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your-dietician · 3 years

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Introduction to Neuropathy – Diabetes Daily

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Introduction to Neuropathy – Diabetes Daily

What is neuropathy? And more specifically, what is diabetic neuropathy? What are the symptoms and how can you prevent and treat neuropathy?

When someone hears about the long-term complications of diabetes, problems with the feet, foot ulcers, and even amputations are often brought up and can be some of the scariest outcomes. What leads to these issues is something called neuropathy, or damage to the nerves.

But neuropathy, and those subsequent complications, aren’t by any means a given – and prevention is possible. What is neuropathy and what can you do to avoid it entirely, or minimize it so that you can keep your feet, and the rest of your body, as healthy as possible?

What is the difference between neuropathy and diabetic neuropathy?

Neuropathy is the term used to describe any damage to nerves in the body (for example, an injury from a car accident can damage the nerves). Diabetic neuropathy, or diabetes-related neuropathy, is the term used to specifically describe the nerve damage from high glucose levels (hyperglycemia) over the long term.

Diabetes can cause three main types of neuropathies: peripheral neuropathy (medically referred to as distal symmetric sensorimotor polyneuropathy), autonomic neuropathy, and focal neuropathy.

Peripheral neuropathy affects the nerves outside of the brain and spinal cord, and often leads to symptoms involving the hands and feet. “This is what most people associate with diabetes-related neuropathy,” said Chris Memering, a nurse and inpatient diabetes care and education specialist at CarolinaEast Health System in New Bern, North Carolina.

Peripheral neuropathy involving the feet is the most common form of diabetic neuropathy. Loss of function in particular nerve fibers can change sensation and reduce strength in the foot. Loss of sensation can lead to injury from shoes that don’t fit, stepping on sharp objects you can’t feel, or not knowing the sidewalk is too hot. Neuropathy can also lead to pain, burning or other unpleasant sensations which may respond to medication.

But diabetes isn’t the only condition that can cause peripheral neuropathy. Other conditions that can lead to peripheral neuropathy include heavy alcohol consumption, trauma, nerve entrapment (such as that which occurs in carpal tunnel syndrome), vitamin B deficiency, chemotherapy, and an autoimmune process that attacks the nerves.

Neuropathy can also affect the functioning of the autonomic nervous system (which controls things like blood pressure, heart rate, digestion, and bowel and bladder function). This is called autonomic neuropathy. Autonomic neuropathy can lead to a variety of complications.

“In diabetes care, many people are familiar with hypoglycemia unawareness, erectile dysfunction or female sexual dysfunction, gastroparesis [when the stomach can’t empty properly and digestion slows], neurogenic bladder [when the nerves that tell your brain to tighten or release the bladder muscles don’t operate properly], or orthostatic blood pressure changes [dropping blood pressure when you stand up],” Memering said, adding that all these could be a result of neuropathy.

Finally, focal neuropathy results from issues with one or more nerve roots and usually happens suddenly. Focal neuropathies often involve both motor functioning – such as weakness – and sensory deficits, which can cause discomfort and pain.

What causes neuropathy?

Chronic hyperglycemia can damage both small and large nerve fibers. Over time, elevated glucose levels, often made worse by high triglycerides (a type of fat that can be found in the blood) and associated with inflammation (the body’s natural way of fighting infection) can cause damage to the nerves. That damage disrupts the way nerves interpret sensory information and how the messages about sensation are transmitted to the brain.

Usually, nerve damage from high blood sugar levels happens in the long nerves first (which run from your spine down to your toes), which is why the symptoms of peripheral neuropathy occur first in the feet. “The length of time someone has lived with diabetes increases their risk of developing neuropathies, as does that person’s level of blood glucose, in terms of A1C, Time in Range, and glucose variability,” Memering explained.

In essence, higher glucose levels over time increases your risk for developing neuropathy. This was confirmed by the famous Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications study (EDIC). The studies showed that the prevalence of confirmed peripheral neuropathy was 64% lower among participants in the intensive management group (those who managed their blood glucose carefully with treatment and kept their levels as close to normal as possible).

What does neuropathy feel like?

Symptoms of neuropathy usually start in the toes and progress upward. The sensations experienced with peripheral neuropathy differ from person to person. Some describe the feelings they have as numbness or tingling, while others say it feels like burning. Some say they are sensitive to being touched and cannot bear the feeling of a sheet or blanket covering their feet, while others describe it as feeling like they are always wearing a sock or a glove.

“Ultimately, you could end up losing protective sensation – which can be very dangerous and puts you at risk of not realizing when a part of your body is hurting or being injured,” Memering said. “While you may be able to still feel pressure – you know you are stepping on the ground with your foot – you may not be able to feel pain if you step on something sharp or hot.” This means you might not withdraw your foot from the unsafe environment, harming it further, and without realizing the extent of the damage.

The biggest concern about peripheral neuropathy involving the feet is that the loss of normal pain sensation can lead to greater skin and tissue damage. “Injury can result in the formation of a foot ulcer, which, if infected, can progress to ongoing tissue damage that can lead to amputation,” said Dr. Robert Gabbay, the chief scientific and medical officer for the American Diabetes Association. That’s why it’s so important to prevent, recognize, and treat any symptoms of neuropathy.

How is neuropathy diagnosed?

To assess for neuropathy, your healthcare team should do a thorough examination of your feet looking for sores or ulcers, changes in skin color, diminished pulses and any abnormality or injury to your foot. They can test for diminished strength, a change in your ability to know the position of your toes, and a change in sensation or sensory perception.

A foot exam will always involve taking off your socks and shoes, and your healthcare professional will inspect your feet to check for color changes, pulses, open areas, redness, rashes, and the overall condition of your feet, said Dr. Cecilia C. Low Wang, a professor of endocrinology, diabetes, and metabolism at the University of Colorado Anschultz School of Medicine.

A monofilament test uses a soft fiber to test for sensation in various parts of the feet and body, and a tuning fork can also help healthcare professionals understand how much sensation a person has lost. The monofilament test, as well as a pinprick test, can check to make sure you have good sensation, while other tests will evaluate vibration and position sense (whether you are aware of where your foot is). “The main question I would suggest asking your diabetes provider is whether they notice anything concerning about your foot exam, and whether they think you need to do anything different, or see an additional specialist, such as a podiatrist,” said Dr. Low Wang.

In this age of telehealth visits, some podiatrists have been sending a monofilament (a small strand of nylon attached to a piece of plastic) to a person’s home and teaching them how to use it to determine if they have reduced sensation in different areas of the feet. Podiatrists might even examine a person’s foot onscreen during a video visit and ask questions about how the foot feels or looks. “If there’s something of concern, they will schedule an in-person visit,” added Memering.

If someone is experiencing symptoms of autonomic neuropathy, a healthcare professional may recommend a specific test depending on what the autonomic symptoms are. For example, if there are issues with blood pressure control, taking your blood pressure as you change positions from lying to sitting to standing or using a formal tilt-table test, may show loss of autonomic control of how your body regulates your blood pressure. If you have symptoms of delayed gastric-emptying (stomach-emptying), specialized radiology tests might be ordered that show the time it takes for food to exit the stomach. The Mayo Clinic has an informative list about many of these tests. If you have any symptoms of autonomic neuropathy, such as bladder or erectile dysfunction, feeling faint on standing up, or bloating and fullness, talk to your healthcare professional and explain what you are experiencing.

What are the best treatment options for neuropathy, especially in the hands and feet?

Although it is not always possible to prevent neuropathy completely, the best way to slow its progression (as shown in the DCCT) is to closely manage your blood sugar levels and try to stay in range as much of the time as possible. If neuropathy does develop, medications can decrease the burning and tingling sensations, said Dr. Gabbay.

“Diabetes is a leading cause of neuropathy, and the higher someone’s blood sugar levels are over time, the more likely they are to develop neuropathy,” Dr. Gabbay said. “The good news is by managing blood sugar levels, one can significantly reduce their risk of developing neuropathy.”

With painful neuropathy, “treatments are generally to try to manage symptoms,” Memering said. “Medications such as Neurontin [gabapentin, a drug used for pain and seizures], Lyrica [pregabalin, a drug used for pain and seizures], or Cymbalta [duloxetine, a drug used for chemical balance in the brain] may be used to help with pain associated with painful peripheral neuropathies. These medications can be very effective, but it may take a few weeks to adjust and find the right dose. However, people should know that the medications can also be somewhat sedating.” Other drugs that may be effective include drugs used for mood disorders such as venlafaxine, nortriptyline, or amitriptyline, said Dr. Low Wang, but they may have side effects at higher doses and with older age.

Dr. Gabbay added that neuropathy “is a very active area of research to identify new and effective treatments.”

There are also various treatments to help improve the symptoms of autonomic neuropathy:

For Postural Blood Pressure Changes:

If you have a significant decrease in your blood pressure on standing, your healthcare professional can teach you how to get up slowly to allow your body to regulate your blood pressure with positional change.

You can also wear an abdominal binder, which Memering described as “a big elastic girdle that puts more pressure on the big blood vessels in the body,” so that they have more support when changing positions.

Other treatments include adjusting salt intake, using compression stockings, doing physical activity to avoid deconditioning, and staying hydrated, said Dr. Low Wang.

For Neurogenic Bladder:

If you are experiencing a neurogenic bladder, urinating at regular intervals during the day and night can help the bladder empty even if you no longer feel the urge to urinate. You might also undergo a urinalysis or a bladder scan, said Dr. Low Wang. Medications can also help.

For Gastroparesis:

Eating low-fiber, low-fat foods in smaller and more frequent meals and getting a greater proportion of calories from liquids might help, said Dr. Low Wang.

Sometimes the drug metoclopramide (Reglan) may be prescribed and gastric electrical stimulation might be used in severe cases.

For Erectile Dysfunction:

You may be prescribed one of the medications – sildenafil, tadalafil, avanafil, or vandenafil – but you may also need to undergo a physical exam, or other tests.

If you are experiencing any of the symptoms of neuropathy, you should speak with your healthcare professional to determine what diagnostic tests need to be done and what treatment course might be best for you.

Can you reverse diabetic neuropathy?

Currently, neuropathy can’t be reversed, but its progression may be slowed. Keeping blood sugar levels in the recommended targets is the key to doing so, Memering said. “The use of diabetes technology may be very helpful – especially continuous glucose monitors – for keeping your blood sugar in range, along with eating a varied diet, including vegetables and fruits, and exercising regularly,” she said.

Tips for living with diabetes and neuropathy

The two best things someone with diabetic neuropathy can do are to:

Manage their blood sugar levels to keep the neuropathy from getting worse.

Check their feet regularly, both at home and during healthcare appointments.

Check your feet at home

Dr. Gabbay, Dr. Low Wang, and Memering each recommended that all people with diabetes, whether young or old, newly diagnosed or not, should regularly check their feet. Dr. Gabbay advised, “Use a mirror to see the bottoms of the feet and make sure there are no cuts or ulcerations” that would need immediate attention to ensure they don’t worsen. If need be, ask someone in your household to help you inspect your feet. To help avoid foot injury, Dr. Low Wang recommended: “Always wear socks and well-fitting shoes, avoid going barefoot, and look at shoes before putting them on to be sure there is nothing in them.”

No matter where you are in your diabetes journey, daily foot checks “partly establish the habit before there are any problems, but are also a way to get to know your body so you can understand what is normal for you and what is not,” Memering said. “That way, when there is a change, you can all your healthcare office right away. Don’t wait until your next appointment – call,” she said, adding that they should be able to tell you if you need to make an appointment right away.

Remember, as with many complications of diabetes, for neuropathy prevention is key! To learn more, view or download our infographic on preventing neuropathy.

About Cheryl

Cheryl Alkon is a seasoned writer and the author of the book Balancing Pregnancy With Pre-Existing Diabetes: Healthy Mom, Healthy Baby. The book has been called “Hands down, the best book on type 1 diabetes and pregnancy, covering all the major issues that women with type 1 face. It provides excellent tips and secrets for achieving the best management” by Gary Scheiner, the author of Think Like A Pancreas. Since 2010, the book has helped countless women around the world conceive, grow and deliver healthy babies while also dealing with diabetes.

Cheryl covers diabetes and other health and medical topics for various print and online clients. She lives in Massachusetts with her family and holds an undergraduate degree from Brandeis University and a graduate degree from the Columbia University Graduate School of Journalism.

She has lived with type 1 diabetes for more than four decades, since being diagnosed in 1977 at age seven.

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qvogels · 7 years

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Bibliography A comprehensive bibliography on relevant logic was put together by Robert Wolff and can be found in Anderson, Belnap and Dunn 1992. The bibliography in Restall 2000 (see Other Internet Resources) is not as comprehensive as Wolff’s, but it does include material up to the present day. Books on Substructural Logic and Introductions to the Field Anderson, A.R., and Belnap, N.D., 1975, Entailment: The Logic of Relevance and Necessity, Princeton, Princeton University Press, Volume I. Anderson, A.R., Belnap, N.D. Jr., and Dunn, J.M., 1992, Entailment, Volume II, Princeton, Princeton University Press [This book and the previous one summarise the work in relevant logic in the Anderson–Belnap tradition. Some chapters in these books have other authors, such as Robert K. Meyer and Alasdair Urquhart.] Dunn, J. M. and Restall, G., 2000, “Relevance Logic” in F. Guenthner and D. Gabbay (eds.), Handbook of Philosophical Logic second edition; Volume 6, Kluwer, pp 1–136. [A summary of work in relevant logic in the Anderson–Belnap tradition.] Mares, Edwin D., 2004, Relevant Logic: a philosophical interpretation Cambridge University Press. [An introduction to relevant logic, proposing an information theoretic understanding of the ternary relational semantics.] Moortgat, Michael, 1988, Categorial Investigations: Logical Aspects of the Lambek Calculus Foris, Dordrecht. [Another introduction to the Lambek calculus.] Morrill, Glyn, 1994, Type Logical Grammar: Categorial Logic of Signs Kluwer, Dordrecht [An introduction to the Lambek calculus.] Paoli, Francesco, 2002, Substructural Logics: A Primer Kluwer, Dordrecht [A general introduction to substructural logics.] Read, S., 1988, Relevant Logic, Oxford: Blackwell. [An introduction to relevant logic motivated by considerations in the theory of meaning. Develops a Lemmon-style proof theory for the relevant logic R R .] Restall, Greg, 2000, An Introduction to Substructural Logics, Routledge. (online précis) [A general introduction to the field of substructural logics.] Routley, R., Meyer, R.K., Plumwood, V., and Brady, R., 1983, Relevant Logics and their Rivals, Volume I, Atascardero, CA: Ridgeview. [Another distinctive account of relevant logic, this time from an Australian philosophical perspective.] Schroeder-Heister, Peter, and Došen, Kosta, (eds), 1993, Substructural Logics, Oxford University Press. [An edited collection of essays on different topics in substructural logics, from different traditions in the field.] Troestra, Anne, 1992, Lectures on Linear Logic, CSLI Publications [A quick, easy-to-read introduction to Girard’s linear logic.] Other Works Cited Ackermann, Wilhelm, 1956, “Begründung Einer Strengen Implikation,” Journal of Symbolic Logic, 21: 113–128. Gianluigi Bellin, Martin Hyland, Edmund Robinson, and Christian Urban, 2006, “Categorical Proof Theory of Classical Propositional Calculus,” Theoretical Computer Science, 364: 146–165. Church, Alonzo, 1951, “The Weak Theory of Implication,” in Kontroliertes Denken: Untersuchungen zum Logikkalkül und zur Logik der Einzelwissenschaften, A. Menne, A. Wilhelmy and H. Angsil (eds.), Kommissions-Verlag Karl Alber, 22–37. Curry, Haskell B., 1977, Foundations of Mathematical Logic, New York: Dover (originally published in 1963). Dunn, J.M., 1991, “Gaggle Theory: An Abstraction of Galois Connections and Residuation with Applications to Negation and Various Logical Operations,” in Logics in AI, Proceedings European Workshop JELIA 1990 (Lecture notes in Computer Science, Volume 476), Berlin: Springer-Verlag. Dunn, J.M., 1993, “Star and Perp,” Philosophical Perspectives, 7: 331–357. Geach, P. T., 1955, “On Insolubilia,” Analysis, 15: 71–72. Gentzen, Gerhard, 1935, “Untersuchungen über das logische Schließen,” Mathematische Zeitschrift, 39: 176–210 and 405–431. [An English translation is found in Gentzen 1969.] Gentzen, Gerhard, 1969, The Collected Papers of Gerhard Gentzen, M. E. Szabo (ed.), Amsterdam: North Holland, 1969. Girard, Jean-Yves, 1987, “Linear Logic,” Theoretical Computer Science, 50: 1–101. Lambek, Joachim, 1958, “The Mathematics of Sentence Structure,” American Mathematical Monthly, 65: 154–170. Lambek, Joachim, 1961, “On the Calculus of Syntactic Types, ” in Structure of Language and its Mathematical Aspects (Proceedings of Symposia in Applied Mathematics, XII), R. Jakobson (ed.), Providence, RI: American Mathematical Society. Moh Shaw-Kwei, 1950, “The Deduction Theorems and Two New Logical Systems,” Methodos, 2: 56–75. Moortgat, Michael, 1995, “Multimodal Linguistic Inference,” Logic Journal of the IGPL, 3: 371–401.

Substructural Logics (Stanford Encyclopedia of Philosophy)

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mikemortgage · 5 years

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Insulin too pricey? Some options to cut costs for diabetics

TRENTON, N.J. — The skyrocketing price of insulin has some diabetics scrambling to cover the cost of the life-saving medication.

Others are skipping doses or using smaller amounts than needed, and sometimes landing in the emergency room, patients and advocates told Congress recently.

About 7.4 million Americans use insulin to keep their blood sugar at safe levels. Insulin needs vary by patient, as do costs depending on insurance coverage.

Amid the public uproar about costs, drugmakers and some prescription plans are starting to offer patients bigger discounts. Express Scripts and its parent company, insurer Cigna, just began offering a month’s worth of insulin to eligible patients for $25 per month. Express Scripts is now lining up other insurers whose prescription plans it manages.

For most insulin and other diabetes medicines, manufacturers offer coupons reducing monthly out-of-pocket costs.

The American Diabetes Association connects patients to assistance programs through http://www.insulinhelp.org , though not everyone qualifies.

“We do not want anyone to skip or ration doses,” says Dr. William Cefalu, the advocacy group’s chief scientific officer.

If you are struggling to afford insulin, tell your doctors, says Cefalu. They might be able to recommend a free clinic or patient assistance plan, or suggest cheaper options.

If cost is an issue, here are other ways to save money:

TRY OLDER KINDS OF INSULIN

Talk to your doctor about switching to older, cheaper kinds of insulin, suggests Dr. Robert Gabbay, chief medical officer at Joslin Diabetes Center in Boston. Dangerous blood sugar plunges are more common with those, as they don’t control blood sugar as tightly as newer, more expensive insulins. Patients using older products such as Novolin and Humulin R must test their blood sugar more often, and more carefully time when they inject insulin before meals, Gabbay stresses.

SWITCH TO VIALS

Patients who’ve been using insulin pens — injection devices containing multiple insulin doses — could switch to insulin vials. They are cheaper but less convenient. It requires drawing insulin out of the vial into a syringe, which makes doses less precise, and the abdominal injections hurt a bit more. Another option is Basaglar, a cheaper near-copy of the popular long-acting Lantus insulin pens.

CHECK INSURANCE

Review your insurance company’s list of covered medications for insulin with the lowest copayments; coverage and copayments often change in January and there may be cheaper choices. Other savings options include getting a 90-day supply instead of 30-day refills.

SHOP AROUND

Check prices at different pharmacies. Prices can vary widely for insulin, other diabetes drugs and the testing strips and lancets needed to check blood sugar levels. Patients can look up drug prices at multiple drugstores and get coupons for big discounts at the pharmacy counter at http://www.GoodRx.com . Or try http://www.healthwarehouse.com , which sells medicines at cash prices, which can be cheaper even if you have insurance.

Medicare and Medicaid patients can’t combine coupons with their insurance, but a coupon alone might be the cheapest option.

The three main insulin makers offer savings, including:

–Sanofi’s Insulins ValYOU Savings Program offers uninsured and cash-paying patients one insulin vial for $99 or one insulin pen for $149 each month. Starting in June, it will offer up to 10 vials and/or pens of most of its insulins for $99. Its Sanofi Patient Connection offers low-income uninsured patients free insulin.

–Eli Lilly will soon sell Insulin Lispro, a half-price version of its top-selling insulin Humalog KwikPens, for $265 per month. Its Lilly Diabetes Solution Center helps patients find affordable options.

–Novo Nordisk has long sold an older insulin, ReliOn, through Walmart for about $25 a vial. It’s now available through CVS Health and Express Scripts. Novo Nordisk offers copay savings cards for Tresiba and other insulins, plus patient assistance with generous income limits at http://www.NovoCare.com .

——

Follow Linda A. Johnson at https://twitter.com/LindaJ–onPharma

from Financial Post http://bit.ly/2GenCgE via IFTTT Blogger Mortgage Tumblr Mortgage Evernote Mortgage Wordpress Mortgage href="https://www.diigo.com/user/gelsi11">Diigo Mortgage

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catalystscradle · 6 years

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Today, critics argue that the price of insulin has far outpaced any innovations. In the past decade alone, U.S. insulin list prices have tripled, according to an analysis of data from IBM Watson Health. In 1996, when Eli Lilly debuted its Humalog brand of insulin, the list price of a 10-milliliter vial was $21. The price of the same vial is now $275. Those costs can be compounded by the multiple vials that diabetics may require to survive each month. “It’s a very big problem,” says Robert Gabbay, chief medical officer at the Joslin Diabetes Center in Boston. “It’s a tragic barrier to care.”

#washington post #insulin #healthcare #healthcare policy #medicine

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teendiabetics-blog · 6 years

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Robert Gabbay, MD, PhD: The Debate About SGLT-2 Inhibitors and GLP-1 Receptor Agonists

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Robert Gabbay, MD, PhD: The Debate About SGLT-2 Inhibitors and GLP-1 Receptor Agonists

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your-dietician · 3 years

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Highlights of the American Diabetes Association's 2021 Annual Meeting

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Highlights of the American Diabetes Association's 2021 Annual Meeting

The American Diabetes Association’s annual conference, known as the ADA Scientific Sessions, is always the biggest diabetes event of the year, and 2021 marked the second time this 5-day congress was held completely online because of the lingering COVID-19 pandemic.

When held in person, the conference normally convenes roughly 16,000 physicians, researchers, and diabetes industry experts from across the globe. This 81st annual event drew 11,600 people from 119 countries between June 25 and 29 — slightly lower than the 12,527 registered attendees for the 2020 virtual event. For both, the event organizers expected more people to tune in afterward, thanks to the recorded online sessions being made available for up to 3 months following the conference.

Despite its virtual nature, this year’s conference included nearly 200 presentations with more than 900 presenters on any range of topics. And to top it off, there were roughly 1,100 research posters delving into the latest science in diabetes. You can catch up on some of the action by searching hashtag #ADA2021.

Many of the big themes this year were extensions of what we saw in 2020 with the first-ever virtual SciSessions, but with even deeper focus. Below is our team’s summary of conference highlights.

Of course, the novel coronavirus that took the world to its knees was a main focal point and recurring theme in a large majority of research presented at this year’s Scientific Sessions.

Whether the topic officially had to do with COVID-19 or not, this was on everyone’s mind — from telehealth to research delays because of shutdowns, hospitalizations, etc. New research highlighted how people with underlying health conditions are six times more likely to die of COVID-19, and diabetes is the second most reported condition tied to those deaths in the U.S.

“Seeing the devastating impact of the pandemic on people with diabetes, the ADA is emboldened to work even harder to lead the fight against diabetes,” said the ADA’s chief scientific and medical officer, Dr. Robert Gabbay. “Our mission is reinforced by researchers from around the globe committed to closely studying specific impacts and interventions to help people living with diabetes during this COVID-19 era.”

Research from the T1D Exchange presented at ADA showed that among people with type 1 diabetes (T1D), use of diabetes technology lowered the risk of adverse outcomes with COVID-19. That point was emphasized throughout the conference, though it was offset by the common barriers of access and affordability issues — as well as racial and ethnic disparities in diabetes technology use.

One disturbing research presentation illustrated how type 2 diabetes (T2D) in children had skyrocketed during the COVID-19 pandemic. More pediatric patients were hospitalized between March and December 2020 than in the previous year. It also shows that stay-at-home orders resulting from COVID-19 exacerbated T2D risk for children overall, largely because of limited physical activity, more screen time and sedentary behaviors, disrupted sleep, and higher intake of processed foods and differing eating patterns during the day. A notable stat presented in one session showed that 1 in 4 PWDs in America reported the pandemic had interfered with their ability to obtain healthy food.

“While our study examined hospital admissions for type 2 diabetes in children at one center, the results may be a microcosm of what is happening at other children’s hospitals across the country,” said Dr. Daniel S. Hsia of the Pennington Biomedical Research Center in Baton Rouge, LA. “Unfortunately, COVID-19 disrupted our lives in more ways than we realize. Our study reinforces the importance of maintaining a healthy lifestyle for children even under such difficult circumstances.”

Another study conducted in October 2020 showed that 1 in 5 adults with diabetes reported anxiety or depression. Nearly half of adults (or 47 percent) with T1D reported moderate to severe distress compared with only 11 percent of adults with T2D. That research came from Dr. Sarah C. Westen at the University of Florida, and she told attendees that it meant PWDs with these pandemic-related psychosocial concerns needed follow-up diabetes care aimed at mental health.

Overall, the most common themes were that COVID-19 led to increased health anxiety, limited social interaction, and routine disruption. Many presenters also emphasized the need for more longitudinal research to better understand how these psychosocial factors specifically impacted diabetes management during the pandemic.

“While we are beyond eager to return to ‘normal’ and are well aware of the devastation that continues to occur because of COVID, we hope to take these silver linings, learn from them, and continue to implement things that we found particularly helpful that resulted out of necessity because of the pandemic,” said Catlin Dennis, MPH, of the Oregon-based Novel Interventions in Children’s Healthcare (NICH) at Doernbecher Children’s Hospital. She presented in a session titled “When COVID-19 Clashes with Diabetes.”

Not surprisingly, racial disparities and inequities within diabetes care were a focal point at the ADA conference as well. Many presenters noted that existing disparities were brought to light quite glaringly during the height of COVID-19.

In August 2020, the ADA published a “Health Equity Bill of Rights” that included statements on access to insulin and other diabetes meds, affordable healthcare, and ensuring that PWDs are able to be free from stigma and discrimination. As of April 2021, the ADA is encouraging scientists to apply for grants to conduct research touching on the impact of disparities in diabetes care.

“We can’t improve the health of all Americans without first addressing health inequities in our healthcare system. It’s crucial that we take a groundwater approach to solving these problems so that the solutions are both sustainable and effective. We have an obligation to dismantle these inequities and eliminate the devastating impact they have on families and communities,” ADA CEO Tracey D. Brown said.

One of the few really eye-popping developments this year was the announcement of a consensus statement between American and European diabetes experts, recognizing for the first time ever that there is, in fact, such thing as adult type 1 diabetes (T1D).

Yes, nearly a quarter century after T1D was officially classified and renamed from “juvenile diabetes,” medical experts have now finally issued official guidance on standards of care for adults with T1D.

The “Management of Type 1 Diabetes in Adults—2021 Draft ADA/EASD Consensus Report” is a multiyear effort between the ADA and European Association for the Study of Diabetes (EASD). It includes a new diagnostic algorithm for T1D that begins with measuring islet autoantibodies.

“We know we have guidance for the management of people with type 1 diabetes, but this gets mixed into broader guidelines and many of those broader guidelines are mostly derived from data in people with type 2 diabetes,” said Dr. Anne Peters, a well-known endocrinologist at the University of Southern California (USC) and director of the USC Clinical Diabetes Programs. “The EASD and the ADA recognized that there was a need to develop a comparable consensus report that specifically addresses the needs of people with type 1 diabetes.”

The report lays out that to achieve individualized care, patients should undergo an initial needs assessment. It also addresses behavior considerations such as alcohol and tobacco use, sleep, sick day management, driving, employment, physical activity, and nutrition.

“There is no one eating pattern recommended,” said Amy Hess-Fischl, a registered dietician and nutritionist and certified diabetes care and education specialist (CDCES) at the University of Chicago. “It is all based on the individual sitting in front of us.”

The report notes that there are four critical times for ongoing diabetes management support and education: at diagnosis, annually or when the patient is not meeting treatment targets, when complicating factors develop, and when transitions in life and care occur.

Dr. Jeremy Pettus, endocrinologist at the University of California, San Diego, worked in the consensus group that evaluated an array of medications that might be useful for T1D — some of them more commonly used for type 2 diabetes currently.

“There are other things wrong in type 1 diabetes physiology that we could potentially address with medications to help the vast majority of T1Ds get their blood sugars down to where they need them to be, help lose weight, improve cardiovascular outcomes,” he said. “Type 1s, even with good glycemic control, are still at high risk for cardiovascular disease.”

A hope is that these newer guidelines can help better diagnose T1D in varying age ranges, to help quell common misdiagnosis. But also, to further emphasize that individualized care is necessary when treating someone with the condition.

Another big theme for this Scientific Sessions — and 2021 overall — was the 100th anniversary of insulin’s discovery.

While so much progress has happened in diabetes and with insulin specifically since that game-changing discovery in 1921 by Drs. Frederick G. Banting and Charles Best in Toronto, the conference also highlighted how there is much left to be done for PWDs.

Affordability is at crisis levels in the U.S. and too many can’t get the life-sustaining insulin they need. Yet ironically, many people with type 2 diabetes continue to live in fear of being prescribed this medication.

Sessions delved into the policy sides of insulin accessibility as well as research on new types of insulin and other islet and beta cell transplants, which fall under the “cure” umbrella.

Dr. Ruth S. Weinstock at State University of New York (SUNY) Upstate Medical University, who currently serves as the ADA’s Science and Medicine division president, highlighted in her Sunday morning address that cutting-edge research is driving new therapies and technologies as well as hope for a diabetes cure. But there’s a lot to be concerned about, too.

“As wonderful as the discovery of insulin was, there was a need for purer and more physiological preparations and better insulin delivery systems,” she said. “We have better insulins now, but their administration is still burdensome and associated with challenges. And importantly, hypoglycemia and hypoglycemia unawareness remain problems, increasing in prevalence with longer diabetes duration.”

She pointed to the price of insulin in the U.S. being higher than anywhere else in the world, and encouraged ADA attendees to work toward a goal of more affordable insulin by January 2022 — the century-mark since a 14-year-old received the first-ever dose of insulin.

Meanwhile, developments in pancreatic beta cells garnered attention at the SciSessions as a possible path toward a T1D cure.

Dr. Esther Latres of the JDRF presented updates on manufacturing insulin-producing cells from stem cells, protecting the beta cells (without immunosuppressive drugs) from being destroyed during the immune system attack on a person’s body that leads to T1D.

Dr. Quinn Peterson of the Mayo Clinic presented his latest research on growing pancreatic islets from stem cells, showing findings that scientifically significant insulin production can be prompted using his technique.

As these researchers encouraged more advances in this type of diabetes research, it coincided with the recent news of President Joe Biden’s proposal for a Moonshot Initiative. This would provide $6.5 billion in the federal budget for the National Institutes of Health (NIH) to fund cure-focused research on cancer and other conditions like diabetes. If that proposal gets approved and implemented, it could lead to even more T1D research on advanced treatments and a potential cure.

Another hot topic at the ADA conference this year was the growing emphasis on Time in Range (TIR), which provides more information about glucose control than the traditional 3-month average known as the A1C.

Multiple diabetes experts in a variety of presentations highlighted the importance of TIR as they discussed latest research findings and management, complications that can materialize despite one’s A1C result, and even policy implications from looking at TIR rather than just A1C.

Generated mainly from the use of continuous glucose monitors (CGM), TIR was highlighted for how it helps people stay within the ideal 70-180 mg/dL range as often as possible in order to improve their diabetes management. This was mentioned in countless presentations and research posters.

In one of the sessions posing the question “Is CGM use an effective tool in primary care?” medical professionals and diabetes experts debated whether this tech can be useful for health consumers beyond diabetes care.

Short answer: It depends on the level of engagement a patient may have, but for those with diabetes who are dependent on insulin, the benefits of CGM are no longer in question. Presenters noted that CGM use allows a move away from focusing solely on A1C, with TIR data instead allowing healthcare providers to make better adjustments to insulin or diabetes meds, as well as determine how eating patterns or other aspects of a person’s life might be tweaked to achieve better outcomes.

The eagerly anticipated full results of the phase 3 SURPASS trials were shared at ADA 2021, generating a lot of buzz.

The study followed up on results from early 2021 focused on tirzepatide, a new once-weekly injectable glucose-lowering combo drug (dual GIP and GLP-1 receptor agonist) from Eli Lilly. It’s still in development, but like the exciting initial results, this latest research shows the new drug leads to a sizable A1C reduction as well as weight loss and fewer hypoglycemic episodes for people with type 2 diabetes.

The ADA conference also traditionally features many different research talks focused on diabetes complications. This year, there were multiple sessions aimed at kidney and cardiovascular risk for PWDs, including how various medications — especially for those with T2D — can reduce the risk of these possible complications.

There were sessions focused on spinal cord stimulation to treat painful neuropathy in the feet and toes, as well as how retinopathy is being treated more effectively now than even just a few years back.

One topic that caught our eye was “diabetes foot selfies.” Although some medical appointments to diagnosis, assess, or treat D-complications must happen in person, during the COVID-19 crisis there was a larger trend of people snapping photos of their feet and toes to have their clinicians look at those virtually to help guide decision-making.

“The COVID-19 pandemic required a rapid shift in best care practices,” said Brian M. Schmidt from the University of Michigan Medical School. “This had a huge impact on patients with diabetic foot ulcers and other complications because most of the time those patients were seen exclusively in face-to-face interactions.”

In California, Dr. Laura Shin discussed how her clinic had also used telemedicine and other methods to provide virtual care for patients with diabetes foot issues. They sent info packets to patients, families, and caregivers on conducting “three-minute foot exams,” and how to take selfies in helping clinicians prescribe care and identify high risk instances.

“A large part of us being able to treat these patients as best we could, especially with using different telemedicine technologies, was the ‘foot selfie.’ If they were flexible or agile enough, they could take the pictures themselves using their cell phones, or have a family member or caregiver take the pictures,” she said.

“With COVID-19, we have learned a lot about accessing patients,” Shin added. “Utilizing different tools and avenues for telemedicine was extremely helpful for us and for our patients with diabetes and diabetic foot care needs. And although it’s not a replacement for inpatient visits, I think we were still able to manage to keep a lot of these patients safe, keep them out of the hospital, and keep them moving in the world.”

An anticipated highlight of the ADA SciSessions each year has traditionally been the sprawling exhibit hall, where scores of diabetes companies go all out with elaborate displays. Sales reps try to woo physicians with the latest and greatest new gadgets and tools, and many companies coordinate timing of announcements and new products with this large conference — particularly since it falls in the final month before the fiscal quarter ends and they’re eager to wow investors.

Of course it’s just not the same with the event being online. The virtual exhibit hall is more of a rudimentary marketing tool where you can click on materials and videos but without the fanfare and opportunity to ask questions face-to-face. But there were still some topics of interest here.

Afrezza inhaled insulin

New research was presented on MannKind’s Afrezza inhaled insulin. This ultra rapid-acting inhalable drug has been available in the U.S. for adults with T1D since 2015, but it’s still being studied for possible use in children and adolescents as well as for those with T2D.

In two smaller studies, MannKind showed data that Afrezza is safe in children and adults with T2D.

Researchers tested Afrezza in 30 children between 8-17 and found the inhaled insulin was safe and saw its peak action about 10-15 minutes after inhalation. Within 2 hours, it was out of their systems. For post-meal glucose drops, the children saw the peak decrease 30-60 minutes after inhalation. All of that shows Afrezza works the same in children as it does in adults. While there was a slight cough observed for some after inhalation, there was no severe hypoglycemia. This research shows a final phase 3 clinical study can now move forward, paving the way for eventual pediatric approval.

As for T2 adults, Afrezza improved their TIR throughout the day to a total 62 percent of time, or 4 additional hours each day with lower amounts of highs and lows.

Medtronic’s new products

Medtronic presented important data on its future technology, including its Extended Wear Infusion Set that is already approved in Europe but is still in development for the U.S. This infusion set could last twice as long as existing infusion sets available for insulin pumps today — meaning it could be worn on the body for up to 7 days, compared with the traditional 2 or 3 days. Research presented at the ADA conference shows that Medtronic’s extended wear set lasted that long for up to 75 percent of the 350+ study participants, which beat out the 67 percent for the current 2-3 day sets.

This extended wear set is already filed with the Food and Drug Administration (FDA) and is awaiting review and approval, and if OK’d it would be the first time the U.S. would see an infusion set allowed to be worn for this long.

Medtronic also presented data on Time in Range for its Bluetooth-connected 770G system, keeping up with competing diabetes device companies that presented TIR research but also setting the foundation for its upcoming 780G device (aka the Advanced Hybrid Closed Loop system) that is pending before the FDA.

With that approval, we will soon have a trio of closed loop commercial systems to choose from: Medtronic’s 780G, Tandem’s Control-IQ and Omnipod 5, the latter of which will be the first tubeless patch pump option with automated glucose control.

CamAPS FX closed loop system

In a clinical study from the University of Cambridge, Dr. Julia Fuchs presented data on the future CamAPS FX closed loop system in kids and teens with T1D. This technology is U.K.-based CamDiab’s version of a hybrid closed loop system, combining an Android smartphone app with a Dexcom G6 CGM and an internationally available insulin pump (either the Dana Diabecare RS pump or the Dana i-pump by Korean company SOOIL).

This system adjusts insulin every 8-12 minutes based on the user’s needs, with a set target glucose of 105 mg/dL. For study participants in the U.S. who didn’t have access to those international pumps, the researchers used a Medtronic insulin pump and CGM. After 6 months, participants spent an average of 3.6 hours more time in range each day, or 68 percent TIR. Their A1C results also dropped by 1.1 percent, and use of the system also had other glucose-lowering benefits, they say.

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usnewsaggregator-blog · 7 years

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Ask Well: How Do People Die From Diabetes?

New Post has been published on http://usnewsaggregator.com/ask-well-how-do-people-die-from-diabetes/

Ask Well: How Do People Die From Diabetes?

Photo

Credit Stuart Bradford

Q. How do people die from diabetes?

A. People who have diabetes cannot regulate their blood sugar levels and if the disease isn’t tightly controlled, blood sugar can spike to abnormally high levels, a condition called hyperglycemia, or dip below normal, a condition called hypoglycemia. Both conditions are potentially life-threatening and can lead to coma and death if not promptly treated.

But complications resulting from the disease are a more common cause of death. Heart disease strikes people with diabetes at significantly higher rates than people without diabetes, “and we don’t fully know why,” said Dr. Robert Gabbay, chief medical officer at Joslin Diabetes Center in Boston. People with diabetes develop heart disease at younger ages and are nearly twice as likely to die of heart attack or stroke as people who do not have diabetes.

People with Type 2 diabetes, which is the more common form of the disease, are more likely to have elevated cholesterol, high blood pressure and obesity, Dr. Gabbay said, all risk factors for cardiovascular disease. “The good news,” he said, “is that a lot of treatments, like those for lowering cholesterol, are even more effective at lowering risk in people with diabetes than in people without.” Some new classes of diabetes medications used for Type 2 diabetes have also been shown to reduce cardiovascular risk, he said.

People with Type 1 diabetes are also at increased risk for heart disease, though the reasons are less clear.

Both types of diabetes can also lead to other long-term complications, like kidney disease, that may result in premature death. Problems like vision loss, nerve damage and infections that may lead to amputations can increase the likelihood of injuries and accidents. Good disease management starting early in the disease process helps people avoid some of these complications, Dr. Gabbay said.

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jusstify-blog · 7 years

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Por que os números de hemoglobina A1C são importantes para o seu diabetes

Hemoglobina A1C é um número que indica seu nível médio de açúcar no sangue nos dois ou três meses anteriores. Se você tem uma hemoglobina A1C de 5,7 a 6,4 por cento, você possui prediabetes. Se o seu hemoglobina A1C for 6.5 por cento ou mais, você tem diabetes. Médicos freqüentemente também usam um teste de glicemia no jejum para determinar se você tem diabetes; Um resultado de 126 miligramas por decilitro ou superior indica diabetes e 100 a 125 mg / dL indica prediabetes.

De um modo geral, uma vez que você desenvolve diabetes, os médicos querem que você mantenha uma hemoglobina média A1C de 6,5 por cento a 7 por cento. Esses números são recomendados por grandes grupos de profissionais em diabetes, como Greenlipo a Associação Americana de Endocrinologistas Clínicos (6,5 por cento) e a American Diabetes Association (7 por cento).

Mas, como esses números alvo de hemoglobina A1C foram estabelecidos para prediabetes e diabetes - e eles são realmente os melhores números alvo para você?

[Leia: 11 dicas para testar o açúcar no sangue em casa.]

A resposta varia para cada pessoa, diz o Dr. Robert Gabbay, diretor médico e vice-presidente do Joslin Diabetes Center, que faz parte da Harvard Medical School em Boston.

Primeiro, vejamos os números A1C que indicam prediabetes e diabetes. Testes como glicemia em jejum e um teste oral de tolerância à glicose de duas horas têm longos históricos como testes de diabetes, diz Gabbay. A hemoglobina A1C tornou-se mais estreitamente associada ao diagnóstico de prediabetes e diabetes tipo 2 mais recentemente depois de especialistas da ADA, da Associação Européia para o Estudo do Diabetes e da Federação Internacional de Diabetes se reuniram e publicaram uma meta de A1C e compartilharam outras recomendações de pacientes, Diz Dr. Rachele Berria, chefe da Unidade Médica de Diabetes dos EUA para a empresa de medicamentos Sanofi. "Esses números de [hemoglobina A1C] são importantes porque eles deixam os profissionais de saúde saberem como uma pessoa que vive com diabetes está fazendo, e o impacto que o alimento, o exercício e os medicamentos têm sobre o açúcar no sangue do paciente", diz Berria.

CONTEÚDO RELACIONADO

8 Complicações de Diabetes

Mantenha o seu açúcar no sangue sob controle para ajudar a evitar essas complicações, muitas vezes graves.

Quando alguém tem resultados de A1C na faixa de 5,7 a 6,4 por cento - ou prediabetes - eles têm a chance de fazer mudanças de vida para que eles não desenvolvam diabetes cheia. "Há mais uma ênfase agora no cuidado preventivo e garantir que os pacientes com prediabetes adquiram a dieta e o exercício físico e, se forem obesos, até mesmo considerar a terapia com metformina, porque sabemos que o risco de doença cardiovascular começa mesmo com prediabetes", diz o Dr. Valentina Rodríguez, endocrinologista da Divisão de Endocrinologia, Diabetes e Metabolismo da Faculdade de Medicina da NYU em Nova York.

[Veja: 6 Dicas para manter os diabéticos fora do hospital.]

Então, há meta de hemoglobina A1C meta de 6,5 ou 7 por cento quando você tem diabetes. A razão pela qual os pacientes atendem seu número de objetivo consistentemente é ajudar a evitar problemas de saúde nos olhos, nervos, rim e outros que surgem quando o açúcar no sangue é consistentemente alto, diz Gabbay. No entanto, "a realidade é que não há um ponto de corte duro", diz ele. E houve controvérsia quando o AACE começou a pressionar pelo objetivo de 6,5 por cento, acrescenta Gabbay.

O objetivo específico da hemoglobina A1C para cada paciente pode variar de acordo com a idade, outras condições médicas, incluindo doença renal e seu risco individual de hipoglicemia (baixo nível de açúcar no sangue). Por exemplo, um médico pode sugerir que um paciente mais jovem apontar para 6,5 por cento, enquanto um paciente mais velho com doença cardíaca pode ter um objetivo mais perto de 8 por cento. O baixo nível de açúcar no sangue é mais perigoso em pacientes com doença cardíaca.

"Como regra geral na minha prática, em pacientes com mais de 70 anos, uso sua década para me guiar", diz a Dra. Lorena Lewy-Alterbaum, endocrinologista do Memorial Regional Hospital South e em clínica privada em Hollywood, na Flórida. "Para um adolescente de 75 anos, o [objetivo A1C seria de 7,5 por cento, e para 80 Greenlipo funciona mesmo anos de idade, é até 8 por cento. Nesses grupos etários, a preocupação é com a prevenção da hipoglicemia, tanto quanto o controle do diabetes ".

Em alguns pacientes, existem outros problemas associados à redução excessiva de açúcar no sangue, incluindo o uso excessivo de medicamentos e os efeitos colaterais e os custos associados a esses medicamentos, diz Alterbaum.

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type2diabetestreatments-blog · 8 years

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The Bitterness over 'Brittle Diabetes'

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The Bitterness over 'Brittle Diabetes'

With the 10th annual Rare Disease Day just around the corner on Feb. 28, it's a perfect time to revisit the issue of "brittle diabetes" and how recognition of it as a rare disease (or lack thereof) has sparked a new wave of controversy recently.

Those watching the news wire may have caught some of the press releases, like the one in January screaming that the "American Diabetes Association Ignores Those Suffering with Brittle Diabetes" and another on Feb. 14 accusing the ADA of taking an "ostrich approach" to brittle diabetes.

The organization behind those announcements is the New York-based Brittle Diabetes Foundation (BDF), which has been lobbying everyone in sight to accept a new classification of "BT1D" (Brittle T1D), for those of us with extreme blood sugar instability.

While this Foundation has successfully lobbied the National Institutes of Health (NIH) to include brittle diabetes as a rare disease in its national database, and other orgs like the JDRF and American Diabetes Association have at least acknowledged it to some extent, the BDF does not believe the ADA has gone far enough -- and is spending a lot of energy on calling out the country's largest diabetes organization over it.

Specifically, the BDF (not to be confused with your Best Diabetes Friend) is blasting the ADA for not including brittle diabetes in its 2017 Standards of Care, an omission the BDF describes as “disgraceful and sad," and they claim it ignores “some 4,500 US residents and 150,000 worldwide diagnosed with BT1D.”

Whoa! Sounds pretty serious, no?!

When this foundation was formed back in 2013, DiabetesMine reported on its origins -- along with the new NIH designation -- and found in large part that medical professionals viewed "brittle" as an outdated term that should no longer be used in official diagnoses, and that's often used loosely to describe dramatic blood sugar swings.

It doesn't appear much has changed on that front among medical professionals, and certainly no official diagnosis code exists for "brittle diabetes." So what's all the current brouhaha about? Is this really an issue the ADA is neglecting, and ought to be addressing in 2017?

Brittle Diabetes Origins

Historically, the label of "brittle diabetes" first appeared in the pre-glucometer days of the 1940s, and was used to describe patients who regularly suffered from both severe hypoglycemia and DKA. Later it evolved into a non-diagnostic term for any diabetes that was simply more damned difficult to control than typical diabetes, characterized by radical -- some would say inexplicable -- swings in glucose levels.

While a number of different schemes have been proposed over the years for how dramatic blood sugar variability should be before using the term brittle, there’s never been any universally accepted definition. Meanwhile, most scientific literature generally regards "brittle" as a rare subset of type 1 diabetes, most commonly seen in young women.

But even from day one, there’s been controversy over whether or not it’s a medically-appropriate label, and over the last few decades the term has been decreasing in popularity in clinical circles. In fact, had it not been for the BDF, the term would most likely have become extinct.

A Personal Quest

As we previously reported, the Brittle Diabetes Foundation is based in East Norwich, New York, and headed by founder Dr. Manny Sorge, a retired college professor and recycling expert. Dr. Sorge started the BDF after nearly losing his 40-year-old daughter to what he believes was brittle diabetes. The organization has become his full-time job, although he acknowledges he's not paid for the 25-30 hours a week he puts in.

Sorge’s efforts have led to brittle diabetes being listed in the GARD, the National Institutes of Health Generic and Rare Diseases register, and, he claims, is also being recognized by the JDRF -- although the only mention of it on the JDRF website is a single blog post. When we reached out to clarify, JDRF Public Relations and Communications Manager Kristy Evans simply stated that "the NIH recognizes brittle diabetes in its register, and so JDRF recognizes it as well.”

Meanwhile, Sorge has been sending out a blizzard of quasi-hostile press releases and has launched at least one petition drive on Change.org.

Despite two “wins,” he clearly believes his quest is far from over. The BDF’s mission statement includes the goal of convicing the World Health Organization (WHO), International Diabetes Federation (IDF), and ADA all to “recognize the existence of brittle diabetes as a rare disease that is a separate and distinct form of type 1 diabetes.”

Calling a Spade a Spade

Even the BDF admits on their website that, “brittleness has a cause. When determined, and treated successfully, (the) individual reverts to stable type 1 condition without the seesaw effect.” In a separate section, the BDF lists 18 diseases and disorders that they say cause brittle diabetes, either individually or together. These include Addison’s, celiac, Cushing’s, hemochromatosis, scleroderma, and even vitamin D deficiency, as well as the diabetes complication gastroparesis. They also list depression as a cause of brittle diabetes, and in fact state, “people dealing with psychosocial problems, those dealing with stress or depression, are at the highest risk.”

Uh… wait a second here.

If a second medical condition, a comorbidity, or a psychosocial issue is frustrating efforts at blood glucose control, that needs to be addressed. BDF is correct on that score. But demanding that a constellation of complication factors deserves a separate diagnostic label as an entirely unique form of diabetes...?

By that logic, we’d also need to create independent classifications for all the various conditions and circumstances that lead to poor blood sugar control, including a special label for TPFP (Too Poor For Supplies) and NGB (Not Gonna Bother) for folks who are truly not motivated and don’t even attempt to control their diabetes.

And I think we can all agree that would be ridiculous.

The fact is, brittle diabetes is not some unique strain, but rather a state of affairs in which T1D is poorly controlled, for a variety of reasons. Even the BDF folks don’t suggest a unique treatment for brittle diabetes, other than identifying and treating the secondary condition that's making BG control difficult.

In short, "brittle diabetes" appears to be diabetes + something that's making it really hard to control.

Why a New Classification?

We reached out to Sorge to pose just that question: Why exactly does "diabetes + something making it hard to control" need to be recognized as a separate and unique illness?

“Since we have a finding and classification [from the NIH’s GARD listing] of BT1D as a rare disease, common sense suggests that it must be uniquely different from that of stable T1D,” he replied.

Well, that’s rather a Catch-22, isn’t it? His organization convinced the NIH to list it as a rare disease, so now it must be unique and separate? Strikes us as uncommon sense.

That aside, Sorge has a long list of perceived benefits to patients that would follow if the ADA recognized BT1D, chief among them that “frustrated” physicians would “have proper guidance in the care of BT1D patients.”

But not all doctors agree with that assessment, and just think this through for a moment:

If you're living with type 1 and are depressed, and as a result have "brittle diabetes," and then receive counseling to overcome the depression and your extreme blood sugar swings cease, are you then "cured"?

See the flawed logic here?

Endo View

We queried Joslin Diabetes Center's Chief Medical Officer Dr. Robert Gabbay for a leading endorinologist's POV. He didn't hesitate to say that you’d “rarely, if ever” hear an endo use the word "brittle" these days, and that it’s mostly used in the primary care arena as a label for people who have difficulty managing their diabetes.

Gabbay doesn’t care for the term, he says, because he feels that it gives primary care providers an easy excuse “not to delve deeper” when working on difficult cases. He says, “It’s almost like saying, ‘I give up, you have brittle diabetes.’”

So rather than giving primary care docs a leg up, as the BDF envisions, adoption of the label could actually lead to a reduction in care efforts?

Gabbay says most cases of difficult-to-control diabetes can be sorted out and helped, although he does admit that there's a small percentage of patients who continue to have highly variable BG levels despite all efforts to the contrary.

So what does Gabbay call someone with crazy-fluctuating blood sugars, if not brittle?

A “patient with a lot of glucose variability," he says.

This echoes what other leading endocrinologists, educators and experts have said on this topic over the years, as documented at Diabetes Forecast, Diabetes Daily, and Insulin Nation.

ADA Response

After the Jan. 17 blast, the BDF issued a second, more reasonably toned press release on Jan. 31 that promoted its own work and detailed its efforts trying to get the ADA to recognize brittle diabetes more officially. Yet then the third on Valentine’s Day that included rhetoric like “the ADA has turned a deaf ear,” a veiled threat that said future releases would address the “need for targeting donor funds,” and a call for “members of the medical community and researchers in this field to end their silence and become a collective voice for BT1D-diagnosed patients who continue to be ignored.”

What’s the ADA’s stance on all of this? We asked.

Immediate Past President Dr. Desmond Schatz told us via email that the ADA’s view is: “While all people with type 1 diabetes endure fluctuations in blood glucose levels, some people struggle to find a regimen that keeps their blood glucose stable, despite significant effort... This severe instability is sometimes referred to as 'brittle' diabetes and should be addressed in close collaboration with a diabetes care team.”

He goes on to say that since no two patients are exactly alike, ADA has "consistently promoted an individual diabetes care plan -- it is a core tenet of our Standards of Care and inherent in the Association’s treatment guidelines."

He wraps with: “The Association remains committed to supporting every person throughout their journey with diabetes and will continue to evaluate special concerns, including extreme variability in blood glucose levels, to ensure that our guidelines are in line with the most current data and evidence.”

Meanwhile, Sorge continues to rail at the lack of an official "brittle diabetes" program, stating in his most recent press release, “Isn’t it about time that the ADA live up to their mission statement to “improve the lives of all people affected by diabetes?”

It's an interesting stand-off, but not a very productive one to our minds. In our opinion, the energy expelled in this "fight" could be put to better use. You know, like for managing the glucose swings that all of us experience and figuring out what works best to tame them. After all, Your Diabetes May Vary.

Dear Readers: What do you all think? Is clearer recognition of "brittle diabetes" important at all to you?

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.

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