Diabetes: Understanding Charcot Foot

For diabetics, foot care is one of the most important aspects of managing the disease. Four out of ten people with diabetes are thought to have lost some feeling in their feet, and nearly half will suffer a foot wound or ulceration in their lifetime. But there are some conditions that are out of the ordinary and one of them is the Charcot foot.

The Charcot foot is a rare condition that can occur in some people with diabetes. The underlying factor that contributes to the development of this condition is a loss of sensation in your feet—nerve damage that is referred to as peripheral sensory neuropathy.

Neuropathy is a common complication of diabetes, seen in people with both type 1 and type 2. The earliest sign of the Charcot foot may be a sudden and unexpected change in the appearance of your foot or ankle, characterized by redness, swelling, and warmth. You may have no recollection of injury.

X-rays of the foot may initially look perfectly normal, or there may be very subtle changes that can be easily missed. This is the most important stage of the Charcot foot for the physician to recognize the problem and to start treatment immediately. The treatment involves rest, elevation of your foot, and, most important, staying off of the affected foot until inflammation subsides and the foot is stable.

Sometimes there is collapse of the arch with the development of bony deformity, a “rocker-bottom foot,” with formation of an open sore (ulcer) on the bottom of the foot. Your doctor will first need to confirm the diagnosis by eliminating other conditions that might have a similar appearance, such as infection or gout.

Most diabetic foot specialists will apply a short non-weight-bearing cast and monitor the condition closely. Serial X-rays are taken to evaluate the healing of fractures and dislocations of one or more joints.

Although we have not yet learned how to prevent the development of a Charcot foot, we can sometimes minimize the extent of deformity with early recognition and prompt treatment. The likelihood of success decreases as the patient passes through the chronic stage of this condition.

Immobilization in a cast can sometimes take three months or longer. Patients are often transitioned from a cast to a removable walking brace, and then to a special shoe. In most cases, patients can be treated with non-surgical care; in the most difficult cases, surgery may be necessary.

Treatment of the Charcot foot is often prolonged, challenging, and frustrating. If you are at high risk—if you have peripheral neuropathy and loss of protective sensation—you should learn the implications of sensory loss, as well as the importance of diabetes self-management.

Foot inspection should be an important part of your daily routine. Compare one foot to the other and look for changes in size or shape. Is one foot swollen? Are there changes in the color or temperature of the skin? If you notice any of these changes, call your podiatrist, diabetes specialist, or family physician, and request an appointment as soon as possible.

Source: American Diabetes Associaltion

Hypoglycemia: Don’y Rely on the Doctor’s Prognosis – Tell Him What Needs to be Done to Save Your Life

Here’s yet another episode of doctors who are clueless about treating complications arising from diabetes. If only the doctors at the hospital attending on him had more knowledge of treating hypoglycemia (low blood sugar), the 46-year-old man would have been alive today.

The diabetic, a self-employed electrical technician, identified only as Mr H, weighed 150kg and was taken by ambulance to the North West Regional Hospital in Burnie, Tasmania, Australia with a very low blood sugar level of just 27 mg/dl (a normal blood sugar level is about 90 mg/dl).

Three sets of clinical observations were taken, at 5.52pm, 6.35pm and 6.40pm, including his blood pressure, which was low. He was provided with sandwiches to eat, which he tolerated, and was observed for an hour and remained well.

After being discharged at 7pm, Mr H went home. About 12.34am, Mrs H awoke but could not rouse her husband. She called an ambulance but, by the time they arrived, Mr H was in cardiac arrest.

An investigation by Coroner Rod Chandler found the 46-year-old was discharged at 7pm and died at home about 1.45am the next day. “Mr H was considered to have suffered a hypoglycemic episode, most likely related to poor oral intake combined with his oral anti-diabetic medication,” the post-mortem report said. In these circumstances the decision to permit Mr H to go home about 7pm on 10 January, 2009, was a regrettable misjudgment,” the coroner said.

“Had he remained in hospital for a longer period and been subject to close monitoring and to more intensive investigations, then it is likely in my view that the seriousness of his condition would have become evident and life-saving treatment put in place. These matters give rise to the question whether the decision to permit Mr H to go home without further monitoring and/or investigation was, in all the circumstances, a reasonable one.”

After carrying out an autopsy, pathologist Terry Brain recommended the case be reviewed by an experienced diabetic physician, “particularly [whether] the decision to allow him to go home played a significant role in his death and what could have been done to prevent this outcome”.

Royal Hobart Hospital Diabetes and Endocrine Services clinical director Tim Greenaway said severe hypoglycemia was a “clinical red flag” and should have attracted careful assessment. “Mr H’s falling blood sugar at the time he was allowed to leave hospital should have resulted in action by the emergency department staff,” he said, adding there were measures that could have been implemented by the medical staff. “Such investigation and treatment is standard practice,” he said.

Indeed, such investigation and treatment is standard practice around the world. Even an intern should know them. But the doctors on duty at the emergency room were ignorant of these procedures. “Regrettable misjudgment” is a terrible understatement, to say the least.

It was reported that the health authorities have implemented new procedures (sic) after Mr H’s death. But that’s no relief for his family.

My advice to all diabetics: If you suffer a hypo episode, instruct your family members to tell the doctors what to do. Also carry a note detailing the measures to be taken ‒ in case you have passed out ‒ in your wallet along with your card that identifies you as a diabetic. Unlike Mr H, you may not be another victim of an ill-trained doctor’s regrettable misjudgment.

Based on a news report in themercury.com.au

How Insulin-Producing Cells Die – Research Offers Potential for New Diabetes Diagnostic Test

The death of insulin-producing beta cells in the pancreas is a core defect in diabetes. Scientists in Italy and Texas now have discovered a new way that these cells die — by toxic imbalance of a molecule secreted by other pancreatic cells.

“Our study shows that neighboring cells called alpha cells can behave like adversaries for beta cells. This was an unexpected finding,” said Franco Folli, M.D., Ph.D., professor of medicine/diabetes at The University of Texas Health Science Center at San Antonio. He is co-lead author on the study with Carla Perego, Ph.D., assistant professor of physiology at the University of Milan.

Alpha and beta cells are grouped in areas of the pancreas called the islets of Langerhans. Alpha cells make glucagon, the hormone that raises blood sugar during fasting. In the same environment the beta cells make insulin, the hormone that lowers sugars after a meal. Imbalance ultimately leads to diabetes.

“We found that glutamate, a major signaling molecule in the brain and pancreas, is secreted together with glucagon by alpha cells and affects beta cell integrity,” Dr. Folli said. “In a situation where there is an imbalance toward more alpha cells and fewer beta cells, as in Type 1 and Type 2 diabetes, this could result in further beta cell destruction.”

Glutamate toxicity is a new mechanism of beta cell destruction not previously known, Drs. Perego and Folli said. It has not been typically thought that alpha cells could themselves be a cause of beta cell damage, they said.

The study also found a protection for beta cells, namely, a protein called GLT1 that controls glutamate levels outside the beta cells. “GLT1 is like a thermostat controlling the microenvironment of beta cells with respect to glutamate concentration,” Dr. Perego said.

A diagnostic test for glutamate toxicity in the islets of Langerhans is being developed by the authors, Dr. Folli said. Eventually an intervention to slow the process could follow.

Glutamate poisoning is a new candidate mechanism for beta cell destruction in diabetes. Others are high glucose, buildup of a protein called amyloid, and free fatty acids, which are found in patients with type 2 diabetes.

“The vicious cycle in diabetes is that there are several substances that have been shown, also by us, to be toxic to beta cells,” Dr. Folli said. “And now we have found a new one, glutamate.”

Aspirin May Help Diabetics With Kidney Disease Avoid Heart Complications

A new study from a team of Japanese researchers at the Nara Medical University shows that low daily doses of aspirin may help reduce risk of heart disease in patients who have both type 2 diabetes and kidney disease.

Heart disease, as we all know, is the most common cause of death for individuals who have type 2 diabetes because persistently high levels of blood sugar in the veins causes inflammation that leads atherosclerosis, which is a hardening of the arteries that causes the heart to work harder, eventually causing it to wear out.

The research, published in the journal Diabetes Care, concludes that there appears to be a strong relationship between diabetes-induced kidney disease and aspirin therapy. If future studies bear out these results, aspirin could provide a simple solution to a major problem that affects millions of people.

“The current study demonstrated that low-dose aspirin therapy reduced the risk of atherosclerotic events in type 2 diabetic patients,” the researchers wrote in their report.

For the study, researchers gave a group of more than 2,500 participants who had type 2 diabetes and kidney disease either an 81 mg daily dose of aspirin, a 100 mg daily dose or no aspirin at all. The researchers then tracked the participants’ medical records for nearly five years. During this time they checked for instances of stroke, heart disease and peripheral artery disease.

They found that individuals who were in either of the groups that received aspirin had significantly fewer atherosclerosis-related incidences than those who did not receive aspirin.

“The current study demonstrated that low-dose aspirin therapy reduced the risk of atherosclerotic events in type 2 diabetic patients,” the researchers conclude.

Confirmed: Fatty Liver Ups Type 2 Diabetes Risk

If you get diagnosed with a fatty liver during a routine check-up, sit up and take notice. Fat deposits in liver are an invitation to diabetes. Although fatty liver and insulin resistance are known to be associated, the relationship between the two in the development of type 2 diabetes mellitus (T2DM) is unclear.

However, a recent study published in The Endocrine Society’s Journal of Clinical Endocrinology and Metabolism (JCEM) found that individuals with fatty liver were five times more likely to develop type 2 diabetes than those without fatty liver.

This higher risk seemed to occur regardless of the patient’s fasting insulin levels, which were used as a marker of insulin resistance. People who consume more oily food, have a sedentary lifestyle, especially those who consume large quantities of alcohol, are at risk of getting the disease.

In recent years, fatty liver has become more appreciated as a sign of obesity and resistance to insulin, a hormone that controls the body’s glucose levels. This new study ‒ ‘Interrelationship between Fatty Liver and Insulin Resistance in the Development of Type 2 Diabetes’ by Ki-Chul Sung and Sun H. Kim of Kangbuk Samsung Hospital, Sungkyunkwan University at Seoul, South Korea ‒ shows that fatty liver may be more than an indicator of obesity but may actually have an independent role in the development of type 2 diabetes.

There seems to be little awareness about the disease even among the physicians. “It is not as innocuous as it looks. It is known to develop into liver failure or liver cancer. Recent studies have shown that fatty liver also increased chances of diabetes,” says Dr Mishra, who is chairman of the Fortis-CDOC Centre for Excellence for Diabetes at New Delhi in India.

According to Kim, “Many patients and practitioners view fat in the liver as just ‘fat in the liver,’ but we believe that a diagnosis of fatty liver should raise an alarm for impending type 2 diabetes…Our study shows that fatty liver, as diagnosed by ultrasound, strongly predicts the development of type 2 diabetes regardless of insulin concentration.”

In the Seoul study, researchers examined 11,091 Koreans who had a medical evaluation including fasting insulin concentration and abdominal ultrasound at baseline and had a follow-up after five years.

Regardless of baseline insulin concentration, individuals with fatty liver had significantly more metabolic abnormalities including higher glucose and triglyceride concentration and lower high-density lipoprotein cholesterol (sometimes called “good cholesterol”) concentration.

Individuals with fatty liver also had a significantly increased risk for type 2 diabetes compare to those without fatty liver.

“Our study shows in a large population of relatively healthy individuals that identifying fatty liver by ultrasound predicts the development of type 2 diabetes in five years,” said Kim. “In addition, our findings reveal a complex relationship between baseline fatty liver and fasting insulin concentration.”

Also see my earlier report “Fatty Liver a Forerunner to Diabetes”

Lap-Band & Bariatric Surgery Find Match in EndoBarrier

The cacophony surrounding the news that a pair of studies has found that a different, older procedure ‒ the Roux-en-Y gastric bypass – is “more effective” and “no riskier” than either the Lap-Band or  the “less-drastic” (sic) sleeve gastrectomy surgery, has drowned out a news of a new British implant devise that helps weight loss and lowers blood sugar levels.

It has been reported that surgeons at a British hospital have pioneered a new treatment that could remove the need for medication to treat type 2 diabetes while helping sufferers lose weight.

Medics at Southampton General Hospital have performed the first 15 implants of a new device called the EndoBarrier.

The EndoBarrier is implanted under a short general anaesthetic and performed as a day case procedure, with all 15 patients participating in the trial discharged home within hours of completion.

Use of the EndoBarrier means that food bypasses a part of the upper intestine, so the body has less time to digest it, and also allows more control over metabolic rate and potentially lower blood sugar levels. It was shown the device could achieve weight loss of over 20 per cent of total body weight.

The sleeve is also performing as well so far as the more invasive gastric band procedure in helping weight loss.

In a 12-month study, patients fitted with the EndoBarrier achieved weight loss of more than 20% (on average 3.5 stone) of their total body weight. The sleeve is also performing as well so far as the more invasive gastric band procedure in helping weight loss.

Southampton University Hospitals NHS Trust is one of three centres in the UK participating in a study to evaluate the effectiveness of the device in patients who are overweight and suffer with type 2 diabetes. The other two are Trafford General Hospital in Manchester and St Mary’s Hospital, London.

Consultant general surgeons Jamie Kelly and James Byrne at Southampton are the first to complete the initial part of the project and say they are pleased with the early findings.

“Initial results among the 15 patients who have had the EndoBarrier inserted have been really encouraging and we are very excited about the potential impact of this new treatment for patients. We are already seeing the benefit to our patients with reductions in the treatment required to manage diabetes as well as significant weight loss. The weight loss so far is tracking as well as we typically see achieved with the more invasive gastric band procedure,’ Bryne explained.

Kelly added: “The procedures performed in this initial study were performed on NHS patients and further evidence of the effectiveness of this treatment will hopefully ensure it will be offered to NHS patients in the future.” At present EndoBarrier is available only to private paying paients.

Anyway, the biggest danger is that new weight-loss options like EndoBarrier, Lap-Band,  Roux-en-Y gastric bypass and sleeve gastrectomy surgery have the potential to encourage overweight people to abandon traditional diet and exercise for procedures that carry some serious risks. That should be a big worry for all diabetes educators and activists.

Diabetes: Why do Doctors Miss the Wood for the Trees?

I find it very strange that when you are hospitalized, the doctors looking after you are concerned only with the problem you have reported at the time of admission and not much else. I mean what you say is wrong with need not necessarily be the only thing a doctor should be worried about – there could be other unknown reasons for your hospitalization.

Back in 1998 when I was hospitalized for “abdominal pain” (my complaint), the doctor’s (correct) prognosis was acute pancreatitis. I went through a battery of tests which confirmed this. However, the CT scan also showed the presence of a number of stones in the gallbladder.

My wife pointed this out to the doctor who dismissed the finding as a “secondary” issue that “could be tackled later. We have to treat the pancreatitis first.”

To cut the long story short, I was soon developing obstructive jaundice periodically. At the same time it was discovered that I had developed Type 2 diabetes and was put on insulin (my choice, since I had researched the problem). And, finally, 3 ERCPs and stentings later, in 2003 it was finally decided that my gall bladder had to be removed surgically (cholecystectomy) because the common bile duct was blocked by a gallstone the size of a small marble.

That is not the end of the story. Five years later, I had chronic pancreatitis and developed pancreatic abscess, and as a result, intestinal adhesions that required emergency surgery. Uncontrolled hyperglycemia added to the problems and I was in hospital for 2 months.

My saga does not end here. Fearing that I might develop an infection during the 2008 surgery (it was touch-and-go for me at that stage), the surgeon decided not to place a mesh to strengthen my abdominal wall. So a year later an incisional hernia developed, which required another surgery a few months ago.

My point is that if the gallstones had been removed laparoscopically in 1998, maybe, just maybe, I might not have developed type 2 diabetes.

I have brought this up with many doctors time and again. My argument is: Gallstones are also a cause for pancreatitis (though not necessarily in my case), which means damage to the pancreas that produce insulin. So why weren’t the gallstones attacked earlier? I may have been a healthier individual today. But, alas, I still have to get an honest, in-your-face answer. As with any profession, in the world of medicine, too, dog doesn’t eat dog.

But this just strengthens my belief – and I’ve written about this basing my argument on empirical evidence – that in the age of ‘superspeciality’, our medical schools are producing graduates who miss the wood for the trees.

I can therefore empathize with a British pensioner who developed diabetes after battling pancreatic cancer and nearly died because medics failed to diagnose the condition.

According to a news report, Raymond Ellerby, 67, lost three stone in four weeks because his diabetes was not spotted. It was only when he slipped into a diabetes-induced coma – a life-threatening condition – that doctors discovered what was wrong with him.

Diabetes is always a risk following pancreatic surgery when part of the pancreas, which produces insulin to regulate the body’s sugar levels, is removed. And Ellerby had an operation to remove part of his pancreas at Castle Hill Hospital at Hull, East Yorkshire, in December 2009. Initially, he seemed to recover well but his health then started to deteriorate late spring, with his weight plummeting and feelings of dizziness, constant nausea and pain.

“It was like being drunk all the time – I didn’t know what I was doing…I was having hallucinations and I knew I didn’t feel like myself. Eventually I was found collapsed on the floor of my lounge by my daughter. If she hadn’t found me, I wouldn’t be here now,” he recalls.

The great-grandfather was taken to Hull Royal Infirmary where doctors told his family he could die within hours. But he came round and was on the Intensive Care Unit for about a week.

Following his recovery, Ellerby complained to the UK Patient Advice and Liaison Service for Hull and East Yorkshire Hospitals NHS Trust. He has now been told procedures to identify diabetes in patients with pancreatic cancer have been “changed completely”.

A letter from Jenny Barker, assistant service manager in digestive diseases at Castle Hill Hospital, dated February 11, contained an apology from Dr Anthony Maraveyas, senior lecturer in oncology. She said: “Dr Maraveyas would like to reassure you that since this incident, the Trust has changed practice completely and all patients with a newly-diagnosed pancreatic cancer, who come to the unit, have a baseline glucose test, which is reviewed at regular intervals. He would like to apologize once again for any distress or anxiety caused due to your diabetic symptoms not being identified initially.”

Wow, even a layman would have thought that if damaged pancreas is involved, “a baseline glucose test, which is reviewed at regular intervals,” would be the first thing ANY doctor would order.

In essence, thanks to the doctor’s incompetence, Ellerby had received a death sentence. That he survived to tell the tale is another story. And all he got in return was a letter from the British NHS Trust chief executive Phil Morley, saying, “Please accept my apologies for the distress you and our family have experienced.”

So my advice to everyone is: Research your condition and take a second opinion. And DON’T put your faith in just one doctor ‒ he may be clueless about treating diabetes-related problems.

Victoza: Is It The New “Miracle Drug” for Type 2 Diabetes?

I had reported last year that Danish pharma giant Novo Nordisk’s gamble on Victoza, its new drug for Type 2 diabetes, often looked like a long shot.

The company’s scientists had spent nearly 10 years trying to develop a molecule that would act like a naturally occuring hormone called GLP-1. Once they did, there were still costly setbacks, puzzling questions and enormous doubts, none of which managed to thwart one researcher’s passionate belief in the hormone’s ability to be turned into a drug for lowering blood sugar.

GLP-1 is short for glucagon-like peptide 1, a naturally occuring compound that works on different organs to lower the levels of blood sugar. For overweight diabetics, there’s another benefit: GLP-1 attaches to a receptor in the brain to decrease appetite, which over time, leads to weight loss.

Since then, Victoza has been used by thousands of diabetics, all with varying results. While the majority are seeing lower blood sugars (some in the double digits) and weight loss, others are seeing no change or too much change. Many have claimed Victoza to be a type 2 diabetes “miracle drug”. That said, doctors are quick to use Victoza as a second line drug when Metformin and other first line drugs aren’t doing their jobs.

Newer drugs to combat diabetes is always good news for those who are living with the disease. As all of us know, managing diabetes is not easy. In fact, for most diabetics it seems like a losing battle. Then a new drug hits the market, raising hopes. But many a time, expectations are dashed when its is discovered that the so-called wonder drug has some rather unpleasant side effects.

Once-a-Week Bydureon Wins European Medicines Agency Approval

In fact, in the case of Avandia, a landmark meta-analysis in 2007 showing a 43% increase in the risk of heart attack on rosiglitazone. People with diabetes are already at increased risk of heart problems. Last year, GlaxoSmithKline spent billions of dollars last year settling claims. And Avandia has been banned in most countries and in the US its use is severely curtailed. For all practical purposes, diabetics around the world have stopped using Avandia even though its supposed to be a “wonder drug”.

How Victoza was “Discovered”

Before we get down to finding out more about Victoza, a little background is in order.

Lotte Bjerre Knudsen, a senior scientist at Novo Nordisk, led the 20-year effort to develop Victoza. Before the drug received its brand name, it was known by its scientific name, liraglutide. And in the research laboratory, Knudsen’s dedication earned her the nickname “Mrs. Liraglutide.’’

“There were doubts about whether this would ever be a drug,’’ Knudsen said in an interview last year. “When you’re making something completely novel, it’s not so untypical.”

The promise of the GLP-1 class of drugs fueled the company’s efforts through major setbacks, including a flawed dosing study that cost researchers 18 months. With each setback, Knudsen had to defend the project to management.

Knudsen said her team postponed celebrating Victoza’s development until the drug was approved by US regulators. “It wasn’t good enough until we received that,” she said.

So What Exactly is Victoza?

Victoza (liraglutide injection) is a non-insulin once-daily injectable medication that may help improve blood sugar levels in adults with type 2 diabetes. It comes in an injectable pen form with three dosage levels. The first level (0.6 mg) is usually used for a week and then increased to the second level (1.2 mg). If the third level (1.8 mg) is needed, it is easily “dialed” and may be started after the body has adjusted to the 1.2 mg level.

Victoza works by helping the pancreas release the right amount of insulin. Victoza is 97% similar to a hormone in our bodies called GLP-1. This hormone is what helps us move sugar from our blood into our cells. Victoza has the same effect as GLP-1, and it also helps food move much more slowly through the stomach. Another benefit of Victoza is that it blocks the liver from releasing too much sugar by lowering the amount of glucagon, a hormone that tells the liver to release glucose into the bloodstream in order to bring glucose levels to normal.

How Do I use Victoza?

One of the great things about Victoza is that it is made for once-daily usage. The pen only has to be refrigerated up until the first use, and then it can be kept conveniently in a non-refrigerated spot, such as a purse or bedside table. Victoza can be injected at any time of day, regardless of food intake. It is recommended to inject Victoza at approximately the same time each day, however, for consistency.

To do the injection, a special needle (which must also be prescribed by your doctor) is placed on the tip of the pen. The dial at the bottom of the pen is then turned to the dosage prescribed by your doctor. The injection may be given in the stomach, thighs or arms (subcutaneously). Throw the needle away, replace the cap, and you’re done!

Side Effects of Victoza

The most common side effects of Victoza are nausea, vomiting and diarrhea until the body is used to the medication. Most patients start out at the 0.6 mg level for this reason. Lightheadedness has also been reported. A list of all side effects can be found on Victoza’s website.

Victoza and Thyroid Cancer

During Victoza’s testing process, the medicine caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer in people.

Victoza and Weight Loss

Many people have claimed to lose a great deal of weight while on Victoza. Although Victoza is not a weight loss drug, medical studies have shown that most people taking it do lose weight. Since weight loss is an important component of living with type 2 diabetes, this is definitely an added benefit.

Important Points About Victoza

• Victoza is not insulin, and it is not known if it is safe and effective when used with insulin.
• Victoza is not recommended as the first choice for treating type 2 diabetes.
• Victoza can be used on its own or with other diabetic medications.
• Victoza should not be used with people with type 1 diabetes or with people with diabetic ketoacidosis.
• Victoza should not be used with children.
• Doctors may recommend that small increases be made when going from 0.6 mg to 1.2 mg and then to 1.8 mg. This is accomplished by increasing by “clicks” on the dial. This is very helpful when side effects are severe.
• Victoza can be costly, depending on insurance. Depending on the dosage, Victoza can cost up to $500 when not covered by insurance. Check with your pharmacy, and visit Victoza’s website for coupons and information on getting your diabetes medication for free.

Making the decision to start Victoza is one that is strictly between a patient and his or her doctor. One must weigh the side effects against the benefits and make an informed choice. Victoza may be called a miracle drug for type 2 diabetes, but it is up to individuals to draw that conclusion when it comes to treating their own diabetes.

Diabetes News: Microworms That Monitor Blood Sugar; New Approach to Bariatric Surgery; Stem Cells to Cure Diabetes

It is now recognized that it is the low- and middle-income countries that face the greatest burden of diabetes. However, many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries.

However, seeing the business potential of investing in diabetes research, pharmaceutical companies are now feverishly developing new drugs and technologies to cater to a booming market. Companies are now moving beyond just drug research and are pushing the frontiers of science from nanoworms that monitor blood sugar to a permanent cure for diabetes using stem cells.

In today’s post I’m highlighting three exciting developments which, if successful, spell new hope for diabetics.

Glowing Microworms That Monitor Blood Sugar

Tiny, glowing ‘microworms’ implanted under the skin could be used to give blood sugar readings for diabetics, or other biomedical information, say researchers at MIT and Northeastern.

Their tube-shaped microparticles, unlike existing spherical versions, won’t be swept away from the initial site over time, they say. The tubes’ narrow width keeps their contents close to blood or body tissue, while their length keeps them anchored for months on end.

The nanoparticles are created by using chemical vapor deposition (CVD) to coat an aluminum oxide layer that’s been etched to contain tiny pores. Then, the coated material is dissolved away, leaving a series of hollow tubes where the pores used to be.

Before that, though, another material can be added that fluoresces in the presence of a specific chemical such as glucose. This means that when the ‘microworms’ are injected under the skin, they form a glowing tattoo that could be used to monitor diabetic patients.

“Tight control over glucose levels can help individuals stave off the devastating side-effects of diabetes – the number-one cause of kidney failure, blindness in adults, nervous system damage, and amputations,” says MIT chemical engineering professor Karen Gleason.

“In principle, this could open the way for avoiding blood tests, which need a central lab, expert nurses, extra time and extra costs. It could be done in a doctor’s office, or even at home,” says Professor Raoul Kopelman of the University of Michigan. “It will also avoid complications for patients with ‘difficult’, or ‘used-up’ veins, patients on blood thinners, etc.”

However, he warns that there could be concerns about long-term toxicity and bio-elimination, as well as complications such as blood clots.

Minimally Invasive Approach to Bariatric Surgery

There are scores of startups offering different approaches to obesity and diabetes eager to address the $174 billion in costs related to diabetes each year.

Now, MetaModix, a Minnesota medical device company, is moving ahead with plans to develop a minimally invasive approach to bariatric surgery and better solve the problem of type 2 diabetes.

The company is “developing a cost-effective minimally invasive therapy for type 2 diabetes” that mimics “certain elements of bariatric surgery through an endoscopic procedure.”

The process would be an out-patient procedure that would last about 30 minutes, according to Kedar Belhe, the company’s chief executive officer.

Bariatric surgery often eliminates a patient’s type 2 diabetes. However, there are concerns over the procedure itself: from post-operative side effects to the long-term impact of the surgery.

Meanwhile, the U.S. Food and Drug Administration just broadened the use of Allergan’s Lap-Band device to include more patients, for example, and other approaches range from stomach stapling, embedding sensors or inserting sleeves in the body.

Stem Cell Research Seeks Permanent Cure for Diabetes

In India, which has about 50.8 million people suffering from diabetes, another start-up, Stempeutics Research, is investing in stem cell research in the hope of discovering a permanent cure for diabetes.

Stempeutics Research has received clearance from the Drug Controller General of India (DCGI) for its investigational medicinal product Stempeucel for conducting phase II clinical trials on patients with diabetes.

“Stem cell therapy aims at addressing the root cause of the disease rather than the symptoms. Our goal is to bring out stem cell based drug in the near future. We will hit the market with our first product by end of 2011.

While the initial foray of Stempeutics is in bone marrow derived mesenchymal stem cells, Stempeutics is investing heavily on its R&D to bring out some innovative products in the near future based on adult stem cells.

There will be continuous research for each disease so as to improve product development for effective therapy. Research will be conducted on effective cell number, route of transplantation,” Stempeutics Research president BN Manohar President said.

According to the procedure, 10 patients will get one particular dosage of stempeucels, another 10 will get a higher dosage and the remaining 10 will get placebo (no drugs). “It will take at least 12 to 14 months to complete the study,” said Manohar.

Promoting Self-Management is Essential to Properly Treat Type 2 Diabetes

One of the most important aspects of diabetes management is educating the patient to manage their condition themselves. This is known as Diabetes Self-Management Education, better known by its acronym DSME. It has been demonstrated by many studies that education works.

DSME is defined as the ongoing process of facilitating the knowledge, skill and ability necessary for effective self-management and is guided by evidence-based standards. Patients with diabetes who do not receive DSME are found to be four times more likely to develop a major complication of diabetes and incur higher diabetes-related hospital costs.

I support the concept of DSME, given the fact that many family doctors do not have enough knowledge to effectively advise diabetes patients (see my earlier post ‘Why most doctors are clueless about treating diabetes’) and visits to a specialist involve long waiting periods and longer commutes.

In this interesting interview conducted by Endocrine Today, Linda Siminerio, RN, PhD, CDE, director of the University of Pittsburgh Diabetes Institute, and associate professor at the University of Pittsburgh School of Medicine and the School of Nursing answers many questions regarding DSME.

How can physicians effectively educate patients who currently have type 2 diabetes?

I think it is always helpful when physicians have access to additional resources to support team-based care. For example, referral to dietitians and diabetes education programs can be a powerful adjunct for comprehensive, quality care given the limited time they have available to spend with their patients. I have been involved in many studies and national surveys on referral practices, and we found that physicians often do not refer patients to these programs.

How can physicians effectively educate patients who are at risk for developing type 2 diabetes?

It is important for physicians to know what lifestyle intervention resources that address weight reduction and physical activity are available in their communities so that they can refer patients appropriately. Local YMCAs that offer lifestyle programs can be a valuable resource for physicians and patients. For example, in Indiana, some YMCAs have adapted the Diabetes Prevention Program (DPP) into a 16-week diabetes reduction program in the community setting. In Pittsburgh, the Diabetes Prevention Resource Center offers a 12–week Group Lifestyle Balance (GLB) program adapted from the DPP that is offered at community sites and in primary care practices. Physicians and practice staff should explore their respective communities to find community-friendly resources for their patients at risk for chronic disease.

What are your recommendations for creating collaboration between physicians and educators?

Physicians can refer their patients to the American Diabetes Association Web site to learn about community-based, recognized self-management education programs. Additionally, the American Association of Diabetes Educators Web site provides a variety of education materials that can be downloaded.

Even if patients obtain referrals from their physicians to participate in a program, they may not attend. I recommend that educators be integrated in the practice so that the educator becomes a part of the practice team. Educators and physicians should work together. Other support mechanisms are available in communities, but they are not always used. Primary care physicians should work with others in the community, such as local pharmacists, to effectively educate patients.

How can physicians promote diabetes self-management?

Diabetes self-management education (DSME) should always be considered as part of the treatment plan, even if a patient is reported to have excellent metabolic control. Attention to self-care behaviors and psychosocial needs are equally as important as metabolic outcomes when managing a burdensome, chronic disease like diabetes. Active listening, providing accurate information and building a patient’s confidence are all important tools used in diabetes education. It is essential that physicians and everyone on the diabetes care team work together to support patient self-management by developing patient-centered goals that will be more likely to be achieved.

How do you determine the best treatment option for patients?

Every patient and situation is individual. Thus, it is important for everyone on the diabetes care team to take time to listen to the patient’s needs and desires. The physician, along with the team, should provide patients with the necessary information to build a realistic care plan. Patients need to be informed so they can make informed decisions about their own care.

Do patients who have received this sort of patient-centered care have better results in the long run versus patients who may not receive ongoing support?

Research shows that diabetes self-management is an important component of diabetes care and has an impressive effect on HbA1c levels. In a meta-analysis, diabetes education was reported to reduce HbA1c by 0.76%. Since a 1% decrease in HbA1c is associated with a dramatic reduction in myocardial infarctions, micro-vascular disease and death, a 0.76% reduction can be considered an enormous benefit. Further, duration of contact time between a patient and an educator is the only significant predictor of the DSME effect. This suggests that DSME alone is not sufficient to maintain improved behaviors and that sustained improvements require contact and follow up.

We also know that if education is not sustained or supported, then HbA1c levels go back up. So, we need to continue to explore opportunities for continued support. Community-based programs, like wellness programs, YMCAs, churches and senior centers are potential forums for community friendly self-management support systems.