News to Empower You!

IS THERE AN IDEAL WAY TO RECEIVE INSULIN?

Many interesting findings were presented at the 2014 EASD (European Association for the Study of Diabetes) conference. Swedish investigators presented data from patients in the Swedish National Diabetes Registry, looking at data from 1996 until 2014 targeting those using multiple daily insulin injections compared to those using insulin pumps for their daily insulin needs. The data included more than 95 percent of the type 1 diabetes (the diabetes that results from lack of insulin production from the pancreas) Swedish population, comparing 2,441 patients using insulin pumps to 15,727 on multiple daily insulin injections.

Results showed that those on insulin pumps had a 29 percent decrease in mortality rate compared to patients on multiple daily insulin injections. Those on insulin pumps had a 43 percent lower risk of developing heart problems that led to death, compared to those on insulin injections. Overall, both fatal cardiovascular diseases as well as overall death rates were significantly decreased with insulin pump therapy. Why the difference? The study did not reveal an answer, although it is tempting to speculate that perhaps those on insulin pumps might have had less variability in their blood sugars. But this is an area that needs further investigation and support!

What is the take-home message?

Insulin delivered through different methods could have an effect on complications of diabetes. Why and through what means remain unclear. Most individuals who are prescribed the pump go through a vigorous training program, learning to be “insulin experts” during their training. Could this training make the difference? Insulin pump therapy is expensive, thus more answers are needed to help understand the different outcomes from different insulin delivery approaches.

SO MANY TYPES OF SURGERY FOR WEIGHT LOSS–IS THERE A “PERFECT” SURGERY?

When comparing different types of available surgeries for weight loss, is there a best one? Recent study data compared gastric banding to gastric bypass surgery, looking at which approach had the better outcomes specific to long-term weight loss, controlling type 2 diabetes, controlling high blood pressure and lowering cholesterol levels. Final conclusions came from a clinical review of 29 previously published studies describing outcomes for gastric bypass, gastric band or sleeve gastrectomy performed on patients with a body mass index (BMI) ≥35 (calculated as weight in pounds multiplied by 703, divided by height in inches multiplied by itself), comparing the effectiveness of each treatment at two years after the procedure. Specific concerns looked at were how much weight was lost, the effect on blood sugar control in those that had type 2 diabetes mellitus, the effect on high blood pressure (hypertension) and the effect on high cholesterol (hyperlipidemia).

Included were 11 gastric bypass studies, 13 gastric band studies and two sleeve gastrectomy studies in looking at weight loss specifically. The results suggested that more weight loss was achieved with gastric bypass than gastric band surgery.

For type 2 diabetes mellitus, control of diabetes was defined as having an HbA1c <6.5 percent without blood sugar-lowering medication; six studies met this criteria. Type 2 diabetes improvement rates were greater after gastric bypass than gastric band. Gastric bypass also led to better control of hypertension than did gastric band surgery. And cholesterol levels improved more after gastric bypass than gastric band.

What is the take-home message?

Speak with your health care team about your expectations for weight-loss surgery benefits, particularly if you have type 2 diabetes mellitus, hypertension and/or high cholesterol. Then discuss what might be the better surgery type to accomplish your goals. These study comparisons were made, however, at just two years post-procedure. What is needed is data at 20 or more years after the procedure to really know what the differences between each surgical approach might be. Stay tuned!

MEDICAL COSTS ARE RISING; IS THERE ANYTHING I CAN DO TO BRING MY COSTS DOWN?

We are all watching our healthcare dollars taking a bigger bite out of our budget. Is there anything that can be done to stop this increase? Well, yes! Dieting and increasing physical activity can reduce healthcare costs among overweight people with diabetes, according to recent study findings. A study evaluating 5,121 obese and overweight people aged 45 to 76 years with type 2 diabetes was done to determine the impact of an intensive lifestyle intervention compared to those having more traditional diabetes support and education.

Overall, 15 percent of participants were overweight (BMI 25-29.9 kg/m2) and 22 percent had a BMI ≥40 kg/m2. Those in the intensive lifestyle group had 11 percent fewer hospitalizations per year compared with the standard control group. Also, annual average days in the hospital were 15 percent lower among the intensive lifestyle group, as were annual rehabilitation/ long-term care needs and home care. Prescription medication use was also lower among members of the intensive lifestyle group. The annual cost of healthcare services and medications was seven percent less among the intensive lifestyle group as compared to the standard group. The fewer hospitalizations and shorter hospital stays resulted in an average savings of $5,280 per-person costs over a 10-year period among the intensive lifestyle group.

What is the take-home message?

Aiming for an approximate seven percent weight loss from baseline weight and about 20-30 minutes of exercise daily can save you money if you have type 2 diabetes and are overweight! Note that these are modest goals. Pass up the pumpkin pie at Thanksgiving!

INSULIN: GOOD OR BAD FOR THE HEART?

There has long been a controversy as to whether insulin is good for the heart or not. News from the EASD suggests there is no increased risk for heart attacks or other vascular events from prolonged use of insulin in people with prediabetes or type 2 diabetes.

The ORIGINALE (Origin and Legacy Effects) study showing ongoing results from an additional 2.5 years of follow-up of more than 8,000 individuals who participated in the original ORIGIN (Outcome Reduction with an Initial Glargine Intervention) study showed no harmful effects on the heart nor any increase in cancers. Fish oil supplements or omega-3 fatty acid supplementation use was also found to have no protective benefit from heart disease.

There was a trend of less development of new diabetes among insulin-treated prediabetes patients than in the no insulin group.

What is the take-home message?

While insulin did not protect from developing heart disease, insulin did not increase the risk of developing heart disease. Nor did it increase the chance of developing cancer. If your endocrinologist prescribes insulin, use it!

Dr. Dace Trence is Director of the Diabetes Care Center and Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the American College of Endocrinology Board of Trustees and chairs the CME Committee and is also chair of the AACE Publications Committee.