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Experts alert to rise in diabetes cases, complications

By Guardian Nigeria
15 November 2021   |   4:15 am
Ahead of World Diabetes Day (WDD), November 14, medical experts have alerted to rise in diabetes cases and complications.

•Say ‘cure’ is possible in 5% of patients as weight loss of 15% can reduce complications, slow progression of disease

Ahead of World Diabetes Day (WDD), November 14, medical experts have alerted to rise in diabetes cases and complications.

They said ageing populations; increasing obesity and a sedentary way of life contribute to the yearly increase in type 2 diabetes worldwide.

The experts, however, said that remission (‘cure’) is possible in five per cent of patients and that weight loss of 15 per cent can reduce complications and slow progression of type 2 diabetes. They said doctors now recommend lifestyle changes and can effectively support those who currently have or are at high risk for developing type 2 diabetes.

Diabetes is a major global health concern, affecting mortality rates and the quality of life of those with the condition and their families.

While numerous treatment options exist to control the disease, many people go beyond managing their illness to achieve remission.

A new study using data from Scotland found that a significant number of people with a type 2 diabetes diagnoses are in remission. The researchers also sought to define the factors that drive remission.

The results were published in the open-access journal PLOS Medicine.

In 2019, over 422 million people worldwide had received a diagnosis of diabetes. Experts estimate that by 2045, 700 million individuals will have the condition. An aging population, growing obesity, and a sedentary lifestyle all contribute to this projected increase.

While many people manage or control their diabetes through glucose-lowering therapy, the broad definition of remission of type 2 diabetes is achieving normal glycemic measures without using glucose-targeted medications.

Some people have achieved remission through bariatric surgeries, including gastric bypass and gastric banding. Others achieved remission following participation in research trials that tested low calorie diets followed by structured weight loss management programmes.

However, this most recent study found that many people achieve remission without surgery and without participating in trials.

Using the Scottish Care Information – Diabetes Collaboration (SCI-DC) registry, researchers used data from more than 162,000 individuals who were older than 30 years, diagnosed with type 2 diabetes, and alive on December 31, 2019.

Study results
The study found that 7,710 of the study participants, or around five per cent, were in remission from type 2 diabetes. The researchers defined remission as hemoglobin A1c levels less than 48 millimoles per mole (mmol/mol) after not using glucose-lowering medications for more than 365 consecutive days.

As the United States Centers for Disease Control and Prevention (CDC) explained, “The A1C test — also known as the hemoglobin A1C or HbA1c test — is a simple blood test that measures your average blood sugar levels over the past three months.”

The results showed that individuals, who achieved remission tended to be older, never took any glucose-lowering medications, had lower blood sugar levels at diagnosis, or had lost weight since the diagnosis of diabetes, either through diet or bariatric surgery.

White people were also more likely to achieve remission than people from other ethnic groups or mixed backgrounds.

The scientists then compared the characteristics of people in remission with those who were not in remission.

According to the authors, understanding the number of individuals in remission and the factors that led to this condition is important to identify which groups are most likely to achieve remission. Targeting the limited resources for intensive lifestyle management of these groups would follow.

While bariatric surgery had a strong association with diabetes remission, the authors are quick to point out that this procedure was rare among study participants.

In an interview with Medical News Today, Dr. Faye Riley, senior research communications officer at Diabetes UK, said: “Identifying people who have put their diabetes into remission outside of research trials is important in ensuring they receive the ongoing support they need. These findings could also provide insight into who within the general population might have the best chance of remission, helping healthcare professionals to start vital conversations with those most likely to benefit.”

In addition to creating a baseline for future initiatives and studies, the information derived from this study indicates the importance of lifestyle choices and education in the treatment and possible prevention of the disease.

Assistant professor of clinical medicine and medical director for Inpatient Diabetes at Indiana University School of Medicine in Indianapolis, Dr. Swapnil Khare, believes it is important to provide a greater level of support for those at risk of developing type 2 diabetes. Khare was not involved in the research.

“As we have seen in society, there is a lot of emphasis on diet,” said Khare in an interview with MNT, “but there are several other lifestyle modifications and diet programs and a lot of social awareness, especially through social media. It’s multifaceted. And it’s very important to catch diabetes earlier and then provide the support.”

While these results are certainly encouraging, it is important to recognise that diabetes remission may not be permanent.

It is also worth noting that 74 per cent of the participants in this study were white. Therefore, the results may not apply to other groups. There was also no information available on why people had undergone bariatric surgery, whether to treat obesity or due to stomach cancer, for example.

The Look Action for Health in Diabetes trial took place in the United States among adults with type 2 diabetes who had overweight or obesity. Of those participants who had attained remission, nearly half of the control group returned to type 2 diabetes within one year, as did one-third of the group who received intensive lifestyle intervention.

The authors of the new study concluded: “Further research is needed to investigate the association between remission and complications of diabetes, including mortality, particularly the effect of different durations of sustained remission.”

Meanwhile, an increasing number of studies suggest a link between a neighborhood’s built environment and the likelihood that its residents will develop chronic diseases such as heart disease, type 2 diabetes (T2D) and certain types of cancers.

A new nationwide United States study led by researchers from NYU Grossman School of Medicine published online in JAMA Network Open suggests that living in neighborhoods with higher availability of fast-food outlets across all regions of the United States is associated with higher subsequent risk of developing type 2 diabetes.

Findings also indicated that the availability of more supermarkets could be protective against developing T2D, particularly in suburban and rural neighborhoods.

The study — notable for its large geographic breadth — uses data from a cohort of more than four million veterans living in 98 percent of U.S. census tracts across the country. It counted fast-food restaurants and supermarkets relative to other food outlets, and is the first, according to the researchers, to examine this relationship in four distinct types of neighborhoods (high-density urban, low-density urban, suburban, and rural) at the hyperlocal level nationwide.

“Most studies that examine the built food environment and its relationship to chronic diseases have been much smaller or conducted in localized areas,” said Rania Kanchi, MPH, a researcher in the Department of Population Health at NYU Langone and lead author of the study. “Our study design is national in scope and allowed us to identify the types of communities that people are living in, characterize their food environment, and observe what happens to them over time. The size of our cohort allows for geographic generalizability in a way that other studies do not.”

The research team used data from the U.S. Veterans Health Administration (the largest single-payer healthcare system in the country) that captures more than nine million veterans seen at more than 1,200 health facilities around the country. Using this data, the researchers then constructed a national cohort of more than four million veterans without diabetes from the VA electronic health records (EHR) between 2008 and 2016. Each veteran’s health status was followed through 2018 or until the individual either developed diabetes, died, or had no appointments for more than two years.

Within each of four distinct neighborhood types, the proportion of restaurants that were fast food, and the proportion of food outlets that were supermarkets were tabulated within a one-mile walk in high- density urban neighborhoods, a two-mile drive in low-density urban neighborhoods, a six-mile drive in suburban communities, and a 10-mile drive in rural communities.

Veterans were followed for a median of five and a half years. During that time, 13.2 percent of the cohort were newly diagnosed with T2D. Males developed T2D more frequently than females (13.6 versus 8.2 percent).

Non-Hispanic Black adults had the highest incidence (16.9 percent), compared to non-Hispanic Whites (12.9 percent), non-White Asian and Hispanics (12.8 percent), Native Hawaiian and Pacific Islanders (15 percent), and Native American and Alaskan Indians (14.2 percent).

When stratifying by community types, 14.3 percent of veterans living in high-density urban communities developed T2D, while the lowest incidence was among those living in suburban and small town communities (12.6 percent).

Overall, the team concluded that the effect of the food environment on T2D incidence varied by how urban the community was, but did not vary further by region of the country.

“The more we learn about the relationship between the food environment and chronic diseases like type 2 diabetes, the more policymakers can act by improving the mix of healthy food options sold in restaurants and food outlets, or by creating better zoning laws that promote optimal food options for residents,” said Dr. Lorna Thorpe, professor in the Department of Population Health at NYU Langone and senior author of the study.

One limitation of the study, according to the authors, is that the study may not be fully generalizable to non-veteran populations, as U.S. veterans tend to be predominantly male and have substantially greater health burdens and financial instability than the civilian population. They are also at greater risk of disability, obesity, and other chronic conditions.

Thorpe and Kanchi said the next phase of the research would be to better understand the impacts of the built environment on diabetes risk by subgroups. They plan to examine whether or not the relationships between fast-food restaurants, supermarkets and community types vary by gender, race/ethnicity, and socioeconomic status.

Meanwhile, according to a recent study by the University of Eastern Finland and the Finnish Institute for Health and Welfare, increased consumption of whole grain foods could significantly reduce the incidence of type 2 diabetes and the costs associated with its treatment in Finland.

The findings were published in Nutrients.

“Our study shows that already one serving of full grains as part of the daily diet reduces the incidence of type 2 diabetes at the population level and, consequently, the direct diabetes-related costs, when compared to people who do not eat whole grain foods on a daily basis. Over the next ten years, society’s potential to achieve cost savings would be from 300 million (-3.3 per cent) to almost one billion (-12.2 per cent) euros in current value, depending on the presumed proportion of whole grain foods in the daily diet. On the level of individuals, this means more healthier years,” says Professor Janne Martikainen from the University of Eastern Finland.

Type 2 diabetes is one of the fastest-growing chronic diseases both in Finland and globally. Healthy nutrition that supports weight management is key to preventing type 2 diabetes. The association of daily consumption of whole grain foods with a lower risk of diabetes has been demonstrated in numerous studies.

Research Manager Jaana Lindström from the Finnish Institute for Health and Welfare said: “According to nutrition recommendations, at least three-six servings of whole grain foods should be eaten daily, depending on an individual’s energy requirement. One third of Finns do not eat even one dose of whole grains on a daily basis, and two thirds have a too low fibre intake.”

The now published study utilised findings from, example, national follow-up studies, such as the FinHealth Study, to assess the health and economic effects of increased consumption of whole grain foods on the prevention of type 2 diabetes.

“By combining population-level data on the incidence of type 2 diabetes and the costs of its treatment, as well as published evidence on the effects of how consumption of whole grain foods reduces the incidence of type 2 diabetes, we were able to assess the potential health and economic benefits from both social and individual viewpoints,” Martikainen said.

Meanwhile, researchers say a weight loss of 15 percent or more can reduce complications and slow the progression of type 2 diabetes. It can even reverse type 2 diabetes in many cases.

According to a review article published in the journal The Lancet, 15 percent weight loss goal, in fact, should be the central focus of disease management for most people with type 2 diabetes.

As noted in the review, the study DiRECT trial showed weight loss benefits in type 2 diabetes management.

The trial involved people who were overweight or obese and had type 2 diabetes for less than six years. In the trial, 70 percent of those who took part in intensive lifestyle intervention achieved remission at two years.

In addition, studies of bariatric surgery for people with obesity and type 2 diabetes have also shown a reduced need for glucose-lowering drugs.

Dr. Laurie A. Kane is an endocrinologist at Providence Saint John’s Health Center in Santa Monica, California. She told Healthline that she agrees that weight management should be a priority.

“Authorities from around the world covered a lot of topics in this extensive article. The focus has always been on lifestyle changes ahead of medicine. The emphasis here is on the degree of weight loss in order to reverse type 2 diabetes. Fifteen percent is a lot. It’s difficult, but studies show it can be done,” she said.

“The scientists discussed investigative therapies in phase 3 trials are showing huge benefits for weight loss and significant lowering of A1C in some patients. All internal medicine physicians and endocrinologists should be reading this to be aware of what’s on the horizon,” added Kane.

Losing that much body weight and keeping it off is a challenge.

As the study authors point out, people with type 2 diabetes and obesity may be reluctant to ask healthcare professionals for help. They may fear being blamed for their weight.

And for many people, bariatric surgery isn’t desirable or feasible.

The researchers say that as more noninvasive treatments become available, people will have more choices. But it will take updated treatment guidelines and obesity management training for providers and support staff.

They also state that health systems should focus on the benefits of reducing weight to prevent or control type 2 diabetes before complications arise.

Exactly how one goes about losing weight depends on the person, said Kane.

Factors to consider are how much weight someone needs to lose, what they’ve tried in the past, and what they’re doing now.

“Lifestyle involves a healthy diet and daily or near daily exercise, and behavior modification. You have to know how to have healthy diet and healthy exercise. Next up is pharmacotherapy: medicine, medical devices, or bariatric surgery,” said Kane.

“It’s an exceptional patient who, just on advice of diet and exercise, will start losing. Most need an intensive program,” she continued.

“We do have studies like the Diabetes Prevention Program that involved 16 visits over six months and helped promote different ways of thinking,” said Kane.

“In my private practice, I have seen many people who have a normal weight but an increased waist circumference,” Routhenstein told Healthline.

“We would still need to address insulin resistance and inflammation to target the abdominal region to help manage type 2 diabetes and reduce risk of other chronic diseases like heart disease,” she continued.

“Excess abdominal weight plays a role in type 2 diabetes because it is the most metabolically active type of fat. It’s directly linked to both insulin resistance and low-grade chronic inflammation,” said Routhenstein.

She helps her clients lower their abdominal weight by addressing insulin resistance and low-grade inflammation through science-based nutrition.

“This includes ensuring macronutrient balanced meals and snacks with limited complex carbohydrates to assist the body in glucose metabolism, decreasing pro-inflammatory foods, and also by adding in therapeutic foods to reduce inflammation and assist with insulin sensitivity, ” said Routhenstein.

Kane stressed the importance of catching type 2 diabetes early or preventing it from developing in the first place.

“Everyone should be screened by age 45 or earlier if they have risk factors such as a history of cardiovascular disease, hypertension, physical inactivity, or insulin resistance. Prediabetes should be treated,” she said.

“Both obesity and type 2 diabetes are serious and progressive. They increase morbidity and mortality. Patients should work with their provider to make sure diagnostic parameters like weight, Body Mass Index (BMI), and waist circumference, are tracked every year,” she said.

Kane notes there are now 11 classes of medicine for type 2 diabetes.

“We can always find a treatment programme, and we can think more about diabetes going into remission,” she said.