Diabetes and Ramadan practical guidelines
International Diabetes Federation
Ramadan, a holy month for Muslims lasts for 29–30 days, during which time the consumption of food and drink, as well as oral and injected medications, is forbidden between dawn and dusk. This year in the UK, it lasts for 18-20 hours and clearly has a significant impact on patients with all types of diabetes due to marked changes in food and fluid intake which increases the risk of hypoglycaemia, hyperglycaemia and dehydration. Islamic law grants exemption to patients with diabetes but despite this, many still wish to fast. A plethora of guidelines already exist yet the International Diabetes Federation have launched a weighty (146 page) tome which seeks to address all aspects of diabetes management ranging from diet to hypoglycaemic agents. However, despite all the advice, the document is unwieldly and clearly needs distilling for everyday use. Above all, it could be condensed into a single sentence – it is important that the decision to fast is taken on an individual basis taking into account the level of risk involved.
The changing face of diabetes complications
Edward W Gregg, Naveed Sattar, Mohammed K Ali. The Lancet Diabetes & Endocrinology. D0i: http://dx.doi.org/10.1016/S2213-8587(16)30010-9
The rising incidence of obesity and diabetes is obvious to everyone who is aware of both medical literature and the general media, both of which describe at length the issue of complications arising from the condition. However, the changing trends in complications are not as clear, especially as intervention impacts on glycaemia and other cardiovascular risk factors. This paper reviewed trends in the classic complications of T2DM in high income countries over the last 20 years, demonstrating reductions in myocardial infarction, stroke, amputations and mortality. There is also evidence that the nature of complications may be changing with (in the USA) a reduction in macrovascular disease in the >65s but an increase in the 45-64 year age group. Furthermore, as mortality is reduced, patients are living longer with the condition leading a different spectrum of morbidity, especially renal disease and cancers with the associated financial impact. Although this article is of interest, the authors themselves point out that the data was obtained from high income countries which are not the areas suffering from the most rapid change in diabetes epidemiology. http://www.thelancet.com/journals/landia/article/PIIS2213-8587(16)30010-9/fulltext
Glucose tolerance status of Asian Indian women with gestational diabetes at 6 weeks to 1 year postpartum (WINGS-7)
Balaji Bhavadharini et al. Diabetes Research and Clinical Practice. Doi: http://dx.doi.org/10.1016/j.diabres.2016.04.050
Asian women are at high risk of gestational diabetes and are one of the groups of patients to receive universal screening. Furthermore, GDM is a risk factor for T2DM in later life with NICE guidance suggesting testing glycaemic status is reassessed post-partum and then annually in view of the long term risk with fasting glucose or HbA1c the recommended diagnostic tools. This study reviewed the results of 161 post-partum glucose tolerance tests. Whilst only 1.2% of patients were diagnosed with T2DM at 6-12 weeks post-partum, 11.9% developed the condition between 6 weeks-1year with many more showing some evidence of glucose intolerance. Overall, within 1-year post-partum, dysglycaemia occurred in 20.3% of women with a BMI>25 increasing the risk four fold. Interestingly, there were many women who had a normal fasting but abnormal challenge result, a group who would be missed when following NICE guidance. Whilst the study reinforces the significant risk in this group of patients, and the need for strategies to prevent T2DM, their engagement with health care professionals tends to be low.
Generation of stem cell-derived β-cells from patients with type 1 diabetes
Jeffrey R. Millman et al. Nature. Doi:10.1038/ncomms11463
Islet cell transplantation is available in the UK with seven centres offering this procedure for patients with type 1 diabetes (T1DM). Unfortunately, the immune process that leads to the beta-cell destruction responsible for T1DM has memory and reactivates leading to islet cell loss. This means that long-term independence from insulin is rare without frequent top-ups of islets; the lack of donor pancreata (all from deceased people) means that this is not an option. The authors of this publication previously reported scalable in-vitro production of functional stem cell-derived beta-cells. Here they describe the generation of beta-cells from T1DM patients. These cells express beta-cell markers, respond to glucose both in vitro and in vivo, prevent alloxan-induced diabetes in mice and respond to anti-diabetic drugs. In addition, they were able to investigate how the cells responded to different forms of beta-cell stress. Using these assays, they found no major differences between these T1DM-derived beta-cells versus those from non-diabetic patients. These results open up all sorts of exciting possibilities for the treatment of T1DM.
The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries
Tessa Van Loenen et al. Scandinavian Journal of Primary Health Care. Doi:10.3109/02813432.2015.1132883
Modern management of type 2 diabetes typically proposes a model where patients are managed in primary care until the complexity of their disease requires specialist involvement. This will vary according to the levels of education and enthusiasm in primary care but might encompass the stage when insulin initiation is required to instances where secondary care multidisciplinary teams are needed (such as pregnancy, renal management and foot complications). One would assume that countries with ‘strong’ primary care (and, therefore, the most advanced primary care diabetes services) would have lower levels of diabetes-related hospitalisations; this is what this study set out to examine. Twenty-three counties were included in the analysis and the investigators reported (to their surprise) that ‘in countries where patients experience good access, they have a significantly higher chance of being admitted for long-term complications’. Whilst acknowledging the difficulties in this sort of analysis (there will be huge variation within countries, for example), it highlights that outcomes cannot be second-guessed without doing the research to prove their effectiveness.