diabetes

Diabetes Professional Care conference 2017 – Day Two review

Day Two of the third Diabetes Professional Care conference included discussions on obesity in practice and putting type 2 diabetes into remission.

Our editorial team had their eyes on the ground as they reported live from Olympia London. Deputy Editor Jack Woodfield and Research Editor Camille Bienvenu reviewed the highlights.

Check out Day 1’s key highlights here.

16:00:

Dr Amanda Avery, an Associate Professor in Nutrition and Dietetics at the University of Nottingham, discussed how early interventions may need to be implemented in order to significantly reduce the prevalence of maternal obesity and improve child health outcomes.

A lot of women of childbearing age are either overweight or obese at the start of their pregnancy. Tackling maternal obesity can make a real difference to the long-term health of the mother and  prevent “metabolic malprogramming” during infancy.

Dr Avery has done a lot of research into this topic and she has found that a high-pre pregnancy body mass index (BMI) and excessive weight gain during pregnancy are associated with a significant increase in the risk of developing gestational diabetes.

Studies that have looked at maternal outcomes by BMI category show that women with a BMI over 40 kg/m2 are eight times more likely to develop gestational diabetes than pregnant women with normal weight.

Dr Avery also found that maternal obesity can cause permanent changes in appetite, neuroendocrine function and energy metabolism, and is linked to complications in the infant like macrosomia (high birth weight) or neural tube defects.

The diet and physical activity of the mother influences the risk of maternal obesity and levels of insulin resistance. According to Avery, it is not uncommon to find that infants born to overweight or obese mothers have higher than normal levels of insulin and higher levels of adiposity at birth.

Avery stressed the importance of balanced nutrition before, during and after pregnancy for a healthy offspring, in light of the many fetal and immediate postnatal nutritional influences on adult health.

An individual’s metabolism can be permanently reprogrammed by overfeeding or increased intake of carbohydrates early in life, for example.

Altered nutrition during the fetal period (due to maternal malnutrition, obesity and diabetes) can have a long-lasting impact on the offspring, predisposing to the development of  obesity, type 2 diabetes and metabolic syndrome in adult life.

Research increasingly suggests that fetal and postnatal malnutrition, and subsequent metabolic malprogramming, can even result in epigenetic modifications that will affect not just the individual as he or she matures, but future generations as well.

Although maternal obesity and maternal malnutrition can contribute to developmental programming in the offspring, there are things that mothers can do to limit those risks.

Two studies outlined by Dr Avery, the Cardiff HELP feasibility study and UPBEAT study, tested possible therapies for improving maternal health and that of the offspring.

One of them found that women involved in lifestyle interventions and who lost weight before giving birth were more inclined to breastfeed. The beneficial effects of breastfeeding on reducing childhood obesity, as well as the impact on the gut microbiome, are increasingly being recognised.

There is currently a lack of emphasis on the importance of early nutritional interventions and weight management support during pregnancy for long-term health. There are also incoherences in NICE guidelines, which state that weight loss should be avoided during pregnancy.

Dr Avery disagrees and concluded her talk by saying that healthy eating and physical activity advice is appropriate and that more resources should be directed to support women in achieving or maintaining a healthy weight throughout their pregnancy.

1500:

The psychological impact of diabetes took centre stage as Professor Cathy Lloyd, Professor of Health Studies at the Open University, examined depression, burnout and ethnicity in regard to mental health.

By 2040, Lloyd said, around 642 million people worldwide will have diabetes, according to estimates. Meanwhile, JDRF reports that people with type 1 diabetes will administer 65,000 injections during their lifetimes. It’s easy to see why this can lead to thoughts of negativity, and people with diabetes have a two times greater risk of depression.

In regard to the NHS, mental health problems within type 2 diabetes costs an additional £2b, but treating depression can improve blood glucose control, and identifying, addressing and conquering depression is pivotal in ensuring patients’ well-being and lessening pressure on the NHS.

Lloyd spoke in detail about data collection her team did in Birmingham which revealed South Asians are up to six times more likely to have diabetes. There are also higher rates of depression among South Asians with diabetes compared to white Europeans.

Screening for depression is of utmost importance within the South Asian community, with Lloyd referring to conversations with patients who preferred a conversational tone during health visits, rather than posh or technical language.

Currently, Etic screening is most commonly used for depression screening within ethnic groups, which involves adapting answers based on ethnicity, but Lloyd argues Emic screening, which comprises screenings taking place within cultures, could be more beneficial. It is, however, also more expensive.

Lloyd finished on a positive note by lauding increasing guidelines and recommendations for treating depression within diabetes.

14:00:

Geoff Hackett, a professor of Men’s Health at the University of Bedforshire, has told attendees that low testosterone is not just a matter of aging, and that it can impact the health of people with type 2 diabetes in profound ways.

One of those ways is that it can worsen erectile dysfunction (ED), a condition that occurs in 75 per cent of all men with type 2 diabetes. About 12 per cent of them also have low testosterone, which is required for normal erectile function.

ED is a consequence of neuropathies that affect the nerves to the penis. There is a narrowing or hardening of blood vessels that prevent blood flow in and out of the penis. Hypertension and dyslipidemia are additional risk factors for ED.

Prof Hackett put forward research in the British Medical Journal, which looked at 7.9 million people, that shows that ED is an independent risk factor for heart disease and therefore shouldn’t be overlooked.

Hackett suggests that there is a tight link between adiposity, ED and hypogonadism (low testosterone). He presented compelling research which evidence a strong correlation between higher body mass indexes (BMI) or waist circumferences and lower testosterone.

On that basis, he believes that all men with type 2 diabetes who are overweight or have an increased waist circumference should be evaluated for testosterone deficiency.

Low testosterone, he explained, can have many deleterious effects on sexual function among people with type 2 diabetes. As testosterone levels fall, men get symptoms of loss of vigour and loss of libido. When levels fall below 8 nmol/l, symptoms of erectile dysfunction start to appear.

Testosterone works on the brain and influences neurotransmitters, like dopamine, as well as a system that controls nitric oxide, a chemical compound that triggers the relaxation of the smooth muscle in the arteries of the penis. This relaxation process increases the blood flow to the penis required for an erection. Low testosterone inhibits this helpful process.

A long-term study known as BLAST, conducted in 2016, showed that low testosterone left untreated increases all-cause mortality, especially in older men.

Hackett showcased a few supporting trials of testosterone replacement therapy in people with type 2 diabetes. One double blind placebo controlled study he co-authored found that restoring testosterone levels in men with type 2 diabetes and baseline testosterone levels lower than 8 significantly benefits sexual function.

The testosterone therapy also modestly improved HbA1c levels and caused some weight loss. Although this is not strongly supported by research, men who lose weight can see a concurrent increase in testosterone levels, because of this link between adiposity and testosterone mentioned earlier.

Hackett believes that all men with type 2 diabetes should be put on testosterone therapy alongside a PDE5 inhibitor, a class of drugs originally developed to treat heart disease which cause vasodilation in the penis and benefits sexual function. PDE5 inhibitors have also been associated with improved neuropathy-related outcomes.

According to Hackett, there should be more attention paid to restoring testosterone levels as soon as people are diagnosed with type 2 diabetes to reduce the risk of developing ED and associated conditions.

13:15

Professor Mike Trenell, Chief Scientific Officer at Changing Health, has been speaking about reversing type 2 diabetes and how it is important for healthcare professionals to remember that people lose weight in different ways.

“We should be finding out what is best for the individual,” Trenell said, adding that a patient’s behaviours will often dictate which dietary intervention, whether it is a low-carb diet, a very low-calorie diet (VCLD) or a Mediterranean diet, works best for them.

Trenell spotlighted some studies from years gone by which have helped shape the evolution of type 2 diabetes reversal, or putting the condition into remission.

Discussing a 1997 study published in The Lancet, which evaluated the benefits of numerous medications, Trenell reviewed, “Drug-based therapies moved the curve to the right,” when in fact the real challenge is moving the curve back to the middle.

In 2013, a BMJ study on the Cuban Economic Crisis demonstrated that when food and fuel spiked in cost, inhabitants ate less, lost weight and exercised more, getting the bike to work for example.

And while Trenell wholly advocates exercise, he argues that diet is far and away the most significant, impactful means of achieving sustainable weight loss and improving metabolism in people with type 2 diabetes, trumping the benefits of exercise.

On the VCLD, a short-term diet where patients eat 800 calories a day, evidence shows non-alcoholic fatty liver disease (NAFLD) can be reversed within two weeks. This, he says, is “something special”. And while it’s not a diet for the long-term, reverting back to a low-carb diet can help maintain health improvements.

Personalised support is an essential element in communication between doctors and their patients with type 2 diabetes, he concluded, and making dietary changes best applicable to patients will further elevate the amount of people changing their lifestyles and reversing their type 2 diabetes.

11:30:

Dr Campbell Murdoch’s talk about “fueling from the fat” tank yesterday set the stage to mediate this morning’s discussion about carb awareness with Dr Sean Wheatley.

Dr Wheatley holds a PhD in metabolic health and has worked as a researcher for X-PERT Health, a charity that helps people with diabetes achieve better blood glucose control by making personalised lifestyle adjustments.

These include increasing physical activity, improving sleep, lowering stress and, perhaps most importantly, optimising macronutrient balance according to metabolic damage and glucose tolerance.

According to Dr Wheatley, people with type 2 diabetes should consume carbs according to their tolerance, eat a moderate amount of protein, and use fat as a lever to increase satiety.

Dr Wheatley first reminded us that the other side of being insulin resistant is being carbohydrate intolerant and that establishing carb tolerance through experimentation is an essential part of building a sustainable dietary approach for people with type 2 diabetes.

The same carb-containing food can elicit different responses in people due to determinants like our genetics, the microbiome and metabolic damage or the degree of insulin resistance. This renders tools such as the glycemic index somewhat obsolete.

For Wheatley, the differences in carb tolerance can be compared to differences in the capacity for consuming alcohol. The amount one person can have without harmful effects might be very different to what someone else can tolerate, and this was the whole premise of this conversation.

The RDI for carb intake, which most people exceed, is set at around 260 g per day. Wheatley’s observations from working with X-PERT Health have been that 200 g of carbs is often more than the body can handle in people with type 2 diabetes, and that reducing carbs to between 50 g and 130 g per day can be beneficial.

The ideal level of carbs, says Wheatley, is one that allows blood sugar balance, reduces hyperinsulinemia and limits weight gain. In those at risk for type 2 diabetes, blood glucose monitoring will provide much quicker feedback to figure out what this level is.

Most medical guidelines currently advocate a high-carb, low-fat diet for managing type 2 diabetes. Dr Wheatley is of the opinion that blood sugar balance is generally more easily achieved with a lower carb diet but he also acknowledges that there can be individual variability in the response.

10:50:

“Type 2 diabetes is bearing down upon our NHS.” – the warning from Dr Alison Tedstone, Chief Nutritionist at Public Health England (PHE), was stark.

However, her solutions left much to be desired.

Dr Tedstone’s conference about sugar reformulation first highlighted the damage sugar intake has in our daily lives – regular consumption increases risks of tooth decay, type 2 diabetes and high BMI.

However, when detailing how bread contains 40% less salt than in decades past, a positive for sure, it seemed odd her example in this case was a food in carbohydrate and sugar.

She also summarised findings from PHE reports in 2015 and 2017. A prominent highlight of the latter, a sugar reformulation program, is PHE’s admirable aim to achieve a 20% sugar reduction in all food and drink products by 2020.

This segued into the childhood obesity strategy. That’s right. The one launched last year that was slammed as being “weak” and “embarrassing”. Dr Tedstone had clearly heard the bad press. She acknowledged, “This has been criticised by non-government organisations … but Downing Street really cares about it.”

In regard to the sugar tax, which comes into effect in April 18, Dr Tedstone insisted it is already having an impact. “We are seeing leading companies take sugary out of sugary drinks.” Of course, the impact would be stronger if the levy was mandatory and not voluntary.

Then came the saturated fat issue. PHE still asserts that saturated fat is the enemy when, in fact, saturated fat is now known to not have the significant impact on heart risks originally purported in the 1980s and 1990s, and foods high in monounsaturated and polyunsaturated fats contain a bounty of nutrients.

PHE aims to lower rates of sugar, salt and saturated fat in our diets and hopes for positive results when they analyse their reformulation program next year.

“It’s up to the government to decide what’s next,” Dr Tedstone concluded.

10:00:

We’ve just heard from Magdi Yaqoob, a Professor of Nephrology at Barts and The London Hospital.

Professor Yaqoob is considered a leading expert in the progression of chronic kidney disease (CKD) and mediators of acute kidney injury, especially in people with diabetes.

In his talk today, he has told us about novel strategies in the treatment of diabetes and kidney disease. He also revisited some principles for the risk stratification of CKD patients.

Yaqoob believes that a more specific classification of estimated glomerular filtration rates (eGFR) – used to determine the level of kidney function – can help identify patients at different stages of CKD with more accuracy.

This more “granular” assessment of the eGFR rate should be coupled with close monitoring of the level of albumin in the urine, which is the typical first sign that the kidneys have become damaged by diabetes.

This research presented by Prof Yaqoob helped further our understanding of the origins of kidney disease and provided healthcare professionals amongst attendees with a roadmap for refining risk analysis in their patients with diabetes.

09:00: The most buoyant of taxi drivers fills me with glee as he bellows “GOOD MORNING!” to my colleague and I. But his morning glory is short-lived as he discovers the weight and quantity of our bags and struggles to make head nor tail of our Birmingham accents.

Alas, the trip to Olympia was satisfactory, and an early dash to the press room meant I was able to secure the one available plug socket.

Dr Alison Tedstone is talking about sugar reformation at 10:05, which I will be attending, while Camille will be learning more about carb awareness.

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