Author Archive

Even “Mid-low-T” Levels Make Men Depressed

Men referred for borderline testosterone levels may have high rates of depression and depressive symptoms that are under-recognized, according to the results of a new study.

“In an era where more and more men are being tested for ‘Low T’ — or lower levels of testosterone — there is very little data about the men who have borderline low testosterone levels.

We felt it important to explore the mental health of this population,” said lead author Michael S. Irwig, MD, associate professor of medicine and director of the Center for Andrology at the George Washington School of Medicine and Health Sciences in Washington, DC.

The number of testosterone prescriptions has grown exponentially over the past decade.

Along with it has been a corresponding increase in direct-to-consumer marketing about the effects of “Low T” on decreased sexual function and low energy in middle-aged men.

The study included 200 adult men, mean age 48 years, who were referred for borderline total testosterone levels between 200 and 350 ng/dL.

Doctors typically treat men for hypogonadism if they have symptoms of low testosterone and their testosterone levels are below 300 ng/dL.

The researchers gathered information on demographics, medical histories, medication use, signs and symptoms of hypogonadism, and assessments of depressive symptoms and/or a known diagnosis of depression or use of an antidepressant.

All of the study participants who were not diagnosed with depression or who were taking medications for the condition answered standardized test questions aimed at measuring mood.

More Than Half Showed Signs of Depression

The results show that more than half (56%) of the men had depression or depressive symptoms, which is significantly higher than rates seen in general populations.

A recent survey of US adults found that 6% of those who are overweight or obese were depressed.

One-quarter of the men used antidepressants.

Rates of depression were 62% for those in their 20s and 30s, 65% for those in their 40s, 51% for those in their 50s, and 45% for those who were age 60 and higher.

Notably, the men had high rates of overweight or obesity and physical inactivity.

Common symptoms were erectile dysfunction, decreased libido, fewer morning erections, low energy, and sleep disturbances.

Sexual and nonspecific symptoms, such as fatigue, likely prompted measurements of testosterone in this selected population, the researchers pointed out.

They concluded that “clinicians should consider screening for depression/depressive symptoms and overweight and unhealthy lifestyle risk factors in men referred for tertiary care for potential hypogonadism.”

Testosterone replacement therapy can improve the signs and symptoms of low testosterone in these men, the researchers said.

The researchers published their results online on July 1, 2015 in the Journal of Sexual Medicine.

Online Community Optimizes Epilepsy Management

Digital communities and online self-management tools have the potential to improve clinical outcomes among epilepsy patients, according to a new study.

Patients with chronic conditions are increasingly encouraged to self-manage their condition, and digital communities have the advantages of convenience, access to large populations, and building a community support network.

“We found that veterans with epilepsy who enrolled in an online patient community reported statistically significant improvements in previously validated self-efficacy and self-management measures,” wrote researchers led by John D. Hixson, MD, Associate Professor of Neurology at the University of California at San Francisco.

The researchers conducted a prospective study of 249 US veterans with epilepsy using validated survey measures of self-management and self-efficacy to determine the effectiveness of a patient-powered research network, PatientsLikeMe.

The 92 individuals who completed surveys over 6 weeks showed improvement in epilepsy self-management and epilepsy self-efficacy scores, with the greatest impact on an information management subscale.

Information management includes the use of a seizure diary, tracking of side effects, and tools for medication adherence.

Online Tracking Tools

“This result potentially demonstrates that study participants believed that the availability of online tracking tools or social support mechanisms improved their self-management capabilities,” they wrote.

About half of the participants agreed that the online network gave them more or better control over their condition and helped them understand their seizures.

The platform was accepted and used by a broad cohort of patients.

Older patients participated at the same rate as younger patients.

The median number of logins, postings to forums, leaving profile comments, and sending private messages were more common in completers than non-completers.

The researchers suggested that patients who are offered this type of service through their health care providers might overcome some of the self-selection bias typical of online communities.

“It is reasonable to hypothesize that this type of online intervention could positively affect other metrics of epilepsy health, such as health care utilization, morbidity, and even epilepsy-related mortality,” they wrote.

“We think that it would be compelling to explore more objective metrics of epilepsy-related health, such as emergency services utilization, frequency of interactions with epilepsy care teams, and medication adherence.”

Traditional medications and other technological interventions remain the essential elements of epilepsy treatment.

However, there is a growing recognition of the importance of psychosocial support, education, and self-management tools for patients.

“As a cost-effective and more time-efficient alternative, online networks and management platforms offer more ubiquitous accessibility and a larger support system than traditional methods,” they concluded.

Epilepsy Websites for Patients

Epilepsy Foundation Helpline. This 24/7 helpline has trained information specialists available to answer questions about epilepsy and seizures and provide support, guidance, and access to national and local resources.

PatientsLikeMe. This network provides an epilepsy-specific support system, as well as digital tools for tracking seizures, symptoms, medications, and comorbidities.

EpilepsyU. This online resource offers information and epilepsy education and access to educational materials, social networking, and group forums.

Lung Disease Often Missed in Long-term Smokers

As many as 35 million Americans who smoke or who are former smokers may have undiagnosed lung disease or impairment.

Long-term Smokers May Have Undiagnosed Lung Disease

• Current and former smokers who do not have airflow obstruction may assume that they are free of disease.

• But millions of long-term smokers with normal spirometry results may have undiagnosed lung disease.

• A cross-sectional, observational study included more than 9000 persons aged 45 to 80 years who had smoked at least 1 pack of cigarettes daily for 10 years.

• Most smoked more than 1 pack per day; about half were considered disease-free based on their lung-function test results.


Nearly Half of Smokers Have CT Evidence of Disease

• One or more respiratory-related impairments were found in 54.1% of patients. This group had worse quality of life compared with never-smokers, as well as a shorter 6-minute walk distance.

• In this group, 42.3% had CT evidence of emphysema or airway thickening.

• Current smoking was associated with more respiratory symptoms, but former smokers had greater emphysema and gas trapping.

• Advancing age was associated with smoking cessation and with more CT findings of disease.

Unrecognized Disease in 35 Million Older Americans

• Those with respiratory impairments were more likely to use respiratory medications, and the use of these medications was associated with worse disease.

• Lung disease and impairments were common in smokers without spirometric chronic obstructive pulmonary disease.

• The researchers projected that 35 million current and former smokers older than 55 years in the United States may have unrecognized disease or impairment.

Take-home Message:

• The effect of chronic smoking on the lungs is substantially underestimated when spirometry is used alone.

Combo Diet-Exercise Programs Trim Diabetes Risk

A combination of diet and physical activity programs offered in the community reduce the risk of type 2 diabetes in patients who are at increased risk, according to new federal data.

Programs Help Patients Revert to Normal Glycemic Levels

• Strong evidence suggests that a combination of diet and physical activity programs can reduce new-onset diabetes for persons at increased risk for type 2 diabetes.

• These programs also increase the likelihood of reversion to normal glycemic levels and improve diabetes and cardiovascular disease risk factors, including weight, blood glucose levels, blood pressure, and lipid levels.

• The US Community Preventive Services Task Force recommends the use of combined diet and physical activity promotion programs to reduce progression to type 2 diabetes in those at increased risk.

Combined Program’s Critical Components

• Critical components of a combined diet and physical activity program include trained providers in clinical or community settings who work directly with program participants for at least 3 months; some combination of counseling, coaching, and extended support; and multiple sessions related to diet and physical activity, delivered in person or by other methods.

• Programs also may use 1 or more of the following: diet counselors in various specialties (eg, nutritionists, dietitians, and diabetes educators); exercise counselors in various specialties (eg, physical educators, physiotherapists, and trainers); physicians, nurses, and trained laypersons; a range of intensity of counseling, with many or few sessions, longer- or shorter-duration sessions, and individual or group sessions; and individually tailored or generic diet or physical activity programs.

• Programs should include specific weight-loss or exercise goals and a period of maintenance sessions after the primary core period of the program.

US Task Force Conducts Systematic Review

• The task force recommendation is based on evidence from a systematic review of 53 studies that described 66 programs.

• Most programs used a combination of in-person individual and group sessions.

• Almost all programs led to weight loss, reduced risk of diabetes, or both.

• More intensive programs led to more weight loss and less development of diabetes.

Group Programs More Cost-effective

• These diet-exercise programs were cost-effective; group-based programs were the most cost-effective.

• Health care providers usually are the primary resource for patients at increased risk for type 2 diabetes.

• The task force suggests that health care providers keep informed about local prevention programs offered by community centers or run by insurers or nonprofit or other private contractors.

Take-home Message:

• A federal task force’s systematic review found combined diet and physical activity programs can help prevent or delay the development of diabetes.

Asthma Pops Up After Step Down

Many patients with asthma experience exacerbations within 2 years of receiving step down medications, new respiratory disease research shows.

Asthma Exacerbations Occur in One-third of Patients

• About one-third of patients with asthma have an exacerbation within 2 years of stepping down controller medication, according to the results of new retrospective study.

• Researchers used a US claims database spanning 2000-2012 to conduct a time-to-event analysis.

• A step down event was defined by a 50% or more decrease in days-supplied of controller medications from one event to the next.

Younger, Female, African American Patients at Increased Risk

• Researchers monitored each patient for 10 consecutive 4-month intervals, 3 prior to stepping down, 1 when the step down occurred, and 6 after the step down.

• Among the 26,292 patients in the study, 32% had an asthma exacerbation in the 2-year period after step down of asthma controller medication, although only 7% visited an emergency department or were hospitalized for asthma.

• Patients at increased risk for a quicker asthma exacerbation included those aged 19 years and younger, females, and African Americans.

Take-home Message:

• About one-third of patients have an asthma exacerbation in the 2 years after a step down event.

• Source: Rank MA, Johnson R, Branda M, et al. Long term outcomes after stepping down asthma controller medications: a claims-based, time-to-event analysis. Chest. 2015 May 21. doi:10.1378/chest.15-0301. [Epub ahead of print]

Physical Activity Trims Breast Cancer Risk

The risk of breast cancer tends to be lower in women who participate in physical activity.

Several studies presented at the recent American Society of Clinical Oncology annual meeting in Chicago demonstrate that even moderate levels of physical activity can help women who have breast cancer live longer lives.

However, women who have received hormone replacement therapy (HRT) may not get the same benefit from exercise.

Community-based programs at Curves or a LIVESTRONG program at YMCAs can help patients with breast cancer increase their fitness and lose weight, improving their quality of life.

High Levels of Physical Activity Reduce Breast Cancer Risk

• A lower risk of breast cancer among physically active women has been reported frequently, but the risk in women who use HRT appears to be higher.

• A systematic literature search of studies that measured physical activity in breast cancer identified 38 studies including more than 4 million women.

• The risk of breast cancer in women who engaged in the highest level of physical activity was 12% lower than in women who performed low levels of or no physical activity.

HRT Nullifies Exercise Effects

• However, there was no reduction in breast cancer risk associated with physical activity in women who used HRT.

• The capacity of physical activity to reduce the risk of breast cancer in women probably has been underestimated by studies conducted after 1989, when HRT use was more prevalent.

• Physical activity probably decreases the risk of breast cancer through lower circulating estrogen levels, but HRT use seems to nullify this action.

• Source: Pizot C, Boniol M, Mullie P, et al. Physical activity, hormone replacement therapy and breast cancer risk: a meta-analysis of prospective studies. J Clin Oncol. 33, 2015 (suppl; abstr 1561).

BMI and Physical Activity in Triple-Negative Breast Cancer

• Modifiable lifestyle factors, including body mass index (BMI) and physical activity, have been well-studied for overall breast cancer prognosis.

• No prospective study has investigated BMI and physical activity in triple-negative breast cancer, defined as ER-/PR-/HER2-.

• These researchers conducted an analysis using data from 5 breast cancer survivor cohorts in the United States, the UK, and China.

High Physical Activity Extends Lives

• The 12,240 stage I-III breast cancer cases with known ER/PR/HER2 status included 1695 triple-negative cases (13.9%).

• Patients self-reported their recreational physical activity.

• After a mean follow-up of 9.5 years, the researchers observed a trend for increasing physical activity and improved breast cancer-specific survival and overall survival.

• This was significant only for high levels of physical activity, the equivalent of 4 or more hours of moderate-intensity physical activity per week.

• Source: Nechuta SJ, Caan BJ, Chen WY, et al. Post-diagnosis BMI and physical activity in association with triple-negative breast cancer prognosis: results from 5 prospective cohorts. J Clin Oncol. 33, 2015 (suppl; abstr 1507).

Weight Loss Study in Breast Cancer

• Weight loss among overweight and obese breast cancer survivors may lead to improved disease-free survival.

• Researchers conducted a 12-month, community-situated physical activity and telephone-based dietary change weight loss intervention in female breast cancer survivors.

• The 25 evaluable patients, median age 57 years, were assigned a telephone counselor and given a 12-month membership to a local Curves fitness center, which offered a 30-minute circuit-based exercise program.

• Patients were counseled 14 times over 12 months and were instructed to exercise 150 minutes per week, walk 10,000 steps per day, and decrease caloric intake by 500 kcal per day.

Meaningful Weight Loss Over 12 Months

• At 12 months, 96% of patients met the diet goal and 28% of them met the exercise goal.

• Average weight loss was 7.6%; the median weight loss was 7.1%.

• The researchers concluded that it is feasible to recruit and retain breast cancer survivors in a multicenter weight-loss trial using dietary change plus physical activity to achieve clinically meaningful weight loss over 12 months.

• Source: Greenlee H, Lew D, Hershman DL, et al. Phase II feasibility study of a physical activity and dietary change weight loss intervention in a subset analysis of breast cancer survivors (SWOG S1008). J Clin Oncol. 33, 2015 (suppl; abstr 9572).

LIVESTRONG at the YMCA Program for Cancer Survivors

• Physical activity has been linked to cancer risk and outcomes, yet many survivors are inactive.

• Researchers evaluated the impact of a 12-week LIVESTRONG at the YMCA program, an exercise program available for cancer survivors at YMCAs across the United States.

Patients With Early-stage Cancer are Mostly Inactive

• A total of 186 participants were randomized, 95 to the LIVESTRONG Program and 91 to a control group.

• The majority of patients had stage I-II disease; half had breast cancer.

• A majority of participants were inactive at baseline; only one-third reported performing at least 150 minutes of physical activity per week.

LIVESTRONG Program Encourages Physical Activity

• Participants randomized to the LIVESTRONG Program attended an average 83% of scheduled sessions over the 3-month program.

• LIVESTRONG participants experienced significant increases in physical activity—three-fourths exercised a minimum of 150 minutes per week compared with one-fourth of controls.

• Exercisers showed improvements in fitness and quality of life compared with controls.

• Source: Irwin ML, Cartmel B, Harrigan M, et al. Impact of the LIVESTRONG at the YMCA Program on physical activity, fitness, and quality of life in cancer survivors. J Clin Oncol. 33, 2015 (suppl; abstr 9508).

Take-home Messages:

• The promotion of physical activity may help lower the risk of breast cancer, but HRT may ameliorate the effects of exercise.

• High levels of physical activity can help patients with breast cancer live longer lives.

• A combination of physical activity and caloric restriction can help patients with breast cancer achieve sustained weight loss.

• The LIVESTRONG program could provide a platform to increase physical activity, fitness, and quality of life in cancer survivors.

High Blood Sugar Elevates Breast Cancer Risks

Higher blood sugar levels that reflect prediabetes or undiagnosed diabetes lead to poorer outcomes in patients with breast cancer, particularly in young women, according to the results of a new study.

“In younger patients, doctors need to be aggressive in controlling blood sugar levels to improve their breast cancer-related outcomes,” said lead author Varinder Kaur, MD, a Fellow in Hematology/Oncology at the Winthrop P. Rockefeller Cancer Institute at the University of Arkansas in Little Rock.

Multiple studies indicate that type 2 diabetes is associated with an increase in mortality in breast cancer.

However, the class of anti-diabetic therapy remains an obvious confounding factor in these studies.

Higher mortality rates have been reported in patients with breast cancer who are treated with insulin than in those treated with metformin.

Choosing a population of patients with breast cancer who have prediabetes and are not receiving anti-diabetic therapy could overcome such confounders.

RANDOM BLOOD SUGAR LEVELS RELATE TO BREAST CANCER

“We conducted a retrospective cohort study to evaluate the relationship between elevated random blood sugar (RBS) levels and breast cancer outcomes,” Dr. Kaur said.

The study included 234 patients, median age 53 years, who had no previous history of diabetes and who were not receiving any anti-diabetic therapy.

Some 159 patients had a documented RBS level.

The patients had stage I-III breast cancer, mostly stage II disease (177 patients); 72 patients had elevated RBS levels (higher than 120 mg/dL) and 87 had RBS levels lower than 120 mg/dL.

The effect of elevated RBS levels on overall survival, event-free survival, and time to tumor recurrence were analyzed.

“We observed that patients with elevated random blood sugar levels experienced significantly shorter overall survival, shorter event-free survival, and shorter time to tumor recurrence,” Dr. Kaur said.

“After adjusting for age, obesity, and race, elevated random blood sugar levels continued to display a high and statistically significant association with shorter survival and time to tumor recurrence.”

In addition, among patients younger than 50 years, elevated RBS levels were associated with a significantly greater frequency of high-grade tumors (80%) compared with RBS levels below 120 mg/dL (45%), suggesting that “elevated random blood sugar levels may have more impact in younger patients,” she noted.

Metformin may help reduce the risk of breast cancer and more tightly control blood sugar levels, Dr. Kaur said.

This may improve outcomes more than if patients are receiving insulin.

YOUNGER PATIENTS NEED BETTER BLOOD SUGAR CONTROL

Metformin may be even more effective in younger patients.

The risk of shorter survival and shorter time to tumor recurrence was more than twice as high in the 97 patients who were younger than 50 years than in the patients older than 50 years, she stated.

In conclusion, Dr. Kaur said, “High random blood sugar levels, reflective of a prediabetic state or undiagnosed diabetic state, are associated with shorter overall survival and time to tumor recurrence in early-stage breast cancer patients. It makes sense to be aggressive and control their blood sugar.”

The researchers presented the results of the study (Abstract 1584) at the American Society of Clinical Oncology annual meeting in Chicago.

Strokes Compounded With Aspirin Resistance

Persons who exhibit a resistance to aspirin may be more likely to have more severe, and larger, strokes than those who still respond to the drug, according to a new study.

“Eventually we may be able to identify people who are likely to be resistant to aspirin and give them higher doses or different drugs to prevent blood clots,” said lead author Mi Sun Oh, MD, of Hallym University College of Medicine in South Korea.

Prior aspirin use has been associated with lower stroke severity and decreased infarction size.

However, the effect of aspirin resistance on stroke severity has been inconclusive.

Doctors do not routinely test patients for aspirin resistance.

STUDY DETAILS

Dr. Oh and colleagues set out to evaluate the effect of aspirin resistance on initial stroke severity and infarct size measured by MRI diffusion weighted imaging (DWI) in 310 patients.

“We enrolled patients with at least 7 days of aspirin before symptom onset, evidence of ischemic stroke on DWI, and aspirin resistance checked within 24 hours of hospital admission,” he said.

A total of 86 patients (27.7%) were resistant to aspirin.

In a multivariable analysis, aspirin resistance was significantly associated with higher initial NIH Stroke Scale score.

Aspirin resistance also was a significant predictor of larger DWI infarction volumes.

The infarct size was 2.8 cc in aspirin-resistant patients compared with 1.6 cc for those who responded to aspirin.

In conclusion, Dr. Oh said: “Aspirin resistance is independently associated with increased initial stroke severity and stroke volume in acute ischemic patients.

However, we need better ways to identify people with aspirin resistance before any changes can be made.

DON’T STOP LOW-DOSE ASPIRIN YET

For now, people who are taking low-dose aspirin to prevent blood clotting and stroke should continue to do so.”

Antiplatelet agents such as aspirin reduce platelet aggregation, the formation of thrombus, and the size and frequency of thrombotic emboli.

When patients do not have adequate platelet inhibition, this may lead to larger and more severe strokes because of larger thrombus and higher rate of thrombotic emboli.

The researchers presented their results at the American Academy of Neurology’s 67th Annual Meeting in Washington, DC, April 18 to 25, 2015.

Abstract title: Aspirin Resistance is Associated with Increased Stroke Severity and Infarction Volume

Erectile, Sexual Function Better in Active Men

The more a man exercises, the better his erectile and sexual function, regardless of his race, according to a new study designed to define a minimum exercise threshold for best sexual function.

Many studies have highlighted the relationship between better erectile function and exercise, but black men have been underrepresented in the literature.

“This study is the first to link the benefits of exercise in relation to improved erectile and sexual function in a racially diverse group of patients,” said senior author Adriana Vidal, PhD, of the Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute and Department of Surgery in Los Angeles.

This cross-sectional study included nearly 300 participants from a case-control study that assessed risk factors for prostate cancer conducted at the Durham Veterans Affairs Medical Center.

The men, about one-third of them black, self-reported their activity levels.

The researchers then stratified them into 4 exercise groups: sedentary, mildly active, moderately active, and highly active.

The subjects also self-reported their sexual function, including the ability to have erections and orgasms, the quality and frequency of erections, and overall sexual function.

MORE FREQUENT EXERCISE = HIGHER SEXUAL FUNCTION

A multivariate analysis showed that men who reported more frequent exercise, a total of 18 metabolic equivalents (METS) per week, had higher sexual function scores, regardless of race.

MET hours reflect both the total time of exercise and the intensity of exercise.

A score of 18 METS is the equivalent of 2 hours of strenuous exercise, such as running or swimming; 3.5 hours of moderate exercise; or 6 hours of light exercise.

“Higher exercise was associated with a better sexual function score.

Importantly, there was no interaction between black race and exercise, meaning more exercise was linked with better erectile/sexual function regardless of race,” the researchers stated.

In contrast, exercise at lower levels was not statistically or clinically associated with erectile or sexual function in men of any ethnicity.

Additional contributors to low sexual function included diabetes mellitus, older age, past or current smoking, and coronary artery disease.

LESS INTENSE EXERCISE BETTER THAN NONE

Study coauthor Stephen Freedland, MD, Director of the Center for Integrated Research in Cancer and Lifestyle in the Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute, cautions that exercise should be tailored for each person.

“When it comes to exercise, there is no one-size-fits-all approach,” said Dr Freedland, who also serves as codirector of the Cancer Genetics and Prevention Program.

“However, we are confident that even some degree of exercise, even if less intense, is better than no exercise at all.”

The researchers published their results online in the March 20, 2015 issue of Sexual Medicine.

Young Diabetes Patients Less Likely to Take Their Medicine

Patients with diabetes who are younger, new to the disease, and receiving few other medications may be at risk for nonadherence to therapy, according to a new study.

Medication nonadherence is fairly common, in about 30% of patients.

There are ‘non-modifiable’ factors associated with lower adherence, such as younger age, being female, and lower income level.

We think it’s helpful to be aware of these factors to increase awareness of risks and also to target programs or interventions to improve adherence,” said M. Sue Kirkman, MD, from the University of North Carolina School of Medicine, Chapel Hill, NC.

“There also are potentially modifiable factors that health care providers could target, such as getting more patients to use mail-order pharmacies or doing more to lower patients’ out-of-pocket costs,” she added.

WHO ADHERES TO MEDICATION

Many prior studies have shown that nonadherence to anti-diabetic medications is associated with many adverse outcomes, including hospitalizations, higher costs, and increased mortality.

Dr. Kirkman and colleagues conducted a retrospective analysis of a large pharmacy claims database to examine patient, medication, and prescriber factors associated with adherence to anti-diabetic medications.

They extracted data on a cohort of more than 200,000 patients who were treated for diabetes with non-insulin medications in the second half of 2010 and had continuous prescription benefits eligibility through 2011.

They used the medication possession ratio, a fairly standard way to assess adherence.

“We pre-specified a number of variables related to patient factors, provider factors, and prescription factors and looked at their association with adherence,” Dr. Kirkman said.

“We then did a multivariate model to look at the independent effects of each variable, since many of them are correlated with one another.”

WHY THEY DON’T TAKE THEIR MEDS

Overall, 69% of patients were adherent.

Nonadherence was associated with a number of factors, including younger age, being female, being new to diabetes therapy, and receiving few other medications.

Nonadherence also was associated with higher out-of-pocket costs and use of retail pharmacies vs mail order.

“We speculate that nonadherent patients may not view themselves as ‘ill’ and may be less likely to take medications for an essentially asymptomatic disease, while older patients who have more comorbidities and are more used to taking medications might be more likely to stay on their diabetes medications,” Dr. Kirkman said, noting that the researchers did not talk to patients directly.

“This suggests that acceptance of a chronic illness diagnosis and the potential consequences may be an important, but perhaps overlooked, determinant of medication-taking behavior,” she noted.

The researchers published their results online January 8, 2015, in Diabetes Care.