Econstudentlog

Diabetes and the lungs – and some related thoughts on running

“The finding of abnormal lung function in some diabetic subjects suggests that the lung should be considered a “target organ” in diabetes mellitus; however, the clinical implications of these findings in terms of respiratory disease are at present unknown.”

Malcolm Sandler wrote this almost 25 years ago. What’s happened since then? Well, I should perhaps point out that you still today have a situation where highly educated individuals who’ve had diabetes for decades may not even be aware that their disease may affect the lung tissue – I should know, because until a few years ago I didn’t know this. You care about the kidneys, you care about the feet, the eyes, the heart, sometimes the autonomous nervous system – but your lungs aren’t very likely to be brought up in a discussion with the endocrinonologist unless you happen to be a smoker, and in that case the concern is cancer risk and cardiovascular risk.

One main explanation is likely that the effects of the disease are minor, and so do not have much influence on the quality of life of the patient:

“Clear decrements in lung function have been reported in patients with diabetes over the past 2 decades, and many reports have suggested plausible pathophysiological mechanisms. However, at the present time, there are no reports of functional limitations of activities of daily living ascribable to pulmonary disease in patients with diabetes. Accordingly, this review is directed toward a description of the nature of reported lung dysfunction in diabetes, with an emphasis on the emerging potential clinical implications of such dysfunction.” (my emphasis, quote from this review)

I am interested in this matter because, well, at least partly because I’m just the kind of person who takes an interest in such matters. But recently I’ve also started to become a bit curious about whether the disease may have already have had an impact on my own lung function, ‘compared to baseline’. It’s far from certain – most studies find that microvascular complications are correlated (say if your eyes start to display signs of damage, it’s more likely that one may also observe damage to the kidneys) and that the link between those complications and metabolic control is strong; and my metabolic control is close to optimal, and my eyes and kidneys look fine.

I’m a long-distance runner. I run ~35 km/week now (and increasing with ~3 km/week), so of course I should not have breathing difficulties walking up and down stairs, and I don’t. And as the quote above makes clear even for patients who may be impacted, the damage is not likely to be all that major. So the fact that I don’t have any overt lung problems isn’t relevant – we wouldn’t expect such to present anyway. But it is worth asking whether I perform as well as I would do without my disease when I run. The obvious answer would be ‘of course not’  – for reasons unrelated to my lungs (taking blood samples take time, loading up on carbohydrates during a run after the blood sample is taken takes time – and I can’t do these things while running). But is there an impact from the lungs as well? I don’t know. Maybe. You can’t observe the counterfactual.

Which is why I thought this recent-ish meta-analysis was interesting:

“Background: Research into the association between diabetes and pulmonary function has resulted in inconsistent outcomes among studies. We performed a metaanalysis to clarify this association.

Methods: From a systematic search of the literature, we included 40 studies describing pulmonary function data of 3,182 patients with diabetes and 27,080 control subjects. Associations were summarized pooling the mean difference (MD) (standard error) between patients with diabetes and control subjects of all studies for key lung function parameters.

Results: For all studies, the pooled MD for FEV 1 , FVC, and diffusion of the lungs for carbon monoxide were -5.1 (95% CI, -6.4 to -3.7; P<.001), -6.3 (95% CI, -8.0 to -4.7; P<.001), and -7.2 (95% CI, -10.0 to -4.4; P<.001) % predicted, respectively, and for FEV 1 /FVC 0.1% (95% CI, -0.8 to 1.0; P = .78). Metaregression analyses showed that between-study heterogeneity was not explained by BMI, smoking, diabetes duration, or glycated hemoglobin (all P<.05).

Conclusions: Diabetes is associated with a modest, albeit statistically significant, impaired pulmonary function in a restrictive pattern. […]

Our metaanalysis shows that diabetes, in the absence of overt pulmonary disease, is associated with a modest, albeit statistically significant, impaired pulmonary function in a restrictive pattern. The results were irrespective of BMI, smoking, diabetes duration, and HbA1c levels. In subanalyses, the association seemed to be more pronounced in type 2 diabetes than in type 1 diabetes. Our study adds evidence for yet another organ system to be involved in bothtype 1 and type 2 diabetes. As a consequence of exclusion criteria, the levels of functional impairment fell within values that are generally considered to be normal. However, to place this in perspective, the magnitude of impairment found in our study closely resembles that of smoking per se.57 Similarly, given the relatively high prevalence of diabetes in COPD,58 it is tempting to speculate that (uncontrolled) diabetes may accelerate progressive lung function decline. However, from our metaanalysis summarizing crosssectional studies, it is difficult to draw conclusions on causality and progression into overt pulmonary diseases.” (my emphasis)

Whether you smoke or not is certainly not a trivial effect when you’re considering the fitness level of a long-distance runner! I know the effects are smaller for T1’s, but this is most certainly an effect to have in mind. Back when I ran my marathon three years ago both me and my brother were surprised that he did so much better than I did (he came in more than half an hour before I did, despite the fact that we both assumed beforehand that I was the one who was in better shape).

I consider some of the findings quite weird, and it’s hard to make heads or tails of some of this stuff:

“One would expect that a longer exposure to diabetes would proportionally increase the chance of connective tissue being nonenzymatically glycated. However, our study suggests that a longer duration is not necessarily associated with additional loss of pulmonary reserves. This is in line with previous longitudinal studies on this topic.59,60 […]

It is intriguing to observe that the pulmonary system remains relatively spared in diabetes when compared with other organs with wide microvascular beds. It is speculated that the large pulmonary reserves protect against severe pulmonary dysfunction.

Because neither the duration of diabetes nor glycemic state appeared to influence the association in our study, one might question whether there is a causal relationship between diabetes and impaired pulmonary function.”

I’ll try to keep my eyes open for updates on this stuff – although the estimated effects may not be big enough for people to seek out medical advice, they’re huge if you’re a long-distance runner considering whether it’s even worth it to participate in future official runs solely for the sake of improving your performance in such competitions.

On a sidenote I should point out that I don’t (/no longer) run in order to obtain a faster time in an official run – I run because I like to run, and I no longer have much desire to participate in official runs – but I’d be lying if I said I didn’t care at all about that stuff some years back when I started out participating in such runs. Imagine what happens with your desire to participate in such official runs if you don’t seem to be able to improve your time much even with strict adherence to running schedules, especially considering the fact that other people who in other respects are similar to you can out-perform you without doing a lot of work. I was above 70 km/week and had several 30+ kilometer runs behind me before my marathon; my brother never even crossed the 40 km/week threshold. And he beat me by more than half an hour. Go figure. I had a bad run for diabetes-related reasons so during the day this was not a surprising outcome, but it was a profoundly annoying outcome. And no, I was not ‘overtraining’; I was rather at the point where a 25+ km run was the ‘standard running distance’ – you know, that distance you managed without thinking much about it every Tuesday, and Saturday, with a short 20 km run in between – and I decreased the kilometer count up to the run as advised by the plan I was following (more or less stringently, but compared to the people whom I entered the goal line with the word ‘more’ is by far the more accurate one). And no, it’s not like I hadn’t heard about interval training, and it’s not like this stuff is hard to implement in a hilly place like Aarhus.

I did make progress from I started running to the point where I decided not to really consider ‘official runs’ to be be worth it anymore – the first half-marathon took me more than 2 hours, the best one I did in an hour and 47 minutes (this performance was achieved at a point in time where I ran 65 km/week and at least cared somewhat about speed and time taken – so, yeah… Compare this again with my brother, whose next goal is 1.35, without ever having been near 50 km/week). Right now my ‘standard running distance’ is 12-15 km – I like to run, but I have a very limited desire to participate in official runs in the future. It’s not worth it – if I go back to very-high intensity training I may improve my official performances, but that could just as easily be due to factors completely unrelated to my actual shape, like whether I was lucky about the starting blood glucose (fewer tests during the run, less time wasted on that), or whether I’d slept well. Who cares? And it’s not like I need to participate in these runs to motivate myself to get out there – I find running enjoyable as it is, especially in the summer when the weather is nice.

But in case you’d forgotten because of all the personal stuff in the end – to just reiterate the main points that made me start out writing this post:

“Diabetes is associated with a modest, albeit statistically significant, impaired pulmonary function in a restrictive pattern. […] the magnitude of impairment found in our study closely resembles that of smoking”.

This is perhaps also a good illustration of how dangerous diabetes is; the fact that the disease may impact the performance of the lungs in a manner not too dissimilar from smoking is not even considered clinically relevant; the patients have much bigger problems to worry about as it is.

May 21, 2013 - Posted by | diabetes, papers, personal

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