Type 2 diabetes in migrant south Asians: mechanisms, mitigation, and management
Naveed Sattar and Dr Jason M R Gill. The Lancet Diabetes & Endocrinology. Doi: http://dx.doi.org/10.1016/S2213-8587(15)00326-5
Managing diabetes in S. Asian patients present unique challenges including attention to diet and other lifestyle issues. Despite education about diabetes prevention, S. Asians are at significantly elevated risk of T2DM compared with white Europeans and usually develop the condition up to 10 years earlier and at a lower BMI. Reasons for this include increased insulin resistance in this population and potentially β cell failure at an earlier age. Although there are no clear genetic factors predisposing this, Asian patients have different levels of adiposity (high percentage of body fat and high proportion of deep subcutaneous and visceral fat) and skeletal muscle (low percentage of lean mass and low cardio respiratory fitness). These findings need to be reflected in a more targeted approach to treatment e.g. recognition of different BMI values and the subsequent need to address weight and physical fitness. Over time, CV risk has been attenuated, possibly with more proactive use of statins, and hypertensive’s etc., but, due to problematic and persistent hyperglycaemia (HbA1c in S Asians tends to be higher than in Europeans) retinopathy and renal complications remain a major problem and requires further attention.
Pregnancy and neonatal outcomes in gestational diabetes treated with regular insulin or fast-acting insulin analogues
You J.Y et al. Gynecologic and Obstetric Investigation. Doi:10.1159/000440616
The 2015 NICE guidelines recommend fast acting insulin analogues (aspart and lispro) over human insulin. Much of the evidence for this comes from patients with Type 2 diabetes who become pregnant rather than those who present with gestational diabetes (GDM). This study investigated 197 women with GDM requiring insulin and randomised them into receiving a fast acting analogue or regular human insulin. The study revealed no significant difference between the groups for a variety of maternal and foetal outcomes including macrosomia, emergency caesarean section and neonatal hypoglycaemia. Although the data from this study revealed similar outcomes between analogue and regular insulin, the former will still be used first line in all diabetic pregnancies because of their established advantages including time of administration and maternal hypoglycaemia. They are also more effective at addressing the 1-hour post meal glucose target, recommended by NICE.
Clinically significant chronic liver disease in people with type 2 diabetes: The Edinburgh Type 2 Diabetes Study
Joanne R. Morling et al. QJM. Doi: http://dx.doi.org/10.1093/qjmed/hcv191
Liver disease is a common finding in Type 2 diabetes (T2DM) and presents as a spectrum of disorders ranging from fatty liver (Non-alcoholic fatty liver disease) through to frank cirrhosis and hepatocellular carcinoma via Non-alcoholic steatohepatitis (NASH). Despite this, however, the association of liver disease and diabetes is not always appreciated by health care professionals Furthermore, the exact disease burden is unknown with patients often being found incidentally through liver function testing. This study was performed to examine the prevalence and incidence of clinically significant chronic liver disease amongst community-based older people with type 2 diabetes and to determine risk factors which might assist in discriminating patients with unknown prevalent or incident disease. Patients enrolled in the Edinburgh T2DM study underwent liver ultrasound and other liver tests. The study revealed a liver disease prevalence of 2.2% with patients having a higher incidence of systemic inflammation and hepatic fibrosis markers. The study confirmed the association of T2DM with a raised incidence of liver disease. The ability to identify patients both with and at risk of developing clinically significant chronic liver disease allows for early intervention and clinical monitoring strategies. Lifestyle changes will need to be reinforced in patients identified with liver disease given the relative paucity of therapeutic interventions.
LDL cholesterol is not a good marker of cardiovascular risk in Type 1 diabetes
Hero et al. Diabetic Medicine. Doi: 10.1111/dme.13007
People with type 1 diabetes (T1DM) frequently resent being lumped together with those who have the type 2 (T2DM) version. Children report being accused of bringing the condition upon themselves whilst adults are denied adequate access to testing strips, both on the basis that they have T2DM. This publication suggests that extrapolation of lipid targets from T2DM to T1DM may also be inappropriate. The authors followed a cohort of 30,778 patients with T1DM from 2003-06 until 2011 and examined the predictive value of LDL-cholesterol (LDL-C) and total/HDL-cholesterol (HDL-C) ratio for cardiovascular disease (CVD). They report that LDL-C is not a good predictor of CVD in this group and suggest that LDL-C targets should be revisited. Perhaps this shouldn’t be a surprise. It is well documented that patients with T1DM who do not develop nephropathy and, by virtue of this, are at low risk of CVD have elevated HDL-C levels. Indeed, they have a phenotype which is the exact opposite of that seen in T2DM; insulin sensitivity, normotension and low body weight. Why would anyone treat them in the same way?
Gastrointestinal actions of GLP-1 based therapies: glycaemic control beyond the pancreas
Mark M. Smits et al. Diabetes, Obesity and Metabolism. Doi: 10.1111/dom.12593
Glucagon‐like peptide‐1 (GLP‐1) lowers postprandial glucose levels by regulating pancreatic islet‐cell function, with stimulation of insulin (beta-cells) and suppression of glucagon secretion (alpha-cells). In addition, gastrointestinal (GI) actions of GLP‐1 may be as important for glucose‐lowering; GLP‐1 slows gastric emptying and small bowel motility, delaying glucose absorption and decreasing postprandial glucose excursions. Furthermore, GLP‐1 may stimulate hepatic glucose uptake, and suppresses hepatic glucose production. This article focusses on GLP‐1 receptor agonists (RAs), the class of anti-diabetic injectables which mimic the effects of GLP‐1 and highlights that individual agents have different impacts on pancreatic versus GI function. This provides a rationale for why GLP-RAs are still effective in long-standing diabetes with so-called ‘beta-cell exhaustion’. It also points to differences between human and small animal physiology, which has guided much of the drug development in this area (the effects in animal models are almost entirely islet-cell mediated). The article misses the opportunity to mention other GLP-1 effects – receptors are also located in the brain, heart and kidney – and the potential for their use in other conditions, Parkinson’s disease being an area of active research.