When Calamity Strikes: How Diabetics Must Prepare For Emergencies

WHEN weather emergencies or natural disasters strike, millions are often left stranded in their homes without power, utilities, or a way out. Being caught unprepared for these types of situations can be devastating and potentially life-threatening, particularly for people with diabetes who are much more susceptible to illness when forced outside their normal care routine.

The American Association of Clinical Endocrinologists (AACE), currently in session at its 20th Annual Meeting and Clinical Congress in San Diego, has once again urged diabetics to be prepared for any eventuality. No country or community is immune when calamity strikes, it was stressed at a press conference. The recent earthquake and tsunami followed by the Chernobyl-scale nuclear accident in Japan is just one example in the past month.

Earlier, it was one of the most devastating winters in North America in recent history, with snowstorms wreaking havoc across the US causing transportation delays, power outages, and structural damage. And with the tornado season set to start this month, Americans now have another type of weather phenomenon with which to contend.

Indeed, many localized incidents may not find mention in the media, but these too affect diabetics in a big way. So it’s very critical that diabetics prepare for these events and remain ready for any eventuality for medical care and supplies are often in short supply in the aftermath of a natural disaster or weather emergency.

Following the destruction caused by Hurricane Katrina in 2005, theAmerican College of Endocrinology (ACE) and Lilly Diabetes joined forces to assemble an emergency kit for people with diabetes.

Called the Power of Prevention Diabetes Disaster Plan, it is a comprehensive checklist of items for people with diabetes to use in order to prepare for a potential disaster. Since 2005, more than 10 million checklists have been distributed in the United States.

Advanced Planning is the Key
Since diabetics may only have a short bit of time during a disaster, you are encouraged to prepare a portable diabetes disaster kit that is insulated and waterproof. The checklist suggests that diabetics also have:

● Information about their diabetes, including past and current medications, complications and adverse reactions.

● A list of all medications, as well as pharmacy and active prescription information and eligible refills.

● A 30-day supply of diabetes medications, including insulin, oral anti-diabetic agents and a severe hypoglycemia emergency kit.

Download Full List of Recommendations of the Plan

● A cooler and at least four refreezable gel packs for storing insulin, empty plastic bottles and/or sharps containers for syringes, needles and lancets.

● A source of carbohydrates to treat hypoglycemic reactions and a 1- or 2-day food supply that does not require refrigeration.

These are all critical things a diabetic needs to have together to take with them in case of an emergency.

Intensive Diabetes Education Programs Improve Blood-Sugar Control

DIABETICS need information in order to manage their disease; but their knowledge about the facts is still not enough for the behavioral change. What is needed is to find a way to be able to give people the skills to solve their problems in all areas of their lives so that they can be able to start caring for themselves.

One of the most important aspects of diabetes management is educating the patient to manage their condition themselves. This is known as Diabetes Self-Management Education, better known by its acronym DSME. It has been demonstrated by many studies that education works.

A team of researchers at Johns Hopkins University School of Medicine have developed a diabetes education program that significantly improves long-term blood-sugar control among patients by educating low income, poorly educated diabetes patients to be able to manage their disease. Their findings have been published online in the March issue Journal of General Internal Medicine.

The researcher’s premise was that lower socioeconomic status is associated with excess disease burden from diabetes and that diabetes self-management support interventions are needed that are effective in engaging lower income patients, addressing competing life priorities and barriers to self-care, and facilitating behavior change.

Promoting Self-Management is Essential to Properly Treat Type 2 Diabetes
Dividing about 56 participants into two groups, the researchers provided an intensive problem solving course in the first group that lasted more than nine sessions and covered standard diabetes self-management and care. They also include the way in managing financial, social, resource and interpersonal issues that relate to the disease.

The second group received only a solid two-session version of the program.

At the end of the program after three months, those who were in the intensive group showed a fall in hemoglobin levels by an average of 0.7 as compared to the levels they had before the program started. Below 5.7 is considered normal while the target of people with diabetes is below 7. The participants in the two-session group did not see any improvement.

The researchers conclude that literacy-adapted, intensive, problem-solving-based diabetes self-management training is effective for key clinical and behavioral outcomes in lower income patients.

Peer Support Improves Diabetes Self-Management
"We know that people need information to manage their disease, but having knowledge of the facts is not enough for behavioral change," said Felicia Hill-Briggs, an associate professor in the general internal medicine division at the Johns Hopkins University School of Medicine and the study's lead author.

"With this novel approach, we have found a way to give people the skills to solve problems in all areas of their lives so that they can take diabetes off the back burner and start caring for their health."

Another DSME advocate Linda Siminerio, RN, PhD, CDE, director of the University of Pittsburgh Diabetes Institute, and associate professor at the University of Pittsburgh School of Medicine and the School of Nursing points out, “Diabetes self-management education (DSME) should always be considered as part of the treatment plan, even if a patient is reported to have excellent metabolic control.

“Attention to self-care behaviors and psychosocial needs are equally as important as metabolic outcomes when managing a burdensome, chronic disease like diabetes. Active listening, providing accurate information and building a patient’s confidence are all important tools used in diabetes education.

"It is (therefore) essential that physicians and everyone on the diabetes care team work together to support patient self-management by developing patient-centered goals that will be more likely to be achieved.”

New IDF Charter Promotes Rights of People With Diabetes

THE International Diabetes Federation (IDF) today launched the first ever Charter setting out the fundamental rights of more than 300 million people living with diabetes.

The landmark document, which forms part of IDF’s Advocacy Toolkit for the United Nations High-Level Summit on Non-Communicable Diseases (NCDs), places the rights of people with diabetes, their parents and careers into three focus areas: the rights to care; information and education and social justice, whilst at the same time acknowledging the responsibilities held by people with diabetes.

The publication of the International Charter of Rights and Responsibilities of People with Diabetes comes at a crucial time. As the global diabetes epidemic continues to escalate, IDF estimates that the number of people with diabetes will rise to 500 million within a generation, killing 4 million people each year and costing the global economy US$378 billion in health care spending.

Priority Actions for the Non-Communicable Disease Crisis

IDF will use the Charter as a powerful campaigning tool to counteract the discrimination and stigma millions of people with diabetes still face, largely due to ignorance and misconceptions surrounding the disease.

In many parts of the world, this promotes a culture of secrecy that can create barriers to services, employment, and even marriage, and may stop people with diabetes playing an active role in society.

Raising awareness about the rights of people with diabetes is a key element of IDF’s demand for coordinated and concerted international action to tackle the diabetes epidemic before, during and after the UN High Level Summit on non-communicable diseases (NCDs) to be held this September in New York.

“Both children and adults alike are denied both the rights to life and health when their diabetes goes undetected or they lack access to affordable technologies and medicines such as insulin, oral blood glucose lowering agents and other necessary medications” said Sir Michael Hirst, President-Elect, IDF.

“This is a ground-breaking document that gives Governments and organizations clear guidance on what the fundamental rights to life, health and freedom from discrimination mean to people with diabetes. It is a gold standard to which they should aspire.”

Articles contained within the Charter urge governments and public authorities to commit to making health care accessible for all and creating conditions that allow people with diabetes to have as normal a life as possible.

IDF encourages all Governments and organizations to sign-up to and aspire to the Charter principles which underpin the rights to life and health for all people with diabetes

Download the International Charter of Rights and Responsibilities of People with Diabetes (pdf, 2MB)

Charter of Rights FAQ

IDF Advocacy Toolkit

New Guidelines on Best Treatments for Diabetic Nerve Pain

THE American Academy of Neurology (AAN) issued a new guideline yesterday on the most effective treatments for diabetic nerve pain, the burning or tingling pain in the hands and feet that affects millions of people with diabetes.

The recommendations of this guideline will serve as the foundation for a new set of tools the AAN is creating for doctors to measure the quality of care they provide people with nerve pain. The measures will be released in 2012.

The guideline ‒ published yesterday in the online issue of Neurology and presented at the American Academy of Neurology's Annual Meeting in Honolulu ‒ was developed in collaboration with the American Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation.

Nerve pain is different from other types of pain, like pain from a muscle ache or sprained ankle. Common pain medicines like aspirin may not work for nerve pain. Nerve pain is unique and feels different than muscle pain. Since all pain is not the same and nerve pain treatment is different from muscle pain treatment, it’s important to understand the source of your pain.

Unfortunately, nerve pain can be one of the most intense pains that people feel. Diabetic Nerve Pain can make normal daily activities more difficult.

When a person has pain that is caused by nerve damage from diabetes, it is simply called Diabetic Nerve Pain or, to use the medical term, painful Diabetic Peripheral Neuropathy (pDPN). The most common cause of Diabetic Nerve Pain is poorly controlled blood sugar levels. Over time, high blood sugar levels can result in nerve damage. Controlled blood sugar levels may help prevent, stabilize, and delay further nerve damage.

All Eyes on Research That May Provide Cure for DiabeticNeuropathy

According to the guideline, strong evidence shows the seizure drug pregabalin (Lyrica) is effective in treating diabetic nerve pain and can improve quality of life; however, doctors should determine if it is appropriate for their patients on a case-by-case basis.

In addition, the guideline found that several other treatments are probably effective and should be considered, including the seizure drugs gabapentin (Gabarone) and valproate (Depacon), antidepressants such as venlafaxine (Effexor XR), duloxetine(Cymbalta) and amitriptyline (Elavil, Endep) and painkillers such as opioids and capsaicin. Transcutaneous electric nerve stimulation (TENS), a widely used pain therapy involving a portable device, was also found to be probably effective for treating diabetic nerve pain.

"We were pleased to see that so many of these pain treatments had high-quality studies that support their use," said Vera Bril who is with the University of Toronto and a member of the AAN. "Still, it is important that more research be done to show how well these treatments can be tolerated over time since diabetic nerve pain is a chronic condition that affects a person's quality of life and ability to function."

Diabetes: Autonomic Neuropathy Far Worse Than ‘Pins & Needles’ in the Feet

To recap, the most common type of diabetic neuropathy is peripheral neuropathy (burning, throbbing, or painful tingling in your hands or feet). In the early stages of peripheral neuropathy, some people have no signs. Some may have numbness or tingling in the feet. Because nerve damage can occur over several years, these cases may go unnoticed. The patient may only become aware of neuropathy if the nerve damage gets worse and becomes painful.

It is estimated that diabetic nerve pain affects 16 percent of the more than 25 million people living with diabetes in the United States and is often unreported and more often untreated, with an estimated two out of five cases not receiving care.

According to one survey, about 50% of people with diabetes have some form of nerve damage known as diabetic neuropathy; 64% of Diabetic Nerve Pain sufferers report that their pain interferes with the daily activities that matter to them; 71% of sufferers say their pain interferes with the daily activities and makes it hard for them to fall asleep; 49% of diabetics had not had a discussion with their doctor about Diabetic Nerve Pain or its symptoms in the last 12 months and 65% say the pain decreases their general motivation.

In short, Diabetic Nerve Pain may make it hard to do what is needed to manage your diabetes. It can create a cycle where one problem just leads to another problem, which makes the first problem even worse. Pain may make it difficult to stay physically active and focus on other areas of diabetes care.

Diabetic Neuropathy: No Clear Answers

If you are not physically active and focusing on diabetes care, it may be hard to keep your blood sugar levels close to the normal range. In turn, if your blood sugar levels are raised for long periods of time (many months or years), you may be more likely to develop more health problems. This may include more nerve damage. Finally, people with Diabetic Nerve Pain also have more risk for symptoms of depression, which can further lower the drive to focus on the day-to-day parts of good diabetes care.

Most diabetic neuropathy is caused by peripheral artery disease, in which the small blood vessels are obstructed or partially obstructed and cannot carry oxygenated blood to areas of the body. These areas have pain or other difficulties due to the lack of oxygen. Diabetic Nerve Pain may make it hard to do what is needed to manage your diabetes. It can create a cycle where one problem just leads to another problem, which makes the first problem even worse.

With Diabetic Nerve Pain, decreasing your activity level is a problem, making it harder to manage your diabetes. (We all know it’s important to be physically active to keep your blood sugar level under control.) With nerve pain, your nerves repeatedly send extra electrical signals to the brain. These extra signals can cause pain when you do something that is not normally painful, e.g. putting on shoes. If this pain is not properly diagnosed and treated, it can cause difficulties with walking, working, or even being in social situations.

Over time, elevated blood sugar levels could potentially lead to different diabetes complications, like kidney and eye (retinopathy) conditions besides leading to nerve damage, especially in the feet. Therefore annual foot exams are crucial to check for diabetic peripheral neuropathy. Indeed, regular examinations are important because a diabetes patient can have peripheral neuropathy without pain, especially in the early stages of the neuropathy.

To be sure, Diabetic Nerve Pain care is an important part of overall diabetes care. And it is a part you may be able to actively improve. With less pain, you’ll feel better and may even increase your physical activity level. This is a key component of good diabetes care.

If you have Diabetic Nerve Pain, it’s very important to keep your blood sugar levels as close to the normal range as possible. This may help stabilize and prevent further nerve damage. It’s also important to keep your pain under control. Then you may be able to return to activities that are important to you.

Diabetes: The Importance of Exercise in Diabetes Management

Just Six Weeks of Exercise Is Enough to Change Both Brain Chemistry and Body Chemistry for the Better; Diets Alone Don't Have the Same Effect

FOR the person with type 2 diabetes, or the high-risk individual who is trying to prevent the development of diabetes, there is an enormous body of research literature documenting the benefits of exercise. Unfortunately, there is little data on how to motivate patients to maintain a long term healthy regimen.

Research currently being carried out by scientists at the University of Colorado's School of Medicine is investigating why exercise feels more difficult for people suffering from type 2 diabetes than it does for people without the disease.

With a recent study showing that under half of all American (and also in other parts of the world, according to anecdotal evidence) with type 2 diabetes take any regular exercise, and that people who do not have diabetes are actually more likely to take exercise, the team hope to pinpoint the reasons why this is.

If this study is able to confirm findings from previous research that revealed that exercise felt harder for those people with diabetes, then it is hoped it will be possible to design specific exercise programs for people with type 2 diabetes.

Indeed, when you can't move much without discomfort, do-ability is the key to enjoying a workout. Body size is a major factor that is often overlooked. Big-made people can't do 'normal' fitness activities like biking and rowing and weight machines because they're too uncomfortable. Their bodies get in the way. They can't bend over, they don't fit, they can't run, either — the impact hurts their joints. So they give up on exercise before even trying.

Finding a doable exercise is crucial for obese people because movement is often the key that locks in weight loss. Diets come and go, but exercise sticks, and it prompts the lifestyle changes necessary to shed pound and keep them off, according to Dr.James A. Levine, a Mayo Clinic expert on nutrition and endocrinology.

"There are psychological and chemical advantages of moving over eating," Levine says. "A diet is a restriction — by definition unpleasant, to be avoided. But when you move it is something you have done and achieved. Every time you do it, you are winning, and feel good about yourself and want to do it again. You not only burn lots of calories, but may be motivated to make better food decisions."

Research is finding that just six weeks of exercise is enough to change both brain chemistry and body chemistry for the better, he adds. Diets alone don't have the same effect.

Exercise feeds on itself — once you get moving you might not want to stop. It is essential that all people hoping to slim down find some kind of exercise they can look forward to every day. Options that fit the largest bodies can be surprisingly fun, including walking, water running, swimming, and elliptical training (on wheels or in a gym).

Obese or not, physical exercise is important for all of us. Physical conditioning is one of the most important quality of life factors that we can actually improve, thus contributing to a longer and healthier life. Even better, exercise is empowering since each person can control the amount of activity they do to achieve the maximum benefit.

What are the benefits of exercise in people with type 2 diabetes?
A major benefit of exercise is its effect on the heart and the associated reduction in death from heart disease. In addition to lowering the risk of heart disease in type 2 diabetes, exercise helps to decrease the chances of developing diabetes. This can be especially important for those with pre-diabetes.

In one study, the risk of developing diabetes was reduced by 24% (based on an energy expenditure of 2000 calories per week through exercise). This protective effect of exercise was seen the most in the group at highest risk for developing type 2 diabetes.

The mechanism for this benefit is that exercising muscles are more sensitive to circulating insulin. They thus take up blood sugar more easily and use sugar more effectively. Research has shown that even short term aerobic exercise improves the sensitivity of muscles to insulin.

There is a strong association between diabetes and the location of fat in the body. It has been known for a long time that people with increased internal belly fat (the classic apple-shaped person with a round belly versus the pear-shaped person with a heavier deposit of fat around the hips and thighs) have a higher risk for insulin resistance, high cholesterol, and high blood pressure.

This triad of diseases is part of a disorder called ‘Syndrome X’. Interestingly, in some patients who are not overweight by definition, internal belly fat may still be high, as visualized with special imaging tests of the abdomen.

For example, a classic apple-shaped obese person is a Sumo wrestler. However, Sumo wrestlers are physically active and actually have low internal belly fat stores. Therefore, they are rarely afflicted with blood sugar or cholesterol problems!

In addition to its benefits on muscle insulin sensitivity, aerobic exercise also improves blood cholesterol levels and blood pressure control. This benefit occurs regardless of weight loss. In one study, patients with type 2 diabetes on a 3-month exercise program reduced their triglyceride levels by 20%, increased their good cholesterol (HDL) by 23%, and decreased their blood pressure to better levels too!

The benefits of exercise in patients with diabetes, and in those at high-risk for developing type 2 diabetes (and those with Syndrome X), may include the following:

• Reduced heart disease

• Prevention of diabetes in those at high risk

• Improved muscle sensitivity to insulin

• Better blood sugar control

• Better blood cholesterol profiles

• Better blood pressure control

• Potential weight loss

• Improved general sense of well being

Though exercise is an important part of managing diabetes in general, like everything else it's not quite black and white. In certain situations, patients with diabetes should approach any exercise regimen with caution.

Additionally, exercise may need to be avoided, at least temporarily, in some patients. And there are a few specific concerns regarding diabetes and exercise that every diabetic trying to maintain a healthy lifestyle should be aware.

Hypoglycemia
Hypoglycemia is a condition that occurs when blood sugars fall to excessively low ranges (usually less than 60mg/dl). With hypoglycemia, patients experience confusion, sweating, shakiness, and in severe cases, coma and seizure.

Note: Exercise can induce hypoglycemia, particularly in patients who are taking insulin, although patients on oral agents are also at risk. In part, this decrease in blood sugar results from an increase in the muscles' use of glucose and because the liver's production of glucose is impaired.

Studies have shown that patients taking insulin who reduced the dose of their short-acting insulin by 33-50% before exercising were able to prevent the onset of exercise-related hypoglycemia. While hypoglycemia can occur during or directly after activity, it can also occur 6-12 hours after exercise. Caution is therefore recommended during this period as well.

For patients who exercise regularly and need insulin therapy, an insulin pump is a great option for delivery. The pump provides a constant infusion of insulin that can be adjusted and allows for an extra amount to cover meals. With the aid of a doctor or nurse trained in pump therapy, the dosing can be adjusted to fit exercise regimens.

The only activities for which the pump may not be well suited are swimming and sports involving vigorous movements. These activities can dislodge the cannula, the tube through which the insulin is infused into the body.

Some strategies to avoid hypoglycemia are listed below:

• Measure blood sugars before, during, and after exercise.

• For planned exercise, if you are on insulin, reduce the short-acting insulin by 33 to 50%.

• For unplanned exercise, take 30 to 20g of carbohydrates extra for each 30 minutes of exercise.

• Avoid injecting insulin into the arms and legs and use the abdomen because the insulin will be absorbed more evenly.

• If you exercise in the evening, you may need to add a snack before bedtime to make certain your sugars don't go too low at night.

Diabetes, Exercise & Small Blood Vessel Disease
Patients with diabetes often have eye disease, whether they have symptoms or not. The eye disease associated with diabetes results from the formation of small, fragile, easily breakable blood vessels in the retina at the back of the eye. When these vessels break, bleeding in the back of the eye occurs. Continued damage can result in loss of vision.

In patients with extensive eye disease related to diabetes (diabetic retinopathy), the intensity and type of exercise may need to be limited. Activities that should be avoided include excessive straining (as in weightlifting), excessively jarring activities (such as boxing), and exercise that involves severe pressure changes (like diving). If there is early eye disease and no new vessel formation, no limitations are necessary. If kidney disease is present, the only precaution is avoiding exercise that can raise blood pressure.

Diabetes, Exercise & Large Blood Vessel Disease
Large blood vessels, such as those that normally supply blood and oxygen to the heart, can also be affected by diabetes. A careful medical history and examination are needed in all diabetic patients who have heart disease before they commit to an exercise program. From a recent Consensus Development Conference on the diagnosis of Coronary Heart Disease in people with Diabetes, the American Diabetes Association has published recommendations for exercise stress testing in diabetes patients. Stress testing should be done before embarking on an exercise program.

The recommendations of the American Diabetes Association for testing are listed below:

• Any patient with cardiac symptoms.

• Abnormal resting EKG.

• Peripheral or carotid artery disease.

• Sedentary lifestyle, age > (greater than) 35 years, and plans to begin a vigorous exercise program.

• Two or more of the following risk factors in addition to diabetes:

• Total cholesterol > 240mg/dl, LDL.160mg/dl, or HDL <35mg/dl;

• Blood pressure > 140/90;

• Smoking;

• Family history of premature heart disease; and

• Kidney involvement from diabetes.

What does this mean for you?
Before starting on any exercise program, a thorough examination and medical history should be performed by your doctor. Patients who have diabetes should pay particular attention to blood vessel complications.

Another important area to discuss is the estimated calorie expenditure and strategies to lessen the risk of hypoglycemia. Food intake ‒ both before and after exercise ‒ should be reviewed.

Approximately 50% of the calories burned during exercise come from a carbohydrate source (with the remainder coming from fat). You can thus calculate that in a 30 minute exercise session, wherein an activity like cycling at 13 kmph burns about 10 cal/min, a person would need to consume about 38g of carbohydrates (50% of 300kcal =150 kcal or 37.5 g of carbohydrate).

We know this because each gram of carbohydrate is 4 kcal, and 150 divided by 4 is 37.5. These calculations, while a little confusing at first, can be a really valuable tool with some practice and guidance.

Regarding aerobic activity, training sessions should begin slowly. Allow 8 to 12 weeks to reach a desired training level. At a minimum, three to four 20 to 30 min sessions are needed to see a benefit. To estimate your predicted maximal heart rate: take 220 and subtract your age in years. You should be working at about 60 to 70% of this maximum rate to ensure a safe, effective workout.

For example, if you are 40 years old, calculate as follows: 220 - 40 =180 and 70% of 180 = 126. This means your heart rate should be up to 126 beats per minute. It is also important to remember to add a warm up and cool down period to your workout to help prevent injury.

In addition to the above information, the American Diabetes Association has made the following recommendations for exercising:

• Carry an ID card and wear a bracelet that identifies you as having diabetes.

• Be alert for signs of hypoglycemia during and after exercise.

• Drink plenty of fluids before, during, and after exercise.

• Measure blood sugar levels and act if the reading is less than 80mg/dl or greater than 240mg/dl.

If you need more specific information, the American Diabetes Association website is a great resource and the International Diabetic Athletes Association has additional information.

Once again, discuss any question or concerns you may have with your physician before starting any activity program. When done safely, there is no doubt that the benefits of exercise in patients with diabetes far outweigh the risks.

With inputs from MedicineNet.com

Efficacy of HbA1c Results Questioned; CGM is the New Standard, Claim Experts

WHILE HbA1c tests have been considered the gold standard for years, these tests do not necessarily correlate to good diabetes control. But HbA1c is only an average of glucose levels over time. A person can have major highs and lows every day, yet still have a "good" HbA1c level.

This is one reason why recent clinical trials reveal that HbA1c tests alone do not necessarily correlate to good diabetic control. It is also important to know that the more often you are outside your target range, the higher your risk of diabetes-related complications.

Indeed, there are many diabetics who experience hypoglycemia and hyperglycemia so often that they no longer realize when they have symptoms. Large-scale studies have shown, over time, these glycemic excursions cause major complications to the vascular system and organs.

Writing in his Endocrine Today blog, Michael Kleerekoper, MD, MACE wonders whether HbA1c is a reliable measure of glycemic control in an individual patient. His answer is: “It depends.”

As far as I can gather, the HbA1c is reliable in patients with fairly stable home blood glucose values, but too few patients measure blood glucose often enough to know this. It’s not the patient’s fault — their insurance carrier is very niggardly about the number of times a day a patient is allowed to measure blood sugar. If only the carrier would recognize the longer-term health care costs in those patients! All too often the patient leaves the glucose meter at home — that’s like going to the pediatrician without the baby.

Serial HbA1c is far less reliable in patients with widely fluctuating blood glucose values. Continuous glucose monitoring (CGM) is being utilized more frequently to document widely fluctuating blood glucose values, and patients learn a lot from the graphical illustration of how well or not well they are taking care of their diabetes.

Point-of-care HbA1c instruments are available and are also being used more often in the clinic. It makes sense to have the data available while the patient is still in the clinic rather than wait 24 hours for the lab result to come back.

Caveat emptor! If you are of a mind to get a handheld HbA1c device for your clinic, I encourage you to first read the editorial and article published in Clinical Chemistry about 1 year ago. Only two of the eight available devices were reliable!

Kleerekoper’s reservations bring us back to the question posed in the headline of this article: Are HbA1c results reliable enough?

Goals of Diabetes Self-Management
Basically, the goal of diabetes self-management is to help patients optimally manage their diabetes based on:

• Individual needs

• Customized goals

• Personal lifestyle considerations

So, do diabetics stick with the old fingerstick monitoring or shift tocontinuous glucose monitoring (CGM)?

Improving Diabetes Management
Over a decade ago, a landmark study called the Diabetes Control and Complications Trial — the largest study of its kind — revealed the importance of good glucose control. New, large-scale studies are revealing even more improvements in glucose control with the use of CGM technology.

In a recent study, people who were considered to be in "good control" showed distinct improvements in time spent within their target zone while using a CGM device. And subjects who were considered to be in "poor control" before the study, had even more impressive improvements with a 70% increase in time they spent in their target zone.

A recent study by the Juvenile Diabetes Research Foundationshowed that using a CGM, for at least 6 days a week can lead to significant decreases in HbA1c and can provide a greater ability to reach the ADA recommended goal of 7%.

Revealing Unnoticed Highs and Lows
A CGM device can call attention to highs and lows that you may often experience, but not recognize. Sometimes people have"hypoglycemia unawareness" — they no longer feel their symptoms of going low. And some people are also unable to feel symptoms of high glucose. Over time, frequently swerving outside of your target range can lead to severe consequences, such as damage to your nerves, eyes, kidneys, and other organs.

Fingerstick vs. CGM: Revealing Unnoticed Highs & Lows

Recent studies reveal that fingerstick testing alone does not provide enough information to stay within their target range — even people who monitor frequently. In contrast, the use of a CGM device does a better job of helping people to stay between the lines. Indeed, CGM, especially in conjunction with HbA1c, helps to show a more complete picture of glucose control.

Real-Time Trending = 288 Fingersticks!
Fingerstick monitoring alone does not provide enough information for patients to act preemptively to avoid hyper- and hypoglycemic events. A major benefit of CGM is that it can help patients identify fluctuations and trends that would otherwise go unnoticed with standard fingerstick testing.

A CGM measures glucose levels and sends a glucose value every 5 minutes from the Transmitter to the Receiver. This is equivalent to a patient taking 288 fingerstick readings daily. However, unlike fingersticks, patients see real-time trending of glucose levels and patterns.

A CGM system shows patients their current glucose value, as well as their glucose trend over the past several hours (1-, 3-, 6-, 12-, and 24-hour trends). It also tells them how quickly their glucose is changing. And when glucose levels go above or below the set target range, alerts notify patients so they are able to take corrective action before going too low or too high — helping them stay between the lines.

Damage Caused By Glucose Variability
There is a growing body of clinical evidence showing that glucose variability itself — independent of HbA1c — initiates a cascade ofphysiological damage. Over time, hyper- and hypoglycemic events significantly increase the risk of diabetic complications, such as retinopathy and general microvascular pathogenesis, at least partially due to increases in oxidative stress and pro-inflammatory cytokines that are triggered by hyper- and hypoglycemic swings.

A CGM device can call attention to dangerously low overnight glucose levels that often go undetected, reveal previously unnoticed hyperglycemia spike trends between meals, show early morning highs in glucose, clarify the way diet and exercise affect your patients' glucose levels and provide a long-term comprehensive assessment of the effects of adjustments in diabetes management.

It is not surprising, therefore, that in recent years CGM has gained acceptance among diabetes experts as an effective tool for helping people achieve their diabetes goals:

• Achieve HbA1c targets without adding hypoglycemia

• Reduce glucose highs and lows

• Reduce hypoglycemia

Indeed, when using a continuous glucose monitoring (CGM) device, study results demonstrate that the patients were actually experiencing extensive fluctuations in glucose levels. CGM, especially in conjunction with HbA1c, helps to show a more complete picture of glucose control.

Incretin Secretion, Action in the Natural History Of Type 2 Diabetes

INCRETIN hormones contribute a major portion to the insulin secretory responses after meals in healthy people. The incretin effect describes the phenomenon that oral glucose elicits approximately threefold greater insulin responses than the elevation in glucose (achieved with glucose administered intravenously) alone.

(Incretins are gastrointestinal hormones that influence insulin secretion, and which have been the basis for the development of new medications for type 2 diabetes.)

The incretin effect is the result of nutrient-stimulated secretion of the incretin hormones glucose-dependent insulinotropic hormone (GIP) and glucagon-like peptide-1 and their insulinotropic effect (ie, the augmentation of insulin secretion at elevated plasma glucose concentrations). In patients with type 2 diabetes, this incretin effect is severely impaired or even absent.

It is the purpose of this commentary to highlight current knowledge in incretin research and to answer the question of whether and to which degree abnormalities in incretin hormone secretion and action accompany the development of type 2 diabetes or even contribute to this process.

The reduced incretin effect in patients with type 2 diabetes was first noticed in 1967 and was clearly established in 1986.

Three types of questions arose from this finding:

• What is the mechanism behind the reduced incretin effect? Is the secretion or insulinotropic action of GIP and GLP-1 at fault?

• Are defects in the enteroinsular axis (the signaling system between the gut, from where incretin hormones are secreted, and the endocrine pancreas, the main target tissue that incretin hormones act on) important for the development and/or progression of type 2 diabetes?

• Can the pathophysiological characterization of the incretin system in type 2 diabetes provide clues for the development of new approaches for the treatment of this metabolic disease?

A severe impairment in the insulinotropic (stimulating or affecting the production and activity of insulin) activity of GIP in type 2 diabetes explains the reduced incretin effect.

A large cross-sectional study by Toft-Nielsen and colleagues comparing GLP-1 responses after meal stimulation suggested a reduced release of GLP-1 in patients with type 2 diabetes and, to a lesser extent, impaired glucose tolerance (“prediabetes”).

This widely quoted study was sometimes interpreted to indicate a progressive loss in the capacity of GLP-1 secretion in the natural history of type 2 diabetes, starting from normal secretion as long as glucose tolerance was normal with slight impairments when IGT develops, with a further deterioration after the diagnosis of type 2 diabetes and little residual capacity for GLP-1 secretion when the condition has progressed.

The logical consequence was to replace a missing hormone by advocating incretin-based antidiabetic agents (GLP-1 receptor agonists [mimicking the action of a naturally occurring substance] or DPP-4 inhibitors [medicines like Januvia(sitagliptin), Onglyza (saxagliptin), and Galvus (vildagliptin) that contain DPP-4].

However, not all studies that have compared the secretion of GLP-1 in patients with type 2 diabetes and in matched healthy people come to the same conclusions.

A recent meta-analysis suggested no uniform reduction in L-cell secretion between healthy and type 2 diabetic patients, but a large interindividual variation, in part determined by age, obesity and plasma levels of glucagon and free fatty acids.

In nondiabetics, the amount of GIP and GLP-1 secreted is significantly correlated to the incretin effect in quantitative terms. Thus, a low secretion of GLP-1 may determine a reduced incretin effect on an individual level, but does not explain the reduced incretin effect in patients with type 2 diabetes by and large.

If secretion is not the culprit, is there any peculiarity regarding the action of incretin hormones in type 2 diabetes? As originally described using GIP of the porcine amino acid sequence, and later confirmed using synthetic human GIP, the endocrine pancreas shows very little secretory response, even if exposed to supraphysiological concentrations of GIP.

This inability to respond to GIP appears to be acquired, since populations at high risk for developing type 2 diabetes do not display a similar defect. Basically, the response to GIP seems to be normal in any form of prediabetes (first-degree relatives, patients recovering from gestational diabetes, etc.), but after diagnosis (ie, with a fasting glucose ≥126 mg/dL), the incretin effect is reduced or lost, as is the ability to respond to exogenous GIP.

Most likely, the inability to elicit insulin secretory responses with GIP, even at hyperglycemia, is explained by a generalized impairment in beta-cell secretory capacity, as is typical for type 2 diabetes, no matter which stimulus is looked at (hyperglycemia, amino acids, sulfonylureas, etc).

Furthermore, rodent studies have suggested a down-regulation of the GIP receptor by chronic hyperglycemia. The fact that this defect becomes apparent when glucose concentrations rise above the normal level has raised the question of whether this phenomenon is reversible by glucose normalization.

A recent study by Højberg and colleagues suggested that this may be the case. However, although the insulin secretory responses to GIP and GLP-1 were significantly improved, normalization was not achieved after improved glucose control.

Abnormalities in the incretin system accompany the development of type 2 diabetes and may contribute to the velocity of progression. Figure 1 depicts the natural history of developing type 2 diabetes and also the progression of the disease after the diagnosis has been made.

Changes in insulin secretory capacity, based on homeostasis model assessment (HOMA) estimation of beta-cell function, and insulin sensitivity preceding the diagnosis were taken from a recent analysis by Tabak and colleagues. The development after the diagnosis of diabetes was based on analyses from the UKPDS and ADOPT study.

Regarding the secretion of GIP and GLP-1, we refer to our recent review indicating no general abnormalities in K-cell (GIP) and L-cell (GLP-1) secretion associated with a diagnosis of type 2 diabetes.

The fact that in none of the studies examining prediabetic populations, insulinotropic GIP effectiveness was impaired, but after the diagnosis, uniformly, a severe inability to respond to GIP with secreting insulin was documented, is the basis for assuming a substantial drop in beta-cell responsiveness to GIP around the time of diagnosis, with no further changes afterward (Figure 1).

In a recent review, we have explained reasons to assume that this inability to secrete insulin in response to GIP stimulation goes along with a general impairment of beta-cell function, which is demonstrable with most other secretagogues as well.

Whether this inability of the endocrine pancreas to respond to GIP contributes to the natural history of type 2 diabetes can only be evaluated by quantitative considerations. If a mechanism to stimulate insulin secretion after meals that normally contributes two-thirds of the overall secretory responses is at fault, this almost certainly has the effect to accelerate the progression of type 2 diabetes because without the additional incretin stimulus, overall insulin secretion should be further impaired.

In the case of GLP-1, the insulinotropic activity is somewhat reduced after the diagnosis of type 2 diabetes, and even worse under the condition of uncontrolled hyperglycemia compared with healthy controls.

High pharmacological doses of GLP-1, nevertheless, have the potential to raise insulin concentrations and to suppress glucagon secretion, with the overall result of normalizing glucose concentrations in the fasting state and after meals over a wide range of patients with type 2 diabetes, ranging from those treatable with lifestyle modification (“diet and exercise”) to those requiring insulin treatments.

Thus, the “resistance” to GIP of the type 2 diabetic beta-cell can be overcome by a compensatory exposure to high concentrations of the incretin hormone, GLP-1. GLP-1 itself appears to be less important than GIP for postprandial glucose control in healthy people and does not seem to be involved in the pathogenesis (origination and development) of type 2 diabetes.

However, because of its preserved efficacy in type 2 diabetes, GLP-1 is an effective agent to treat hyperglycemia in type 2 diabetic patients, with the added benefits of inducing weight loss and avoiding hypoglycemia.

By Michael A. Nauck, MD, PhD, Irfan Vardarli, MD (Diabeteszenstrum Bad Lauterberg), and Juris J. Meier, MD (St. Josef-Hospital, Ruhr-University of Bochum, Germany)

Source: Endocrine Today