JANUARY
2008 NEWSLETTER
ANOTHER YEAR – 2008!
The Trustees of IDDT send their best wishes for
2008 to all our members and readers. It’s a time to make New Year resolutions
even though sometimes we know in our heart of hearts that we won’t keep them!
However flippant or serious our resolutions may be, they do mean that we have
looked at our lives and decided that there are things that we would like to try
to change. Perhaps it is the trying that is really important. Diabetes is a
condition where we have to try all the time, whether as someone with it or as a
parent or carer.
I am sure there are others that will join me in a
New Year wish that in 2008 all our trying will be appreciated when we go to the
diabetic clinic. Our results may not be what the doctor or nurse want to see,
but that doesn’t mean we haven’t been trying. It doesn’t mean that we deserve a
slap on the wrists or to be told ‘you must have been eating the wrong things’!
Some useful and practical advice on how to achieve their targets without
increasing the numbers and severity of hypos would help but so too, would some
praise!
Perhaps only those who live with diabetes can
appreciate that we can try our utmost but sometimes, it just goes adrift and we
don’t know why. Perhaps you have to live with diabetes to understand that this and
the constant trying can just get us down - the Americans call it ‘diabetes burn
out’. A bit of praise, encouragement and understanding wouldn’t go amiss and
can play a big part in preventing ‘diabetes burn out’.
So what are IDDT’s resolutions for 2008? That we will keep trying too!
At the end of 2007 Novo Nordisk pork insulin
disappeared but the need for pork insulin has not. IDDT will continue to do all
it can to ensure the Department of Health keeps its promise that pork insulin
will continue to be available.
We will also continue to try to ensure that people
with diabetes have the informed choice of treatment they deserve. If this means
that we raise issues that are unpopular in some quarters, so be it. If this
means that we identify gaps in research to show that the treatments of adults
and children with diabetes are not evidence-based, we see this as step forward as
it highlights the need for further research.
We will continue to hold the view that it is
unacceptable for people with diabetes to be automatically treated or changed to
the latest insulin or drug, simply because it is ‘modern’. There has to be
evidence of benefit and superiority and as patients, parents and carers, we
have to know that new insulins and drugs have been fully investigated using
outcomes that are important to us, such as comparisons of mortality and
complications rates, quality of life and above all, that long-term safety is
known. As individuals we can all play our part in ensuring that our treatment
is not changed simply because a new ‘modern’ insulin or drug has come on the
market – we just have to ask for the evidence about risks and benefits of the
proposed changes in treatment.
IDDT is a relatively small organisation but just as
individual people with diabetes try, so does IDDT. We have no hidden agenda, no
outside influences upon us and we are completely independent of the
pharmaceutical industry. We are motivated by the need for people who live with
diabetes to have an informed choice
of treatment, to have treatment that is individualised to their needs and that
is known to be safe.
To help us achieve these goals, we could all make
the same resolution for 2008 – that we will be more assertive, we will not be
afraid to ask questions about our treatment, we will not unquestioningly accept
changes and we will be involved in making decisions about our own diabetes and
ultimately, our health.
YOUR OPINION COUNTS
Creative Market Research
Ltd [CMR] is a specialist research company operating exclusively in the field
of healthcare. They are effectively the channel through which people with
diabetes can feed back their ongoing experience direct to the meter, pen and
insulin manufacturers, a process that helps to drive the development of better
and more effective products.
CMR operates to the
highest ethical standards and is meticulous when it comes to patient
confidentiality. Research at CMR is internet-based and involves no phone calls
If you have access to
the web and are prepared to share your experiences for the benefit of yourself
and others, log on at: www.medisurveys.com
If you would like to
help improve the products you use every day, join the panel.
If you have any problems
or questions do call Sue Reynard on 01473 832211 or email her at
sue@creativemarketing.co.uk
DIABETES
AND YOUR SKIN
After
a time I think that most of us start to realise that diabetes can affect almost
every part of the body and the skin is no exception.
Facts about skin
·
It
is the largest organ of the body.
·
The
skin of an average sized adult covers about 18 square feet and weighs about 7
pounds.
Structure of the
skin
The
skin is made up of three layers: the epidermis, the dermis and the subcutaneous
layer.
The epidermis - is the outer
layer of the skin and contains cells that determine skin colour and protect
against damage. Epidermal cells are constantly being warn away and replaced
with new ones. Damage to this layer of the skin is not normally a problem
because it repairs itself very quickly but in people with diabetes this healing
process is often slower than in people without diabetes.
The dermis – is the layer
under the epidermis and contains:
·
blood
vessels and sweat glands to help regulate body temperature
·
nerve
endings
·
hair
follicles
·
sebaceous
glands [glands that produce oil] to help prevent loss of too much sweat by
coating the skin with a layer of oil.
Injury
to this layer of the skin is a greater problem than injury to the epidermis
especially for people with diabetes. As diabetes can affect the nerves and
blood vessels, the dermis can cause the skin to become dry. Once it is dry, it
can crack and become open which means it is more difficult to heal.
The subcutaneous
layer
– is below the dermis where fat is stored. The sweat glands originate here and
it supports the blood vessel and nerves that feed the outer layers of the skin.
Any damage or injury to the dermis or subcutaneous layers will cause pain as
they both carry the nerves, this assumes that the nerves are not damaged by
diabetic neuropathy or any other cause. The pain caused by a response from the
nerves to the brain acts as a protection eg if you touch a hot oven, it is the
nerves in the dermis and subcutaneous layers of the skin that pass pain
messages to the brain. In diabetic neuropathy [nerve damage] the nerves do not
work properly so pain is not felt and there is a risk of further injury due to
lack of feeling of pain.
Diabetes can affect
your skin
If
blood glucose levels are too high and you pee a lot, then this can lead to
dehydration. Then the blood vessels and glands that normally keep your skin
moist can be affected causing dry skin. Dry skin can cause premature aging but
more importantly, the dry skin can crack and infections can develop and this is
made worse by the slower healing due to diabetes.
Prevention is the
best
As
with many aspects of diabetes, preventing the problem from arising is the best
course of action and as with all things connected with the care of diabetes,
firstly this means aiming for blood glucose levels and blood pressure to be as
near normal as possible, eating a healthy diet with plenty of fluids and taking
regular exercise. [I know we’ve heard it all before!] It is also important to
look at your skin to detect any changes and to keep all your skin clean and
moisturised with moisturisers, lotions or creams and this is not just important
for the ladies!
AT LAST!
Up to now the American Diabetes Association [
LATEST NEWS…..
ON AVANDIA
And would you believe? Research presented
at the European Association for the Study of Diabetes in September 2007 showed
that drinking green tea was as effective as Avandia at lowering blood glucose
levels in people with Type 2 diabetes who were just able to tolerate sugar. And
without the risk if heart attack! Green tea contains the antioxidant
epigallocatechin gallate and at the end of the 10 week trial, the green tea
extract was also found to preserve insulin-producing tissue and offered other
protective effects in the pancreas.
ON ANTI-OBESITY DRUGS
British Medical Journal, 16.11.07 – a meta-analysis review of 30 trials of
anti-obesity drugs suggests that in many cases ant-obesity pills achieve little
in terms of weight loss. 20,000 obese people weighing on average 100kg [15.7
stone] reduced their weight by 2.9kg with orlistat [Zenical and Alli in the
US], 4.2kg with subtramine [Meridia] and 4.7kg with rimonabant [Acomplia] but
it was unclear whether this was sufficient to have big health benefits.
Orlistat reduced the incidence of Type 2 diabetes in one study and all three
drugs lowered certain types of cholesterol. A separate study in The Lancet the
same week, found that patients given rimonabant were at increased risk of
severe psychiatric events, including suicide.
Distributors of
orlistat have applied for it to be an over-the-counter drug [OTC] in Europe as
it is in the US but in an editorial in the BMJ Prof Gareth Williams, said,
“Selling antiobesity drugs over the counter will perpetuate the myth that
obesity can be fixed simply by popping a pill and could further undermine the
efforts to promote healthy living, which is the only long-term escape from
obesity.” He is concerned that casual users will abandon it due to the
unpleasant side effects, such as oily stools and faecal incontinence. Its
modest benefits which are equivalent to leaving a few French fries off the
plate, eating an apple instead of an ice cream or having 10-20 minutes sex.
In March 2007 the United Nations’ International
Narcotics Control Board [INCB] issued a warning about the rise in the use of
weight loss drugs in a number of countries stating that they are being used
indiscriminately in some countries to feed society's obsession with being slim.
Some countries have introduced measures to reduce their use but in others such
as
In
October 2007, the drug regulatory body in the
Can Byetta be
substituted for insulin in people with Type 2 diabetes already using insulin? A study carried
out by manufacturers of Byetta, Lilly, has shown that this was possible in less
than two thirds of patients without alteration of glycaemic control. However,
in an editorial, the design of the study is highly criticised because no
attempt was made to optimise insulin treatment and therefore the results could
well be biased in favour of Byetta – good for marketing it! [Diabetes Care Vol
30, No 11]
November 2007, the once a week
version of Byetta is superior to the currently used twice-daily version. A
30-week study involving 295 patients with type 2 diabetes compared HbA1c
levels. Once-weekly Byetta showed a statistically significant improvement of
about 1.9% compared to an improvement of about 1.5% for twice-daily Byetta.
Similar weight loss of about 8 pounds (3.6kg) on average was seen with both
patient groups. The once-weekly version may not receive approval until 2009 and
may be beaten to the market by Novo Nordisk’s type 2 drug liraglutide.
JUST A THOUGHT……….Since the 1980s,
the recommended diet has been high carbohydrate/ low fat diet for the general
population as well as people with diabetes. 25 years later we have a population
that is more overweight and obese than ever before. Common sense would suggest
that the recommended diet isn't working. Isn't it time for a re-think by the
powers that be?
AND ANOTHER ………..The pharmaceutical
industry spends £850 million a year marketing its products to UK GPs. Does this
influence GPs when it comes to writing prescriptions? It is claimed that it
doesn't but if this is the case, it seems a waste of their £850million!
FOR
THE LADIES
·
Pregnant
mums with diabetes - important message
An
issue that has been raised with IDDT is that mums who have given birth to
healthy babies have had their babies removed from them and placed in the
special baby care unit – even in hospitals with a ‘good reputation’. Some
pregnant diabetic women are being told that their newborn baby will be placed
in the special care unit as if this is a necessary and normal procedure.
Obviously
this could be necessary on health grounds but many diabetic mothers are being
separated from their babies for no other reason than hospital convenience or
‘hospital policy’.
Recently
the Confidential Enquiry into Maternal and Child Health [CEMACH] stated that in
over half of mothers with Type 1 and Type 2 diabetes their babies are
automatically moved to a special care baby unit. CEMACH goes on to say that if
the babies are healthy at birth there is no reason for this and it has negative
impacts – breastfeeding becomes difficult because infant formula is used in the
special care unit and newborns’ body temperature becomes harder to regulate. It
does not require a report from CEMACH to know that mums and their newborn
babies are better not separated unless there are health grounds for doing so.
The
Chief Executive of CEMACH has stated that more babies could stay with their
mothers than is presently the case and mothers with diabetes should be
encouraged and supported to breastfeed their babies. He goes on to say that if
these aims were achieved, it should be better for both mother and baby and also
save the NHS money.
IDDT advice to
pregnant women with diabetes: make sure that you know the hospital
system before you are due to have your baby and make it clear that you don’t
want to be separated from your newborn baby unless there are medical grounds
for doing so.
·
Analogues
and pregnancy
Naturally
pregnant women or those considering pregnancy are always concerned about any
medications they take at this time. Clearly women with diabetes have to take
insulin but still need to know about any safety issues for both themselves and
the unborn baby. Here is some information that may be helpful.
Lantus - some experimental
studies have shown that insulin analogues have growth-promoting effects and
concerns have therefore been raised that use of Lantus insulin during pregnancy
could cause excessive foetal growth and other problems. Reuters reported that a
review actually recommended Lantus was not used during pregnancy, but called
for further studies to investigate its safety.
A
small study carried out in
There
were no significant differences in birth weight between infants born to Lantus
users and those born to standard insulin users. [The rate of excessively large
babies was actually slightly lower in the Lantus group: 38 versus 41%.] The
groups were also comparable in terms of infant complications, admission to
special care infant units, and congenital abnormalities.
The
authors recommend that large trials should be carried out to confirm the
efficacy and safety of Lantus for the treatment of pregnant women with Type I
diabetes and those with gestational diabetes.
Ref
1 British Journal of Obstetric and Gynecology, April 2007
NovoRapid – information from
the manufacturers of NovoRapid [NovoLog in the
A
recently published study [ref 1] concluded that NovoRapid is as safe and
effective as GM 'human' insulin in pregnant women with Type 1 diabetes as the
mother and pregnancy outcomes were the same. In this study the long-acting
insulin used was NPH insulin, a 'human' intermediate insulin and NOT an
analogue insulin.
Ref
1 Diabetes Care, April 2007
For the use of
other analogues in pregnancy, the Specific Product Characteristics documents
say:
Humalog: Data on a large
number of exposed pregnancies do not indicate any adverse effect on pregnancy
or on the health of the foetus/newborn.
Levermir: There is no
clinical experience with Levemir [insulin detemir] during pregnancy. ….Caution
should be exercised when prescribing to pregnant women.
Apidra: There are no
adequate data on the use of Apidra [insulin glulisine] in pregnant women.
Caution should be exercised when prescribing to pregnant women.
·
Fertility
in women with diabetes has improved
A
population-based study in
The
good news is that reduced fertility was confined to those diagnosed before 1985
although the presence of complications reduced fertility in all years. The
number of new born babies with congenital malformations was 11.7% in the years
1973-1984 but dropped significantly to 6.9% during 1995-2004. The researchers
suggest that stricter metabolic control during the last 20years may well have
helped to improve fertility and reduce the number of new born babies with
congenital malformations. Yet another good reason for keeping 'good' control.
[Diabetes Care,
·
Girls and
women skipping injections to lose weight.
Diabetes
UK estimate that 1 in 3 women with diabetes under the age of 30 in the UK are
missing insulin injections at any one time, to help them lose weight with a
high proportion of these are teenage girls. These figures are based on a small
study carried out in
With
today’s pressures to be thin, teenage girls and young women easily discover
that not carrying out some or all their injections results in swift weight loss
but those that have done it, admit that they feel ill a lot of the time, also
tired and thirsty. One of the problems is that people who are doing this are
unlikely to own up to it at the time but there will be many who admit that they
have done it at some time in their lives.
For parents who are wondering why their daughter’s blood glucose levels
are erratic, this could be one possible explanation.
· Genetic variation may account
for severe PMT
Researchers have found a genetic variation that makes women more
likely to suffer from the most extreme form of premenstrual tension or
syndrome. They carried out genetic tests on women suffering from premenstrual
dysphoric disorder (PMDD) - sometimes referred to as severe or extreme PMT and
discovered that the women had mutations in hormone receptor genes and also in a
gene that regulates the part of the brain responsible for mood.
The symptoms, such as severe depression, irritability and anger can have a
severe impact on quality of life, both for the women and their loved ones. This
research is only at a very early stage and more work will have to be done but
eventually it could help scientists to develop a diagnostic test and discover
drugs to treat it. [Biological Psychiatry,
·
Poor sleep
may lower women’s libido
A
study has found that low libido during menopause may be linked to disturbed
sleep and this is the first time that sleep disturbances have been
independently associated with diminished sexual desire. Of the 341 women in the
study, 64% reported a low libido and 43% said they had trouble sleeping. The
study author suggested that it seems reasonable that night sweats can disturb
sleep and poor sleep can reduce energy levels for everything, including sex. [American Journal of
Obstetrics and Gynecology, June 2007]
NEWS IN BRIEF
Inhaled
insulin has failed
Exubera,
the first inhaled insulin has failed to appeal to doctors and patients and in
October 2007 the manufacturers, Pfizer, announced that they were pulling it
from the market and would be offering advice over the next 3 months on
alternative products. The lack of sales is blamed on
the size of the inhaler, injections of long-acting insulin still being
necessary and concerns about long-term safety.
IDDT has not been alone in saying that industry should have
consulted people with diabetes about what is important to them and for the
majority, injections are not the worst part of having diabetes – it is the
daily grind of living with testing, with thinking about food, with planning
ahead, the fear of complications – do I need to go on?
The
financial press referred to Exubera as a ‘market flop’ and that Pfizer is
writing off the huge amount of $2.8billion (€1.96bn).
Global sales only achieved $4million.
Lilly and Novo Nordisk are developing their own versions of
inhaled insulin expected to reach the market in 2009 and 2010/11 respectively.
Both companies have stated that they will continue to develop these products.
We shall see……….
Nasal
insulin delivery
Nasal
drug delivery systems have been around for some time but there have been
problems. Now NanoDerm, an Israeli company, has developed a system that seems
to combat the difficulties and make insulin delivery through the nose not only
a viable option but perhaps a better option that inhaled insulin. The system is
based on nano-droplets [very, very tiny] of 10-50nm that form a gel in the
nostril so far less insulin has to be given nasally to lower blood glucose
levels than with inhaled insulin. These lower volumes are less likely to cause
irritation to users. It's already been tested in rabbits…………
Changes in
warnings for Zyprexa
Many
psychiatrists have expressed concerns that the antipsychotic drug Zyprexa
[olanzapine] raises blood glucose levels that can lead to Type 2 diabetes. On
October 8th 2007, the manufacturers, Lilly, officially agreed that
Zyprexa carries a greater risk of causing raised blood sugars than almost all
other drugs in the same class. Following discussions with the FDA [the
REPORT COMING SOON – ‘INSULIN AND CANCER’
The
first International Workshop ‘Insulin and Cancer’ took place in
PARTICULARLY
FOR CHILDREN………….
We
reported in the October 2007 Newsletter that Eli Lilly launched a second
re-useable insulin pen product – the Humapen Luxura HD pen for use with Lilly
insulin 3ml cartridges. This is now available in the
To
support children and their carers, Lilly are providing a pack of educational
materials with the Humapen Luxura HD featuring cartoon character Hu-Mee the
Frog and including a booklet, lunchbox, insulin pen case, monitoring diary and
Hu-Mee stickers. For more information visit www.lilly.com
REPORT OF THE 2007 ANNUAL MEETING OF IDDT
As ever, the meeting was well attended - over 130
members and non-members. Many described the meeting as enjoyable and thought
provoking – just what it should be. It was an opportunity to look at different
ways of living with diabetes and the various treatment options. It once again
made us realise that many people with diabetes have never been given choices
whether these are choices about diet, types of insulin or different insulin
regimes.
‘30 Years
of Synthetic Insulin, are people with diabetes getting the best deal?’
Co-Chairman, Jenny Hirst, opened the meeting with
the launch of this new IDDT Report. The report highlights a recent article [ref
1] by Professor Edwin Gale et al entitled ‘Nice
Insulins, pity about the evidence’ in which he acknowledges that there is
no evidence of benefit from the use of insulin analogues and questions whether
people with diabetes are getting the best deal. “When the choice is between treating 150-200 patients with
long-acting analogues instead of ‘human’ insulin or employing a full-time nurse
specialist educator at the same cost – which would be best for patient care?”
When children with diabetes are receiving
suboptimal care, and Primary Care Trusts (PCTs) are unable to fund educational
programmes, diabetes specialist nurses or provide essential self testing strips
for diabetic patients, it is shocking that PCT budgets are being consumed by
ever-increasing insulin costs that provide little benefit to patients.
The Report calls for:
·
Studies of ‘human’, analogue and animal insulins to
be carried out to compare the outcomes which are important to patients -
mortality rates, complication rates and quality of life.
·
The long-term safety and efficacy of insulin
analogues to be established.
·
Investigation into the cost effectiveness of
insulin analogues to ensure that valuable NHS resources are not being wasted on
these significantly more expensive insulins that have no substantial advantages
over ‘human’ and animal insulins.
·
The development of comprehensive guidelines on the
use of all insulins by National Institute for Health and Clinical Excellence
[NICE] to provide informed choice and to protect the safety of people with
diabetes.
IDDT has raised
these important issues by sending the Report to MPs who have supported IDDT’s
call for insulin choice, to primary care trusts all of whom need to look at
their expenditure on diabetes and to diabetes associations across the world,
especially important for countries where safe but affordable insulins are vital
for the survival of people with diabetes.
If you would
like a copy of this Report, please contact IDDT on 01604 622837, write to IDDT,
Ref 1 Nice Insulins, pity about the evidence.
Diabetologia (2007) 50;1783-1790. Holleman F, Gale EMA.
‘How you can achieve normal blood sugars with diet
and insulin’
Dr Katharine Morrison, a GP whose teenage son has
Type 1 diabetes gave a talk on how she has chosen to look after her son’s
diabetes. The points she made were:
People with diabetes deserve the choice over:
·
Dietary education
·
Insulin regime
·
Blood sugar monitoring regime
·
Complications monitoring regimes and treatment of
complications.
What levels of blood sugar control is right for
you?
·
What are your personal circumstances? What degree
of blood sugar control do you want to have? For instance, safe target blood
sugars differ if you live alone, are a driver, are pregnant or are a teenager,
a toddler or are elderly.
Dr Morrison’s choice for her son is to try to
completely avoid diabetic complications from high and swinging blood sugars and
to try to achieve normal blood sugars his regime is:
·
Low carb / low glycaemic index diet with good carb
counting skills
·
Avoid snacks – a protein rich breakfast helps to
avoid hunger pangs for snacks.
·
7 units maximum for each insulin injection
·
Careful matching of insulin type to food type
·
Consistent exercise regime.
To absolutely minimize the risk of complications Dr
Morrison suggested:
·
Testing frequently with very strict levels of
eating to the meter test results
·
Fasting and pre-meals targets of 4.7 to 5.2 mmols/l
and one hour after meals below 7.2mmols/l and 6.0mmols/l 2 hours after eating.
·
Resistance training exercises.
Dr Morrison pointed out that this type of regime
requires time to learn all the information, to plan and prepare food and to
learn the skills involved. Audience discussions emphasised the need for choice
of different approaches and many people felt that this strict and time
consuming regime was not a practical option for living as normal a life as
possible with diabetes.
‘Fitness, Motivation and Adherence’ was the theme
of John Roberts’ talk.
Between 20 and 70% of people starting an exercise
programme will drop out within 6 months but John pointed out that people do not
plan to fail, they just fail to plan. He highlighted some the reasons for
stopping exercising [familiar to many of us!] and gave us some tips to overcome
these:
“I get frustrated when I do not get results” – ask yourself if your goals are realistic and remember that progress can
take weeks and getting support can help.
“I get bored easily” – so try new routines, join
an exercise group, implement exercise into everyday activities.
“Exercise is not enjoyable or fun for me” – combine it with something you do enjoy, vary the type of exercise,
watch TV or read during exercise.
“I don’t know how I am going to find the time” – so break up your exercise to short sessions, limit TV watching, make
commitments to specific times.
“I’m tired” – exercise at the same time, you will feel more energetic
after you begin, keep regular bed times.
John’s final points were:
Discussion groups
This year more time was given to discussion groups,
the most popular ones being about insulin regimes and carbohydrates, showing
once again the need for people with diabetes to be provided with better
education.
This was followed by a panel discussion and the
meeting ended with Dr
IDDT would like to thank all the speakers and group
leaders and the people who attended for making our Annual meeting such an
interesting and enjoyable day.
IDDT
Annual Conference 2008
A
date for your new diary – IDDT’s Annual Meeting for 2008 will be held on
Saturday October 18th. We hope that you will be able to join us!
SICK DAY RULES
Professional advice – sometimes it needs a government health warning!
A member of IDDT who attended our Annual Meeting
brought with him a leaflet from his diabetes clinic ‘Diabetes and Sick Day Rules’. He has no wish to be difficult but
he was extremely concerned at the advice being given. So I might add was
everyone else.
In the section for people with insulin-treated
diabetes, these Sick Day Rules quite correctly say that:
·
NEVER STOP insulin injections
·
illness such as ‘flu or a chest infection may cause
the blood sugar to rise [actually any
illness or even slight infection, can cause blood sugars to rise].
·
blood sugars should be measured at least four times
a day, before meals and before bed.
·
If the appetite is poor replace normal meals with
fluids - milk, Lucozade, fruit juice.
But the problems arise when it gives advice on increasing the doses of
insulin!
It advises that:
“if the blood sugar is between 10 and 15mmol/l give 6 units extra of
clear insulin before each meal and at bedtime; if between 15 and 20mmols/l give
8 units extra of clear insulin before each meal and at bedtime; if over
20mmols/l give 10units extra of clear insulin before each meal and at bedtime.”
Just at a glance there are some obvious mistakes
here that could be dangerous!
·
It says clear insulin – for those on rapid-acting and long-acting
analogues, both insulins are clear. It should not
be assumed that people know that it actually means the short or rapid-acting
insulin – what about the relatively newly diagnosed?
·
It doesn’t say whether people have to increase their insulin dose as a
result of one higher than normal blood test or several. Are people supposed to increase their daily dose by 24 units [4 x 6
extra units advised] as a result of one test that could just be an odd one?
·
It advises on insulin dose increases without any regard for the dose of
insulin being used on normal days. Some people only
take 6 units or even less before each meal while others may take 20 or more
units – so 6 extra units in some people is a doubling of the normal dose but in
others it is a much smaller percentage increase.
·
It does not consider the different types of insulin that people may be
using which have different peaks and durations of actions. If people are using human or animal insulins before meals with twice
daily intermediate-acting insulin, this advice could lead to hypoglycaemia as
the short-acting insulin lasts longer and the intermediate insulins peak while
there is still some short-acting working.
·
What about people using pre-mix insulins? Whether using human, analogue or animal pre-mix insulins, then these
‘sick-day rules, simply do not apply to them as most of them will not have any
‘clear’, short-acting insulin! Unless of course, it is OK to take pre-mix
analogues which are clear. I don’t know – but isn’t that just the point?
The possible thinking behind these Sick Day Rules……..
Perhaps these ‘Rules’ were developed on the basis
that everyone is on the same type of insulin with the same regimes, which as we
know is not the case. Perhaps the authors of the ‘Rules’ believe everyone with
diabetes is the same, which we know is not the case. Perhaps they believe that
everyone takes large doses of insulin regardless of the type of insulin used,
which they don’t as those on animal insulin tend to take less insulin, as do those
on low or restricted carbohydrate diets.
To be fair these Sick Day Rules do advise people to
seek medical advice if blood sugars are over 20 on more than two occasions, if
vomiting develops, if moderate or large ketones are present or if you don’t know
what to do. But with Sick Day Rules like these, how can people be expected to
know what to do? We can only advise that you check that you know the correct
Sick Day Rules for you, for your insulin and for your regime.
WRONG SIZED SHOES
A study at
If shoes are too narrow, tight or loose, they can
cause blisters or ulcers which can be slow to heal and lead to infections.
Another concern is that people with neuropathy may choose shoes that are too
tight because the increased pressure makes them feel the right size. In
addition, feet get larger and broader in older people but they often continue
to buy the same size. The study showed that a third of the patients said they
took a different shoe size from the one they were actually wearing, probably
due to the fact that shoes sizes vary from maker to maker. It also showed that
only 29% of people checked their feet and legs regularly for any sign of damage
that could lead to problems and 22% never checked their feet.
There is a call for shoe manufacturers to
standardize their shoe sizes and increase the range of width fittings. But
there is a clear message here for people with diabetes – having well-fitting
shoes may be expensive but not as costly as the damage that can be done by not
doing this!
CHANGES WE NEED TO SEE IN 2008
Restriction of blood glucose test strips
There are increasing numbers of people having
restrictions placed on the number of test strips being supplied by their GP
including people with Type 1 diabetes and those with Type 2 using insulin. The
Dept of Health has stated that there are no restrictions on the numbers of
blood glucose strips that can be supplied, therefore restrictions are being
made at local level, either by GP practices or by Primary Care Trusts [PCT].
There is research that shows that long-term blood
glucose measurements [HbA1cs] are not improved by blood glucose testing.
However, this research does not take into account that blood glucose testing is
not just a matter of blood glucose control but also of giving people the
security of knowing their blood sugars at any given time, especially important
for people who have reduced or no hypo warnings. We know that some people take
no action as a result of blood glucose tests but this is often because they
don’t know what action to take, so it is a failure in diabetes education, not
their fault and not a reason to restrict strips.
Contradictions and mixed messages
·
We are told to test before every meal and before
bed
·
We are told to test every time we drive and if we
are driving a long way, to test every 2 hours. Where accidents have occurred,
courts are increasingly looking at the numbers of tests people carry out in
terms of whether or not they are taking a responsible approach to they
diabetes.
·
When ill, Sick Day Rules advise testing more
frequently than normal.
·
Extra testing if blood glucose levels go high or
low for any reason.
Many people are only being supplied with one box of
25 strips for a month and this does not even cover one test a day!! Are we
going back to the old days where people have to buy their strips, in which case
those that can afford the high costs of strips will test and those that can’t
won’t.
Diabetes clinics are giving all the above advice
and even slapping wrists for not testing enough but when it comes to obtaining
a prescription – it’s a different story! The practice staff refuse to supply
test strips or say to people using insulin ‘you
only need to test 2 or 3 times a week’. What value does this have to
anyone?
What action can we take?
As there are no restrictions placed on the supply
of test strips by the Dept of Health and their response to complaints is that
Primary Care Trusts decide how to allocate their funding, then it has to be up
to us as individuals to take action at local level. So if you do not receive
the number of test strips you require:
In IDDT’s experience, the complaint to the practice
manager usually results in the required number of strips being supplied but if
it doesn’t, then make a complaint to your local Primary Care Trust.
Raising the profile of Type 1 diabetes
A frequent comment made to IDDT is that Type 1 diabetes is being
sidelined in favour of Type 2 diabetes both in terms of research and public
awareness.
Research - one only has to look at medical journals to see
that the vast majority of research in diabetes is investigating Type 2
diabetes. While we can understand that Type 2 diabetes is reaching epidemic
proportions and costing health providers huge amounts of money, this is not a
reason to lose sight of the importance of research into Type 1 diabetes. The
two types of diabetes are quite different and should be treated as such for
funding and increased funding for either condition should not be at the expense
of the other.
Many of those who have grown up with Type 1
diabetes can’t remember life without it, whereas people with Type 2 diabetes
have had at least 40years free from diabetes. Type 1 diabetes cannot be
prevented and it is a lifelong condition so the importance of research to
investigate the unanswered questions should never be forgotten.
In answer to a Parliamentary Question
on diabetes research expenditure [Oct 31, 2007] it was stated that the
Department of Health supports NHS research and development through the National
Institute for Health Research [NIHR] which presently includes a study involving
identical twins with Type 1 diabetes. It also funds the
Public awareness – in many ways we have
stepped back in time and the good work done in the past to raise the profile of
Type 1 diabetes and the needs of those with it, has been undone. All too often,
thanks to increased publicity about Type 2 diabetes and often inaccurate press
coverage, the public perception is that ‘diabetes’ is caused by being
overweight or obese with no differentiation between Type 1 and Type 2 diabetes.
Even this is incorrect because there can be a hereditary factor involved in
Type 2 diabetes. But above all, this misconception that both forms of diabetes
are caused overweight and lack of exercise carries with it the belief that
diabetes per se is self-inflicted and one of the common statements to slim
people with Type 1 is “Well you must have
been overweight as a child”!!!!
While is extremely irritating, the underlying
problem is much greater than just irritation. The lack of differentiation between
Type 1 and Type 2 diabetes and the belief that diabetes is self-inflicted can
and does affect the public attitude to those with Type 1 diabetes – less
understanding of what their life with diabetes is really like and less
understanding of their needs. This can have far reaching consequences from
attitudes of employers, teachers, friends to reduced donations for research.
IDDT plans for 2008
We are discussing ways to raise the profile of Type
1 diabetes and the need for more research and we would like to hear your views
and ideas, so please contact Bev or Jenny at IDDT on 01604 622837 or e-mail enquiries@iddtinternational.org
If you have internet
access, you can start by signing a petition on the
“We the undersigned petition the Prime
Minister to increase funding for research into a cure or alternative long-term
treatments for diabetes Type 1.”
Injecting and testing at school
In the last year one of the most frequently raised
issue by parents of young children with Type 1 diabetes is the difficulties
they are experiencing at school with injecting and blood glucose testing.
According to a report published on World Diabetes Day: “Children’s health is being put seriously at risk and thousands of
families are suffering emotionally and financially because of a lack of support
for children with diabetes in schools.”
This is partly being put down to school staff not
being given enough training to help children with diabetes to manage their
condition. Also blamed is that when surveyed, 70% of schools said that where
children are unable to give insulin injections themselves, parents have to come
in and do it for them. The charities involved in the survey and subsequent
report have said that this is unacceptable as it can alienate and isolate
children from school life and have serious repercussions for families. While
this is absolutely true, it is worth remembering that long verbal and written
battles between parents and schools also has repercussions – it risks the
parents being labelled as ‘nuisance parents’ and draws even more attention to
the child with diabetes which can also cause him/her to feel alienated and
isolated.
This is a thorny problem but as with any other problem, there are two
sides to the story. Undoubtedly the school system should provide for children
with diabetes at school and Government Guidance [Managing Medicines in Schools
and Early Years settings] requires schools to make arrangements for teachers to
voluntarily administer medicines. However, teachers cannot be compelled to give
injections, so it can be a matter of persuading a teacher to help.
A new website www.medicalconditionsatschool.org.uk
was due to be launched in October but at the time of writing it is still not
available. Hopefully this will provide clear guidance for both teachers and
parents.
But we must look further and ask why has this problem arisen now?
Lunchtime injecting and testing at school has become much more of a
problem as a result of multi-daily injection regimes [MDI] with insulin
analogues. Rapid-acting insulin only has a short duration of action and doesn’t
last long enough to cover lunch. If young children are on a regime that
requires a lunchtime injection and at least one blood glucose test during the
school day, what are parents supposed to do? At the risk of IDDT being
outrageous yet again, there are other ways and we suggest asking several
questions, the first being the most important of all.
·
What is the evidence for children being on 4 daily
injections a day and has this evidence taken into account quality of life? Does
injecting at lunchtime make your child feel different from the rest of the
class whoever carries out the injections? Is this causing your child extra
stress [and this can raise blood sugars]?
·
Have all the choices of insulins and insulin
regimes been discussed with parents and children?
·
Should insulin analogues be used in children?
·
In prescribing MDI regimes, are clinics are fully
aware of the difficulties that arise at schools and are they taken into account
when transferring children to pre-meal injections?
Looking at the evidence for multi-daily injections in children
Firstly, studies which suggest that MDI is the best regime for children,
nearly always quote the famous 1991 DCCT study which showed that tight control
with 4 daily injections [MDI] results in better control [HbA1cs], less
long-term complications but importantly, also a threefold increase in severe
hypoglycaemia. But, and it is a big but, this study was carried out in highly
selected ADULTS with Type 1 diabetes – NOT children, so it cannot
and should not be assumed that the DCCT findings apply to children. However,
there are two recently published long-term, large-scale studies investigating
insulin regimes in children that have surprising results and raise serious
questions about modern MDI treatments for children.
First study:
Prevailing therapeutic regimes and predictive factors for prandial insulin
substitution in 26, 687 children and adolescents with Type 1 diabetes in
The researchers classified the information about 26,687 children treated
from 1995 to 2005 in 152 paediatric clinics, average age of 13.6 years and
average duration of Type 1 diabetes of 5.4 years. 73% were treated with 4 or
more daily injections [intensive therapy], 14% with continuous subcutaneous
insulin infusion [pumps] and 13% with 1-3 injections per day [conventional
therapy].
The researchers concluded that:
·
87% of the children were treated with
intensive or pump therapy but while this percentage increased over the period
of the study, the average HbA1c [approx 8.0%] was almost constant – it did not
improve.
·
Those using insulin analogues received
up to 11% higher insulin doses per day compared with those treated with human
insulin – and higher insulin doses can lead to problems.
Second study: Continuing
stability of centre differences in pediatric diabetes care: do advances in
diabetes treatment improve outcome? Diabetes
Care, September 2007
This international study in 21 paediatric diabetes
centres investigated the influence of changes in insulin regimes and other
factors on HbA1cs, hypoglycaemia and ketoacidosis. The 2,269 participants aged
between 11-18 had had Type 1 diabetes at least a year. Fourteen of the centres
had participated in previous studies so allowing a direct comparison of
glycaemic control between 1998 and 2005.
The average HbA1c result for the whole group was
8.2 and the HbA1c results for the different regimes were as follows:
Regime
HbA1c 8.2
Insulin dose [by body weight]
Miscellaneous 8.2 0.66
Twice daily
premix 8.6 1.01
Twice daily free mix 7.9 1.00
Thrice
daily 8.2 1.24
Basal bolus 8.2 1.03
Pumps 8.1 0.92
The researchers concluded that:
Despite many changes over the past 10 years
including increased use of insulin analogues, basal bolus regimes [4 injections
+ a day] and pumps:
·
participants in the 2005 study had a higher BMI
[weight] and were on more intensive regimes than in the 1998 study.
·
There has been no significant improvement in HbA1cs
and no difference in the frequency of hypoglycaemia.
·
Those using twice daily free mix of soluble/regular plus NPH [intermediate-acting] had
lower HbA1cs than all other groups. “This
suggests that the so-called conventional regimes may be superior to modern
intensive regimes.”
·
HbA1cs on pump therapy were not significantly
different from the total group even in centres where larger numbers of children
were using pumps.
The researchers concluded that despite major and
continuing changes in insulin and insulin regimes, glycaemic control has not
improved over a decade in 21 international centres.
Then we have to look at the evidence and
manufacturers’ advice for the use of insulin analogues in children
There are ongoing concerns about the unknown long-term safety of insulin
analogues in adults and children due to their similarity to IGF-1 [insulin-like
growth factor]. In addition, trials investigating the safety and efficacy of
insulin analogues in young children have not taken place, even in older
children the trials have only been of short duration and in relatively small
numbers of children. So the safety and efficacy of analogues in these age
groups are unknown. The Special Product Characteristics documents produced by
the manufacturers as part of the drug approval process make the following
statements:
NovoRapid - no studies have been performed in children under the age of 2 years.
It can be used in children in preference to soluble insulin human when a
rapid onset of action might be beneficial.
Humalog - should only be used in children in preference to soluble insulin when a
fast action of insulin might be beneficial.
Lantus - for the treatment of adults, adolescents and
children of 6 years or above.
Due to limited experience, the efficacy and safety
of Lantus could not be assessed in children below 6 years of age.
Levemir – the efficacy and safety of Levemir were
demonstrated in children and adolescents aged 6 to 17 years in studies up to 6
months but have not been studied in children below the age of 6 years.
So back to injecting at school………..
Glycaemic control with safe insulins and a happy childhood are paramount
for our children with diabetes. The above evidence gives choices that parents
and clinics may not have considered. There is no way that IDDT would recommend
that the best treatment for children should be sacrificed because the school
system cannot handle it. But we have to be sure that children with diabetes are
receiving the best treatment based on the available evidence. In all the
coverage of this issue, the question of whether the best treatment for children
is multi-daily injections with insulin analogues is never addressed.
If injecting at school is a problem or your child does not want to have
so many injections, the alternative of twice daily injecting is a very real
option especially as recent research has shown that twice daily injections of
short and intermediate-acting insulins appear to give the best HbA1cs, require
a lower daily insulin dose that reduces the risk of diabetic ketoacidosis and
there is less weight gain!
Note: this issue is covered in greater detail in the November 2007 Parents’
Bulletin and this includes how a regime of free mix short and intermediate
acting insulins works. If you would like a copy of this article, call IDDT on
01604 622837 or e-mail enquiries@iddtinternational.org
IDDT NEWS
·
IDDT Membership cards to help you
Many of our members have asked us for both
membership cards and cards that say ‘I have diabetes’ so in response to this we
now have a credit card-style IDDT membership card. One side confirms membership
of IDDT and the other states:
‘I have diabetes. If I am disorientated or conscious, please call an
ambulance on 999’.
The cards will be sent out with your next
membership renewal letter but if you would like one immediately then call us on
01604 622837 or e-mail enquiries@iddtinternational.org
People who pay by standing order will receive their
new cards during January 2008.
NB Clearly this card must NOT be used by members who do not have diabetes.
·
Just to
remind you……..
‘Insulin: A Voice for Choice’ By Arthur Teuscher
We told you about this book in our October 2007
Newsletter described by James Le Fanu, MD, FRCP, Columnist for the Daily
Telegraph, as a “lucid analysis of the
saga of human insulin should be compulsory reading for patients and
professionals alike. This is a cautionary tale of how an over-mighty
pharmaceutical industry has, under the guise of progress, adversely influenced
the best interests of those with diabetes.”
On October 22nd 2007, James Le Fanu
wrote a piece in the Daily Telegraph describing the adverse effects that some
people have with human insulin, how this may affect as many as one in four
people and how this has largely fallen in deaf ears. The article included
IDDT’s details and once again, we received many, many phone calls from people
who recognised the symptoms in themselves but knew little about animal insulin
and by people who had been informed that animal insulins were no longer
available – not so of course. We are grateful for Dr Le Fanu for helping to
keep people informed.
If you would like a copy of ‘Insulin:
a Voice for Choice’ it can be purchased from IDDT for £12.50. To place an
order, contact IDDT at
STANDARDISATION
OF THE HbA1c TEST
The
first stages of an international study have shown that the HbA1c truly
represents average blood glucose levels measured at home by patients. If the
final results of the study are the same as these earlier ones, then it is
likely that doctors will recommend that HbA1c results will be reported in new
average glucose units [AG] to enable patients to understand the results more
easily. At present the HbA1c results are measured as percentage units and self
monitoring as mmols/l which can lead to confusion. The aim is that the HbA1c
results and self-monitoring can be reported in the same units.
The
International A1C-AG study is comparing HbA1c results to thousands of blood
glucose test results measured in 700 volunteers of various races and
ethnicities with Type 1 and Type 2 diabetes and in people without diabetes over
a 4 month period.
By
comparing the measurement of HbA1c with the average glucose levels, an equation
can be derived so that HbA1c results can be interpreted accurately as an
average blood glucose level or AG. The study was scheduled for completion by
September 2007 and already experts are recommending for standardisation across
the world.
FROM
OUR OWN CORRESPONDENTS
Consultants
really should listen to patients
Dear Jenny,
I concur with the points being made in the July Newsletter
[Listened to at Last] - consultants really should listen to patients.
I have had diabetes for over 20 years and in Sept 2006 I
very reluctantly went back on to human insulin as my sugar levels were
persistently high. For almost 18 months the consultant had been including
on the notes that he sends to myself and my GP, that I wouldn't listen and
there was nothing he could do without me transferring to the new synthetic
human insulins.
Being a qualified engineer I could see the advantages of a
faster acting short insulin, and reluctantly agreed, taking 3 dosages of short
and initially 1 long but subsequently changed to 2. A diabetic nurse helped
with the transfer and she insisted that one unit adjustment was all that was
needed at a time, but I quickly proved that her incorrect, and 2 was
required. When she went on holiday, a colleague took over and calculated
that indeed, 2 was correct and that the 2nd long-acting insulin would be better
with the evening meal, rather than prior bed. This did help, and we
constructively increased the dosages quite a lot – quite a difference in
approach which seemed to be more logical and worked better.
But my sugar levels were never really under full control,
even varying from 20 in the mornings down to 2, but on a random basis. My
HBA1c had reduced, but with such widespread variations only on odd days,
something was still wrong. After 10 months I began to have blinding headaches,
chronic nightmares at
The nurse approached the consultant on my behalf, as my GP
wouldn't give any answers, always referring me back to the Hospital, despite
the fact that he was the Practice Senior Manager, Diabetic contact, and they
achieved top points for extra payments. As the Consultant was unable to
bring a regular visit forward by even 4 weeks, my GP did agree to change me
back to pork insulin.
After only 3 injections, most of the above symptoms
disappeared, and the high and wide swings of sugar readings disappeared. I
still have to have the latest HBA1c test, but believe this will again be
down. True I still get some variations, but not as much as before. I
am on similar dosages as the human, but about twice as much as the previous
time on pork.
Over 20 years ago I started on pork mixtard, went on
to monotard, then human insulin when the medical profession in its wisdom
imposed the ‘overnight’ change of everyone to human. I only used human insulin
for 3 days, as I was so ill, with many of the symptoms mentioned
above. About 3 years later I had suspected colitis, and was transferred to
human for about another 3 years, and was reasonably OK, except towards the end
when I was really struggling again. Again many symptoms disappearing after
my latest transfer back to animal. Overall I have quite a brittle
condition, but consider many of the problems I have today are as a result of my
time on human. When in
My other concern is that my consultant stood up at his
annual Care Group review 2 years ago and said he was a big believer in animal
insulins. 12 months later he was proud to announce he had been working closely
with insulin manufacturers with their new synthetic human versions, and was
very impressed with them. (ie Novo Nordisk Detemir and NovoRapid) I will not comment
to my reactions. Was this the reason to push everyone on to human?
Try listening to the patient once more!
Mr
S.M.
I
know I shouldn’t blow my own trumpet but I just had to let you know that after
40 years of Type 1 diabetes I have just received the result of my eye screening
which showed no signs of diabetes affecting my eyes – thank goodness for animal
insulin. While I was on human insulin I had terrible problems with my eyes and
required stronger lenses each time they were tested but since I have been on
animal insulin they have stayed the same.
I
am also hitting HbA1cs around 7 so all in all, I am feeling quite proud of
myself. I have to say that none of results came easy as it is an uphill
struggle to keep things right. To put it into context, I take one tablet every
morning for my blood pressure and the problem is solved but with diabetes it is
a 24/7 job – testing and varying the insulin dose to suit. Even when you think
you have got it sorted, it creeps on when you are not looking and goes up or
down for no known reason! So as I said, you have to keep an eye on it all the
time but it pays off.
Mrs T.T.
Metformin and weight loss
Dear
Jenny,
I
was pleased to read about metformin in your October 2007 Newsletter.I was
diagnosed with Type 1 diabetes in 1997 and prescribed human insulin. After
several years, having read all your information, I eventually had my insulin
changed to animal insulin [much to the disgust of my then consultant!]. My
weight steadied with animal insulin I stopped gaining. Then in August a new
consultant prescribed metformin for me and I have lost about 10lbs since then
and I feel fine. This has definitely given me the incentive to try to lose a
bit more.
I
enjoy the Newsletter. Keep up the good work
D.J.
Friendly and positive atmosphere
Dear
Jenny
I
am sure you must have received a lot of compliments after the IDDT conference
last Saturday [October 13th]. However I would just like to add
our thanks for a mega informative day which was of so much benefit to us
both.
The
atmosphere was so positive and friendly that for the first time since being
diagnosed I no longer feel alone. Although it will take many hours to recall
and absorb a fraction of what we heard, it was great to meet you and your team
so thank you for all your hard work and creating the IDDT.
Kindest
regards
Mr and Mrs N.T.
South
NOW
WE HAVE ‘DOUBLE DIABETES’!
In the past few
years doctors have started to see patients with both Type 1 and Type 2 diabetes
– meaning that they are not producing insulin [as in Type 1 diabetes] and the
insulin they inject is not being used properly by the body [as in Type 2
diabetes]. So they are calling this ‘double diabetes’. [New Scientist Oct 2007]
DIABETES RELATED TO HIP FRACTURES
A
review of 16 studies involving over 800,000 people who sustained a total of
nearly 140,000 hip fractures has found that having diabetes, especially Type 1
diabetes, makes people more likely to have hip fractures. The review of 12
studies showed that people with Type 2 diabetes are 70% more likely to fracture
their hip and in the review of 6 studies, those with Type 1 over 6 times more
likely to do so. The researchers suggest that the cause could be diabetes
complications, such as retinopathy, neuropathy, low blood sugars and stroke making
people more likely to fall.
A study [J Cell Biochem, Nov 2007] refers to bone loss [which can
lead to osteoporosis] as ‘a less well-known complication of Type 1 diabetes’
and that there are differences between bone loss in Type 1 diabetes and
age-related bone loss. It suggests that possible contributors to the
suppression of bone formation in Type 1 diabetes include: increased marrow
adiposity, hyperlipidemia, reduced insulin signaling, hyperglycemia,
inflammation, altered adipokine and endocrine factors, increased cell death,
and altered metabolism.
Another
study carried out in
People
with Type 2 diabetes have an increased fracture risk thought to be caused by
increased risk of falling. The research suggests that people with Type 2
diabetes may benefit from early visual assessment, regular exercise to improve
muscle strength and balance and specific measures for preventing falls.
A drug to treat osteoarthritis pain has been suspended
And by the way……… in the US the manufacturers
of Vioxx, Merck, has agreed to pay $4.85 billion to settle 27,000 lawsuits by
people who claim they or their family members suffered injury or died after
taking the drug. This is one of the largest settlements ever in civil
litigation with Merck’s legal defence fees running at $600 million a year!
RESEARCH AND THE INTERNET – THE NEED TO BE CAREFUL
I was looking at one of the recommended websites www.childrenwithdiabetes.com
when I came across the abstract for a study with the title ‘Long-term efficacy
of insulin’ [published in Curr Med Res Opin 2007 Nov 5].
The objective of the study was: “To investigate the effect of initiating
insulin glargine (LANTUS), a once-daily basal insulin analogue, plus an
educational programme, on glycaemic control and body weight in patients with
type 1 diabetes in clinical practice.”
The conclusions were interesting: “Patients with type 1 diabetes treated with
insulin glargine over 30 months in combination with educational support and close
clinical supervision decreased their HbA(1c) levels without weight gain versus
previous treatment with NPH insulin or insulin lente.”
So it would not be unreasonable to assume that
everyone would be better switched from NPH [intermediate-acting insulin eg
Insulatard] or lente [long-acting human insulin not available in the
This study looked at the records of patients who
were treated with NPH or NPH+Lente who then received a diabetes education
programme before being changed to glargine and being given close supervision
for the 30months of the trial. In addition, to glargine, they were also given
short-acting insulin with each meal. I’m sure you can spot the differences.
1.
On NPH and/or lente insulins, they did not receive
an education programme.
2.
On NPH and/or lente insulins, they did not receive
close supervision.
3.
On NPH and/or lente insulins, they did not receive
short-acting meal time insulins
So the research did not compare like with like and
therefore it could not, or more correctly, should not have come to the
conclusions it did. But then if they had compared like with like, glargine may
well not have appeared any better than the old tried and tested insulins!
There are two messages for us here:
·
Research - just because research is published does not
means that it is good quality research. Before we let research influence our
decisions, we need to look closely at the quality of the research itself, who
funded it and whether or not the authors have any conflicts of interest ie drug
company connections.
·
Websites - this study was on an often recommended website
with no comments or criticisms and could so easily mislead people. So we need
to be very careful when looking at websites, recommended or otherwise, and
remember that a professional qualification on a website may appear to give it
credibility but it does not automatically mean that the information is valid or
correct.
The internet is a wonderful source of information
but it is has to be treated with caution and remember that anyone can put
anything up there but it doesn’t mean it is correct.
YOUR HEALTHCARE TEAM'S TARGETS AND WHAT YOU CAN EXPECT
In
this target-driven health system it is not always clear what is expected of us
and what we should expect of the health system. Targets are set by healthcare
teams and it is their job to try to ensure we achieve them. While we may not
achieve them, we should know what they are.
Targets your
healthcare team aim for you to achieve:
·
Blood pressure: 130/80mmHG is the
optimal target but 145/85 is the audit target for doctors
·
Diabetes control as
measured by the HbA1c test: less than or equal to 6.5 to 7.5 percent, where
realistic.
·
Cholesterol: total cholesterol
equal to or less than 4.0mmols/l, LDL [bad cholesterol] 2.0, HDL [good
cholesterol] equal to or greater than one 1.0 or an LDL reduction of 30%.
What you treatment
you should expect to receive:
·
Feet - a trained person
to carry out an annual assessment of your feet and referral where necessary.
·
Eyes - a trained person
to carry out an annual screening and referral where necessary.
·
Education - about
medication, diet, exercise and weight reduction where appropriate. This should
also include discussions about your treatment options and topics such as
driving, travelling etc.
Breath test to detect high blood sugars in children
Scientists may have
found a way of monitoring for diabetes in children using breath analysis
according to a study published in the Proceedings of the National Academy of
Science Journal. Children with Type 1 diabetes were found to exhale
significantly higher concentrations of methyl nitrates when they are
hyperglycaemic [high blood sugars]. It is hoped that this could lead to the
invention of a device that could warn people with diabetes of high blood sugars.
CONTINUOUS BLOOD GLUCOSE MONITORING IS GETTING
NEARER
One of the day to day worries for people with
diabetes and parents of children with diabetes is hypoglycaemia, especially at
night. A continuous blood glucose monitoring system with an alarm to warn when
blood glucose levels drop too low or go too high will give greater peace of
mind. We are not there yet but it is on the way.
US approves seven
day blood glucose monitor
In
June 2007 the U.S. FDA approved a blood glucose monitor for those over 18 which
measures glucose levels continuously for up to seven days. The STS-7 Continuous
Glucose Monitoring System measures glucose levels every five minutes throughout
a seven-day period and it is aimed at tracking patterns in glucose levels that
wouldn't be captured by finger prick tests that just give a snapshot picture at
any one time. However, the FDA advise that finger prick tests must be used to
decide on whether insulin doses should be increased.
The
STS-7 System, manufactured by DexCom Inc. of
And for children
In the
The
device uses directional arrows and display real-time blood glucose levels and
trend graphs. Warning alarms alert parents and patients when blood glucose
levels drop dangerously or rise above pre-set levels, even when children are
sleeping. It will help to provide a sense of comfort that hypoglycemia will not
go unrecognised and will be especially good for parents who get up all the time
because they are worried about night hypos.
The
device will show trends and patterns in blood glucose levels for instance the
effects of exercise, lifestyle and diet but it is not expected that it will
replace fingerprick tests - yet.
RESEARCH
NEWS
First patient successfully dosed
with pig cell implant
In
June Living Cell Technologies Ltd announced that it has successfully transplanted
6 people with Type 1 diabetes in a world-first Phase1/11 clinical trial under
current regulatory standards. The patients will receive two low doses of the
pig islet cells [DiabeCell] every 6 months over a 12month period. This first
low dose trial is to demonstrate safety. The company hopes to commercialise the
product for general use by 2012. The trial s taking place at Sklifasovsky
Institute in
Age-related macular degeneration [AMD]
and carbohydrates
AMD
is the most common cause of vision loss in older adults in the general
population. Researchers have carried out a study of 4,099 people between the
ages of 55 and 80 and classified them into 5 groups according to the severity
of their AMD and other factors.
The
results showed that people who had regularly eaten a diet with a high glycaemic
index [carbohydrates that quickly raise the blood sugar levels] had a
suignificantly increased risk of AMD relative to those who had eaten a diet
with a low glycaemic index [slowly absorbed carbs]. The researchers calculated
that 20% of AMD cases could have been prevented if the study participants has
consumed low glycaemic index diets. They state that AMD appears to share
several carbohydrate-related mechanisms and risk factors with diabetes-related
diseases, including eye and cardiovascular disease.
Cholesterol- reducing drug could
also prevent retinopathy
A
new study by the
A
large study conducted over 8 years in
Statins
and fibrates are already widely recommended for people with Type 2 diabetes to
help prevent heart attacks and now it appears that they may have another use –
to prevent nerve damage [neuropathy], a common complication of diabetes. The
study showed that statins and fibrates reduced the risk of developing
peripheral neuropathy by 35% or 48%, respectively.
Neuropathy
is the most common form of nerve damage caused by diabetes and affects about
50% of people with diabetes. Finding medications that help neuropathy has
proved difficult and still the usual advice is ‘good blood glucose control’.
The researchers state that people with diabetes should not shy away from taking
statins or fibrates but statins are usually the first choice because of strong
evidence of their protection against cardiovascular disease. [They do not
mention the adverse reactions that many people have when taking statins!]
SNIPPETS
Vinegar in the mornings!
Researchers
in
Onions cut heart disease risk
Meals
rich in compounds known as flavanoids reduce the risk of early signs of heart
disease according to research by the Institute for Food Research. The research
focused on one flavanoid, quercetin, found in tea, onions, apples and red wine.
It is metabolised very quickly by the
intestine and liver and is not actually found in human blood so the research
looked at compounds produced after quercetin is broken down by the body. They
found that in the case of the inflammatory process, one of the reasons arteries
fur up, eating 100g to 200g of onions had an impact on the cells lining the
arteries.
Spinach can reduce the risk of
age-related macular degeneration
Spinach,
kale, cabbage and other dark green leafy vegetables are high in an antioxidant
called lutein. New research studying the progress of 4518 people between 60 and
80 years old suggests that the lutein in these vegetables can reduce the risk of age-related macular
degeneration. The greatest source of lutein is in raw kale followed by cooked
kale, cooked spinach, cooked collard greens and cabbage. [Arch Ophthal,
2007: 125]
What next? Broccoli for the sun
New
research on 6 people [only 6 people!] has shown that suncream made from 3 day
old broccoli sprouts can reduce the effects of sunburn. Apparently, the
broccoli cream does not absorb UV light to prevent it entering the skin but
works by boosting the production of enzymes that protect the skin against UV
damage. [Reported
in the journal Proceedings of the National Academy of
Sciences]
Almonds may help weight loss
Almonds
are rich in mono-unsaturated fats and researchers in
Warning - Smoothies adverts got it
wrong
A
Smoothie advert that claimed that the fruit drink can rid the body of toxins
has been criticised by the Advertising Standards Authority [ASA]. The Smoothie
is made by Innocent Ltd of acai berries, pomegranate and blueberries. Acai
berries are a nut-like fruit that grows in the Brazilian rainforests which
contains high levels of anti-oxidants. The advert claimed that one of these
Smoothies contained ‘even more
antioxidants than the average five a day’ ie the five daily portions of
fruit and vegetables we are all supposed to eat. The ASA ruled that neither the
detoxifying nor the antioxidant claims could be backed by evidence and that
smoothies and fruit juice could only count as one of the five a day portions.
A
survey suggested that Innocent Ltd are one of the fastest growing companies in
the food industry fuelled by the popularity of ‘healthy’ fruit juices and
smoothies. Hardly surprising if everyone thought they were getting their five a
day in one hit!