is a high incidence of diabetes in the worldwide Afro-Caribbean population (which includes African-Americans). As I keep saying this article is about Diabetes, it isn't about Diabetes in the US (or anywhere else specific). The article is already US-centric enough without adding more weighting. ---- WebHamster 23:46, 14 October 2007 (UTC)

Prove it.

Cite a reliable source that says that there is a high incidence of diabetes in the worldwide Afro-Caribbean population.

Cite a reliable source that says that the Afro-Caribbean population includes African-Americans. Nbauman 02:02, 15 October 2007 (UTC)

Hmmm, let me see now, bearing in mind I don't have university or professional access to many medical reports, and just have everyday net access...

• http://www.kcl.ac.uk/depsta/ccm/CCM_diabetes.html
• http://news.bbc.co.uk/1/hi/health/1005664.stm
• http://au.health.yahoo.com/050923/23/9v13.html
• http://books.google.com/books?id=PfPbZ3NKTsIC&pg=PA376&lpg=PA376&dq=diabetes+%22afro+caribbean%22+worldwide&source=web&ots=q5o5-X7FXz&sig=3xrKf-YIqn5pbGBYxHjyzp-_qN4
• https://www.ivillage.co.uk/health/ghealth/discon/articles/0,,181033_644033,00.html

And how about the first paragraph in African-American. ---- WebHamster 04:04, 15 October 2007 (UTC)

Exubera inhaled insulin withdrawn

Business news reports recount the accounting charge (a couple of $billion) resulting from a decision to abandon Exubera. These accounts don't suggest an inherent problem with the product (reactions, deaths, etc). I expect that when present stocks are exhausted there will be no further advertising. Perhaps a few months? ww 17:16, 29 October 2007 (UTC)

2nd Paragraph

In an effort to contribute to the distinction between types 1 and 2, I think the following line should be changed: "Ultimately, all forms are due to the beta cells of the pancreas being unable to produce sufficient insulin to prevent hyperglycemia." It is ostensibly referenced from a NEJM article, but without a subscription, I can't verify this online. I suspect that the NEJM article said this in a different way. While it is true that the inability to produce sufficient insulin is the cause in both cases, for type 2 the cause is primarily a result of needing a very large amount of insulin because of cells' insulin resistance. This is an important distinction that generally makes treatments and potential cures for one or the other completely different. AnthroGael 22:52, 9 November 2007 (UTC)

Agreed. Be bold and do it. ww 22:21, 10 November 2007 (UTC)

Typo?

Other types

There are several rare causes of diabetes mellitus that do not fit into type 1, type 2, or gestational diabetes; attempts to classify them remain controversial. Genetic mutations (autosomal or mitochondrial) can lead to defects in beta cell function. Abnormal insulin action may also been genetically determined in some cases.

Should read:

Other types

There are several rare causes of diabetes mellitus that do not fit into type 1, type 2, or gestational diabetes; attempts to classify them remain controversial. Genetic mutations (autosomal or mitochondrial) can lead to defects in beta cell function. Abnormal insulin action may also be genetically determined in some cases.

(changed the word "been" to "be" in the last sentence)

11 November 2007

Measures of overweight

PMID 17494056 seems to indicate that BMI, waist circumference and waist-hip ratio are roughly equally predictive of DMII. JFW | T@lk 12:01, 25 November 2007 (UTC)

link fa|sr

This article is now a featured article in Serbian Wikipedia. However I could not add the {{Link FA|sr}} tag because the parser does not like some external link which I was not happy to remove just for this reason. It'd be nice if someone can take care of this, thanks. --Dzordzm (talk) 02:09, 6 December 2007 (UTC)

Characteristic symptoms (1st para)

Are the characteristic symptoms listed in the first paragraph true for both type 1 and type 2 diabetes. From what i understand, they mainly occur in type 1 and are rare in type 2. So i don't think its right to call them the the characteristic symptoms of diabetes.

Even if they are characteristic symptoms it is not important enought to be in the opening paragraph. However, it would be okay in the opening paragraph on an article about type 1 diabetes.

Ziphon (talk) 10:50, 7 December 2007 (UTC)

The symptoms, if they occur together, are highly indicative of any form of diabetes. JFW | T@lk 23:16, 12 December 2007 (UTC)

Smoking

Smoking, apart from causing complications in diabetics, also increases the risk of type II: http://jama.ama-assn.org/cgi/content/abstract/298/22/2654 JFW | T@lk 23:16, 12 December 2007 (UTC)