A new study from the National Institutes of Health (NIH) and Centers for Disease Control highlights how common type II diabetes is among American adults. The study is summarized in this NIH news release. 6.5% of American adults have diabetes. Even more alarming is that a third of them don’t know they have it.

Type II diabetes has serious potential consequences, and its high prevalence makes it a common cause of disability. Type II diabetes is the most common cause of blindness, kidney failure, and limb amputation, and is a major risk factor for strokes and heart attacks. The many Americans with undiagnosed diabetes are at high risk for these complications, all of which are potentially preventable.

The news release listed the following risk factors that increase the probability of diabetes.

You are at greater risk of developing pre-diabetes and type 2 diabetes if you:

• are age 45 or older
• have a family history of diabetes
• are overweight
• have an inactive lifestyle (exercise less than three times a week)
• are members of a high-risk ethnic population (e.g., African American, Hispanic/Latino American, American Indian and Alaska Native, Asian American, Pacific Islander)
• have high blood pressure: 140/90 mm/Hg or higher
• have an HDL cholesterol less than 35 mg/dL or a triglyceride level 250 mg/dL or higher
• have had diabetes that developed during pregnancy (gestational diabetes) or have given birth to a baby weighing more than 9 pounds
• have polycystic ovary syndrome, a metabolic disorder that affects the female reproductive system
• have acanthosis nigricans (dark, thickened skin around neck or armpits)
• have a history of disease of the blood vessels to the heart, brain, or legs
• have had impaired fasting glucose or impaired glucose tolerance on previous testing.

Anyone who sees a physician regularly has most likely been tested for diabetes. But if you know someone with some of these risk factors who hasn’t seen a physician in a few years, suggest to him that he get checked by his doctor. What he doesn’t know can definitely hurt him.

A sad fact of our current healthcare marketplace is that a large number of Americans can’t afford medical care other than in the emergency room. It’s impossible to have a private practice without considering those for whom even the basics of primary care are an unaffordable luxury.

Since I went into private practice six years ago, I made a commitment to volunteer caring for indigent patients. One afternoon every month I volunteer at the Simms/Mann Health and Wellness Center (formerly called the Burke Health Center) which is a clinic in Santa Monica operated by the Venice Family Clinic. Their internal medicine clinic is staffed by UCLA residents and supervised by attending faculty physicians, like me. It’s a great opportunity for me for lots of reasons. I interact with and teach UCLA residents (and remind myself that I was one just a decade ago). I demonstrate to residents (who are exposed mostly to role models who are employees of large medical groups) that they can build a career in which they work for their patients, not for administrators. Most importantly, I help care for patients who otherwise would have no access to care. I always look forward to my afternoons at Simms/Mann.

So if you call on the third Wednesday of every month and ask to see me in the afternoon, my receptionist will politely suggest a different time. Now you know why. This summer, after I withdraw from Medicare, I’ll start spending two afternoons a month there.

Will two afternoons a month fix the problem of indigent health care? No. But imagine what could happen if more doctors got out of their non-stop high-volume practice, spent more time with each patient, and then donated some time for patients who can afford nothing.

I’ve introduced you to the Medical Letter in a previous post. It’s a great source of unbiased reviews of the medical literature. In their most recent issue, the Medical Letter reviewed the available evidence about acupuncture. Since I can’t link to the full text (it’s available only to subscribers) I’ll summarize their review.

Anesthesia The studies supporting the use of acupuncture for postoperative pain and nausea suggest it may be useful as an adjunct to traditional anti-nausea and pain medications, not as a sole treatment.

Cancer palliative care The results of studies of acupuncture for cancer pain or for chemotherapy-related nausea have been mixed. One review of several studies showed a small advantage in using acupuncture for nausea in addition to standard anti-nausea medicine.

Low back pain Acupuncture is more effective than no treatment or than sham acupuncture (inserting needles at points other than the traditional acupuncture points) for low back pain. One study suggested that acupuncture was more effective than physical therapy.

Headache Results of studies of acupuncture for chronic headaches have been mixed, with some demonstrating no benefit over standard therapy, and others showing that acupuncture decreases need of pain-relieving medication.

Osteoarthritis of the knee More than one study has shown that acupuncture is effective in treating arthritis.

Other uses Acupuncture is currently used in smoking cessation, weight loss, addiction, depression, and stroke. There is no convincing evidence that acupuncture is effective for these problems.

The article concludes:

Acupuncture alone has not been shown in rigorous, duplicated studies to benefit any defined medical condition. It may be worth trying in patients with chronic pain, especially low back pain that is refractory to conventional management. It may also be effective as an adjunct to other drugs for headache and to antiemetics for chemotherapy-related nausea and vomiting.

Proponents of evidence-based medicine are sometimes accused of being dismissive of non-western medicine, so I think it’s important to fairly assess the evidence of all therapies, regardless of where they originate. Acupuncture clearly has a proven role in some conditions.

Obesity is a serious problem in America and in my practice. Obesity predisposes to type II diabetes, high blood pressure, and high cholesterol. It also increases stress on joints and worsens arthritis. Nevertheless, losing weight for most patients is very difficult. Dietary modification and exercise have been the most proven weight loss techniques, but many patients can not adhere to a strict exercise and diet regimen.

More recently, surgical treatments for weight loss have offered an alternative for patients who have not lost weight with diet and exercise. Though these treatments seemed promising, until now there have been no rigorous randomized trials comparing surgical treatments to diet and exercise.

The most recent issue of the Annals of Internal Medicine features a trial in which mild to moderately obese patients were randomized to receive medication aimed at weight loss, and intensive diet and exercise counseling versus laparoscopic gastric banding. Gastric banding involves surgically placing a small belt around the stomach which can be adjusted to different lengths to constrict the stomach and promote satiety. Because it is placed laparoscopically (with scopes through small incisions) it involves a much faster recovery than gastric bypass and is frequently done as an outpatient.

The study showed that the patients treated surgically had more weight loss and better quality of life than those treated medically, after being followed for two years. This is the strongest evidence so far that surgical approaches to weight loss are effective. That’s encouraging news for patients who have struggled for years unsuccessfully with diet and exercise.

Last month’s New England Journal of Medicine has a great lesson about how we should think about risk factors.

It’s been long known that homocysteine is a risk factor for heart disease. That means that, when looking at large numbers of people, those with high levels of homocysteine have more heart attacks on average than those with low levels. Too frequently, we confuse a risk factor with a cause, and we jump to the conclusion that homocysteine causes heart attack. A risk factor, however, is not necessarily a cause. It may simply be a marker of risk.

It has also been long known that supplements of vitamin B12, vitamin B6 and folic acid decrease homocysteine levels in patients with elevated levels. This persuaded many doctors (me included) to recommend these vitamins to our patients with elevated homocysteine in the hopes that doing so would help prevent heart attacks. A study in April’s New England Journal of Medicine demonstrates that our hopes were not founded.

The study randomly assigned patients who recently had a heart attack to take the vitamin supplements or placebo. The patients who were on vitamin supplements had significant lowering of their homocysteine but no difference in their risk of a future heart attack. The implications are clear: homocysteine is a marker of cardiac risk, but altering it does not alter the risk itself.

I’m asking my patients taking the supplements for heart-attack prevention to discontinue them. We should instead be focusing our attention on risk factors for heart disease that have been proven to prevent heart attacks when well controlled: blood pressure, cholesterol, diabetes, and smoking.