Type of Drug For Diabetes Can Cause Heart Failure

A new study published in the

current issue of The Lancet

Diabetes and Endocrinology has

examined that the type of glucose or sugar-

lowering medications prescribed

to patients with diabetes may increased risk for the

development of heart failure in

these patients.



The study was conducted at American

College of Cardiology and examined

clinical trials of more than 95,000

patients and found that for every

one kilogram increase in weight as a result of sugar-lowering

diabetes medication or strategy,

there was seven

per cent increased risk of heart

failure directly linked to that

medication or strategy.



Dr. Jacob Udell, the study's

principal investigator, and

cardiologist at the Peter Munk

Cardiac Centre, University Health

Network (UHN) and Women's

College Hospital (WCH), said that

patients randomized to new or

more intensive blood sugar-

lowering drugs or strategies to

manage diabetes often showed an

overall 14 per cent increased risk

for heart failure directly

associated with the type of

diabetes therapy that was

chosen, as some drugs cause heart failure than

others, compared with placebo

or standard care.

Dr. Barry Rubin, Medical Director,

Peter Munk Cardiac Centre,

University Health Network (UHN),

asserted that the results of this

study could prove to be the

catalyst for how diabetes

patients at risk for heart disease

were managed.



It must be noted that heart failure is a common

occurrence for patients with type

2 diabetes and a major determinant of one's life expectancy

and quality of life and

healthcare costs.

3 Steps To Reduce The Risk of Diabetes

3 Steps To Reduce The Risk of Diabetes

Diabetes is a condition that causes the victim to have excess level of sugar in the bloodstream. There are two type of diabetes type 1 and type 2. Type 1 starts mainly in childhood and only account for about 10% of all diabetes. Type 2 which this article is about, accounts for about 90% of all diabetes cases.

Risk For Type 2 Diabetes

One major risk is excess body fat, especially fat accumulated in the belly and waist. Also, fat in the pancreas and the liver appear to disrupt the body's blood sugar metabolism.

Effects of Type 2 Diabetes

Damage to vital organs, impairment of blood circulation, may lead to foot or toe amputation, kidney disease and blindness. It can also result to death through heart attacks or stroke.

3 Major Steps To Reduce The Risk of Diabetes

1. Eat Healthful Food
Drink water, tea, or coffee instead of carbonated beverages and sugary fruit juice. Eat small portions of meat, nuts, fish and beans. Avoid refined foods, instead eat whole-grain bread, pasta and rice in small portions.

2. Exercise
Exercise can make you active physically while lowering your blood sugar and help you maintain a healthy muscles.

3. Took Action If You Are In A High-Risk Group
A medical disorder known as prediabetes often precedes type 2 diabetes. Unlike diabetes, it can be cured. Prediabetes may go unnoticed as it may have no obvious symptoms. Therefore, if you have a family history of diabetes, overweight or not physically active, you might already have prediabetes. Take action by having your level of blood sugar tested.

Association Between Diabetes And Advance Breast Cancer

According to Dr. Lorraine

Lipscombe, a scientist at the

Institute for Clinical Evaluative

Sciences and Women's College

Hospital in Toronto, Women with

diabetes may have an increased

risk of being diagnosed with

advanced breast cancer.



She said:

"Our findings suggest that

women with diabetes may be

predisposed to more advanced-

stage breast cancer, which may

be a contributor to their higher

cancer mortality."



The research which took place in Canada analyzed data

from more than 38,000 women with age range 20 to 105 who were

diagnosed with invasive breast

cancer between 2007 and 2012.



The result of the study published

March 24 in the journal Breast

Cancer Research and Treatment shows that about "16 percent of the women

had diabetes and that women with diabetes were 14

percent more likely to have stage

II breast cancer, 21 percent more

likely to have stage III breast

cancer, and 16 percent more

likely to be have stage IV breast

cancer, compared to having

stage I breast cancer, which is

the most treatable stage.

Five-year survival for breast

cancer patients with diabetes

was 15 percent lower than for

those without diabetes."



The researchers also notice that

breast cancer patients with

diabetes were more likely to have

larger tumors and cancer that

had spread, compared to those

without diabetes due to lower

mammogram rates in women

with diabetes, which could

account for later-stage disease.



It must be clearly understand that the research only found a link

between diabetes

and advanced breast cancer and not that diabetes will cause advance

breast cancer or any type of breast cancer.

Thoughts from the Diabetes UK Professional Conference 2015

I'm a bit late posting this, but I just wanted to jot down a few thoughts following last week's Diabetes UK Professional Conference 2015 (#dpc15). I was, as the saying goes, dead chuffed to be invited to be one of the bloggers/tweeters co-opted onto Diabetes UK's Press Team for the three day conference in London's sunny docklands where the great and the good of the world's diabetes healthcare professionals, researchers and pharma companies gather for a good old chinwag about all things pancreatically challenged.

DPC is one of the biggest events in the global diabetes calendar and patients are not normally allowed to attend for complex reasons involving a Pharmaceutical Industry code of practice (and possibly also so that they can speak fluent doctor-technobabble unhindered and don't have to watch what they are saying about how bloomin' annoying patients are and how the whole business would be much easier without us). However as honourary members of the Press Team we were encouraged to tweet, blog and generally feed information from the conference to the world at large, including you lot.

It was the first time I have been at an event anything like this and it was absolutely huge. Whatever presentation you were attending you got the distinct impression that there were at least six other things running simultaneously that you'd like to be having a look at. Attendance this year was apparently bigger than ever, though #DOC peeps who had been to previous conferences commented that Excel's cavernous spaces made it seem a bit more spread out.

At least as valuable as the presentations themselves seem to be the incidental networking and bumping-into opportunities. Everywhere you went people near you were meeting up, rekindling connections and sharing information. People who have attended more than a few of these conferences must have quite a hard time getting to any sessions at all, because there are so many people to chat with as you move from one place to another.

On a personal level it was great to be able to meet again, or for the first time with so many amazing members of the DOC incuding, Grumps, Annie A, Laura, Sandy, Charlotte, Hannah, John, Annie C, Kath, Roz, Lis, Partha, Pratik, Pete, Neil and others whom I have doubtless forgotten (sorry!). It was also a great privilege to meet with Barbara Young, Chief Executive of Diabetes UK who took time out of her hectic schedule to meet with the bloggers/tweeters and stayed chatting longer than she had intended. She was quite an inspiration, and seemed genuinely interested in listening to feedback and input from the diabetes coal face - about what matters to people with diabetes and their families. Someone commented that Diabetes UK often get a hard time about occasional gaffes, but rarely seem to blow their own trumpet when they do make a positive impact (like here, where they have got the Government to change ther mind about prescription fines). It was only a brief conversation, but it was quite uplifting and I got the feeling that DUK was in very safe hands. It was great too to be able to meet up with representatives of various pharma and device companies that I have bumped into over the last few years to get a feel for any exciting new toys that might be in the pipeline.

Between us, the bloggers/tweeters tried to divide up and 'live tweet' from as many sessions as possible. This proved to be quite a challenge as the talks are short and intensely packed with information, new research data and other interesting snippets. By the time you have tried to compose a phrase which is as close to a quote as you can remember, with or without a photo of the projected slide and then edited for 140 characters, the speaker has chased on at a rate of knots and you are playing catch up.

Here are a few thoughts from some of the sessions I covered, based on the hasty notes I took:

Could intermittent fasting have a role in diabetes management? Michelle Harvie, Manchester
Short answer, yes. For people with type 2 diabetes various intermittent fasting apporaches (eg 5:2) seem to be easier to stick to and more effective for weight loss than continual energy restricted approaches. Fasting days in the research data tended to be approx 650cals and low carb, but results were equally good if low carb but not calorie restricted. For those in whom the approach worked there tended to be an effect on the non-fasting days too. Even though people *could* eat more freely, they did not necessarily do so.

Fermentable carbohydrates: Their role in diabetes management Nicola Guess, London
Not something I'd really heard of, but fermentable carbohydrate (think dietary fibre... pulses... resistant starch... oats...) seem to have promising effect in the context of type 2 diabetes. Results were a little mixed across different studies, not least perhaps because it can be quite hard to evaluate how much FC is in different foods. It may act as a sort of appetite suppressant. When 21g was given as a dietary supplement it resulted in reduced energy intake for the diet of people with Type 2 even if they were not asked to eat less. Fermentable carb was shown to have a positive effect on the phase 1 insulin response of people with type2 and even non diagnosed family members. Insulin sensitivity has been shown to improve in the presence of fermentable carb too. Unfortunately too much fermentable carb can have unfortunate gastric side effects - the gas released from the fermentation of pulses in the gut being an obvious example.

Advancing inpatient diabetes care 5 presentations chaired by Gerry Rayman, Ipswich
This was an extremely data-rich overview from some new JBDS data, including effective new protocols for management of people on corticosteroids and variable rate insulin infusion (sliding scale) in inpatient settings. Also presented a was a huge new piece of research by Norfolk and Norwich Hospitals into nationwide outcomes/detail of DKA management. Some of which was pretty scary stuff - the risk to inpatients with diabetes of experiencing Severe Hypoglycaemia for people with diabetes is 1 in 50 and risk of developing DKA while in hospital is 1 in 200. As alarming as this presentation might have been there was certainly a sense of concerted effort to tackle the challenges of inpatient management of diabetes and establish effective protocols that improve outcomes.

3DFD Integrating Diabetes Care into an individual's world Mary McKinnon Lecture by Carol Gayle and Khalida Ismail, London
I was really taken by this presentation. It outlined a 'three dimensional' model for improving diabetes care by fully integrating clinical, psychological and social approaches. Both type 1 and type 2 diabetes are associated with every major type of psychological disorder, and people with any of these mental health challenges find self-management of this complex and fickle condition additionally challenging. In addition, people living with severe social deprivation are significantly less able to self-manage. Put simply, diabetes is way down on their list of priorities. Address other areas in patients' lives (housing/debt/mental health) and they are released into better self care.

The 3DFD is a short-term intervention with a lasting impact and has moved from an interesting research idea to become a commissioned service in several UK locations. Initially seen as a 'luxury service' it is not only cost-effective, but actually pays for itself several times over in terms of savings made in other areas.

Lessons from the study of hypoglycaemia RD Lawrence Lecture, Rory McCrimmon, Dundee
Some really interesting stuff here about what happens when the body is subjected to repeated mild hypoglycaemia. The exact brain and body chemistry that is at work in the loss of hypo warning signs, and also the loss of counter-regulatory hormone response (epinephrine/glucagon/liver dump). Initially the brain fires all it's warning bells when blood glucose levels drop too low, but soon enough it learns to adapt. Attempting to 'perform better' at those lower levels and not expending the energy of those warning signs. Ultimately though, the brain can no longer function at the lower and lower glucose concentrations that can be reached without warning. Avoidance of hypoglycaemia can reverse this and 'reset the switch', but many struggle with undetected nocturnal hypoglycaemia which sets back their efforts.

Integration of psychologists into paediatric services 3 presentations chaired by Mark Davies
It was really good to see psychological support given so much coverage at the conference. Particularly in relation to children and young people where effective and timely psychological interventions can have such a dramatic effect.

Workshop: Psychological techniques for addressing hypoglycaemia unawareness Nicole de Zoysa and Victoria Francis, London
Great stuff here from the folks behind DAFNE HART, a successful pilot which demonstrates the importance of psychological support in changing people's behavior and understanding of their own relationship with hypoglycaemia. It was particularly good to see the 'compare and contrast' conversation scenarios between healthcare provider and PWD. The difference between people feeling told off/lectured and people being supported to make positive change through responsive listening and motivational interviewing.

Social Media, Why Bother with a Fad? Partha Kar, Annie Cooper, Roz Davies and Laura Cleverly
Great to see social media and peer support getting such a good response at a conference like this. Topics covered ranged from social media in support of nursing practice; tackling isolation and the building of patient communities; and whether social media could be the 'missing part' of someone's diabetes care. Not only that, but Partha Kar opened his talk by suggesting that the term 'non compliant' be removed from the diabetes phrasebook as a result of some social media interactions at the conference. The session ended with a frantic live Tweet Chat and I just hope that some of those who saw the presentations might begin to consider how to integrate social media/peer support into their own practice.

Cognitive decline in people with diabetes 3 presentations chaired by Richard Holt, Southampton
A bit of a mixed bag across these three presentations. Both type 1 and type 2 diabetes seem to associate with 'cognitive decrement' (which I don't like the sound of to be honest), though this only subtle and does not seem to worsen over time. When it comes to type 2 diabetes the Edinburgh study suggests that vascular changes may be the predominant factor. Blood pressuse has little effect, HbA1c has a small effect but smoking has much more of an effect. Overall, improved diabetes management and lack of diabetes complications seem to be a good thing as far as keeping your marbles is concerned. Conversely people with both Alzheimers and T2D are at significantly increased risk of severe hypoglycaemia.

When it comes to young people, there did not seem to be much evidence that mild hypoglycaemia was associated with impaired cognitive function in the long term. Though there may be small risks to very young children who experience severe hypoglycaemia and coma, the brain quickly becomes more resilient in older children and young people.

Hot topics - Diabetes and cardio-vascular risk 4 presentations chaired by Naveed Sattar and Jiten Vora
I was particuarly struck during Miles Fisher's presentation about assessing cardio-vascular risk in people with diabetes when he described the decision to recommend statins for the primary prevention of CVD in people with type 1 diabetes as an 'OBSAT' decision. With a twinkle in his eye he explained the acronym as 'old boys sat around a table'. He suggested that the research evidence did not support the recommendation and that there was a risk of 'over medicalising' the population. His opinion was that the presence of micro-abuminuria was a more reliable marker for prescribing statins for primary prevention in T1D.

In general terms intensively managing blood glucose levels, the earlier the better, significantly protects against CHD for people with diabetes.

Physical activity and Type 1 3 presentations chaired by Jason Gill, Glasgow
This was my last session of the conference and the one that provoked perhaps the greatest interest on Twitter. One of the slides in Rob Andrew's presentation showed a flow chart which seemed to contradict itself. Beamed off into the ether without the explanatory dialogue many people responded, "Ehhhhhhh?!" but the presentation had moved on apace. A lesson learned perhaps in the perils of trying to share complex ideas in 140 characters at speed. There was a lot of detail from Rob Andrew about managing exercise and type 1 diabetes, you can find more information here when the site launches soon. Some interesting snippets too from Richard Bracken about bone strength in T1D. I had not realised that type 1 was associated with an increased risk of fractures, but it seems that resistance training can help improve bone condition and strength.

Summary
On the whole I was really encouraged by the conference programme, and by the tangible sense of passion and commitment from those working in the field who are aiming for better outcomes and more personalised care for people with diabetes. Huge thanks to Diabetes UK for inviting me to be a part of the event.

Disclosure: My travel, accommodation and entry to the conference were paid for by Diabetes UK. I was not paid to write this post or any tweets relating to #DPC15.

Abbott Freestyle Libre available to new customers again

There were excited murmerings on Facebook last week and on Friday I received a phone call that confirmed what many, many people have been waiting for over the last few months.

Abbott have begun to take on new customers for the Freestyle Libre again

Wooooo hoooooooo!!!

I think it is probably fair to say that Abbott were a little taken aback by the level of demand for their new toy immediately after launch (the Libre 'flash' glucose not-quite-CGM monitor). It wasn't long before they realised that consumer enthusiasm was going to outstrip their production capabilites and they took a tough decision to stop taking on new customers in order to protect supply to those who had signed up first. Probably the right thing to do, but pretty frustrating for many people - myself included, who hadn't quite got around to registering with their e-shop early on.

Some people have got quite cross about this, but I'm more inclined to give them the benefit of the doubt. This was a completely new piece of technology in a relatively small market place (certainly in the UK). They had to anticipate what sort of level of early take-up there might be, but it's not entirely surprising that they didn't get it spot-on. And deciding to limit supply so that fewer people got better service rather than many people getting rubbish service seems to have quite a consumer-focussed feel to it. They didn't just take everyone's money and not deliver, they concentrated on ensuring that those who signed up early could get full-time sensor coverage if they wanted it.

But for the rest of us, the weeks turned into months... and still we waited.

Until now.

As of last week they have begun to issue emails to people who signed up on the website. They are doing this on a 'first come first served' basis, so those who asked to be told when Libre was available to new customers in October/November 2014 will be hearing first.

Of course they will have to weed out a bunch of dead results from those expressions of interest. People who have changed their minds and so on - so if you recive an email you will need to act on it pretty promptly.

According to what I've been told by Abbott, it works like this:

• People will receive an email alert which (I think!) outlines the process
• People then recive a second email which gives them a relatively short window of opportunity to respond
• They then need to sign up as a new customer
• You also need to place an initial order to activate your account (minimum of one sensor approx £50)
• Thereafter a maximum of 2 sensors can be ordered every 14 days

Looking forward to receiving my email :)

Update: Hurrah! No more waiting list!

25 not out - stick THAT up your nose diabetes!

At some point during the last week (I'm not entirely sure which day) I made my quarter century of living, more or less successfully, with type 1 diabetes. Twenty five years later and I've still got both feet, my eyes are pretty much unscathed and my kidneys still seem able to cope with clearing up after all the stuff I throw at them. Not a bad effort.

Also this week, I stumbled across two interlinked snippets of information that interested me:

We're dooooooooomed!

The first came via a retweet from Dr Pratik Choudary about some research from the T1D Exchange that suggests that the longer you have lived with type 1 diabetes, the more likely you are to experience severe hypoglycaemia (needing assistance of a third party, family member, friend or paramedic to recover). I've come across Pratik's work during my sifting of research for the NICE Guidelines update, and he seems to have his finger on the pulse, so was intrigued - interesting people sharing interesting stuff...

I confess I was slightly surprised at the findings. I suppose in a sense there is a certain logic to them, older people will have any residual 'helping hand' action from their own pancreas long gone, and more opportunity to have succumbed to a degree of hypoglycaemia unawareness. Still a bit odd that incidence of severe hypoglycaemia looks to increase year on year though - I would have expected a good deal of difficulty in managing BG in early childhood (tiny doses... erratic hormones... growth spurts... irregular physical activity) and certainly during teenage years (rebellion... wanting to fit in... more growth spurts and raging hormones). Even during young adulthood and middle years there's a degree of chaos going on with life in general. Particularly if people become parents themselves - when focussing entirely on yourself tends to slip into the background, replaced with sleep deprivation and general exhaustion. By contrast my own life seems to have become slightly more settled post-40. Much more time to sort out my own stuff.

When we began writing our blog it was not at all uncommon for Jane to have to help me out early in the morning from a nasty low (thanks Lantus!). When I look back, I am ashamed that I put everyone through this for so many years and did not sort it out earlier. But thanks to the support, wit and wisdom of the DOC, over the last few years I have gone a long way to reduce my hypoglycaemia in general and severe hypoglycaemia in particular. I can't remember the least time I got so low that someone in the family had to lend me a hand - but it was probably three or four years ago.

I for one have exactly the opposite experience of the T1D Exchange findings. What about you? If you are living with type 1, are you seeing more or less severe hypoglycaemia than before? Should we accept an increase in severe hypoglycaemia as inevitable*?

* The answer, of course, is NO!

Nasal Glucagon

Photo: Mike Hoskins

The second thing that caught my eye came as an email, following a presentation at the Advanced Technologies & Treatments for Diabetes (ATTD) conference in Paris last week, concerning a novel new glucagon treatment that is in development. Glucagon is used as an emergency treatment for severe hypoglycaemia. Currently it involves injecting sterile water into a vial of powder, mixing into solution and injecting into a person who has become so hypoglycaemic that they are either unconscious or otherwise unable to consume any high glucose treatment. Glucagon is a great treatment, but the current delivery method is pretty complex. I first came across the 'nasal puff' concept via Mike Hoskins in the US, who posted on Diabetes Mine following involvement in a trial of the device. It's ingenious! Developed by a tiny private company with parents of T1D children at the helm, it seems driven by passion and practicality.

I know that when I have tried to mention Glucagon kits to anyone among my family and friends they immediately take on a distinctly 'rabbit in the headlights' expression and start mumbling about "erm... yes... or I'd call an ambulance". The idea that at a time of extreme stress, possibly in the middle of the night, someone entirely untrained in giving injections would be able to calmly proceed through a multi-step process of mixing, drawing up, selecting injection site and administering (especially if I were thrashing about) seems crazy.

This new treatment involves simply 'puffing' dry powder up the nose. It doesn't need to be inhaled (designed for people who may be unconscious), simply pushing the base of the container ejects a cloud of dry glucagon into the nasal passages where it is absorbed directly. No needles, no mixing, no faffing about in the dark.

The device is not currently available, but phase 3 clinical trials are currently underway and I will watch the story with interest.

Disclosure: I was not paid to mention Locemia's nasal glucagon device (ha! chance would be a fine thing!). It just sounds like a great idea.

6.5% A1c target - A reply to a comment that got out of hand

I've had a couple of comments on my post about the proposed new HbA1c target in the draft NICE guideline that is currently out for consultation. I was rattling in a 'quick' reply, when I thought - this is *ridiculous*. I can't even see this any more in this tiny box - so I've decided to post it here instead :)

Here are the comments:

Tamer Hassan said...
how do you achieve these numbers?

thanks

Tim said...
These numbers are impossible to reach...
Or at least give me some suggestions on how to reach these levels. Thanks.
Tim

'How to reach these numbers' is a question for your healthcare provider really. Don't just ask some random nutter on the Internet! However (and desperately trying to avoid sounding like Mr Smug of No 22 Smug Gardens, Bigheadshire) I have had a sub 6.5% HbA1c for over 3 years now, so I know that it *is* possible if only perhaps for the lucky few. Plus I've never had fewer hypos in my life with diabetes either - so it's not that I am 'paying' for A1c improvements with the hefty cost of Severe Hypoglycaemia.

I cannot really tell why some people seem to put in so much effort and get such scant rewards, and that is why I think individualised targets are SO important.

But it does seem pretty clear to me that the closer you can get to those standard-issue BG targets (5-7mmol/L waking, 4-7mmol/L pre meals and <9mmol/L by 2 hours after meals) for as many days in the week as you can manage, the closer you will get to these kind of tough, aspirational, borderline non-diabetic A1c targets. My own HbA1c has fallen by around 1.5% in recent years, and I think only around 0.5% of that is attributable to the pump - though Artoo has gone a LONG way to reduce my number of irritating low-level hypoglycaemia dips. When I look back over the changes that I have made in recent years I can see a few things that I think were important. I don't offer these as any kind of guide or advice - it's just what I did.

1. Education. Get access to proper structured education regarding diabetes management. In the UK we have DAFNE which is highly thought of, but other options are available. Things that should be included (in my opinion) are:
   
   1. carbohydrate counting, working out how to check and change insulin:carb ratios for different times of the day
   2. SMBG technique - when to test and what to do with the results *including* basal testing to PROPERLY adjust basal on an ongoing basis
   3. correction factors - when and how to correct (with insulin or fast-acting carbs) to aim bring you back into range without jumping aboard the gluco-coaster
   4. exercise and alcohol
   5. dealing with illness
   If structured education courses are not available in your country/area you can do a lot worse than buying 'Think like a pancreas' (Scheiner), 'Type 1 Diabetes' (Hanas) or 'Pumping Insulin' (Walsh/Roberts) which cover much the same ground. Though the benefit of peer support in group sessions should not be underestimated



2. Test more often AND RECORD THE RESULTS. Find some way of keeping notes daily as you go along. What you are eating, units and timing of doses (how long before... split doses...), exercise, mood, everything! Without a fairly detailed set of records I find it impossible to see what is going on. Personally I still love mySugr for this.



3. Gadgets - seek out new tech that can help you manage your diabetes more easily. It might be a 0.5u pen; a smartphone tracking app, or copy of 'Carbs and Cals'; or it might be a BG meter with a bolus wizard so that you can have properly fine-tuned ratios without having to worry about keeping the maths easy. Additionally, ask your clinic about access to Insulin Pump therapy and CGM.



4. Seek peer support - join a forum or two, join Twitter, read some blogs (thanks!) or even *crazy!* join a local group and meet face to face. Living with diabetes is tough, but it's even harder if you are battling on your own. For everyone there's a little corner of the internet that can provide support, encouragement and shared experiences.

At the end of the day we each have to find our own balance between living a life and managing our diabetes. Somewhere in the middle you'll find your perfect A1c and it won't drain all the joy out of life to reach it.

Good luck :)