Kellion Victory Medal for Brian’s 50 years with diabetes

WHEN you're diagnosed with diabetes, there's not a lot to celebrate.

But when you've been living with the disease for more than 50 years - it's an achievement worth boasting about.

Leichhardt resident Brian Leslie has had Type 1 diabetes since 1964.

The retired photographer said living with diabetes in those days was no easy task.

"In the mid-1960s, not many people - doctors included - knew much about Type 1 diabetes and the treatments and lifestyle changes required to live with the condition," he said.

"When I was diagnosed, there was no support for people with diabetes because it was so rare, there were certainly no low-calorie food or drinks.

"Decades before that, those with diabetes were probably looking at a death sentence. Back then it was called 'the wasting disease' where little could be done."

At 72, Mr Leslie said he owed his overall good health to the support and care of his wife of 32 years, Glenys.

"Without her, my life and outlook for the future would be significantly different," he said. "She has always been there, watching out for warning signs which would indicate a hypoglycemic attack and helping me avoid them."

Mr Leslie was recently awarded a Kellion Victory Medal as part of World Diabetes Day celebrations.

The award marks a huge personal triumph, commemorating those who have lived with diabetes for 50, 60 and 70 years or more.

The Victory Medal was presented by Diabetes Queensland president Dr Maarten Kamp who said he looked forward to honouring recipients each year. Dr Kamp said the award was a reminder people can still live a long and productive life.

More information from diabetesqld.org.au/

Kellion Victory Medal

The Kellion Victory Medal is named after Claude Kellion. When diabetes claimed the life of his son John, Claude, a successful businessman, established the Kellion Diabetes Foundation in John's memory. Funds raised through the foundation contribute to Diabetes Australia Research Trust projects.

4 effective ways to beat diabetes

Standard diabetes prevention advice (lose weight, exercise, eat better) is not getting through to — or even worse, is letting down — millions of North Americans! The proof is in shocking new statistics from the Centers for Disease Control and Prevention: 29 million Americans now have Type 2 diabetes, and 86 million more have prediabetes, a 10 percent jump in just two years.

That means more than 1 in every 11 Americans has Type 2 diabetes and is at increased risk for heart attack, strokes, vision loss, nerve damage, kidney failure, even amputation of toes, feet or legs, along with higher odds for depression, dental trouble, pregnancy complications and high vulnerability to the flu and pneumonia.

The 1 in 3 Americans with prediabetes face huge health risks, too: Having elevated blood sugar levels AT ALL ups the chance for a heart attack or stroke, cognitive problems, depression and sexual problems. Plus, within three years, 15 percent to 30 percent of people with prediabetes will develop full-blown Type 2.

In the 1970s, about 4 million Americans had Type 2 diabetes. While the number of those with Type 1 diabetes (caused by an autoimmune attack that stops the body’s production of insulin) has grown slightly, the prevalence of Type 2 — caused by inactivity, being overweight, unhealthy food choices and perhaps a genetic predisposition — has soared. YOU can turn this epidemic around by taking steps that will make your diabetes-stopping habits stick.

Here are four “betcha didn’t think of these” obstacles that may be what’s keeping you from effectively applying the standard advice of “move more, eat better, lose weight.”

1 Stress pumps up blood sugar.

Learn to chill.

Stress increases your blood sugar by switching on your body’s “fight or flight” response and by making you reach for foods that widen your waistline (a diabetes risk) and mute your body’s ability to use blood sugar. You can tame tension by getting plenty of sleep, learning a relaxation technique that works for you (deep breathing, meditation, progressive muscle relaxation) and making time for friends and family.

2 Overcrowded days make healthy choices difficult. Do what you can.

Discouraged because you can’t fit in a half-hour walk today? Don’t be. Grab a 10-minute walk at lunchtime. No time to meditate before you rush off to a morning meeting? Use that 15-minute wait before your boss shows up to do a short, relaxing breathing exercise. Gotta feed the family fast before another hectic evening of activities and homework? Hit the supermarket salad bar instead of the fast-food drive-thru.

3 Unhealthy food choices follow you through your day.

Make over your whole food environment.

Start at home by banishing the Five Food Felons: trans and saturated fats, added sugars and syrups and refined grains. Replace those villains (all of which mess with healthy blood sugar levels) with 100 percent whole grains; good fats found in nuts, avocados and olive and canola oils; fruit; vegetables, especially leafy greens; and salmon or ocean trout. These good foods contain fiber, mono- and polyunsaturated fats, vitamins, minerals and other nutrients that help regulate blood sugar and reduce the bodywide damage that diabetes and prediabetes can wreak.

Don’t stop there. Pack healthy lunches for yourself and your kids. And keep healthy snacks on hand at work and in the car. We love baby carrots, a handful of nuts or a juicy piece of sun-ripened fruit, along with water or herbal tea.

4 Don’t go it alone!

Working with a diet and/or exercise buddy is a proven to help you get better results. Sign up for diabetes education classes in your community. Got prediabetes? Check out the diabetes prevention programs (cdc.gov has lists) offered by YMCAs, hospitals, community centers and houses of worship.

Insulin therapy for type 2 diabetes 'may do more harm than good'

A new study published in the journal JAMA Internal Medicine suggests that for older patients with type 2 diabetes, medications to lower blood sugar levels may "do more harm than good."

Approximately 25.8 million people in the US have diabetes, with type 2 diabetes accounting for 90-95% of all cases.

Type 2 diabetes is characterized by insulin resistance - the inability of the body to produce enough insulin or use the hormone effectively, which causes high blood sugar levels. Over time, high blood sugar levels can cause kidney, eye or heart diseases, nerve damage or stroke.

Diagnosis of type 2 diabetes is usually determined through a blood test that measures hemoglobin A1c levels in the blood. This test reveals the average level of glucose the patient has had in their blood over the past 3 months.

In the US, type 2 diabetes is diagnosed when hemoglobin A1c levels reach 6.5% or higher. The higher A1c levels are, the greater the risk of other health problems.

Sometimes the condition can be managed through changes in diet, but other patients with type 2 diabetes may need medication - such as insulin or metformin - to help lower their blood sugar levels, and ultimately, reduce the risk of diabetes complications.

But the researchers of this latest study, from University College London (UCL) in the UK, the University of Michigan Medical School and the Ann Arbor Veterans Affairs Hospital, MI, claim that the benefits of such treatment - particularly for people over the age of 50 - may not always outweigh the negatives.

"In many cases, insulin treatment may not do anything to add to the person's quality life expectancy," says study co-author John S. Yudkin, emeritus professor of medicine at UCL. "If people feel that insulin therapy reduces their quality of life by anything more than around 3-4%, this will outweigh any potential benefits gained by treatment in almost anyone with type 2 diabetes over around 50 years old."

For their study, led by Sandeep Vijan, professor of internal medicine at the University of Michigan Medical School, the team assessed 5,102 patients in the UK with type 2 diabetes who managed their condition through the use of insulin pills or injections.

Over a 20-year follow-up, the researchers looked at how the treatments affected patients' overall quality of life and whether they were effective in reducing their risk of diabetes complications.

They then compared the reduced risk of such complications with the burden of using diabetes medications and the side effects associated with them.

According to the researchers, they found that the benefits of insulin therapy for patients with type 2 diabetes are very much dependent on their age at treatment initiation and the potential side effects, rather than their blood sugar levels.

For example, they estimate that a person with type 2 diabetes who begins insulin therapy at age 45 and lowers their hemoglobin A1c levels by 1% may experience an extra 10 months of healthy life.

But for a patient who starts treatment for type 2 diabetes at age 75, they estimate the therapy may only gain them an additional 3 weeks of healthy life. The researchers say this prompts the question - is 10-15 years of pills or injections with possible side effects worth it?

Prof. Yudkin comments:

"Ultimately, the aim of a treatment is not to lower blood sugar for its own sake but to prevent debilitating or deadly complications. If the risk of these complications is suitably low and the burden of treatment correspondingly high, treatment will do more harm than good. The balance between the two can never be defined by a simple figure like blood sugar level."

The team says their findings apply to type 2 diabetes patients with hemoglobin A1c levels below 8.5%. But they note that patients with levels above 8.5% may be likely to see greater benefits from insulin therapy, as they are at greater risk of diabetes complications.

However, the team concludes that using a patient's hemoglobin A1c levels alone to judge whether they will benefit from insulin therapy is a "fundamentally flawed strategy."

"Instead," they add, "each glycemic treatment decision should be individualized, mostly on the basis of the patients' views of the burdens of therapy, with age and initial level of glycemic control important secondary considerations."

"Currently, we are failing our patients by not recognizing that their preferences and views of treatment burden are the most important factors in helping them make glycemic treatment decisions that are best for them."

Earlier this year, Medical News Today reported on a study published in the journal PLOS One, in which researchers took to Mount Everest in order to show how hypoxia - low oxygen levels in the body - isassociated with development of type 2 diabetes.

Written by Honor Whiteman

FDA Approves Inhaled Diabetes Medication

People with type 1 or 2 diabetes now have a new means of getting their medication, with the U.S. Food and Drug Administration's approval on Friday of the first inhaled medicine for the blood sugar disease.

The drug, Afrezza, "is a new treatment option for patients with diabetes requiring mealtime insulin," Dr. Jean-Marc Guettier, director of the Division of Metabolism and Endocrinology Products in the FDA's Center for Drug Evaluation and Research, said in an agency news release on Friday.

He said that Afrezza's approval "broadens the options available for delivering mealtime insulin in the overall management of patients with diabetes who require it to control blood sugar levels."

Diabetes falls into two main categories: type 1, an autoimmune illness which is often inherited and involves a dysfunction of insulin-producing cells in the pancreas; and type 2, which develops over time and is tied closely to obesity. Between 90 percent and 95 percent of diabetes cases are of the type 2 variety, according to the U.S. National Institutes of Health.

The FDA estimates that almost 26 million Americans -- about 8.3 percent of the population -- now live with diabetes, which can lead to dangerous complications such as heart disease, vision loss and nerve and kidney problems. Many patients must take injected insulin daily to maintain healthy blood sugar levels.

Afrezza's approval came after a study involving more than 3,000 people -- approximately 1,000 with type 1 diabetes and nearly 2,000 with the type 2 form of the illness.

For people with type 1 disease, researchers compared the effectiveness of Afrezza in adult patients against that of fast-acting insulin (aspart), used in both cases alongside basal insulin (long-acting insulin). Over 6 months, the combo of long-acting insulin and Afrezza met required treatment effectiveness in terms of blood sugar control, the FDA said.

For patients with type 2 diabetes, researchers combined Afrezza with standard diabetes pills and compared the use of the inhaled drug at mealtimes against the use of standard medications plus a placebo. At six months, the Afrezza-plus-standard medications combination produced better results overall, the FDA said.

The agency stressed that Afrezza should never substitute for long-acting insulin, and patients with type 1 diabetes must use the drug in combination with long-acting insulin. Smokers should avoid Afrezza, as well, the agency said, and the drug is not to be used in the treatment of a condition called diabetic ketoacidosis.

People with certain lung conditions should also not use Afrezza, due to a dangerous complication called acute bronchospasm. For this reason, the FDA has ordered a warning be placed on the product's labeling to caution people with chronic obstructive pulmonary disease (COPD) from using the drug. The FDA is also advising that people with asthma avoid Afrezza for the same reason.

According to the agency, the most common side effects from Afrezza were hypoglycemia (low blood sugar), cough, and throat pain or irritation.

The FDA is also ordering that "post-marketing studies" be conducted to track the safety and effectiveness of Afrezza in children, and to see if there is any connection between the use of Afrezza and any lung cancers.

A Novel Approach to Treating Type 2 Diabetes: Short-Term Intensive Insulin

Type 2 diabetes is a progressive disease with worsening beta cell function over time.  Traditional treatment of type 2 diabetes begins with oral medications, including metformin, sulfonylureas, or DPP-4 inhibitors and then progresses to GLP-1 agonists and/or insulin injections. Dr. Mariela Glandt, an endocrinologist and director of the Diabetes Medical Center in Tel Aviv, however, uses a short course of intensive insulin therapy in order to “reset” beta cells and help them return to an earlier and more manageable stage of the disease. 

Beta cell function declines in response to multiple factors in type 2 diabetes, and insulin therapy has been shown to counteract several of these. For example, treatment with insulin can reduce glucotoxicity – the toxic effects of excess sugar in the blood, lipotoxicity (due to chronically elevated free fatty acids), inflammation, and resistance to incretins.

Studies[1] have shown the effectiveness of short-term intensive insulin therapy (IIT) early in the presentation of type 2 diabetes. Dr. Glandt is applying this same concept to treat diabetes years after the original diagnosis.  In her private practice she has brought over 80 patients with complicated diabetes to a place where their diabetes is much easier to manage, and they have near normal HbA1c’s.

When did you start treating patients with intensive insulin therapy?

It all started when a patient with a 10-year history of diabetes and an A1c of 14% came into my office.  His previous doctor had prescribed Janumet, a combination pill of metformin and sitagliptin, a few months prior to the visit, but still there was no improvement, and he was exhausted and hopeless.  I suggested he stay on the medication he was taking, but told him that in addition to his current medication, from now on he should behave as if he has type 1 diabetes, meaning he would take insulin with everything he ate (including snacks).

I started treating my new patient with low doses of insulin and made the corrections slowly because I knew that if l lowered his blood sugar too fast he would feel bad, as if he were hypoglycemic, although he really wasn’t.  I told him to come to the clinic every week, and we slowly fine-tuned his insulin regimen.  At first I increased and increased the insulin doses, then after a while of his blood sugar levels being near normal, he started to need less and less insulin.  After 6 weeks, I was able to peel off the insulin entirely and he ended right back on his original medication, Janumet.  Now, more than two years later, he is still on Janumet with A1c of 6.9%. 

Since then I’ve treated dozens of patients this way and I am shocked by the successful results.  On average my patients have been diabetic for 10 years and on average their A1c is 9.8% at the beginning of treatment.  After 6 months the average A1c is 6.9%

Most patients who have A1c of 14% are placed on insulin? What’s different about your treatment?

I think the key point is that the insulin has to be taken in such a way as to really bring the blood sugar close to normal levels.  Most patients like this would be started on insulin and would probably be kept on it for the rest of their lives.  It is the fact that my patients take insulin like a patient who has well treated type 1 that allows the pancreas to start working, as I see by the fact that they don’t need insulin anymore and still their sugars are well-controlled

What is the mechanism behind this?

A few studies (see footnote 1) conducted on patients close to the time of diabetes diagnosis show that when insulin is given this way for a few weeks, the patients can revert to a state of no-diabetes for one to two years.  It is believed to be due to the fact that the beta cells improve their function when they are no longer smothered in sugar. High glucose levels are toxic to cells (glucotoxicity), which means that the cells are stunned and cannot secrete insulin appropriately. Generally, these cells are not dead and can go back to working if given the opportunity.  As I often say, “give beta cells a chance.”

Since these patients have had diabetes for many years, what are your expectations after the intensive insulin therapy?

Some beta cell deterioration is reversible and some is not.  It seems to depend on how long the patient was exposed to hyperglycemia and the degree of hyperglycemia.

Those who are recently diagnosed are able to come off medications for one to two years and remain in good control. Those who have had diabetes for ten years (which is the average I see in my clinic) are able to significantly improve their insulin secretion, but must continue to take simpler medications, that don’t require frequent checking of blood sugar levels because they don’t lead to hypoglycemia.

So what medications are used after the intensive treatment is over?

Unless there is a contraindication most patients are kept on metformin- a very safe and well known drug.  In addition, GLP-1 agonists such as liraglutide seem to be very effective – they help with both weight maintenance and keep blood glucose levels in the range of normal without putting the patient at risk for hypoglycemia.  The downside of GLP-1 agonists is that they are expensive.

Many patients come to me already on a GLP-1 agonist, but because their glucose levels are high, the GLP-1 agonist is not working.  However, as soon as the glucotoxicity goes away with the insulin treatment, the GLP-1 agonist starts to work and patients even start to complain of the usual side effects as if they had just started taking the medication.  I often have to lower the dose of GLP-1 when I start intensive insulin therapy just so patients won’t suddenly get the side effects. There is a paper[2]that shows that when beta cells are exposed to hyperglycemia for a long time they lose the GLP-1 receptors.  When they are re-exposed to normal sugars then the beta cells regain the GLP-1 receptors.  This helps to explain the phenomenon I often see in clinical practice.  Suddenly, a medication like liraglutide, which was described to me by the patient as “it did nothing for me” is now very effective.

Are you really able to stop the insulin on all patients?

Certainly not on all patients, but in those who I don’t manage to take off the insulin entirely, they often remain only on a low dose of long acting insulin. Eating a low carb diet and doing some kind of physical activity – of course – significantly improves the chances of coming off insulin, even if the patient has been a diabetic 20 years. 

It seems like you have to bring the patients’ blood sugar levels quite close to normal for this to work. In these patients who on average have had diabetes for 10 years, are you not concerned about the data from studies like the ACCORD trial[3] which showed that bringing glucose to near-normal levels in patients with long history of diabetes increased cardiovascular risk.

[The goal of ACCORD (the part that checked the impact of glycemia) was to determine whether cardiovascular disease event rates could be reduced by intensively treating glucose levels.  There were two arms of the study – one aiming for A1C <6  an the other 7–7.9%] 

It is, of course, something I have given a lot of thought to, but my understanding from trials like the ACCORD trial is that low A1C is unlikely to account for the increased risk of mortality.   In fact, rapid reduction of A1C from high levels did not increase risk of death.  Participants who were unable to reduce A1C after starting the intensive strategy and continued to have average A1C >7% seemed to be at greater risk than those with average A1C <7% using the same strategy or than those with A1C >7% using a standard strategy.[4]

At my clinic I have always seen the glucose levels decrease relatively slowly, but surely, with no hypoglycemic events because the insulin is given in a physiological way, and the treatment includes very frequent contact with the doctor, nurse, and dietician. 

A recent publication from the ACCORD trial actually showed that the intensive arm  (which reached HbA1c levels below 6.5% ) had great glucose control more than one year after therapy is relaxed[5], which is similar to my findings.  

How do you convince patients to take 4 shots a day (at a minimum)?

It’s not so hard because most of these patients are tired of feeling that diabetes is uncontrolled, doing damage, and that they can’t do much about it.  The good news is that the plan is to be on insulin for one to two months.  Because it is temporary, it’s easier to accept. The interesting part is that many patients actually enjoy the process because insulin becomes a tool that empowers them and gives them back control over their life (even for those on multiple shots a day for years). I achieve this with the help of a glucometer called Insulinx, which has a built in sliding scale and recommends to the patient how much insulin to take according to what I program in it, and the dose is something that I change on a weekly basis. It’s a very helpful tool.  

How long does the diabetes stay well controlled after they stop the insulin? 

We know from the trials (see footnote 1) done in patients with new onset diabetes that the beta cell improvements seen after intensive insulin therapy decline over time.  In our practice we’ve seen over the last two years that overall patients are able to stay with A1c under 7%, particularly if they are on GLP-1 agonist.  A  study by Ravi Retnakaran  presented at the America Diabetes Assoication’s Scientific Sessions Conference in Chicago last month showed that liraglutide after a short course of intensive insulin therapy preserved the  beta cell function gained after a short course of intensive insulin therapy. 

The exception is in cases where patients have other reasons to go off track, for example intermittent illness, such as an asthmatic patient who requires high doses of steroids.  In some cases A1c starts to go slightly up and the patients themselves request a “booster” (another short course of intensive insulin therapy).

The ongoing RESET IT trial[6] investigates the effect of administering a short course of intensive insulin therapy every three months –i.e., using insulin as both the initial and maintenance therapy.  It will be interesting to see the results of that.

This whole process seems like a lot of work for you and the patients, but the results are so impressive.  I assume it’s all worth it.

For me it’s worth it because I see how the patients react. At the beginning it’s tough because of the amount of injections. But as patients gain control over their lives and they feel great because they are no longer tired due to the chronic hyperglycemia, I sometimes have to convince them that it’s time to stop.

U doctors think a cheap pill for gout may delay onset of diabetic kidney disease

Paul Wild has been a reliable research volunteer at the University of Minnesota for 20 years, participating in two landmark studies that changed the standard of care for diabetes, a disease that afflicts more than 24 million Americans.

“Looking back, it was probably the best thing I ever did,” said the 61-year-old Mendota Heights dentist.

Now, Wild is among 480 patients being recruited for a $24 million, 3½-year test to see whether a medication that has been used routinely to prevent gout can delay the onset of potentially fatal kidney disease in patients with Type 1 diabetes.

If the study succeeds, the medication, called allopurinol, could be to diabetic kidney disease what baby aspirin is to heart attacks, said Dr. Luiza Caramori, an endocrinologist helping to oversee the study at the U. The drug could delay the need for dialysis and kidney transplants by eight to 10 years, she said, saving thousands of lives and tens of millions of dollars in medical spending.

Diabetes has reached epidemic proportions in the United States, with rates increasing so fast that researchers predict 1 in 3 Americans born after 2000 could develop either type 1 or type 2. As many as 30 percent of diabetics will develop serious kidney disease within 10 to 20 years of their diagnosis, making it the leading cause of kidney failure in the United States. And because the waiting list for a kidney is so long, hundreds of patients die each year waiting for a transplant.

While the U study is limited to subjects with Type 1 diabetes, Caramori said positive findings will likely benefit the far more common Type 2 diabetics, as well.

“It’s amazing that in the past 20 years we’ve basically made no progress in delaying kidney disease in patients with diabetes,” she said. “It’s also disappointing and scary, because the rates of complications are quite high in these patients.”

Type 1 diabetes occurs when the immune system destroys the body’s ability to produce insulin. It affects fewer than 1 in 10 diabetics. The much more common Type 2 often results from genetic predisposition, coupled with obesity and lifestyle factors, leading initially to resistance to the body’s own insulin.

The U is one of seven U.S. sites and two international locations recruiting participants for the study, which is being led by Dr. Michael Mauer, a professor of pediatrics and medicine at the U’s medical school, and Dr. Alessandro Doria, an epidemiologist at Joslin Diabetes Center and associate professor at Harvard Medical School.

If allopurinol works as expected, it could become the standard treatment for treating diabetic kidney complications, Doria said in comments released last year.

Study seeking volunteers

Results from three small preliminary studies indicate that allopurinol shows real promise. It suppresses the production of an enzyme, xanthine oxidase, a result of metabolic activity, which can lead to excess acid in the urine. The World Health Organization lists it as an essential medicine for health systems.

It’s also cheap and has been used in the Untied States for nearly 50 years to prevent gout flare-ups.

The study seeks volunteers between 18 and 70 who’ve been diagnosed with Type 1 diabetes for at least eight years and who are concerned about possible kidney disease.

Although allopurinol is generally safe, researchers will screen study applicants for possible drug interactions and for a genetic profile that puts some at risk for a rare, serious skin disease.

The study will assign subjects randomly to two equal groups. They will get either allopurinol or a placebo — neither the patients nor their doctors will know which — and they’ll have to visit a study center or a site working remotely with the centers 17 times over three years for a variety of procedures and tests.

The U is one of nine institutions known as the Preventing Early Renal Function Loss in Diabetes (PERL) Consortium, which received the $24.3 million grant from the National Institute of Diabetes and Digestive and Kidney Diseases, a division of the National Institutes of Health (NIH). The nonprofit Juvenile Diabetes Research Foundation also is contributing to the PERL study.

Caramori said that leading diabetic researchers are involved and that they have big hopes for it.

FDA Approves Inhaled Insulin

The FDA has approved inhaled insulin to treat type 1 and type 2 diabetes.

The insulin, called Afrezza, is a rapid-acting insulin and is meant to be taken at mealtime or soon after.

“Today’s approval broadens the options available" for delivering insulin in people with diabetes, Jean-Marc Guettier, MD, director of the FDA's Division of Metabolism and Endocrinology Products, says in a news release.

The FDA estimates that 18.1 million people have diabetes. About 7 million more are undiagnosed, the agency says.

This is the third time the drug was up for FDA approval. Its maker, MannKind Corporation, conducted additional safety studies after the first two attempts.

Patients with type 1 diabetes will need to use the drug in combination with long-acting insulin. Patients with type 2 diabetes will use it in combination with oral medications.

Afrezza carries a warning as it may cause a sudden tightening of the chest.  It is not recommended for people with asthma or COPD. It is also not recommended for people that smoke or for the treatment of diabetic ketoacidosis.

"Our expectation is it should be priced comparably to current fast-acting insulins delivered in pen form," says Matthew Pfeffer, a spokesman for MannKind.