Diabetes developments – by Simon O’Neill
In a regular blog series, Simon O’Neill, Diabetes UK’s Director of Health Intelligence and Professional Liaison, rounds up the latest diabetes news.
This week Simon rounds up the latest research news, technologies and other issues.
A WHO report from April showed that the number of adults with diabetes quadrupled worldwide between 1980 and 2014 to 422 million, and that Type 2 diabetes is fast becoming a major problem in poorer countries, especially as they start to see ageing populations and rising levels of obesity.
The study found that northwestern Europe has the lowest rates of diabetes among adults, with age-adjusted prevalence lower than 4% among women and at around 5 to 6% among men in Switzerland, Austria, Denmark, Belgium and the Netherlands. But rates of diabetes rose significantly in many low and middle income countries, including China, India, Indonesia, Pakistan, Egypt and Mexico. In fact in China and India rates more than doubled for men in this time period. The largest increases in diabetes rates were in Pacific island nations, followed by the Middle East and North Africa. Sadly no country has seen any meaningful decrease in diabetes prevalence.
The data also showed that half of adults with diabetes in 2014 lived in five countries – China, India, the United States, Brazil and Indonesia.
Simon Stevens has announced that, from 2017, millions of people could receive devices and apps free on the NHS to help them manage conditions such as diabetes and heart disease in a major drive to use technology to improve health and to save tens of thousands of lives a year.
Rather than such apps and devices being purchased by individuals, the plan is to incentivize their use by a new tariff so that technology companies, producing innovative devices, get both fast-track approval and get their products ‘prescribed’ by doctors and nurses.
Examples announced were AliveCor, a mobile heart monitor that works with a smartphone to help patients detect and monitor atrial fibrillation (AF). AF causes about 20% of all strokes that occur annually and costs the NHS more than £2.2bn a year to treat. MyCOPD is another app that helps people with chronic obstructive pulmonary disease, such as emphysema and bronchitis, to manage their condition on their smartphone or tablet. The app advises them when to take their medication and how to do exercises that reduce the risk of them suffering an exacerbation of their illness, which could prove fatal.
A panel of experts will approve the first 10 to 15 such devices and apps later this year. Simon Stevens said that “millions of devices of different types will be funded via this route. For people with diabetes or heart disease, or pregnant women or acutely ill in-patients, there’s a huge opportunity to improve the quality of care and also save money in other parts of the NHS by getting millions of new medtech devices into the hands of doctors, nurses and therapists.”
Watch this space to see whether any diabetes apps or devices get the fast track approach.
“Digital snake oil”
The CEO of the American Medical Association, Dr James Madara, has described the current technological landscape, of apps and digital health products, as a “digital dystopia” and “the digital snake oil of the early 21st century”. His concern is that many of these tools lack the medical evidence necessary to demonstrate their efficacy, with a scarcity of clinical trial data and lack of evidence justifying their use.
His point of view has been supported by an analysis of about 1,000 patient-facing health apps targeted at individuals with long term conditions. The study found that only 43% of iOS apps and 27% of Android apps were in fact useful.
But his comments go against the view of many patients, who have a significantly different appreciation of emerging medical technology and its potential value. A survey of more than 1,400 clinicians and 1,100 patients revealed very different attitudes towards digital tools. In the survey, patients preferred new technologies for a medical diagnosis (39.7%), compared with providers (13.8%), while more providers (28%) reporting feeling uneasy about using technology for a diagnosis than consumers (15.9%). Another survey also showed that 65% of consumers indicated that apps improved their health, and a majority had strong faith in the accuracy and effectiveness of the apps.
Perhaps the answer lies in using those tools, whether good or bad, to build better conversations between the HCP and the person with diabetes, so that they can enhance the care planning process.
Global trends in BMI
An analysis from Imperial College of global trends in body mass index has shown that more than 640 million people globally are now obese and the world has more overweight than underweight people in it.
The study analyzed data on weight and height from nearly 20 million adults from 186 countries and looked at obesity rates over the last 40 years. They found that the number of people with a BMI over 30 has risen from 105 million in 1975 to 641 million in 2014. This means that more than one in 10 men and one in seven women are now obese. The study also found that morbid obesity, a BMI over 40, where a person’s weight interferes with basic physical functions such as breathing and walking, now affects around 1% of men and 2% of women. In total, 55 million adults are morbidly obese.
Although the rise in obesity is stark, and probably needs a global approach to tackle it, including addressing the price of healthy foods versus unhealthy foods, and taxing high sugar and highly processed foods, the study also showed that very low body weights were still a serious public health issue in many of the world’s poorest countries. In South Asia, for example, almost a quarter of the population is underweight. In Central and East Africa, about 12% of women and 15% of men are underweight.
The study found that over the past four decades, the average age-corrected male BMI rose to 24.2 from 21.7, and in women rose to 24.4 from 22.1 which is equivalent to the world’s population becoming on average 1.5 kg heavier each decade. The researchers predicted that if these global trends continue, 18% of men and 21% of women will be obese by 2025.
The LEADER Trial
Many drugs used in diabetes to successfully lower blood glucose have also been asked to produce data on cardiovascular (CV) outcomes, which is a major cause of death in diabetes. The LEADER trial is the latest of these to report, looking at the CV outcomes for liraglutide (Victoza). Last year the EMPA-REG trial found CV benefits for another drug, empagliflozin (Jardiance).
The trial was a multicenter, international study, following 9340 high-risk adults with T2D for 3.5 to 5 years, randomly assigned to receive either a subcutaneous injection of liraglutide 1.8 mg once daily (or the maximum tolerated dose) or a placebo injection along with standard treatment. The study was looking for the first occurrence of any of a three-point major adverse cardiac event (MACE) components: cardiovascular death, nonfatal myocardial infarction (heart attack) or nonfatal stroke.
The degree of risk reduction for MACE was 13% including a 22% lower rate of cardiovascular death and a 15% reduction in all-cause death. Liraglutide also reduced HbA1c, body weight, and hypoglycemia, and its safety profile was similar to what has been seen in previous trials.
This trial, and the earlier EMPA-REG trial, have sparked debate as to what the best second line treatment after metformin should be, with doctors considering the CV benefits of certain drugs as well as the glucose lowering qualities.