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

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

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

10 Low-Carb Products I Am Eating Now

I find that sticking to a low-carb lifestyle is easier when I have delicious healthy products at home. Luckily, there are plenty of great companies catering to those who eat low-carb. Each of these foods and snacks has a low-carb count and doesn’t spike my blood sugar. It is nice to have these foods as options so I can keep my blood sugars in check and stick to my nutritional goals.

Here are the 10 low-carb food products I am eating now. While they aren’t the most inexpensive options, they are all made with the healthiest ingredients possible and still manage to deliver on taste, which isn’t an easy feat!

Only Bean

Photo credit: Only Bean

Only Bean

This is a delicious pasta substitute made with edamame, black bean, or soy. My favorite is the edamame spaghetti, which packs in 44 grams of protein, 19 grams of fiber, and 16 net carbs. Top this dish with ground beef, chicken meatballs, or grilled shrimp, and add even more health benefits to this dish!

choc zero

Photo credit: Choc Zero

Choc Zero

This is low-sugar chocolate that is sure to satisfy your sweet tooth. Choose from peanut butter cups, chocolate bark, chocolate baking chips, syrups, and more. This company boasts avoiding artificial sweeteners and uses monk fruit instead. My favorite is the chocolate baking chips, as they are extremely versatile and can be paired with greek yogurt, an acai bowl, thrown into your protein shake, or used to make a delicious low-carb treat. Their baking chips come in milk chocolate, white chocolate, and dark chocolate. I love using dark chocolate, which only contains 1 g net carbs, to top a Too Good Yogurt for a healthy protein-packed treat!

NGR Bites

Photo credit: NGR Bites

NRG Bites Protein Snack Bar

Made by Paul Kahan, a fellow person living with type 1 diabetes, this is a perfect low-carb and high-protein snack on the go. I love to grab one on my way to the gym or pair it with coffee for a delicious and blood sugar-friendly start to my day. Offered in chocolate chip brownie, peanut butter, birthday cake, Strawberry Frosted Donut, and vegan chocolate chip banana bread, NRG Bites are a great choice for anyone looking for a healthy snack.

chicken burrito bowl real good

Photo credit: Real Good Foods

Real Good Food

A diabetes online community favorite, Real Good Foods promises low-carb, high-protein, and delicious foods that can be made in minutes. Aside from their new ice cream (which is out of this world!), my latest favorite is their chicken burrito bowl. This is a perfect lunch or dinner and comes in at 9g net carbs and 15g of protein. I highly recommend checking out their website as they have an extensive list of products to choose from.

swee2ooth

Phot credit: Swee2ooth

Swee2ooth

This is a whey protein powder created with people living with diabetes in mind. Their blend contains 20 grams of protein, between 2-3.5g net carbs depending on the flavor, and offers plenty of healthy vitamins and minerals. These super wholesome nutrients could help reduce glucose spikes, keep you fuller for longer, lower blood pressure, and help reduce the risk of cardiovascular disease — to name a few! Use Swee2ooth in smoothies, add to iced coffee, or use it for baking some of your favorite high-protein desserts.

legendary foods

Photo credit: Eat Legendary

Legendary Low-Carb Toaster Pastry

It is hard to find a low-carb, high-protein breakfast that isn’t mostly just eggs and bacon. Thanks to Legendary, you can enjoy a tasty breakfast pastry that contains only 3g net carbs and 170 calories. Compare that to a regular toaster pastry at 35 g net carbs and 210 calories. It also is packed with 9 grams of protein, which you can’t get from any other kind of morning pastry! I found these to be absolutely delicious and they didn’t put me on a blood sugar roller coaster.

keto enlightened ice cream

Photo credit: Eat Enlightened

Enlightened Ice Cream

I have tried many different types of low-carb ice cream, and Enlightened is my number one. I always look forward to this dessert and enjoy knowing that my blood sugars won’t get out of whack.  With a great variety of flavors, they have something for everyone. All of the Enlightened products, both bars and pints, are sweetened with monk fruit and erythritol, which are all-natural, zero-carb sweeteners. The keto collection is made with real cream and zero-carb sweeteners. They come out to 1 g net carb per serving once you factor in their high fiber content. They all were rich and creamy, and the bits of flavor were plentiful, a delicious surprise inside every bite.

Chipmonk Baking

Photo credit: Chipmonk Baking

Chipmonk

These low-carb, high-fat bite-size snacks come in an assortment of flavors and are made with almond flour, butter, and eggs, and include allulose and monk fruit as the sweeteners. I think they taste great, and with only 1g net carb and 80 calories per serving, this is a great sweet treat that won’t impact your blood sugar levels. They also offer a variety of other goods, including keto bites, dry mixers, sweeteners, and more, so be sure to check them out.

perfect snacks

Photo credit: Perfect Snacks

Perfect Bar Dark Chocolate Sea Salt Peanut Butter Cup

I first tried Perfect Bar’s original refrigerated protein bar a few years back and gave it rave reviews, so I was pleasantly surprised to see they have a new product offering.  The dark chocolate and sea salt peanut butter cup puts the original peanut butter cup to shame thanks to its generous sprinkling of crunchy sea salt, rich peanut butter, and chocolate goodness. Coming in at 7 grams of protein and 13g net carbs, this is a decadent treat that will also keep your blood sugars stable.

Photo credit: SkinnyDipped

Skinny Dipped Almonds

This is a delicious tasty treat that contains no artificial flavors and also no sugar alcohols, which can cause an upset stomach. Coming in an assortment of flavors, Skinny Dipped offers not only regular size but single sized packets allowing you to exercise portion control which will help prevent a blood sugar spike. All their flavors range from 11-16 grams of carbs and 5-6 grams of protein per serving. I highly recommend trying their new products, the Skinny Dipped Chocolate Bars and Peanut Butter Cups.

Having healthy store-bought snacks makes sticking to my nutrition goals much easier. I highly recommend giving some of these suggestions a try. Have you found any great products to share? Like and comment below!

Source: diabetesdaily.com

The Extraordinary Almost-Olympian Charlotte Drury and the Trials of Type 1 Diabetes

It was 2020 – right around the dawn of the pandemic in the United States – when Charlotte Drury’s athletic abilities mysteriously began to decline.

“I wasn’t building any muscle, I wasn’t getting any better. And I was training more and more because I could feel myself regressing. My skills just got worse and worse.”

Charlotte, now 25, is a trampoline gymnast. She’s a former world champion and knows her body well. She knew something was wrong.

“Am I just past my prime? Am I not trying hard enough?”

“Looking back, it’s nice to have an explanation that it wasn’t my fault.”

It wasn’t her fault. Charlotte Drury was about to find out that she had type 1 diabetes.

The Lost Year

If gymnastics fans already know Charlotte Drury for one thing, it’s for an earlier and unrelated health catastrophe. In 2016, with the Rio Olympics about to take place, Charlotte was considered America’s best female trampoline gymnast. In previous years she had won individual gold at both the World Cup and the USA Gymnastics Championships. But her Olympics dream was crushed when she broke her ankle during the final qualifying event of the season.

The tragic injury could have ended her competitive career, but Charlotte decided to give the Olympics another shot. She’s fearless—you sort of have to be to make a living flying 30 feet into the air while flipping and twisting.

“I was on top of my game when the pandemic hit. But suddenly, I was all by myself, and training started to get really, really hard. At first, I just chalked it up to training alone in the middle of a pandemic.”

“Later, I was struggling with some depression. I told myself, you’re probably just fatigued from the depression, it’s in your head, you just have to push through.”

It wasn’t in her head. Charlotte was suffering from acute hyperglycemia due to her undiagnosed type 1 diabetes. The critical lack of insulin in her body meant that she wasn’t getting energy from the food she ate. Insulin is a growth hormone and promotes fat storage; without it, our muscles falter, our bodies wither, and the calories we desperately need are flushed uselessly out with our urine.

Later she would recognize that there were other red flags – a bizarrely increased thirst, a new tendency to pee in the middle of the night. But as her body failed her in real-time, she found reasons to disbelieve what was happening.

“I basically gaslit myself into believing it was all in my head for almost a year.”

In December 2020, Charlotte visited her doctor to discuss her depression, which she mistakenly thought was at the root of her troubles. Shockingly, she was still four months away from understanding what was plaguing her. Finally, the mounting setbacks just became too much to ignore.

“In April [2021], we had a national team training camp. I knew how hard I’d been working, and I was looking at everyone around me and realized that there was something wrong with me. There’s absolutely no way I could be this far behind. Something was wrong.”

“There’s a lot of power needed in this sport. I could barely make my triples anymore, and I’ve been making those skills since I was 16.”

The Diagnosis

As soon as Charlotte got home from the camp, she called her doctor, who ordered up bloodwork. Soon thereafter the doctor called her and told her that she was experiencing a medical emergency.

“She said, ‘You have type 1 diabetes. You need to come in right now.’”

Charlotte’s A1c was 14.6%, and her blood glucose over 500 mg/dL. Despite the length of time it took to get a proper diagnosis, she can probably still thank her uncommon awareness of her own physical condition for avoiding diabetic ketoacidosis. Had she not been so in tune with her physical fitness, as professional athletes need to be, who knows how long it would have taken to make that call to the doctor?

Now at last she had an explanation, but a bittersweet one—her life had changed unalterably. And, oh yeah, if she wanted a chance to join the competition she’d spend her entire life preparing for, she had just a few months to figure everything out.

Charlotte Drury Bounces Back

For the first two weeks, she was “miserable.”

“Mentally I was just done. I thought there was no way I could go to the Olympics. There’s no way I can figure out how to manage this, get healthy and strong enough, and train in three months. It was really, really overwhelming.”

At first Charlotte was only taking basal insulin, so “I was still having these crazy mealtime spikes.” It took days of advocacy by her diabetes educator to get the prescription for fast-acting mealtime insulin that she so clearly needed. And she was still coming to grips with the enormity of her diagnosis.

“When I first was told that I had to start mealtime insulin, I just broke down and started crying. I have to do what every time I eat?

But once Charlotte started using rapid mealtime insulin, “it was an incredible turnaround.”

“After two weeks of getting my blood sugars back in range, I literally felt like a different person. A completely different person.”

Her training improved overnight. She regained energy and mental clarity. Her muscles came back to life.

“I had no idea how bad I was feeling until I started to feel good. And now I will do anything to feel this good. I will do the injections, I will monitor, I will wear whatever devices you want – anything to feel good again.”

And suddenly, the Olympics didn’t seem so far-fetched after all.

Trials and Tribulations

Charlotte’s comeback was never going to be easy.

In a mini-documentary filmed prior to her diagnosis—highly recommended for a good look at how insane trampoline gymnastics really is—Charlotte says that repeatedly bouncing as high as 30 feet into the air feels like riding a rollercoaster. The blood sugar rollercoaster was not what she had in mind.

Consider, for a moment, just how dangerous hypoglycemia could be in the life of a trampoline gymnast. Imagine first perceiving a severe blood sugar low while you’re soaring through the air, and what might happen when you land with anything less than precise technique.

The first time Charlotte got hit with a blood sugar low on the trampoline, “I immediately started crying and hyperventilating. ‘Something’s wrong, get me off the equipment!’”

Now imagine developing a comprehensive eating and insulin dosing regimen that allows you to maximize your athletic potential on the global stage, and doing it in a matter of weeks.

“I’m still in the days of figuring it out.”

Charlotte told me that trampoline training is more or less like the most difficult HIIT or CrossFit exercise you’ve ever imagined. 20 seconds of pure max effort, a minute or two of rest, and repeat. For two hours. Those intense workouts are usually preceded by some 30 minutes of vigorous warmup work, cardio that can drive blood sugar down before the stress and effort of the routine drives it back up. Good luck preparing properly for all that.

“It’s a lot of moving parts.”

Life still throws up curveballs. Just when Charlotte thought she had a system down, a trip to Italy for an important round of Olympic trials taught her just how powerfully unanticipated variables can impact diabetes management.

“Everything I knew went out the window.”

During her first practice in Italy, her blood sugar dropped from 100 mg/dL to 48 within 5 minutes. “It felt like I got hit by a wall. It took me three juiceboxes to get back to 70.” That hypo took a full 30 minutes to recover from, 30 minutes of vital practice time on competition equipment that she lost and couldn’t get back.

A Gold Medal Teammate

One of her “saving graces” has been her roommate, the Olympic gold medalist Laurie Hernandez, who has had close family members with insulin-treated type 2 diabetes. Actually, it was Laurie who first told me Charlotte’s story.

“Laurie came in clutch. She came to my doctor’s appointment, she came to my endo appointment, she was taking notes, she’s my Dexcom pal and when I go low in the night she opens a juicebox and brings it to me.”

“There’s a lot of things that I’m very grateful for. When it rains, it pours, but I’ve got a lot of friends and support to help hold an umbrella up.”

The 2021 Olympics

When I first talked to Charlotte, she had completed two of the three trial events that would determine which Americans would make the Olympic team. Despite her remarkable turnaround since beginning insulin treatment, she still wasn’t yet performing at her peak, and her scores reflected that. To make the Olympics, she told me, “I’m gonna have to pull out something pretty amazing in the last trial.”

She almost did exactly that. At the USA Gymnastics Championships in late June, Charlotte nailed her routine and placed second. It didn’t get her the coveted single spot as an Olympic competitor, but was good enough to get her named the alternate on the team. In the following days, she was downgraded to second alternate after a controversial decision to let another teammate re-try her routine. So, Charlotte will be going to Tokyo as a member of the Olympic team, but with an exceedingly low chance of actually competing.

There’s no question in Charlotte Drury’s mind that if she hadn’t developed type 1 diabetes, she’d be competing in Tokyo. But an entire year of frustrating and ineffective practice was just too much to overcome.

Looking Forward

Charlotte hasn’t ruled out another run on the Olympics. The Paris games are only three years away, after all, and her strong final performance has her optimistic about her potential to earn the spot that she might have already won twice were it not for medical disaster. She told me that she’d like to see what she’s capable of after she regains her peak physical condition and combines it with the hard-earned wisdom of the last five difficult years.

Meanwhile, she’s strategizing how to get started on her dream career, a good one for an uncommonly sensitive and fearless young woman. Charlotte wants to be a photojournalist, documenting global suffering and conflict, and is ready to throw herself into war zones to do it.

No matter what comes next, she’s determined that her new condition won’t get in her way: “This won’t stop me.”

“I want to be proud of how far I’ve come so quickly, but at the same time, I didn’t really have a choice, just like anyone with type 1.”

 

All photos courtesy of Charlotte Drury.

Source: diabetesdaily.com

Debate at the ADA: Should Athletes with Diabetes Go Low-Carb, or High-Carb?

By Maria Muccioli and Ross Wollen

***

Do you need carbohydrates to optimize athletic performance? Or can athletes with diabetes do even better when they fuel their bodies with protein and fat?

By now it’s clear that the low-carb approach to diabetes has largely gained clinical acceptance, for people with both type 2 and type 1 diabetes (T1D). But some questions remain about when carbohydrate restriction is and isn’t appropriate.

One of those big questions: athletics. It’s long been conventional wisdom that athletes – whether elite professionals or weekend warriors – absolutely need carbs to fuel performance. But when you’ve got diabetes, “carb loading” the night before a big race is a tricky proposition.

At this year’s ADA Scientific Sessions, two experts went head-to-head in a debate on “Carbohydrate Intake and Its Impact on Athletics and Health.”

Read on to hear what happened – and who, in our opinion, won the debate.

The Case for a High-Carb Diet

In his presentation titled “High/Normal Carbohydrate Intake Optimizes Performance and Glycemia,” James P. Morton, PhD argued in favor of a normal-to-high carbohydrate approach for athletic performance and blood glucose management. Morton is a professor of exercise metabolism at Liverpool John Moores University.

Morton focused his talk on the importance of fueling high-energy expenditure for elite athletes, such as those on multi-week bicycle races. He presented some data showing that people who consumed a high-carb load were able to exercise for longer periods of time than those who consumed a placebo solution. Morton pointed out that for professionals, even tiny differences can make the difference between victory and defeat.

As an example, Morton presented a case study of Tour de France winner Chris Froome. In 2018, Froome made a very dramatic comeback on the 19th day of a multi-week cycling race. He ate an incredible amount of carbohydrates that day and the day previous, which Morton believes contributed significantly to his victory.

How do carbs fuel performance? The primary explanation centers around the availability of glycogen (branched glucose molecules) in the liver and muscle. The higher the glycogen levels, the more glucose is readily available to power activity.  Morton also presented evidence that those who eat high-carb delay the point at which they begin burning fat for energy, and claimed that delaying this crossover point was important for top performance in endurance athletes.

In addition, Morton cited personal testimonies from some elite endurance athletes, such as audio of interviews from his podcast, claiming that support of high-carb for athletic performance is “unanimous.”

Unfortunately, little of this presentation had much to do with the unique challenges of athletes with diabetes. And for that matter, its focus on truly elite professionals may be of limited relevance to even the most avid part-time athletes. Morton has never worked directly with athletes with type 1 diabetes, but referred to the opinions of his “friend and colleague” Sam Scott, PhD, a researcher at Novo Nordisk. Scott has plenty of firsthand experience with high-performing diabetic athletes: he works with Novo Nordisk’s inspiring all-diabetes pro cycling team.

Morton invited the audience to read Scott’s recent publication concerning type 1 diabetes, carbohydrate intake, and athletic performance. In that paper, Scott concludes that low-carb diets “represent an effective strategy to improve glycaemic control and metabolic health in people with T1D,” but that their effect on athletic performance is basically unknown:

Despite low carbohydrate training being one of the most widely debated topics amongst athletes, coaches and sport scientists, there is very little published research specific to athletes with T1D.

Some evidence suggests that people with type 1 diabetes might especially benefit from “train low” strategies – basically, limiting carbohydrate intake during regular training, and increasing carb consumption for competitions. Beyond that, however, there simply isn’t enough evidence to make concrete claims.

Leaning on his experience with non-diabetic athletes, Morton concluded:

Regardless of whether you have normal glycemic responses or you have type 1 diabetes, the principle of ensuring high carbohydrate availability should always be upheld, because carbohydrate will certainly make you go faster.

The Case for a Low-Carb Diet

In his presentation titled “Low Carbohydrate Intake Optimizes Performance and Glycemia”, Dominic D’Agostino, PhD argued that because low-carbohydrate diets are optimal for blood glucose control, they are therefore also optimal for athletic performance.

D’Agostino, a molecular pharmacologist, is something of a minor rock star in the keto community. He’s a frequent guest on podcasts and Youtube shows, and has a fair personal understanding of keto athletic achievement: he’s an impressive powerlifter to boot.

D’Agostino started by acknowledging that we do not really know the best level of carb intake for athletes. But in his telling, practices even among the elite are far from unanimous, with athletes experimenting with a variety of strategies, ranging broadly from carb restriction to carb loading.

Many athletes choose a low-carb diet because they like the way that it feels – some claim, for example, that keto results in more consistent energy throughout competition, making them much less likely to “bonk” or hit the wall. But for people with diabetes, the primary point in favor of a low-carb diet is the degree to which it optimizes glucose control.

A very low-carb or ketogenic diet doesn’t just steady blood sugar – it also appears to result in some measure of “hypoglycemic resilience”. This isn’t a small matter for diabetic athletes. Hypoglycemia during exercise or competition won’t just ruin athletic performance: it can be very dangerous.

Not only does ketosis protect against hypoglycemia, he explained, but recent research also shows additional benefits of ketosis, such as reduction of oxidative stress. D’Agostino also noted that increased fat utilization can lead to “glycogen sparing”, and that a low-carb diet does not cause glycogen depletion in the muscle. These features may confer additional athletic advantages.

Photo by Adobe Stock

While Morton’s presentation was largely founded on the assumption that athletes with diabetes are fundamentally like athletes without diabetes, D’Agostino emphasized a different principle:

Normal glycemia is optimal for health, performance and recovery.

Of course, normal blood glucose levels are very difficult to achieve for people with type 1 diabetes, especially during exercise. But the low-carb diet has been validated as perhaps the best method of doing so.

D’Agostino explained that his own thoughts on the subject were formed partially by the experience of his former Ph.D. student, Andrew Koutnik, who lives with type 1 diabetes. Initially, D’Agostino believed that type 1 diabetes was “the one condition that I thought you would want to stay away from low-carbohydrate nutrition,” but Koutnik’s success first convinced him otherwise.

I reached out to Koutnik, now a research scientist at Florida Institute for Human and Machine Cognition.

He stressed that most studies comparing high- and low-carb athletic results show mixed or neutral results; when there is a difference, the difference “is often of little meaningful impact to most individuals engaging in physical activity.”

Dr. Koutnik argues that any nutritional program that doesn’t consider glycemic control is missing the most important factor: “Very few will debate that poor health leads to poor performance. Additionally, few will debate that normoglycemia is likely to lead to better performance than hyper- or hypoglycemia.” Therefore, for the T1D athlete, performance is a “consequence” of health.

Who Won the Debate?

Here are our thoughts:

At a diabetes conference, the focus should remain on diabetes. Although Morton presented some evidence to support the performance benefits of high-carbohydrate intake in elite athletes without diabetes, it’s a mistake to assume that the same benefits would occur in athletes with diabetes, or that they wouldn’t be counterbalanced by the known downsides of high-carb consumption. Glycemic management is a huge issue during exercise, and both low and high blood sugars can have dramatic effects on performance.

exercise woman

Photo by Andrew Tanglao (Unsplash)

Most of Morton’s talk also focused on elite endurance athletes. But what we learn from the best athletes on the planet may not be very useful for the rest of us.

In our opinion, D’Agostino showed a better understanding of the balancing act that athletes with diabetes (especially type 1 diabetes) need to perform.

Even if we accept that carb loading can provide a perceptible boost to serious athletes, we have to acknowledge that those carbs (and any accompanying insulin) also make it more likely for the athlete to experience hypo- or hyperglycemia, which can instantly ruin any sports outing. And the more predictable and stable your blood sugar, the more confident you can be, and the less mental space you’ll have to waste on monitoring and micromanaging glycemic changes. And if a ketogenic diet really does provide some protection against hypoglycemia, that’s just even more reason to choose a very low carb diet.

If you’re actually an elite athlete, maybe carbohydrates can help push you to the peak of performance. But maybe not – the scientific evidence is not overwhelming. For the rest of us, blood sugar control remains of paramount importance. It seems to me that a low-carbohydrate diet is more likely to deliver confident performances and strong athletic results.

What are your thoughts on this debate?

Source: diabetesdaily.com

Can Snacking Help You Manage Diabetes?

There are many reasons we snack, both good and bad. Some snacks are healthy and helpful, but sometimes we snack out of boredom, stress, or anxiety.

Can snacking actually help your diabetes management? Yes! Some foods and habits can help keep your blood glucose in your desired range. We met with registered dietician and strength and conditioning coach, Ben Tzeel, to discuss snacking!

Best Overall Snacks

Snacks that include protein tend to keep you satiated, and promote stable blood sugars over time. A snack with a large amount of fast-acting carbohydrates may spike your blood glucose quickly and lead to a low afterward, while a snack high in fat may contribute to elevated blood glucose hours later.

For folks following a ketogenic or ultra low-carb diet, a mini charcuterie snack with cheese, meat, and pickles might work well. And for those looking for something quick and easy, staying under 15 net grams of carbs (like the ones found in this list) works well to get you to your next meal. One of Ben’s favorite brands is the NRG bites from NRG Foods, with ~110 calories per bar and 4 to 6 grams of fat, 8 to 10 grams of protein, and 8 to 12 grams of net carbs (depending on flavor).

Snacks and Dawn Phenomenon

While there isn’t a magical snack that stops dawn phenomenon, there are some foods that don’t contribute to higher blood glucose levels overnight. Dawn phenomenon, or dawn effect, is when blood sugar rises in the early morning from about 2 am until 8 am. In order to wake up, hormones such as cortisol and glucagon are released. These trigger the liver to increase glucose production. Normally, the pancreas would then produce insulin to adjust. However, the impaired (or complete lack of) insulin response characteristic of diabetes causes blood sugar to rise. Small snacks with protein and fat work better after dinner than snacks containing carbohydrates. Leftover protein from dinner or a small serving of nuts, such as low-carb trail mix, works well!

Best Snacks Prior to Exercise

While this may seem counterintuitive if you’re counting calories for weight loss, our bodies need fuel to stay active for longer periods of time. In certain situations, having a snack before exercising can help keep blood sugar stable. Please note, we don’t recommend having a snack and giving an insulin bolus to cover for the snack. For pumps using automated insulin delivery (AID) you’ll need to pay attention to timing. Eat it too soon and an AID pump will see a rise in BG and begin to adjust, giving you more insulin. Definitely not what you want right before exercising!

Ben recommends having your snack 30 to 45 minutes before exercise, giving your stomach enough time to start digesting the food and to stabilize your blood glucose. Try avoiding anything too high in fat or dairy products to prevent gastrointestinal upset. Staying below 20 grams of carbohydrate, mixed with some protein and fat, will help slow the absorption and blood glucose rise, and avoiding a large spike before exercising.

If you’re taking long-acting insulin or a medication that lowers your blood glucose, you may find having a small snack beneficial in preventing a low (hypoglycemia) during exercise. If you’re using an insulin pump and adjusting your basal rates or using an exercise profile, you may not need or want a snack prior to a short-duration exercise. If you’re using an insulin pump, you may find it useful to reduce your basal rates 30-90 minutes prior to exercise, or to use the exercise/activity function rather than snacking for short duration activity. Exercising for longer than an hour? You may want to include food as a way to manage your blood glucose levels and/or fuel your body for exercise. For more information about longer-duration exercise and type 1 diabetes, read more from Dr. Mike Riddell and his colleagues in the Exercise Management in type 1 diabetes: a consensus statement.

 

No matter the way of eating you follow, you can adjust snacks to fit your lifestyle and help keep your blood sugar in your desired range!

Our thanks to Ben Tzeel from Your Diabetes Insider for joining our online session and for providing his expertise and insights. To learn more about or contact Ben, you can find him on his website or Instagram page.

References

Riddell, Michael & Gallen, Ian & Smart, Carmel & Taplin, Craig & Adolfsson, Peter & Lumb, Alistair, et al. (2017). Exercise management in type 1 diabetes: A consensus statement. The Lancet Diabetes & Endocrinology. 5. 10.1016/S2213-8587(17)30014-1.

Source: diabetesdaily.com

3 Things Every T1D Parent Should Know (That Your Endo Hasn’t Told You)

This content originally appeared on Beyond Type 1. Republished with permission.

By Lauren Bongiorno

As the parent of a child with type 1 diabetes (T1D), do you ever feel like there’s more to know about diabetes than you could ever learn? You may have an attentive and caring endocrinologist but still find that there are gaps in your education as a parent. It could be tangible tools, holistic resources, or more support that is missing, putting you in a constant reactive state chasing highs and running after lows.

It’s like you’ve been handed the keys to a car and given a few vague, verbal directions of how to get to your destination. That’s far from the ideal set up for a road trip! You need a map, a full tank of gas, and snacks for the ride. The same is true for a journey from childhood to adulthood with T1D.

Today we are breaking down the top three cornerstones of our family coaching programs that will help parents like you ease the future roadmap for your T1D child.

 1. Challenge Everything

If your GPS tells you to take the main road, but you think the back roads would be faster, what would you do? Make your own route! One way isn’t better than the other, but the best route is the one that feels natural, easy, and meets your needs.

It is okay, and encouraged, to question what you’ve been told and follow your instincts. An endocrinologist is one of several resources available to you, but not the only resource. By actively participating in conversations with your child’s endocrinologist about their diabetes, you can become the leader of your child’s diabetes management and model for them what it means to be self-reliant and self-advocating.

2. Your Family, Your Rules

While there are certain rules of the road we all have to follow, like staying within the speed limit and stopping at red lights, you get to set the expectations within your own car. As the driver, you get to determine how loud the music is played and the frequency of bathroom stops. Your family has the flexibility to create the road trip experience that works for you.

Checking blood sugar and giving insulin are two rules you can’t change, but other strategies are more fluid based on your child’s unique patterns and needs. Some kids’ blood sugars go low after sports practice. Others have a delayed high. Some need a snack before bed, while some don’t. It might take some time to understand what your child’s patterns are, but it’s key to recognize that not all bodies are the same and there is no one-size-fits-all diabetes management routine. So, discovering what works for your child, and your child alone, is the primary goal.

3. Holistic Approach

When you get in a car for a road trip, it’s about more than just getting from one place to another. The drive is a whole experience of its own! The music, snacks, and pit stops along the way are just as significant.

Similarly, holistic diabetes management is more than counting carbs and giving insulin. The other macronutrients, fat and protein, have an impact on blood sugars too, but this is less commonly understood. Beyond food, exercise, sleep, stress, hormones, relationship to food, and mental health are important elements of diabetes management, which is why over-simplifying diabetes just leads to more frustration and challenges. A holistic scope that takes in all of the factors is the key to a deeper understanding and more empowered relationship with your child’s T1D.

As a parent, you already know that kids are unpredictable and being adaptable is basically a parenting survival skill. While adaptability is always needed, it’s possible to get diabetes from interrupting your child and family’s life as much. For more support on an integrative approach to taking care of yourself, your child, and their T1D, click here to download this free video resource.

Source: diabetesdaily.com

Insulin at 100, Part 3: Insulin’s Uncertain Future

This content originally appeared on diaTribe. Republished with permission.

This is Part 3 of James S. Hirsch’s exploration of the riveting history of insulin, on the occasion of its 100th birthday.

Part 1: The Discovery

Part 2: Failed Promises, Bold Breakthroughs

Insulin’s Uncertain Future

Insulin

Image source: Emily Ye, Diabetes Daily

As further refinements in insulin occurred, the insulin narrative should have become even more powerful – that insulin not only saves people, but in reaching new pharmacological heights, it is allowing patients to live healthier, better, and more productive lives. These should be insulin’s glory days – as well as days of unprecedented commercial opportunity. According to the International Diabetes Federation, in 2019, the global population of people with diabetes had increased a staggering 63 percent in just nine years – to 463 million patients.

Insulin sales should be booming, with a new generation of Elizabeth Evans Hughes and Eva Saxls to tell the story. In fact, insulin sales are declining, and insulin has no spokespeople. Reasons vary for these developments, but one fact is undeniable: insulin has lost its halo.

Insulin is still essential for any person with type 1 diabetes, though even with type 1 patients, insulin is sometimes under-prescribed as doctors fear getting sued over a severe hypoglycemic incident. The belief is that patients are responsible for high blood sugars, doctors for low blood sugars.

Where insulin has lost its appeal is with type 2 patients, which has driven the diabetes epidemic in the U.S and abroad. According to the CDC, from 2000 to 2018, America’s diabetes population surged 185 percent, from 12 million to 34.2 million, and an estimated 90 percent to 95 percent of that cohort has type 2. (The global percentage is similar.) These patients have long had options other than insulin – metformin, introduced in 1995, remains the ADA’s recommended first-line agent. But as a progressive disease, type 2 diabetes, in most cases, will eventually require a more intensive glucose-lowering therapy. Nothing achieves that objective better than insulin, but insulin is delayed or spurned entirely by many type 2 patients.

Some concerns are longstanding; namely, that insulin can lead to weight gain because patients now retain their nutrients. Some type 2 patients wrongly associate insulin with personal failure surrounding diet or exercise, so they want to avoid the perceived stigma of insulin. Some people just don’t like injections. Meanwhile, other patients associate insulin with the medication that an ailing patient takes shortly before they die: insulin as a precursor to death. Some clinicians who care for Hispanic patients refer to insulin pens as las plumas to avoid using a word that carries so much baggage.

What’s striking is how dramatically the cultural narrative has changed, from insulin the miracle drug to insulin the medical curse. And where are the commercials, the movies, the documentaries, and the splashy publicity campaigns about the wonders of insulin? They don’t exist.

The greatest impact on insulin use in type 2 diabetes has been the emergence of a dozen new classes of diabetic drugs. These include incretin-based therapies known as GLP-1 agonists and DPP-4 inhibitors (introduced in the 2000s) as well as SGLT-2 inhibitors (introduced in 2014). diaTribe has covered these therapies extensively, and their brands are all over TV: Trulicity, Jardiance, Invokana, and more. They all seem to have funky names, and like insulin, they can all lower blood sugars but – depending on which one is used – some have other potential advantages, such as weight loss. (Some have possible disadvantages as well, including nausea.)

The expectations for these drugs were always high, but what no one predicted was that GLP-1 agonists and SGLT-2 inhibitors have been shown to reduce the risk of both heart and kidney disease – findings that are a boon to type 2 patients, who are at higher risk of these diseases. These findings, however, were completely accidental to the original mission of these therapies.

Insulin, the miracle drug, has been eclipsed by drugs that are even more miraculous!

Consider Eli Lilly, whose Humalog is the market-leading insulin in the United States. In 2020, Humalog sales fell 7 percent, to $2.6 billion, while Trulicity, its GLP-1 agonist, saw its sales increase by 23 percent, to $5 billion.

That’s consistent with the global insulin market. Worldwide insulin sales in 2020 declined by 4 percent, to $19.4 billion, marking the first time since 2012 that global insulin sales fell below $20 billion.

It’s quite stunning. Amid a global diabetes epidemic, and with the purity, stability, and quality of insulin better than ever, insulin sales are falling. (Pricing pressures from insurers and government payers have also taken a revenue toll.) In 2019, Sanofi announced that it was going to discontinue its research into diabetes, even though its Lantus insulin had been a blockbuster for years. More lucrative opportunities now lay elsewhere.

Falling sales may not be the insulin companies’ biggest problem. Public scorn is. Though the insulins kept getting better, the prices kept rising, forcing many patients to ration their supplies, seek cheaper alternatives in Canada or Mexico, or settle for inferior insulins. Some patients have died for lack of insulin. According to a 2019 study from the nonprofit Health Care Cost Institute, the cost of insulin nearly doubled for type 1 patients in the United States between 2012 and 2016 – they paid, on average, $5,705 a year for insulin in 2016, compared to $2,864 in 2012.

Many patients are outraged and have used social media to rally support – one trending hashtag was #makeinsulinaffordable. Patient advocates have traveled to Eli Lilly’s headquarters to protest. In March of this year, nine Congressional Democrats demanded that the Federal Trade Commission investigate insulin price collusion among Eli Lilly, Novo Nordisk, and Sanofi, asserting they “are using their stranglehold on the market to drive up costs.” The letter notes that as many as one in four Americans who need insulin cannot afford it, and at least 13 Americans have died in recent years because of insulin rationing.

The criticism has been unsparing. In April 2019, in a hearing for the U.S. House of Representatives on insulin affordability, Democrats and Republicans alike pilloried the insulin executives. At one point, Rep. Jan Schakowsky (D-Illinois) said to them, “I don’t know how you people sleep at night.”

Insulin is hardly the only drug whose price has soared, but as the Washington Post noted last year, insulin is “a natural poster child of pharmaceutical greed.”

In response, the insulin companies have adopted payment assistance programs to help financially strapped consumers. They also blame the middlemen in the system – the PBMs, or the Pharmaceutical Benefit Managers – for high insulin prices, who in turn blame the insulin companies, and everyone blames the insurers, who point the finger at the companies and the PBMs.

Drug pricing in America is so convoluted it’s impossible for any patient to accurately apportion blame, but the history of insulin explains in part why the companies have come under such attack. When Banting made his discovery, he sold the patent to the University of Toronto for $1. He said that insulin was a gift to humankind and should be made available to anyone who needs it. Insulin was always profitable for Eli Lilly and the few other companies who made it, and critics have complained that the companies found ways to protect their patents by making incremental improvements in the drug.

But for years, those complaints were easily dismissed. The companies were revered for their ability to mass produce – and improve – a lifesaving drug that symbolized the pinnacle of scientific discovery while doing so at prices that were affordable.

When prices became unaffordable – and regardless of blame – the companies were seen as betraying the very spirit in which insulin was discovered and produced, and their fall from grace has few equivalents in corporate history.

Is the criticism fair?

Hard to say, but even the companies would acknowledge that they’ve squandered much good will. Personally, I’m the last person to bash the insulin companies – they’ve kept me and members of family alive for quite some time. Collectively, my brother, my son, and I have been taking insulin for 117 years, so I feel more regret than anger: regret that at least one insulin executive didn’t stand up and say loudly and clearly:

“Insulin is a public good. No one who needs it will be without it. And we will make it easy for you.”

Insulin

Image source: Emily Ye, Diabetes Daily

Whatever that would cost in dollars would be made up for in good will – and such a public commitment would honor the many anonymous men, women, and children, before 1921 and after, who gave their lives to this disease.

The next chapter for insulin? It will almost certainly include continued improvements. Both Eli Lilly and Novo Nordisk are trying to develop a once-a-week basal insulin to replace the current once-a-day options – that would be a major advance is reducing the hassle factor in care. Research also continues on a glucose-sensitive insulin, in which the insulin would only take effect when your blood sugar rises. That would be a breakthrough, but investigators have spent decades trying to make it work.

Since its discovery, the ultimate goal of insulin has been to make it disappear, as that would mean diabetes has been cured. It turns out that insulin therapy may indeed disappear someday, even if no cure is found. Since its discovery, the ultimate goal of insulin has been to make it disappear, as that would mean diabetes has been cured. It turns out that insulin therapy may indeed disappear someday, even if no cure is found.

Stem-cell therapy has long held promise in diabetes – specifically, making insulin-producing beta cells from stem cells, which the body would either tolerate on its own (perhaps by encapsulating the cells) or through immunosuppressant drugs. Progress has been halting but is now evident. Douglas Melton began his research in this area in 1991, and in 2014, he reported that his lab was able to turn human stem cells into functional pancreatic beta cells. The company that Melton created for the effort was acquired by Vertex Pharmaceuticals, and earlier this year, Vertex announced that it had received approval to begin a clinical trial on a “stem-cell derived, fully differentiated pancreatic islet cell therapy” to treat type 1 diabetes. Another company, ViaCyte, also announced this year that it will begin phase 2 of a clinical trial using encapsulated cells in hopes that they will mature into insulin-secreting beta cells.

It may take 10 to 15 years, but leaders in the field are cautiously optimistic that a cell-based therapy will someday provide a better option than insulin.

Diabetes would survive, but the therapy once touted as its cure would be dead.

Because I have a soft spot for happy endings – and because so much of own life has been intertwined with insulin – I have my own vision for insulin’s last hurrah.

A group of researchers in Europe are conducting a clinical trial to prevent type 1 diabetes. Called the Global Platform for the Prevention of Autoimmune Diabetes, the initiative began in 2015, and researchers are testing newborns who are at risk of developing type 1 to see if prevention is possible.

And what treatment are they using?

Oral insulin.

Like the discovery of insulin itself, this effort is a longshot, but if it works, insulin will have eradicated diabetes – a fitting coda for a medical miracle.

I want to acknowledge the following people who helped me with this article: Dr. Mark Atkinson, Dr. David Harlan, Dr. Irl Hirsch, Dr. David Nathan, Dr. Jay Skyler, and Dr. Bernard Zinman. Some material in this article came from my book, “Cheating Destiny: Living with Diabetes.”

About James

James S. Hirsch, a former reporter for The New York Times and The Wall Street Journal, is a best-selling author who has written 10 nonfiction books. They include biographies of Willie Mays and Rubin “Hurricane” Carter; an investigation into the Tulsa race riot of 1921; and an examination of our diabetes epidemic. Hirsch has an undergraduate degree from the University of Missouri School of Journalism and a graduate degree from the LBJ School of Public Policy at the University of Texas. He lives in the Boston area with his wife, Sheryl, and they have two children, Amanda and Garrett. Jim has worked as a senior editor and columnist for diaTribe since 2006.

Source: diabetesdaily.com

How Your Diet May Make Stress Even Worse (ADA 2021)

By now we’ve all heard that stress has huge effects on our physical health. The scope of the problem may still be surprising.

In a recent presentation at the American Diabetes Association’s annual scientific conference, Wake Forest’s Dr. Carol Shively exclaimed that “Stress accounts for more deaths annually than Alzheimer’s or diabetes.”

Stress is strongly linked to both major illnesses like diabetes, cancer, and heart disease, in addition to other major causes of death, such as accidents and suicide. High rates of stress also help explain why there are such appalling disparities in American health outcomes between the socioeconomically secure and disadvantaged communities.

Stress, which is so often due to factors that are entirely out of our hands, is not easy to alleviate. There are some options, but there may be one other modifiable factor that you haven’t thought much about: your diet.

Dr. Shively believes that diet can have a huge impact on how stress can affect our bodies. If stress and diet interact to create real physiological changes, perhaps the negative effects of stress can be ameliorated with dietary change.

Monkeys and Stress

How do you study chronic stress? Dr. Shively does it with the help of the cynomolgus monkey, or crab-eating macaque.

These monkeys are good experimental analogues to human beings, because their responses to stress, diet, and aging are fairly similar to our own.

Cynomolgus monkeys form linear and stable hierarchies. It is immediately obvious to researchers which monkeys are dominant, and which are subordinate. And scientists can say with some confidence that the subordinate monkeys are more stressed.

Subordinate monkeys are the subject of more aggression, spend more time alone, and spend more time in a state of apparent vigilance than do monkeys higher in the social order. They also receive less grooming, a kind of pampering that relaxes monkeys and lowers their heart rate and blood pressure, just like a nice massage. Physiological indications—such as high cortisol levels—confirm that the subordinate monkeys experience more stress.

Social stress of this sort has an undeniable effect on the physical health of these monkeys. Stress leads to increases in visceral fat and atherosclerosis, just like it does in humans, two significant risk factors for chronic disease and early death.

Two Diets

Dr. Shively wondered if different diets might alter the way that stress impacts the monkey’s metabolism.

In a first study, monkeys were assigned to either the Western diet or a Mediterranean diet. They enjoyed these diets for 31 months – on a human timescale, that would be about 8 years.

These two diets were matched for macronutrients, so monkeys in each group ate about the same amount of protein, fat, and carbs. The composition of those nutrients differed quite a lot, however. The Mediterranean fats were more often plant-based, with a very high percentage of healthy monounsaturated fats, such as olive oil, resulting in a much healthier ratio of Omega-6 to Omega-3 fatty acids. Western carbs were also more likely to come from refined sources, such as high-fructose corn syrup; the Mediterranean carbs were mostly found in fruits and legumes.

The results weren’t surprising. Monkeys on the Western diet ate more food, gained more weight, had higher insulin and triglyceride levels, and had fattier livers than monkeys on the Mediterranean diet. These are similar to the results with humans. The growth of the Western diet, after all, is almost universally seen by experts as a primary cause in the global explosion of obesity and type 2 diabetes. (The two groups of monkeys got the same amount of exercise, by the way.)

The Diet-Stress Connection

When Dr. Shively subjected the monkeys from the two different groups to stress tests, she found that her hypothesis had been confirmed. The monkeys consuming the Western diet got much more stressed, secreting significantly more cortisol in response to social stress.

“The Western diet exaggerates physiological responses to stress, the Mediterranean diet did not.”

A second study split monkeys into two different groups, not by diet, but by stress level. Actually, the monkeys do it by themselves: in any group of four monkeys, two are always dominant, and two subordinate. The subordinate monkeys reliably experience more stress, as explained above.

In this study, all monkeys were fed the same Western-style diet for 3 years. At the end of the study, subordinate monkeys had higher triglycerides, higher fasting glucose, higher levels of circulating insulin, and more insulin resistance than when they began the study. By contrast, the dominant monkeys barely experienced any metabolic change at all, despite eating the same foods.

Nearly 25% of the subordinate monkeys had high enough fasting glucose levels to qualify as pre-diabetic; not a single one of the dominant monkeys had the same condition.

This study suggests that the unhealthy diet was not itself enough to cause metabolic dysfunction—both stress and diet had to be present.

Takeaways

Animal studies always have to be taken with a grain of salt – we can’t generally assume that what happens in the body of a crab-eating macaque will happen quite the same way in our own.

Nevertheless, the similarities between monkey and mankind are striking. Both social stress and the Western diet cause some of the very same negative physiological effects in monkeys as they do in humans.

The diet-stress connection is not far-fetched. While it would be almost impossible to prove a causal relationship in studies of humans, other scientists have already explored the interactions between the Western diet, stress, and metabolism. And there is much work to be done on the topic to tease out causation and correlation and test other dietary approaches.

In the meantime, Dr. Shively’s work may give readers one more reason to set aside the junk food and reach for more wholesome choices. Stress already causes so much metabolic damage—and that damage that may only be compounded by what you eat.

Source: diabetesdaily.com

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