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Global Diabetes Summit

Updated: 8/14/21 2:00 pmPublished: 2/29/08

In December 2007, diaTribe attended the Global Diabetes Summit in Columbus, OH. It was one of the most exciting and best organized meetings of the year. Approximately 650 people from at least 14 countries attended the first day of the conference, filling the Hilton Hotel ballroom. Organizing the conference was Dr. Kwame Osei of Ohio State University Medical Center, who began preparing for the event over two years ago, arranging for many leading experts to speak. This is his second diabetes meeting - 12 years ago he arranged a much smaller Global Diabetes Summit in Ghana. Given the success of the recent gathering, Dr. Osei now hopes to hold a Global Diabetes Summit every four years in Columbus.

The multi-track meeting covered a number of important topics in diabetes, but we will focus on the ongoing.

review and update on the artificial pancreas

Dr. Barry Ginsberg (former Vice President, Becton Dickinson Medical Affairs for Diabetes Care) reviewed the promise, progress, and challenges that remain for the development of a fully automated artificial pancreas - also known as a closed loop. The closed loop is often looked upon as the Holy Grail of diabetes care. He provided some background on conventional and intensive approaches to diabetes management, underscoring that conventional management requires the patient to adjust food for insulin dose and timing. Conversely, with intensive management, the patient adjusts insulin dose and timing for food. About 66 percent of type 1s and 20 percent of type 2s are intensively managed, according to Dr. Ginsberg. In the landmark Diabetes Control and Complications Trial (DCCT), intensive insulin therapy lowered A1c by about 1.8 percent. Although intensive insulin therapy offers great benefits to patients, it has limitations. While some patients are in great control, most only achieve better control with hypoglycemic episodes occurring 2-5 times per week. These episodes often come as a result of errors in carbohydrate counting, insulin-dose calculation, and administration.

The idea behind the closed-loop is to minimize the occurrence of hypoglycemia (and hyperglycemia) by simulating a real pancreas with the aid of a continuous glucose monitor and an insulin pump that "talk" to one another. The difference between a closed-loop and a hybrid closed-loop is that the latter still requires some input from the person using the device, primarily to input a rough estimate of food and exercise. Great progress on a closed-loop has been made, but many challenges remain. For example, the current generation of continuous monitors do not measure blood glucose directly and thus are not at a level of accuracy where they can prompt decisions on insulin dosing without human intervention. Getting down to the statistics behind the accuracy, the 95 percent confidence limits are +/- ~30 percent, meaning that a blood glucose reading of 200 mg/dl (11.1 mmol/l) indicates that blood glucose has a 95 percent chance of being between 140 mg/dl (7.8 mmol/l) and 260 mg/dl (14.4 mmol/l). For a closed-loop system, accuracy will need to increase significantly - scientists have their work cut out for them. Also very important and currently in development will be more rapid-acting insulins - e.g. Viaject – and new improved technologies for insulin delivery such as the microneedle.

It will be difficult to detect when a meal has been eaten, and pretty much impossible to tell how much or what is eaten. A final challenge is that the duration of insulin action (i.e., insulin on board) changes from time to time and from person to person. It will be necessary to know how much insulin is present to avoid overdosing, and current systems have not yet achieved this.

Best estimates by independent experts are 2013-2015 for the availability for the first closed loop systems. We will keep our fingers crossed and sugars extra tight until then.

the metabolic syndrome debate:

The metabolic syndrome has generated a lot of discussion in the medical community as evidenced by its multiple aliases - Syndrome X, Reaven's syndrome, insulin resistance (syndrome), and even CHAOS in Australia. At its core, it is defined by the American Heart Association (AHA) as being characterized by a group of risk factors including but not limited to glucose intolerance, hypertension, increased triglycerides, "bad" cholesterol, reduced levels of "good" cholesterol, and abdominal obesity.

In a panel discussion on insulin resistance and the metabolic syndrome, Dr. David Kelley of the University of Pittsburgh reviewed the source of controversy regarding the metabolic syndrome, namely:

  1. There is considerable doubt regarding its value as an indicator heart disease.

  2. The criteria used for "diagnosis" of the metabolic syndrome must be adjusted for different ethnicities, especially blacks.

  3. These criteria are somewhat arbitrary designations by medical experts. Nobody has actually taken the time to design a study specifically to define the metabolic syndrome.

There is little controversy about the prevalence of the metabolic syndrome (despite the arguments about definition), and there is little controversy that a healthcare provider must step in when the metabolic syndrome is diagnosed. The controversy is only about the "added value" of the metabolic syndrome's precise categorization of symptoms, and whether these criteria are justified by clinical research.

In presenting his lecture on the panel, Dr. Robert Eckel of the University of Colorado explained that the metabolic syndrome is often misinterpreted as a tool to predict overall risk for coronary heart disease (CHD). Furthermore, the metabolic syndrome was actually designed only to encourage lifestyle intervention, although it does in fact confer greater risk of CHD. Physicians need to address multiple risk factors but also spend more time talking to patients and stressing the importance of healthy lifestyles. Less than 10 percent of cardiologists ask questions about weight loss or food intake patterns or other diet-related matters. Family practitioners aren't much better; only about 15 percent of them ask about diet.

On the subject of diet and lifestyle intervention, Dr. Eckel pointed to a recent comparison of the Atkins, Ornish, Weight Watchers, and other diets published in the Journal of the American Medical Association (JAMA), and the study found that all the diets were similarly ineffective. One factor was that adherence to all the diets was low. The Atkins diet was found to be the worst diet because it introduces dangerous concepts of nutrition that may have bad effects long after the diet is stopped.

 

What do you think?