Diabetes damages every part of the body, from the brain to the feet. High blood sugar, the hallmark of diabetes, wreaks havoc on blood vessels. It makes sense that keeping blood sugar under control should prevent diabetes-related damage — but how low to push blood sugar is an open question. A study published in The New England Journal of Medicine (NEJM) provides reassuring evidence that so-called tight blood sugar control is good for the heart and circulatory system. A 10-year follow-up of the Veterans Affairs Diabetes Trial showed that participants who aimed for tight blood sugar control had lower blood sugar and fewer heart attacks and strokes than participants whose blood sugar was allowed to float a bit higher. Although tight blood sugar control can help prevent diabetes-related damage, it can have drawbacks such as bouts of low blood sugar (hypoglycemia), which can be dangerous. Current guidelines from the American Diabetes Association recommend tight blood sugar control, but also recognize there’s no one-size-fits-all rule.
Ninety years ago, type 1 diabetes was a death sentence: half of people who developed it died within two years; more than 90% were dead within five years. Thanks to the introduction of insulin therapy in 1922, and numerous advances since then, many people with type 1 diabetes now live into their 50s and beyond. But survival in this group still falls short of that among people without diabetes. A Scottish study published this week in JAMA shows that at the age of 20, individuals with type 1 diabetes on average lived 12 fewer years than 20-year-olds without it. A second study in the same issue of JAMA showed that people with type 1 diabetes with better blood sugar control lived longer than those with poorer blood sugar control.
Over the past decade, a barrage of reports linking low vitamin D levels to cancer, heart disease, diabetes, and a host of other ills led many doctors to routinely test vitamin D levels in their healthy patients. But there is no good reason to do that, according to a new recommendation from the U.S. Preventive Services Task Force (USPSTF) published in this week’s Annals of Internal Medicine. The task force concluded that it isn’t helpful for most people to know their vitamin D level, and that even if you have a “low” vitamin D level there’s little evidence that taking a vitamin D supplement will do most people any good.
Researchers at Boston University and Massachusetts General Hospital have developed a bionic pancreas. In an early test of the device, reported online this week in the New England Journal of Medicine, it helped control blood sugar levels in 20 adults and 32 teenagers with type 1 diabetes who went about their daily lives without the constant monitoring and injecting that’s required with type 1 diabetes. Right now, this artificial pancreas is essentially an app that runs on an iPhone wirelessly connected to a monitor worn on the abdomen that continually checks blood sugar and two pumps, one for insulin and one for glucagon. The team that developed the bionic pancreas have begun a second round of testing, and hope to have a more sophisticated version on the market in five years. While not a cure, the development of a bionic pancreas represents a bridge that would let people with type 1 diabetes control their blood sugar with less hassle, and more safely, than they do now.
Two reports released this week shed light on the current state of type 2 diabetes in this country, and their conclusions are promising and sobering. First, the good news: An article in The New England Journal of Medicine shows that rates of diabetes-related problems like heart attack, stroke, and lower-limb amputation are down by more than 50% over the last two decades. Now the bad news: during the same time period, the number of people with diabetes has soared, according to a report in the Annals of Internal Medicine. Today, about 21 million American adults are living with diabetes, and that number is on the upswing. Nearly 70% of Americans are overweight or obese. Unless something is done to reverse this trend, millions more Americans could edge closer to diabetes. Dr. Osama Hamdy, medical director of the Obesity Clinical Program at Harvard-affiliated Joslin Diabetes Center and author of The Diabetes Breakthrough, a newly published book from Harvard Health Publications, offers some strategies for preventing diabetes.
There are many reasons to keep your blood sugar under control: protecting your arteries and nerves are two of them. Here’s another biggie: preventing dementia, the loss of memory and thinking skills that afflicts millions of older Americans. A study published today in the New England Journal of Medicine shows that even in people without diabetes, above normal blood sugar is associated with an increased risk of developing dementia. The study does not prove that high blood sugar causes dementia, only that there is an association between the two. For that reason, don’t start trying to lower your blood sugar simply to preserve your thinking skills, cautions Dr. Nathan. There’s no evidence that strategy will work, although he says it should be studied. But it is still worth keeping an eye on your blood sugar. Excess blood sugar can lead to diabetes and a variety of other health problems, including heart, eye, kidney, and nerve disease.
An old, aspirin-like drug called salsalate could help control blood sugar in people with type 2 diabetes. In the TINSAL-T2D trial, 286 volunteers took pills containing either salsalate or a placebo for nearly a year. Over the course of the trial, those in the salsalate group had lower blood sugar levels, and some were even able to reduce dosages of other diabetes medications they were taking. Experts aren’t exactly sure how salsalate helps control blood sugar, but its effectiveness supports the idea that inflammation plays a role in type 2 diabetes. Although the results are promising, what we really need to know about salsalate (or any new or repurposed drug) is how its long-term benefits and risks stack up against each other. The trial was too small and too short to determine those risks. According to the researchers, such “outcomes require continued evaluation before salsalate can be recommended for widespread use” by people with type 2 diabetes.
Long-awaited results from a nearly 10-year trial exploring the effect of changes in diet and exercise among people with diabetes weren’t what most people expected. The Look AHEAD trial found that intensive efforts to lose weight by eating less and exercising more didn’t provide any more protection against heart disease—a common co-traveler with diabetes—than standard diabetes support and education. The spin from some media reports is that weight loss doesn’t reduce heart disease risk among people with type 2 diabetes, but I think that’s the wrong interpretation. The results of the Look AHEAD trial don’t contradict the value of lifestyle changes. People in the intensive change group improved their blood sugar with fewer drugs, saving an estimated $600 per year, they were also less likely to have developed chronic kidney disease and less self-reported vision problems. The Look AHEAD results reinforce for me that diabetes care needs to be tailored to the individual.
City dwellers often think of rural America as a throwback to past “good old days.” But when it comes to obesity and diabetes, people living outside urban areas offer a frightening glimpse of the future. While more than 8% of Americans now have diabetes, in some rural counties 20% of the residents have diabetes. Those counties also tend to have high rates of obesity. Barriers to healthy living contribute to both obesity and diabetes. So does lack of primary care physicians. One answer may be greater reliance on community health workers—lay people trained to provide diabetes education and outreach. In Birmingham, Alabama, the Cities for Life program has doctors refer people with diabetes to “patient navigators” who help them find local resources such as nearby exercise classes or mobile farmers’ markets.
A lot is known about diabetes. But a discovery that could change how this disease is treated shows just how much more there is to learn. A team of Harvard Medical School researchers has discovered a hormone called betatrophin made by liver and fat cells that signals the body to make more insulin-producing beta cells. A report of their work appears in this month’s issue of the prestigious scientific journal Cell. In mice with diabetes, experimentally turning on the production of betatrophin inside liver and fat cells caused an increase in beta cells and a dramatic improvement in blood sugar. It will, of course, take much more research in mice—and then in humans—to determine if this newly discovered hormone can serve as a treatment for diabetes. So it’s too soon to get excited that the discovery of betatrophin will translate directly into a new treatment for diabetes. But it is another example of the human body’s power to naturally repair itself.