European Researchers, Physicians Tackle Diabetes Issue
One of the most important conferences in diabetes every year is the annual meeting of the European Association for the Study of Diabetes (EASD) – think of it as the trans-Atlantic version of the American Diabetes Association (ADA)'s annual Scientific Sessions. This year, EASD took place from September 17-21 in gorgeous Amsterdam, where over 14,000 researchers, healthcare providers, and other attendees gathered for five action-packed days of symposia and discussions. Here are our top takeaways from the meeting:
- Intensive management will require a greater role for the patient. On September 19, the International Diabetes Federation (IDF) announced an aggressive new post-meal glucose goal of <140 mg/dL (7.5 mmol). The organization emphasized its belief that good control of fasting plasma glucose (FPG – that means before you eat breakfast!) is necessary but not sufficient; rather, tight postprandial glucose control is an important part of adequate glycemic control at any A1c level. To meet this new postprandial (postmeal) target, the IDF recommends that people taking insulin test blood sugar at least three times a day, varying the timing and doing one test at two hours after a meal. The IDF also suggested that continuous glucose monitoring (CGM) might also be a useful tool in controlling postprandial hyperglycemia. This development definitely fits into the overall trend we've observed over the past few years of increasingly tight goals for patients.
- When it comes to reducing cardiovascular risk, the best tactics involve intense treatment. Cardiovascular risk is best reduced through tight glycemic control and intensive therapy, including early insulin initiation. The importance of tight glycemic control in cardiovascular health is indisputable; 69% and 39% of patients admitted to the hospital for heart attack or stroke have impaired glucose tolerance (IGT) or undiagnosed type 2 diabetes, respectively. Furthermore, the most common risk factors for cardiovascular disease in individuals under 45 years old are undiagnosed metabolic disorders and obesity. Study results indicate that good glycemic control after a heart attack strongly reduces the risk for a second heart attack and increases survival time. The American College of Cardiology is currently working on new guidelines that demand glucose testing before patients admitted to a hospital for acute heart disease can be released.
- Insulin therapy may support cardiovascular health. Early insulin initiation is linked to improvements in cardiovascular risk factors such as reduced severity of heart attack, less inflammation, and lower rates of heart disease. Insulin reduces inflammation through numerous mechanisms, which is important because chronic inflammation is increasingly thought to play a role in cardiovascular disease.
- Recent findings on brain activation during hypoglycemia contradict a major theory on hypoglycemia awareness and unawareness. Previously, scientists accounted for differences in hypoglycemia unawareness by assuming that there are differing levels of glucose uptake in the brain in different individuals. However, brain imaging studies show that glucose content during hypoglycemia changes similarly in hypoglycemia aware and unaware individuals. The differences are in neuronal activation, not blood flow. During hypoglycemia, individuals who are hypoglycemia-aware show activation in the regions of the brain responsible for food seeking and anxiety—leading to the characteristic symptoms of a low—whereas in hypoglycemia-unaware individuals, hypoglycemia is associated with activation of the area of the brain that processes pleasure stimuli—almost an incentive to remain in the hypoglycemic state. These findings provide insight into clinical tactics to re-sensitize people who are hypoglycemia unaware.
- RISC results show widespread benefits of physical activity. While exercise and lifestyle intervention were not central themes of the conference, impressive data from the RISC trial suggest many benefits from all forms of physical activity. Total activity, not just intense exercise, improves insulin sensitivity, and increased activity is associated with improved insulin sensitivity independently of waist circumference. This is great news for people who work in an office all day—moving during the day is extremely beneficial irrespective of intensity.
- Beta cell replenishing research has made dramatic progress in recent years. Beta cell loss is an integral part of diabetes progression, so techniques for reversing it are under heavy research. Dr. Phillippe Halban of the European Foundation for the Study of Diabetes and the Alliance for European Diabetes Research explained that research on replenishing beta cells has moved quite along in recent years. Beyond islet transplants from human donors, new sources of potential beta cells include embryonic stem cells and adult stem cells. The biggest hurdle in embryonic stem cell research has recently been crossed—driving the definite differentiation of endoderm cells, which is the first step in the developmental journey that eventually produces a fully differentiated beta cell from a stem cell. Dr. Halban was very positive about future possibilities with this recent achievement. The other option involves adult stem cells from organs such as the liver, pancreas, brain, muscle, bone marrow, and skin. Ideally, these cells would be replicated in vivo (i.e. in the patient) and then driven to differentiate into beta cells. This line of research carries some clinical risks associated with poorly regulated insulin secretion. Dr. Halban ended his talk on a very positive note, exclaiming, "Decades of multidisciplinary research have transformed science fiction into scientific possibility!"
- Genetics research has exploded, and new insights on cause and cure are anticipated with great excitement. The growing role of genetics in understanding and treating diabetes was at the forefront of the conference. In the opening lecture we heard about how groups around the world have joined forces in making large sample sizes available for genetics research. As a result, genetics researchers have made big strides in recent years using large-scale studies with huge quantities of data. The number of known type 2 diabetes-related genes continues to increase, which should allow for the exploration of new treatment pathways as they help scientists identify specific genes and processes in the diabetes pathway.
- There is dissatisfaction with the current cost of diabetes drugs despite continued enthusiasm for newer therapies. Interestingly, among the 1,500 people who attended a symposium on evidence-based medicine, 90% felt that we are not getting enough value for the money we spend on diabetes drugs. At the same time, most audience members were very enthusiastic about newer (and thus more expensive) drugs such as Byetta and Januvia – a contradiction, perhaps, but not surprising since cost-benefit analysis is an area of sparse research. Intuitively, it makes sense to us that better therapies that allow patients to achieve tighter control with fewer side effects would eventually lead to fewer complications in the long term. Indeed, Dr. Jens Holst from the University of Copenhagen made a compelling argument that GLP-1-based therapies such as Byetta and Januvia—which do not cause hypoglycemia or weight gain and may lead to weight loss—should replace the older class of sulfonylureas, which do cause both hypoglycemia and weight gain. The consensus was that sulfonylureas shouldn't be abandoned altogether—more options are always better—but GLP-1-based therapies may be a better option for many patients.
- Obesity is a disease, and it's time to treat it like one. This year at EASD, talks about obesity focused on therapeutics and medical procedures rather than diet and exercise. Regardless of whether the speakers thought diet and exercise works, all agreed that it is time to take the disease seriously. What does ‘get serious' mean? Well, mainly drugs and surgery. Research has shown that surgery is a powerful and effective intervention to get morbidly obese individuals on track towards better health. Furthermore, data suggest that the effects of surgery are lasting, with participants in one study successfully maintaining weight loss for 12 years, and even after regaining the weight, demonstrating a 30% reduction in mortality. Given such positive results, why don't providers recommend surgery more often? Well, in the UK at least, the government has recently added both drugs and surgery to recommended treatment timelines for obesity.
Kelly Close is Editor-in-Chief of diaTribe, an electronic newsletter that helps people learn about new ways to manage diabetes better. diaTribe focuses on new drugs, devices and research. diaTribe is free and available online at www.diatribe.us.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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James Joyce said that “mistakes are the portals of discovery.” I wonder if insulin levels have been our mistake. Could it be that this hellish week of blood sugars were somehow meant to be? Drastic times call for drastic measures, right? Maybe we were too afraid in the past to take the plunge into drastic measures. Maybe this is oddly what we needed. We had to be truly frightened in order to make bigger, bolder changes. ...