How I Crushed Type 2 Diabetes in Only Weeks and Completely Changed My Outlook on Life

Editor’s note: We found Rey’s remarkable story in the diabetes online community, and asked him if he would share it with us. Rey experienced extraordinary rapid success by following a precise diet and medication regimen immediately after diagnosis with type 2 diabetes. His improvement was incredible, but others making the same changes may not experience the same success. Please speak to your doctor or caregiver before enacting any major health changes of your own.

I’m Rey, and I’m a 44-year old male with a history of high blood pressure and being overweight, but until recently I had no major health issues. Only this past summer I learned that I had dangerously uncontrolled diabetes. Within the span of just a couple of months, I completely changed my diet, started and then stopped glucose-lowering medications, and got my blood sugar back into the normal, healthy range. Here’s my story.

My First Health Scare

My story is ultimately a diabetes story, but there were some bumps along the way that I think are worth including before I jump into the diabetes.

My adventure really began in the summer of 2020. After some stressful life events, I developed a rather constant state of anxiety, which seemed to be preventing me from getting good sleep. Even while using a sedative, I was up at least 4-5 times during the night, every night. I didn’t have a previous history of mental health problems, so this was all new to me. The especially challenging part was that as time passed, lying in bed became a trigger for the anxiety, which made the sleep even harder to come by. I felt like I was just going through the motions to get through life.

Fortunately, after months of stubbornness and sucking it up the best I could, I finally got to the bottom of things. I discovered it was sleep apnea, and started CPAP treatment. The result was truly life-changing, sleep returned to normal, and my anxiety went away 100%.

Life was great and I’d survived and handled my major mid-life health crisis…. or so I thought! Little did I know, but that relief would prove to be short-lived as in the coming months I started to experience a new set of symptoms.

I was at my highest weight yet and my BMI was creeping towards 30. Some reading this will scoff and think “30 is nothing, I’m well above that,” but everyone’s body is a little different and apparently 30 was my personal breaking point.

My fasting blood sugar was over 100 mg/dL, and my doctor said something about pre-diabetes, but she didn’t sound too concerned about it.

The Symptoms

I was again experiencing sleeplessness. Now I was finding that instead of sleep apnea waking me up during the night, my bladder was sure filling up and I was getting up to pee several times a night. Also, I was quite thirsty when this would happen. I did notice it was nights that I’d eat pizza or pasta for dinner that were the worst. Some combination of stubbornness and perhaps denial kept me from taking this too seriously, so I just kept on with things. Besides, this was March 2021 and you didn’t dare go into a medical clinic unless you were on your covid deathbed. Surely, this was no big deal, and getting checked out could wait.

Still, I sensed something was wrong and I reduced the amount of pizza and pasta I was eating for dinner (maybe twice a week instead of five nights a week), eating beans with rice and veggies for dinner instead. In hindsight, not great, but a minor improvement.

The next major symptom arrived in April: blurry vision. At first, I wasn’t worried. I’d gotten LASIK eye surgery done 12 years earlier, and this change seemed like a mild return of my nearsightedness. I was also in my mid-40s, which I’m told is a time where focusing becomes harder and your vision changes.

Then it got really bad: I was on a trip to Florida when I couldn’t read a menu board that was 8 feet in front of me. I had to resort to taking a picture of it with my phone and then looking at that picture to read the menu. Something was majorly wrong!

When I got back from Florida (after some real nerve-wracking and likely dangerous driving), I went in to get my vision checked and received a -2.0 diopters prescription. The optometrist was shocked that I had let my vision get that bad before getting glasses and made a comment about diabetes, but was also of the impression that my vision would change throughout the day as my blood sugar changed. That clearly wasn’t happening to me (turns out it’s more complicated than that).

The last major symptom was that I had been losing weight at a pretty decent clip (5-10 pounds a month). Obviously, this must have been due to cutting back on pizza and pasta, right? Curiously, past attempts at eating better had never been quite this effective, but why question such great progress when you’re on a roll! At this point, it was late April and the earliest I could get in for a check-up was mid-June, so why not ride out another month of weight loss and see how great my labs come back then?

My Diagnosis

A little over a week before the appointment I started researching diabetes online, since I was starting to wonder about what my doctor and optometrist had said. But surely that takes years to develop, right?

Obviously, my “diet” was working since I had now lost 25 pounds this year and weighed less than I did in my 30s. Who knew eating healthy was so easy!

After a little light reading, I quickly realized how wrong I was, that everything that had happened in the last few months was explained perfectly by diabetes, and that the weight loss might have been diabetes rather than my new diet. This was hard to process.

I picked up a blood sugar meter, and on a Friday night fumbled with the thing enough to figure out how to get a reading. I was shocked when the meter read 567 mg/dL. That can’t possibly be right! My girlfriend tried the meter and her result came in at 77 mg/dL. I tested mine again and this time it registered 596 mg/dL!

At this point, it was 11 PM on a Friday night, and my safest course of action would have been to go to the ER, but I figured if high blood sugar hadn’t killed me in the last 3-4 months, it probably wasn’t going to kill me that weekend. I decided to read more about diabetes, give myself a couple of days to get my wits about me, and go into urgent care on Monday. I also continued to test my blood sugar and it seemed to stay in the 300 to 450 mg/dL range that weekend, regardless of what I ate or whether I was eating.

At urgent care my A1c came in at 13.7%, and my fasting blood sugar was 449 mg/dL. Based on my history, I was more likely to have type 2 diabetes (and additional testing would later confirm that). I was prescribed metformin, and advised to take insulin, advice that I wasn’t ready to take.

Rey kept track of his blood sugar measurements from the moment he began testing, before he was diagnosed with diabetes. You can see his girlfriend’s healthy reading, 77 mg/dL, on the first day.

A New Diet

I now understood that the reason I had lost so much weight so quickly was my uncontrolled diabetes, at least 3 months of it!

I immediately cut most high-carb foods out of my diet and subsisted largely on a diet of full-fat cottage cheese, full-fat plain Greek yogurt, hard cheese, nuts, avocadoes, and canned beans with olive oil. I also kept some fruit and berries in my diet initially. Throughout the day I ate random combinations of these foods. I didn’t really prepare them or fancy them up at all with cooking (other than heating the beans in the microwave so they’d be warm).

I knew I had screwed things up, and if there was going to be any hope of reversing the damage I feared I had done to my body I needed to focus. Maybe I would be able to go back to eating pizza, pasta, and all those delicious carb-filled foods that I loved someday, but it was clear now wasn’t the time for that.

I’d certainly thrown in the towel on diets plenty of times before and gone back to eating like crap, but this time it felt like there was a gun held to my head, and quitting wasn’t an option. Perhaps I’m being overly dramatic about this, and perhaps it wasn’t the healthiest outlook, but it’s how I saw things and it got me through the first weeks where I was at my highest level of motivation.

I wasn’t using a particular diet system I had found on the internet or in a book, it was just me trying to think of all the foods (as a vegetarian) that I normally ate that were lower on the glycemic index, and sticking to those. Frustratingly, there seemed to be a lot of disagreement online in regards to what the “best” diet was for a diabetic, but I’ll come back to that later.

The Right Medications

With this diet and metformin, my blood sugar still ranged from about 250 to 400 mg/dL that first week. My blood sugar really needed to come down since the longer it remained elevated, the greater my risk for diabetes-related complications. Clearly, a week of my new diet and metformin wasn’t enough, and I was more open to exploring what else could be done.

When I saw my primary doctor after that week, she wanted to put me on insulin too, in order to stabilize my blood sugar. Although I knew that insulin would have rapidly brought my blood sugar down to normal levels, using it would have made it difficult for me to gauge if my dietary changes were getting the job done.

Through my research, I had become convinced that SGLT2 inhibitors were the only class of drugs that made any sense for a person with new uncontrolled type 2 diabetes to take (in addition to metformin). Normally in uncontrolled diabetes, your kidneys excrete sugar to your urine as a means of keeping your blood sugar from getting dangerously high, but that effect doesn’t really kick in until your blood sugar levels are way up there. With an SGLT2 inhibitor, your kidneys are just doing that all the time, keeping your blood sugar down in the process. The real beauty of this is instead of insulin, which causes your body to store that excess sugar (only delaying the problem), once you pee out the excess sugar, it’s gone forever.

I asked my doctor for a referral to an endocrinologist and a prescription for an SGLT2 inhibitor instead. She didn’t have much experience with SGLT2s and started talking about other drugs, but she could see I had a pile of notes with me on different drug classes, the research I had done on them. I think she also realized that although she was the one to write the prescription, that I was ready to argue my case.

As soon as I started taking the SGLT2 inhibitor my blood sugar came down almost immediately.

On Farxiga, within days my blood sugar dropped to the 100 to 150 mg/dL range. I had to pee a little more at first too, which suggested the drug was doing exactly what it was supposed to. After a few days, I found I wasn’t peeing any more than normal, which was probably due to my fairly low-carb diet.

[Editor’s note: Rey had an incredibly positive experience with SGLT2 inhibitors, but they are not for everyone, and do carry side effects and risks, especially when combined with low-carbohydrate diets. Please speak to your doctor about changing your medication.]

This was a great improvement over where I was before, but like every newly-minted diabetic I had dreams of reversing my diabetes and getting my blood sugar back to “normal.” I obviously wasn’t there yet and just because you want something doesn’t mean it’s possible or realistic, but I was holding onto that dream.

Remission is a very controversial topic. Most ADA and official-looking literature I found said that diabetes was a progressive disease. As time passes, more drugs are required to maintain the same degree of control, and some pretty awful complications occur as it gets worse and worse. That was a rather depressing outlook. If it all falls apart in the end, why not just go back to enjoying all those carb-rich foods that I love and enjoy whatever time I’ve got left? Fortunately, I didn’t fall into that trap, but I have to imagine many do.

Intermittent Fasting

I was aware of internet doctors out there on the fringes saying type 2 diabetes can be reversed and people can manage through diet alone, without drugs. Are they selling false hope, similar to new-age healers selling energy crystals to cure cancer? Most of them are talking about low-carb and “keto,” which I’d previously assumed to be just another random fad diet. “They’re obviously quacks,” I thought. I figured that American Diabetes Association was most certainly correct about diabetes being progressive, just giving me the cold hard truth. But just for the sake of argument, I decided to hear the quacks out first.

Of the doctors on Youtube, the first to really suck me in was Dr. Jason Fung, a Canadian nephrologist. He had a very intuitive model for explaining type 2 diabetes, and used research on treating the condition with gastric bypass surgery (which has been highly successful) as a starting point. He suggested a low-carb diet combined with fasting in various forms. Hey, I’m already doing the low-carb thing and it seems to be helping. Maybe fasting would be the next nudge I needed.

I started with 3 set meals a day (eating between 7:30 AM and 7:30 PM, and then fasting from 7:30 PM until 7:30 AM the next morning). Around the time I started Farxiga, I moved into the next phase of fasting, which was to skip breakfast and then eat only lunch and dinner (eat at 12 PM and then 8 PM). To my surprise, I no longer felt hunger when I wasn’t eating. I now know that’s a common benefit to the keto diet, but if someone had tried to tell me about that a year earlier, I would have thought they were crazy. Also, I didn’t really know I was doing keto. I was just doing a tighter version of the diet I’d explained earlier, with less fruit and no beans.

I completed my first full-day fast the weekend after starting Farxiga. I didn’t eat anything at all starting Friday after dinner until around 1 PM on Sunday, for a 40+ hour fast. Again, Farxiga had gotten my blood sugar down to under 150 mg/dL on a regular basis, but this was the kick that finally got me back under 100 mg/dL. Throughout Friday it was testing 130 to 150 mg/dL, Saturday morning I was at 144 mg/dL, but as Saturday dragged on and my fast continued I started getting multiple readings under 100 mg/dL. My Sunday morning fasting result was 96 mg/dL and, it got as low as 79 mg/dL on Sunday afternoon before I finally broke my fast. To my surprise, breaking my fast only bumped me to 119 mg/dL and 5 hours later my blood sugar was back down to 82 mg/dL. Seeing this progress felt truly amazing and it was only 16 days after finding out I had diabetes!

Maintenance

Rey’s blood sugars improved rapidly and remarkably with the right combination of diet and medication.

Of course, you don’t eat your way to diabetes in two weeks and you don’t undo your diabetes in two weeks either. I was taking 2,000 mg of metformin a day as well as the SGLT2 inhibitor. The week after my big fast, my fasting blood sugar readings would go back over 100 mg/dL, but I kept plugging away, only eating two larger meals a day during a narrow set of eating hours. I also tested the high-carb waters with a 6-inch Subway sandwich – it spiked my blood sugar to 190 mg/dL, which is much higher than a non-diabetic would likely hit from that meal. That helped knock me back down a peg and remind me that I still had diabetes, after all.

The next weekend I noticed that my blood sugar numbers were starting to come down to under 100 mg/dL without extended fasting. I also noticed that foods that previously spiked my blood sugar a great deal were now spiking it much less. On June 28th (day 24 of knowing I had diabetes and 13 days after starting my SGLT2) I decided to stop taking Farxiga and see what effect it would have. This was not a responsible decision, as you should always consult with your doctor before discontinuing medication, but with my improved blood sugar levels, I questioned if Farxiga was still doing anything for me. It turned out my guess was correct. There was no significant change in fasting or post-meal blood sugar readings in the days that followed, and my type 2 diabetes was now well-controlled via just diet and metformin!

About a week later I started wearing a Freestyle Libre 2 to get a broader picture of my blood sugar trends, and for convenience. My readings were still in the 80-90 mg/dL range throughout the day, with small bumps up over 100 mg/dL after a meal. When I finally was due for my appointment with an endocrinologist to discuss my diabetes treatment, the feel of the visit could best be summed up as “why are you here?” My data showed that my average blood sugar in the previous 10 days had been 95 mg/dL, which would extrapolate to a 4.9% A1C (compared to the 13.7% result when first tested). This is, of course, only an estimate. And my blood sugar had only been well controlled for 2-3 weeks at this point.

Blood sugar wasn’t the only improvement either over last year’s numbers: total cholesterol dropped from 238 mg/dL to 172 mg/dL, with HDL (“good cholesterol”) fairly steady from 64 to 62 mg/dL. LDL (calculated) dropped from 141 to 90 mg/dL. Triglycerides dropped from 165 to 102 mg/dL. The endocrinologist agreed that I no longer needed Farxiga and indicated there really wasn’t a reason for me to see her again, but that I was free to set up another appointment if things changed.

My Best Path Forward

Since then, I’ve done more reading on the keto diet and feel that’s my best path forward to continue to maintain my health, both in terms of diabetes and beyond. I’ve improved enough that I no longer wear a CGM or perform finger sticks to check blood sugar on a regular basis, only checking maybe once a week “just to be sure.” Although I’ve tested out eating some of my old high-carb favorites and been impressed by how much less they spike my blood sugar now, I’m no longer interested in eating them on a regular basis, which is surprising to me. I’ve also found I can sleep through the night just fine without my CPAP machine due to the 35 pounds of weight I have lost from my peak of 215 lbs. The sleep apnea isn’t completely gone, so I still wear the mask most nights, but it appears to be dialed back from severe to mild.

It’s a very weird feeling: when I first found out I had diabetes I wanted nothing more than to continue eating the foods I loved and found comfort in. I felt like something had been stolen from me and feared that my body was permanently broken. Why should other people be able to eat what they want to, and I can’t? It felt very unfair and I really wanted there to be a drug or a treatment that would let me eat how I wanted to. Now that I’ve immersed myself in a better understanding of just how bad those foods were for me, I view things very differently.

I share my story not to lord my results over you if you’ve been less successful with your diabetes. I got really lucky, finding good dietary advice quickly after my diagnosis. Sadly, much of the official guidance out there seems sure to fail. I was also lucky with my uncontrolled diabetes “helping” with the first 25-30 pounds of weight loss.

I no longer have aches and pains when I get up out of bed or have to roll a certain way to avoid them, my memory has improved quite a bit and I’m no longer struggling to recall things I was just told, as I did with high blood sugar levels. I have so much more energy and stamina rather than feeling lethargic or struggling to complete physical activities. It’s like I’m in my 20s all over again (except for a little gray hair)! The downside is I now know if I go back to a lifestyle of enjoying carbohydrate-rich foods, things will go poorly for me, but as long as I don’t, I get to enjoy life so much more than I had before. And there are plenty of delicious foods that aren’t packed with carbs that I’m free to enjoy.

I think diabetes has been a net positive for me, as strange as that sounds. The me of today is very different than the me of a year ago.

Source: diabetesdaily.com

“Our Trials are Totally Different.” The Denise Faustman Interview

There’s no question that Dr. Denise Faustman does things differently.

Dr. Faustman’s research has won her avid fans and raised millions from donors, but it has also provoked significant pushback from major diabetes organizations. Dr. Faustman wears that repudiation like a badge of honor, proof that her work is disruptive and important.

A Maverick Approach

Dr. Faustman takes an unconventional approach. Her work, which is focused on the underlying immune response responsible for type 1 diabetes, has led her to a very old and inexpensive drug, a tuberculosis vaccine used widely in the developing world. It’s a treatment that may have been hiding in plain sight for generations.

Dr. Faustman’s immune intervention trials also concentrate on adults with long-standing type 1 diabetes. By contrast, virtually all of her peers have targetted patients with new-onset diabetes, or even patients that have yet to develop diabetes. This approach is generally considered more likely to succeed, because the targets of the interventions have not yet entirely lost their ability to secrete insulin. But in Dr. Faustman’s telling, it hasn’t accomplished much yet:

“Over the last 30 years, immune intervention trials in type 1 diabetes haven’t had very good outcomes. The important diabetes advances have been different versions of insulin and new forms of blood testing, but the immune intervention trials have been a very sad point. Nothing’s worked very well, no new treatments have been approved.”

“Our trials are totally different. They’re all in people that have had diabetes for decades.”

Dr. Faustman told me that a who’s who of diabetes experts has told that her approach is crazy, a response that has clearly tickled her contrarian side.

“We thought the need is to treat the people that actually have the disease. It sounds like a no-brainer, but keep in mind that nobody else is doing it!”

The decision to study patients with long-established diabetes, which was originally made well over a decade ago, was inspired in part by financial constraints: “we could not afford to do new-onset diabetic trials.” And focusing on an incredibly inexpensive generic drug meant that Dr. Faustman had no way of interesting large pharmaceutical companies and their very large R&D budgets.

“It’s a terrible drug to make money off of.”

BCG

The drug is BCG, the Bacillus Calmette–Guérin vaccine, which was first used a century ago in order to protect patients from tuberculosis. It is considered extremely safe, and is still administered to millions of infants annually, most prominently in the developing world.

BCG first piqued Dr. Faustman’s interest because it was “the only drug in animal models that has worked in established diabetic mice.” Exactly why it worked, though, still requires some unraveling. The results of her Phase I trial – results that were both celebrated and questioned – showed that patients receiving the vaccine experienced impressive improvements in glucose control without restoring insulin production or insulin sensitivity.

Most immune intervention drug trials involve the suppression of immune cells that are harming the body – in the case of type 1 diabetes, the T-cells that attack the pancreatic Beta cells. But the BCG vaccine works the opposite way, not by depleting the immune system, but by putting something else back in.

“BCG adds to the microbiome. It’s actually the tuberculosis organism, inactivated. So you’re putting back in, effectively, tuberculosis. When you revaccinate with this vaccine, the reason it takes a little while is that it gets to your bone marrow and actually resets your stem cells in your bone marrow.”

Why would you want tuberculosis in your bone marrow? Dr. Faustman referred to the hygiene hypothesis, the idea that many autoimmune and allergic diseases are caused at least in part by our excessively sanitary modern world. Myobacterium tuberculosis may have co-evolved with humans for thousands of years, and its absence may therefore trigger immune system dysfunction.

“The absence of this organism has allowed these rogue immune systems to take off and create all these autoimmune diseases. We’re just reestablishing this synergistic relationship to get immune tolerance.”

Because of its many possible effects, BCG has lately become “fashionable” in the research community, Dr. Faustman told me. The old vaccine is being evaluated as a treatment for other serious autoimmune diseases, and it has also been theorized to provide protection against the novel coronavirus that causes COVID-19.

But how does all that help with your blood sugar levels? Dr. Faustman believes that when BCG vaccine “retrains” the immune system, it also causes the immune system itself to begin utilizing large amounts of glucose in the bloodstream.

“What really happens is that their white blood cells now become the regulator of sugar, and have restored sugar transport. So there are underlying defects in type 1 diabetes in the use of the lymphoid system as a sugar regulator, and BCG restores that.”

The Effect

“It’s definitely a game-changer. Our hope, based on the early results, is that it will lower your A1c 10-15%, stably. You can use less insulin, and have better blood sugar control.”

It is, however, a slow process:

“It takes a number of years to have its metabolic and immune effects. We know we need to follow these patients for 3-5 years to get the maximal effect. But it’s got good durability. It’s quite permanent.”

The nine patients that originally received the BCG vaccine for the Phase I trial are still checking in with Dr. Faustman’s lab every six months, and she says that they continue to enjoy dramatic improvements in glucose management.

“Everyone wants to know if we have any [trial participants] off insulin. We have one person off insulin. Normally when he’s on a fairly low dose of insulin his A1c is in the normal range. When he goes off insulin, he no longer goes into DKA, but he goes up to around 7.2%.

“Is it gonna last twenty years? Thirty years? We don’t know yet.”

Sample Size

One of the chief concerns that other experts have raised with Dr. Faustman’s work is the tiny sample used in her Phase I trial: a mere nine patients received the BCG vaccine.

Dr. Faustman is completely unphased by this criticism, arguing that the statistical significance of her results speaks for itself.

“A p-value of .05 is as statistically significant in a sample of 10 as it is in a sample of 200,000. The only difference is, in the sample of 10, everybody responded, and the magnitude of the response was large.

“If you have to design big trials, you have small effects and unresponsive groups. And that’s what you’re seeing in the [rest of the] diabetes community.”

The criticism of her work by major diabetes authorities, particularly ADA and JDRF, doesn’t seem to have phased her, although she admits that it has slowed down the pace of her trials. She quoted one of her most significant boosters, the late Lee Iococca, a rockstar among American executives as the CEO of Chrysler during the 1980s. Iacocca told her, “I love it when they’re shooting the cannons at me. It means I’ve got something good.”

Dr. Faustman continued: “If they didn’t think it was competitive, it wouldn’t matter to them. The fact that they shot their cannons, to issue statements that were not truthful, it shows that it mattered to them a lot, that it was threatening to them.” She believes that the criticism set forth by the ADA and JDRF in a remarkable joint letter was not only misguided but dishonest.

Don’t Do It Yourself

Referring to the BCG vaccine’s long history of safety, Dr. Faustman suggested that there was little downside to her proposed intervention.

I felt an uncomfortable comparison to some of the pandemic era’s health controversies, in particular to the arguments advanced by many in favor of poorly investigated COVID-19 treatments such as hydroxychloroquine and ivermectin. I asked her what she would say to readers that are ready to go get the BCG vaccine themselves, before it’s been evaluated by the FDA. It’s a question she deals with constantly.

About once a month, Dr. Faustman gets a call from a physician, asking confidentially where one might acquire BCG of the correct strain. Sometimes it’s pharmacies attempting to fulfill a prescription, sometimes it’s the patients (or parents) themselves.

“Everyone’s trying to do it in the closet because it’s a safe drug, right? People try to do it all the time. But you should really wait until we get the right strain and the dosing. What we try to say is that if you get vaccinated with the wrong strain of BCG, we’re not sure, when we give you the right strain, that it’s gonna work.”

The BCG vaccine may be easy to come by in countries where it is used frequently, but there’s no telling what strain you’d get and what the effects would be.

For patients that are very eager about BCG, Dr. Faustman recommends registering for one of her clinical trials.

Timeline to Treatment

There’s already a phase II trial underway, which will test the BCG vaccine in adults with long-standing type 1 diabetes. This expands the study size from 9 to over 200; Dr. Faustman expects that good results in a much larger cohort will finally resolve the criticism and controversy that has dogged her for years.

Meanwhile, her lab is beginning its first trial of children with type 1 diabetes.

In an ideal world, she told me, the phase II trial for adults would be followed by phase III, an even larger study which she would then present to the FDA for evaluation. In a best-case scenario, the approved drug could be administered to regular patients in “five to eight years.”

“We’re moving as fast as we can.”

Source: diabetesdaily.com

Your Brain and Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Brett Goerl and Matthew Garza

Recent studies have shown a link between brain diseases like Alzheimer’s and Parkinson’s and diabetes.  Unfortunately, these conditions are becoming more common as our population grows older. Find out more and ways to improve brain health.

What are neurodegenerative diseases?

The term “neurodegenerative diseases” refers to a range of diseases in which the cells in our brains break down and can no longer perform their designated functions associated with movement or mental ability, according to the EU Joint Programme – Neurodegenerative Disease Research. The most common neurodegenerative diseases that affect people with diabetes are mild cognitive impairment (MCI) and dementia, which includes Alzheimer’s disease.

As we age, it is completely normal for our memory, thinking, and judgment to slightly decline. However, MCI occurs when our mental abilities decline faster than expected and begin to interfere with our daily lives. Age is by far the biggest risk factor for MCI, but diabetes, smoking, high blood pressure and cholesterol, obesity, and depression can further increase a person’s risk of developing MCI.

In around 10-15% of cases each year, the mental decline seen in MCI may progress further, making it difficult for us to carry out a healthy and happy life. When this happens, it is called dementia. The two most common types of dementia that affect people with diabetes are Alzheimer’s disease (AD) and vascular dementia.

While the symptoms of AD and vascular dementia are similar, they are caused by two different processes that occur in our brains. AD is thought to be caused by the abnormal build-up of proteins in the brain. One protein is “amyloid,” which clumps together in spaces around brain cells. The other protein is “tau,” which get tangled up inside brain cells. Vascular dementia, on the other hand, occurs when the blood vessels in our brain become narrow or start to bleed. This reduces the brain’s ability to get the oxygen it needs to keep brain cells healthy and for the brain to function properly. In both cases, brain cells become damaged, leading to a wide range of problems such as memory loss, worsened judgment, and personality changes.

AD is the most common form of dementia in the US, making up 60-70% of dementia cases. In the US, an estimated 5.4 million people of all ages are affected by AD, and one in eight people 65 years and older suffer from it. Considering the 14.3 million adults aged 65 and older in the U.S. who have diabetes, and it is easy to see why Alzheimer’s disease and diabetes are two of the most common diseases of aging. And recent research has suggested that they may be linked in various ways.

How do neurodegenerative diseases like Alzheimer’s and vascular dementia relate to diabetes? 

We often think of diabetes as a problem with our metabolism since the lack of insulin (in type 1 diabetes) or insulin resistance (in type 2 diabetes) affects our body’s ability to maintain normal blood glucose levels. However, our brain consumes the most glucose compared to any other organ in our body. While the brain accounts for roughly 2% of our body weight, it uses almost 20% of the sugars we eat or release from our body’s stores.

An increasing amount of research shows that people with AD and other forms of dementia experience insulin resistance in the CNS (central nervous system, which includes the brain and the spinal cord), similar to what people with type 2 diabetes experience in other areas of the body, such as the muscles, the liver, and the fat. Scientists have yet to determine exactly what the relationship between diabetes and AD or other forms of dementia may be caused by, but there are a few theories that have been proposed.

  • One of these theories focuses on brain insulin resistance, which is when brain cells stop responding normally to insulin, leading to problems related to the ways our brain cells communicate, use energy, and fight infection.
    • Insulin receptors can be found in many areas of the brain, where they are involved with brain cell growth, communication, and survival. While insulin levels are lower in the brain than in the bloodstream, all the insulin that makes its way to the brain comes from the same insulin produced in the pancreas – it crosses over what is known as the blood-brain barrier (or BBB). This barrier prevents unwanted things from the bloodstream from entering the brain. However, injected insulin does not cross the BBB. The reduced transport of insulin across the BBB may be why brain insulin levels are lower when the body experiences insulin resistance (such as in pre-diabetes and type 2 diabetes) and in diseases such as AD.
    • Insulin in the brain is known to help control our metabolism in certain other organs of the body, like the liver and fat tissue. The hypothalamus, the part of our brain that controls hunger, thirst, and emotions, is highly sensitive to levels of insulin in the brain. The association between type 2 diabetes and brain health may be due to problems with insulin’s actions in the hypothalamus, increasing a person’s likelihood of developing whole-body insulin resistance.
  • Diabetes also increases the risk for damaged blood vessels, leading to heart disease and stroke. Damaged blood vessels can starve the brain of oxygen, leading to cognitive decline and vascular dementia.
  • Diabetes disrupts how our bodies produce amylin, a hormone related to insulin that helps our bodies digest food. People with obesity and pre-diabetes often have high amounts of amylin, some of which can circulate and cross into the brain. Studies have shown that amylin can interact with the same protein deposits in the brain known to cause AD.
  • Experiencing hyperglycemia for long periods of time can degrade the myelin sheath (a protective layer that surrounds your neurons). This leads to issues in how your nerves send and receive signals to your body. It can also lead to your brain cells dying.

Type 1 diabetes could be a risk factor for dementia for many of the same reasons as type 2 diabetes. In particular, the cardiovascular complications such as heart disease and stroke that are associated with type 1 diabetes could provide an explanation for its relationship with vascular dementia. Additionally, higher rates of cognitive dysfunction for those with type 1 diabetes could be related to frequent cases of hyperglycemia and hypoglycemia. Indeed, severe hypoglycemic and hypoglycemic events are associated with increased dementia risk for older adults with type 1 diabetes.

Is diabetes a risk factor for developing neurodegenerative disease? 

On average, people with diabetes experience slightly more cognitive difficulties associated with MCI across their lifespan, but experiencing cognitive difficulty does not mean you will eventually get diagnosed with dementia or AD. The prevalence of type 2 diabetes and neurodegenerative diseases, however, both increase with age, meaning it is more common for older people (65+ years) with type 2 diabetes to get diagnosed with vascular dementia or AD.

Data suggests that people with diabetes have a 73% increase in the risk of developing any type of dementia and 56% increase in the risk of developing AD compared to people who do not have diabetes. This makes diabetes one of the strongest risk factors for getting dementia aside from aging. Health measures like A1C, cholesterolhigh blood pressure(or hypertension), and eGFR are negatively impacted by diabetes and may also be associated with cognitive performance and neurodegenerative diseases.

  • In the ACCORD-MIND trial, the largest and most rigorous study on diabetes and the brain to date, higher A1C levels were associated with lower cognitive function in people with diabetes. Similarly, another study found that the risk for dementia increased as a person’s A1C level increased, regardless of whether or not the person had type 2 diabetes.
  • A recent analysis of over 100 studies found that higher levels of LDL cholesterol (known as “bad cholesterol”) was an independent risk factor for the development of AD.
  • High blood pressure in middle-aged people has been linked to future cognitive decline and dementia, and in particular, vascular dementia. This may be due to high blood pressure in the brain causing damage to blood vessels, such as small blockages and bleeding.
  • In a study on kidney health and dementia recently published recently, researchers found that lower rates of kidney filtration (as measured by eGFR) were associated with higher risk of onset of both vascular dementia and AD.

What about Parkinson’s Disease?

Parkinson’s Disease (PD) is another neurodegenerative disease associated with aging. In PD, the cells in your brain deteriorate and begins to affect a person’s ability to perform daily activities associated with movement. Symptoms can include tremors (rhythmic shaking), muscle stiffness and rigidity, and PD can even slow your movement in a process called bradykinesia. It can also lead to other symptoms not associated with movement such as disrupting sleep, constipation, anxiety, depression, and fatigue.

As with other neurodegenerative diseases, research has been conducted to identify if there is a link between diabetes and PD. In particular, one study from 2018 showed an association between the two conditions. The researchers looked at the English National Hospital Episode Statistics and Mortality Data from 1999-2011 and divided the data into two cohorts, those with type 2 diabetes (2,017,115 people) at the time of hospital admission and those without (6,173,208 people). It was found that those with diabetes had a 30% higher chance of developing PD than those without, and the younger a person was with diagnosed type 2 diabetes, the more likely their chance of developing PD.

Though researchers do not yet understand the exact way that diabetes and PD are related, they do have a few hypotheses. Namely, there is the chance that certain genetic abnormalities that lead to diabetes may also lead to PD; even if one of these conditions does not directly cause the other, people who have one may be more likely to also have the other. In addition, when diabetes and PD coexist in a person, they may create a more hostile environment in the brain, leading the neurodegenerative processes underway in PD to speed up and be more severe.

What are strategies to reduce the risk of developing a neurodegenerative disease?

There is evidence that leading a healthy lifestyle can reduce your risk of developing diabetes-related complications like dementia or PD. For example, heart attacks and stroke can increase the risk of developing vascular dementia; therefore, lifestyle modifications that help you maintain an ideal blood pressure and levels of cholesterol for your age and health status are important. This can be accomplished by exercising regularly and consuming a diet low in saturated fat, salt, and sugar.

Below are some other tips for improving brain health, which can go a long way in reducing the risk of neurodegenerative diseases like AD. The good news is that many of these strategies are also recommended for managing diabetes.

  • Take control of your blood glucose levels by aiming for a greater time-in-range (TIR). To learn more about time-in-range goals, click here.
  • Smoking is associated with higher rates of dementia. In a recent review, smokers were 40% more likely to develop AD than non-smokers. Given that people with diabetes are at an increased risk of developing dementia, smoking is likely to increase this risk further. If you smoke or experience nicotine addiction, talk to your healthcare professional about a plan to quit or cut back.
  • Keep blood pressure at the target discussed with your health care provider (which might be 130/80 mmHg or less, if you are at high risk of cardiovascular disease) by exercising regularly and eating a diet low in salt (aim for less than 2,300 mg of sodium each day)
  • Take your diabetes medications consistently and as directed by your healthcare team. Some early evidence shows that certain diabetes drugs, like GLP-1 receptor agonists, may be beneficial for brain health. In fact, exenatide, a GLP-1 receptor agonist, is currently in clinical trials for treating PD.
  • A very active area of research focuses on the dementia-preventing effects of having an active and stimulating mental life and rich social networks. Working to maintain an active and socially rich lifestyle could help prevent some of the effects of diabetes on dementia risk.

If you are 65 years of age or older and have memory concerns or other cognitive complaints (i.e., brain fog, depression, personality change), talk to your healthcare provider about getting a cognitive assessment. Learn more here.

Source: diabetesdaily.com

Remission, Not Reversal: Experts Agree to Define Ultimate Type 2 Diabetes Success

Type 2 diabetes can be considered “in remission” if patients can maintain non-diabetic blood glucose levels (<6.5% A1c) for 3 months without medication, according to an international panel of experts.

On August 30, the American Diabetes Association joined the Endocrine Society, the European Association for the Study of Diabetes, and Diabetes UK in co-authoring a consensus statement on “the definition and interpretation of remission in type 2 diabetes.” Here’s a press release, and here’s the full statement.

Remission is Becoming More Common

Type 2 diabetes remission has always been rare – a 2014 survey concluded that fewer than 2% of adults with diabetes experienced any level of remission without bariatric surgery – but in recent years, it has become more common.

The increasing prevalence of diabetes reversal owes partially to the rise in bariatric surgery, but is also likely due to the proliferation of new weight loss and diabetes management techniques. Although diabetes rates continue to rise unabated throughout the world, experience and understanding of the disease have led to superior treatment strategies, allowing a minority of patients to return their blood glucose levels to non-diabetic levels.

Now there are even companies, such as Virta Health, that have based their entire business strategy on the belief that diabetes “reversal” is within the reach of millions of adults with the condition.

With so much attention paid to diabetes remission, the world’s major diabetes authorities decided that the phenomenon of diabetes remission or reversal needed to be properly addressed, named, and described. The consensus statement should help guide study of the phenomenon, and give doctors and patients a framework for understanding just what remission really means.

What’s in a Name?

The experts seem to have given very careful consideration to what word doctors should use to refer to the achievement of regaining non-diabetic blood sugar levels. Many in the diabetes world use words like “reverse” or “correct” or even “cure” to refer to this phenomenon, each of which has its own implications. To speak of a “cure,” for example, is to imply that the disease has left and will never return; in the case of a patient that needs to keep up with dramatic lifestyle adjustments to keep their blood sugar at non-diabetic levels, this is a plainly inaccurate label. “Reversal” and “resolved” likewise suggest similar shades of meaning.

The panel decided,

that diabetes remission is the most appropriate term. It strikes an appropriate balance, noting that diabetes may not always be active and progressive yet implying that a notable improvement may not be permanent.

The term also accounts for the fact that while patients with diabetes may have achieved normal glycemic levels, they may still suffer from insulin resistance and/or deficiency, factors that may mean that they need to continue keeping a careful watch on their blood sugar management.

An earlier statement from the American Diabetes Association on type 2 remission categorized patients into different types of remission – partial, complete, and prolonged. These categories have been discarded as unhelpful.

Diagnosing Remission

Type 2 diabetes remission is now defined “as a return of HbA1c  to < 6.5% (<48 mmol/mol) that occurs spontaneously or following an intervention and that persists for at least 3 months” without the use of insulin or glucose-lowering medications. (The statement also allows for some other manners of diagnosing remission, such as using fasting blood glucose, in cases where HbA1c may be unreliable.)

The 3- month time parameter helps weed out both fluke A1c results and the lingering effect of medication, which can last for months after it’s been discontinued. Lifestyle interventions (changes to diet and exercise) and surgery (especially gastric bypass) can precipitate diabetes remission.

At the moment, the experts advise that patients in remission should have their A1c, as well as any potential diabetic complications, checked annually.

By definition, patients with type 1 diabetes cannot achieve remission (except under perhaps under unique and extraordinary circumstances), given their lifelong reliance on exogenous insulin

How to Achieve Remission

The most reliable way of creating type 2 diabetes remission is through bariatric surgery: nearly half of the patients in a Swedish cohort experienced lasting remission.

Bariatric surgery, however, is a very intense and expensive operation, and it comes with its own risks and complications; most patients with type 2 diabetes will not be considered good candidates. For the rest, weight loss, however it may be achieved, appears to be the best path to remission. Experts additionally debate the efficacy of specialized eating patterns, such as low-carbohydrate diets and therapeutic fasting.

Remission may not be a realistic goal for everyone, and researchers don’t yet have a solid understanding of why some patients are better able to reset their metabolic health than others.

We have an entire article on diabetes remission – originally published using terminology that is now officially out of step with mainstream practice: What You Need to Know About Reversing Type 2 Diabetes.

Going Forward

There’s an awful lot we still don’t know about remission. To date, diabetes remission has not attracted much attention from researchers, possibly because it was considered such a rarity. But with that changing, the diabetes authorities behind the consensus statement recognized a need to guide the questions of researchers.

The statement includes a laundry list of areas where future study is required, including:

  • How often patients in remission need to be re-evaluated
  • Whether or not patients in remission could still benefit from metformin and other drugs
  • Whether other metabolic parameters (such as cholesterol levels) need to be monitored
  • How long remission can be expected to last
  • What impact remission has on longterm health outcomes

Having finally named and described the phenomenon, the panel hopes to spur research into the reality of the condition so that it may be better understood.

 

Source: diabetesdaily.com

Danger Ahead: One-Upmanship in the Type 1 Diabetes Community

We type 1s face danger at every curve: the yummy meal laden with carbs, the pump that suddenly malfunctions, the low that plunges to scary territory, the high that won’t come down, the infusion set that bleeds upon insertion, the CGM that needs constant calibration…the list goes on.

But there is perhaps a larger danger lurking out there, one that can have a devastating effect on our attitude if we let it. It is called one-upsmanship. What do we mean by that?

When speaking with fellow people with diabetes, how often do you hear some of the following lines?

  • I have no problem with control. I have an A1c of 5.1.
  • I’m in range 99% of the time.
  • My pump is great. It keeps my average sugar at 95.
  • I rarely, if ever, go low.
  • My numbers could not be better.
  • My endo tells me I’m doing perfectly.
  • I never go above 150.
  • If I’m at 200, I bring it down in minutes.
  • I have no problem saying no to sugar.
  • Managing diabetes is no big deal.

My reaction to such comments is: Really? I wonder what planet these folks live on. Are they being truthful?  If so, why are my numbers so different? What are they doing that I’m not?

Am I the only type 1 who is not doing that well? Why can’t I be like them?

People with diabetes who brag or boast to others about their ability to handle diabetes are basically sending the message that they can manage better than you. They are putting themselves above you and playing a vicious game of one-upsmanship.

In our constant, ongoing battle with diabetes, our toughest job is to remain optimistic. When we hear others boast of great control, we tend to think less of ourselves. We lose confidence.

Without a strong belief in ourselves and our ability to stay in the diabetes fight, we can get discouraged. Not only do we feel depressed, but worse, we are tempted to say, “The heck with it.” Why should I eat so carefully if I can’t get results like my friend’s?

Some argue that it is human nature to promote ourselves over others or simply want others to know how good we are. Facebook, one might argue, is often a look-at-me activity, where people describe all the wonderful things in their lives. Multi millions around the globe participate in Facebook just to show the world their daily achievements.

How does this make others feel? If, for instance, someone on Facebook shows pictures of a delightful vacation to Paris, France, some readers might say to themselves, “Wish I had that kind of money.” Or: “Wish I had free time.” Or: Wish I had friends to go with.”

The same holds true with diabetes. When others flaunt their abilities to deal with the disease, we can easily start to feel incompetent.

Here’s some advice: Avoid those who would continuously boast about their victories over diabetes. Most of the stories simply are not true. Those that are don’t do us much good.

We need to choose our diabetes support circle as carefully as we choose insulin pumps and carbs at meals. We need to stay positive in the daily struggle and associate with those who provide us honest emotional support.

Source: diabetesdaily.com

How Do We Measure Successful Diabetes Care?

This content originally appeared on diaTribe. Republished with permission.

By Arvind Sommi, Andrew Briskin

Quality measures are tools to evaluate the effectiveness and quality of healthcare. Measures such as A1C, blood pressure, and cholesterol are used to understand health at the population level to ensure people with diabetes are getting the best care possible. At The diaTribe Foundation, we believe that Time in Range would be a valuable addition to the quality measures for diabetes care.

During a routine office visit, your healthcare provider may check certain health measures such as your A1C, blood pressure, and cholesterol. These tests are primarily used to assess your individual health and the effectiveness of your diabetes treatment plan. They are also used to evaluate the overall quality of care provided when these results are combined across all patients in a healthcare professional’s office, healthcare system, or health plan.

Recent advances in glucose monitoring, and the increasing use of continuous glucose monitors (CGM), has led to wider use of the metric Time in Range (TIR), which is a helpful supplement to A1C in assessing your glucose management. Because of this, TIR could be a valuable addition to the quality measures for diabetes care if it became a more widespread metric – a feat that is challenged by barriers to accessing CGM and integrating it into electronic health records.

What is a quality measure?

Quality measures can encompass many things but generally include different types of measurement domains, as outlined below.

Diabetes care

Source: diaTribe

Some tests, such as A1C screening or blood pressure monitoring, can serve as both a healthcare process and an outcome measure.

At the population level, outcome measures evaluate whether certain established goals are reached for a group of people. For example, this might be the percentage of patients in a healthcare practice with an A1C greater than or less than 9.0%. Quality measures, in this way, are used by insurance providers, people with diabetes looking for the best healthcare professionals to use, researchers, employers, and reporting agencies to better understand the effectiveness of diabetes treatments and evaluate how effective healthcare professionals or health systems are.

How are quality measures used in diabetes care?

Quality measures are important in diabetes care because achieving these goals can decrease the risk of diabetes complications and lead to improved health outcomes for everyone. There are several quality measures in diabetes care, many of which you may be familiar with through routine office visits with your healthcare team, such as:

Primarily, the combined data from these tests across many people with diabetes is used to determine if certain treatment methods are effective for the entire population. The data can also be used to reinforce or dispute established standards of diabetes care and respond to new care innovations (such as the latest technology or treatments).

Along with their use in evaluating treatments and standards of care, quality measures can also be used to evaluate healthcare professionals. In some cases, healthcare provider reimbursements from Medicare or other insurance providers may be tied to results, particularly under a value-based care model (learn more about value-based care here). For example, A1C screenings might be reimbursed only if enough patients meet A1C targets below certain thresholds.

Why might including Time in Range in quality measures be helpful to you?

While A1C is the current quality measure used to assess glucose management in people with diabetes, A1C has limitations. The accuracy of A1C measurements can vary based on factors such as race/ethnicity or chronic kidney disease. A1C tests are also generally limited to every two to three months and only represent an average blood glucose level over that time, which means daily highs and lows are not explicitly captured. Additionally, while low blood sugar may lower your A1C, it can also increase your risk of severe hypoglycemia – meaning a lower A1C may be dangerous if you experience frequent low blood sugars or mild hypoglycemia.

Time in Range is a glucose metric typically measured by a CGM. It is the amount of time you spend in the target range – generally between 70 and 180 mg/dL. The goal for most people with diabetes is to have at least 70% of your glucose readings within this range. Understanding your TIR as well as your time above and below range can help you and your healthcare provider assess how your body responds to medications, food choices, daily activities, stress, and a variety of other factors that affect your glucose. The increased use of TIR could help equip people with diabetes and their healthcare team with the information they need to make vital healthcare decisions and experience better diabetes care.

Time in Range allows for quick, actionable steps to improve diabetes management and corresponding health outcomes,” said Dr. Diana Isaacs, a diabetes care and education specialist from the Cleveland Clinic. “Time in Range can be assessed more frequently and provides more actionable insight into glucose management. Making it a quality measure would increase the utilization of this powerful tool. It has the potential to revolutionize how we take care of people with diabetes.”

Increases in TIR have been associated with a reduced risk of microvascular complications such as eye (retinopathy) and nerve disease (neuropathy), with similar evidence emerging for other macrovascular complications such as heart disease. Plus, the use of CGM has increased dramatically over the last few years (for example in people with type 1 diabetes in the T1D Exchange registry, this number rose from 6% in 2011 to 38% in 2018), allowing more people with diabetes to use TIR data on a regular basis.

However, there are still barriers to integrating TIR as a quality measure for diabetes care. One major challenge is the many barriers to using a CGM. For instance, most insurers cover CGM only for a limited number of people with diabetes (for example, those with type 1 diabetes who take insulin). Until access is substantially expanded and more people are able to use CGM who wish to, TIR adoption into the standard quality measures will be difficult.

An additional challenge is that TIR data is not integrated into most electronic health records (EHR) used by clinicians, making it difficult for providers to analyze TIR data for all patients and to assess TIR at the community level. Efforts are currently underway to change these systems so that TIR can be integrated into her systems, similar to metrics like A1C and blood pressure; at the ADA Scientific Sessions this year Dr. Amy Criego spoke to the success that the International Diabetes Center in Minnesota has had with integrating Abbott LibreView data into their EHR.

Through the efforts of the Time in Range Coalition, diaTribe is working to increase awareness and hopefully the eventual adoption of TIR as a meaningful quality measure in diabetes care.

Source: diabetesdaily.com

Is Digital Diabetes Coaching Worth the Cost?

Does digital diabetes coaching really work? And is it worth the money?

While these programs were basically unknown only a few years ago, there is now a dizzying number of businesses claiming to offer personalized mobile diabetes coaching programs. A diaTribe guide to the services lists fifteen different options, a number which may only grow in coming years. (In a related phenomenon, there are also many new coaching services that utilize continuous glucose monitoring for people without diabetes).

What is digital coaching?

Digital coaching is not telemedicine or telehealth. A digital diabetes coaching service can only supplement, but not replace,  your doctor, endocrinologist, or diabetes educator. Digital diabetes coaching services cannot order prescriptions and cannot address more complicated health issues.

Digital diabetes coaching services aim to help “fill in the gaps” between regular visits with an existing care team, as a representative of MySugr, one of the better-known services, puts it:

I really see the benefits of having those touch points in between physician appointments because the day-to-day is what really matters with diabetes. If you’re just going in every several months it’s hard to make changes that stick. If you’re able to check in with a coach every so often without having to make an appointment, not only does it help the management, but it helps ease anxiety which is a huge part of diabetes too.

While the details will vary from one business to another, the basic idea is that the patient will share his or her data (blood sugar, insulin use, weight, etc) through a mobile app. The app provides feedback and advice, whether it’s delivered by an algorithm or a trained professional. Even if the mobile coach doesn’t deliver any revelations, the hope is that little check-ins and notifications will help keep patients more mindful of their condition and in a better frame of mind to apply themselves to their diabetes management, leading to improved results.

Some coaching platforms are paid for by insurers or employers. Others require patients to pay for them directly – a common price is about $50 per month.

The case against digital coaching

Digital coaching services have studies that show that their coaching programs deliver big results – improving HbA1c, weight loss, and reductions in insulin and other glucose-lowering medications. But in a recent debate at the American Diabetes Association’s Scientific Sessions conference, Dr. Kasia Lipska of the Yale School of Medicine expressed doubt about the quality of the evidence in favor of these programs.

After reviewing the clinical literature, Dr. Lipska noted that most studies of the services tend to be sponsored by the companies themselves. They are typically of very short duration, and some are barely up to good standards for clinical science.

She referred particularly to a study run by Omada Health of its own program. Among the problems with this study: no control group, no randomization (perhaps meaning that participants were highly motivated), and missing data, in addition to the obvious conflict of interest.

Omada has also run a randomized controlled trial, considered a far more thorough approach. Those results, which have only been made public in a press release thus far, were “relatively modest,” showing some weight loss but less than a 0.1% improvement in HbA1c. A similar trial, of the Noom coaching platform, had similar results, showing no difference in A1c and a relatively minor improvement in weight loss.

The best-designed study of digital coaching platforms that Dr. Lipska was able to find “did not demonstrate clinical effectiveness.”

“I think we have to squint a little bit to see a lot of evidence for clinically important significant outcomes,” she stated.

Dr. Lipska also expressed some personal skepticism about the programs.

“The thing that really bothers me is that they’re really not aligned with the healthcare team. Me as a clinician, I have no input into the feedback that my patient gets.”

The case in favor of digital coaching

Arguing the opposite case was Dr. Anne Peters, the director of the University of Southern California’s Clinical Diabetes Programs, and a much-honored diabetes advocate.

Dr. Peters took a broader view of the problems that digital coaching is meant to solve, noting that the healthcare costs of diabetes continue to spiral and that many people with diabetes still struggle to achieve the targets set by their doctors.

Even if patients enrolled in digital coaching services do not experience better outcomes, the programs may be worth the cost to insurers and employers if it helps reduce the frequency of in-person visits to the medical center. Some studies have found that digital coaching systems reduce patient medical spending and office visits, big benefits for patients, insurers, and medical practitioners alike.

Moreover, in Dr. Peters’ telling, patients can use all the help we can get them. Technology and medication have improved significantly in recent years, but they are not effective without training and professional assistance. For decades we have known that diabetes education improves outcomes – is there a good reason to doubt that education delivered through a smartphone would fail to do the same?

Both debaters agreed that digital coaching platforms were only likely to help a certain percentage of diabetes patients, those with a modicum of technical acumen and a willingness to commit to a more intensive management style. It’s possible that such patients are already highly motivated to pursue management success and are therefore less in need of help than others less likely to use such a service. While Dr. Lipska argued that this means that digital coaching services may exacerbate healthcare inequities, Dr. Peters took a more optimistic view of the matter, counting any new treatment options as a positive even if they do not serve all patients equally well.

Takeaways

Digital diabetes coaching hopes to supplement standard medical care for diabetes by filling in the gaps between visits to the doctor’s office. By offering advice and reminders, they hope to keep your mind on your condition, setting you up for diabetes management success.

The evidence in favor of digital diabetes coaching is mixed. The proof that these platforms actually lead to improved outcomes is meager, but there is better evidence that they may save money for insurers and employers that offer the programs by reducing the frequency of in-person visits.

Would a digital diabetes coaching service be worth the cost to you? For a certain type of person, especially a patient ready to take his or her glucose management to the next level and willing to keep up with frequent online check-ins, these programs may well be highly effective.

 

Source: diabetesdaily.com

Reasons to Try Low-Carb… and Reasons Not To

If you are looking to lose weight and/or lower your blood sugars, you may have considered eating low-carb. There are many health benefits to reducing your carbohydrate intake. For those of us with diabetes, our bodies cannot properly break down sugar, so lowering carbs should naturally lower our blood sugar. Also, if you use insulin, cutting back on the carbs can also help you to reduce your insulin requirements.

With that said, people can be successful at weight and blood sugar management on both low-carb and high-carb diets. When I was eating very low-carb, I found the diet too restrictive and it messed with my mental health. In a previous article, I talked about how I increased my carb intake and still achieved the same A1c of 5.8.

The main goal is to find a way of eating that works for you, one that you can sustain and be successful at. I thought it would be nice to hear our community’s thoughts and experiences on eating low-carb…or not. While the definition of low-carb changes from person to person, the voices below define it as 100 grams of carbs a day or less.

People Living With Type 1 Who Prefer to Stay Lower Carb

“I feel better on low-carb for most things. Nothing strict, but I like to choose high protein and high fat over carbs. I think it’s definitely a personal preference. And I do splurge sometimes, though I’ll sometimes regret it because I can *feel* the unpleasant spike.” – Jessica R.

“I love low-carb. It helps me manage with way better accuracy and I do a lot of sports. The biggest issue is when I reintroduce a night out and I make a calculation error and it takes a couple of days of fumbling back to get on track.” – Nick G.

“I am not keto but do eat lower-carb. I have for many years and find it to be very helpful. I eat a higher protein diet. I am also an endurance athlete.” – Cathy J.

“Super easy and it regulates my blood sugar. I use a modified Paleo-type diet as a guideline. I typically have between 30-45 grams of carbs a day.” – Annie A.

“I try my best to be low-carb. It definitely helps me to lower my blood sugar. I try not to buy high-carb things when I shop, like bread and crackers, and when I eat out I do the best I can. If I am at a sandwich shop, I’ll eat what is on the menu and adjust my bolus for it.” – Mason R.

“I accidentally started low-carb one day and it has been great. Every 2-4 hours I eat 4 oz of protein and 2 oz of any vegetable. I never have to give myself insulin for it and my blood sugars stay stable all day with no unexpected highs or lows.” – Kelley B.

“I have been keto for about 10 years and have had type 1 for 32 years. I cycle and run and have found it much easier to manage under a keto diet. With so much less insulin on board, any highs or lows come on much more slowly. I have ridden century rides and run marathons with only needing water and with solid flat readings on my CGM the entire time. I miss a good carby beer, but overall well worth it.” – Owen F.

“I stick to low-carb most of the time but I don’t deprive myself if I want something carby. I use my insulin and most of the time my blood sugar remains stable.” – Allison C.

People Living With Type 1 Who Prefer Moderate to High Carb

“I don’t really worry about low-carb, I just try to eat good carbs. I know white rice, white flour and other types of carbs shoot my blood sugar through the roof so I try to limit those. I eat a lot of fruit though and whole wheat bread (love Dave’s Killer Bread). I can’t imagine doing keto or very low-carb though.” – Amanda S.

“I was low-carb, high-fat for about a year. Most days I was eating under 20 grams and always under 40 grams of carbs. Low-carb, high-fat worked great for snowshoeing at 9,000+ feet. It worked poorly for life in general (brain function, dependant on glycogen, glucogenesis from fat is slow). Cardio like running or cycle was a real struggle. Heart lungs and legs need glycogen when your heart rate elevates.” – Rob C.

“I work out 5 days a week and do strength training. For me personally, I like to use carbs before my workout for energy and I don’t limit them in general. Mastering the right dose of insulin at the right time is what it is all about” – Matt F.

“People with type 1 can still eat whatever they want. I enjoy my pizza and cake and still maintain optimal blood sugars.” – Kelly V.

Photo credit: iStock

People Living With Type 2 Who Choose Low-Carb

“I eat low-carb because it simplifies my life and reduces stress. I am a very carb-intolerant type 2. I ‘eat to my meter’ i.e. limit carbs enough to keep my meter readings in an acceptable range. For me, that’s about 30 grams of carbs a day. My choices are to eat what my body can handle or eat more carbs and take medication. I prefer to take the least amount of medicine, so low-carb it is. I don’t find it a big sacrifice, and after 11 years of low-carb, I feel better and less bloated, less hungry with no carb cravings.” – Lynn W.

“I needed to find a way of eating that helped all of the health issues I was facing (basically metabolic syndrome). A low-carb, healthy fat, moderate protein “diet” fit that bill quite nicely.” – Forum member

“[Low-carb] brought my blood sugar down, off all drugs. Sometimes I go off a bit (birthday parties?) but I see the impact on my daily blood test and it keeps me on course. Now I just avoid sugar and common carbs (rice, potatoes, bread, pasta) and that is enough. Oh, I have a house full of sugar substitute non-wheat flour baked bread, muffins, cookies & cake so I don’t miss anything. Just have to watch when out eating socially although there is usually enough to choose from.” – Forum member

“I joined a diabetes forum the day I was diagnosed with type 2 in 2011 and read many stories of doing well on an LCHF diet by members. The foods they reported eating to bring their diabetes under control are many of my favourites, so I decided to give it a go. The result was that I discovered I was very grain intolerant and my digestion improved dramatically when I stopped eating them. My weight started to drop fast as well, even though I was eating very high calories. Six months later I decided to take the extra step to go to a ketogenic diet, and everything improved even more as [I lowered] my carb intake to 12-20g a day and tested my ketones daily to make sure I was constantly in nutritional ketosis. I still test my ketones daily with my fasting glucose, and report both numbers here to keep myself honest. Nearly 10 years after starting low-carb, the weight loss has been maintained and I have never taken even a single metformin tablet. My quarterly HbA1c has been constantly between 5.0 and 5.2 (except for two 5.4 results) since six months after starting my low-carb diet. And I love the food I eat, so see no reason ever to go back to eating carbs for energy.” – Forum member

“I have type 2 and had my A1c in the 12 range. I was carb intolerant. My goal is to be medicine-free, have normal numbers, and to limit disease progression – and to keep the weight off.

“’Keto’ along with exercise helps my numbers remain ‘normal,’ weight is coming down slowly, BP numbers are in check, cholesterol is in normal limits, no longer have sleep issues/apnea. No T2 meds required, hope to be off my BP meds soon. A1C now in the low 5’s with normal fasting numbers.” – Forum member

People Living With Type 2 Who Prefer Moderate to High-Carb

“I’m type 2 and I don’t go low-carb since it’s a very restrictive diet. I have done low-carb in the past, and lost weight doing it. I just found it too hard to stick with when the people I dine with aren’t doing low-carb.” – Forum member

“I’m doing CICO (calories in and calories out) since you are allowed to eat anything as long you don’t go over calorie budget.” – Forum member

“I have been a type 1 since 2019. Before discovering low-carb I ate the advised 45-60g per meal which I got from Google/USDA guidelines. Truth is I’ve never been low-carb, more like moderate carb 100-200g per day. That was enough to promote rapid weight loss & return insulin sensitivity which improved over a year. My CGM trial had my A1c estimated at 4.6% & I only spent 1% of time above 140mg/dl.”- Forum member

“I do a lot of weight training and rely heavily on carbs for energy.” – Peter M.

“I’ve done research ad nauseum on what diet works best for diabetes, and long term, it appears that low-carb can actually increase insulin resistance. At first, it will definitely help your numbers, but other diets like the Mediterranean diet (which I am currently following) and Paleo have fared better in the long-term. It’s ultimately very individualized and depends on what works for you.” – Forum member

As you can see from our community members’ experiences, you can achieve both optimal blood sugars and weight on any diet. The trick is to find something you enjoy so that you can stick with it long-term.

Have you tried eating lower-carb? What was your experience like?

Source: diabetesdaily.com

Five Reasons Why I Choose Multiple Daily Injections

Since the day I was diagnosed, I have had people telling me I should consider an insulin pump. Seven and a half years later, I still say no. My A1c has always been in a healthy range, and I am fine with only having one device, the Dexcom G6 continuous glucose monitor (CGM), on my body. I know pumpers rave about their tight control and I am truly amazed by the pump’s capabilities, even more so now with the new features on the Medtronic 670G. However, I prefer a KwikPen, which is true to its word — it is quick and easy and just the way I like it!

Here are my five top reasons for being on team MDI (multiple daily injections):

1. No Kinks or Knots

I constantly hear stories of people waking up with a blood sugar in the 300s, and they had no idea. This is because there was a kink or knot in their tubing and the insulin wasn’t getting into their body all night long. Yes, if they are wearing a continuous glucose monitor (CGM), it should have alerted them, but that sounds like a pain you don’t get from the poke of a pen!

2. Fewer Bruises and Scar Tissue

Don’t get me wrong, the pokes of 6-8 injections a day does add up, and I do have bruises on my body. But have you seen the needle on those pump infusion sets? They are a lot longer and thicker than my Humalog pen. Also, the cannula stays in your body, therefore, leaving much larger holes. This means more bumps and bruises and also means more scar tissue.

3. No Crazy Calculations

As I mentioned above, I am amazed at what a pump can do. It can give you a precise amount of insulin right down to the decimal point. It can also tell you what your insulin on board (IOB) is. My pen can’t do either of these things! However, I do use Humalog Luxura, which is a half-unit pen so I can get more accurate dosing. Also, I mostly eat low-carb, so my dose is usually between 1-3 units. I prefer not having to count every carb I consume; math is not my strong suit!

4. Quick and Easy

KwikPens are quick and easy and take one second to use! I compare these seconds of my day to a lifetime of walking around with another device attached to me, tubing included, and that’s just not for me. Between CrossFit and being a mom, the tubing would not be kind to me.

5. I Don’t Have to Carry Around My Pancreas

When people first recommended the pump, I really only focused on not wanting to wear something else attached to my body. What I didn’t consider was the fact that I would have to actually carry around my new pancreas! When I went to my first type one weightlifting event, Bolus & Barbells, I was so surprised to see everyone with their phones in one hand and their stand-in organ in the other. I imagine that showering and going to the bathroom is a little more challenging than it is for the average Joe!

Photo by Allison Caggia

While I know there are many benefits to wearing a pump; it is just not something I am considering at this time. For me, the fewer reminders of this disease, the better. And with another device attached to me, especially with tubing, I would feel tethered. If I were to consider a pump, it would be the Omnipod since it is tubeless. For now, I will remain loyal to team MDI.

Are you someone who is on multiple daily injections and won’t have it any other way? Or are you someone who was MDI and made the switch to a pump and are glad you did? Share your story!

A previous version of this post has been updated.

Source: diabetesdaily.com

Tackling Type 1 Diabetes – Where Are We on Technology and Research?

This content originally appeared on diaTribe. Republished with permission.

By Andrew Briskin

Andrew Briskin joined the diaTribe Foundation in 2021 after graduating from the University of Pennsylvania with a degree in Health and Societies. Briskin is an Editor for diaTribe Learn.

At the Milken Institute 2021 Future of Health Summit, leading experts in type 1 diabetes research and innovation discussed the path toward a cure, the latest in glucose monitoring technology, and the importance of screening for type 1 diabetes.

A group of leading experts in type 1 diabetes research and innovation took part in the panel discussion, “Tackling Type 1 Diabetes: Where the Science is Heading” at the Milken Institute 2021 Future of Health Summit last month. They exchanged insights on the advantages of continuous glucose monitoring, automated insulin delivery (AID), Time in Range for better diabetes management, as well as tantalizing new possibilities for curing type 1 diabetes.

The discussion from June 22nd was moderated by diaTribe Founder Kelly Close and included:

  • Aaron Kowalski, Ph.D. – CEO, JDRF International
  • Shideh Majidi, M.D. – Assistant Professor, Pediatric Endocrinology, Barbara Davis Center for Diabetes
  • Felicia Pagliuca, Ph.D.  – Vice President and Disease Area Executive, Type 1 Diabetes, Vertex Pharmaceuticals
  • David A. Pearce, Ph.D. – President of Innovation, Research and World Clinic, Sanford Research

The panelists began by discussing how continuous glucose monitors (CGM) now provide people with type 1 diabetes even more information and the power to manage their glucose levels. CGM data provides people with crucial metrics such as Time in Range (TIR), which corresponds to the percent of time someone spends within their target glucose range – usually 70 to 180 mg/dL. This target glucose range may vary though, for example, if you are pregnant. You can learn more about the helpful metrics that CGM provides here. Alongside A1C, TIR allows more insight into your day-to-day diabetes management by showing fluctuations in glucose levels caused by factors like meals, exercise, illness, and more.

However, CGM is not perfect or widely accessible yet. The panelists touched on this issue of access to CGM and the existing disparities in care across race and type of insurance. Dr. Majidi emphasized that in populations with access to this technology, CGM use has increased from 20% to over 80% of patients over the last five years. However, some studies have shown that providers tend to prescribe technology only to certain patients due to unconscious biases about which patients may be able to handle using advanced technology.

Advocating for early and consistent training for healthcare providers on addressing these biases, as well as provider and patient education on CGM and other technologies for glucose management, Dr. Majidi said, “we need to look at these unconscious biases to start providing everyone with the opportunity to use and learn about new technology.”

The panel then explored the advantage of AID hybrid closed-loop systems. These systems combine a CGM, insulin pump, and an algorithm that allows the CGM and insulin pump to talk to each other. Dr. Kowalski said he was especially encouraged by the advancements in AID systems, emphasizing that it not only decreases the number of highs and lows, but it also removes much of the burden of diabetes management from patients and their families.

AID systems especially benefit families with children who have diabetes, reducing concerns from parents about the safety of their children during the night or at other times when the risk of hypoglycemia is high. The panelists said they were hopeful that these new innovations are bringing us closer to developing a fully closed-loop artificial pancreas, which could automatically respond to changes in glucose in real time without the need for a person to deliver manual boluses or calibrations.

Echoing their advice on how to address disparities in CGM use, the panelists noted the importance of education for healthcare providers to combat disparities in prescribing AID to ensure equal opportunity for all to achieve better health outcomes.

The discussion then shifted to the latest research towards a cure for type 1 diabetes, focusing on beta cell replacement therapies. Because type 1 diabetes occurs as a result of the body’s immune system attacking and destroying its own pancreatic beta cells (the cells that make insulin), scientists have been researching how to replenish the beta cell population from stem cells. Scientists believe that stem cells, not yet fully differentiated or mature cells, could potentially be directed to become functioning beta cells.

Dr. Pagliuca shared updates from her work at Vertex, studying stem cell-derived beta cell transplants in type 1 patients with impaired awareness of hypoglycemia. This initial study relies on systemic immunosuppressive drugs (these are drugs that “turn off” the body’s immune system so it won’t attack the implanted cells) to protect the implanted beta cells. The hope is that future studies will seek to use a different method called encapsulation, which protects beta cells from the immune system with a physical barrier, avoiding the need for immunosuppressant medications.

So far, with the successful conversion of stem cells into mature beta cells accomplished in controlled lab settings, the science has developed to the point of testing stem cell-derived beta cells in clinical trials, with Vertex first clinical trial now enrolling patients. This initiative will encompass the entire type 1 community, with Dr. Pagliuca stressing that “transitioning these breakthroughs into the clinical phase will require participation from all stakeholders, patients, researchers, and healthcare providers.”

Considering the latest research into the immunobiology of type 1 diabetes, the panelists advocated for significant increases in screening for type 1 across the general population.

Dr. Pearce advised that testing for the presence of specific autoantibodies (small molecules in the body that are the cause of the immune system attacking a person’s own beta cells) in the general population is essential for implementing prevention programs, given that the presence of at least two of these autoantibodies is a very predictive measure to assess the risk of developing type 1 diabetes.

According to him, the predictive power of these screenings make it is possible to classify an individual as having type 1 diabetes years in advance of any symptoms, even while they still have normal glycemic control. In this way, type 1 diabetes can be classified into 3 stages – stage 1 is when someone has two or more diabetes-associated autoantibodies, but normal glycemia and no symptoms. Stage 2 is when you have the autoantibodies, have begun to develop glucose intolerance or abnormal glycemia, but still no symptoms. Stage 3 is when symptoms begin and you are diagnosed with type 1 diabetes. Classifying diabetes in this way and identifying those in the early stages could increase patient involvement in clinical trials, and help connect individuals to new drugs such as teplizumab (not yet approved by the FDA), that aim to delay the onset of symptomatic type 1 diabetes or prevent it altogether.

Drs. Pearce and Kowalski agreed, recommending a screening strategy involving primary care providers and screening children during the toddler years. On the importance of this screening process for involvement in clinical trials, Dr. Kowalski noted, “Diabetes is a global problem. The voice of the patient is hugely important on new devices and therapies, and clinical trial pathways are delayed when there isn’t equal participation in the trials.”

You can watch the panel discussion and hear insights from the four incredible experts here.

Source: diabetesdaily.com

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