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Re: Diabetes news for spring 2019

ichigan Medicine - University of Michigan
Summary:
Vaccinating babies against a virus that causes childhood 'stomach flu' greatly reduces their chance of getting so sick that they need hospital care, a new study shows. But the study also reveals a surprise: Getting fully vaccinated against rotavirus in the first months of life is associated with a lower risk of developing Type 1 diabetes later on.
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Vaccinating babies against a virus that causes childhood "stomach flu" greatly reduces their chance of getting so sick that they need hospital care, a new study shows.

But the study also reveals a surprise: Getting fully vaccinated against rotavirus in the first months of life is associated with a lower risk of developing Type 1 diabetes later on.

As a group, children who received all recommended doses of rotavirus vaccine had a 33 percent lower risk than unvaccinated children of getting diagnosed with type 1 diabetes -- a lifelong disease with no known prevention strategies or cure.

A team from the University of Michigan made the finding using nationwide health insurance data, and published their results in the journal Scientific Reports.

The study provides strong post-market evidence that the vaccine works. Children vaccinated against rotavirus had a 94 percent lower rate of hospitalization for rotavirus infection, and a 31 percent lower rate of hospitalization for any reason, in the first two months after vaccination. Rotavirus hits infants and toddlers hardest; it can cause diarrhea and vomiting that can lead to dehydration or loss of fluids.

Yet the study finds more than a quarter of American children don't get fully vaccinated against rotavirus, and that the rate varies widely across the country. Less than half of children in New England and Pacific states were fully vaccinated. Two-thirds of children in the central part of the country were fully vaccinated.

The Centers for Disease Control and Prevention recommends that infants receive the multi-dose vaccine starting no later than 15 weeks, and finish receiving it before they are eight months old. Infants receive the vaccine in oral drops.

Type 1 diabetes relationship

The paper's authors, led by epidemiologist Mary A.M. Rogers, Ph.D., caution that they cannot show a cause-and-effect relationship between rotavirus vaccination and Type 1 diabetes risk.

"This is an uncommon condition, so it takes large amounts of data to see any trends across a population," says Rogers, an associate professor in the U-M Department of Internal Medicine. "It will take more time and analyses to confirm these findings. But we do see a decline in Type 1 diabetes in young children after the rotavirus vaccine was introduced."

The new result echoes the findings of a study of Australian children published earlier this year, which found a 14 percent reduced risk of Type 1 diabetes after the rotavirus vaccine was introduced in that country. That study, and the new one, suggest that a childhood vaccine may lead to a lower risk of a later chronic condition.

It also fits with laboratory studies showing that rotavirus attacks the same kind of pancreas cells that are affected in people with Type 1 diabetes.

The death of insulin-producing cells, called beta cells, means people with Type 1 diabetes depend on injections of insulin, and multiple daily checks of their blood sugar, for life. If the condition is not managed well, people with Type 1 diabetes may develop problems with their kidneys, heart, eyes, blood vessels and nerves over time.

Data-driven discovery

The U-M team used anonymous insurance data from 1.5 million American children born before and after the modern rotavirus vaccine was introduced in 2006. In nearly all cases, the vaccine was free, with no copayment, to the family of the infant. The total lifetime cost of caring for an individual with Type 1 diabetes has been estimated in the millions of dollars.

The risk was especially lower among children who received all three doses of the pentavalent form of the vaccine than those who received two doses of the monovalent form. The pentavalent rotavirus vaccine protects against 5 types of the rotavirus while the monovalent vaccine protects against 1 type.

Children partially vaccinated -- that is, started the vaccine series but never finished it -- did not have a lower risk of Type 1 diabetes.

More than 540,000 of the children in the study and born after 2006 received the complete series of rotavirus shots; nearly 141,000 received at least one dose, and more than 246,000 did not.

Another comparison group, born in the five years before the vaccine was available, included nearly 547,000 children.

In absolute terms, Rogers and her colleagues report that eight fewer cases of Type 1 diabetes would be expected to occur for every 100,000 children each year with full vaccination.

Type 1 diabetes, once called "juvenile diabetes," only affects a few children out of every 100,000, so having such a large pool of data can help spot trends, says Rogers, an epidemiologist who worked with internist Catherine Kim, M.D., M.P.H. and statistician Tanima Basu, M.S. Rogers and Kim are members, and Basu is a staff member, of the U-M Institute for Healthcare Policy and Innovation, which provided the data used in the study.

"Five years from now, we will know much more," says Rogers. "The first groups of children to receive the rotavirus vaccine in the United States are now in grade school, when Type 1 diabetes is most often detected. Hopefully, in years to come, we'll have fewer new cases -- but based on our study findings, that depends upon parents bringing in their children to get vaccinated."

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Materials provided by Michigan Medicine - University of MichiganNote: Content may be edited for style and length.

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Re: Diabetes news for spring 2019

A mum has volunteered her baby to take part in a medical trial she hopes will protect the youngster from diabetes.

Chloe Phippard's five-month-old daughter Ava will take a daily dose of insulin powder to see if it can prevent children developing the condition.

The trial will explore if the immune system can be trained to tolerate the body's own insulin to prevent onset of type 1 diabetes.

Mrs Phippard said the trial "could give her a chance at living a normal life".

Type 1 diabetes means the body stops producing insulin, causing glucose levels in the blood to become too high.

It can be life-threatening and even with treatment can lead to blindness, cardiovascular disease and strokes.

I

A linked study found Ava had a genetic risk of the condition, which her five-year-old sister Amelia was diagnosed with aged two.

"I cried when I found out about the risk because I knew what Amelia had gone through and I didn't want Ava to go through that as well," said Mrs Phippard, from Milton Keynes.

  •  

Amelia's diagnosis came as a shock to Mrs Phippard, 24, and her husband Carl, 28, as they had no family history of diabetes.

 
 

She now has insulin administered through a wearable device and a tube placed under her skin.

"She's never going to live a life without diabetes and it's all she's ever known," said Mrs Phippard.

Image copyright Chloe Phippard Image caption Five-year-old Amelia Phippard wears a device to measure her blood sugar levels and deliver insulin

The Primary Oral Insulin Trial hopes to sign up 100 babies at increased risk in Berkshire, Buckinghamshire, Milton Keynes and Oxfordshire to take part in the trial.

Participants will be given an insulin powder or placebo until the age of three, and will be monitored for six years.

About 1% of children have genes which put them at high risk, meaning they have a greater than 10% chance of developing type 1 diabetes.

In the UK, the study is being led by the University of Oxford, with support from the National Institute for Health Research.


Diabetes

There are two main types of diabetes:

  • Type 1 - where the pancreas does not produce any insulin
  • Type 2 - where the pancreas does not produce enough insulin or the body's cells do not react to insulin

Type 1 diabetes can develop at any age, but usually appears before the age of 40, particularly in childhood.

About 10% of all diabetes is type 1, but it is the most common type of childhood diabetes, so it is sometimes called juvenile diabetes or early onset diabetes.

 

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Re: Diabetes news for spring 2019

Is potato starch LCHF? Could it lower your blood sugar? Incredibly enough, the answer seems to be “yes” – if you don’t heat it.

The latest hot trend on health blogs is resistant starch. It seems to have positive effects on blood sugar, especially in type 2 diabetics. Perhaps it also makes you feel fuller and more satisfied, which could facilitate weight loss.

Even more speculative is that it may improve overall gut health, which potentially could be beneficial for those with an autoimmune condition.

It all sounds strange when you first hear about it. How can starch improve blood sugar – isn’t starch broken down to glucose, which raises blood sugar?

How it works

The beauty of resistant starch is that it doesn’t break down to glucose. It isn’t broken down at all in the body, but instead it becomes food for the gut microbiome in the colon. The gut bacteria digest the resistant starch into short-chain fatty acids, which are absorbed by the body.

Therefore, resistant starch will not act as a carbohydrate. Instead, it is food for gut bacteria and what your body absorbs has been converted into fat.

Resistant starch is in reality LCHF – low carb, high fat – with food for the gut flora as a bonus.

Feeding the good gut bacteria – and the cells of the intestinal lining – seems to be able to affect hormone levels in the body (GLP-1 etc.), that in turn has an effect on blood sugar regulation and insulin sensitivity.

It seems also to be beneficial to ensure that gut bacteria and cells get adequate nutrition. Our ancestors no doubt did so, as there are plenty of sources of resistant starch in nature.

Do you want to try getting more resistant starch?

What to do

The easiest way to eat a lot of resistant starch – free from regular starch – turns out to be cold potato starch. Not very yummy, but a couple of tablespoons stirred in water, per day, seems to be enough for a positive impact.

It may be wise to start with less and increase gradually to reduce the risk of a side effect: gas. Also note that you shouldn’t heat the potato starch – then it will be converted to regular starch that raises your blood sugar.

Those who are not carbohydrate sensitive – for example lean, healthy, exercising people – have more possibilities:

  • Resistant starch – along with plenty of regular starch – are found for example in beans, lentils and peas.
  • A lesser portion of the starch in a boiled potato or boiled rice is converted to resistant starch if it’s allowed to cool before being eaten.
  • Raw potatoes or green, unripe bananas are also possibilities.

Conclusion

Resistant starch is a special form of fibre. It doesn’t raise blood sugar, but is converted to fat in the colon, while feeding good gut bacteria and the cells of the intestinal lining of your colon.

This may lead to positive effects on hormones from your gut. At least for some people it may improve blood sugar regulation. It may also provide more satiety and could potentially facilitate weight loss.

Especially for type 2 diabetics it’s well worth trying. Many people have reported improved blood sugar levels.

Future science and experience will lead to more knowledge about who will benefit from resistant starch and how to best take it. Today, knowledge is still limited and it’s a good idea to try for yourself and see what effect you get.

 

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Re: Diabetes news for spring 2019

If your love of ribeye knows no bounds, perhaps you’d be interested in the carnivore diet. The rules are simple—eat only meat—and the purported benefits seem boundless. More energy. Less body fat. You can even cure your Lyme disease, depression, and rheumatoid arthritis.

Or at least, so say the proponents of the carnivore diet, including Shawn Baker, a former orthopedic surgeon who has been one of the biggest public advocates for consuming only meat. Other high-profile members of the carnivore club (or “tribe” as they call themselves) include Canadian psychologist Jordan Peterson and his daughter Mikhaila. You can read about all the miraculous, really-too-good-to-be-true benefits of gorging yourself daily on pork chops on any number of pro-meat websites, but it’s also spreading out to other areas of media. Instagram. Medium. Facebook. The internet is even more of a sausage fest than usual.

All of these posts claim a scientific basis for their suggestions, so we thought we should take a look at what the evidence really has to say. After all, Shawn Baker had his medical license revoked in 2017 in part for “incompetence to practice as a licensee”, Mikhaila Peterson has absolutely no scientific or medical qualifications, and while her father may be a psychologist, he has no training in nutrition.

What makes their testimonies compelling isn’t really their qualifications, though, it’s their conviction. These are real people who are earnestly saying that switching to a carnivorous diet helped them live better lives. Mikhaila Peterson reportedly had arthritis—now she doesn’t (or at least, she thinks she doesn’t, and that’s really what counts when it comes to pain management). Shawn Baker says he had tendinitis and now says he’s cured. Both say they feel less sluggish. Both say their workouts have improved. It’s tempting to believe them. They say things like “meat contains all the nutrients you need” and “carbs are bad for you” that sound an awful lot like they could be true.

But are they? Let’s start with the question of nutritional content.

There Are Some Nutrients You Just Can’t Get From Meat

You need 13 vitamins in order to live, and though you can actually get most of them from eating a variety of meats, you’re going to miss out on some crucial ones if you totally forego flora. Folate, along with vitamins C and E, pretty much only come from veggies, mostly green leafy ones and citrus. This is why sailors used to get scurvy—not enough vitamin C in their largely fish- and other-meat-based diets. Plus, if you don’t get enough vitamin E your body can’t use vitamin K as well, so even though you’re getting enough from fish, liver, and beef you won’t actually be able to make use of it.

And then there’s the issue of fiber. Meat has no fiber, yet we know that fiber is crucial to a healthy diet. It promotes a diverse, robust microbiome in your intestines, and your microbiome seems to impact everything from your basic digestion to your immune system to your mood. You need fiber, and meat can’t give it to you.

Many proponents of protein-dense diets like this point to cultures that have historically eaten mostly or entirely meat. If they can be healthy, why can’t we? Take the Inuit, for instance, who almost exclusively eat very fatty meats (though they supplement with berries in the short-lived summer). They’re healthy on a diet of blubber and liver. But as it turns out, the Inuit stay healthy because they eat a wide variety of meats, most of which fad-dieters are not consuming. They stave off scurvy by feasting on collagen-rich, vitamin-C-dense whale skin and other fresh, uncooked meats. And the flesh they consume often isn’t mostly protein—it’s about 50 percent fat, much of which is of the healthier, unsaturated variety. The meat you buy in a grocery store is largely saturated fat, since that’s the kind that develops on animals who get little exercise and eat mostly corn.

You could, arguably, take supplements for all of the deficiencies that eating only farm-raised animals brings on. Many of the diet proponents, including all of the people mentioned earlier in this article, do not promote taking supplements because they believe that meat is nutritionally complete. But if you were being smart about it you could certainly improve the diet by adding vitamin pills and fiber powder. Neither of these is as good as getting those nutrients from real, whole foods, but it’s better than nothing.

Red Meat is Problematic For Your Colon and Your Heart

Eating lots of red meat has long been linked to colorectal cancer, along with pancreatic and prostate cancers to a lesser degree. The World Health Organization report on red meats supported that link and backed it up with evidence that, when cooked at temperatures exceeding 300°F, flesh produces certain chemicals that are carcinogenic.

Animal meat also tends to push the balance of our good and bad cholesterol (called HDL and LDL, respectively) toward the bad end. You want more HDL and less LDL, along with low levels of triglycerides. Fatty red meats do the opposite: they raise your LDL and triglycerides while lowering your HDL.

Nutritionists like Teresa Fung, who also served on a panel of experts evaluating diets for U.S. News & World Report, are scared by the levels of animal fat even in diets that involve less than 100-percent meat intake, like keto. Blood cholesterol levels rise quickly, but she says “cardiovascular risks don’t rise in a matter of months.” Instead, they build more insidiously over a long period of time, which can be especially problematic if you’re not starting from a good baseline. “High blood cholesterol for a few months isn’t going to be an issue, especially if you have healthy arteries, but for someone who already has atherosclerosis you don’t want to push it.”

Again, you could try to combat this by eating less red meat and opting for healthier options, like lean poultry and fish, both of which have more nutrients than beef and seem to generally be better for you. Organ meats from all sorts of animals have plenty of vitamins, which can also help supplement your diet in small quantities. But if all you ever eat is meat, eating just fish and chicken could get pretty monotonous.

If You’re Eating Only Meat, You’re Probably Taking in Fewer Calories

This is, most likely, why you lose weight on any diet. Give someone rules that alter their eating habits, especially really strict ones that make it hard to find random things to snack on throughout the day, and they’ll probably end up consuming less overall. Protein is an especially satiating food, so the calories per meal will be much lower than any in which you consume carbs.

If you’re looking to lose weight, cutting calories is obviously a good thing, but you need to do it in a sustainable way. Studies consistently show that most people lose 5-7 pounds per year on a new diet, regardless of the nutritional composition, and that most gain that weight back later. Nutritionists instead advise that you pick a way of eating that you can maintain for life. “Eating is a lifestyle,” Fung says. “It’s not the kind of thing where you get to where you want and then just stop.”

But Don’t Eat Only Vegetables Either

Pretty much any extreme diet is going to be problematic. Fruit may be good for you, but if all you ever ate was fruit you’d end up with serious nutritional deficiencies. Even vegans, who generally still eat a diverse group of foods, have trouble getting certain nutrients like vitamin B12, which our bodies aren’t very good at absorbing from plant sources.

It’s not flashy, but panels of experts consistently recommend consuming a wide variety of foods, all in moderation. And yes, that can include meat. But you should sneak yourself a few veggies in there when you can.

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Re: Diabetes news for spring 2019

 A case for walking...  it is too long to bring it over

 

 

https://elemental.medium.com/the-case-for-walking-431b82f1eaa9

 

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Re: Diabetes news for spring 2019

pt 3

 

Endocrinology Advisor: What are additional takeaways for clinicians, remaining research needs in this area, or any other points you would like to mention about the topic?

Dr May: Unfortunately, the current weight-focused paradigm makes it difficult for clinicians to see beyond weight loss as a treatment. Given that weight loss is not a sustainable intervention and did not reduce cardiovascular complications in the Look AHEAD trial,12 shifting the focus to other behaviors proven to improve diabetes management and decrease complications is a better use of time and resources. In a 2017 paper regarding the Look AHEAD trial, the author stated that it is “important to avoid prioritizing weight loss as a primary goal of treatment and instead to shift attention to improving blood glucose levels and reducing diabetes-related complications.”13

Ms Paulsen: Providing diabetes care in a weight-neutral manner is about treating patients as partners in the management of their health. So many patients feel the stigma of having a larger body and may avoid medical care because of this. We as clinicians can be that “soft place to land” for our patients, where they can feel empowered to manage their disease instead of fighting their weight. The change in the patient’s perspective can often been seen immediately when they are cared for in a weight-neutral manner. Patients often become more engaged in their health care as a result.

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References

• Centers for Disease Control and Prevention. Childhood Obesity Facts. Prevalence of Childhood Obesity in the United States. https://www.cdc.gov/obesity/data/childhood.html. Updated August 13, 2018. Accessed May 3, 2019.
• Centers for Disease Control and Prevention. Adult Obesity Facts. Obesity is common, serious, and costly. https://www.cdc.gov/obesity/data/adult.html. Updated August 13, 2018. Accessed May 3, 2019.
• Centers for Disease Control and Prevention. Prevalence of Both Diagnosed and Undiagnosed Diabetes. https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed.html. Updated February 2, 2018. Accessed May 3, 2019.
• Sabin JA, Marini M, Nosek BA. Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS One. 2012;7(11):e48448.
• Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.
• Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233.
• Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity. 2006;14(10):1802-1815.
• García-Mayor RV, García-Soidán FJ. Eating disorders in type 2 diabetic people: brief review. Diabetes Metab Syndr. 2017;11(3):221-224.
• Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10(1):9.
• Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad Nutr Diet. 2015;115(9):1447-1463.
• Miller CK, Kristeller JL, Headings A, Nagaraja H. Comparison of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a randomized controlled trial. Health Educ Behav. 2014;41(2):145-154.
• Wing RR, Bolin P, Brancati FL, et al; the Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369(2):145-154.
• Salvia MG. The Look AHEAD trial: translating lessons learned into clinical practice and further study. Diabetes Spectr. 2017;30(3):166-170.

Additional recommended resources:

www.haescurriculum.com

www.intuitiveeating.org

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Re: Diabetes news for spring 2019

pt 2

 

he Case for Weight-Neutral Diabetes Care: Part 1


Tori Rodriguez, MA, LPC

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Holly Paulsen, RD, LD, CEDRD-S: Research supports a strong correlation between diabetes and disordered eating. Some studies indicate that up to 40% of patients with T2D meet criteria for an eating disorder.8 The promotion of intentional weight loss and restrictive eating plans (ie, diets) as treatment for diabetes may actually increase the occurrence of eating disorders in this population.

Disordered eating is incompatible with optimal blood glucose control. Continued attempts at dieting and weight loss often lead to weight cycling, or periods of weight loss followed by weight gain. Weight cycling in itself can have metabolic consequences, with some studies finding increases in mortality and morbidity correlated with such practices.9

Endocrinology Advisor: What are the reasons that clinicians should move toward weight-neutral care for these patients?

Dr May: A weight-neutral or weight-inclusive approach aligns the clinician and patient toward effective and sustainable behavior changes. A systematic review and meta-analysis published in 2015 concluded that “weight loss for many overweight or obese individuals with type 2 diabetes might not be a realistic primary treatment strategy for improved glycemic control. Instead, nutrition therapy for individuals with T2D should encourage a healthful eating pattern, a reduced energy intake, regular physical activity, education, and support as primary treatment strategies.”10

Ms Paulsen: When we continue to characterize weight loss as a ‘behavior’ and use this as our focus for treatment, we are failing to acknowledge that there are only a very small percentage of individuals who can maintain weight loss in the long term.

Shifting the focus from weight-centered care to encouraging behaviors the individual can control such as regular eating, balanced meals, enjoyable exercise, and attention to overall emotional well-being has been shown to improve glucose levels.

We can promote good health and management of diabetes without focusing on restrictive eating and weight loss. Patients can benefit from realizing that their health is more than just a number on a bathroom scale. This approach is freeing for the patient, as it reduces their disease burden and the shame and hopelessness that often follow unsuccessful attempts at weight loss.

Endocrinology Advisor: What does this approach look like in practice, and what are your recommendations for those who are interested in offering or learning more about weight-neutral diabetes care?

Dr May: Weight is not a behavior! Rather than recommending futile and repeated weight loss attempts for diabetes self-management, the clinician who is weight inclusive will choose to focus on implementing evidence-based interventions such as physical activity, balanced eating, glucose monitoring, medication adherence, preventive care, problem solving, developing support, and other skills and behaviors for diabetes self-management. Whether the patient loses weight or not, these behaviors improve glycemic control.

Ms Paulsen: A weight-neutral approach in diabetes education and counseling encourages patients to engage in specific behaviors that promote health, independent of weight changes. The focus would be on scheduling regular medical appointments, taking medication as prescribed, monitoring blood sugars if appropriate, employing strategies for managing stress, eating balanced meals, and engaging in regular physical activity.

The nutrition piece of weight-neutral care strives to empower the patient to eat regularly and balancing macronutrients when possible. With mindful eating or intuitive eating approaches to diabetes management, the individual is ultimately following internal signals of hunger, fullness, and satisfaction with food choices to guide eating.11 These methods reduce restrictive eating that often fuels disordered eating and binge eating in particular.

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Re: Diabetes news for spring 2019

Weight neutral  diabetes care  Pt 1

 

 

Some experts propose that an emphasis on healthy behaviors rather than on weight loss may be a more effective approach to limit diabetes progression and manage disease symptoms.
The number of people in the United States who are considered to be overweight or obese has increased along with the prevalence of diabetes. According to the Centers for Disease Control and Prevention, the prevalence of obesity in 2015 to 2016 was 18.5% in children and adolescents and 39.8% in adults, and the prevalence of diabetes in 2015 was 9.4% for the total US population.1-3

While these parallel trends are often viewed as being closely linked, there is no definitive evidence that a high body mass index (BMI) causes type 2 diabetes (T2D) or that weight loss is an effective strategy for long-term diabetes management in all patients. In addition, studies have shown that weight stigma — which has been found to be highly prevalent among physicians4 — is associated with a greater risk for negative health outcomes and mortality than a high BMI, and a focus on weight can reinforce and promote this stigma (see “Is Weight Stigma Worse Than Obesity? How to Provide More Compassionate Care”). Nonetheless, the goal of weight loss is a key component of treatment plans for many patients with T2D.

Some experts propose that an emphasis on healthy behaviors rather than on weight loss may be a more effective approach in helping people with diabetes limit disease progression and manage symptoms, while also supporting their mental health and reducing weight stigma. To learn more about this view and related research findings, Endocrinology Advisor checked in with several proponents of weight-neutral diabetes care.

Below are interviews with Michelle May, MD, founder of Am I Hungry? mindful eating programs and coauthor of Eat What You Love, Love What You Eat with Diabetes: A Mindful Eating Program for Thriving with Prediabetes or Diabetes, and Holly Paulsen, RD, LD, CEDRD-S, a certified eating disorders registered dietitian at Jones Regional Medical Center in Anamosa, Iowa. Part 2 of this article will feature an interview with Megrette Fletcher, MEd, RD, CDE, diabetes educator, and Dr May’s coauthor of the book mentioned above. Ms Fletcher is also cofounder of The Center for Mindful Eating and a partner in the Weight Neutral 4 Diabetes Care Symposium, an online conference for healthcare professionals.

Endocrinology Advisor: What are some of the problems associated with the current weight-focused approach to diabetes care?

Michelle May, MD: The association between higher weight and diabetes is just that — an association. While BMI is correlated with certain conditions, available data cannot confirm that BMI causes these diseases. Causality can only be inferred by experimental design.5 There are many other factors that may explain or partially explain the link, including insulin resistance, social determinants of health, weight stigma, exercise, and nutrition, to name just a few.

Diabetes is a chronic condition that requires a sustainable approach to self-management, and weight loss is not a sustainable intervention. A review of 31 long-term studies on dieting found that the majority of individuals are unable to maintain weight loss over the long term and one-third to two-thirds of dieters regain more weight than they lost. The authors concluded that “…there is little support for the notion that diets lead to lasting weight loss or health benefits.”6

Another review of weight loss studies concluded that no weight loss initiatives to date have generated long-term results for the majority of participants. At best, only 20% of participants maintain weight loss at 1 year after completing a weight-based lifestyle intervention, and the percentage of those maintaining weight loss decreases further by the second year.5

Related Articles

• Low Serum Cholesterol Levels May Worsen Peripheral Nerve Damage in Type 2 Diabetes
• Effect of Behavioral Weight Loss Intervention on Neural Food Cue Reactivity
• Mediterranean Diet Adherence Supports Cognitive Function in Type 2 Diabetes

In addition, the most common outcomes of a weight-focused approach are yo-yo dieting and weight cycling, disordered eating, and weight stigma:

• Yo-yo dieting: Patients with diabetes who yo-yo diet may vacillate between hyperglycemia and hypoglycemia, making diabetes more difficult to manage and contributing to diabetes distress.
• Disordered eating: Obsessively measuring and logging food intake, preoccupation with body size, and/or a hyperfocus on exercise distracts individuals from self-care and living their lives fully.
• Weight stigma: In a survey of nearly 2500 patients, 53% reported inappropriate comments from doctors about their weight. They also reported experiencing stigma from nurses (46%), dietitians (37%), and mental health professionals (21%).7

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Re: Diabetes news for spring 2019

WEDNESDAY, June 5, 2019 (HealthDay News) -- Type 2 diabetes is a known risk factor for heart disease, and researchers thought that five years of really tight blood sugar control might reduce the risk of heart disease for years to come.

But a new 15-year follow-up study found that was not the case. The findings suggest it might be more important to control other risk factors for heart disease, such as high blood pressure, cholesterol and unhealthy weight.

"Glucose-lowering has a modest benefit, but it's not enough by itself. We need to address all the other cardiovascular risk factors," said the study's lead author, Dr. Peter Reaven. He's a staff physician at Phoenix Veterans Affairs Health Care System, in Arizona.

 
 
 

Reaven emphasized that these findings apply to this particular population -- people who had type 2 diabetes for more than 10 years on average before the study began. Their average age was around 60, and the study group was nearly all men.

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So it's not yet clear what the results might be if a blood sugar-lowering intervention was started soon after diagnosis with type 2 diabetes. It's also not known if these findings apply to people with type 1 diabetes.

The initial phase of the study included almost 1,800 people. They were randomly selected to receive either standard diabetes treatment or intensive blood sugar-lowering treatment.

Both groups received the same medications. The difference was in the dosing. People in the intensive group were given enough medication to lower their hemoglobin A1C levels below 7%. Hemoglobin A1C is a blood test that provides an estimate of average blood sugar levels.

 

An A1C of under 5.9% is considered normal. Researchers aimed to get the intensive treatment group to below 7%. Reaven said the initial average A1C of the whole group was about 9%.

During the intervention part of the study, the group getting usual care lowered their A1C to 8.4%. The intensive group had an average A1C of 6.9%. The intervention lasted nearly six years.

Approximately 10 years after the study began, the researchers found a 17% drop in the risk of heart disease and stroke.

"We wanted to learn if there was a continued benefit, a 'legacy' effect," Reaven explained. And, at least in the short-term, it appeared there might be.

But the 15-year follow-up found no statistically significant difference in the rate of heart attacks and strokes, or deaths.

"This was a fairly definitive assessment, and in this group of older type 2 diabetes patients, there's no evidence of a legacy effect," Reaven said. "Our data suggests that for glucose-lowering to have continued benefit, it must be sustained."

Since the intervention portion of the study was done, newer medications -- some that have specifically been shown to reduce the risk of heart disease -- have been introduced for type 2 diabetes. It's not clear what the long-term effect of these medications might be, or if these newer drugs have a legacy effect.

Results of the study were published June 6 in the New England Journal of Medicine.

Dr. Kasia Lipska from Yale School of Medicine is co-author of an editorial in the same issue of the journal.

"We've learned over time that how you lower blood glucose matters when it comes to cardiovascular risk. With newer medicines that have different mechanisms of action, the benefits for cardiovascular disease are pretty quick," she said.

But she said that controlling other risk factors for heart disease and stroke is crucial. "Very tight control of glucose for cardiovascular disease is not the best way to reduce risk. Avoiding smoking, blood pressure control, statin therapy [to lower cholesterol] are known to reduce cardiovascular disease risk," Lipska said.

That doesn't mean that controlling blood sugar isn't important, it is. But there needs to be a balance. People shouldn't be trying to lower their blood sugar so much that they end up having a dangerous low blood sugar episode.

"Patients need to have a conversation with their doctor about what is right for them," she advised.

Dr. Gerald Bernstein is program coordinator at Lenox Hill Hospital's Diabetes Institute, in New York City. He pointed out -- as did the study authors -- that widespread use of blood pressure and cholesterol medications may have affected the potential benefits from lowering blood sugar. He said this study's findings shouldn't change current blood sugar management.

"The upshot is, control of blood glucose is better than not," Bernstein said.

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Re: Diabetes news for spring 2019

A group of adults with type 1 diabetes that have not needed insulin for an average of 10 years and are maintaining near normal blood glucose thanks to islet cell transplantation, a new study shows.

Islet transplantation is where isolated islets - groups of insulin-producing beta cells from the pancreas - from a donor are transplanted.

Researchers from University of Miami's Diabetes Research Institute used continuous glucose monitoring to track the performance of the transplants in five people with type 1 diabetes.

The results showed trends in glucose level control, which were near normal, as well as close to perfect time-in-range metrics.

The participants were given islet transplants into the liver (intrahepatic islet transplant) from 2002 and 2010 and were then insulin independent for between seven and more than 16 years.

Researchers carried out a seven-day assessment with the participants wearing continuous glucose monitors to assess glucose levels during the follow up. The glucose level data was compared to that of adults with type 1 diabetes who had not had the transplants but were using the latest diabetes technology (a hybrid closed-loop system) to help control their diabetes as well as possible.

The results of the comparison showed that each one of the participants that had a transplant demonstrated an improvement in time-in-range glucose levels as well as less variability in glucose levels and lower exposure to low glucose levels (hypoglycemia).

The participants were chosen as those who had achieved excellent success following transplantation. While these participants have achieved exceptional results, staying free from insulin injections for many years is not a guaranteed result of islet cell transplants. Many people undergoing the transplant need to start taking some exogenous insulin (insulin that is not produced by the body itself) again after months or years, depending on personal circumstances.

One of the lead researchers on the study, Dr David Baidal said: "Using continuous glucose monitoring, we now have the ability to accurately evaluate patients' glucose profiles and their variability. The CGM data we have obtained from our islet transplant patients clearly demonstrates that islet transplantation can result in glucose levels that are close to those in people who do not have type 1 diabetes, even 10 years or more after undergoing the cell-replacement procedure."

Dr Camillo Ricordi, who is a Joy Goodman Professor of Surgery as well as the director of the Diabetes Research Institute, has been named as the world's top islet transplantation researcher. Commenting on the study, he said: "This report confirms the superiority of transplantation of insulin-producing cells compared to insulin therapy, with glucose control results that were even better than the goals of CGM in hybrid closed-loop systems.

"Hopefully, this will be of assistance in bringing islet transplantation closer to FDA approval, allowing the treatment to be made available to US patients, as has already been the case in several other countries, for many years."

The results of the study were shared at the American Diabetes Association's 79th Scientific Sessions, which took place in San Francisco between June 7 and 11. They will also be presented at the 17th World Congress of the International Pancreas and Islet Transplant Association, which will take place in France between July 2 and 5.