At the 79th American Diabetes Association Scientific Sessions on San Francisco, Dan Drucker, MD, of the University of Toronto highlighted the most important scientific advances in diabetes over the last year. Here are seven of them.
1. Diabetes remission through weight loss
Type 2 diabetes remission through weight loss works, if people keep the weight off. Dr. Roy Taylor of Newcastle University in the UK has done several studies showing that very-low-calorie diets can put diabetes into remission, defined as an A1C level (a measure of glucose control over the previous 2&ndassh;3 months) below 6.5% without taking diabetes medications. But he had never done long-term follow-up to see if the results can last.
Now, the Diabetes Remission Clinical Trial (DIRECT) has followed about 270 diabetes patients for two years. All participants had been diagnosed within the last six years. After an initial rapid weight loss with a 700-calorie-a-day liquid diet, patients were helped with a stepped food reintroduction, and then given structured support for weight maintenance. A control group got regular diabetes care.
After two years, 11.4% of the intervention group maintained a 15-kilogram (33-pound) weight loss, down from 24% at one year. Twenty-four percent of the intervention group maintained a 10-kilogram (22-pound) weight loss. Diabetes was in remission for 35.6% of the intervention group and 3.4% of the controls. The average weight loss of those in remission was 10.4 kilograms (23 pounds), and of those not in remission was 3.2 kilograms (7 pounds). Blood pressure, cholesterol and quality of life levels all improved in the intervention group.
Remember that the intervention group received ongoing support for weight management, and some went back on the very-low-calorie liquid temporarily. Most people don’t have that kind of support. Still, only 24% of the group maintained a 22-pound weight loss, and over 64% of them were no longer in remission after two years. So don’t expect a cure, but do be aware that a supported weight-loss program like this does seem to help some people for a couple of years. Follow-up is continuing for at least one more year to track how participants fare.
2. Ketogenic diets
Very-low-carb, high-fat “ketogenic” diets are being managed over the Internet, and Dr. Drucker said the results seem as good or better than standard medical care. One company involved, Virta, defines diabetes as “carbohydrate intolerance.” Three studies of their program have been published showing that 60% of users got their A1C below 6.5% without medications. The program costs $500 to start and $360 a month for the first year for private-pay patients. Virta guarantees users and insurers that they pay nothing if patients’ A1C doesn’t come down dramatically.
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3. Microbiome research
Microbiome research is “exploding.” According to some studies, our gut bacteria’s genes influence our blood glucose levels and lipid (fat) levels more than our diet does. Several companies invite you to send them a stool sample, and they’ll send you a personalized diet based on analysis of the sample. However, Dr. Drucker said we don’t know yet how well this approach will work.
4. Closed-loop insulin delivery
“Closed-loop insulin delivery” is getting closer. Closed-loop means patients will no longer have to do anything to give themselves insulin — continuous glucose monitors and insulin pumps in combination will keep the right amount of insulin in the blood at all times. We’re not really there yet, but a lot of companies and groups are trying (a hybrid closed-loop system, the Minimid 670G, is FDA-approved and available). A system like this is sometimes called an “artificial pancreas.”
5. SGLT2 inhibitors and type 1 diabetes
A class of diabetes medicines known as SGLT2 inhibitors (also called “flozins”) are now being used in type 1 diabetes. They increase time in a healthy glucose range and they seem to reduce heart failure and hospitalizations for heart problems. They do come with the risk of certain problems, though, such as higher rates of diabetic ketoacidosis (DKA), a life-threatening complication.
6. Reducing diabetes complications
Treating or managing all risk factors can reduce the chance of complications to nondiabetic levels. People with normal blood pressure and cholesterol levels, who don’t smoke, who practice good mouth and foot care and who reduce stress have very low risks of diabetes complications.
7. Teplizumab and type 1 diabetes
A new drug may stop or severely delay type 1 diabetes before it starts. Type 1 does not come on all at once, as commonly thought. At diagnosis, most patients still have functioning beta cells. This accounts for the “honeymoon period” often seen after diagnosis and treatment of type 1. Then, beta cell destruction resumes and leads to full type 1 diabetes.
Patients given 14 days of an engineered antibody called teplizumab at the time of type 1 diagnosis or shortly after had much lower insulin requirements and better blood sugar levels for 2–5 years afterward. Their insulin production remained steady for over a year but did start to drop in the second year after treatment. New trials are testing a second course of treatment after six months, which may slow the disease down further. The drug doesn’t seem to reverse already existing type 1.
These drugs are still considered experimental, have significant flu-like side effects, and are currently extremely expensive, but they do give hope for the future of type 1 treatment.
Want to learn more about the 2019 ADA Scientific Sessions? Read “ADA 2019 Roundup: Diabetes Products and Services.”