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Issue 2 Alzheimer’s Insights by Curation Health 2 April 2015
This week we look at the risks of breast cancer with diabetes, whether we actually need to self-monitor blood glucose in type 2 diabetes and why sitting does us all no favours. Also we learn that texts can help us manage diabetes and we preview another new single-pill combination therapy coming to market.
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Diabetes and advanced breast cancer
The increasing evidence that type 2 diabetes increases the risk of certain cancers was reinforced in a study from Canada, published in Breast Cancer Research and Treatment. Researchers analysed the records of 38,407 Canadian women aged 20 to 105 years who had been diagnosed with breast cancer. They looked at how advanced the breast cancer was at the time of diagnosis and found that the 6,115 women with diabetes had a higher risk of having a more advanced cancer by the time they were diagnosed.

Breast cancer is classified by the size of the tumour, if it has spread and to where. The earliest stage is stage I where the cancer is small and localised. The most advanced stage is stage IV where the cancer has spread to other parts of the body (metastasized). The later the stage at diagnosis, the harder it is to cure any cancer, so it is always best to diagnose cancer at the earliest stage. Regular mammogram screening at defined intervals aims to spot the earliest breast cancers before they can even be noticed by women or have spread.

This study showed that the women with breast cancer who had diabetes were more likely to be diagnosed at a later stage compared with those without diabetes. Also, the tumours were larger and more likely to have spread to local lymph nodes. As all the women in the study had similar breast screening mammogram patterns this might suggest that having type 2 diabetes predisposes women to develop more aggressive breast cancers which grow and spread more quickly than those found in women without diabetes.

This is obviously a worrying idea and the authors of the study have suggested that enhanced breast screening of women with diabetes may be needed. All women in the UK, regardless of whether they have diabetes, are encouraged to be “breast aware” and report any suspicious changes to their doctor. They should also take part in the appropriate mammogram screening programs.

This study does re-emphasise the importance for all women with diabetes to remain vigilant around this issue. If breast screening policy changes and women with diabetes are to be offered enhanced breast screening then we shall let you know.

Diabetes Complications
Don’t take diabetes sitting down
Sitting for long periods of time is not healthy for people with type 2 diabetes a study from the USA, published in the official journal of the American College of Sports Medicine, has confirmed. Researchers looked at the existing exercise levels of 519 adults with type 2 diabetes and found they spent 65% of the waking day being sedentary and almost half of that time (45%) was spent in long periods (30 minutes or more) of inactivity. It was calculated that just by interrupting these long periods of sitting, people would lose weight and reduce their waist circumference.

Swapping sitting for some light physical activity would have even more benefit as it raises the level of HDL cholesterol – the “good” cholesterol. Not all cholesterol is bad for you, when someone is told they have a problem with “high cholesterol” it refers to the LDL cholesterol level, not the HDL cholesterol. It is the LDL cholesterol that is the “bad” cholesterol and a raised level can lead to atherosclerosis (“furring of the arteries”). Anything that increases HDL cholesterol levels is actually a good thing.

The mainstay of treating and even reversing type 2 diabetes is to lose weight (hopefully even achieving an ideal body mass index), to eat healthily and to exercise more. This study shows that even just breaking up any half-hour blocks spent sitting has tangible benefits in type 2 diabetes.

The message is to simply avoid sitting still for extended periods, something which most people ought to be able to manage. This could mean getting out the chair for a potter during TV commercial breaks, or ensuring you have an alert to remind you to take a break when you are sitting at a computer screen.

People with type 2 diabetes are encouraged by expert guidelines to spend 150 minutes (two and half hours) each week engaged in moderate- to vigorous-intensity physical activity, as well as some muscle-strengthening activity twice a week. Many people just do not manage this, but they should not be disheartened. This study and many others do show that any increase at all in activity has its benefits in type 2 diabetes. Obviously it is wise to check with your doctor if it is safe for you to exercise more.

A simple mantra is to “walk a little further, a little faster and a little more frequently” and build up the activity levels from there. Perhaps we should now add to this “sit a little shorter and less often” too…

Diabetes Lifestyle
Synjardy in the pipeline for Europe
In Europe, The Committee for Medicinal Products for Human Use of the European Medicines Agency have recommended approval of a new single-pill combination therapy for the treatment of adults with type 2 diabetes. The drug combines into one pill the standard first-line drug for type 2 diabetes, metformin, and a drug mentioned in last week’s INSIGHTS, empagliflozin. The proposed trade name will be Synjardy.

Empagliflozin is a SGLT2 inhibitor that works by causing the kidneys to excrete more glucose through the urine. It does this by reducing the normal reabsorption of glucose from the urine by the kidneys. Metformin works by reducing the production of glucose by the liver and makes fat and muscle more sensitive to the action of insulin so they take more glucose out of the blood.

Both these drugs thus significantly lower the level of glycated haemoglobin (HbA1c). The HbA1c level reflects the average level of blood glucose over the preceding few weeks. In diabetes, a lower HbA1c means that the blood glucose levels are better controlled and so the risks of developing any future complications are reduced. Both drugs also cause weight loss which is an important aim in type 2 diabetes therapy too.

Typically in type 2 diabetes, a person will be given metformin alone as first-line therapy (along with diet and exercise). Other drugs are then added if control is not adequate. For those successfully taking metformin and empagliflozin as two separate medications, the single combined pill could offer convenience and cost savings. For those who are not adequately controlled on either metformin alone or metformin combined with other diabetes drugs, then this combined pill might be considered.

There does seem to an increasing trend in type 2 diabetes for pharmaceutical companies to co-operate in combining their different drugs into single pills. As it is not unusual for some people with type 2 diabetes to require three different drugs to control their diabetes, a single “triple pill” may even be a realistic prospect for the future.

Diabetes Treatment
To self-test or not to self-test?
It is thought that much of the self-monitoring of blood glucose in type 2 diabetes is just not necessary. An intervention in east London, reported in the British Journal of General Practice, achieved a major reduction in such unneeded self-monitoring.

The value of self-monitoring is undisputed in people with type 2 diabetes who use insulin, as their insulin doses need to be adjusted according to blood glucose levels. In others not using insulin but at risk of hypoglycaemia, for example those taking sulfonylureas and meglitinides (repaglinide and nateglinide), then self-monitoring may be required.

However, for the majority with type 2 diabetes not being treated with insulin there is no real proven benefit in regular or frequent self-monitoring. Indeed there is evidence it leads to poorer quality of life and can make people feel anxious and low. It is also disheartening if the diabetes care team are disinterested in the results or not really sure what to do with them.

Over a four year period the researchers implemented a simple, cheap programme that “combined education, enhanced patient reviews, IT support and peer feedback of performance” to reduce unnecessary self-testing.

In people with type 2 diabetes on metformin alone or no treatment, they were able to reduce self-monitoring rates from 29.6% to 6.0%. In all people with type 2 diabetes not using insulin, the rate fell from 42.8% to 16.5%. In the UK, self-monitoring of blood glucose accounts for 21% of diabetes prescribing costs - the majority of which is spent on the testing strips or meter refills. If these self-monitoring reductions were applied across the UK it could save an estimated £21.8 million.

Despite this, the decision to not self-monitor glucose with type 2 diabetes is one that perhaps should only be made after informed discussion with the diabetes care team. This is because both The National Institute for Health and Care Excellence and the Driver and Vehicle Licensing Agency (DVLA) do recommend it for certain patients with type 2 diabetes.

Diabetes Research
Texting and diabetes plus smart contacts
A systematic review of reviews published in The Annual Review of Public Health found that the majority of published text-messaging interventions were effective for addressing diabetes self-management. The most successful texts for diabetes were those that were interactive and personalised. The use of such texts was also good for smoking cessation and encouraging exercise but rather less helpful for other issues such as weight loss, yet it was not clear why this was the case.

As texting is so cheap it is hoped that, for relatively little cost, they could have a significant positive health impact across a large population. This would be especially so for poorer communities who have access to mobile phones, but not to the smartphones or tablets where the more sophisticated diabetes software or apps come into their own.

It is easy to be seduced by gadgets and gizmos when it comes to self-management of type 2 diabetes, so it is heartening to learn that an “old school” intervention like SMS texting can still hit the spot.

Following on from last week’s INSIGHTS discussion on continuous glucose monitoring technology, comes the news that the U.S. Patent & Trademark Office has just granted Google a patent for a new type of smart contact lens. It is thought that it will be used to monitor glucose levels painlessly. This is one piece of technology that we will be literally keeping an eye out for in the future!

Diabetes Technology
You are not alone… famous people with type 2 diabetes
Actress Halle Berry has type 2 diabetes. In 1989 she collapsed into a diabetic coma. You can read her story in this interview from the Daily Mail.
And Finally…
When does having type 2 diabetes become a disability in the eyes of the law? This was recently clarified in the UK in an Employment Appeal Tribunal which accepted that people with diabetes (type 1 or type 2) are usually considered to be disabled for the purposes of the Equality Act if they require medications to control the condition.

The area of dispute centred on whether people with type 2 diabetes controlled by diet alone (i.e. without any diabetes medications) were disabled within the meaning of the Equality Act. The tribunal ruled that they were not. It argued that, amongst other issues, controlling type 2 diabetes by diet did not lead to an impairment or interference with normal day-to-day activities.

Whilst this may seem an arcane legal point, it will have impact on all those with conditions managed by avoiding certain foods/drinks (e.g. allergies, intolerances) as they will now find it harder to claim that they are disabled.
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
Ophira Ginsburg (@OphiraG)
Women with diabetes > likely diagnosed w advanced breast cancer see our @WCRInstitute Dr Lipscombe et al…
Kevin B. O'Reilly (@kboreilly)
Diabetes Care study: 23% surge in newly ID'd diabetics in states that expanded Medicaid under #ACA.
Eric Topol (@EricTopol)
How does fat tissue induce inflammation and T2 #diabetes? A new review
Kenny Lin, MD, MPH (@kennylinafp)
Medicalising the healthy: is 'pre-diabetes' a useful term? via @Telegraph
Dr Mark Bowman MBA (@biomed_wales)
'Artificial pancreas' for diabetes sufferers gets approval for use in UK via @Telegraph
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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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