Dr Louise Johnson updates us on the latest changes in the diabetes arena to help you plan your medical resolutions for the next decade.
The basis of diabetes treatment has always revolved around the ‘three wild horses’: diet, exercise, and medication. Going into a new decade, there are quite a few dramatic changes in this arena.
The American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) 2018/19 consensus report has coined the acronym SMART. The goals that you and your doctor set must be SMART. This is:
S – Simple. Goals should be one step at a time and easy to follow.
M – Measurable. Blood pressure, cholesterol, HbA1c, fasting and postprandial (after meals) glucose, kidney function, eye check annually, feet examination once a year by a podiatrist. Stop smoking.
A – Achievable. Goals should be small enough. A problem is like an elephant. You eat it bite by bite.
R – Realistic. Weight loss should be five to 10% of total weight and re-evaluated regularly.
T – Time limited. The time frame set on this is three months until goals are met. This is important with all goals set.
Goals for 2020 onwards:
Get your body mass index (BMI) between 18 and 24
This is calculated by length multiply by length (in meters). The weight in kg is divided by this number. For example: 1,6 x 1,6m = 2,56. Weight (80 kg) divided by 2,56 = 31,1. This is the BMI. There are a few diets to try to lose weight effectively.
The number one diet is still the Mediterranean diet. The Predimed trial (NEJM) showed weight loss and improvement in cardiovascular health with this diet.
The best weight loss diet for 2020 is still Weight Watchers. This is a low-carbohydrate diet with good nutrition.
Talk to a dietitian about the correct diet for you. The goal waist circumference for females is 80 cm and for males 94 cm.
People who battle to lose weight can consider bariatric surgery for permanent weight loss and reversal of Type 2 diabetes. Contact a qualified bariatric team for this.
Vaping can be used as an interim measure to help stop smoking without gaining weight. Set a clear three-month goal of lesser nicotine vape liquid and then stop after month three.
The newest data, in The Journal of the American Medical Association (JAMA), for 2020, showed that in 17 000 women, it was found that the cut-off to improve mortality is 4 400 steps per day.
There are many apps and smart watches available to assist in the achievement of exercise goals. Remember the guidelines for diabetic exercise is cardio-training (30 minutes) five times per week.
Your blood pressure should be measured regularly and should not be above 140/90mmHg. Get yours checked at every doctor’s visit. Consider buying your own electronic upper arm blood pressure machine should you suffer from ‘white coat hypertension’ (high blood pressure in doctor’s office).
The risk of cardiovascular disease (heart attacks, strokes and peripheral vascular disease (leg blood vessels) are closely linked to low-density lipoprotein (LDL). The bad cholesterol. In people living with diabetes, the LDL should be 1,8 mmol/L or lower. Get your number and push to target. Remember there are a few different cholesterol-lowering drugs that your doctor can prescribe. Some have fewer side effects.
This is the three-month glucose average. In 2020, the range is from 6,5 to 8,0%. This variation depends on the duration of diabetes, existence of comorbid diseases, such a kidney failure and cardiovascular disease, and age. This range will be discussed and determined by your doctor.
Time in range (TIR)
This is a brand-new term for 2020 and equates to the percentage of 24 hours that your blood glucose can stay in the range decided on by your doctor. Usually 5 mmol/L to 8 to 10 mmol\L.
The TIR is important since this determines your glucose variability (GV). This means how much your glucose is going up and down, which can be easily monitored with a continuous glucose monitor (CGM).
The International Diabetes Federation (IDF) suggest that all Type 1 diabetes patients use a CGM.
Obtain the correct medication. This will be a tablet or injection that lowers blood glucose without gaining weight and without causing unnecessary hypoglycaemia (low blood glucose levels).
Get your Prevnar 13 injection to prevent streptococcus infections life-long and influenza injections yearly around the end of March to prevent influenza.
See your dentist and get your teeth cleaned annually to lower inflammation.
Regular bone mineral density tests are important since diabetes patients have an increased risk of osteoporosis. Also go for regular mammograms since diabetes patients have a 4-fold increase risk of cancer.
Go for regular urology visits to examine the prostate since diabetes patients have a 4-fold increase risk of cancer. Should erectile dysfunction (ED) or impotence occur, visit your specialist physician, and cardiologist for a coronary evaluation since there is an increase in cardiovascular disease in men with ED.
Type 2 ‘hot-off-the-press-trials’
In the Type 2 diabetes portfolios, there is a new class with dramatic data. Most Type 2 diabetes patients should be on this class should they qualify.
Medication and trials
The dapagliflozin heart failure trial is the most talked about trial of 2019. Dapagliflozin is a sodium glucose cotransporter 2 inhibitor (SGLT2i).
This class of drug works in the kidney on the proximal tubule (top absorbing pipe). It prevents the re-absorption of glucose into the circulation by blocking the enzyme SGLT2. This causes an increase of glucose in the urine. The amount of sugar lost is 14 teaspoons per day which equals 70g of carbs.
It is quite clear to deduct that this will cause weight loss (3 to 6kg), lowering in blood pressure and lowering in blood glucose. It also causes lowering in gout levels (uric acid).
The group of SGLT2 inhibitors that are available in South Africa is dapagliflozin (Forxiga) and empagliflozin (Jardiance).
The DAPA-HF trial was of interest because it looked at people with heart failure with poor heart function (less than 40%) with and without Type 2 diabetes.
This drug showed after 18 months of taking the active drug versus the placebo that heart failure occurrence was reduced by 16%. This is currently the ‘wonder drug’ in cardiology and diabetes and there are a lot of investigations to exactly establish all the mechanisms of action. Some people called it a ‘smart diuretic’ (tablet causing loss of water by producing more passing of urine). There are many more mechanisms involved.
This trial was done with canagliflozin, a SGLT2i, in people with impaired kidney function. The estimated glomerular filtration rate (eGFR) (average kidney function) was between 30 and 60ml/min.
This trial was stopped early due to its phenomenal outcome. It improves the kidney function and the lower the number the better the result. The two drugs available in South Africa, dapagliflozin (Forxiga) and empagliflozin (Jardiance), will have their data at the end of the year and next year.
This is good news for all Type 2 diabetes patients. The data with these classes of drugs are still ongoing and should not be used in Type 1 diabetes due to the risk of diabetic ketoacidosis.
Smart things coming for Type 1 diabetes
The newer and faster short-acting insulins will launch in the last part of 2020.
There are two basal (background) insulins that last longer than 24-hours available: Glargine U300 (Toujeo) and Degludec (Tresiba). They both have less hypoglycaemia effects.
The newer, smart ‘artificial pancreas’ is available with a pump that stops insulin if glucose levels goes too low and increases insulin if glucose levels go too high. This is done with the help of a sensor that sends data via Bluetooth to the pump. Unfortunately, this is still very pricey.
Remember that every person living with diabetes is a unique individual and needs unique individual attention and treatment. Find your unique team and start working together.
MEET THE EXPERT
Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.