What Time You Eat May Lead to Diabetes


CME NUGGETS

Ed Susman

Mr. Susman is a freelance medical writer based in Florida, USA. He travels worldwide to report from medical conferences, writing regularly for wire services, internet websites, and medical journals such as the Journal of the National Cancer Institute and AIDS.

For comments, edwardsusman@cs.com


CHICAGO, Illinois – The time of day you eat – particularly when you eat dinner – might make you more susceptible to development of diabetes, researchers suggested here at the 2018 scientific sessions of the American Heart Association.

Individuals who consumed 30 percent or more of their daily energy intake about 6 p.m. had a higher risk of hypertension and of prediabetes than people who ate less than 30 percent of their daily total energy before 6 p.m., said Nour Makarem, PhD, a nutritional and chronic disease epidemiologist and an American Heart Association Go Red for Women Postdoctoral Fellow in Population Science at Columbia University, New York.

In her poster discussion, Dr. Makarem said that among 12,708 adult participants in the Hispanic Community Health Study/Study of Latinos, 35.7 percent of daily energy consumption occurred after 6 p.m. More than half of the individuals in the study who were free of cancer or diabetes at baseline consumed more than 30 percent of their daily energy at nighttime – defined as after 6 p.m.

When they were compared with individuals who ate less than 30 percent of their daily intake before nighttime, Dr. Makarem found: The nighttime eaters had a higher average fasting glucose: 93.7 mg/dl compared with 93.0 mg/dl for those who ate less at nighttime (p<.001).

The nighttime eaters had a higher average fasting insulin: 12.4 mU/L compared with 11.6 mU/L for those who ate less at nighttime (p<.001).

The nighttime eaters had a higher HOMA-IR (Homeostatic Model Assessment of Insulin Resistance) 2.9 compared with 2.7 for those who ate less at nighttime (p<.001).

The nighttime eaters had a higher systolic blood pressure: 118.7 mmHg compared with 117.5 mmHg for those who ate less at nighttime (p<.004).

–The nighttime eaters had a higher diastolic blood pressure: 72.2 mmHg compared with 71.0 mmHg for those who ate less at nighttime (p<.001).

“This is the first population-based study to demonstrate that consuming a larger proportion of energy in the evening may be associated with reduced glycemic control and higher odds of prediabetes and hypertension in US Hispanics/Latinos,” Dr. Makarem said.

Vitamin D, fish oil flop

In other studies at the AHA, researchers reported that neither fish oil nor vitamin D supplements will protect you against cancer or heart disease. In the so-called VITAL studies involving more than 25,000 people who were followed for more than 5 years, the 793 people receiving vitamin D development invasive cancer compared with 824 people receiving placebo (P=0.47), not even a trend towards showing a benefit with the supplement, reported JoAnn Manson, MD, professor of medicine at Brigham and Women’s Hospital/Harvard Medical School, Boston.

And in the same group of people, a major cardiovascular event occurred among 386 people taking marine n-3 (omega-3) fatty acids compared with 419 participants in the study taking placebo (P=0.24), also non-significant.

The studies were published online by the New England Journal of Medicine as they were being presented at the AHA meeting.

“Neither omega-3s nor Vitamin D significantly reduced the primary endpoints of major cardiovascular events or total invasive cancer,” Manson said, but she stoked the embers of the Vitamin D and fish oil hypotheses by noting there were secondary outcome measures that hinted at benefit for supplementation.

“Omega-3s reduced total myocardial infarction by 28 percent (nominal p=0.003), with greatest reductions in those with low dietary fish intake and in African Americans. Percutaneous coronary interventions, fatal myocardial infarction and total coronary heart disease were also reduced,” she said. “Vitamin D reduced total cancer mortality in analyses excluding early follow-up.”

Manson suggested that researchers might consider another clinical trial focusing on omega-3 fatty acids impacts on myocardial infarction. She also noted that multiple other aspects of the VITAL study, including vitamin D’s impact on fractures, are still being analyzed.

The discussant for the study, Jane Armitage, MBBS, professor of medicine at the Oxford University, United Kingdom, however, said, “The most robust finding from this study is that neither omega-3 fatty acids nor vitamin D significantly reduced the primary endpoints of major cardiovascular disease events or total invasive cancer.” The secondary findings were less robust, she said.

The researchers enrolled 25,871 individuals in a 2-by-2 study protocol that allowed multiple research questions to be answered in one trial. In the Omega-3 fatty acid side of the study, 12,933 individuals were assigned to the fish oil supplements and 12,938 were assigned to placebo. In the vitamin D part of the study, 12,927 individuals were assigned to receive vitamin D supplements and 12,944 people were given placebo. The mean age of the participants was 67.1 years and 50.6 percent of the cohort was women. Non-whiles represented 71.3 percent of the participants; 5,106 of the participants identified themselves as African-Americans – 20.2 percent of the total. About 4 percent of the VITAL participants were Hispanic.

Computer assist

When patients are hospitalized for atrial fibrillation, which puts them at risk for a stroke, anticoagulation therapy is generally recommended, but often patients leave the hospital without getting that prescription.

To try to improve on that, researchers used a computerized decision support system to alert doctors that they may have missed something in their therapy prescription. They were rewarded by significantly increased the number of patients diagnosed with atrial fibrillation that were placed on anticoagulation therapy in the perihospitalization period.

Anticoagulation was prescribed in hospital to 25.8 percent of patients who received an alert from a computerized decision support system compared with 9.5 percent of patients whose clinicians were not informed by the computer pop-up (P<0.0001), said Gregory Piazza, MD, assistant professor of medicine at Brigham & Women’s Hospital/Harvard Medical School, Boston.

About 23.8 percent of patients with atrial fibrillation were prescribed anticoagulants at discharge if their physicians were being alerted by the computer software system compared with 12.9 percent of patients whose doctors did not have the computerized decision support system (P=0.003), Dr. Piazza said.

At 90 days, prescriptions for anticoagulation were written for 27.6 percent of patients whose doctors were being alerted compared with 17.1 percent of patients in the usual care protocol of the so-called AF Alert trial (P=0.007).

In total, anticoagulation was prescribed during hospitalization, at discharge or at 90 days – the primary endpoint of the trial – to 19.4 percent of the patients whose doctors were receiving alerts and to but 7.1 percent of the patients whose doctors did not have the computerized decision support system as back-up (P<0.001), Piazza said.

Although under powered to show a benefit in preventing cardiovascular events, patients who were in the alert system experienced an 11.3 percent rate of the composite of death, myocardial infarction, stroke, transient ischemic attack or systemic ischemic event compared with 21.9 percent of the patients who were not in the alert group (P=0.002).

Piazza said that this secondary endpoint finding, was actually the more dramatic result of the clinical trial.

“Despite a multitude of evidence-based clinical practice guidelines and five effective oral coagulants for stroke prevention, at least 30 percent of atrial fibrillation patients remain unprotected,” he said. “Failure to prescribe anti-thrombotic therapy in these highrisk patients results in a 36 percent increase in major adverse events, including stroke and myocardial infarction.”

The researchers recruited patients who were hospitalized for atrial fibrillation and had a CHA2DS2-VASc score of 1 or greater and for whom no active order for anticoagulation was observed. The assigned 248 of these patients to doctors who received alerts and 210 patients were assigned to clinicians who did not receive the computerized alerts. No patients in either arm were lost to follow-up

The alert notified the clinician that according to the electronic medical record the patients had a score that put him or her at risk of stroke and asked the physicians if they wanted to order anticoagulation; if they wanted to review the guidelines or if they decided not to order coagulants and to indicate why (Most doctors indicated they declined because they thought their patients was at risk for bleeding).

That concern about bleeding was not borne out. The clinically relevant bleeding rate among patients in the alert group was 4.4 percent compared to 7.6 percent among the patients whose doctors did not get the alerts (P=0.15).

Dec 2018 Health and Lifestyle

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