Artificial Sweeteners

I’m living a relatively sugar free life but that doesn’t mean I don’t get to enjoy sweet tasting food and beverages.  Why?  Artificial (intense) sweeteners.  The FDA has approved several including:

Aspartame - an artificial sweetner that is ubiquitous in American society, occuyping a place in most diet sodas, Crystal Light and a host of other foods. It is know as “NutraSweet”. Aspartame is 200 times sweeter than sugar and is synthesized rather than extracted. Despite controversies concerning its saftey (and some wild claims), aspartame is viewed by the FDA as one of the most thoroughly tested and studied food additives every approved.

Sucralose - an artificial sweetener that is not digested which makes it non-caloric. Incredibly, it is 600 times as sweet as sugar and, unlike aspartame, is suitable for baking (i.e., stable when heated). The most common brand name is Splenda although it is also marketed under the names SucraPlus, Candys and others.

Stevia - as natural extracted from a plant in the sunflower family, the sweetener has a slower onset and longer duration than sugar but may have an after taste. Interestingly, it was once banned in the United Staets and the European Commission are currently deciding whether to approve it. However, recent studies suggest no adverse effects and that stevia may improve insulin sensitivity.

Saccharin – found in Sweet ‘N Low was once thought to cause cancer until scientists discovered that the animal model (rats) was invalid. Warnings have been removed and the sweetener has found a resurgance of use.

My favorate is Granulated Spenda – I use it every morning on my multi-grain cereal (yum).

 

Victoza Approved for Diabetes Treatment in China

Novo Nordisk announced today that the Chinese State Food and Drug Administration (SFDA) has approved Victoza® for the treatment of type 2 diabetes.

With Western foods and higher incomes, Type 2 Diabetes is a growing problem in the most populated country on the planet.

Victoza, a brandname for liraglutide, is a once-daily human Glucagon-like peptide analogue and is used as an add-on to metformin.

 

The Growing Problem of Alzheimer’s Disease

This is staggering…

The Alzheimer’s Association 2011 Annual Report reveals that Alzheimer’s disease is the sixth leading cause of death, has risen 66% fom 2000-2008 and, among the top 10 fatal conditions, is the only one that can’t be “prevented, cured or even slowed.”  One in eight older Americans have the disease including 50% of those over the age of 85.  What’s more, caregivers provide 17 billion hours of unpaid care and suffer as a result:

Because of the toll of caregiving on their own health, Alzheimer’s and dementia caregivers had $7.9 billion in additional health care costs in 2010. More than 60 percent of family caregivers report high levels of stress because of the prolonged duration of caregiving and 33 percent report symptoms of depression

And the situation won’t get any better.  When the first wave of baby boomers reaches age 85 years (2031), an estimated 3.5 million people aged85 and older will have Alzheimer’s.  Here’s a video that will further communicate the crisis.

 

The Run on Potassium Iodide – an Anti-Cancer Drug

Japan is literally staring down a potential nuclear holocaust and some Americans, fearing the worst, have begun buying potassium iodide, a drug that can protect people from radiation-induced thyroid cancer.  Will the fall-out really traverse the Pacific Ocean?

 

Metformin Remains Number One Type Two Drug

As one of the most widely prescribed diabetes drugs, the preferential application of metformin to treat Type 2 was confirmed by a new study.

The study examined and compared six different types or classes of medications for treatment of Type 2 Diabetes:  DPP-4 inhibitors (Onglyza, Januvia), sulfonylureas (Amaryl, Glucotrol and others), thiazolidinediones (Avandia, Actos), meglitinides (Prandin,Starlix), GLP-1 receptor agonists (Byetta and Victoza),  and metformin (Fortamet, Glucophage,Glumetza, and Riomet).

Metformin was found to be efficacious (reduced hemoglobin A1c), had the fewest side effects and was the cheapest.

Adult Stem Cells Continue to Show Promise for Diabetes Research and Therapy

Stem cell research is a promising component of what we hope will bring about a cure-like therapy for diabetes.  It may also provide models that enable the unraveling of Type 1 Diabetes and the mechanisms that bring about an auto-immune attack on islet cells.

We understand the ethical problems with destroying and harvesting an immature human in support of embryonic stem cell research. In addition, ESCR carries with it other challenges that have signifantly limited practical success including rejection and the potential for unpredictable growth.

Adult stem cells, derived from the same person they will be used to eventually treat, may enable the growth of insulin-producing cells, which could be used to repair the imcomplete pancreas.  Alok Jha, writing for the Observer, has an excellent piece that details the advantage that reprogrammed adult stem cells have:

Key to this is the discovery, in the past few years, of a way to make stem cells that do not require the destruction of embryos. In one move, these induced pluripotent stem (iPS) cells remove the ethical roadblocks faced by embryonic stem cells and, because they are so much easier to make, give scientists an inexhaustible supply of material, bringing them ever closer to those hoped-for treatments.

(…)

In 2007, Shinya Yamanaka at Kyoto University in Japan demonstrated a way of producing ES-like cells without using eggs. He took a skin cell and, using a virus, inserted four specific bits of DNA into the skin cell’s nucleus. The skin cell incorporated the genetic material and was regressed into an ES-like cell – it had been “reprogrammed” using a batch of chemicals in the lab. In a few short experiments, scientists had a near-limitless supply of stem cells that were, seemingly, as good as ES cells for their research.

As I mentioned earlier, one of the key applications for these cells is the development of models to study disease states:

Models using iPS cells have proliferated in a few short years: they are now available for, among other things, motor neurone disease, juvenile diabetes and sickle cell anaemia.

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Nick Jonas revisits event where he first announced he has type 1 diabetes

Yesterday, Nick Jonas joined the Diabetes Research Insititute for the organziation’s annual fundraiser, the Carnival for a Cure:

Hundreds of families have come to expect a whirlwind of surprises at the always-entertaining Carnival for a Cure, benefiting the Diabetes Research Institute. At this year’s 6th annual affair, to be held on Sunday, March 13, 2011 from 1 p.m. to 4 p.m. at the Metropolitan Pavilion located at 125 W. 18th St., guests enjoyed a special appearance by Nick Jonas, who talked about life with diabetes during the program.

It was at the 2007 event that Jonas first announced to the world that he has type 1 diabetes.

“I’m looking forward to attending and sharing my story about how diabetes hasn’t slowed me down,” he wrote in a recent blog post. Jonas serves as a spokesperson for Bayer Healthcare Diabetes Care, a sponsor of the event.

 

Closed-Loop Control for Anesthesia Delivery

Earlier today I commented on my optimism concerning closed-loop control for glucose management.  A different application but somewhat analagous system (i.e., closed-loop) has been developed and tested for anesthesia delivery:

We have developed a proportional-integral-derivative controller allowing the closed-loop coadministration of propofol and remifentanil, guided by a Bispectral Index (BIS) monitor, during induction and maintenance of general anesthesia. The controller was compared with manual target-controlled infusion.

The controller allows the automated delivery of propofol and remifentanil and maintains BIS values in predetermined boundaries during general anesthesia better than manual administration.

You can see the system in action below (video uploaded by Medgadget):

Artificial Pancreas and Closed Loop Control – is it really that far off?

For many years academic researchers and device companies alike have investigated, developed and studied that artificial pancreas.   The system isn’t really a pancreas per se but rather a multi-component system that  continuously measures glucose (via a subcutaneous sensor), uses a computerized closed loop controller to determine the proper insulin infusion rate and and then automatically adjusts insulin delivery via a subcutaneous insulin pump.

Many of these automatic feedback control systems are in clinical trials and there has been enthusiasm generated by NIH and JDRF sponsored research in this field.

I don’t think the artificial pancreas is far off at all, although the first generation may not be the fully automated high performing system that we dream about.  Insulin pumps are reliable and sophisticated control systems have been developed that optimize insulin delivery decisions using a personalized predictive model (i.e., determines future glucose response via an adaptive nonlinear PK/PD equation).   The weak link, in my opinion, is the glucose sensing system.  Continuous glucose monitors have improved but may not be at the point were tight glycemic control is possible.  However, some level of autonomous action does seem feasible – today.

 

Coffee Drinkers be Encouraged

You may not know this about me but I love a good cup of coffee.  Fresh ground coffee beans, filtered water, perfect temperature … and I’m good to go first thing in the morning (with my whole grain cereal).   In the past, I often noted the health benefits of drinking coffee despite the seemingly negative view many health conscious individuals seem to hold.

Well, here’s another benefit:

Women who have at least one cup of coffee — or even five cups — daily may be reducing their risk of stroke by as much as 25 percent, new Swedish research shows.

And women who don’t drink coffee at all may actually be increasing their risk for stroke, the researchers noted.

That seemed clear-cut to me although I’d like to the same research repeated on men (I volunteer as long as I’m not in the control group).   Clear cut, that is, until I read the next sentence:

However, the researchers added, these findings are preliminary and should not cause any change in coffee-drinking habits.

Another set of “preliminary” findings strikes again … never-the-less, I think this does bode for coffee consumers.

Eat Whole Grain – the glycemic index is back, again

low-glycemic index

Some things seem to be reported in never-ending cyclic patterns.  This might be one of them but I tend to think that it is actually the journalists interpretation that brings about the feeling of deja vu rather than the researcher’s investigation.

It’s not necessarily the amount of carbohydrates you consume as it is the type (or the glycemic load), so says a “new study” recently reported by Reuters after being published in the American Journal of Clinical Nutrition:

How many carbs you eat might be less important for your blood sugar than your food’s glycemic load, a measure that also takes into account how quickly you absorb those carbs.

That’s the conclusion of a new study of healthy adults, which questions the way people with type 1 diabetes determine how much insulin they should take before meals.

Well, measuring how fast carbohydrate is absorbed has been around for a long time and we’ve been avoiding simple carbohydrates in preference to whole grain cereals and complex carbs as long as I can remember.  Perhaps I’m missing something or the actual research was under-reported but there is a reason I’m eating the 7-grain cooked cereal in the image above rather than corn flakes – the difference in glycemic index!

Never-the-less, any study that can help educate us on the damaging impact of post-prandial variability has value and perhaps a read of the research as reported rather than interpreted will add additional insight.

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How to begin and enjoy an exercise program

Begin and enjoy and exercise programOver the past six months I’ve adopted an exercise routine that has helped me reach a few but very significant health related goals, not the least of which is weight loss.  This time around I’ve been more consistent and actually look forward to my (almost) daily workout.

Exercise doesn’t have to be drudgery to burn calories, improve cardiovascular health and stamina and provide a much need outlet for stress.

I’m not a fitness guru or a health provide but I do have a few tips that helped me:

  • Join a convenient health club close to home – this was a significant reason why I’ve been able to succeed.  In this demanding age of overtime and activity, convenience saves driving time and encourages greater consistency.
  • Starting out, avoid over-exertion – nothing kills an exercise program like soreness and exhaustion.  You may be enthusiastic and anxious to get in shape but be patient and take it easy (at first)
  • Design an exercise routine that is enjoyable – I picked the treadmill instead of a stair master for interval training and use free weights in preference to machines.  Returning to the gym is so important that I prioritized those activities that I preferred above some that came highly recommended.
  • Keep a journal of exercises, weights, distances, times, etc. which enables weekly progress to be seen - even though I was out of shape, seeing regular gains in strength and stamina were motivational.  Later, looking back over months, I’ve been able to see significant improvement which would not have been remembered to the same degree
  • Set realistic and practical goals – I decided not to dream of becoming an olympic pole vaulter but instead strive to burn fat, improve stamina and gain strength in specific ways.  My goals were not tied to how I look but rather were aimed at improving health, managing blood sugar (and stress) and gaining energy so that I could be there for my family.
  • During aerobic training, listening to book-on-tape or watching movies – the time simply slips away when I have something engaging to watch of listen to.
  • Take guilt-free time off when needed – when you’re tired don’t feel guilty about resting – you need it.

On days in which motivation has been low, I went anyway and come back feeling refreshed and more energetic then when I left.   Exercise is key to managing diabetes and good health in general – it improves both physical and mental performance.  Further, discipline now provides freedom and opportunity to engage more activities later.

Infection, Diabetes and Septic Shock

Sepsis should be one of the most feared diseases facing individuals with diabetes.  I’m not sure that it is, probably because it is generally not well understood and is not reported in the same dramatic manner as other illnesses.

However, those diagnosed with sepsis have up to a ~16% mortality rate.  This rises 40% for those with severe sepsis and to over 60% for those with septic shock.  Unlike cancer, which is significantly less deadly (see the figure), sepsis can strike in a matter of days and takes its toll on the young and old alike.  To make matters worse, there is apparently not a clear diagnostic criteria until the disease has progressed.  Until then, clinicians look for two or three indication that are often qualitative.  And, every hour that treatment is delayed carries a 7% increase in mortality.

What is sepsis?  It is the overwhelming response of the body to an infection.  It is the body’s deady response to infection or injury.

I once attended a talk in which the presenter described the body’s immune system as a booby-trap that is set to self-destruct when an intruder enters its premises.  The infection is the intruder and the response of the body’s immune system is what actually causes the deadly blast.

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Ultra Long Acting Insulin – Degludec – Three Times per Week

We’ve been hearing about Novo Nordisk’s Ultra Long Acting Insulin, Degludec, as a result of the series of preliminary studies that were published last year.

Now a more comprehensive investigation, conduced in India, Canada, US and South Africa, has been completed which compared the insulin to Glargine (or Lantus).  A significant difference between the treatment protocol was the frequency of injection with Glargine requiring a daily administration while Degludec was taken every 48 hours.  However, the total daily dose (TDD) administered was the same for each.

Investigators found Degludec to be equialent to Glargine in terms of effectiveness (similar reductions in HbA1c).  The duration of apparently consistent insulin action is intriguing and I’d like to see a plot comparing the pharmacokinetics of the two insulins.

At last year’s European Association for the Study of Diabetes (EASD) annual meeting, the following was presented:

Despite the poor scaling and 24 rather than 48-hour x-axis, the concentration-time profile is flat.

Novo Nordisk spokesperson reportedly told WebMD that the company plans to seek approval later this year to market the long-acting insulin in both the U.S. and Europe.

So here’s the question…. not knowing the cost of Degludec, let’s just assume it’s more expensive.  If you had to pay more for Degludec but were able to inject every other day would you?

My Top Reasons for Eating Breakfast – and why you should too

Late last year I had a rough visit with the doctor. Rough because he pointed out the blatant health risks in the bluntest of terms associated with my eating habits and resulting BMI. Needless to say, he made an impact and I changed, lost weight and have adopted a new lifestyle.

breakfast is esstentialAmong several modifications to my daily habits is a return to breakfast. My fast pace and stress filled lifestyle gave rise to the coffee-on-the-go morning meal which inevitably made me irritable and starved by noon.

Doc told me to eat a large breakfast and I’ve followed his advice.

Having thought, read and acted upon doc’s advice, I’d like to share with you my top reasons for eating breakfast:

  • Stops impulse binging and overeating as a result of hunger and craving – no more mid-morning hypo, fast food cravings. Instead I eat an equally healthy lunch
  • Enables normal metabolic rate and activity – the body needs fuel and when it doesn’t it begins to slow down calorie consumption. Breakfast gets the metabolism up and running and burning calories at a normal rate.
  • Maintains a normal insulin response — studies indicate that skipping meals leads to hyper insulin response when calories are later consumed, which in turn encourages fat accumulation
  • Provides energy when you first need it — I need energy first thing in the morning and am now able to hit the ground running
  • Gives clarity of thought – I’ve experienced a noticeable difference and an improvement in concentration and efficiency
  • Gives Essential nutrients — the nutrients that are bypassed by skipping breakfast are essential to good health
  • Lower cholesterol, which reduces the risk of heart disease as suggested by researchers
  • Satisfies hunger- I always said I’m not hungry in the morning – well, now that I’ve adopted healthy eating habits I am. No more late night snacking leads to a healthy appetite in the morning
  • Time for Morning Contemplation – taking time out first thing in the morning is enjoyable and provides an opportunity to think, pray and prepare for the rest of the day
  • Family time – breakfast has increase the time I spend with my family

As I mentioned above, this has made a big difference in my health and daily routing, not the least of which is weight loss.  I’ll detail some of my other changes in future posts but hope that this one will encourage my friends to consider breakfast as an essential to the start of each day.

David Broder

Sadly, award winning columnist David Broder has past away due to complications related to diabetes (type 1). Broder was 81.

To most of us, Broder needs no introduction. Since the 1960s he profoundly influenced political journalism to the point that some say he defined the practice. He won the Pulitzer Prize for his coverage of Watergate and was revered by his colleagues at the Wasington Post.

Few realized Broder struggled with diabetes until a 2009 interview in which he described his experience of losing toes for an untreated foot infection.

Our condolences to David’s friends and family.

The Cure – devices, transplants, stem cells and stopping beta cell attackers

I’m a proud techno-geek.  As a result, when I think about diabetes I tend to gravitate to technology oriented device solutions.  An Artificial Pancreas, a non-invasive blood glucose meter and interchangeable/inter-operable pumps and meters.

And, I like data, lots of data.

While technology is very important, the holy grail of diabetes research is not the future medical device with Star Trek capability unless it is able to promote and bring about a cure.

Pancreas and islet transplants have benefit individuals but have not yet provided a treatment that is worth the risk for most individuals.  And, even if the risks were mitigated, the lack of suitable donors is another impediment.

To me, the ideal is the development of implantable islets from adult stem cells take from the same individual who will receive them.  Rejection of the islets would be minimized and the us of immunosuppressive drugs, I would guess, could be minimize.  In short, Autologous Stem Cell Therapy Transplant requiring no immunosuppression

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New drug uses SGLT2 inhibition – excess glucose kidney excretion – to lower glucose

This is interesting, perhaps even exciting because it represents an innovative way to manage diabetes independent of insulin (press release emailed to me this AM):

Bristol-Myers today announced that the U.S. Food and Drug Administration (FDA) has accepted for review a New Drug Application (NDA) for dapagliflozin, an investigational compound for the treatment of adults with type 2 diabetes mellitus. A Marketing Authorisation Application (MAA) for dapagliflozin has also been validated by the European Medicines Agency (EMA). The NDA and MAA submissions for dapagliflozin were filed in December 2010. The Prescription Drug User Fee Act (PDUFA) goal
date for the FDA is October 28, 2011.

The U.S. and European submissions included data of up to two years in duration from a global development program involving approximately 6,000 individuals in 40 clinical studies. In accordance with FDA guidelines, the U.S. application also includes data assessing the cardiovascular safety of dapagliflozin in adults with type 2 diabetes.

If approved, dapagliflozin would potentially be the first in a class of novel agents for diabetes that inhibit sodium-glucose cotransporter-2 (SGLT2), a specific target located in the kidney. Through this mechanism, dapagliflozin is designed to help control glycemia independently of insulin pathways, leading to the excretion of excess glucose and associated calories in the urine.

How does it work?

The renal SGLT system plays a major role in overall glucose balance in the body. Normally, the kidney filters ~180g of glucose each day, and virtually all is reabsorbed back into circulation. Glucose reabsorption occurs in the proximal tubule of the kidney via the SGLT system. Selective inhibition of SGLT2 by an insulin independent mechanism of action is designed to lead to the excretion of excess glucose and associated calories in the urine, thereby lowering blood glucose levels.

I’ll research and update later.  Comments?