Delivering insulin in a pill

Researchers have developed an oral delivery method that could dramatically transform the way in which diabetics keep their blood sugar levels in check | Proceedings of the National Academy of Sciences | via ScienceDaily

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Insulin therapy, by injection just under the skin or delivered by an insulin pump, generally keeps the glucose levels of most diabetics in check. However, many people fail to adhere to that regimen due to pain, phobia of needles, and the interference with normal activities. The resulting poor glycemic control can lead to serious health complications.

Finding a way to deliver insulin orally has been elusive; the protein does not fare well when it encounters the stomach’s acidic environment and it is poorly absorbed out of the intestine. The key to the new approach is to carry insulin in an ionic liquid comprised of choline and geranic acid that is then put inside a capsule with an acid-resistant enteric coating. The formulation is biocompatible, easy to manufacture, and can be stored for up to two months at room temperature without degrading, which is longer than some injectable insulin products currently on the market.

Full story at ScienceDaily

Full reference: Banerjee, A et al. | Ionic liquids for oral insulin delivery | Proceedings of the National Academy of Sciences | published online June 25th 2018

Setting the top 10 research priorities to improve the health of people with Type 2 diabetes

Finer, S. et al. | Setting the top 10 research priorities to improve the health of people with Type 2 diabetes: a Diabetes UK–James Lind Alliance Priority Setting Partnership | Diabetic Medicine | Volume35 Issue7 | p862-870 | July 2018

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Abstract
Aims
To describe processes and outcomes of a priority setting partnership to identify the ‘top 10 research priorities’ in Type 2 diabetes, involving people living with the condition, their carers, and healthcare professionals.

Methods
We followed the four‐step James Lind Alliance Priority Setting Partnership process which involved: gathering uncertainties using a questionnaire survey distributed to 70 000 people living with Type 2 diabetes and their carers, and healthcare professionals; organizing the uncertainties; interim priority setting by resampling of participants with a second survey; and final priority setting in an independent group of participants, using the nominal group technique. At each step the steering group closely monitored and guided the process.

Results
In the first survey, 8227 uncertainties were proposed by 2587 participants, of whom 18% were from black, Asian and minority ethnic groups. Uncertainties were formatted and collated into 114 indicative questions. A total of 1506 people contributed to a second survey, generating a shortlist of 24 questions equally weighted to the contributions of people living with diabetes and their carers and those of healthcare professionals. In the final step the ‘top 10 research priorities’ were selected, including questions on cure and reversal, risk identification and prevention, and self‐management approaches in Type 2 diabetes.

Conclusion
Systematic and transparent methodology was used to identify research priorities in a large and genuine partnership of people with lived and professional experience of Type 2 diabetes. The top 10 questions represent consensus areas of research priority to guide future research, deliver responsive and strategic allocation of research resources, and improve the future health and well‐being of people living with, and at risk of, Type 2 diabetes.

Full article available here

Type 2 diabetes mellitus in older people: key principles of modern day management

Strain, W. et al. |Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative | Diabetic Medicine | Volume35, Issue 7 | July 2018 | p838-845

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Abstract

Rates of population ageing are unprecedented and this, combined with the progressive urbanization of lifestyles, has led to a dramatic shift in the epidemiology of diabetes towards old age, particularly to those aged 60–79 years.

Both ageing and diabetes are recognized as important risk factors for the development of functional decline and disability. In addition, diabetes is associated with a high economic, social and health burden.

Traditional macrovascular and microvascular complications of diabetes appear to account for less than half of the diabetes‐related disability observed in older people. Despite this, older adults are under‐represented in clinical trials.

Guidelines from organizations such as the National Institute for Health and Care Excellence (NICE), the European Association for the Study of Diabetes, and the American Diabetes Association acknowledge the need for individualized care, but the glycaemic targets that are suggested to constitute good control are too tight for frail older individuals.

We present a framework for the assessment of older adults and guidelines for the management of this population according to their frailty status, with the intention of reducing complications and improving quality of life for these people.

Full document available here

 

People with type 2 diabetes at increased risk of Parkinson’s disease

NIHR | June 2018 | People with type 2 diabetes at increased risk of Parkinson’s disease

According to the findings of an NIHR study people with type 2 diabetes are almost a third (32 %) more likely to develop Parkinson’s disease than those without diabetes. The publication of this study marks the largest ever study on the link between the two conditions.

Researchers supported by the NIHR Biomedical Research Centres at Oxford and University College London Hospitals followed over 2 million people who were diagnosed with type 2 diabetes between 1999 and 2011.  People in this group  people were compared with over 6 million people without diabetes.  Over 14000 individuals with diabetes had a diagnosis of Parkinson’s disease, compared with 20,878 in the comparison group. The scientists excluded some people with similar conditions and applied controls to the data set, they found that people with type 2 had a likelihood of 32% of having a further diagnosis of Parkinson’s disease.

The lead author of the study, Professor Tom Warner, at the UCL Institute of Neurology, said: “We can now say more definitely that there is a link between diabetes and Parkinson’s, but we need to do more research to understand the relationship – whether it’s due to genetics, the effect of diabetes on the brain, or both.”

The full press release is available from NIHR 

A paper based on these findings has now been published in the journal Neurology  

Objective To investigate the association between type 2 diabetes mellitus (T2DM) and subsequent Parkinson disease (PD).

Methods Linked English national Hospital Episode Statistics and mortality data (1999–2011) were used to conduct a retrospective cohort study. A cohort of individuals admitted for hospital care with a coded diagnosis of T2DM was constructed, and compared to a reference cohort. Subsequent PD risk was estimated using Cox regression models. Individuals with a coded diagnosis of cerebrovascular disease, vascular parkinsonism, drug-induced parkinsonism, and normal pressure hydrocephalus were excluded from the analysis.

Results A total of 2,017,115 individuals entered the T2DM cohort and 6,173,208 entered the reference cohort. There were significantly elevated rates of PD following T2DM . The relative increase was greater in those with complicated T2DM  and when comparing younger individuals.

Conclusions We report an increased rate of subsequent PD following T2DM in this large cohort study. These findings may reflect shared genetic predisposition and/or disrupted shared pathogenic pathways with potential clinical and therapeutic implication

Full reference:

De Pablo-Fernandez, E. GoldacreR.,  PakpoorJ.,  Noyce,  Alastair J.,   Warner, T.T. | 2018| Association between diabetes and subsequent Parkinson disease|

Health matters: preventing Type 2 Diabetes

Public Health England | June 2018| Health matters: preventing Type 2 Diabetes

Public Health England  (PHE) has recently published guidance on preventing Type 2 diabetes, to support health professionals to optimise the NHS Diabetes Prevention Programme (NHS DPP). The programme helps to to identify those already found to be at risk of developing Type 2 diabetes and offer support that will help them reduce their risk of developing the disease (PHE).

PHE Health-Matters preventing type 2
Image source: gov.uk

The full guidance is at PHE 

Related: PHE blog Health Matters – Your questions on Preventing Type 2 diabetes

 

National Diabetes Insulin Pump Audit 2016-2017

Health Quality Improvement Partnership | June 2018| National Diabetes Insulin Pump Audit 2016-2017

The Insulin pump audit collects information on the number and characteristics of people with diabetes using an insulin pump, the reasons for going on an insulin pump and the outcomes achieved since starting the pump. The data included in the attached report was collected between 2016-2017 from Trusts based within England and Wales. 

National Diabetes Insulin Pump Audit, 2016-2017
Image source: hqip.org.uk

Key findings include:
Improved participation and data quality means that the report this year is more comprehensive and clinically useful

  • The rate at which people with Type 1 diabetes are starting pump treatment has stabilised
  • The proportion of people with Type 1 diabetes attending specialist services that are treated with pumps varies from more than 40% to less than 5%
  • Between two thirds and three quarters of pump users are recorded as achieving their pump treatment goals
  • Nine out of ten people reached their target goal for hypoglycaemia
  • Seven out of ten people reached their target goal for glucose control
  • Despite being a younger cohort, Type 1 diabetes pump users more often achieve all their treatment targets, and on average have a lower HbA1c, than their non-pump using peers.

The full audit is available to download as PowerPoint slides from NHS Digital via HQIP 

 

Men’s Health Week 2018

Men’s Health Forum | June 2018 | Men’s Health Week 2018: Diabetes

This year Men’s Health Week coincides with Diabetes Week, as a result Men’s Health Forum have decided to raise awareness of diabetes in males. They are highlighting how men are affected by the condition and have released a number of facts to support this.

1 in 10 males diabetes
Image source: menshealthforum.org.uk

  • One man in 10 now has diabetes and in middle-aged men the disease is expected to increase sharply in frequency over the next 20 years.
  • Men are more likely to get diabetes than women, more likely to experience complications like leg amputation and more likely to die from the condition.
  • Men are 26% more likely to develop Type 2 diabetes than women – with Public Health England estimates showing that 9.6% of men have type 1 or type 2 diabetes vs. 7.6% of women. One man in 10 now has diabetes.
  • Men are more likely to be overweight (BMI 25+) and to develop diabetes at a lower BMI (body mass index) than women.
    (Source: Men’s Health Forum)

They have produced a report, Diabetes for Men, how to avoid it, how to live with it  which is available to order from their website

New hope from the “seven year switch” in Type 1 diabetes

University of Exeter | June 2018| New hope from the “seven year switch” in Type 1 diabetes

Type 1 diabetes affects around 400,000 people in the UK. The disease commonly starts in childhood but can develop at any age, and causes the body’s own immune system to attack and destroy the insulin-producing cells in the pancreas, leaving the patient dependent on life-long insulin injections. 

A new study from the University of Exeter Medical School measured C-peptide, a substance which is  produced at the same time and in the same quantities as the insulin that regulates blood sugar.  By measuring C-peptide levels in blood or in urine, scientists can tell how much insulin a person is producing themselves, even if they are taking insulin injections as treatment.

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Over 1500 participants (n= 1549) living with Type 1 diabetes from Exeter and Tayside, Scotland were involved in the study. The team found that evidence that the amount of insulin produced declines by almost 50% each year for seven years. At that point, the insulin levels stabilise. This finding contradicts previous belief that the insulin produced by people with Type 1 drops relentlessly over time.

Lead author Dr Beverly Shields said “This finding is really exciting. It suggests that a person with Type 1 diabetes will keep any working beta-cells they still have seven years after diagnosis.  We are not sure why this is; it may well be that there is a small group of “resilient” beta-cells resistant to immune attack and these are left after all the “susceptible” beta-cells are destroyed. Understanding what is special about these “resilient” beta-cells may open new pathways to treatment for Type 1 diabetes.”

SourceUniversity of Exeter

The full news release is available from the University of Exeter
The study has been published in Diabetes Care 

Abstract

OBJECTIVE: The decline in C-peptide in the five years after diagnosis of Type 1 diabetes has been well studied, but little is known about the longer-term trajectory. We aimed to examine the association between log-transformed C-peptide levels and duration of diabetes up to 40 years after diagnosis
RESEARCH DESIGN AND METHODS: We assessed the pattern of association between urinary Cpeptide creatinine ratio (UCPCR) and duration of diabetes in cross sectional data from 1549 individuals with Type 1 diabetes using non-linear regression approaches. Findings were replicated in longitudinal follow-up data in both UCPCR (n=161 individuals, 326 observations) and plasma C-peptide (n=93 individuals, 473 observations).
RESULTS: We identified two clear phases of C-peptide decline: an initial exponential fall over 7 years (47% decrease per year followed by a stable period thereafter. The two phases had similar duration and slope in patients above and below the median age at diagnosis (10.8 years) although levels were lower in the younger patients irrespective of duration. Patterns were consistent in both longitudinal UCPCR (n=162) less than 7y duration: -48% per year ; more than 7y duration -0.1% and plasma C-peptide (n=93) more than 7y duration only: -2.6%.

CONCLUSIONS: These data support two clear phases of C-peptide decline: an initial exponential fall over a 7 year period, followed by a prolonged stabilization where C-peptide levels no longer decline. Understanding the pathophysiological and immunological differences between these two phases will give crucial insights into understanding beta-cell survival.


Full reference: 

 Shields, B. M. & McDonaldT. J. et al | 2018| C-peptide decline in type 1 diabetes has two phases: an initial exponential fall and a subsequent stable phase| Diabetes Care |ePub ahead of print|

Diabetes Awareness Week

Diabetes UK | June 2018 | One in three turn to internet over a GP for medical advice

New online research has been released to mark the start of Diabetes Week 2018 (11-17 June 2018) has revealed that one in three people would seek advice online before talking to a GP about a health concern. A poll of 2000 people commissioned by Diabetes UK demonstrates that one third of people favour searching the internet to talking to their GP about their diabetes. Although three- quarters (75 per cent)  said they would be comfortable discussing relatives and friends medical conditions, only 65 per cent or those surveyed with diabetes would be comfortable discussing their own health (via Diabetes UK).

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In response to their findings, Diabetes UK have produced some top tips for people living with diabetes to talk to health professionals:

· Diabetes is complicated and different for everyone. There’s no such thing as a silly question. So don’t be afraid to ask about whatever’s on your mind.

· It’ll help if you go to your appointment with some questions in mind. You could write them down or send them to your healthcare team beforehand.

· This time is for you, so let your healthcare team know what you’d like to talk about from the start.

· Sometimes you’ll have more to talk about, and you might need more time. If you can, book a double appointment so you don’t have to rush.

· There might be things you feel uncomfortable talking about. But your healthcare team is there to help, so be honest and make the most of their medical expertise.

Language Matters

NHS England | June 2018 | Language Matters: Language and diabetes 

This new guidance from NHS England provides practical examples of language that will encourage positive interactions with people living with diabetes and subsequently positive outcomes.

Language Matters
Image source: england.nhs.uk

People with diabetes internalise messages from the media, from those around them, but most of all from their healthcare providers. When these messages are perceived negatively, whether it is intended or not, this can lead to feelings of shame, guilt and resentment. People who are ashamed of a condition will find it much harder to engage and manage that condition proactively (Source: NHS England).