Diabetes developments – by Simon O’Neill
This week Simon reports on the latest research and other issues.
Be kind to yourself…
A study published in Diabetes Care suggests that being less harsh or judgmental on yourself can help you manage diabetes better and prevent depression. In the first randomised controlled trial of self-compassion, 32 volunteers with both Type 1 diabetes (T1D) and Type 2 diabetes (T2D) participated in an eight week “mindfulness training on self-compassion.” Their outcomes were compared with 31 people on the waiting list for the course, who just received standard care.
The course comprised weekly, 2.5 hour long sessions that included formal meditation and training in “self-compassion practices aimed at developing the cognitive, behavioural and physical capacities to sooth and comfort oneself when depressed”. Those taking part also received an email, two days after each session, which summarised what had been covered and highlighted practices they could continue to try at home between sessions.
Participants answered questionnaires before the course and at the end of it, as well as three months later. These questionnaires rated any symptoms of depression and their level of distress related to their diabetes. They also measured feelings of self-kindness, common humanity and mindfulness as well as negative feelings like self-judgment and isolation. The participants also had their HbA1c measured to consider diabetes control.
Not surprisingly no changes in mood, self-compassion or HbA1c were seen in the control group at 8 or 12 weeks. However, in the group who undertook the training, self-compassion improved while distress and depression symptoms were reduced. There was also a 1% (approximately 10mmol/mol) reduction in HbA1c at the three-month test. This may not have a direct relation to the course content – but may be because the individuals who felt less stressed and depressed were better able to manage their diabetes day to day. However, being under stress does effect hormone production, so the reduction in stress may have had a direct benefit on control.
Many people do find diabetes very stressful, with the relentless day to day challenges – and the potential feeling of failure when you don’t achieve the daily outcomes you want, especially when there seems to be no rhyme or reason behind a high blood test result or when you don’t achieve the weight loss you were trying for. The aim of the course is to recognise when you are being harshly self-critical or judgmental, which can make stress and distress worse, and to teach ways of managing your mood to reduce that stress.
Longer life expectancy
The ground breaking DCCT (Diabetes Control and Complications Trial), that ran from 1983 to 1993 provided evidence that tighter blood glucose control (average HbA1c of 7% -53mmol/mol) reduced the risk of microvascular complications (blindness, kidney disease and nerve damage) and led to changes in the way that T1D was managed globally. 90% of that same cohort of people with T1D was then followed up in a separate and ongoing trial called EDIC (Epidemiology of Diabetes Interventions and Complications).
The cohort in EDIC were unable to maintain such a tight level of control as in the original study over the next 23 years and their average HbA1c worsened slightly. Meanwhile the control group, with tighter HbA1c control becoming the norm, improved their HbA1c (from an average of 9% – 75mmol/mol) and both groups in the EDIC study run at similar levels of HbA1c (at around 8% – 64mmol/mol). However, various analyses of ongoing data have shown that the years of tighter control in the DCCT study are still offering benefits against the control group, despite their similar HbA1cs for the last 23 years.
The latest research has looked at life expectancy between the cohorts. The researchers estimated expected mortality between 1983 and present using the current age-, sex-, and race-specific risks in the general U.S. population, and compared observed versus expected mortality. The really encouraging news is that mortality in the intensive therapy cohort was similar to that of the general population. Those in the control group had significantly higher mortality rates.
This appears to further confirm the thesis that getting control as good as possible early on can confer longer term benefits even if control worsens slightly over time. The challenge, of course, is that establishing good control, especially in teenage years, can be difficult – but the benefits are great.
The Flu Vaccine is good for you
All people with diabetes are encouraged to get vaccinated against flu and pneumococcal pneumonia every year – but many people don’t take up that offer. Some new research suggests that you really might want to accept the invitation when it comes from your GP surgery this year.
People with diabetes who get the flu vaccine may be less likely to end up being admitted to hospital for cardiovascular or respiratory problems, the study suggests.
The researchers examined seven years of data on almost 125,000 people in England with T2D. Although we may think of the flu as just being a bad cold, real influenza can not only lead to chest infections, which can temporarily worsen diabetes control, but can also increase the risk of heart attack and stroke in susceptible patients. In this study, people who had had their flu jab saw a 30% lower hospital admission rate for stroke, 22% lower rate for heart failure, and 15% lower rate for pneumonia or influenza. Those who had been vaccinated also had a 24% lower death rate from all causes during the study period.
Although it can’t always prevent influenza infection, vaccination can limit the effects of the flu, reducing your response to it. And it’s free for all people with diabetes, not just the elderly or those with T2D.
Pharma payments to HCPs
The ABPI has launched a public database to lay out what the pharmaceutical industry has paid to clinicians in the UK. This is all part of a European initiative to bring more clarity to the situation, which in the past has been harmful to the reputation of the industry, who were seen to be ‘paying’ HCPs in order to get them to prescribe their products. The European scheme is voluntary, so there is no compulsion for clinicians to declare, unlike in the US where the ‘Sunshine Act’ enforces disclosure
However, rather than bringing the clarity that was hoped for, the new database actually seems to raise more issues as many clinicians, who appear to be paid the most by industry, have chosen to remain anonymous, as allowed under European data protection law. £111M was given to clinicians by pharma and biotech companies in 2015. 52% of this funding was given to just 30% of all funded HCPs and it is they who have chosen to remain anonymous.
There is no question that the funding hasn’t been given legitimately to cover such things as travel and accommodation at relevant meetings, consultancy fees, joint working initiatives, donations and grants but the lack of clarity is disappointing.
On average companies spent £1,550 per healthcare professional and around £9,506 per healthcare organization with the highest payment to a named individual being around £98,000.
Anyone can search the database
You can search by name of the doctor, nurse, pharmacist, healthcare professional or organisation, with their professional address to see any payments that have been declared. Industry also paid £229m for R&D activities for new medicines but these payments are not named on the database as there is separate transparency work around this through clinical regulatory procedures.
Diabetes UK has only been listed by two companies, although we receive some funding from others, but this is probably because of the definition of a Healthcare Organisation which different companies may interpret in different ways. It is the responsibility of the pharma company to make the listings, not the person or organisation who has received funding.
This is the first iteration of the database and it is hoped, as companies, clinicians and the public understand it better that transparency will improve.
It has long been recognized that the blunt definition between T1D and T2D doesn’t really highlight all the subtleties of the conditions. Although overweight and obesity are present in the large majority of people with T2D, we know that about 12% of those newly diagnosed with T2D in the 2014/5 National Diabetes Audit were of normal or under weight. Likewise, we know that T1D can occur at any age, but those who develop the condition later in life seem to have less erratic control and fewer complications.
In light of this, researchers from Sweden have looked at information on genetic and non-genetic markers of diabetes in 10,785 newly diagnosed people aged 0 to 97. The findings of this project (ANDIS – All New Diabetics in Scania) have been validated against other registries containing another 9,107 patients.
The researchers looked at factors including age at onset, BMI, HbA1c, insulin secretion and action, and GAD autoantibodies and now believe that they can classify diabetes in to 5 specific subgroups, which enables them to identify those most likely to see more problematic control of HbA1c and more rapid progression to complications.
Each of the 5 categories have distinct genetic profiles and some also showed changes in metabolites. The five sub types were defined as:
- Cluster 1 (11%) mainly traditional T1D
- Cluster 2 (20%) included people who showed impaired beta-cell function but with no evidence of autoimmune problems
- Cluster 3 (6%) included the most insulin-resistant people with the highest risk of kidney disease
- Cluster 4 (20%) included the most obese patients
- Cluster 5 (43%) was age-related and most like the traditional view of T2D
Although at a very early stage, the hope is that these findings will enable the development of pathways for different people, leading to intensified treatment for those who would most benefit from it and hopefully to thereby prevent more complications from developing. It could also help pharmaceutical companies target drug trials at specific groups of people, to identify where new drugs might be most impactful.