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Issue 3 Diabetes Insights by Curation Health 9 April 2015
How important is it, really, to get up off the couch and get active in order to prevent diabetes? We consider the importance of erections to male sexual satisfaction and the problems caused by excessive fat in the liver. Finally we muse on magnesium levels and welcome a new device to monitor glucose levels for two weeks at a time.
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Get off the couch to prevent type 2 diabetes
In people with a high risk of developing type 2 diabetes, each hour spent daily watching television increases their risk of eventually getting diabetes by 3.4% according to this US study in Diabetologia. This complements the findings, discussed in last week’s INSIGHTS, that merely interrupting long periods of sitting has health benefits for those with already established type 2 diabetes.

This study is important because it reinforces the positive effects of avoiding a sedentary lifestyle for those who are at a high risk of developing diabetes (“pre-diabetics”). In the research on these high-risk individuals, the relationship between the time spent in sedentary activities and the risk of going on to develop diabetes was observed over a three year period. The conclusion was that each hour per day spent sitting (mainly watching TV but also at work) increased the risk of developing type 2 diabetes.

The lifestyle message is clear for those at a high-risk of developing diabetes: it is important not to sit around for extended periods. Sitting for shorter periods and for less total time per day will reduce the risk of developing type 2 diabetes. This benefit is entirely separate from the additional positive effects gained from actually engaging in some moderate-vigorous activity, like brisk walking. Such exercise is already acknowledged to reduce the risk of developing diabetes. Combining exercise with weight loss are the two key lifestyle interventions to prevent or reverse type 2 diabetes.

For people who are pre-diabetic or have type 2 diabetes then just getting off the couch will do them good, but getting off the couch and also adding in some exercise would do them even better!

Always check with your diabetes care team if you have doubts that it is safe for you to start exercising.

Diabetes Lifestyle
Diabetes and problems with erections
Men with erectile dysfunction (ED) can still remain concerned and dissatisfied with their sex lives despite using medications that successfully treat their impotence. A study of 2,600 nationally-representative English men (aged 50-87) by the University of Manchester, reported in International Journal of Impotence Research, showed that many were not happy to merely get their erectile function back with treatments.

Problems with erections are a common complication of Type 2 diabetes because high glucose levels damage the blood and nerve supply to the penis. Around a half of men with diabetes will suffer from ED within ten years of diagnosis.

Most ED sufferers are prescribed a class of drugs called oral phosphodiesterase type 5 inhibitors (PDE5i). Commonly used examples include Viagra, Cialis and Levitra. At the time of the study, 7% of the men reported using a PDE5i drug to enhance their erections over the preceding three months. These drugs relax the blood vessels in the penis, resulting in increased blood flow and an erection.

Despite achieving erections, the users still expressed dissatisfaction or concern around their sexual health and relationships. A good erection does not always mean a good sex life…

Another important finding was that some of the men’s erectile problems might have been caused by medications they were taking. Many men with type 2 diabetes take medications for other conditions such as hypertension and some treatments for these, especially commonly used drugs like beta blockers and diuretics, can cause ED.

Around one fifth of the men reported that they had ED but that it was untreated. The advice to men with type 2 diabetes and erectile problems is to discuss it with their diabetes care team. Not only are there are effective treatments available, but also ED may be a sign that the diabetes is poorly controlled and this needs addressing before the health and function of the heart becomes affected as well.

Diabetes Complications
Treating “fatty liver” in type 2 diabetes
The majority of people with type 2 diabetes do have excessive amounts of fat in their liver. This condition is called nonalcoholic fatty liver disease (NAFLD) and it is a complication of diabetes that receives little publicity.

In people with type 2 diabetes it has just been shown that treating the diabetes with Lantus, a long acting insulin glargine, reduced these excessive amounts of fat. The Canadian research, published in Diabetes Care, also found that Victoza (liraglutide), a drug that is also injected to treat diabetes but is unrelated to insulin, seemed to have no such beneficial effect on reducing the “liver fat burden” seen in diabetes. Both treatments had a similar benefit on the control of blood glucose levels.

Excessive fat in the liver can cause the liver to not work properly and this is typically diagnosed by blood tests of liver function. The liver may also be seen to be enlarged and fatty during an abdominal ultrasound examination.

As more fat continues to deposit in the liver, it can become inflamed leading to a condition called nonalcoholic steatohepatitis (NASH). This may then progress even further leading to cirrhosis (which can ultimately lead to liver failure) or cancer of the liver. The better controlled the diabetes is, the less fat there is laid down in the liver and so it is less likely that this dangerous progression will occur.

This study showed a 24% decrease in whole-liver fat with the use of insulin glargine, compared with no change with liraglutide. As the study was small in scale, it is too early to say that insulin glargine might be preferentially offered to people with poorly controlled type 2 diabetes and excessive fat in their liver.

What is true is that the “silent” problems of NAFLD and NASH are being taken much more seriously and the search for optimal treatments continues. We will keep you updated in future as there is a lot more research in the pipeline.

Diabetes Treatment
Magnesium levels and diabetes control
Measuring Levels of magnesium in the blood might be a useful indicator of the duration and control of type 2 diabetes according to a study from India… but perhaps not quite yet.

Researchers investigated 50 people with type 2 diabetes and grouped them into three categories (good control, needing intervention and poor control) based on their glycated haemoglobin (HbA1c) level - the higher the HbA1c level is, the poorer the control of the diabetes.

When they measured their blood magnesium levels it showed that the magnesium levels reduced with increasing levels of HbA1c and with the longer duration of type 2 diabetes. It is hoped that monitoring magnesium levels could be more sensitive and cheaper than testing the HbA1c level, however further studies are definitely needed. Other research has not found such strong correlations between magnesium levels and the control and duration of diabetes.

It is accepted that low levels of magnesium (hypomagnesaemia) are associated with diabetes mellitus but it is not clear why. A further complication is that a low magnesium level may be due to a low dietary intake of magnesium, regardless of whether a person has diabetes or not.

It thus looks likely that measuring HbA1c will remain the gold standard to assess control of diabetes for the time being. As a reminder, for most adults with type 2 diabetes the HbA1c target is below 48 mmol/mol, although certain individuals may be set a different figure. If the target is reached then the complications of diabetes will be much reduced, but any lowering in the HbA1c from a raised level is worthwhile even if the target level cannot be achieved.

Diabetes Research
New device gives 14 days of glucose readings
India has become the first county to launch a new device to be used by health professionals to monitor blood glucose levels frequently over a 14-day period. The FreeStyle® Libre Pro Flash Glucose Monitoring System is related to a device already available to the public in Europe since October 2014: the FreeStyle Libre Flash Glucose Monitoring System. The FreeStyle® Libre Pro device, however, is for use by health professionals only.

The device is a coin-sized sensor that is applied by a health professional to the back of the upper arm and secured in place by self-adhesive pad. It remains there for 14 days, recording glucose levels every 15 minutes via a small filament that is inserted just under the skin. It records glucose levels in the interstitial fluid - the fluid that surrounds all cells in tissues - rather than the blood itself.

After 14 days, the person returns to the clinic, where a reader device scans the sensor and quickly uploads the possible 1,340 glucose readings taken. These can then be charted to give a complete profile of glucose levels day and night for the two preceding weeks. The profile can be interpreted to look for hypos and times of poor control and any problems with treatment, diet or lifestyle issues that are highlighted can be appropriately addressed. This would be especially of value in those using insulin or prone to hypos due to other diabetes therapies.

Around one fifth of the global population who have diabetes live in India and 90 per cent of them are thought to be poorly controlled, so anything that might improve these statistics is welcome.

Diabetes Technology
You are not alone… famous people with type 2 diabetes
Blues singer BB King was recently admitted to hospital with dehydration thought to be due to his type 2 diabetes. He has had type 2 diabetes for over 20 years. Read the story in Rolling Stone here.
And Finally…
This week I got a letter from the NHS “Help With Health Costs” department reminding me to renew my medical exemption certificate and get my doctor to complete another FP92A application form to ensure I hold a valid certificate that covers the date I have an NHS prescription dispensed free of charge.

In England, people aged between 18 and 60 who require insulin or drugs to manage their diabetes (type 1 or 2) are entitled to claim free prescriptions but must present a valid medical exemption certificate. Many of these certificates have expired and since autumn 2014, thousands of people with diabetes were shocked to discover that they have been fined for having claimed free prescriptions without valid certification. The good news is that following an outcry these “penalty charges” will be cancelled if the person affected either has a valid certificate or gets one within 60 days of the fine being issued.

This all acts as a timely reminder to ensure that all the paperwork around our diabetes is valid and current, from medical exemption certificates to holiday or health insurance policies.

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
Steven Dickman (@cbtadvisors)
Borisy: Key legislative/FDA priority: expand Breakthrough Designation to diabetes, #Alzheimers and other key indications #xconbio
Simon Chouldjian (@simonig1)
$ARNA Significant Weight Loss & Drop in A1c with New Combo of Lorcaserin & Phentermine-> #Diabetes #Weightloss #Oprah
New blog on how #PartD helps #diabetes patients and also saves money in Parts A&B. More here: #MedicareMonday
Shawn Watson (@Shawn_G_Watson)
* Rhythm begins Phase IIb trial of relamorelin to treat diabetic gastroparesis | @bioDiabetes…
Biosimilarz (@biosimilarz)
$MRK completes PhIII study of MK-1293 (#biosimilar insulin glargine) in type 2 diabetes patients;…
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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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