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Issue 6 Alzheimer’s Insights by Curation Health 30 April 2015
In the week that a new muesli-type bar was hailed as a breakthrough in the dietary treatment for type 2 diabetes, we look at the research. What does the media furore around “diet versus exercise” in obesity actually mean for those with type 2 diabetes? Also, there is new hope for those with fatty livers - liraglutide might just become the first ever effective drug treatment. On a less positive note, alarm bells rang on the risk of vitamin B12 deficiency for those on metformin using indigestion remedies. Finally, we look at health professionals’ views on mobile medical apps: most don’t think they will help the doctor-patient relationship…
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CHORI-bars hailed as “breakthrough” in type 2 diabetes
A most promising study from the USA, published in The FASEB Journal and first picked up by the Daily Express, has carried been out using CHORI-bars. These are specially formulated low-calorie, fruit-based bars fortified with micronutrients and fibre, created by the Children's Hospital Oakland Research Institute (CHORI). The bars were specifically designed to provide health benefits for people with type 2 diabetes and, hopefully, taste good.

In the research, people were asked to eat two CHORI-bars a day for two months and that was it - no other changes were made to their diet. The results were positive and included weight loss, reduced chronic inflammation, and increased HDL cholesterol levels (the "good" cholesterol).

All these changes would help lower the risk of type 2 diabetes and heart disease in those who regularly munch on the CHORI-bars. Hailed by some as a breakthrough, it is hoped CHORI-bars might form part of weight loss regime to prevent or reverse type 2 diabetes, especially for those who find sticking to a healthy diet a challenge.

Sadly, a study on the health benefits of yoghurt showed no health gains; in fact yoghurt has no significant beneficial impact on health according to scientists in Madrid, Spain. This bombshell for yummy mummies was picked up by many health websites but originally appeared in the Journal of the Academy of Nutrition and Dietetics. Researchers observed yoghurt eaters for over three and a half years but found no significant changes in their physical health attributable to yoghurt.

It had been suggested that smoking and a non-Mediterranean diet negated any benefits of yoghurt, yet even in those who didn’t smoke and followed a Mediterranean diet, the yoghurt had no benefit. Studies in the past, however, have shown that yoghurt intake may reduce the risk of type 2 diabetes, so the exact position of yoghurt in relation to preventing type 2 diabetes is unclear. There is no dispute though, that people with type 2 diabetes should avoid sweetened yoghurts!
Diabetes Treatment
Metformin plus indigestion remedies might lead to vitamin B12 deficiency
If you take metformin to treat your type 2 diabetes and also regularly use some of the commonly used indigestion remedies then you may be at increased risk of developing vitamin B12 deficiency and even a peripheral neuropathy. Research from the USA , published in Clinical Diabetes, found that taking metformin along with certain acid-suppressing medication increased the rates of B12 deficiency from the usual rate of around 22-26% to 34.2%.
Both types of the acid-supressing medicines studied, proton pump inhibitors and H2 Receptor agonists, are commonly used by many people, but especially in those with type 2 diabetes who do tend to be overweight and thus even more prone to acid reflux and indigestion. It is generally thought that these “tablets for stomach acid” are overprescribed and overused, in any case.

The importance of maintaining vitamin B12 levels in type 2 diabetes lies in the role that a deficiency may have in causing a peripheral neuropathy. Whilst most cases of diabetic peripheral neuropathy are thought to be due to long-term raised blood glucose levels, lack of B12 may also cause a neuropathy, even in those without diabetes at all. Thus poor control of glucose, plus a deficiency in vitamin B12, is a bad combination for anyone with type 2 diabetes. Indeed, some neuropathies presently labelled as “diabetic” may, at least in part, be due to B12 deficiencies.

It is thought 60-70% of people with diabetes have some form of nerve damage. In a diabetic peripheral neuropathy, sufferers may have reduced sensation to touch and pain signals, which can lead to injuries and infections not being noticed, especially in the feet. In a painful diabetic peripheral neuropathy, nerves may send out abnormal signals which are perceived as pain, even though there is no physical injury. (Incidentally, a recent pilot study in Pain Medicine suggests that aerobic exercise can have some beneficial effect in patients with a painful diabetic neuropathy…)

All this may mean that, in the future, screening for vitamin B12 deficiency may be justifiable in those taking metformin. Furthermore, vitamin B12 supplementation (pills and/or injections) might be offered to people taking metformin, especially those regularly using proton pump inhibitors and H2 receptor agonists, those who have been on metformin for several years, older people and other people at risk for reduced dietary vitamin B12 absorption.
Diabetes Research
New hope in fatty liver disease
Promising developments continue in the fight against nonalcoholic fatty liver disease (NAFLD), the ‘silent’ cause of chronic liver disease in type 2 diabetes. In type 2 diabetes fat builds up in the liver, which can cause inflammation (steatohepatitis) and this can eventually lead to permanent scarring (cirrhosis). Hopeful news comes from the European Association for the Study of the Liver (EASL) International Liver Congress 2015 in Vienna concerning a possible role for liraglutide (Victoza). This is a drug already used to treat type 2 diabetes and is generally used alongside other drug treatments.

In a small study, nine (39%) of 23 overweight patients with non-alcoholic steatohepatitis (NASH) who took daily liraglutide were found to have resolution of their condition. This was over four times the rate found in patients just given a placebo. The question is whether this is a direct effect of the drug or whether this is just a reflection of the weight loss that liraglutide caused, as weight loss in those who are overweight does benefit NASH.

Time will tell, but any drug treatment for NASH or NAFLD would be welcome as there is no licensed therapy for it at present. The importance of preventing NAFLD progressing to NASH was highlighted by another study, from the same conference, of almost a million people in the UK that found, over a 14-year period, the chances of dying from NASH was around 50% higher than for those with NAFLD.

Until a treatment comes along, the mainstay of therapy in both NASH and NAFLD is to lose weight, exercise, eat healthily, and avoid excessive amounts of alcohol or any medications that may further damage the liver.

Diabetes Complications
Keep exercising in type 2 diabetes and address those risk factors
The suggestion raised in an editorial in the British Journal Of Sports Medicine that what you eat is much more important than exercising in preventing obesity was widely dissected by the mainstream media, including this article in the Daily Telegraph. The proposition was that public health messages should talk more about eating habits and the intake of sugars and carbohydrate, and less about encouraging exercise. However, it must be remembered that this assertion is in relation to preventing obesity, not in managing type 2 diabetes.

The value of exercise in type 2 diabetes is not in dispute, regardless of whether it actually leads to any weight loss or not. Any activity, no matter how minimal, has benefits in type 2 diabetes. Eating healthily is thus neither a substitute for, nor an alternative to, exercise in type 2 diabetes. People with type 2 diabetes should do both. They should eat a healthy diet, try to lose weight, be active and ideally exercise by spending 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.
The importance of addressing cardiovascular risk factors in type 2 diabetes was highlighted in this recent study from Diabetes Care which, for nearly five years, followed 859,617 adults with diabetes, 31% of whom already had existing cardiovascular disease (CVD).

It was found that the percentage of cardiovascular events (heart attacks, strokes, heart failure) and deaths associated with the inadequate control of risk factors was 11% and 3% respectively for those with CVD. For those without CVD, the figures were 34% and 7%.

So, what were the risk factors that those with type 2 diabetes must control? In this study they were:
  • Smoking
  • Blood pressure ≥ 140/90 mm Hg
  • Low density lipid cholesterol (the “bad” cholesterol) ≥ 100mg/dL
  • Glycated haemoglobin (Hba1c) ≥ 7%
Thus, if you want to reduce your risk of strokes or heart attacks, you should strive to stop smoking, control your blood pressure, achieve satisfactory “bad” cholesterol levels and have good long-term control of blood glucose. None of this lifestyle advice is new, but it is good to be reminded that studies continue to show the great benefits lifestyle changes can have in type 2 diabetes.

Diabetes Lifestyle
No escaping apps
Even if you personally try to avoid them, you will not be able to escape mobile medical apps as a half of the UK health professionals surveyed by digital data collection provider Research Now said they planned to introduce such apps in the next five years. At present only ten percent of healthcare professionals are using mobile health apps.

However, only a third of health professionals believe that these health apps will improve their relationship with their patients. In contrast, two-thirds did hope that they would encourage people to take more responsibility for their health. For people with diabetes, almost three-quarters of health professionals believed apps would help them manage their condition.

Currently most people just use health apps to help them lose weight and to track their exercise. Three-quarters of the public thought the NHS should invest more in smartphone technology, but only around a half of health professionals agreed. At present, the National Information Board is in charge of the strategic priorities for technology and data within the NHS and you can read their vision for the future here.

Diabetes Technology
You are not alone… famous people with type 2 diabetes
Scottish Hollywood actor Brian Cox was diagnosed with type 2 diabetes in 1998. In an article in The Scotsman he blames it on his “Dundee Diet”…
And Finally…
Many of us will recall Blinky the three-eyed orange fish from TV cartoon series The Simpsons, whose mutation was caused by leakage of radioactive waste into its aquatic home from the nearby Springfield Nuclear Power Plant. Now it seems that metformin in the water might just be the culprit in a different type of fish mutation, intersex, which has caused male fish to lay eggs.
According to the journal Chemosphere there is a lot of metformin contaminating Lake Michigan and this is affecting the fishes’ sexual development. This is a surprising outcome, not least to the fish, because metformin is not actually a hormone at all. It is suggested that metformin, the first-line drug for type 2 diabetes, somehow disrupts the normal balance of hormones in fish.

The good news is that very few of these intersex fish have poorly controlled type 2 diabetes…

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
Adam Feuerstein (@adamfeuerstein)
$MNKD Afrezza Contributes to $SNY Subpar Diabetes Unit Sales… via @TheStreet
John Fauber (@fauber_mjs)
Diabetes market out of control? Sanjay Kaul quote and our investigation
Brian Gallagher, Jr. (@bmgallagherjr)
@AndyBiotech Interesting agree but makes a lot of sense. Intarcia has the potential to completely disrupt diabetes treatment & is well $$$
Michael Koeris (@mkoeris)
How a failed cancer drug led to a potential diabetes breakthrough for Intarcia Therapeutics via @BosBizDon
Harlan Krumholz (@hmkyale)
This piece by @medpagetoday tells truth on #diabetes. A must read.… @PeggyMP @fauber_mjs
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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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