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Diabetes: what’s new and what’s next

It’s no exaggeration to say that diabetes is an international health emergency. It is estimated that 422 million people are living with diabetes all over the world.

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International health emergency
International health emergency
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It’s no exaggeration to say that diabetes is an international health emergency. It is estimated that 422 million people are living with diabetes all over the world. Type 1 diabetes, caused by an immune system attack on the pancreas, usually strikes younger people and follows them through their lives. Type 2 is more common and is caused by resistance to the hormone insulin, which tells the body to absorb blood sugar.
 
Worldwide, some 350 million people exhibit signs of prediabetes, which means they have a one-in-ten chance of developing type 2 diabetes if not treated.
 
But here’s the good news: over just the past few years, a remarkable number of diabete treatments, from medications to surgical solutions to high-tech devices, have shown promise. It’s too soon to declare ­victory, but these smart lifestyle tips and medical breakthroughs have given ­people with diabetes winning strategies for today and considerable hope for the future. Separating diabetes myths from truths.
 

For Prediabetes and prevention
For Prediabetes and prevention
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For those considered to be at a higher risk of developing type 2 diabetes, large-scale randomised control trials have shown that in up to 58 per cent of cases, the condition can be delayed or even prevented through lifestyle changes. Check out these 21 hints and tips for eating well with diabetes.

Losing 5-10 per cent of total body weight helps
Losing 5-10 per cent of total body weight helps
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Losing weight: a weight loss of as little as 5-10 per cent of your total body weight can prevent type 2 diabetes in up to nearly 60 per cent of people. Here are the 15 best superfoods to eat if you have diabetes.

Not smoking
Not smoking
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Not smoking: the average smoker is 44 per cent more likely to develop diabetes. It takes 20 years after quitting for your risks of diabetes to reflect that of a non-smoker. Here's what happens to your body the moment you quit.
 

Regular physical activity
Regular physical activity
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Regular physical activity: as little as 30 minutes exercise, such as a walk five times a week, can reduce risks of diabetes by 30 per cent.
 

Make healthy food choices
Make healthy food choices
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Making healthy food choices: ­following an eating plan that is lower in kilojoules and total fat.According to British diabetes ­expert Dr Stephen Lawrence, managing portion sizes and reducing fat are key – “This involves no medication at all.”

Dr David Nathan, professor of medicine at Harvard Medical School, adds, “Fat cells, particularly at the abdomen, ­release hormones that ­increase risk for diabetes and it takes only a small amount of weight loss to lower risk. We found that dropping just 0.9 kilograms lowers your odds for diabetes over three years by about 16 per cent.”

Manage cholesterol levels
Manage cholesterol levels
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Managing cholesterol levels: choosing foods that contain less saturated fats; ideally less than 10 per cent of your total energy should come from saturated fats. According to British diabetes ­expert Dr Stephen Lawrence, managing portion sizes and reducing fat are key – “This involves no medication at all.”
 
Dr David Nathan, professor of medicine at Harvard Medical School, adds, “Fat cells, particularly at the abdomen, ­release hormones that ­increase risk for diabetes and it takes only a small amount of weight loss to lower risk. We found that dropping just 0.9 kilograms lowers your odds for diabetes over three years by about 16 per cent.”

How does Metformin work?
How does Metformin work?
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The drug Metformin has been found to reduce the incidence of type 2 diabetes among people with impaired glucose tolerance. It’s widely prescribed for people with prediabetes in Australia, New Zealand and parts of Asia such as Singapore, Hong Kong and Malaysia.
 
How it works Metformin reduces blood sugar by lowering the amount of sugar coming from the liver. A 2017 Georgetown University review showed that it cuts the risk of developing type 2 diabetes by 18 per cent over 15 years.

For type 2 diabetes: metabolic surgery
For type 2 diabetes: metabolic surgery
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Rerouting the digestive system with gastric bypass surgery (so-called because it creates a smaller stomach and bypasses part of the small intestine) or with a sleeve gastrectomy (which reduces the size of the stomach by about 80 per cent) is a drastic diabetes solution. After all, it’s major surgery, with small but real risks for such complications as infections, bleeding, and gastrointestinal problems. While available in Australia, New Zealand and Asia, this is not a government-funded procedure for type 2 diabetes and can be costly. It’s also not a stand-alone solution.

Reducing the size of the stomach means smaller portions
Reducing the size of the stomach means smaller portions
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How does it work? Reducing the size of the stomach makes it easier for people to stick with smaller portions – but people are also strongly urged to follow a healthy diet. New research is showing that the surgery produces safe, long-lasting benefits, particularly in people with ­recently diagnosed diabetes, such as John,* 37, who was diagnosed with type 2 diabetes three years ago. His doctor suggested gastric bypass ­surgery when John weighed 107 kilograms and had high cholesterol and hypertension.
 
“Being fairly young, I was looking at, for the rest of my life, simply being on pills that treated the symptoms but caused problems themselves,” John says. “Even if I kept my sugar down, type 2 diabetes still causes damage and, honestly, would never go away.”
 
Four months after his gastric ­bypass surgery, John has lost 24 kilos and has stopped taking medication for diabetes, cholesterol and blood pressure. His blood-sugar levels are in the healthy range.

Surgery increases chance of a complete remission
Surgery increases chance of a complete remission
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Research has shown that people who have surgery within five years of being diagnosed with type 2 diabetes have a 70 to 75 per cent chance of a complete remission.
 
“If you have diabetes for three years, four years, the diabetes can go into remission within some weeks, but if you have ten years of diabetes, the recovery takes more time in the patient and may not happen,” says John’s surgeon, Rudolf Weiner, president of the German Society for Bariatric Surgery, who has performed more than 7500 surgeries since 1993. “People will live longer and have a better quality of life, and they are free from all medications and complications.”
 
In 2016, more than 45 medical organisations endorsed bariatric surgery for people with moderate to severe obesity and diabetes.

Double-duty drugs
Double-duty drugs
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These tablets, which combine two ­diabetes drugs into one medication, have become more commonplace. The availability of particular drugs differs in each country, but a number of combination ­diabetes therapies are widely available in Australia, New Zealand, Singapore and Malaysia. The trend gives ­people fewer tablets to swallow at each sitting, making it easier to follow treatment plans.
 
“They can end up with three different diabetes medications,” Dr Lawrence says, “and that’s ­before you’ve considered that they’ll be taking treatment, potentially, for their high blood pressure and their cholesterol level.”
 
How they work Two-in-one treatment is quickly becoming standard for people living with type 2 diabetes. Up to 43 per cent of them now take two or more diabetes drugs, according to a recent international study. They may help diabetes ­patients live healthier lives.

“There are well-known studies that show if you can reduce the number of medications that patients have to take, then you improve their adherence,” Dr Lawrence says. What is double diabetes?
 

For type 1 diabetes: the artificial pancreas
The artificial pancreas
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The so-called artificial pancreas, referred to as a ‘hybrid-closed loop’ system, is a ­device that mimics the blood sugar function of a healthy pancreas. It has three parts: a sensor, placed under the skin, for continuous glucose monitoring; a laptop or smart phone component that receives information from the sensor, performs a series of algorithms to predict glucose levels and directs them to the pump; and the pump, which delivers insulin as required to tissue under the skin. A continuous loop is created without the need for human intervention.
 

Artificial pancreas: how it works
Artificial pancreas: how it works
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How does it work? When Anthony Tudela, 44, does mountain-bike ­racing, he’s no longer concerned that the intense physical exertion will lead to too-low blood sugar, known as ­hypoglycaemia. Since 2017, he’s worn an experimental artificial pancreas known as the Diabeloop DBLG1 ­system, which measures his blood-sugar levels every five minutes and consistently keeps him within target levels. When Tudela plans to physically ­exert himself or eat something, he inputs the data into the Diabeloop interface system on his mobile phone. The artificial pancreas then adjusts his insulin dose accordingly. The complete device checks his blood-sugar levels regularly, so if Tudela over- or under-calculates, the system should be able to adjust to keep ­glucose levels in range.

Managing sugar levels
Managing sugar levels
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“I can take sugar immediately, and 15 minutes later, the sugar level is OK,” says Tudela, who was diagnosed with type 1 diabetes at age seven.
 
Before receiving an artificial pancreas, Tudela’s blood-sugar levels were on target only 30 to 40 per cent of the time. His A1C levels hovered between 11 and 12 per cent, and he experienced hypos regularly.
 
With the hybrid-closed loop system, Tudela’s blood-sugar levels are on ­target 76 per cent of the time. His A1C levels have decreased to 7.5 per cent, and he doesn’t have hypos anymore, because the device keeps his blood-sugar levels in range.
 
“With this machine I feel free – I can live as if I wasn’t diabetic,” Tudela says. “But you have to trust the device. For decades, you got accustomed to the idea that you have to control your disease; you are responsible for it. And all of a sudden, the device is responsible. You have to let it go, and it is not so easy.” Check out this extra info on what to eat to feel your best
 

Next trial studying children
Next trial studying children
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You can’t yet buy a hybrid-closed loop system like Tudela’s experimental one, but that could change soon. Diabeloop, a small French company, is in the process of marketing the DBLG1 system, which could become commercially available in the near future.
 
“Insulin pumps have no intelligence; they just deliver insulin, ­according to a programme developed by the endocrinologist,” says Pierre-Yves Benhamou, head of the endocrinology-diabetology department at the Grenoble University Hospital Centre in France, who’s part of the Diabeloop medical development team. “The DBLG1 system is completely different. The quantity of insulin delivered to the patient adapts all the time according to the blood-sugar level of the patient.”
 
All of the clinical trials thus far have been done on adults with type 1 ­diabetes, but the next trial will study children and adolescents. The goal is to eventually decrease the risk of hypoglycaemia in all people with type 1 diabetes.
 

Islet cell transplants
Islet cell transplants
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Islet cells in the pancreas make insulin. If they are destroyed, type 1 diabetes is diagnosed. So, wouldn’t transplanting healthy new islet cells fix the problem? Islet cell transplants are available in many countries, ­including Australia, Hong Kong, the UK and some European countries.

“Islet transplantation is only considered if patients have been tried on optimal conventional treatment first,” says Professor Paul Johnson, director of the islet transplant programme at the University of Oxford. “They need to have been treated with the best possible modern insulins and insulin pumps, and despite that, still be getting hypoglycaemic unawareness.” All you need to know about insulin.
 

A less invasive procedure
A less invasive procedure
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How do they work? Islet cell transplants aren’t for everyone. “Islet transplantation is only considered if patients have been tried on optimal conventional treatment first,” says Professor Paul Johnson, director of the islet transplant programme at the University of Oxford. “They need to have been treated with the best possible modern insulins and insulin pumps, and despite that, still be getting hypoglycaemic unawareness.”It’s a much less invasive procedure than a whole pancreas transplant: ­islet cells are typically injected into the liver via the ­portal vein where they start to ­function as they would in the pancreas.
 
“It isn’t a major operation,” Prof Johnson says. “It’s like having an ­intravenous drip run through. Nearly all the islet transplants are done in the X-ray department, with the patient still awake, but with a local anaesthetic injection over the liver and some sedation.”

Some people can stop taking insulin
Some people can stop taking insulin
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Most people need two consecutive islet cell transplants to ensure that the procedure is effective and that the ­islets last. (The cells can last for many years but tend to function for three to five years.) Patients who receive islet cell transplants ­need to take anti-­rejection medication (immunosuppression) for the rest of their lives.
 
Many people are able to stop taking insulin for some period of time: In a recent study, when 48 people whose type 1 diabetes was extremely difficult to manage (leading to life-threatening low blood sugar ­episodes/hypoglycaemia), received islet cell transplants, 52 per cent had in range glucose levels one year later without insulin.

An islet transplant can be life-saving
An islet transplant can be life-saving
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“Even if they require some insulin, an islet transplant can be life-saving in terms of preventing sudden death of undetected hypos,” Prof Johnson says, “and life-improving by helping to prevent complications such as blindness, ­kidney failure and heart disease ­resulting from high blood sugars.”
 
Adapted from an article by Sari Harrar. Additional reporting by Victoria Polzot.

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