Diabetes Pill Might Replace Injection to Control Blood Sugar

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An injectable class of diabetes medication — called glucagon-like peptide-1 or GLP-1 — might one day be available in pill form, research suggests.

Based on the results of a global phase 2 clinical trial, the study authors reported a significant drop in blood sugar levels for people on the oral medication, and no significant increase in low blood sugar levels (hypoglycemia) compared to a placebo over six months.

The findings also showed that people taking the highest dose of the pill lost a large amount of weight — about 15 pounds — compared to a weight loss of fewer than 3 pounds for people on the inactive placebo pill.

The research was funded by Novo Nordisk, the company that makes the drug, called oral semaglutide.

“Semaglutide could transform diabetes treatment,” said Dr. Robert Courgi, an endocrinologist at Southside Hospital in Bay Shore, N.Y.

“Glucagon-like peptide receptor agonists are agents that are highly recommended according to diabetes guidelines, but rarely used because they require injection. Most patients prefer a pill,” Courgi explained.

Dr. Joel Zonszein, director of the clinical diabetes center at Montefiore Medical Center in New York City, agreed that these new findings were exciting.

“This medication looks pretty good. The high dose matched the [injection] version. There was low hypoglycemia. It controls blood glucose. There was weight loss and it’s not an injection. This is the same molecule that’s been shown [as an injection] to decrease cardiovascular mortality,” Zonszein said.

“It has all the ingredients for an excellent medication. If this comes to market, it would be very good for people with type 2 diabetes,” he added.

Zonszein and Courgi were not involved in the current study.

The study included just over 1,100 people with type 2 diabetes recruited from 100 centers in 14 countries around the world.

The volunteers’ average age was 57. The average time they’d had type 2 diabetes was six years. On average, they were considered obese.

The participants’ average hemoglobin (HbA1C) levels were between 7 and 9.5 percent. HbA1C — also called A1C — is a measure of average blood sugar control over two to three months. The American Diabetes Association generally recommends an HbA1C of less than 7 percent for most people with type 2 diabetes.

The study volunteers were randomly placed into treatment groups that lasted 26 weeks. One group was given a once-weekly injection containing 1.0 milligram (mg) of semaglutide. Five groups were given one of five doses of oral semaglutide — 2.5, 5, 10, 20 or 40 mg. Another group was given escalating doses of the pill version, starting with the smallest dose and ending at 40 mg. The final group was given an oral placebo.

The highest dose of the pill performed similarly to the injectable form as far as blood sugar control and weight loss. Those on the 40-mg oral dose and those who got the injection saw an average drop in their HbA1C of 1.9 percent, the study showed. More than 70 percent of those who took the pill saw a weight loss of at least 5 percent.

According to the study’s lead author, Dr. Melanie Davies, “The A1C reductions and weight loss were very impressive and similar to what we’ve seen with the weekly injection of semaglutide.” Davies is a professor of diabetes medicine at the Diabetes Research Centre at the University of Leicester in England.

The two forms of the drug were also similar in the reported side effects, which affected up to around 80 percent of those taking both forms of the drug. The most common side effects were mild to moderate digestive concerns that tended to go away with time. Nausea was less common in people who started on the lowest dose and then were given stronger doses.

There were three reported cases of pancreatitis — inflammation of the pancreas — a potentially serious condition that has been linked to this class of medication in previous studies. One person was taking the injectable form of the drug. The other two were on the oral drug — 20 mg and 40 mg.

Zonszein noted that “pancreatitis was a bit more in those who took the drug. This may be an issue we have to pay attention to, and it may help to start with a lower dose.”

He also added that GLP-1 drugs, whether by injection or by mouth, should be given in combination with the standard first line type 2 diabetes drug metformin.

“We get more mileage from combining drugs and patients really do much better,” Zonszein said.

Findings from the study were published in October in the Journal of the American Medical Association. Davies said phase 3 trials of the pill are already well under way.

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Diabetes Technology Moves Closer To Making Life Easier For Patients

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Pricking your fingers may someday be a thing of the past for diabetics as new technologies aim to make blood sugar regulation more convenient.

For people with diabetes, keeping blood sugar levels in a normal range – not too high or too low – is a lifelong challenge. New technologies to ease the burden are emerging rapidly, but insurance reimbursement challenges, supply shortages, and shifting competition make it tough for patients to access them quickly.

One new product is a fast-acting insulin from Novo Nordisk. It is designed to help to minimize the high blood sugar spikes that often occur when people with diabetes eat a meal containing carbohydrates.

This new formulation, branded “Fiasp,” adds niacinamide (vitamin B3), which roughly doubles the speed of initial insulin absorption compared to current fast-acting insulins taken at mealtime. This new insulin hits the bloodstream in under three minutes.

Another advance is Abbott’s new monitoring device called the FreeStyle Libre Flash. It’s new in the U.S. but has been available in Europe since 2014. It’s a round patch with a catheter that is inserted on the arm for up to 10 days and a durable scanning device that the user waves over the patch to read their blood sugar level.

The FreeStyle Libre Flash lets users monitor blood glucose levels without having to frequently prick their fingers for blood testing.

The Libre works a bit differently than the two currently available continuous glucose monitors (CGMs) made by Dexcom and Medtronic. The Libre doesn’t require users to prick their fingers for blood tests to calibrate it, whereas users of the other monitors must perform twice-daily fingerstick calibrations.

Also, the Libre is approved for longer wear – 10 days (14 in Europe) versus seven days for the two current CGMs. And, it is likely to be considerably less expensive, although Abbott isn’t providing cost information for the U.S. just yet. In Europe, the Libre system costs about four Euros a day (about $4.70).

But, unlike the current devices, the Libre doesn’t issue alarms to users when their blood glucose levels get too high or too low. And the U.S. version also doesn’t allow for the “share” capability, by which loved ones can follow Dexcom glucose monitor users’ blood sugar levels remotely via a smartphone app.

The Libre has been extremely popular in Europe among people with type 1 diabetes. There, fewer people use traditional CGMs compared to the U.S., in large part because they are not frequently covered by European insurance.

Type 1 diabetes requires regular insulin doses to allow cells to use glucose, because the pancreas does not make any of its own. With type 2 diabetes, the insulin being made doesn’t adequately meet the body’s needs.

About a quarter of people with type 2 diabetes take insulin, and of those, a smaller number take fast-acting insulin before meals. Those doses can lead to low or high blood glucose levels if not matched perfectly by timing and amount to the meal’s carbohydrates. There’s lots of room for user error.

University of California, Los Angeles endocrinologist Dr. David T. Ahn, who specializes in diabetes technology, believes that in the U.S., the Libre will be more useful for people with type 2 diabetes. Most people with type 2 do not use CGMs and may also not perform frequent fingerstick checks.

“I think it’s something that really empowers people, and that’s what’s really exciting, Ahn says. “[Y]ou literally see firsthand what exercise, diet, rest, and stress do to your blood sugars.”

Of course, he adds, “There’s benefit really for everybody, but the most important question is where is the cost justified. I would say that at least right now, it probably is only worth the cost for someone on insulin, especially on fast-acting insulin.”

Jared Watkin president of Abbott Diabetes Care Division, tells Shots that the Libre was designed for people with either type of diabetes who require frequent glucose testing, and the lack of alarms was intentional. Research shows “alarm fatigue” is one of two main reasons many patients mention for not wanting to use CGM systems, he says. The other reason is cost.

He points out that research on the Libre has also shown that people using the device achieve better glucose control and experience fewer low blood sugar episodes overnight compared to fingersticks alone even without the alarms, presumably because they’re making more insulin dose adjustments.

Aaron Kowalski is the chief mission officer for JDRF, formerly the Juvenile Diabetes Research Foundation, which funds much of the research into diabetes technologies. He says it will be interesting to see how U.S. patients with type 1 diabetes who haven’t adopted CGM take to the Libre. “If you’re coming at it from fingersticking, it makes massive sense … For some people with type 1, I think it will be a really good option.”

Closing the Loop: Progress And Pitfalls

Both continuous glucose sensing and fast-acting insulin are critical components to the development of so-called “closed-loop” or artificial pancreas systems, which aim to automate insulin delivery to the point that patients themselves don’t need to make complicated and error-prone calculations about how many carbs are in their meals or how much to cut back their insulin doses for exercise.

In September 2016, The U.S. Food and Drug Administration approved Medtronic’s 670G, the first device that partially accomplishes the closed-loop goal via an algorithm that allows the system’s CGM to instruct its insulin pump to cut off delivery if the user’s blood sugar drops, or increase it if the levels go too high.

Several other companies are working on similar technology. One of those, a start-up called Bigfoot Biomedical is working with Abbott to use a next-generation version of the Libre’s sensor. Except for Medtronic, the other major closed-loop competitors – Insulet, Tandem, and Beta-Bionics – are all collaborating with Dexcom.

Bumps in the Road, But Optimism Overall

As might be expected, not everything in this field has gone smoothly. Due to both high demand and the fact that one of Medtronic’s manufacturing plants located in Puerto Rico was damaged by Hurricane Maria, it has been unable to ship part of the 670G to new users, and may not be able to meet demand until 2018.

In addition, the insurance company Anthem has said it won’t cover the 670G because it has concluded “there is not yet enough data on the longer-term safety and efficacy” for the system.

Meanwhile, although Medicare agreed in January 2017 to cover the Dexcom continuous glucose monitor for beneficiaries who use insulin, the agency recently determined that the device would not be covered if beneficiaries use the accompanying smartphone app that reads the glucose levels via bluetooth, because it doesn’t meet the definition for “durable medical equipment.”

The decision means that seniors have to carry around a separate receiver device, and don’t have access to the share function. Dexcom is negotiating with federal regulators to work out a solution. In a recent blog post, Ahn wrote “While CGM approval by Dexcom is a huge win overall (it really is), restricting smartphone integration is absolutely ridiculous.”

In another blow to the diabetes technology world, major pump manufacturer Animus recently announced that it was pulling out of the market and is shifting its approximately 90,000 current customers to Medtronic. Not surprisingly, some of Medtronic’s competitors are offering deals to lure them to their own products.

Despite the roadblocks, Kowalski says, “I have tremendous optimism about the future for people with type 1 diabetes. These tools are really starting to … improving blood sugar and making life easier. And that’s a great thing. The more options the better.”

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Voice-powered, in-home care platform wins Amazon Alexa diabetes competition

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Seattle-based Wellpepper, developers of a digital patient engagement service, have been announced the winners of the Alexa Diabetes Challenge for their voice-enabled diabetes support platform Sugarpod.

Consisting of a scale, foot scanner, and mobile interface along with a Amazon Alexa voice functionality, Sugarpod is designed to support type 2 diabetes care plans by integrating engagement and regular screening into a patient’s daily routine, Wellpepper CEO and Cofounder Anne Weiler explained. The prototype platform does so by living in the home, and permitting numerous engagement interfaces via SMS, email, web, mobile app, and voice.

“There are times when voice is a fantastic interface, and times when voice is not the right interface,” Weiler told MobiHealthNews. “We see this as one of many interfaces that you can use to engage people and meet them where they are.”
Weiler said that the inclusion of prototype hardware in the scale and scanner was new ground for her team, whose existing Wellpepper platform is software-based. However, they pursued the concept when they realized that having both the scale and the scanner in a diabetes patient’s home offered a unique opportunity for regular home check-ins.

“First thing in the morning, [a user] steps on the scale. It takes her weight and then it also asks if it can take pictures of her feet, and then it puts those through a machine-learning image classifier that looks for problems,” Weiler said. “It’s basically looking for early indication of diabetic foot ulcers. Diabetic foot ulcers cost the health system $9 billion a year, and people who have them are at greater risk of amputation, hospitalization, and even death.”

Along with gathering these data, Sugarpod asks users questions about their habits and provides diabetes management tips, relevant educational material, and messages from their care professional. If voice prompts aren’t convenient, patients can also access all of this information on their smart devices through the accompanying mobile app, Weiler explained.

“So, she can do things like take a survey, or she may snap a picture of her lunch to share with her health coach. And then when she gets home in the evening she may interact again with her care plan either on the mobile device or via voice with the Amazon Echo,” she said.

While the platform was imagined and pitched as an in-home solution, the team deployed Sugarpod within health clinics to test and fine-tune its capabilities during development. In light of this implementation’s extremely positive feedback from users and clinicians, Weiler said that her team is no longer ruling out its uses within provider settings as they make plans to move forward with the new platform.

The Alexa Diabetes Challenge was sponsored by Merck, supported by Amazon Web Services, and organized by Luminary Labs. The competition was announced in April, with a submission deadline just a month later. Five finalists were selected among 96 submissions to move into a “Virtual Accelerator” stage of the competition, where they received mentorship in preparation for a live demo for judges in late September. Along with Wellpepper’s $125,000 grand prize, each finalist also received $25,000 in funds and $10,000 in credit to finance their Amazon Web Service usage.

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Celiac Disease May Follow Type 1 Diabetes

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Screening for early signs of both conditions should be done at birth, study suggests

Parents of young children with type 1 diabetes need to be on the lookout for symptoms of another autoimmune condition — celiac disease, new research suggests.

The study found these youngsters appear to face a nearly tripled risk of developing celiac disease autoantibodies, which eventually can lead to the disorder.

Type 1 diabetes and celiac disease are closely related genetically,” explained study author Dr. William Hagopian.

“People with one disease tend to get the other. People who have type 1 diabetes autoantibodies should get screened for celiac autoantibodies,” Hagopian said. He directs the diabetes program at the Pacific Northwest Research Institute in Seattle.

Type 1 diabetes is an autoimmune disease that causes the body’s immune system to mistakenly attack the insulin-producing cells in the pancreas, according to the American Diabetes Association. Insulin is a hormone that helps to usher the sugar from foods into the body’s cells to be used as fuel. Because the autoimmune attack leaves people with type 1 diabetes without enough insulin, they must replace the lost insulin through injections or an insulin pump with a temporary tube inserted under the skin.

Celiac disease is an autoimmune disease that causes the immune system to attack the lining of the small intestine when gluten is consumed, according to the Celiac Disease Foundation. Gluten is a protein found in wheat. Symptoms of celiac disease include stomach pain and bloating, diarrhea, vomiting, constipation, weight loss, fatigue and delayed growth and puberty.

Dr. James Grendell is chief of the division of gastroenterology at NYU Winthrop Hospital in Mineola, N.Y. He explained why knowing ahead of time that celiac may be developing can be helpful.

“Early diagnosis of celiac disease is important to initiate treatment with a gluten-free diet to prevent complications, particularly growth retardation in children,” he said.

“Other significant complications include iron-deficiency anemia, osteoporosis and a form of skin rash. Less common, but potentially lethal, complications include lymphoma and carcinoma of the small intestine,” Grendell added.

Treatment for the disease is avoiding eating or drinking anything containing gluten.

According to Hagopian, “Celiac is about three times more common in the general population than type 1 diabetes.”

Previous research has pegged the co-occurrence of type 1 diabetes and celiac disease at around 5 percent to 8 percent, the study authors said.

To get a better idea of when these diseases start to occur together, as well as what might trigger them, the researchers looked at data from a prospective study of children with a high genetic risk of developing type 1 diabetes. The primary aim of the study was to find environmental causes of type 1 diabetes.

The research included almost 6,000 youngsters from six U.S. and European medical centers. The participants all had the necessary autoantibody testing. The median follow-up time was 66 months (5.5 years), the study said.

Autoantibodies linked to type 1 diabetes were found in 367 children, according to the report. Autoantibodies linked to celiac disease were found in 808 youngsters. Autoantibodies associated with both conditions were found in 90 children.

Autoantibodies for type 1 diabetes typically appeared before those for celiac disease, the study authors noted.

That doesn’t necessarily mean that type 1 diabetes caused the development of celiac autoantibodies, said Dr. Christine Ferrara, an adjunct assistant professor at the University of California, San Francisco. She co-authored an editorial that accompanied the study.

“The results of this paper demonstrate an association, but do not establish causation,” Ferrara said.

The findings were published online Oct. 10 in the journal Pediatrics.

Hagopian said it’s possible that type 1 diabetes may somehow trigger celiac disease. But it could also be an overlapping environmental factor that starts the disease process in both cases, he added.

Ferrara explained that “people need to recognize that regulation of the immune system underlies multiple disease processes.”

Hagopian said it’s important to note that the study only looked at children under 6.

Grendell agreed with Hagopian that a diagnosis of type 1 should signal the need to look for celiac disease.

“The take-home message for the public is that type 1 diabetes mellitus appears to be a risk factor for the development of celiac disease and, as already recommended, patients [usually children] diagnosed with type 1 diabetes mellitus should be screened for this highly treatable disease,” he said.

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No More Finger Prick. New Technology May Help with Diabetes Management.

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The FreeStyle Libre system allows people with diabetes to check their glucose without a skin prick, but there are concerns about its lack of alarms.

diabetes finger prick

Type 1 and type 2 diabetes technology and medications have come a long way since the invention of insulin in 1921.

But day-to-day management still requires countless finger pricks to draw blood and measure glucose levels.

FreeStyle Libre Flash Glucose Monitoring System, manufactured by Abbott Diabetes Care Inc. and officially approved on September 27 by the U.S. Food and Drug Administration (FDA), strives to be a true game-changer for people with diabetes.

Unlike the Dexcom or Medtronic’s Guardian and Enlite continuous glucose monitors (CGM), which require a minimum of twice-daily finger pricks to calibrate the CGM’s readings with that of a traditional blood glucometer, the Libre system requires zero calibration.

The technology is still similar in that the Libre also uses a small sensor wire that a patient inserts into their subcutaneous tissue.

This sensor measures glucose levels in the interstitial (body fat) fluid versus glucose in the bloodstream.

How the device works

Where the technology continues to differ greatly is in how the glucose levels measured by the sensor wire are then reported to the person using it.

From the get-go, the Libre requires a lengthy 12-hour startup period before the sensor is able to measure and report glucose levels while the Dexcom and Medtronic sensors startup window is a mere two hours.

The most significant difference between these technologies is that the Libre isn’t “continuous.”

When a patient wants to measure their blood glucose level, the Libre requires them to wave a small handheld “mobile reader” over the part of the body where their sensor is located.

The handheld device then displays the glucose level, allowing the user to determine if it’s too high (hyperglycemia) or too low (hypoglycemia).

Dexcom and Medtronic CGMs both send blood glucose data wirelessly to a handheld device (or the user’s own iPhone), which displays a simple graph with new glucose measurements automatically marked every five minutes.

The Libre sensor itself can be used for up to 10 days.

Dexcom and Medtronic’s sensors are FDA approved for use up to seven days, but users of these CGMs have learned that simply stopping and restarting the sensor’s “startup” process enables them to use a sensor for as long as the sensor’s tape keeps it attached to their body.

Many report getting 10 to 14 days out of a sensor.

“I’ve gotten as much as 22 days out of one Dexcom sensor,” reports Sarah “Sugabetic” Kaye, who has lived with type 1 diabetes for 29 years and is well-known in the blogging community for her diabetes technology reviews at

All three glucose monitoring technologies provide a graph on their handheld devices, allowing patients and their healthcare providers to identify patterns and make changes in their medication regimen and improve overall blood glucose levels.

Missing a critical detail

As groundbreaking as the FreeStyle Libre’s prick-less and zero-calibration system may be, the most notable shortcoming of this new technology is its lack of alarms.

“Libre is a good option for those who don’t check their blood sugar a whole lot using traditional finger-stick meters,” explained Gary Scheiner, MS, CDE, author of “Think Like a Pancreas” and founder of Integrated Diabetes Services.

“It’s easy to use and minimally inconvenient. And it will provide healthcare providers with some robust data for making beneficial recommendations and adjustments,” he told Healthline.

“However, I don’t think many current CGM users will (or should) switch to Libre since it lacks those all-important high and low blood sugar alerts. Without early high and low warnings, users open themselves up to potentially dangerous hypoglycemia as well as prolonged and more severe hyperglycemia.”

In addition to simply alerting patients when their blood glucose levels are rising or falling with indicating arrows, Dexcom and Medtronic technology allow them to customize their own alarm settings, and automatically alert them if glucose levels drop below 55 milligrams per deciliter (mg/dL).

This customizable alert feature is crucial, for example, because the blood sugar goals for a patient during pregnancy will be tighter than the goals of a non-pregnant patient.

Blood sugar goals for a teenager or a young child are generally going to be far more lenient than they would be for an adult.

Those with a history of “hypoglycemia unawareness,” in which they no longer experience symptoms of low blood sugars such as lightheadedness and trembling, would likely want to be alerted far sooner than others.

For parents of children with diabetes, the alarms provide a level of security and peace of mind, especially while children are sleeping, playing sports, at recess, or at a friend’s home for a sleepover.

Reluctant to make the switch

The lack of alarms in the Libre isn’t just an inconvenience, it may actually deem the technology useless for many.

This crucial detail is likely the strongest motivators for a patient being willing to wear a sensor wire in their flesh 24 hours a day, 7 days a week.

“For me, the purpose of a monitoring system is to have those alerts and alarms,” Kaye told Healthline. “If it doesn’t do that, then using a standard meter is just as good as the Libre in my opinion. To be honest, the Libre is not even on my radar of interest because of the lack of alarms.”

While all of the sensors themselves are thin and short, they are inserted with a large, thick needle, which is a quick but still painful application process.

Possible side effects of wearing any type of sensor include skin rashes due to the medical tape, constantly healing punctures from past sensor locations, and the constant presence of the noticeable external parts of the device that can be as thick as a stack of three or four quarters sitting on the skin.

The trade-off for that sometimes tedious discomfort is the safety and security provided by the alarms.

Those pertinent alarms are also perhaps the only way to reduce the anxiety and worry that any patient (or their parents) taking daily doses of insulin inevitably experience due to the risks associated with taking even just slightly too much or too little.

“The Libre feels like a good replacement for your traditional blood glucose meter,” explained Scott Benner, host of the all-things-diabetes Juicebox Podcast and whose daughter was diagnosed with type 1 diabetes as a toddler. “However, the lack of the ‘C’ in the ‘CGM’ makes the Libre an unworthy competitor to the Dexcom [or Medtronic] device. The ‘C’ in continuous glucose monitoring is where the value lies.”

Already available in more than 40 countries, the FreeStyle Libre system is expected to be available in the United States by the end of this year.

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Diabetes Prevention is Essential

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Andrew Boulton, MD, is feeling “cynical” about the global diabetes scourge. But as soon as he admits that, he changes his description to “realistic.”

Andrew Boulton, MD

“We’re in an epidemic, and it’s getting worse,” says the immediate past president of the European Association for the Study of Diabetes (EASD). In Pakistan, for instance, 1 in 4 people has diabetes, and in India, the prevalence has doubled in the past 15 years, he says. He places some of the blame on the “McDonald’s-ization of the world,” plus society’s aversion to walking and cycling in favor of driving cool cars.

“I wonder if legs will still be needed in the future,” he says wryly.

At the annual meeting of the EASD, held recently in Lisbon, Portugal, the big news was about clinical trials of new drugs or new uses for older drugs, and particularly about the arrival of diabetes medications that not only control glucose but also offer some cardiovascular and renal protection for people who use them. Dr Boulton was EASD president when the first such drug was validated at this conference 2 years ago, and he has witnessed great improvements in diabetes care over the course of his career. Yet, he remains skeptical.

“It’s great to have new drugs,” he says, “but we also need to be more active in primary prevention.”

Dr Boulton’s frustration with a lack of progress in stemming the international diabetes epidemic is evident, and he’s not the only one.

Last year, at the annual meeting of the American Diabetes Association, then-president Desmond Schatz, MD, delivered an impassioned speech about the “staggering” prevalence of diabetes and about the need for improvements in diagnosis and treatment, along with increased funding for research.

Studies show that about one half of all type 2 diabetes cases could be prevented with lifestyle adjustments, Dr Boulton notes. But the burden of prevention shouldn’t be placed on individuals alone.

“We need societal adjustments as well,” he says. Cities and buildings need to be designed in ways that encourage healthier lifestyles, such as improving public transportation and walking paths. Advocacy organizations, such as the International Diabetes Federation, need to be more proactive in advancing the diabetes agenda.

“They need to be heard; they need to be seen!” Dr Boulton says. Right now, governments still don’t take diabetes very seriously, especially compared with the attention and funding dedicated to cancer. Leaders of the diabetes community could learn from efforts to raise awareness and drive research in the field of cancer, he said, as well as from efforts to increase cancer screening.

“Fear arousal works,” he says. Many more people now get mammograms and other cancer screenings because they don’t want to die of cancer.

Unfortunately, prevention and screening are harder to “sell” with diabetes.

“The thing is, it’s not very sexy to take off your socks and shoes,” Dr Boulton says, referring to diabetic foot exams.

“But it works. You don’t need anything expensive to screen. The most important thing is to look at the eyes and the feet. And it’s the same with the kidney; you just need a urine test,” he continued.

“We’re talking about very simple tools that can be used in primary care that everyone with diabetes should have done once a year. And that would have a huge impact and would reduce costs by trillions of dollars each year.”

Everyone knows these things, Dr Boulton says, but it’s still tempting to instead focus on a novel drug that reduces the desire for sweets, for example.

“We can talk about all this fancy new stuff, but we’ve got to do the basics first,” he said.

As he contemplates the proliferation of restaurant food buffets, and valet service that keeps customers from walking even a short distance from their cars, Dr Boulton’s cynicism resurfaces. The end of the EASD meeting signals the start of another year for more education and advocacy for diabetes prevention and care.

“Maybe I’ll be more optimistic a year from now,” Dr Boulton says unconvincingly.

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How Red Meat and Poultry Tied Effect Type 2 Diabetes

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Eating red meat or darker cuts of poultry may be associated with increased risk of type 2 diabetes, with higher levels of consumption linked to higher risk, according to new results from the Singapore Chinese Health Study, published in the American Journal of Epidemiology.

The trial is one of the largest to evaluate meat consumption and diabetes risk in Asian populations.

“Compared with those who ate the least amount, those with the highest levels (approximately one serving a day) of red meat or poultry consumption had a 23% and 15% increased risk of diabetes, respectively,” lead author Woon-Puay Koh, PhD, a professor at Duke-NUS Medical School, Singapore, commented by email.

Results also suggest that different types of meat may have different effects on type 2 diabetes risk. Varying levels of heme iron, which is found only in meat, may be involved.

“After adjustment for heme-iron content in the diet, the red-meat/diabetes association was still present, suggesting that other chemicals present in red meat could be accountable for the increase in risk of diabetes,” Dr Koh explained.

“Conversely, the association between poultry intake and diabetes risk went away, suggesting that this risk was attributable to the heme-iron content in poultry.” The darker cuts of poultry, such as chicken thighs, have higher heme-iron content than breast meat, she noted.

Results also indicate that the increased diabetes risk associated with red meat and poultry was reduced if they were substituted by fish or shellfish. “Replacement of red meat and poultry with fish/shellfish may reduce type 2 diabetes risk, and it is worth testing this theory in experimental studies,” she added.

Asked for outside comment, Keith Ayoob, EdD, a nutritionist and associate professor emeritus at Albert Einstein College of Medicine, New York, noted several strengths of the study, including the long-term follow-up, the large study population, and face-to-face dietary interviews.

But, he said, it’s still a big leap to say that consumption of heme iron increases the risk of type 2 diabetes.

Rather than advocating one particular dietary pattern or nutrient over any other, Dr Ayoob emphasized overall lifestyle: physical activity, controlling portion size, and food preparation that stresses lean foods over fried and fatty ones.

“It’s not about one food, it’s about a lifestyle. That’s where I’d put my money as a clinician. Would I tell someone to eat more fish? Yes. Would I tell them to eat lean red meat? Yes. I’d take a lean strip steak over fried chicken breasts, hands down.”

Is Heme Iron One of the Culprits?

Past studies in Western populations have linked red-meat consumption to increased risk for type 2 diabetes, but results in Asian populations are varied.

That may partly be due to different dietary patterns. Compared with Western populations, Asians tend to eat less red meat overall — more pork and less beef — and more poultry and fish or shellfish. Cooking styles also vary, which may have an impact on diabetes risk. Asians also develop type 2 diabetes at a lower BMI than Western populations.

To further investigate the issue, the researchers conducted a cohort study that included 63,257 middle-aged and elderly Chinese adults in Singapore (mean age, 55.2 years; 57.3% women). At the beginning, participants were interviewed and self-reported their usual diet over the past year on a questionnaire developed and tested just for this population. At two follow-up interviews, participants self-reported physician-diagnosed type 2 diabetes. Participants were followed for an average of 11 years.

Analyses were adjusted for multiple variables related to age, sex, education, physical activity, smoking, alcohol intake, high blood pressure, and dietary pattern.

Results showed that the highest intake of red meat and poultry was significantly linked to type 2 diabetes, compared with the lowest intake (red meat multivariate adjusted HR, 1.23; P for trend < .001; poultry HR, 1.15; P for trend = .004).

Risk of type 2 diabetes was not significantly linked to eating fish/shellfish (HR, 1.07; P for trend = .12).

Replacing one serving per day of red meat or poultry with fish/shellfish was linked to 26% and 22% lower risk of type 2 diabetes, respectively.

Analyses adjusting for heme iron intake showed that the association with poultry disappeared, and only red meat intake remained significantly associated with type 2 diabetes (HR, 1.13; P for trend = .02).

Other studies have suggested a link between dietary heme iron intake and increased type 2 diabetes risk.

“A high intake of red meat, which contains high concentrations of heme iron, can lead to heme-iron accumulation in our body,” Dr Koh noted.

While the mechanism remains unclear, Dr Koh explained that keeping the right balance of iron in the body is critical: too little can lead to anemia, while too much can increase oxidative stress and damage tissues. In particular, the insulin-producing cells of the pancreas tend to be sensitive to oxidative stress.

That suggests that heme iron may be mediating the increased type 2 diabetes risk with poultry, but more may be going on with red meat.

Other components in red meat, like advanced glycation end products, may also contribute to insulin resistance. And eating red meat can promote inflammation. These other factors may muddy the picture, which could explain why heme iron seemed to only partially mediate the link between red-meat consumption and type 2 diabetes.

Describing the key take-home message for the public in a press release from her institution, Dr Koh concluded: “We don’t need to remove meat from the diet entirely. Singaporeans just need to reduce the daily intake, especially for red meat, and choose chicken breast and fish/shellfish or plant-based protein food and dairy products to reduce the risk of diabetes.

“We want to provide the public with information to make evidence-based choices in picking the healthier food to reduce disease risk.”

Improve Overall Lifestyle: Help People Eat “Beyond the Headlines”

Dr Ayoob said the observational nature of this Singapore study means that the results can be used only to generate a hypothesis, not prove that consuming heme iron causes increased risk for type 2 diabetes.

Other factors may explain the results.

For example, people who ate more red meat were less likely to exercise, and being sedentary could have contributed to increased risk of type 2 diabetes.

Also, the study lumped pork and beef together, which could affect results. Finally, levels of heme iron may vary based on types of meat consumed: fatty cuts of red meat may have less heme iron than leaner cuts and chicken.

And one of the biggest limitations is that researchers assessed dietary intake and physical activity only at the beginning of the study, he pointed out.

“The taking of dietary data only once at baseline is a red flag for me,” he said, “I’m a nutritionist, and I’ve changed my diet in 20 years. I can’t imagine that other people haven’t. That’s just unrealistic.

“The study is too vague and has too many unknowns to draw conclusions that can help in clinical practice,” he said, “A good study helps people like myself counsel patients. Poor studies add to confusion. I have to help people eat ‘beyond the headlines,’ so they don’t feel they have to change their diets after every study.”

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Fracture Risk Higher for Seniors With Diabetes

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Bone weaknesses seen in those with blood sugar disease

WEDNESDAY, Sept. 20, 2017 (HealthDay News) — Seniors with type 2 diabetes may be at increased risk for fractures. And researchers think they know why.

“Fracture in older adults with type 2 diabetes is a highly important public health problem and will only increase with the aging of the population and growing epidemic of diabetes,” said study author Dr. Elizabeth Samelson.

Samelson and her colleagues used special medical scans to assess more than 1,000 people over a three-year study period. The investigators found that older adults with type 2 diabetes had bone weakness that cannot be measured by standard bone density testing.

“Our findings identify skeletal deficits that may contribute to excess fracture risk in older adults with diabetes and may ultimately lead to new approaches to improve prevention and treatment,” said Samelson, of Hebrew SeniorLife’s Institute for Aging Research in Boston.

Fractures among seniors with osteoporosis — the age-related bone-thinning disease — are a major concern. Such fractures can lead to decreased quality of life, disability and even death, as well as significant health care costs, she said in an institute news release.

Even those with normal or higher bone density than their peers appeared to have a higher fracture risk if they had type 2 diabetes, the researchers said.

Specifically, these people had a 40 percent to 50 percent increased risk of hip fracture, the findings showed. This is considered the most serious type of osteoporosis-related fracture.

The study authors said that better understanding of the various factors that influence bone strength and fractures will aid prevention efforts.

The report was published Sept. 20 in the Journal of Bone and Mineral Research.

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Type 2 Diabetes is ‘Reversible Through Weight Loss’

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having blood sugar checked
Experts urge healthcare professionals to better record remission rates.
Many doctors and patients do not realize that weight loss can reverse type 2 diabetes. Instead, there is a widespread belief that the disease is “progressive and incurable,” according to a new report published in the BMJ.

This is despite there being “consistent evidence” that shedding around 33 pounds (15 kilograms) often produces “total remission” of type 2 diabetes, note Prof. Mike E. J. Lean and other researchers from the University of Glasgow in the United Kingdom.

The thrust of their paper is that greater awareness, when combined with better recording and monitoring of remissions, could result in many more patients no longer having to live with type 2 diabetes and a massive reduction in healthcare costs.

The global burden of type 2 diabetes has nearly quadrupled over the past 35 years. In 1980, there were around 108 million people with the disease, and by 2014, this number had risen to 422 million.

The vast majority of diabetes cases are type 2 diabetes, which is a disease that results when the body becomes less effective at using insulin to help cells to convert blood sugar, or glucose, into energy. Excess body weight is a main cause of this type of diabetes.

In the United States, an estimated 30.3 million people, or around 9.4 percent of the population, have diabetes – including around 7.2 million who do not realize it.

Diabetes accounts for a high portion of the national bill for taking care of the sick. The total direct and indirect cost of diagnosed diabetes in the U.S. was estimated to be $245 billion in 2012.

In that year, of the $13,700 average medical spend for people with diagnosed diabetes, more than half (around $7,900) was directly attributed to the disease.

Treatment ‘focuses on drugs’

Prof. Lean and colleagues note that the current management guidelines for type 2 diabetes focus on reducing blood sugar levels and cardiovascular risks primarily through the “use of antidiabetes drugs, with only lip service paid to diet and lifestyle advice.”

The result is that many patients develop further health problems and live, on average, 6 years less than people who do not have diabetes.

In the meantime, while remission of the disease “is clearly attainable for some, possibly many, patients,” the authors note that currently, it is “very rarely achieved or recorded.”

For example, they highlight a U.S. study that followed 120,000 patients over 7 years and found that only 0.14 percent of them were recorded as remissions.

Another example is that of the Scottish Care Information database, which holds records for every patient in Scotland. It shows that only 0.1 percent of type 2 diabetes patients are coded as being in remission.

Better coding guidance needed

Part of the problem, argue the study authors, is that clinicians hesitate to code patients as being in remission because of a lack of agreed criteria and guidance.

However, they suggest that the main likely cause of low remission recording in type 2 diabetes is that few patients are actually trying to achieve it.

They urge health authorities worldwide to agree clearer guidelines about how to measure type 2 diabetes remission and make sure that it is officially recorded.

“Appropriate coding,” they note, “will make it possible to monitor progress in achieving remission of type 2 diabetes nationally and internationally and to improve predictions of long-term health outcomes for patients with a known duration of remission.”

Clear benefits to patients

Better coding could also raise awareness and result in more people trying to reverse the condition, such as by losing weight, rather than accepting that they have to live with it.

Not only are there clear health benefits to reversing type 2 diabetes, but it can also give people a sense of achievement and empowerment.

In addition, it removes the stigma of being labeled “diabetic” and may even result in lower premiums for health insurance, travel insurance, and mortgages.

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Singapore’s War on Diabetes Aims to Save Lives & Limbs

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It’s estimated that one in eight Singaporeans have diabetes, compared to one in 10 Hongkongers, and experts say those numbers will continue to rise; Lion City focuses on prevention, starting in childhood

“Do you love your wife and your grandchildren?” the doctor asked his patient, after telling him that he had type 2 diabetes. Bagio Tomas Soliano was shocked as his doctor described the urgent lifestyle changes needed if he wanted to spend many more years with his family.

Just six months before, the 57-year-old had been given a clean bill of health during a routine check-up. Diabetes had set in quickly, with his blood-sugar level (tested while fasting) shooting up to what Soliano describes as a “crazy” reading of 18.5 millimoles per litre; normal levels are between three and six mmol/L.

Type 1 diabetics either produce too little or no insulin, a hormone that allows your body to use glucose for energy or storage, and helps to regulate blood sugar levels. Type 2 diabetics are resistant to the insulin they produce.

The doctor told him such a sudden onset of diabetes was unusual and alarming – and he wanted him to start daily insulin injections. “Hold on. Slow down. Let me see what else I can do first,” Soliano told the doctor.

This scene in Singapore plays out all too frequently in other Asian cities, too. The International Diabetes Federation estimates the number of adults with diabetes worldwide is 415 million, and is set to rise to 642 million in 2040. The Asian Diabetes Prevention Initiative says 60 per cent of the world’s diabetics live in Asia. In Singapore, one in eight adults are estimated to have diabetes, compared to one in 10 in Hong Kong, including both diagnosed and undiagnosed cases.

While both places have stepped up campaigns to educate citizens on diabetes prevention measures, Singapore has greater impetus: to save lives – and limbs.

Health Minister Gan Kim Yong declared a “war on diabetes” in 2016, when he told parliament that “four Singaporeans a day lose a limb or appendage due to diabetic-related complications”. That is one of the highest rates of lower extremity amputation in the world. What’s more, one in five people who lose a lower limb die within a year due to complications, a decade-long study of more than 2,000 patients from Tan Tock Seng Hospital found last year.

About 400,000 Singaporeans have diabetes, Gan says, and one in three have a lifetime risk of developing it. Of those who have the disease, one in three have not been diagnosed; of those diagnosed, one in three have poor control of their condition. Uncontrolled diabetes can lead to stroke, heart or kidney failure, and blindness. The annual diabetes cost burden – promoting healthy living, getting more people to go for screenings, and the loss of productivity – is more than S$1 billion (US$745 million).

Professor Chia Kee Seng, a member of Singapore’s Diabetes Prevention and Care Taskforce that was set up to help win the diabetes war, says a rapidly ageing population and the rise in obesity among the younger demographic are the prime drivers of spiralling diabetes rates. Chia is also Dean of the National University of Singapore’s Saw Swee Hock School of Public Health, and says it projects one million diabetics in Singapore by 2050.

While some Asians may not look obese and have body mass index levels which are lower than their Caucasian counterparts, they have fat stored around their internal organs, Chia says. In Singapore, he says six in 10 ethnic Indians and five in 10 ethnic Malays that are over the age of 60 are estimated to have diabetes. In comparison, only 2.5 in 10 of their Chinese counterparts have the disease.

There has been a shift of emphasis to prevention, rather than management, and the good news is public awareness has risen very remarkably.
Chia Kee Seng

This is key to the difference between the diabetes rates in Singapore and Hong Kong, “as 95 per cent of residents in Hong Kong are Han Chinese,” notes Andrea Luk, an associate professor in the Chinese University of Hong Kong’s Department of Medicine and Therapeutics’ Endocrinology division.

“From clinical experience, amputation is very uncommon in our [Hong Kong] population,” Luk says. “Our patients have a high incidence of diabetic kidney disease, and close to half of new referrals for renal dialysis are related to diabetes.”

In Singapore, the aim is to get everyone from an early age to make healthy living their goal. The health ministry adopted a three-pronged approach, starting with a high-profile public education campaign targeting people from different age groups. Its key messages are to slash sugar intake, to eat less and to move more. The campaign included a video, titled Kungfu Fighter, Hidden Sugar, that went viral after its release just before Lunar New Year, and a diabetes prevention mobile app. The government also launched cheap or even free screening to identify diabetics early, and now offers more ways to support diabetics in managing their disease.

“There has been a shift of emphasis to prevention, rather than management, and the good news is public awareness has risen remarkably,” Chia says. Still he predicts the diabetes battle will play out over decades, rather than years.

Singapore’s 18 residential community polyclinics are on the front line of the diabetes battle. David Ng, the head family physician and consultant at the Toa Payoh Polyclinic, says they typically discover that patients have diabetes when they screen them for some other medical complaint.

“We aim to have a good ongoing relationship between patients and our team,” Ng says. That team consists of doctors and nurses, who are trained in counselling and diabetes management, and dietitians, social workers and psychologists, who help diabetics with issues such as challenging financial circumstances or depression.

This multidisciplinary approach seems to be paying off and Ng reports that they “have success stories every day”.

Soliano’s is one of them. A good support system is a mighty weapon, as is a patient’s commitment to fighting. He has both. His wife Magdeline stepped up when he was in early denial. “She is my silent inspiration. She brought me around, nursed me back to health and walked the rough road to my success,” he says.

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