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Issue 9 Alzheimer’s Insights by Curation Health 21 May 2015
It’s been a bad week for those using SGLT2 inhibitors: we look at a recent health warning in the US. Back in the UK, sugar and obesity are in the headlines as the battle against “added sugar” in soft drinks begins. The role of different metabolisms on weight loss is defined – do you have a “thrifty” or “spendthrift” metabolism? A new stocking technology may help “the diabetic foot” and finally we muse on diabetes and the mind: why are we more prone to both dementia and depression?
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FDA Issues Warning on Type 2 Diabetes Rx Drugs
Diabetes Doesn't Discriminate
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FDA's SGLT2 warning bad news for AZ, J&J and Lilly--but could be a boon for Merck
Adolescents with diabetes
SGLT2 inhibitors increase risk of ketoacidosis
The US Food and Drug Administration (FDA) has sent out an alert that SGLT2 inhibitors, commonly used to manage type 2 diabetes, may cause diabetic ketoacidosis (DKA). This is a serious and potentially fatal condition requiring hospitalisation that is much more commonly seen in type 1 diabetes. In DKA (ketosis) the body begins to burn up fatty acids which generates harmful acids in the blood called ketone bodies. If the levels of ketone bodies become too high, it can lead to coma and death. The FDA has warned all users of SGLT2 inhibitors to be aware of the symptoms of DKA and to seek urgent medical care should they develop them.

Typical symptoms of DKA include abdominal pain, vomiting, deep gasping breathing, confusion, lethargy, stupor and eventual coma. Sufferers also have large amounts of ketones in their urine, which is easily detected using the appropriate urine testing strips. Sufferers also have raised blood glucose levels.

The SGLT2 inhibitors identified by the FDA as problematic were:
  • canagliflozin (Invokana)
  • empagliflozin (Jardiance)
  • dapagliflozin (Farxiga)
All 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. None of these drugs is used in type 1 diabetes.

People presently using SGLT2 inhibitors are advised by the FDA not to alter or stop their medications but to discuss the issue with their diabetes care team.

Diabetes Treatment
Sugar to go low at Tesco – every little helps!
Supermarket giant Tesco will be the first retailer to commit to a major sugar reduction programme according to The Grocer. It says the supermarket giant will promise a “5% year-on-year, open-ended reduction in sugar across its entire soft drinks range”. The story was then reported widely in the UK media, including a piece in The Daily Mail.

In Diabetes INSIGHTS, issue 7 we discussed the finding that just swapping the daily consumption of one serving of a sugary drink with either water or unsweetened coffee/tea could lower the risk of developing type 2 diabetes by between 14% and 25%.

The UK government (which is advised by the Scientific Advisory Committee on Nutrition), as well as other groups, have become increasingly concerned about the excessive amount of sugar in our diets, especially “added-sugar soft drinks”. The campaign group Action on Sugar, for example, has called for a 40% reduction of sugar in food and drinks of by 2020. In contrast, the British Soft Drinks Association refute/reject the link between sugar-sweetened beverages and type 2 diabetes.

As Tesco accounts for around 30% of all UK soft drinks sales, their sugar reduction programme could be a major first step in lowering the sugar content of soft drinks nationally and this may help halt or reverse the rising obesity levels in the UK.

Of course, tackling obesity on an individual level requires the recognition that you are, in fact, obese or even overweight. A recent study from the Association for the Study of Obesity has highlighted that the British are the worst in Europe for recognising when they are obese, even though Britain is the most obese country in Europe. Its survey found one third of obese British adults thought of themselves as being merely “overweight”, rather than obese. Also, in those who truly were just overweight, one in five believed they actually had a “healthy weight”. This latter figure compares unfavourably to Italy, where the comparable proportion was only one in ten.

Regardless of peoples’ self-image, in type 2 diabetes weight loss, exercise, calorie reduction and a healthy diet are all essential lifestyle changes to make to help manage the condition and reduce the risks of complications.

Diabetes Lifestyle
A glimpse of stocking not so shocking
Soon your phone may alert you that you are standing still for so long that it is putting you at risk of developing a diabetic foot ulcer. That, at least, is one of the hopes of the Fraunhofer Institute for Silicate Research ISC in Germany which has developed a special stocking with 40 integrated dielectric elastomer sensors. These measure the pressure loads and weight distribution experienced by the feet.

Unlike the current sensors available that are typically shoe inserts placed under the bottom of the feet, these stockings measure the compression levels all around the feet. This data can then be sent wirelessly to a phone or tablet to alert the wearer that their foot position or weight distribution needs to be altered.

Since individuals with diabetes have a 15–25% lifetime risk of foot ulceration, any technology that might 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 to 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. Symptoms such as numbness, altered sensation, tingling, pins and needles or burning of the feet could be a sign of developing neuropathy.

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 foot care is thus a vital part of self-management in diabetes. All people with diabetes are advised to check their feet every day for problems which should be reported to the diabetes care team. Regular foot examinations (at least annually) by professionals are also vital.

Diabetes Technology
Weight loss influenced by individual’s metabolism
For the first time researchers have found some justification for obese people saying they just can’t lose enough weight because of “their metabolism”. A study, published in Diabetes, of 12 men and women with obesity at the metabolic unit of the Phoenix Epidemiology and Clinical Research Branch in the US was able to differentiate a “thrifty” metabolism from a “spendthrift” metabolism.

In those with a “thrifty” metabolism, when they had a reduced calorie intake, their metabolism slowed down and they did not lose as much weight as those with a “spendthrift” metabolism. In contrast, the “spendthrift’s” metabolisms slowed down far less and they lost more weight when they had their calorie intake reduced. What is not clear is whether these differences are genetic or develop over time.

Regardless of whether your metabolism is “thrifty” or “spendthrift” and whether you were born that way or not, the researchers are adamant that such biology does not equate to destiny. A healthy, calorie-reduced diet and regular physical activity combined for a long period remains the key to weight loss; even if you may have to work a bit harder than others to achieve the same weight loss.

As we discussed in Diabetes INSIGHTS issue 8 in type 2 diabetes, even if no weight loss is actually achieved, exercise and a calorie-reduced diet each have their own individual and cumulative benefits in reducing the risk of any future complications of diabetes.

Diabetes Research
The link between diabetes and Alzheimer’s looks firmer
The worrying discovery of a link between Alzheimer’s and diabetes was strengthened by a Washington University study published in The Journal of Clinical Investigation which suggests that raised blood sugar levels can have harmful effects on the function of the brain and worsen Alzheimer's disease. In Diabetes INSIGHTS, issue 5 we briefly deliberated on whether Alzheimer’s could be reasonably called “diabetes type 3” after a study found that people with diabetes had a 20% increased risk of developing dementia.

This new study, performed on mice, has now suggested a mechanism for this link. It showed that raised glucose levels in the blood can rapidly increase the levels of amyloid beta – a substance which is present in the characteristic brain plaques that are found in Alzheimer's disease.

Researchers found that doubling the blood glucose levels increased the amyloid beta levels in the brain by 20 percent. The better news was that researchers were able to stop this happening, not by lowering blood glucose levels, but by using drugs which acted directly on the brain. The hope is that this type of discovery may lead to some new therapies for Alzheimer’s.

In the meantime, the good news is that all the lifestyle changes recommended to reduce the risks of type 2 diabetes also reduce the risk of developing dementia. So you are getting an additional benefit for all your good efforts!

Diabetes Complications
You are not alone… famous people with type 2 diabetes - Randy Jackson
The former American Idol judge learned he had type 2 diabetes in 2001. He had gastric bypass surgery in 2003 and has campaigned to raise awareness of type 2 diabetes.
And Finally… Diabetes and depression = chicken and egg?
The upcoming 2015 Annual Meeting of the American Psychiatric Association has provoked a flurry of interest in the relationship between diabetes and depression. Around one in five people with diabetes develop depression, which is twice the rate of those without diabetes. It is also a two-way street: people with diabetes tend to get depressed and depressed people tend to get diabetes. There is now growing evidence that depression and type 2 diabetes may share similar underlying biological mechanisms.

However, just to muddy the waters, some of those with diabetes who are diagnosed with “depression” may not be depressed at all – they are just experiencing "diabetes distress". This is a fancy way of saying that people living with diabetes can just get fed up of living with diabetes. Unlike depression, which is a constant emotional state, distress is more of a waxing and waning emotional struggle with the annoyances, compromises and limitations involved in having to live with diabetes.

I know that when I was diagnosed with diabetes I was pretty fed up and gloomy for a while, but I certainly never thought of myself as depressed. The truth is that diabetes is not the sort of condition that puts you in a good mood and fills you with optimism; sometimes it can feel rather like the Sword of Damocles is hanging over you…

The only thing we people living with diabetes can do is fight the good fight against it, change our lifestyles for the better, be kind to ourselves and hope that the future will bring new treatments to make it all just a little bit easier to bear. On the diatribe website you can read an interesting personal view on how to cope with diabetes distress using the four M’s: Mindset, Movement, Mindfulness, and a Morning routine.

However, if your diabetes really is getting you down then you should have a chat with your diabetes care team, because there are many things out there that can help you.

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.
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$ARNA Paulsen Introduces the Treat and Reduce Obesity Act #Diabetes #Oprah
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Depression among #Diabetes patients is a global concern. Glad to know that scientists are trying to find a cure.
Sam Minot (@sminot)
Who knows what evil lurks in the hearts of diabetic foot infections? The e-nose knows...…
PLOS Medicine (@PLOSMedicine)
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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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