glucose levels

Simply standing more daily could reduce cardiometabolic risk

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Standing, stepping, and engaging in other non-sitting activities for 2 hours daily significantly lowered glucose levels and improved total vs high-density lipoprotein (HDL) cholesterol ratios, both important cardiometabolic risk factors, according to a recent study.

Each additional 2 hours a day spent standing was associated with about 2 percent lower fasting plasma glucose, 6 percent lower total/HDL-cholesterol ratio, 14 percent lower triglyceride levels, 3 percent lower 2-hour plasma glucose and about 0.07 mmol/L higher HDL-cholesterol levels. [Eur Heart J 2015; doi:10.1093/eurheartj/ehv308]

Every 2 hours a day spent stepping was significantly linked to about 11 percent lower BMI, 8 cm lower waist circumference, 6 percent lower total/HDL-cholesterol ratio, 20 percent lower triglyceride levels, 14 percent lower 2-hour plasma glucose and about 0.14 mmol/L higher HDL-cholesterol levels. However, neither standing nor stepping was significantly associated with changes in systolic or diastolic blood pressure or HbA1C or LDL-cholesterol levels.

These results contrast with those spent in a sedentary position (sitting), where every additional 2 hours a day spent sitting was linked to about 3 percent higher BMI, 1 percent higher fasting plasma glucose, 5 percent higher total/HDL-cholesterol ratio, 12 percent higher triglyceride levels, 4 percent higher 2-hour plasma glucose levels, and 0.07 mmol/L lower HDL-cholesterol levels.

Every 2 hours spent stepping instead of sitting led to significant reductions in BMI (about 11 percent), waist circumference (7.5 cm) and post-load glucose levels (12 percent). On the other hand, every 2 hours spent standing instead of sitting led to significant reductions in fasting plasma glucose (about 2 percent), total/HDL-cholesterol ratio (6 percent) and triglyceride levels (11 percent), as well as 0.06 mmol/L higher HDL-cholesterol levels.

The study included 782 participants aged 36 to 80 years from the Australian Diabetes, Obesity and Lifestyle Study who were monitored for 24 hours per day for 7 days with an activPAL3TM monitor strapped to the thigh. [J Sci Med Sport 2014;17:293-299]

While the impact of physical activity on cardiometabolic risk factors has been confirmed, the findings suggest simply substituting standing for sitting could exert health benefits.

9 Devices That Are Changing Medicine

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slide 1

Introduction

In 1922, a diabetic teenager in a Toronto hospital became the first person to be injected with insulin. Nearly a century later, patients with diabetes are on the verge of being able to set their insulin doses using their smartphones. The progress in tech-based treatment in recent years is staggering, with wireless and implantable technologies emerging that just a few years ago might have seemed like science fiction.

slide 2

An Artificial Pancreas

People with type 1 diabetes may soon be able to set their insulin doses by smartphone. Researchers from Massachusetts General Hospital and Boston University are testing a “bionic pancreas,” a pump that goes under your skin that when paired with an app and a small chip tracks blood sugar levels and adjusts amounts of insulin and glucagon on its own. In a small study[1]published in the New England Journal of Medicine, among 20 adults and 32 adolescents who were told that they could eat as they wish, the system maintained glucose levels in the acceptable range 79% and 75% of the time, respectively, vs 58% and 65% of the time when participants used their regular monitoring systems. A follow-up study is planned followed by a submission for US Food and Drug Administration (FDA) approval in 2017.

slide 3

Smart Pills

No more missed doses: Researchers in the United States and the United Kingdom are testing a silicon tablet called Helius (Proteus Digital Health; Redwood City, California) that helps monitor medication adherence. The once-daily “pill” has a sensor resembling a grain of sand; the sensor is covered in magnesium and copper, which generate power by reacting with stomach acid, sending a signal indicating the time of pill ingestion (other pills, that is) to a wearable patch. The patch in turn forwards this information to a patient’s smartphone using Bluetooth. Current studies include patients with heart failure or hypertension; however, the Helius manufacturers plan to study the technology in other chronic health conditions soon.

slide 4

Cuff That Curbs Heart Failure

An experimental treatment called C-Pulse® (Sunshine Heart; Eden Prairie, Minnesota) has the potential to slow down and possibly even reverse heart failure. The device is implanted through a small incision in the chest; it wraps around the aorta and consists of a cuff that inflates and deflates in rhythm with a patient’s heartbeat, improving blood flow. An external battery powers the C-Pulse.

 

slide 5

Dime-Sized Heart Monitor

A tiny device approved last year by the FDA alerts physicians when their patient’s heart failure symptoms are worsening. The CardioMEMS™ HF System (St Jude Medical; St Paul, Minnesota) is inserted through a catheter into the pulmonary artery; it wirelessly measures and monitors pulmonary arterial pressure and uploads the data to a website. Treatment response can also be monitored in real time.

 

slide 6

A Disc to Ease Inflammation

Data are mounting supporting a connection between our immune and nervous systems. An investigational iPad®-driven neuromodulation device (SetPoint Medical; Valencia, California) reportedly reduces systemic inflammation by stimulating the vagus nerve via an implantable pulse generator. A small study[2] presented at the 2012 American College of Rheumatology Annual Meeting reported positive results in patients with rheumatoid arthritis; a study in patients with Crohn disease is also planned.

slide 7

Annual Implants to Treat Diabetes

This matchstick-size pump—currently called the ITCA 650 (Intarcia Therapeutics; Boston, Massachusetts)—could replace pills and injections for type 2 diabetes. It’s implanted under the skin of the abdomen and releases doses of the glucagon-like peptide-1 agonist exenatide (Bydureon®, Byetta®) to help control blood glucose. It must be replaced yearly. Clinical trials are nearing completion, and the maker hopes to bring the device to market in 2016.

slide 8

A New Option in Sleep Apnea

Many patients with sleep apnea aren’t so keen on cumbersome, often uncomfortable continuous positive airway pressure (CPAP) machines. As an alternative, last year the FDA approved a device called Inspire® (Inspire Medical Systems, Maple Grove, Minnesota) that improves upper airway patency during sleep. Here’s how it works: A respiration sensor in the chest delivers a signal to an implanted generator, which in turn stimulates the hypoglossal nerve in between the end of expiration and the beginning of the next expiratory phase.

slide 9

Meds via Microchip

New investigational technology from MicroCHIPS (Lexington, Massachusetts) may make long-term, wireless drug delivery possible. The microchip-based implant is placed under the skin and contains 200 microreservoirs that can each store 1 mg of medication. Clinicians can remotely control medication release wirelessly; it can also be outfitted with sensors that release drugs in response to physiologic measures. The first human study[3] of the chip system reported that women receiving teriparitide for osteoporosis absorbed the same therapeutic drug levels as those receiving daily injections. The device also resulted in more dose-to-dose consistency.

slide 10

An Injectable for Back and Leg Pain

A new treatment for chronic back and leg pain is about the size of a staple. The Stimwave Freedom Spinal Cord Stimulation System (Stimwave; Miami Beach, Florida) is injected and powered by an external battery; the tiny stimulator delivers pulsed electric current to nerve fibers near the dorsal aspect of the spinal column to lessen pain sensation. The FDA approved the device in 2014.

NEW BRAIN PATHWAY OFFERS HOPE FOR TREATING HYPOGYLCEMIA

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For those with diabetes, managing blood sugar is a balancing act — if blood sugar is too high it raises the risk for nerve damage, blindness, kidney failure, and heart trouble, and if too low it can lead to a seizure or unconsciousness.

Now a team of scientists from the United Kingdom and the University of Michigan Comprehensive Diabetes Center has taken a step forward in understanding how the brain senses low glucose levels and triggers the body’s response. The discovery may accelerate work to safely control diabetes.

Researchers identified a novel pathway buried deep within a region of the brain called the parabrachial nucleus that produces cholecystokinin (CCK), a brain hormone that acts as a crucial sensor of blood glucose levels. The hormone helps orchestrate responses around the body when levels drop too low, according to the study published in Nature Neuroscience.

“It is remarkable to find that such an incredibly small set of cells in the brain play such an important role in maintaining normal glucose levels,” says study authorLora K. Heisler, Chair of Human Nutrition at the Rowett Institute of Nutrition & Health at the University of Aberdeen.

It’s known that CCK cells in the brain modify things like appetite and anxiety but they had previously been overlooked in relation to blood sugar levels, authors say.

“The discovery of the important function of this brain hormone raises the possibility of using drugs targeting the CCK system to boost defences against hypoglycaemia, the clinical syndrome that results from low blood sugar,” says study author Martin G. Myers, Jr., M.D., Ph.D., the Marilyn H. Vincent Professor in Diabetes Research at the University of Michigan Comprehensive Diabetes Center.

The authors worked with an international team or researchers from the University of Cambridge, University of Edinburgh, University of Chicago on the findings.

Heisler says the identification of the role played by CCK could be of particular significance to an estimated 20 percent of those with diabetes who suffer side effects of low blood sugar, called hypoclycemia.

“When patients suffer repeated bouts of hypoglycemia they can develop ‘unawareness’ which means they find it difficult to detect symptoms that their blood sugar levels are falling and it is this group particularly that we hope could benefit from our findings in regard to the role played by CCK,” Heisler says.

Stress Hyperglycaemia in Hospitalised Patients and Their 3-Year Risk of Diabetes: A Scottish Retrospective Cohort Study

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Hyperglycaemia during hospital admission is common in patients who are not known to have diabetes and is associated with adverse outcomes. The risk of subsequently developing type 2 diabetes, however, is not known.

We linked a national database of hospital admissions with a national register of diabetes to describe the association between admission glucose and the risk of subsequently developing type 2 diabetes.

Methods and Findings

In a retrospective cohort study, patients aged 30 years or older with an emergency admission to hospital between 2004 and 2008 were included. Prevalent and incident diabetes were identified through the Scottish Care Information (SCI)-Diabetes Collaboration national registry. Patients diagnosed prior to or up to 30 days after hospitalisation were defined as prevalent diabetes and were excluded.

The predicted risk of developing incident type 2 diabetes during the 3 years following hospital discharge by admission glucose, age, and sex was obtained from logistic regression models. We performed separate analyses for patients aged 40 and older, and patients aged 30 to 39 years.

Glucose was measured in 86,634 (71.0%) patients aged 40 and older on admission to hospital. The 3-year risk of developing type 2 diabetes was 2.3% (1,952/86,512) overall, was <1% for a glucose ≤5 mmol/l, and increased to approximately 15% at 15 mmol/l. The risks at 7 mmol/l and 11.1 mmol/l were 2.6% (95% CI 2.5–2.7) and 9.9% (95% CI 9.2–10.6), respectively, with one in four (21,828/86,512) and one in 40 (1,798/86,512) patients having glucose levels above each of these cut-points. For patients aged 30–39, the risks at 7 mmol/l and 11.1 mmol/l were 1.0% (95% CI 0.8–1.3) and 7.8% (95% CI 5.7–10.7), respectively, with one in eight (1,588/11,875) and one in 100 (120/11,875) having glucose levels above each of these cut-points.

The risk of diabetes was also associated with age, sex, and socio-economic deprivation, but not with specialty (medical versus surgical), raised white cell count, or co-morbidity. Similar results were obtained for pre-specified sub-groups admitted with myocardial infarction, chronic obstructive pulmonary disease, and stroke.

There were 25,193 deaths (85.8 per 1,000 person-years) over 297,122 person-years, of which 2,406 (8.1 per 1,000 person-years) were attributed to vascular disease. Patients with glucose levels of 11.1 to 15 mmol/l and >15 mmol/l had higher mortality than patients with a glucose of <6.1 mmol/l (hazard ratio 1.54; 95% CI 1.42–1.68 and 2.50; 95% CI 2.14–2.95, respectively) in models adjusting for age and sex.

Limitations of our study include that we did not have data on ethnicity or body mass index, which may have improved prediction and the results have not been validated in non-white populations or populations outside of Scotland.

Conclusion

Plasma glucose measured during an emergency hospital admission predicts subsequent risk of developing type 2 diabetes. Mortality was also 1.5-fold higher in patients with elevated glucose levels. Our findings can be used to inform patients of their long-term risk of type 2 diabetes, and to target lifestyle advice to those patients at highest risk.

Bionic pancreas device shows benefits in type 1 diabetes patients

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An experimental three-part wearable device to manage glucose levels outperformed standard monitoring and insulin pump management regimes in adults and adolescents with type 1 diabetes.

This “bionic pancreas,” which consist of a small subcutaneous glucose sensor, automated insulin and glucagon pumps, and a wirelessly connected iPhone with a monitoring app, can correct for blood plasma glucose levels that are too high or too low.

The device kept blood sugar lower and prevented fluctuations better than normal monitoring via stick tests and manual pumps.

“A cure is always the end goal,” said lead developer Dr. Ed Damiano, a biomedical engineer at Boston University in Massachusetts, US who has a son with type 1 diabetes.

“As that goal remains elusive, a truly automated technology, which can consistently and relentlessly keep people healthy and safe from harm of hypoglycemia, would lift an enormous emotional and practical burden from the shoulders of people with type 1 diabetes, including my child and so many others.”

The study included a group of 20 adults (age ≥21) and 32 young people aged 12-21 with at least a 1-year history of type 1 diabetes who were also using insulin-pump therapy. [NEJM 2014; doi:10.1056/NEJMoa1314474]

Patients’ blood plasma glucose levels were closely monitored in person and remotely over two 5-day periods of bionic pancreas intervention and self-management with their own insulin pumps. Daily activities, including food intake and exercise, were unrestricted and patients were encouraged to behave as normal.

Among the adults, there were 37 percent fewer instances of hypoglycemia that required intervention during the bionic pancreas period (43 cases) compared with the control period (68 cases, p=0.15).

Among the adolescents, the instances of hypoglycemia more than halved when patients used the bionic pancreas, with 97 cases compared with 210 cases during the control period (p=0.72).

Mean glucose levels in both groups improved significantly overall and remained more consistent when monitored and controlled by the bionic pancreas compared with the control period (133±13 vs 159±30 mg per dL, p<0.001 in adults; 142±12 vs 158±27 mg per dL, p=0.004 in adolescents). This improved outcome was particularly important through the night, when patients, especially younger patients, are in danger of becoming hypoglycemic.

The most common adverse event associated with bionic pancreas use was nausea and vomiting. Patients using the bionic pancreas still had to perform stick tests to make sure the monitor was accurate.

The researchers noted that the device can overcorrect for glycemic control in patients who are already poorly controlled, although the repercussions of this require more study. The bionic device also requires wireless connectivity but this may be solved in future iterations with a single-unit device.

However, the researchers reported the current prototype was already a more seamless device for type 1 diabetes patients, for whom constant monitoring and manual adjustment of plasma blood glucose can be a heavy burden.

“The performance of our system in both adults and adolescents exceeded our expectations under very challenging real-world conditions,” Damiano said.

Glucose control after breakfast improved HbA1c in type 1 diabetes.

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In patients with type 1 diabetes, glucose improvement during the period after breakfast appears to be influential in reducing HbA1c levels, according to recent study findings. Additionally, the study researchers found that improvements in overnight glucose control yielded improvements in ensuing breakfast-time glucose.

“Improving breakfast meal period glucose levels had the greatest independent effect on lowering HbA1c levels in patients with type 1 diabetes, and improved overnight control had a sustained effect associated with lower [continuous glucose monitoring]-glucose levels during the morning,” David M. Maahs, MD, PhD, of the Barbara Davis Center for Childhood Diabetes in Aurora, Colo., and colleagues wrote. “Although glucose control should be improved at all times, methods to improve overnight and post-breakfast glucose levels may be of primary importance in improving glucose control in patients with type 1 diabetes.”

The researchers evaluated 196 patients from the STAR 3 study database aged 7 to 70 years who had type 1 diabetes.

The patients were randomly assigned to undergo sensor-augmented pump therapy. Their glucose levels were collected for roughly 1 week at baseline, and then continuously throughout the study. All levels studied were recorded using continuous glucose monitoring (CGM). The researchers utilized the complete days of the baseline period and the measurements taken during the final month of the study to compare glucose changes. HbA1c levels also were measured at baseline and after 1 year.

Changes in HbA1c and mean glucose from baseline to 12 months were calculated, as well as mean glucose levels for each meal period.

Mean glucose level changes for each meal period were compared based on four improvement categories: daytime and overnight, daytime only, overnight only, and no improvement.

The researchers found that improvements in HbA1c levels after 1 year were related to mean glucose levels during the daytime period (6 a.m. to midnight) overnight (midnight to 6 a.m.), and at each meal time period (P<.0001 for each). Multivariable analysis revealed that only improvement in breakfast meal period glucose levels was independently associated with improvement in HbA1c after 1 year (–0.46%, P<.0001).

Additionally, patients who did not demonstrate overall daily improvement but demonstrated improved glucose during the overnight interval had a related 26 ± 22 mg/dL improvement in breakfast meal period glucose (P<.01).

Source: Endocrine Today