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Issue 1 Diabetes Insights by Curation Health 26 March 2015
Today we look at the worrying link between antibiotic use and the risk of developing type 2 diabetes, celebrate the significant benefits of eating whole grains and cereals, and welcome the first preventative device for diabetic foot ulcers. We also preview Glyxambi, a new combination drug, and muse on blood glucose testing technologies.
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Antibiotic use linked to type 2 diabetes
A clinical study published in The European Journal of Endocrinology linking the use of antibiotics to the risk of developing type 2 diabetes caused alarm this week. Researchers traced antibiotic prescriptions given out to 208,000 people with diabetes (type 1 or 2) in the year before they were diagnosed with the condition. The study compared their antibiotic use with those of 816,000 non-diabetic people of the same age and sex.

It found that people who had between two and five courses of penicillin showed an 8% increased risk of developing type 2 diabetes, compared with those who took none or a single course. The risk rises further in those prescribed more than five courses of penicillin - they showed a 23% increased risk compared to those who took none or a single course.

It was also found that the increased risk of developing type 2 diabetes applied even more to other types of antibiotic use: two to five courses of quinolones increased the risk by 15%, having over five courses increased the risk by 37% compared with those who took none or a single course.

The risk of developing type 1 diabetes was not linked with antibiotic use. Interpreting what all this means is not straightforward - is the link between antibiotics use and developing type 2 diabetes a true cause and effect? The use of antivirals or antifungals seemed to have no significant link with the risk of developing type 2 diabetes, so this has led researchers to suggest that antibiotic use changes the bacterial ecosystem in the gut. It is already thought that the mix of bowel bacteria can affect the risk of developing obesity, insulin resistance (cells responding less well to insulin) and type 2 diabetes.

Other commentators point out that people with prediabetes or undiagnosed type 2 diabetes are more prone to develop infections and so would have been given more antibiotics than others in those months leading up to their eventual diagnosis of type 2 diabetes.

As with most things in medicine, time will reveal the answer as more research is clearly needed to clarify this situation. What is agreed on by all is that antibiotics are overprescribed generally and that efforts will need to continue to reduce their overuse. If this also leads to a reduction in the numbers developing type 2 diabetes, then this can only be a good thing.

Diabetes Research
Glyxambi launches in the USA
A new combination drug for treating type 2 diabetes, Glyxambi, has just been launched in the USA. The once daily tablet is used to improve glycaemic control in people with type 2 diabetes who are not controlled sufficiently using diet and exercise alone. It is a combination of two types of existing drugs, Jardiance (empagliflozin) and Trajenta (linagliptin), which act in different ways.
Linagliptin is a DPP-4 inibitor. These drugs increase the release of insulin in response to rising blood glucose levels and also stimulate the liver to produce less glucose. They achieve this by increasing the levels of incretin hormones - chemical messengers which stimulate the beta cells in the pancreas to produce insulin. Empagliflozin is a SGLT-2 inhibitor. These drugs work by causing the kidneys to excrete more glucose through the urine. They achieve this by reducing the normal reabsorption of glucose from the urine by the kidneys.

By using these two differing mechanisms, the combination drug reduces raised blood glucose in type 2 diabetes. Glyxambi is not used for people with type 1 diabetes or for diabetic ketoacidosis. The drug was approved by the FDA in the USA based on a phase III clinical trial that showed Glyxambi combined with high-dose metformin performed better than high-dose metformin combined with either one of the two constituent drugs.

Glyxambi is not yet available in the UK, but both the individual constituent drugs already are. By combining both drugs into one tablet, it is argued that it is more convenient and cheaper for users. Glyxambi will probably be launched in UK/Europe later this year, so we will revisit it in more detail then.

Diabetes Treatment
A step forward in preventing foot ulcers
The world's first device to prevent foot ulcers in diabetes has been approved by the NHS and is now available on NHS prescription. Liqua-care Diabetic Flowgel Orthotics are simply slid into the shoe like a traditional insole. They are a few millimetres high and made from a liquid gel. They work by adjusting the distribution of body weight to the feet, stopping too much pressure being placed on the vulnerable foot areas. They also improve local blood circulation and have a massaging effect.

Since individuals with diabetes have a 15–25% lifetime risk of foot ulceration any device that is approved to prevent them is most welcome. Foot ulcers are the leading cause of amputation and half of those having such surgery will survive less than two years.

In diabetes, foot ulcers are due a combination of factors, the most important being the development of peripheral neuropathy. Consistently high blood glucose levels damage the small blood vessels which provide nutrients to the nerve cells. As a result, the nerves become less sensitive. This means that rubbing or trauma to the feet can go unnoticed. In diabetes, the circulation to the foot may also be compromised and the high blood glucose levels additionally impair healing. All these factors combine to allow breaks in the skin of the feet to become infected and heal poorly, ultimately leading to ulcers which are very distressing and hard to treat.

Because the foot is so vulnerable to complications in diabetes it even has its own label in the medical world, ‘the diabetic foot’. Meticulous footcare is thus a vital part of self-management in diabetes. All people with diabetes are advised to check their feet every day for problems such as cuts, grazes, breaks in the skin, redness, rashes, corns, verrucas, thickened skin, swelling, blisters or changes to nails. Symptoms such as numbness, altered sensation, tingling, pins and needles or burning of the feet could be a sign of developing neuropathy. All such foot issues should be reported to the health care team. Regular foot examinations (at least annually) by professionals are also vital.

Finally, to look after your feet, ensure that footwear does not rub, wash the feet daily, regularly cut the toe nails and prevent skin cracking by using moisturisers. Because of the risk of encouraging fungal infections (athlete’s foot) moisturisers should not be used between the toes.

Diabetes Complications
Whole grains and cereals reduce diabetes deaths
The importance of a balanced healthy diet in diabetes was highlighted in a US study from Harvard Public School of Health. The study showed that a higher intake of whole grains and cereal fibre may reduce the risk of dying from chronic diseases such as diabetes, cancer, cardiovascular disease, respiratory disease, infections, and other causes.

Researchers analysed the diets of 566,339 participants by asking questions about their consumption of various food groups and their portion sizes and followed them up over 14 years. The results showed a 17 per cent reduction in early death rates from all causes for those who consumed 34 grams of whole grains per day when compared with those eating only 3.98 grams daily.

In diabetes, those with the highest intake of whole grain had a 48 per cent reduced risk of dying early from diabetes. The benefits of whole grains were seen regardless of other lifestyle issues such as exercise, body mass index, smoking or alcohol consumption. Higher cereal fibre intake also had a significant benefit on lowering death rates, but it was lesser when compared to higher whole grain intake.

Past studies have already shown the protective effects of whole grain intake on diabetes, cardiovascular disease and certain cancers. However people with diabetes do need to be vigilant in their choice of cereals to ensure that they are rich in whole grain and fibre but not in sugar. Many popular breakfast cereals are laden with sugar and you are advised to carefully read the labels on the packaging to avoid these.

People with diabetes always benefit from consulting with a dietician to get tailored advice on how to achieve a good diet and reach a healthy body mass index.

Diabetes Lifestyle
Smart money going into smart technology
The flow of money into technology to aid the management of diabetes continues unabated. Last week health technology company Glooko announced that it has raised $16.5 million to fund expansion of the company’s mobile and cloud based diabetes management system. Using Glooko's existing MeterSync™ software, people with diabetes can already synchronise their blood glucose readings from more than 30 popular meters directly to supported Apple and Android devices. In the past Samsung Ventures made an investment in Glooko leading to rumours that the new Samsung S6 phone would have a case with built-in health sensors.

Meanwhile, the much anticipated Apple Watch will be able to help monitor glucose levels via a wireless link to a continuous glucose monitoring (CGM) device. A CGM device uses a sensor inserted beneath the skin - not actually into the blood stream itself - which measures glucose levels within the interstitial fluid, typically every few minutes. Interstitial fluid is the fluid that surrounds all cells in tissues. The glucose level in the interstitial fluid is then converted to calculate the actual blood glucose level. There is time lag of around ten minutes before a rise or fall in blood glucose is reflected in the interstitial fluid glucose level.

Sadly, even Apple hasn’t cracked the problem of finding a viable needle-free solution to glucose monitoring, so most of us will have to stick to self-testing using lancing devices for the foreseeable future. When self-testing, people are advised to prick the less sensitive sides of the fingers rather than the tips or pulps of the finger. Washing the hands in warm water ensures the site is clean and also increases the blood flow to the fingers, as does giving the hands a few shakes. Testing can also be done in other sites such as the upper arm or thigh but not all testing devices are suitable for this.

Of course, closely monitoring blood glucose levels via the latest gadgets is no substitute for actually doing something about them! Self-testing is not an end in itself; it is done to help you adjust your treatments and lifestyle to ensure the tightest control of blood glucose levels. Only this will then lead to a reduced risk of complications from diabetes.

Diabetes Technology
You are not alone… famous people with type 2 diabetes  
Recently NASCAR driver Jamie Dick was diagnosed with type 2 diabetes after feeling dizzy and tired after a race. The full story can be read here
And Finally…
Developing diabetes is no laughing matter but that doesn’t mean we can’t use our sense of humour to make living with it slightly more bearable. Despite it being so common, it’s rare to see mainstream comedians riffing on the subject. It is left to people with diabetes to joke about it on video sharing sites themselves. The main source of comedy seems to lie with other people’s reactions to hearing that you have diabetes. This ranges from “have you got the good kind of diabetes or the bad kind?” to sagely offering quack cures. This is all nicely summed up in this YouTube video from American teenager HaleyAnn who has type 1 diabetes. I hope you enjoy it and do remember that laughter truly can be the best medicine. After all, this study did show that laughter lowers the increase in blood glucose after meals…
More Diabetes Feeds on CurationHealth
Diabetes Complications
Diabetes Lifestyle
Diabetes Technology
Diabetes Research
Diabetes Treatment
CurationHealth is a health communications company and not a healthcare company. The information it relays from online and offline publications is provided as is without either endorsement or warranties as to the accuracy or fitness for any specific purpose and should under no circumstances be read as medical or scientific advice, neither as in any sense a prescription or a substitute for the professional advice of a doctor or otherwise trained specialist in matters of health and wellbeing. While information relayed from third parties is conveyed in good faith, no warranties are offered as to the accuracy of information supplied in this way, nor indeed from such agents or follow-on links quoted by third parties from other sources.
Tweets of the week twitter logo
Pearl Freier (@PearlF)
Roche Venture Fund @Venture_Invest invested in @mysugr; makes it easier 4patients 2live w/diabetes by @cbtadvisors
Rajesh Velagapudi (@velagraj)
Fiercebiotech FierceBiotech News AstraZeneca buys into Harvard's stem cell tech for diabetes R&D
MedPage Today (@medpagetoday)
New mouse studies suggest a role for stem cells in the treatment of type 2 diabetes
fezziwig2008 (@fezziwig2008)
@PinkyG123 The only $HALO rumor I know of is-Kenneth Schultz MD was brought in from Medtronics Diabetes to sell all Hylenex Diabetes rights
Amer. Diabetes Assn. (@AmDiabetesAssn)
A Native American community may hold a clue to why some people w/ #type2 #diabetes develop kidney disease: #research
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About Diabetes Insights
Diabetes Insights is an online newsletter created for people who live with the challenge of diabetes. The present focus is mainly on Type 2 diabetes. Based upon intelligent search algorithms that scour the Internet for the most read, relevant and useful stories from around the world, it is curated and published each Thursday by a team of health and publishing experts.
Fintan Coyle  
Fintan Coyle Senior Curator
A retired General Practitioner, Fintan has been a writer, columnist and medical editor for both consumer titles and medical journals. His strong personal interest in diabetes began when he developed late onset type 1 diabetes in his thirties. He is committed to highlighting the important issues for you, applying his medical knowledge to breaking stories alongside his real-life insights into what it’s like to live with diabetes.
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