Practice Update: Endocrinology | Volume 1. Number 2. 2016

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JOURNAL SCAN
Life-years lost to diabetes
Diabetes Research and Clinical Practice
Take-home message
• This matched case-control study looked at years of life
lost to diabetes in the United States; adults with diabetes
had a lifespan 10.5 years shorter than matched controls.
Life-years lost to diabetes decreased as age at diabetes
diagnosis increased; those diagnosed before 20 years of
age lost 20 years whereas those diagnosed after 80 years
of age lost no years. In people with pre-existing CVD, 20.3
life-years were lost compared with only 8.5 years in those
without CVD.
• “Life-years lost to diabetes varies by age at diagnosis and
comorbidities, and the results of this study provide clini-
cians with estimates that are useful for counselling patients,
prognostication, and weighing health risks.”
Abstract
AIM Previous estimates of life-
years lost to diabetes are highly
inconsistent. This study pro-
vided the updated estimates
of life-years lost to diabetes in
the United States.
METHODS Each of a nation-
ally representative sample of
21,829 adults with diabetes in
the US National Health Inter-
view Survey 1997–2009 was
individually matched to one
without diabetes by age, sex,
race, survey year, BMI, smoking
status, pre-existing cardiovas-
cular disease and pre-existing
cancer. All-cause mortality from
original surveys to 31 December
2011 and median survival ages
were estimated for those with
diabetes and their matched
controls.
RESULTS Overall median survival
age for adults with diabetes
was 10.5 years shorter than that
for matched controls without
diabetes. Estimated life-years
lost associated with diabetes
decreased with increasing age
at diagnosis from 20.0 years
for those diagnosed before
age 20 years to no difference
for those diagnosed after 80
years. Hazard ratios for mortal-
ity decreased from 3.03 (95%CI
2.41–3.80) for those with diabe-
tes diagnosed before 20 years
to 1.04 (95% CI 0.78–1.39) for
those diagnosed after 80 years.
The estimate of life-years lost
associated with diabetes was
much higher among those with
pre-existing cardiovascular dis-
ease (20.3 years) than among
those without cardiovascular
disease (8.5 years).
CONCLUSIONS The effect of
diabetes on survival depends
on age at first diagnosis of
diabetes and the presence of
pre-existing diseases. The life-
years lost are higher for those
with diabetes diagnosed at
younger ages. This study pro-
vided the updated estimates of
life-years lost associated with
diabetes in the United States.
Life-years lost associated
with diabetes: An individually
matched cohort study using
the US National Health Inter-
view Survey data. Diabetes
Res Clin Pract 2016;118:69–76,
Z Wang, M Liu.
EXPERT OPINION
Diabetes landscape in Australia is fast evolving
Interview with Prof Sof Andrikopoulos
Professor Andrikopoulos speaks with Carolyn Ng on the evolving landscape in the treatment of type 2
diabetes, a need for a national strategy to prevent diabetes, exciting research that could better our
understanding of diabetes as a chronic disease, and the prospect of an artificial pancreas system and
its impact on patients with type 1 diabetes.
One of the biggest conversation points in diabetes these
days is around the impact of the newer diabetes drugs
such as empagliflozin and liraglutide on cardiovascular
mortality. The EMPA-REG OUTCOME trial1 for example
reported that patients with type 2 diabetes taking empagliflozin
had a 38% significantly (P < 0.001) lower risk of death from CV
disease compared with patient on placebo. This is big result.
The other big study is the LEADER trial2, results of which were
released at the recent American Diabetes Association meeting.
It reported similarly positive outcomes among type 2 diabetes
patients taking liraglutide – a marked reduction in death from
CV disease compared with patients on placebo.
These are significant results in that it’s the first time we’re
seeing glucose-lowering drugs confer CV protection. The ques-
tion now then is how do we use these drugs in the treatment
algorithm? For the Australian Diabetes Society, our main chal-
lenge is informing ourselves to apply what we now know from
these studies in the appropriate management of our patients
with type 2 diabetes. Both empagliflozin and liraglutide are
approved in Australia, with empagliflozin also subsidised on
the Pharmaceutical Benefits Scheme as second-line and triple
therapy, and as add-on to insulin.
The question that remains to be answered is whether we can
use these clinical trial data and apply them to all patients with
diabetes? The entry point for these clinical trials is that patients
have had to have a prior CV event or a strong predisposition to
CV events. Does this mean that these drugs are only useful in
diabetes patients with established CV disease or can they be
used to prevent patients from a CV event?
National strategy needed for diabetes prevention
Preventing diabetes is still a challenge at a national level. The
Australian National Diabetes Strategy 2016–20203 document
has dedicated a whole section on the prevention of diabetes.
Is it appropriate to talk to patients about lifestyle modification
at the prediabetes stage? It probably is. Can we use pharmaco-
therapy to prevent the conversion of prediabetes to diabetes?
Well we currently don’t have any drug that is indicated for
prediabetes. Do we need a national strategy for the prevention
of diabetes? I think we do.
We need to implement the recommendations of the Aus-
tralian National Diabetes Strategy to prevent the burden of
diabetes, not just on the health system in Australia but also
on the country’s economy. We are well aware of the statistics:
there are 1.7 million people in Australia with diabetes; 280 in-
dividuals are diagnosed with diabetes each day; and the indirect
cost to the national economy is $14.6 billion annually in loss
of income as a result of the disease. These are big numbers.
Prevention of diabetes is therefore a conversation we need to
have. The key stakeholders – the Australian Diabetes Society,
Australian Diabetes Educators Association, Royal Australasian
College of Physicians, and the Department of Health – need
to come together and come up with a national strategy for the
prevention of diabetes.
Getting to the root of diabetes
While there is evidence of a strong genetic predisposition,
we don’t as yet know the exact causes of diabetes.
In type 1 diabetes, we know that there are major genetic
loci that are more prevalent in people getting type 1 diabetes.
In the last 15–20 years, that genetic load has reduced and
there seems to be a lot of environmental factors that may be
contributing to the accelerated rate of type 1 diabetes such as
insulin resistance or overweight.
Can we prevent type 1 diabetes? I think we can by fully
understanding the mechanism of the disease: why the body’s
immune system attacks and kills beta cells resulting in insulin
deficiency which then causes diabetes.
The topic of epigenetics and its role in predisposing someone
to diabetes, whether type 1 or type 2, is of particular interest
to me. First, what are the epigenetic changes that cause type 2
diabetes and second, what are the environmental influences that
cause epigenetic changes. Can we as clinicians intervene? Can
we reduce or remove these environmental influences; avoid the
epigenetic changes and thereby prevent the onset of diabetes?
Another emerging research area is looking into the gut mi-
crobiota and how these predispose us to chronic diseases such
as diabetes. An interesting paper published in Nature4 recently
reported that gut microbiota can influence human metabolism,
predisposing to obesity and potentially triggering diabetes. So
it could very well be that if we have better gut health we may
be able to prevent a lot of the chronic diseases we see today.
Closing the loop in type 1 diabetes
We’re making huge strides in type 1 diabetes with the closed
loop system, or the artificial pancreas, being so close to reality.
The artificial pancreas, which combines an insulin pump with
glucose and a continuous glucose monitor, will reduce glycaemic
excursions, preventing an increase in HbA1c and complications
as a result of better plasma glucose control. I find this absolutely
fascinating. The artificial pancreas will save lives; it will not only
prevent diabetes complications but actually save lives.
References
1. Zinman B, Wanner C, Lachin JM, et al. N Engl J Med 2015; 373:2117–2128.
2. Marso Sp, Daniels GH, Brown-Frandsen K, et al.N Engl J Med 2016;
375:311–322.
3. Department of Health. Australian National Diabetes Strategy 2016–2020.
Commonwealth of Australia 2015. Canberra: DoH 2016. www.health.gov.
au/internet/main/publishing.nsf/content/3AF935DA210DA043CA257EFB
000D0C03/$File/Australian%20National%20Diabetes%20Strategy%20
2016-2020.pdf (accessed 8 August 2016).
4. Sonnenburg JL and Bäckhed F. Nature 2016;535:56–64.
Professor Sof Andrikopoulos is President
of the Australian Diabetes Society, Head of
the Islet Biology and Metabolism Research
Group at the Department of Medicine,
University of Melbourne, and Editor-in-
Chief of the Journal of Endocrinology and
Journal of Molecular Endocrinology.
Meeting of minds at the 2016
ADS–ADEA annual meeting
Prof Andrikopoulos says an interesting topic that will be dis-
cussed at this year’s meeting, one topic of many, is on the
use of technology in the management of diabetes. “We are
excited to host a number of high profile international speakers
including Professor John Pickup of the King’s College London,
a technology specialist who’ll be talking about the closed loop
pumps making headlines in diabetes. We’ll also be discussing
clinical data from the latest trials such as the LEADER trial; so
hot topics and very timely discussions that will be relevant to
healthcare professionals with an interest in diabetes.”
The ADS–ADEA 2016 Annual Scientific Meeting will be held
at the Gold Coast, 24–26 August. For more information visit
JOURNAL SCAN
Text message support increases weight
loss in patients with prediabetes
Diabetes Care
Take-home message
• In this randomised controlled trial, researchers analysed the ef-
ficacy of text message support in achieving weight loss in 163
patients offered diabetes prevention program classes. Patients
in the text message group lost more weight compared with the
control group (mean 2.6 vs 0.6 pounds; P = 0.05). Furthermore,
a higher rate of patients in the text message group achieved 3%
weight loss (38.5% vs 21.5%; P = 0.02).
• Text message support improved weight loss in patients with
prediabetes, highlighting the importance of engaging patients
in weight loss programs.
Abstract
OBJECTIVE Although the benefits
of in-person Diabetes Prevention
Program (DPP) classes for diabe-
tes prevention have been dem-
onstrated in trials, effectiveness
in clinical practice is limited by
low participation rates. This study
explores whether text message
support enhances weight loss in
patients offered DPP classes.
RESEARCH DESIGN AND METHODS
English- and Spanish-speaking
patients with prediabetes (n = 163)
were randomised to the control
group, which only received an
invitation to DPP classes as de-
fined by the Centers for Disease
Control and Prevention, or to
the text message-augmented
intervention group, which also
received text messages adapted
from the DPP curriculum for 12
months.
RESULTS Mean weight decreased
0.6 pounds (95% CI -2.7 to 1.6) in
the control group and 2.6 pounds
(95% CI -5.5 to 0.2) in the inter-
vention group (P = 0.05). Three
percent weight loss was achieved
by 21.5% of participants in the
control group (95% CI 12.5–30.6),
compared with 38.5% in the inter-
vention group (95% CI 27.7–49.3)
(absolute difference 17.0%; P value
0.02). Mean glycated haemoglo-
bin (HbA1c) increased by 0.19% or
2.1 mmol/mol (95% CI -0.1 to 0.5%)
and decreased by 0.09% or 1.0
mmol/mol (95% CI -0.2 to 0.0%)
in the control group and inter-
vention participants, respectively
(absolute difference 0.28%; P =
0.07). Stratification by language
demonstrated a significant treat-
ment effect in Spanish speakers
but not in English speakers.
CONCLUSIONS Text message sup-
port can lead to clinically significant
weight loss in patients with pre-
diabetes. Further study assessing
effect by primary language and in
an operational setting is warranted.
Text message support for
weight loss in patients with pre-
diabetes: a randomized clinical
trial. Diabetes Care 2016 Aug
01;39:1364-1370, HH Fischer, IP
Fischer, RI Pereira, et al.
DIABETES
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