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Issue 4 Alzheimer’s Insights by Curation Health 16 April 2015
It’s been a big week for lovers of diabetes guidelines – we give you the edited highlights. The value of exercise in diabetes remains unassailable and this week it’s the liver and penis that reap the benefits – just don’t do it near heavy traffic! Finally, we look at screening for diabetes in adults and marvel at devices that may (or may not!) help you avoid losing your insulin and testing kit.
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New type 2 diabetes guidelines released in US
This week, the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) issued their new Type 2 Diabetes Guidelines. It’s been four years since these were updated so they were eagerly awaited. These important statements are presented in two different ways.

The ACE guideline is an 87-page document which seeks to answer 24 key questions in diabetes, starting from “how is diabetes screened and diagnosed?” and finishing with “which occupations have specific diabetes management requirements?” It will tell you ‘everything you want to know about diabetes but were afraid to ask’, but it can be very technical and somewhat blunt. For example, the lifestyle advice to persons with prediabetes is that they “should modify their lifestyle, including initial attempts to lose 5 to 10% of body weight if overweight or obese and participate in moderate physical activity (e.g., walking) at least 150 minutes per week.”

The AACE diabetes management algorithm is a 10-page document that is more visual and aimed primarily at health care professionals as an aide-memoire but is easily understood. The glycaemic control algorithm page illustrates when to start monotherapy (treatment with one drug), when to progress to dual and triple therapy (treatment with two or three drugs, respectively) and finally when to add or intensify insulin therapy. As these are important decisions to make in the journey through type 2 diabetes therapies, it is helpful to see them presented in an accessible way that is easily understood.

Of note is that one whole page of the AACE algorithm is devoted solely to highlighting one particular number – the target glycated haemoglobin (HbA1c) level of 6.5%. For patients without concurrent serious illness and low risk of hypos their target level is below or equal to 6.5%. For the others, the target level is allowed to be above 6.5%, but still should be as low as possible.

This target number should be fixed in the mind of all people with type 2 diabetes. Thankfully you now don’t need to plough through an 87 page report to find it!

Diabetes Treatment
Screening for diabetes in adulthood and pregnancy
A major US review of studies, published in Annals of Internal Medicine, has shown that screening for diabetes in asymptomatic adults did not improve mortality rates after 10 years of follow-up. Because type 2 diabetes can be reversed in the early stages by weight loss and exercise it would seem logical to screen for diabetes in people with no symptoms and/or seek out those with “pre-diabetes”. Finding people with impaired fasting glucose (IFG), or impaired glucose tolerance (IGT) or asymptomatic diabetes could lead to lifestyle interventions and treatments to improve outcomes. This review showed that screening for asymptomatic diabetes showed no real benefit.

The better news was that lifestyle changes and medications do both seem to be effective in delaying or preventing progression from IFG or IGT to type 2 diabetes in people with a high body mass index (BMI). So whilst the value of screening for asymptomatic diabetes in adults is doubtful, it is clear that those with IFG or IGT should lose weight, exercise more, eat healthily and, if appropriate, take medications in order to delay or reverse the progression to type 2 diabetes.

The value of screening for diabetes in pregnancy (gestational diabetes) was also recently clarified in the USA following a review of evidence. The U.S. Preventive Services Task Force now recommends that all pregnant women be screened for gestational diabetes after 24 weeks of pregnancy. This policy is different from that in the UK where routine screening for diabetes during pregnancy is not recommended by the NHS for all women: it is reserved for women identified as high risk only. A woman who has a first-degree relative with diabetes is considered to be at high risk of gestational diabetes and should be offered screening in the UK, something worth bearing in mind if you or a close member of your family is planning a pregnancy.

Untreated gestational diabetes can lead to very large babies that are difficult to deliver and it also increases the risk of pregnancy loss, premature labour and stillbirths. Gestational diabetes usually develops after 28 weeks of pregnancy but resolves after the baby is born. However, women who have suffered it are then more likely to develop type 2 diabetes later on in life.
Diabetes Research
Exercise is good for you. It’s a simple as that
Exercise is a mainstay of treating type 2 diabetes, but maybe it is best avoided near heavy traffic - at least for those who take insulin. A new study from Boston USA, published in Environmental Pollution, found that living next to heavy traffic increases inflammation in type 2 diabetics who use insulin compared with those who do not. Researchers compared levels of C-reactive protein (CRP), a marker of inflammation, in the blood of people with type 2 diabetes living close to, and far away from, heavy traffic.

It is already acknowledged that people exposed to heavy traffic pollution are at an increased risk of inflammation. For those living close to heavy traffic, these researchers found that it was only those people with type 2 diabetes using insulin who had increasing levels of CRP, suggesting that using insulin makes people with type 2 diabetes even more susceptible to such pollution–induced inflammation. In contrast, those on oral diabetes medications showed no increased susceptibility to pollution. The expert advice is to reduce exposure to traffic pollution, for example by closing windows and avoiding heavy exercise near busy traffic.

For those of us who do want to exercise more but fear we may keel over whilst doing it, there is great reassurance in this US analysis from Circulation. It confirms the benefits of sports activities in middle age far outweigh the small risk of having your heart stop during it. Sudden cardiac arrests (SCAs) occur mostly during middle age and this review of 1,247 SCA cases in the US found only 5% occurred during sports activities. Furthermore, nearly two-thirds of these were in those who had already been diagnosed with cardiovascular disease or had previous heart symptoms. The authors suggest that the findings are “likely to encourage sports activities among middle-aged athletes”. This may be especially true for women who were 19 times less likely to suffer a sports-related SCA…

Finally, in INSIGHTS, Issue 3 we looked at erectile dysfunction and it seems that exercise even has benefits for this too. The first research to link the benefits of exercise in relation to improved erectile and sexual function in a racially diverse group of patients has just been published in The Journal of Sexual Medicine. The authors said that when it came to helping ED they are confident that “even some degree of exercise, even if less intense, is better than no exercise at all”, which is a mantra that surely applies to type 2 diabetes and all its myriad complications.
Diabetes Lifestyle
Heart concerns around gliptins and hope for NASH
New heart safety concerns regarding two drugs used to treat type 2 diabetes, saxagliptin (Onglyza) and alogliptin (Vipidia), were highlighted by the US Food and Drug Administration (FDA) advisory committee this week. Both drugs belong to the class of drugs known as DPP-4 inhibitors or “gliptins”. These are of benefit in type 2 diabetes because they increase levels of incretins - hormones that act to lower glucose production in the liver and also increase the production of insulin.

People with diabetes are at an increased risk of cardiovascular complications such as heart disease, heart attack, heart failure, stroke, and poor circulation. It is thus important that any treatment for type 2 diabetes does not unacceptably raise the risk of such complications nor raise the death rates from them.

The FDA advisory panel did not recommend any restrictions on the prescribing of either drug. It advised that the cardiovascular risk profile of saxagliptin is “acceptable”, but its label should warn about a potential increased risk of heart failure. There was less concern expressed around the cardiovascular risk profile of alogliptin, however some experts believe the higher risk of heart failure may eventually be found to apply across all of the gliptin drugs once more trials have reported their findings. We will keep you updated as the data comes in.

In INSIGHTS, Issue 3 we discussed the complication of nonalcoholic fatty liver disease (NAFLD), the “silent” cause of chronic liver disease in type 2 diabetes. A timely Australian trial, published in Journal of Hepatology, has shown that regular aerobic exercise reduces liver fat, as well as body fat, in overweight adults who were previously inactive.

The findings lead to the hope that the risk of developing NAFLD could be reduced by aerobic exercise. What is especially heartening is that the actual volume or intensity of aerobic exercise made no difference to the level of benefit to the liver; just the fact of starting to regularly exercise gives all the benefit. This should act a powerful incentive to for inactive people with type 2 diabetes to begin to exercise.

Once NAFLD is established, losing weight is an important treatment along with exercise.

Diabetes Complications
Phones and insulin and abscesses
Insulin Angel, self-billed as “the world's smartest medication tracker”, is now looking for funding on the crowd funding site Indiegogo. The small device monitors any medication's temperature and also warns when the device is getting too far from your connected smartphone. The result is that if you store the Insulin Angel with your insulin, then you will be alerted if your insulin is overheating. It even knows at what temperatures different insulin types should be stored at. It is important that insulin is stored at the correct low temperature, especially since a significant minority of domestic fridges cannot maintain the cool temperatures required.

If you keep the Insulin Angel with your diabetes equipment you will be notified if you have forgotten to bring it out with you or just left it behind somewhere. Parents or carers can also receive these temperature and proximity warnings. Sadly, the alerts cannot pinpoint exactly where your misplaced diabetes equipment actually is, it merely informs you that it is somewhere more than 20 metres away from your smartphone…

Meanwhile, digital start up Akibah announced that it wants to compress all the glucose testing paraphernalia we might carry into the case of our smartphone itself. The case would combine the strips, the lancets and the glucometer into one plastic sleeve that the smartphone slips into. Whilst very convenient, I fear this may be putting all your diabetic eggs into one basket. I am not sure the research has been done, but I do imagine people with diabetes lose their phones much more often than their diabetic testing equipment…

Away from smartphones, in the world of surgical technology there was less positive news. An innovative surgical device, the EndoBarrier, which mimics the hormonal effects of a gastric bypass, has had an important trial of its use halted by the FDA in the USA. This was because of concerns around the risk of developing a liver abscess – this is a collection of pus within the liver, usually caused by a bacterial infection, which requires urgent treatment with antibiotics.

The EndoBarrier device is a 60cm liner that is put temporarily into the duodenal bulb (just beyond the outlet to the stomach) via an endoscope. It acts to lower blood glucose levels and reduce body weight in people who have Type 2 diabetes and are obese. Its future role, at least in the USA, is now uncertain.
Diabetes Technology
You are not alone… famous people with type 2 diabetes
Because we have discussed gestational diabetes this week, read actress Salma Hayek’s experience with it on
And Finally…
This week I received a letter with the result from my annual diabetic retinopathy screening. How I hate opening that particular envelope! The result? Well, the one eye is perfect and the other slightly less so. Does this mean that one of my eyes is actually more diabetic than the other? I’m not sure…

I do know that the NHS annual diabetic retinopathy screening system seems very efficient; turn up, have drops put into eyes, a few seconds of stinging, sit for 20 minutes, endure a couple of bright flashes and then it’s a bus ride home squinting like a vampire because the daylight is now too much for me - this is why they advise you not to drive for a few hours afterwards. Once home, I look deeply into my wife’s eyes and she swoons at my massively dilated pupils…

So this is just to remind you to make sure that you have your annual diabetic eye examination. It’s easy to forget about it or put it off, but sight is too precious to put at risk needlessly. The early detection and treatment of diabetic retinopathy could lead to a 90% reduction in the number of people who would otherwise lose their vision.
More Diabetes Feeds on CurationHealth
Diabetes Complications
Diabetes Lifestyle
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Diabetes Research
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Tweets of the week twitter logo
Luke Scicluna (@Biotech_Updates)
Diabetes: WPI to run pilot study on foot ulcer app
MedPage Today (@medpagetoday)
.@methodsmanmd takes a closer look at study examining link between gestational diabetes and autism
Harlan Krumholz (@hmkyale)
Just saw #diabetes drug direct to consumer ad that says: love ur number. They should say don’t know if it will help u live longer/better.
ben goldacre (@bengoldacre)
Man diabetes is a mess
Harlan Krumholz (@hmkyale)
Evry diabetic shld know 0/30 #diabetes drugs apprvd by F㍲ in last 10yrs have evidenœ of improving clinical outcomes.…
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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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