In this episode of the JIM Podcast, Editor-in-Chief Richard McCallum speaks with David Cistola of Texas Tech University Health Sciences Center El Paso about American Diabetes Month.
Comprehensive care in patients with diabetes and CKD
Management of CKD in diabetes can be challenging and complex, and a multidisciplinary team should be involved (doctors, nurses, dietitians, educators, etc). Patient participation is important for self-management and to participate in shared decision-making regarding the management plan. (Practice point).
We recommend that treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) be initiated in patients with diabetes, hypertension, and albuminuria, and that these medications be titrated to the highest approved dose that is tolerated (1B).
Lifestyle interventions in patients with diabetes and CKD
We suggest maintaining a protein intake of 0.8 g protein/kg)/d for those with diabetes and CKD not treated with dialysis (2C).
On the amount of proteins recommended in these guidelines, they suggest (‘recommend’ becomes a ‘suggest’ at this level of evidence) a very precise intake of 0.8g/kg/d in patients with diabetes and CKD. Lower dietary protein intake has been hypothesized but never proven to reduce glomerular hyperfiltration and slow progression of CKD, however in patients with diabetes, limiting protein intake below 0.8g/kg/d can be translated into a decreased caloric content, significant weight loss and quality of life. Malnutrition from protein and calorie deficit is possible.
We recommend that patients with diabetes and CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance (1D).
Diabetologia (Sept 8, 2020) – Insomnia with objective short sleep duration has been associated with an increased risk of type 2 diabetes in observational studies [27, 28]. The present MR study found strong and suggestive evidence of a causal association of insomnia and short sleep duration, respectively, with increased risk of type 2 diabetes.
The present study verified several previously reported risk factors and identified novel potential risk factors for type 2 diabetes. Prevention strategies for type 2 diabetes should be considered from multiple perspectives on obesity, mental health, sleep quality, education level, birthweight and smoking.
2020 American Diabetes Association (ADA) guidelines recommend that after a trial of metformin, doctors add additional drugs based on the presence of cardiovascular and kidney-related comorbidities, risk of weight gain and hypoglycemia, and cost. In this video, Irl B. Hirsch, MD, of the University of Washington in Seattle, explains the rationale for starting insulin next for patients with persistent HbA1c elevation above 9-9.5% despite lifestyle changes and metformin.
Click https://ja.ma/2DhR4DV for complete details.
Technology is finally innovating diabetes management. With the advancement in technologies like continuous glucose monitors, traditional insulin pumps are evolving into smarter devices that can automate insulin delivery.
Medtronic and Tandem Diabetes are the only two companies to offer hybrid closed loop systems. A community of diabetics are also hacking pumps to do the same thing. CNBC’s Erin Black just switched from the hacked system to Tandem’s Control-IQ and takes a look at how insulin pumps are getting smarter.
From The Lancet Diabetes & Endocrinology (June 2020):
Our findings show that the intensive lifestyle intervention led to significant weight loss at 12 months, and was associated with diabetes remission in over 60% of participants and normoglycaemia in over 30% of participants. The provision of this lifestyle intervention could allow a large proportion of young individuals with early diabetes to achieve improvements in key cardiometabolic outcomes, with potential long-term benefits for health and wellbeing.
From a Diabetologia online study release (April 15, 2020):
“Having normal body weight is crucial in the prevention of type 2 diabetes, regardless of genetic predisposition.”
“The results suggest that type 2 diabetes prevention by weight management and healthy lifestyle is critical across all genetic risk groups.”
“Overall, the results indicate that a favorable lifestyle should be universally recommended in the prevention of type 2 diabetes, regardless of genetic predisposition, thus supporting current public health guidelines,”
We examined the joint association of genetic predisposition, obesity and unfavourable lifestyle with incident type 2 diabetes using a case-cohort study nested within the Diet, Cancer and Health cohort in Denmark. The study sample included 4729 individuals who developed type 2 diabetes during a median 14.7 years of follow-up, and a randomly selected cohort sample of 5402 individuals.
Obesity (BMI ≥ 30 kg/m2) and unfavourable lifestyle were associated with higher risk for incident type 2 diabetes regardless of genetic predisposition (p > 0.05 for GRS–obesity and GRS–lifestyle interaction). The effect of obesity on type 2 diabetes risk (HR 5.81 [95% CI 5.16, 6.55]) was high, whereas the effects of high genetic risk (HR 2.00 [95% CI 1.76, 2.27]) and unfavourable lifestyle (HR 1.18 [95% CI 1.06, 1.30]) were relatively modest.
From a Technology Networks online article:
By comparing the pancreatic cells of type 2 diabetic human donors with those of healthy people, researchers at the University of Geneva (UNIGE) and at the University Hospitals of Geneva (HUG), Switzerland, were able to demonstrate, for the first time, that the pancreatic islet cells derived from the Type 2 Diabetic human donors bear compromised circadian oscillators.
The disruption of the circadian clocks was concomitant with the perturbation of hormone secretion. Moreover, using clock modulator molecule dubbed Nobiletin, extracted from lemon peel, the researchers succeeded in “repairing” the disrupted cellular clocks and in partial restoring of the islet cell function. These results, published in the Proceedings of the National Academy of Sciences of the United States, provide a first insight into innovative approach for diabetes care.
The circadian clock system (from Latin “circa diem”, about a day) allows the organisms to anticipate periodical changes of geophysical time, and to adjust to these changes. Nearly all the cells in our body comprise molecular clocks that regulate and synchronize metabolic functions to a 24-hour cycle of day-night changes.
Today, increasing evidence show that disturbances in our internal clocks stemming from frequent time zone changes, irregular working schedules or ageing, have a significant impact on the development of metabolic diseases in human beings, including type-2 diabetes. Such disturbances seem to prevent the proper functioning of the cells in the pancreatic islet that secrete insulin and glucagon, the hormones that regulate blood sugar levels.
From a Newcastle University news release:
“When fat cannot be safely stored under the skin, it is then stored inside the liver, and over-spills to the rest of the body including the pancreas. This ‘clogs up’ the pancreas, switching off the genes which direct how insulin should effectively be produced, and this causes Type 2 diabetes.”
This latest paper builds on previous Newcastle studies supported by Diabetes UK showing exactly why Type 2 diabetes can be reversed back to normal glucose control. Those studies led to the large DiRECT trial which showed that Primary Care staff can achieve remission of Type 2 diabetes by using a low calorie diet with support to maintain the weight loss.
A quarter of participants achieved a staggering 15 kg or more weight loss, and of these, almost nine out of 10 people put their Type 2 diabetes into remission. After two years, more than one third of the group had been free of diabetes and off all diabetes medication for at least two years.
In 2020, this approach to management of short duration Type 2 diabetes is to be piloted in the NHS in up to 5,000 people across England, and a similar programme is being rolled out in Scotland.