Cocoa and Weight: What do mice have to do with it?

I regularly consume cakes and cookies made with pure cocoa powder.  I choose cocoa powder because I understand that it contains substances (e.g., antioxidants, polyphenols, flavanols) that promote health similar to the way fruits and vegetables do.  I also choose it because it adds great flavor - a wonderfully rich chocolate taste - acts like a leavening agent (and therefore must be one, because my cakes and cookies with cocoa are fluffier than those without it), and adds only a small amount of calories.

I do not add cocoa to my foods because I think it will allow me to eat a calorically dense high fat diet without consequence.  In other words, I would never read the headline Eating Chocolate Keeps You Thin and 1) believe it, or 2) start eating a lot of chocolate. So when I saw this actual headline: “Eat Chocolate to Get Thin? Study Touts Cocoa for Weight Loss,” in Forbes magazine, I decided to find and read the actual research. The study was published in the Journal of Agricultural and Food Chemistry.  The study subjects in were not people and they were not given cocoa in the sense that you and I know cocoa.

I have just finished reading – really reading – my first scientific study in which the subjects were animals, mice in this case.  The details on the mice were fascinating: where the mice came from, how they were kept (i.e., the type of cage, the number of mice to a cage, the air temperature, the humidity, and the cage cleaning schedule), how their body composition was measured, how they were fed, tested for glucose and insulin tolerance, and finally euthanized and autopsied.  Well ok, the killing of the mice was not at all fascinating; it sort of broke my heart a little.

As I said, the study was published in a chemistry journal, so I am trying to simplify something I can only begin to grasp.  The scientists in this study (Dorenkott, et al 2014) began by explaining that the chemical properties of cocoa have shown health promoting effects in previous animal studies, but the exact mechanism of effect is not fully understood (e.g., if mice who consumed cocoa had less heart attacks than mice who did not consume cocoa is it because the cocoa reduced plaque buildup? lowered LDL cholesterol? raised HDL?).  In addition, researchers have not identified the specific part of cocoa that is creating the positive outcome.

Cocoa is rich in a compound called flavanol, which researchers believe drives its health promoting or disease inhibiting effects. Flavanol breaks down into several other components and in this study, the researchers wanted to compare cocoa extract and three fractions from the extract: polymer rich, oligomer rich, and monomer rich fractions. The researchers were specifically testing how these 4 substances influenced weight and body fat (i.e., obesity markers); and glucose/insulin tolerance (i.e., diabetes markers).  

This was a feeding study, not a weight loss study and the mice were NOT put on diets.

In order to compare the 4 substances, the researchers fed a group of mice one of six diets.  Each cage of mice was randomly assigned to one of six diets: a low fat diet with no cocoa ‘parts,’ a high fat diet with no cocoa ‘parts,’ a high fat diet with cocoa extract, a high fat diet with a monomer rich fraction, a high fat diet with a polymer rich fraction or a high fat diet with an oligomer rich fraction. Staff prepared and weighed the food before providing it to the mice. At the end of each of 12 weeks, the food was removed (if left over) and weighed again – similar to a plate waste analysis – and fresh food was provided.  The researchers placed the exact same amount of calories in each cage, but the mice on the low fat diets consumed more total grams of food.  I expect this is because the number of calories per gram is higher in a high fat diet. 

What I described sounds like the ideal controlled experiment. The mice could NOT cheat on their diet and were not aware of which study condition they were in.  All the mice lived in the same ‘neighborhood.’  The mice did not self-report their food intake or weight and every mouse was tested with the same calibrated device.  The study lasted 3 months, which is enough time to get an idea of an effect; and because it was an experiment, we can be confident that any difference in the outcomes was due to diet type.

Still, even in this near perfect situation there was an issue regarding the dietary intake.  As already noted, there was more food intake (by weight) in the low fat diet.  In addition, the texture of the diets was different.  Texture can influence diet likability and accuracy of the plate waste measurement.  The low fat diet was a powder-based diet; calories were in the powder and the powder was hard to clean from the feeders.  Some of the powdered feed could have dispensed into the cage uneaten and unnoticed by staff.  So, as a consumer of research, keep in mind this limitation.  It is possible that the low fat mice did eat fewer calories than the high fat mice even though the study was set up so that the calories would be the same. 

The high fat diet mice all ate the same amount of food – across the 5 high fat diets.  This is important because in other studies, one concern has been that the cocoa extract/fraction was making the food less enjoyable, leading the mice to eat less food and therefore gain less weight because they were consuming fewer calories (not because cocoa was limiting their weight gain).  In this study, the researchers are confident that the calorie intake was the same, so any differences in actual body weight, body fat and diabetic markers is attributed to whichever supplemented diet (if any) showed such differences.

I may have a limited understanding of the chemistry of cocoa, but the graphs showed a clear difference in outcomes between any high fat diet and the low fat diet. The mice on the high fat diets gained more weight and increased their body fat more under any of the cocoa conditions than the low fat diet mice.  There were a few subtle differences between the diets on the diabetic markers.  The low fat mice always had the best outcomes (e.g., lower fasting blood glucose), but in some cases one or more of the high fat diets with supplementation was equal to the low fat diet or one of the high fat supplement conditions was better than the high fat diet without any cocoa substance.   The high fat diet without any cocoa substances was always worse than the low fat diet.  Remember when I say diet, I mean meal plan; the mice were fed a high number of calories in order to cause weight gain they were not ‘dieting.’  

The researchers will be following up on the oligomer rich cocoa fraction as it showed the most promise in this study.

An important side that I want to point out is that the researchers justified the study by stating as fact that high fat diets are detrimental to health because they lead to obesity and metabolic dysfunction.  This leaves me wondering why we still debate the pros and cons of a high fat diet and why we are using our resources to find fixes for things we could change.  Is the goal of the research to give people a cocoa extract pill that allows them to eat a high fat diet without jeopardizing their health?  I suppose that makes sense if the high fat diet refuses to die; we will need alternative measures to improve health outcomes. 

The researchers killed and autopsied the mice at the end of the 12 weeks.  I find that the most disturbing part of this study – the headline should be, “Mice die so you can keep eating a high fat diet.’

Dorenkott, M. R., Griffin, L. E., Goodrich, K. M., Thompson-Witrick, K. A., Fundaro, G., Ye, L., ... & Neilson, A. P. (2014). Oligomeric cocoa procyanidins possess enhanced bioactivity compared to monomeric and polymeric cocoa procyanidins for preventing the development of obesity, insulin resistance, and impaired glucose tolerance during high-fat feeding. Journal of agricultural and food chemistry.

Is Obesity Always Associated with Poor Health Outcomes?

I will be the first to admit that my headline question seems anathema to me.  I believe that being over fat, if nothing else, puts undo stress on ones joints and can lead to ambulatory problems.  Moreover, I believe in and promote the science suggesting that excess adipose tissue (i.e., being over fat) increases the risk of developing diabetes, heart disease and some cancers.  So why would I question the adverse effects of obesity in a headline?  My pause, if you will, has to do with a provocative and interesting narrative written by Victor Etuk and published in the Hektoen International (A Journal of the Medical Humanities).  In his article, Mr. Etuk describes "fattening rooms," which are a part of Efik culture in the Nigerian state of Calabar. You can read his article here, and another by Enang Oe here.  

As part of a ritual of passage into adult hood, young women between the ages of 15 and 18 , according to Oe, spend up to a year or more in 'fattening rooms.' In these rooms, the young women eat a lot of food (calorically dense food) and engage in very little physical activity.  They also take part in other traditional rituals that signal a rite of passage.  In the Efik culture, plumpness is positive; it signals well being and prosperity, not personal failure and unhealthiness as it does in the US.

Both Etuk and Oe write about the tradition, which has been declining, in an effort to end it. Mr. Etuk focuses on the high level of obesity - in itself a reason for discontinuing the 'fattening rooms' and Mr. Oe focuses on the risk of diabetes associated with obesity - which is associated with (and the purpose of) the tradition.

I exchanged several emails with Mr. Etuk in an attempt to learn one thing:  Is obesity in these specific women associated with adverse health outcomes? Mr. Etuk never directly answered my question, instead he said, "well, the obesity rates are very high in these women."  I expect that we had some communication challenges, but what I specifically wanted to know, and did ask, was whether the obesity in Efik women led to diabetes, heart disease, arthritis, etc.  I think the answer is, 'we don't know."  Mr. Oe's article referenced the diabetes rate for Nigerian woman, a low 2%, and only speculated that, due to the high level of obesity in Efik women, they would have high rates of diabetes.

Of course, it is a plausible theory, even quite likely.  In the US and similar countries, the link between obesity and the adverse health consequences I mentioned are established.  I was pushing Mr. Etuk because his article was calling for a substantial, other imposed, cultural change - a breaking of centuries old tradition.

The end to 'fattening rooms' may absolutely be merited, but I wouldn't dare 'assume' it so.  There could be genetic factors in this tribe of women which protect them from otherwise obesity related outcomes, or other parts of their culture may somehow protect them.  I shared my thoughts with Mr. Etuk - that there might be something protective about the culture, he noted that positives included "homekeeping, good mannerism, femininity and beauty etiquettes" and asked if I thought those would be protective against obesity.  That wasn't exactly where I was headed, but I appreciate that Mr. Etuk spoke with me. I think his article is interesting and obviously thought provoking.  I, however, crave evidence. 

I expect the reason health outcomes are not given is because they are not known.  It is possible that the Efik culture does not wish to share this information, or perhaps its members do not practice traditional medicine or even classify disease the way that Western cultures do.  The bottom line of my post is that while I promote obesity prevention based on the evidence I see, it is specific to men and women in the US and similar countries.  I am conscious of the many complexities of how obesity leads to disease and don't think that what applies to Western nations necessarily applies to a tribe of Nigerian women - it very likely could, but before anyone attempts to topple a meaningful, cultural tradition, they ought to check.

The Real Diabetes Link

    I am referring to type 2 diabetes which is by far the most common type and the one for which we have the most information on cause and risk.
    I am writing about this today because I am disturbed by the attention processed foods are getting from certain sources, like news paper journalists.  I provide information from vetted sources, researchers and endocrinologists as well as other medical specialists.  The information I share is available from reputable websites like the NIH, CDC, AHA and ADA.

Here is what you need to know:
    The link between diabetes and processed foods is not direct. It is not processed foods = diabetes.  The link has to do with a common feature of processed foods - high levels of saturated fats and added sugar.
   Consumption of saturated fats and added sugar is also not the direct link.  But it gets us closer.
   Processed foods, because they are higher in saturated fats and added sugar, make it easy if not likely, that persons will over consume calories.
   Too many calories = weight gain.  Overweight and obesity - and the above factors that led to them are all modifiable.  We can change these parts.
   Now - Overweight and Obesity ARE directly linked to metabolic dysfunction which leads to insulin resistance and if untreated >>> to diabetes.
   There are two other parts to the diabetes picture.  The next one, by order of importance, is physical inactivity.  We have learned that sitting too long and too often also contributes to metabolic dysfunction.
   Lastly, there is a link to genetic susceptibility - if people in your family have diabetes you may be more at risk than someone who does not have family members with diabetes.  This is the smallest cause and also the one you cannot change. (it is not modifiable)
   The thing you need to know about 'susceptibility' is this. I explain with an example,  I am providing imaginary numbers.  Let us say that being overweight or obese increases the risk of diabetes by 40%, and that being inactive increases it by 30%.  Instead of everyone starting with a 0% risk, 'susceptible' people start with 5%.  That means that it is even MORE important for those people to have a normal weight and to exercise and move a lot.  Not less important, MORE important.

bottom line - processed foods are not the cause of diabetes - but eating a lot of them is a bad idea.
 

A Billion Dollar Disease

   A couple of weeks ago, I read a post by Cris Frangold.  Cris pronounces a love for investing and writing about it.  I would consider him or her a financial blogger, with a  focus on medical services and the health sector.
   The piece that I read in Seeking Alpha regarded the value of Merck and purchasing its stock.  One reason offered to invest in the company was its drug Januvia.  Januvia is meant to treat the symptoms of type 2 diabetes.  Cris noted that 2012 Q2 sales of the drug were over 1billion dollars. Then he or she said:

Januvia has a potential to be a real moneymaker because the American Diabetes Association estimates that 25.8 Americans, or 8.3% of the population have Type 1 and Type 2 diabetes - the majority are Type 2.

   Type 2 diabetes in adults and children is related to diet - diet as it produces obesity.  It appears that excess body fat leads to metabolic dysfunction or disregulation so that blood sugar, blood pressure, and cholesterol irregularities follow.   Our diabetes rates have doubled in the past 30 years in tandem with our increase in obesity.  The 30 year trend of rising weights has been attributed to an increase in availability and consumption of high calorie, nutrient poor foods and beverages.
   Sure we can make billions on treatment and millions investing in those treatment options, but isn't there a better response?  I suggest that there is.  Investing in a diabetes drug means counting on a disease to continue, needing it to continue in order to enhance a portfolio or fund a retirement account.  That seems to be a good example of maleficence.    
   What of the better good?  I say the noble thing to do is invest in the food environment so that meals and drinks contain reasonable amounts of sat fat, sugar and calories.  And yes - sometimes that takes a mandate.

 American Diabetic Association
National Diabetes Information Clearinghouse.  Program of the National Institutes of Health

Your Numbers - Your Risks

   Before we move on to another topic, I want to assure myself that the information I shared with you yesterday made some kind of impact.

from the American Heart Association website

   Did you view any food labels today?  Were the trans fat grams high or low?  If they were not 0 to 0.5  then they were high.
   Do you have any existing health condition that makes avoiding trans fat especially important?  (heart disease, high blood pressure, diabetes)
   Is there any reason to avoid trans fats if you do not have those conditions?  YES.  Do normal weight people need to avoid trans fats? YES.  Do people who exercise every day? YES.
   Not sure what I am talking about?  Maybe you missed yesterday's post. You can review it here.



 

Degree Not Needed, Sugar Pooh

I purposefully left my Monday blog up for two days.  I felt that the issue was important enough for us to dwell on.  Yesterday the Diane Rehm show discussed diabetes and its association with weight, the importance of choosing better foods and the benefit of adding exercise to every day.  A caller to the show talked about his diagnosis of diabetes and how hard it was to eat well outside of his own home.  He had gone to an event to support one of his children and  he recalled the breakfast they served; toast, hashbrowns, bacon, eggs, and so on .  He said it was as if the culture we live in was set up to create a diabetes epidemic.  Some public health experts would agree.  Diane added some comments about how hard it was to find anything of quality to eat when traveling by plane.  I think that is changing a little, but you really have to know what you are doing in order to make healthy choices.  I linked her show in case you want to listen.  She had several experts on as guests.

I had to mention the show because it was important, but my post today really centers on something that I observed in one of my classes last night.  The student sitting next to me had a canned drink that at first appeared to be an energy drink because of its size.  I think it was just a smaller can of coca cola.  I could see the back and the label.  I noticed that it had 25 grams of sugar and 90 calories.  I thought, well, if she would have had a 150 to 200 calorie drink, that is better.  At class break, she came back with a pack of nabs and a 12 ounce bottle of regular Dr. Pepper.  Meanwhile, I had a diet Mt Dew and half a peanut butter sandwich.  My classmate weighs significantly more than me, possibly 100 pounds more.  
On the one hand, we could say, "Well this isn't rocket science then.  One of us was monitoring or moderating our intake and the other was not."  Of course, what an observer doesn't know and I don't know, is what goes into the decisions people make.  Food decisions tend to be much more nuanced than they appear to be.  I would, however, like to show people how they can eat and drink more without taking in extra calories (extra meaning more than they need to maintain a healthy weight). 

But especially after the last post on sugar sweetened beverages, I found last nights observation troubling.

Let Not Your Limbs Be Idle

Something we hear often when health experts discuss the rising rates of both obesity and diabetes is that the population as a whole has become more sedentary (less active) over time and that this change in activity level is contributing to the problem.
In January I mentioned research that supported this assertion and in fact, suggested that even daily runners were at risk for heart disease and other health problems if they spent the rest of their hours being relatively still.

A NY Times journalist (Olivia Judson) offered a similar post in February, but she graciously ended her piece with a bibliography of several research studies. One of those studies, Role of Low Energy Expenditure and Sitting in Obesity, Metabolic Syndrome, Type 2 Diabetes, and Cardiovascular Disease. Marc T. Hamilton Deborah G. Hamilton and Theodore W. Zderic, offers insight into what exactly happens when we spend all this time on our bottoms. Ms. Judson suggests that we have 15 hours of time not spent sleeping that we can spend active or inactive.

The researchers mentioned above actually did a little reverse science. There is ample data to show what happens to us physiologically when we exercise. We know about heart rates and endorphins, oxidative stress and oxygen consumption, as well as calorie expenditure and sleep stasis – we have no doubt that physical activity, especially frequent and intense exercise – prevents disease and disability. What about the opposite? What happens on a molecular level – what happens inside our cells, tissues and organs – when we are still for extended periods of time?

As it turns out – our metabolism changes and we actually use and store sugars and fats in ways that cause harm. I like the phrase that the researchers use when discussing their study – they call it “inactivity physiology”. They admit that there is not a lot of study into this phenomena and that it is a great place to spend some research time and dollars.

Hamilton, et al offer four tenets of inactivity physiology – The first is the idea that there is a curve of wellness associated with extra physical activity. We may be at the middle (an average, fit persons) and our health improves or shifts to the right, when we exceed the 30 min of activity/day that is often recommended – but does it shift to the left if we do not even do the 30 mins? (most of us agree this has been shown to be true) . The second tenet is that the episodes of sitting and the episodes of focused physical activity have very distinct effects on our bodies. Meaning, even the most active person’s body has an adverse biological response to being still. The third tenet suggests that the adverse effects of sitting for too long are not simply the reverse of the positive effect of a 30 minute walk. That sounds like tenet two, but I think it to mean something a little different. There may be a specific way that exercise boosts HDL which does not mean that sitting just prevents higher HDL – sitting too long may affect cholesterol in a completely different – but harmful way. The fourth tenet has to do with large groups of people, or cohorts, who are aging together in this sedentary mode and the increases in heart disease, diabetes, obesity and more that will occur in large numbers. It is of vast importance to get these people moving, especially if we are talking about a cohort of third graders!

The article is a big read – you are welcome to view it here. The take home message however is this – get up and stretch or move about every hour that you are not asleep and you will reduce the negative metabolic actions that sitting too long can activate.

gestational diabetes

I chose this topic today because a woman I care a great deal about has recently learned that she has gestational diabetes.

So what is that and what does it mean?
Diabetes is defined as having a blood sugar level over 130 if fasting and 180 if after a meal. When blood sugar levels run high after one becomes pregnant but not before, then it is gestational diabetes. (there are some instances of gestational diabetes however, that fall into the category of previous diabetes that was undiagnosed). There are not always symptoms, but increased thirst, light headedness and frequent urination are a few. A blood glucose test is usually performed during pregnancy.
Gestational diabetes can cause problems and it is important to get blood sugar levels under control and to treat the condition with the utmost respect. Gestational Diabetes affects about 4% of pregnant women. It usually occurs and is diagnosed between the second and third trimester. Though only around 30% of women with gestational diabetes develop diabetes beyond pregnancy, there is a 60% chance that this will occur for each woman who has gestational diabetes. There is also increased risk of the infant becoming obese and also developing type 2 diabetes. What this really tells us is that the recommendations to maintain a healthy weight, to eat frequent, consistent, small meals and to exercise are universal and paramount.

Women who are diagnosed with this condition, often because of screening during their sixth month, must control their blood sugars. When diagnosed, the mother should receive a referral to a certified diabetes educator who will assist in meal planning. How one eats can do a lot to prevent blood sugar spikes and thus less need for insulin to be secreted. Exercise can also reduce blood sugar, however, there may be a need for exogenous insulin and if so, special education on how to use the medicine is needed as well. No other diabetes medication is considered safe during pregnancy.

Insulin and exercise are both known to lower blood sugar levels. Pregnant women should not start new vigorous exercise, but are usually able to continue with the same physical activity level they had before they become pregnant, unless of course they were sedentary. Walking is usually considered a safe activity. All women who are pregnant and especially those with these risks, should maintain regular prenatal care and get direction from their provider on what exercise is best and how often it should be done.

With regard to controlling blood sugar through nutrition; frequent, small meals are suggested. Complex carbohydrates, whole grains, fruits and vegetables as well as lean proteins are recommended. It is also noted that saturated fat, fried and greasy foods should be avoided. Pregnant women are also encouraged to consume 20+ grams of fiber each day, and to drink plenty of water.

As you can see, these suggestions are pretty much the same as those for the general population. These guidelines can reduce weight gain and prevent chronic disease. Women with gestational diabetes are also encouraged to monitor their weights. I cannot emphasize enough that this is not a disease to tackle on your own. The baby and the mother are at risk for problems - birth problems, growth problems and still birth. The risk is greatest if the diabetes is not controlled. This is different than being diagnosed with DM2 and twenty years later having a heart attack from it - the adverse outcome can happen within months if the condition is not taken seriously.

Risk factors and etiology:
There are some risk factors, but please note, many cases of gestational diabetes are in women who did not have the named risk factors. If you are curious, they include - being overweight prior to pregnancy, being over age 25, having had gestational diabetes during a previous pregnancy, having a family history of diabetes, and being a person of color.
The disease develops (etiology) during the course of a normal pregnancy phenomena. When pregnant, the placenta itself makes hormones. The hormones have many effects but one is to reduce the impact of the mothers insulin on her blood sugar level. The idea is to increase nutrient flow from the mom to the baby and in so doing the mom might be at risk for low blood sugar, so the body is trying to prevent that outcome by interfering with natural insulin response. However, sometimes that back fires and the mothers blood sugar is too high. Usually the mother will begin to produce extra insulin (from the pancreas) to account for this change, but in gestational diabetes this extra insulin does not move the blood sugar out of the blood stream. The infant's pancreas is also working so that when the infant has too much blood glucose, it will release insulin. The glucose passes through to the baby but the mom's insulin doesn't. Glucose or blood sugar that cannot be used is stored as fat. The baby is at risk for a condition in which it has too much fat (macrosomia) at birth and it will continue to be at risk for obesity and diabetes after birth.

All this being said, controlling the blood sugar of the mother, through smart eating and exercise can prevent these adverse outcomes. A woman with this condition should take advantage of any and all resources made available to them by their OBGYN. To control the blood sugar, testing is required. Certified Diabetes Educators, both nurses and dietitians can educate on how to test blood sugar and use insulin if needed. Blood testing cannot be avoided. The baby may also undergo fetal monitoring, ultrasound and other tests as the pregnancy progresses. At birth the baby will undergo some testing to make sure his or her blood sugars are normal. Again, the baby will be at risk for obesity which is a big factor in diabetes - parents should provide the child with the same healthful diet the mother was encouraged to consume. After birth, the mother will also be tested for some time to see if her blood sugar and insulin response returns to normal. It should because the placenta is no longer there to cause hormone challenges, but again about one third of women will develop diabetes, or may have had undiagnosed diabetes prior to pregnancy.

If you have this condition you should read more, as the links below were my resources. Start here: http://www.cdc.gov/ncbddd/bd/diabetespregnancyfaqs.htm#willmybaby
and here:
http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html
and here:
http://www.webmd.com/baby/tc/gestational-diabetes-topic-overview

When Newer Isn't Better

I am going to write today about information that was presented at a recent American Diabetes Association conference.

Several research studies, clinical studies, have been conducted on the newer diabetes medications popularly known as Avandia and Actos. They are made by different companies and compete for market share. Of course they were studied for effectiveness and side effects prior to market and during FDA hearings some clinicians voiced concern about the risk of heart attacks and heart failure but the drugs made it to market none the less. They have for some time been noted as do not use drugs by the consumer group Public Citizen.

http://www.citizen.org/

I am not writing so much about that today as I am the concept of comparative or effectiveness research. You have heard me mention this before and I am a proponent of it.

This week a study that compared these medications to insulin, and procedures to unclog arteries in diabetics to use of medications for the same purpose was released by the NIH.
In both cases, the more expensive options did NOT provide better results.

The diabetes drugs Avandia and Actos are meant to help the body use the insulin better, there by eliminating the need for insulin injections. They also prevent the blood sugar from becoming too low. We have to look at this further though. Controlling the blood sugar is a step taken to prevent a more fatal outcome, i.e. a heart attack. If the heart attack still occurs at the same frequency then nothing was gained at an increased cost.

The same goes with angioplasty and by pass surgery. If the rate of death, heart attack or stroke is the same or even higher than occurs with a less invasive less expensive treatment ( generic heart drugs, like beta blockers) then the procedure (over 10,000$) is not cost effective.

I believe that this is important and I believe that our health plans have a right to this research and a right to refuse to cover this. I know we all think that newer and costlier techniques are better but that just isn't always the case. If benefits managers are not allowed to make informed decisions on coverage, all of our insurance costs will increase.

Additionally, new risk factors for the two diabetes medications were noted.

I wasn't able to find a report of the actual research, it may not be in print yet, but here is a link to the WSJ article which triggered this blog entry.

http://online.wsj.com/article/SB124441644145192397.html

Much of diabetes can be prevented as it is often associated with weight and what one eats.