Weight gain: An avoidable side effect of glycaemic control
A new report assessing the combined global threat posed by obesity and diabetes has issued a call to action for doctors and patients to no longer accept weight gain as an inevitable price to pay for glycaemic control.
The Weight of the World report, authored by some of the leading figures in the field of diabetes, investigates the detrimental effects that weight gain can have both physiologically and psychologically on people with diabetes.
‘While glucose control remains the key goal, the avoidance of weight gain should now be considered a fundamental aspect of diabetes management,’ said Dr Vivian Fonseca, Professor of Medicine and chief of the Section of Endocrinology at Tulane University Medical Centre in New Orleans, US. ‘Careful selection of available therapies and management of diet and lifestyle can help to minimise weight gain in diabetes patients.’
The report argues that even relatively modest weight loss can result in improved glycaemic control, reduce the risk of heart disease and increase life expectancy.
IDF recommends tighter blood glucose control after meals
New guidelines launched by the IDF at the 2007 EASD conference emphasise that people with diabetes should have their blood glucose levels monitored closely after meals in order to optimise diabetes control and reduce the risk of complications, particularly cardiovascular disease.
The new guidelines recommend that people with diabetes try to keep postprandial blood glucose levels below 7.8mmol/l for the 2 hours following a meal. The IDF goes on to suggest that self-monitoring of blood glucose is the most practical method for measuring postprandial glucose levels and allows people with diabetes to obtain ‘real-time’ information. This allows the individual and their healthcare providers to make timely adjustments to their treatment regimens to achieve and maintain blood glucose targets.
Insulin still not reaching many who require it in poorer countries
The IDF’s Life for a Child programme currently supports 700 young people with diabetes in 15 developing countries. Without this support, many would die.
The programme was started in 2000 with a few children in three countries and has since expanded. Support will soon begin in Cameroon, where quality care will be provided for a hundred of the neediest children in the country. In Bolivia, Tanzania and Rwanda, where self-monitoring is prohibitively expensive, the programme will soon be able to provide inexpensive self-monitoring for all young people with diabetes.
‘The collaboration with Insulin For Life has been a tremendous resource. They have helped us not only to provide insulin and syringes, but also blood glucose-monitoring facilities, HbA1c testing, education and technical support for health professionals when requested’, said Dr Wim Wientjens, Vice-President of the IDF.
Pioglitazone data show reduction in risk of stroke and MI in T2D
Research presented at EASD suggests that type 2 diabetes regimens that include pioglitazone are associated with significant reductions in the risk of stroke (RR: 20% lower) or MI (RR: 28% lower) compared with non-thiazolidinedione regimens. This was a retrospective analysis of case records from a large managed care database of people with type 2 diabetes.
John Betteridge, Professor of Endocrinology and Metabolism at University College, London, said: ‘The results of this analysis support the findings from the PROactive study of pioglitazone for secondary prevention of vascular events.’
Inadequate blood glucose testing in type 2 diabetes
A global survey of 1400 HCPs and 1000 patients in eight countries demonstrated that the use of HbA1c testing in clinical practice was below that recommended by the IDF.
Additionally, the survey found that communication about the importance of testing is inadequate and patient understanding of HbA1c is low. Other key barriers to optimal glycaemic control included short, infrequent consultations and adherence to complex regimens.
Sitagliptin and metformin dual therapy offers significant HbA1c benefits over monotherapy
In a 1-year study of 748 people with type 2 diabetes, initial combination therapy with sitagliptin and metformin provided significant improvement in blood glucose control compared with metformin alone. Up to 67% of participants on sitagliptin and metformin initial combination therapy achieved an HbA1c of <7% at 54 weeks, compared with only 44% on metformin alone, according to new data presented at the EASD conference.
Mean HbA1c reductions up to 54 weeks from baseline were 1.4% in those treated with sitagliptin 50mg plus metformin 500mg twice daily, 1.3% in participants treated with metformin 1000mg twice daily, 1.0% in people treated with metformin 500mg twice daily, and 0.8% in those treated with sitagliptin 100mg once daily.
Characteristics of people with T2D initiating insulin defined
Study findings indicate that people with type 2 diabetes in Europe undergo insulin initiation at a mean HbA1c of 9.6%. Additionally, more than 12 months prior to insulin initiation, the mean HbA1c was 8.3% and mean BMI was 29.9kg/m2. Both HbA1c figures are significantly higher than the IDF recommended target of <6.5%.
These data come from the INSTIGATE study, an ongoing prospective study involving 1172 individuals that aims to gather data on medications for diabetes, clinical outcomes, health-related quality of life, and cost and resource use when people with type 2 diabetes initiate insulin.
‘The INSTIGATE data underscore the importance of successful disease management,’ said Dr Andreas Liebl, Medical Director of the Center for Diabetes and Metabolism in Bad Heilbrunn, Germany.
Further evidence of detemir weight benefits
In a 2-year study, people with type 1 diabetes treated with insulin detemir gained significantly less weight than those on NPH insulin and at the same time had significantly improved glycaemic control compared with those on NPH insulin. This long-term study with a modern basal insulin versus the older and commonly used NPH insulin demonstrates that the weight advantage of insulin detemir is sustainable, while simultaneously providing significantly better glycaemic control and reduced nocturnal hypoglycaemia.
The benefits of insulin detemir are further confirmed in the large randomised clinical trial PREDICTIVE, involving more than 5000 patients. People with type 2 diabetes who were switched from NPH insulin or insulin glargine to insulin detemir over a period of 26 weeks actually lost weight, while still experiencing significant improvements in glycaemic control and reduced rates of hypoglycaemia.
EASD expresses concern over lack of clinical trials
While clinical research is addressing some of the issues concerning the epidemic of diabetes, the EASD reports that many large-scale trials are failing to improve clinical decision or stem the tide of complications. Additionally, the EASD is concerned about the limited range of clinical trials and studies, their relevance and their funding.
Called for in particular are large scale trials, which, if extending over 3 years can cost over €300000, to address some of the most basic therapeutic options, especially related to the use of polypharmacy. Furthermore, the EASD claim that clinical research needs funding for small-scale mechanistic studies to establish the basis of the condition and investigation to test new approaches to the onset, progression and complications of diabetes.
Europe-wide, the EASD calls for awareness regarding how the lack of funding will stifle progress and degrade the position of European science and medical practice.
Insulin resistance not sole cause of cardiometabolic risk
Insulin resistance, obesity, central obesity and a high insulin response each make an independent but partial contribution to the metabolic syndrome, according to data from the Risk between Insulin Sensitivity and Cardiovascular risk (RISC) study. The study involved more than 1500 healthy volunteers from 14 countries.
Preliminary data demonstrated that impaired ß-cell function was associated with a three-fold risk of developing either diabetes or pre-diabetes and a two-fold risk of developing abdominal obesity after 3 years.
The RISC study further showed that physical activity is beneficially associated with insulin sensitivity even in the more obese. Additionally, physical activity appears to decrease age-related stiffening of arterial walls in a young-to-middle-ages population at low CV risk.
Opportunities for people with diabetes to advance research
At their annual conference, the EASD advocated using all avenues to engage the public in decisions about ways in which research should be carried out and the opportunities for people with the condition to participate in clinical research that they can find rewarding.
EASD suggests that the diabetes community should be clearer in its message about rights and responsibilities. People with diabetes have rights to safe, efficacious medications and good clinical care. The society poses that it may not be unreasonable to expect that people with diabetes participate in systematically conducted post-authorisation studies in order to determine whether or not newer agents are really an improvement and whether or not they represent good value for money.
Attempts to achieve remission, or at least a substantial improvement in glycaemic control, should be the initial focus at type 2 diabetes diagnosis.
9 May 2024