The heart of the American Diabetes Association's huge yearly Scientific Sessions conference is of course reams of new research. So naturally, last week's 79th annual event – held in an unseasonably hot downtown San Francisco – featured updates on loads of new studies from around the country and world, now ready to be presented to medical peers.
The poster hall alone displayed a whopping 2,000+ research posters. In past years, the ADA handed out guides the size of phone books to all attendees that listed details on every poster and its authors. But this year, they eliminated the physical book and instead used their mobile app and online 2019 program to feature all that info in searchable format.
The numerous official categories include: diabetes complications, education, exercise, nutrition, psychosocial, clinical therapeutics, healthcare delivery/economics, pregnancy, pediatrics, epidemiology, immunology, insulin action, obesity and more.
Needless to say, it's a lot to soak in.
New Diabetes Research Presented at #ADA2019
You can follow attendees' reactions to many of the presentations by perusing posts with hashtag #ADA2019.
We'd like to share some of the topics that most caught our eye:
Delaying the Onset of Type 1 Diabetes
One of the most-discussed studies presented at this year's conference was from the ongoing nationwide study TrialNET, showing that in those who are at "high-risk" for type 1 diabetes (i.e. siblings and other family members), the use of immunosuppressant drugs can delay the onset of T1D by at least two years (!).
This NIH-funded study (a direct result of Special Diabetes Program funding) is the first to show clinical evidence that T1D can be delayed by two or more years using any drug, and it involved using a medication called Teplizumab, an anti-CD3 monoclonal antibody. Researchers enrolled 76 participants ages 8-49 who were relatives of type 1 PWDs (people with diabetes) who showed at least two types of diabetes-related autoantibodies and abnormal glucose levels -- indicating they may be on the pathway to developing T1D. The early interventions worked.
“The difference in outcomes was striking. This discovery is the first evidence we’ve seen that clinical type 1 diabetes can be delayed with early preventive treatment,” said Dr. Lisa Spain at the NIH's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). “The results have important implications for people, particularly youth, who have relatives with the disease, as these individuals may be at high risk and benefit from early screening and treatment.”
There are limitations, of course, and the study authors caution the D-Community to not go down the rabbit hole of describing this as a potential cure for T1D. It may lead to more discoveries on how the disease progression happens in certain people and new opportunities for early intervention, but quite a bit more research is needed before broader implications can be understood.
Delaying Type 2 Diabetes and Reducing Complications
On the topic of delaying diabetes, there was big research on the T2D front showing that when the onset of type 2 is delayed by six years, that leads to huge reductions of risk for cardiovascular and microvascular complications. The study “Early Progression to Diabetes or Regression to Normal Glucose Tolerance” involved a 30-year follow-up to a China-based study, and showed that those who delayed their onset were 30% less likely to develop stroke, heart failure, or myocardial infarction, and 58% less likely to develop complications such as neuropathy, nephropathy, or severe retinopathy during the next 24 years.
Restoring Beta Cell Function in Type 2 Diabetes
In what's dubbed the DiRECT (Diabetes Remission Clinical Trial) study, researchers also found that in early type 2, insulin-producing beta cells are not damaged and "irreversibly lost" as previously thought. In fact, they can be restored to normal function. Almost 300 patients were enrolled, showing that a commercial weight loss plan followed by dedicated weight loss management allowed 36% of the participants to go into T2D remission and keep that up for two years. Interestingly, one of the lead UK study authors, Dr. Roy Taylor, says this may indicate a new focus for type 2 diabetes management and messaging that the medical community should embrace: weight loss is a way to better handle the rising T2D epidemic globally.
Long-Term Success with Islet Cell Implantation
The Diabetes Research Institute (DRI) out of Florida announced results from a new study in which five people who'd received islet transplants into the liver 6-17 years ago were still completely able to go without insulin injections. Notably, this research used CGM during the trial to keep tabs on glucose levels -- something that's becoming common practice in this new era of highly accurate continuous sensors. Of course, not everyone who receives a transplant is able to go that long independent of insulin, the study authors pointed out. But it remains an important and impressive finding that a decade or more is possible, showing that islet transplantation has quite some potential to succeed.
Glucose "Time in Range" Research
Many in the D-Community have been arguing for years that beyond A1C, the three-month average glucose measure that is currently gold standard, Time-in-Range (TIR) possibly matters more. TIR is of course time spent within a healthy glucose range throughout days and weeks, when patients are not experiencing overly High or Low glucose levels. While many organizations and clinicians are embracing TIR these days, we have a long way to go in making it an established measure that researchers, industry and regulators accept into their processes. But the TIR concept is most certainly gaining ground, as witnessed by its appearance in so many scientific posters and talks at #ADA2019. Two stood out specifically:
- New TIR Clinical Recommendations: Presented by the International Consensus on TIR, a panel of global diabetes experts, these guidelines lay out different TIR glucose range goals for different populations of people with diabetes (absent any more personalized, individual care from HCPs). The stated goals are 70-180 mg/dL for those with T1D and T2D; 63-140 mg/dL for pregnant women with diabetes, with a set of different targets depending on the time or amount of CGM readings from the expectant mother; and more conservative ranges for those who are older or more high-risk for hypoglycemia. The guidelines can be viewed online in the journal Diabetes Care.
- TIR for Type 2: The TIR measurement is generally dependent on CGM technology and focused on the type 1 universe. Implications for the type 2 community hadn't really been studied, until now. A research poster presented by Verily (formerly Google Life Sciences that's working with Dexcom on next-gen CGM tech) and Onduo (the joint Sanofi and Verily venture), addressed this topic. In a reverse move, researchers looked at how A1C levels might predict TIR for those living with type 2. The findings show that the two metrics are closely related, but the predictive nature is more difficult because T2s don’t have the same type of Highs and Lows that T1 PWDs do.
Fear of Hypoglycemia
Yep, people whose lives depend on insulin live with a fear of going Low... No kidding, right? Research presented by the T1D Exchange showed that there's an important need in the D-Community to screen for anxiety, depression and distress related to hypoglycemia experiences and that healthcare providers need to talk more with their patients about this issue. The study showed that active avoidance of hypos led to higher A1Cs and diabetes-related comorbidities, and those are outcomes that can be changed.
Danger, High Blood Pressure!
This one is a bit scary, especially for teens with T1D. A study found that despite all the fear of high blood sugars, higher blood pressure levels are just as dangerous for teens with T1D in developing heart disease. Actually, the risk doubles when BP levels are at or greater than 120/80 mmHg.
This Pittsburgh Epidemiology of Diabetes Complications (EDC) study included over 600 T1Ds diagnosed at 17 or younger, who were seen within a year of diagnosis between 1950-1980 at Children’s Hospital of Pittsburgh. The study followed them for a full quarter-century, looking at BP goals for minimizing heart risk. “Our researchers were intrigued by the findings suggesting that blood pressure and glycemia are similarly important for cardiovascular risk prediction in this type 1 diabetes patient group,” said lead study author Dr. Jingchuan Guo. “Since blood pressure control is likely to be as important as glucose control for cardiovascular risk prevention in people with type 1 diabetes, the initial treatment focus should be on glucose control, when HbA1c is very high, but as HbA1c approaches the high-normal range, an increasing focus on blood pressure becomes critical.”
Mental and Psychosocial Impacts of Diabetes
This has become a much more common theme in the SciSessions over the years, and for 2019 it was a focus of several key sessions. One of the most heartfelt was a discussion panel including several well-known patient advocates that actually focused on the realities of living with diabetes complications: "The Emotional Toll of Diabetes Complications." But really, as one of the panelists noted, you could've just taken "complications" out of the title and left it as "The Emotional Toll of Diabetes." The patient panelists certainly brought a raw perspective to the healthcare professionals in the room. We hope they were listening with their hearts as well as their minds.
A research poster presented by the University of Utah covered a unique study that examined communication between partners about T1D, and impacts on the relationship and psychological health of both partners. Nearly 200 couples filled out a survey on measures of relationship satisfaction and depressive symptoms, and then participated in an 8-min video-recorded discussion about T1D in their lives.
Naturally, the researchers hypothesized that more "destructive communication" (e.g., criticism) would be associated with poorer outcomes (i.e., lower levels of relationship satisfaction and higher levels of depressive symptoms), and vice-versa. While this was true to some extent, it turned out that the information provided in the survey was not always consistent with the way the couple appeared to be communicating on camera. Oh, the complexity of human relationships!
In any case, we're heartened to see this research and the authors' recognition that "understanding how persons with T1D and their partners perceive communication around diabetes provides a window into their individual and relationship well-being."
Talking Food and Diabetes
Of course there were many sessions focused on nutrition and food-related topics, including numerous mentions of the ADA's Nutrition Consensus Report released earlier this year.
One well-attended session was led by CDE and fellow T1D Patti Urbanski, addressing the benefits of a low-carb diet for adults with all types of diabetes (T1, T2, and Prediabetes). She discussed the evidence from five clinical trials examining low-carb eating and a systematic review of health outcomes. This is an especially big deal given that ADA as an organization has historically been slow to recognize the value of low-carb eating for people with diabetes, continuing to officially recommend high levels of grains and starches in its food pyramid until at least 2008.
While Urbanski's session was powerful, her concluding statement on the research was a bit lukewarm: “The evidence suggests that a very low-carbohydrate diet may have health benefits for adults with type 1 diabetes, but clinical trials of sufficient size and duration are needed for this and all eating patterns.”
Debating Diabetes Pregnancy Care
Should women with diabetes or prediabetes be induced at 38 weeks, no matter what? This was a lively Pro and Con discussion led by University of Michigan researcher Jennifer Wyckoff. Much of the talk centered around information from a
That was one of many pregnancy-related sessions and research posters presented at ADA. New research from T1D Exchange showed a general decrease in A1C levels for pregnant women these days, compared to six years ago. One of the likely causes is that more women with T1D are using CGMs during pregnancy. In 255 pregnant women followed between 2010 and 2013, and then from 2016 to 2018, A1C levels dropped from 6.8% to 6.5% while the number of women using CGM doubled. This study brought up discussion about the January 2019 news that the British healthcare system NHS will provide CGMs to women with T1D during pregnancy, beginning in 2021.
It's also notable that earlier this year the ADA unveiled updated diabetes and pregnancy guidelines outlining everything from BG and blood pressure targets, to medications to avoid during pregnancy, to lactation management and postpartum care.
Vitamin D and Type 2 Diabetes
The effects of vitamin D on people with diabetes were mentioned in no less than nine research posters.
The main session on this topic covered the big nationwide D2d study, a large-scale clinical trial that investigated whether vitamin D supplementation helps prevent or delay type 2 diabetes in adults who are at high risk. The study included a whopping 2,423 participants from 22 locations across the US. But the results, published during the ADA conference, were unfortunately rather "meh."
The researchers note: "We found that among people with prediabetes and sufficient vitamin D level, vitamin D supplementation at 4,000 units per day did not significantly reduce the risk of diabetes."
Still, they insist that taking vitamin D capsules is a good choice for anyone with diabetes:
"These findings do not change the need for all individuals to meet the vitamin D requirements set out by the Institute of Medicine. Adults up through age 70 need 600 units of vitamin D intake daily and those older than 70 years need 800 units daily. People get vitamin D from food and sunlight. However, very little vitamin D is found in food, and your body’s ability to make vitamin D from sunlight depends on many factors, including your exposure to the sun, where you live, the time of year, and the time of day. Supplements can be used to help you meet the daily requirement."
Show Us the Fish!
One of the quirkiest presentations came from Dr. Olga Gupta of the University of Texas Southwestern Medical Center, who did a study showing that caring for pet fish can help adolescents with higher A1Cs who weren't previously managing their diabetes as well as they should be. She found that A1Cs improved by a half percentage point in those who took care of their pet fish, in association with managing type 1 diabetes.
The routine: Upon waking up in the morning, teens fed the fish one pellet and also checked and logged their own glucose levels; the same bedtime routine, and once a week they changed the fishtank water and also reviewed their BG logs with a healthcare provider. It was a fun pilot study of using an "Innovative Simple Intervention to Improve Adherence" that Gupta noted could be easily scaled to struggling T1D teens and young adults everywhere.
This wasn't the only mention of fish at this year's conference, btw. There was "Lessons from Zebra Fish," a joint ADA/EASD symposium exploring "Zebrafish is an attractive model system for studying metabolic diseases because of the functional conservation in lipid metabolism, adipose biology, pancreas structure, and glucose homeostasis."
Fish also popped up in a half-dozen other sessions including one on intake of fish and related nutrients on obesity in Japanese patients with type 2 diabetes, and a study of the impact of fish oil on diabetes prevention. A recent study out of Utah looked at the potential of marine snail venom to improve insulin effectiveness in humans with diabetes. Whoa!
And in the big wrap up session on science advancements in the past year, there was mention of a study on insulin resistance in dark-dwelling cavefish who live at the bottom of the ocean where nutrients are limited. Researchers found those fish have higher fasting glucose levels, which could have implications for human studies on ways to improve insulin resistance. Future research may involve taking these cavefish into higher-up waters to gauge the impact, and exploring how that knowledge might translate into human-based interventions. Pretty mind-blowing…
Thank you, Fish!
Translating the Science...
While all of this clinical research is fascinating and important, there's the question of real-world impact.
In that "year in review" highlights session towards the end of the ADA conference, Dr. Daniel Drucker of Mt. Sinai Hospital expressed concern about a growing gap between all these clinical studies and practical, clinical care being delivered to patients. "The research is not being translated effectively," he said.
We see that too -- not just on the access and affordability points, but even on the basics of what new science and "clinical guidelines" really mean to those of us living with diabetes "in the trenches."
Drucker was extremely frank: "We are fascinated to develop new meds, but we aren’t doing what we need to with what we have now. To me, that’s the biggest gap… We aren’t successful with the very effective interventions and treatments we have today. That's a big problem for our field and for the diabetes community."
At the end of the day, we're reminded that the ADA Scientific Sessions is indeed a conference by and for medical professionals – something we patients need to keep in mind. That was apparent in some of the smaller exhibitors especially, such as a booth selling customized lab coats for HCPs.
Meanwhile, the ADA is making an effort to better connect with the patient community through its recent rebranding effort. Here's hoping that helps the organization get a clearer picture of what it takes to grapple with diabetes IRL, every day of your life.