Update on technologies, medicines and treatments

Abstract

We know that being more active is important for preventing type 2 diabetes and managing blood glucose levels, but a recent study has looked specifically at walking and whether the speed you move can have an impact on your risk of developing type 2 diabetes.¹

Researchers collected data from 10 prospective cohort studies undertaken in the United States, Japan and the United Kingdom. The duration of the studies was between 3 and 11 years. Walking speed was divided in to four categories—easy or casual (less than 2 mph), average or normal (2–3 mph), fairly brisk (3–4 mph) and very brisk or brisk/striding (greater than 4 mph).

People who walk at the average speed had a 15% lower risk of developing type 2 diabetes than those who walk at the easy/casual speed and those who walked at a fairly brisk pace had a 24% lower risk. Those who walked the fastest had nearly a 40% lower relative risk. They also looked at whether adjusting for total physical activity or time spent walking per day changed these findings, but walking at a faster pace still showed benefits for reducing risk, regardless of these factors.

The researchers pointed out some limitations to their study, as the different cohort studies did not all measure walking speed or diagnosis of type 2 diabetes in the same way. They also point out that participants with faster walking speed are more likely to perform more physical activity and have better cardiorespiratory fitness, greater muscle mass and better health status. But overall, they concluded that increasing the pace when you walk could be an extra boost for preventing type 2 diabetes, on top of just walking more in general.

Researchers at Texas A&M University have found evidence suggesting a connection between type 2 diabetes and Alzheimer's disease. In their study, which has not yet been published in a scientific journal, the researchers investigated how these two diseases are related by conducting experiments on mice. They discovered that a specific protein in the gut, called jak3, is affected by consuming a high-fat diet. When this protein is suppressed, mice experienced inflammation starting from the intestine, spreading to the liver and the brain. These mice then displayed symptoms similar to Alzheimer's, such as memory loss.

The researchers propose that managing or avoiding type 2 diabetes could potentially reduce the risk of Alzheimer's disease. Previous studies have shown a link between diet, lifestyle and the development of both diabetes and Alzheimer's. Additionally, the researchers found that the jak3 protein is associated with a condition called leaky gut, which causes chronic inflammation and may contribute to the development of type 2 diabetes, as well as impair the brain's ability to clear toxins, leading to dementia-like symptoms.

By adopting a healthy diet and managing blood sugar levels, it might be possible to prevent or mitigate these diseases. This could involve starting healthy eating habits early or making lifestyle changes to prevent the onset of high blood sugar or reverse prediabetes. Around 81% of people with Alzheimer's also have type 2 diabetes, with the risk of dementia increasing with earlier onset of diabetes. Some researchers even refer to this link as ‘type 3 diabetes’. Experts believe that high blood sugar levels can damage the brain over time, increasing the risk of Alzheimer's. Treating type 2 diabetes involves preventing it from causing other health issues, such as heart disease and obesity.

In the United States, doctors recently performed groundbreaking surgery where they transplanted a pig's kidney into a person for the first time. This was possible because scientists changed the genetic makeup of the kidney and used a new antirejection drug. This is not the first time a pig organ has been used in a human. In the past, people who had transplants of pig hearts only survived for a few months.

The recipient lives with diabetes and high blood pressure. He had a human kidney transplant before, but it stopped working last year. He decided to try the pig kidney transplant because he thought it might help him and give hope to others who need transplants too. The surgery was allowed under a special rule called compassionate use by the FDA. This rule lets people with serious illnesses try new treatments when there is nothing else that can help them.

Transplantation from non-human species, called xenotransplantation, uses advanced biotechnology. CRISPR was used to modify the genetic structure of the kidney, removing potentially harmful pig genes and adding certain human genes to improve its compatibility. They also inactivated porcine endogenous retroviruses in the pig kidney to eliminate any risk of infection in humans, which were the cause of death in one of the earlier transplants.

The as yet unlicensed drug used to prevent rejection is tegoprubart alongside another off-label use of ravulizumab. These drugs are not commonly used yet, but they are being tested to see if they can help people receiving organ transplants.

Doctors are excited about this new approach because of the shortage of donated human kidneys, leaving many people on dialysis for years. If it can be shown to be safe and effective, xenotransplantation might be a solution to this problem, but further research and long-term review will be needed to make it a reality.

A new system for managing insulin in people with type 1 diabetes, controlled by a smart computer program, might work just as well as the traditional method based on equations, according to research from the University of Virginia. With continuous glucose data, they are teaching an artificial intelligence neural network to act as a closed-loop insulin delivery system called a Neural-Net Artificial Pancreas (NAP).

To make this work, researchers train the neural network using a lot of data covering all the possible actions an automated insulin delivery system might take. They have already developed one of these smart artificial pancreases and are testing it in two clinical trials approved by the FDA. In one trial, they compared it to a typical insulin delivery method using a closed-loop system.²

During the trial, participants wore a device controlled by either the smart artificial pancreas or the traditional algorithm for 18 h. Then they switched to the other method. The results showed that the smart artificial pancreas performed similarly to the traditional method, keeping blood sugar levels in check. There is also another trial where participants used the smart artificial pancreas continuously for 5 days. The results were promising, showing that it kept blood sugar levels stable even without strict meal and activity guidelines.

Overall, the smart artificial pancreas seems to be a promising tool for managing insulin in people with type 1 diabetes. It might even work better on small devices with limited processing power. This could be a step towards fully automated insulin management systems in the future.

New data suggest that the level of HbA1c can predict the likelihood of adolescents with overweight or obesity developing type 2 diabetes.³ Over a 10-year period, researchers looked at a large group of young people in California. They found that while the overall rate of type 2 diabetes was low among adolescents with overweight or obesity, the risk increased for those with higher HbA1c levels.

The study reviewed data on 74,552 children and adolescents aged 10–17 years with overweight or obesity. Compared with a baseline HbA1c of less than 37 mmol/mol (5.5%), risk increased 9-fold for HbA1c of 41 mmol/mol (5.9%–6.0%), 23-fold for 43–44 mmol/mol (6.1%–6.2%) and 72-fold for 45–46 mmol/mol (6.3%–6.4%).

For those in the lowest HbA1c ranges of 39–40 mmol/mol (5.7%–5.8%), the annual incidence of type 2 diabetes was only 0.2% which is much lower than in a similar group of adults. The authors suggested that these adolescents would probably benefit from some form of lifestyle intervention but probably did not require annual screening, whereas those at HbA1c over 42 mmol/mol (6%) should be screened regularly.

In total, 698 people of the group developed diabetes during the study, with almost 90% of them being diagnosed with type 2 diabetes. On average, it took about 3.8 years from when they first entered the study until they were diagnosed.

The study also found that the risk of type 2 diabetes increased with greater obesity severity. Additionally, there were differences in risk based on gender and ethnicity, with women and certain ethnic groups showing higher incidence rates.

This suggests that we should be checking HbA1c on young people with overweight or obesity to try and identify those most at risk of going on to develop type 2 diabetes so that actions to prevent its onset can be taken early.

Insulin icodec is a new kind of insulin that only needs to be injected once a week. It is being reviewed by the European Medicines Agency but is currently only licensed in Canada. The hope is that this might help people with type 2 diabetes self-manage more effectively and feel more satisfied with their treatment, as they do not have to inject themselves as often. This study aimed to find out if once-weekly insulin icodec is as effective and safe as other types of insulin for managing type 2 diabetes.⁴

The study was a meta-analysis of all the studies, where people with type 2 diabetes were given insulin icodec and compared it with other types of long-acting analogue insulin in randomized controlled trials. They reviewed five clinical trials involving 3764 people.

They found that once-weekly insulin icodec helped reduce HbA1c, slightly more than other insulin types did. More people using insulin icodec achieved a target HbA1c level of less than 53 mmol/mol (7%) compared to those using other insulin types, and they did so without experiencing low blood sugar levels as often. The time spent in the target range for blood sugar levels was similar between insulin icodec and other types of insulin. Overall, the side effects and adverse events related to insulin were similar between insulin icodec and other types of insulin.

They concluded that once-weekly insulin icodec seems to be better at reducing HbA1c levels and helping people reach their blood sugar targets compared to other types of insulin that need to be injected daily. There were not any major safety concerns regarding low blood sugar levels or other side effects.

In February, the FDA issued a warning against the use of smartwatches or smart rings that claim they can measure blood sugar levels without pricking the skin and drawing blood.⁵ They stress that no such devices have been approved yet, and using them could be risky. The same is true in the United Kingdom, where there are currently no MHRA-approved non-invasive monitors. These devices are different from the ones that display data on an app from approved glucose monitors that do require pricking the skin, like continuous glucose monitoring devices (CGMs).

The warning applies to any smartwatch or smart ring claiming to measure blood sugar without skin piercing, no matter who makes it. While big companies like Apple and Samsung, as well as startups such as Movano, in the United States and Afon Technology, based in Wales, are working on non-invasive blood sugar monitoring tech, it remains experimental. The danger of using these unapproved devices is serious because they could give inaccurate readings, leading people with diabetes to make wrong decisions on treatment or missing episodes of hypo- or hyperglycaemia.

These unapproved devices are being sold online and on social media, with many listings claiming to measure blood sugar, as well as other unlikely things like blood lipids and uric acid levels. A simple Google search found many of these devices available in the United Kingdom from about £39.99.

Some manufacturers try to get around rules by saying their products are not medical devices, such as one that says in large print ‘Say goodbye to blood collection. No pain and no needles’ and then in much smaller print adds ‘This product is not a medical product, the measurement data is for reference only, and cannot be used as a medical clinical diagnosis report’. If a device claims to diagnose, treat or prevent a disease or affect the body's function and it is not a drug, it falls under medical device regulations and needs appropriate approval.

The FDA, and Diabetes UK, would strongly advise against buying or using these smartwatches or smart rings, just because they are non-invasive.

Research from the New York Eye and Ear Infirmary of Mount Sinai suggests that a sophisticated AI system, known as GPT-4 from Open AI, can be as good as or even better than human eye doctors at diagnosing and treating conditions like glaucoma and retinal diseases.⁶ This AI system is trained on a huge amount of data, including text and images, and it could become a valuable tool for supporting eye doctors in making decisions about these conditions, which affect millions of people.

In their study, researchers compared the performance of GPT-4 with that of 12 eye specialists and 3 senior trainees from Mount Sinai. They asked them a set of common questions about glaucoma and retinal diseases and presented them with patient cases. The responses from both the AI system and the human specialists were then analysed and rated for accuracy and thoroughness.

The results showed that the AI system performed as well as or better than the human specialists in giving accurate and comprehensive medical advice. It was especially good at answering questions about glaucoma and providing advice on how to manage cases, while it was equally accurate but more thorough than humans in responding to retina-related questions.

According to Dr. Andy Huang, who led the study, this AI system has the potential to assist eye specialists by providing diagnostic support, particularly in complex cases or when there is a high number of patients. This could lead to quicker access to expert advice for patients and help doctors make more informed decisions about their treatment.

Although more testing is needed, this research suggests a promising future for AI in the field of ophthalmology, where it could improve patient care and lighten the workload of eye specialists.

A new computer program has been developed to help predict when patients in hospital might experience hypoglycaemia. This program, based on artificial intelligence, focuses solely on using blood sugar measurements taken from a finger prick test. According to a study presented at the Diabetes UK Professional Conference 2024, the program has shown to be very accurate in foreseeing hypoglycaemic events.⁷ The researchers also looked into which aspects of blood sugar levels were most important for predicting these events. They found that extreme and fluctuating blood sugar levels were the strongest indicators of potential hypoglycaemia.

Dr. Chris Sainsbury and his team from Gartnavel General Hospital in Glasgow, Scotland, spearheaded this study. They emphasized that preventing hypoglycaemia is crucial, as it can lead to serious health issues for patients with diabetes during their hospital stay.

The program analyses blood sugar data obtained from over 250,000 patients from routine tests and used it to calculate the likelihood of a hypoglycaemic event occurring within the next day or week. This information could help hospital staff intervene early to prevent such events.

Dr. Sainsbury and his team plan to test the program in different hospital settings to see how well it works in real-world situations. They hope that by identifying patients at risk early on, they can reduce the incidence of hypoglycaemic events and improve patient outcomes.

Over 1 billion people worldwide, including children, teens and adults, are living with obesity, making it a widespread problem. This number has been reached sooner than expected, mainly due to a shift from people being underweight to becoming obese, particularly in lower income and middle-income countries.

A recent study involving over 1500 researchers from various organizations analysed data from more than 220 million individuals across nearly 200 countries.⁸ They looked at both underweight and obesity rates, which are two different types of malnutrition harmful to health. Adults were considered obese if their body mass index (BMI) was 30 or higher, while children and teens were classified based on their age and sex.

The findings revealed that in 2022, nearly 880 million adults and 159 million children were living with obesity. Shockingly, obesity rates among children and teens have quadrupled since 1990, while rates among adults have more than doubled.

Interestingly, the analysis showed a decline in underweight cases in most countries, with obesity rates now surpassing underweight rates in two-thirds of the world. This transition has been particularly noticeable in low- and middle-income countries, with places like Polynesia, Micronesia, the Caribbean and the Middle East experiencing high obesity rates.

Surprisingly, countries typically associated with wealth, except for the United States, were not on top of the list for obesity prevalence. This rapid global shift towards obesity underscores the urgent need for action, particularly in reshaping food systems through effective public policies.

Experts emphasize the importance of addressing both obesity and underweight simultaneously through targeted policies. These policies could involve initiatives like promoting breastfeeding, taxing sugary drinks, regulating food marketing aimed at children and ensuring nutritious food availability in public places like schools.

Governments, communities and the private sector need to work together, guided by evidence-based policies, to tackle this issue effectively. It is crucial to monitor food manufacturers, ensure fair access to healthy food and prioritize public health over profits.

There have been some positive examples of policy changes globally, such as France's national nutrition plan and initiatives in South America regarding food labelling and taxation of unhealthy products. These efforts highlight the potential for impactful interventions that integrate healthy eating and physical activity promotion within communities. This worrying trend will also have an impact on the growing rates of type 2 diabetes worldwide.

A new recommendation from the International Diabetes Federation suggests using a 1-h glucose test to better detect people at risk of developing type 2 diabetes.⁹

The idea is that some individuals might have normal glucose tolerance based on tests like HbA1c or fasting glucose, but they could show abnormalities after having a glucose load. Dr. Michael Bergman, the lead author of the statement, explained that the 1-h glucose test is more sensitive in spotting these high-risk individuals early on.

This recommendation comes after a panel of 22 international experts reviewed the evidence and proposed a screening algorithm for identifying those with ‘intermediate hyperglycaemia’ and type 2 diabetes. The process involves using a validated questionnaire to identify high-risk individuals, followed by a 1-h glucose test for those flagged as high risk.

If the 1-h glucose level is above a certain threshold, individuals are considered to have intermediate hyperglycaemia or even type 2 diabetes, depending on the level. Lifestyle changes and further evaluation are recommended for those identified as high risk. The recommendation is based on research showing that the 1-h glucose test is a better predictor of future diabetes and related complications than other tests like the 2-h oral glucose tolerance test. However, some experts express concerns about the logistics of implementing this test in busy clinical settings and question its impact on improving outcomes.

The term ‘intermediate hyperglycaemia’ refers to a state between normal blood sugar levels and diabetes. This recommendation aims to catch individuals in this intermediate state early to prevent progression to diabetes.

While some researchers support the use of the 1-h glucose test, others argue that focusing on lifestyle interventions and managing risk factors like obesity and hypertension may be more effective in preventing diabetes. However, the International Diabetes Federation believes the 1-h glucose test is a simple and cost-effective screening tool, especially for middle- and low-income countries.

Overall, the hope is that organizations like the American Diabetes Association and the World Health Organization will adopt this recommendation to improve diabetes screening and prevention efforts.

Data from a study presented at the Diabetes UK Professional Conference¹⁰ suggest that a special device called EndoBarrier can help improve various health markers in people with stubborn type 2 diabetes and obesity.

The study, led by Dr. Bob Ryder from Birmingham City Hospital, showed that after 1 year of having the EndoBarrier implanted in their gut, patients experienced weight loss, better control of blood sugar levels and improvement in fatty liver conditions. Even after 2 years of removing the device, 80% of patients continued to see significant improvements in their health.

EndoBarrier is a thin sleeve placed in the first part of the small intestine, preventing some food from being absorbed. This triggers changes in how the body processes glucose and nutrients. Unlike permanent weight loss surgeries, EndoBarrier is reversible and involves a relatively simple procedure. During the study, patients followed a special diet after having the device implanted. They gradually returned to regular food over several weeks. When the device was removed after a year, patients had lost an average of about 37 pounds, and their blood sugar levels had dropped significantly.

Two years after the removal, more than half of the patients maintained their weight loss and blood sugar improvements. Some even stopped needing insulin. However, about 20% of patients returned to their previous health status. Despite its benefits, some patients experienced side effects like gastrointestinal issues, but they recovered fully after the device was removed.

In the days before the development of human insulin in the late 1970s, all insulin was derived from animal pancreases, mainly pigs and cows. Scientists then used human DNA spliced into bacteria, such as E. coli, to create the first ‘artificial’ human insulin.

Now scientists from the University of Illinois Urbana-Champaign and Universidade de São Paulo, Brazil, have come up with a groundbreaking way to produce insulin: a cow that has been gene-edited to produce human insulin in its milk. Matt Wheeler, an animal sciences professor at the University of Illinois and the lead author of a study published in the Biotechnology Journal, explained that cows are natural protein factories. By adding a piece of human DNA to the embryos of 10 cows, they created a calf in Brazil that could make insulin in her milk.¹¹

To their surprise, not only did the cow produce a type of insulin precursor called proinsulin, but she also converted it into active insulin—and in large quantities. Just 1 L of milk contained enough insulin for thousands of doses.

The team plans to continue their work, hoping to improve the process even more. They are considering using a gene-edited bull to create a whole herd of insulin-producing cows. The authors believe that this method could eventually outperform other ways of making insulin, like using yeast or bacteria. But to make it work on a large scale, they will need facilities to collect and purify the insulin, which will require approval from health authorities.

Despite these challenges, they envision a future where a small herd of these special cows could supply insulin for an entire country. And with a larger herd, they could meet the needs of the whole world in just a year. So perhaps it's the return of the cow for insulin production?