Yada Yada : World Diabetes Congress Report

Hi again!

Fresh back in smoky Melbourne, writing to you today with a wrap-up from last week’s enormous World Diabetes Congress in Cape Town which I attended, thanks to a generous travel grant from the International Diabetes Federation.

This is an incredibly brief overview of some very complex topics (hope I don’t offend anyone whose 10 years of research is now just 10 words!). Have included a few of my happy snaps as well.

I could write a page or more on every dot point below, and then many more on the experience and general impressions of a mind-blowing week, and I have notes and memories to do so! But I don’t have time to write up every single thing, sadly, though I do want to share some more of this incredible experience with you.

Please let me know what you want to hear more about, if anything. Hit reply and ask questions, tell me what you’re interested in, and I’ll happily expand on the bits that are most popular with a few more detailed articles.

If you live in Melbourne, you have a funner option for both of us - come along to the Christmas party on Wednesday 20th in South Melbourne – I am bringing all my photos and collected goodies from the conference for you to check out!

My report today is split into two sections – New Stuff (OK, so not all of it's incredibly new to those of us who live with D, but new in the sense that the official world of D has gathered evidence and all of that which is important too!) and then some not necessarily new but still Interesting Stuff.

Highlights of the World Diabetes Congress

Highlights of the Congress for me included the following bits of news and developments. The researcher, doctor, group whose presentation in which each issue appeared is in the brackets.

Islet transplantation continues to progress rapidly despite the buzz having died down in recent years – there are many barriers but they are apparently all surmountable!! (James Shapiro, Edmonton, Canada)

Stem cells. We now know the full process by which real stem cells actually develop into cells that will produce insulin in response to glucose levels - this is a major breakthrough towards us being able to force stem cells to do this in a lab. (Wendy McFarlane, Brighton, UK)

Hypos during exercise may be reduced by doing a 10-second sprint during and before moderate intensity exercise. (Vanessa Bussau and Tim Jones, Perth)

Guidance for exercising with Type 1, tables recommending carb loadings and insulin reductions needed for different types of exercise in different sized people have now been calculated. Also, normal or target blood glucose range during exercise should be considered 4.5 – 10 mmol/L. (Michael Riddell, Toronto, Canada.)

Hypo unawareness – 3 mmol/L seems to be the important level. Reducing drops below 3 has been proven to restore hypo awareness. (Stephanie Amiel, London, UK)

Hypoglycaemia is getting better understood: Type 1s have been shown to lose our natural Glucagon response to hypos after 5 years and epinephrine, the other hormone that should kick in when sugars drop low, is also impaired in Type 1s. It’s thought hypo unawareness happens because the stress response when the body has to fix a hypo is toxic and therefore unawareness is a type of protective mechanism. (Rory McCrimmon, New Haven, USA)

If you Smoke, and have an Hba1c of 6.5, you may as well have an a1c of 9. (Denis Daneman, Toronto, Canada)

Teenage years misunderstood: Parents and health professionals think diabetes gets easier as we get older (from childhood through teenage years to adulthood) but teenagers themselves perceive their quality of life to be declining at this time. (Hvidoere Study Group, Denis Daneman, Toronto, Canada)

Adolescents who say their parents are over-protective have worse diabetes control. (Hvidoere Study Group, Denis Daneman, Toronto, Canada)

Adelaide's very own DiabetesCounselling.com.au also featured at the Congress, with Helen Edwards receiving an IDF grant to attend, and presenting a poster about the evaluation of her online counselling service. Great to see Aussie innovation being recognised!

Nicole Johnson, Miss America 1999, insisted her now husband wear a pump and test his sugars and carb count for 3 days before she would answer his proposal of marriage!

In 25% of pregnant women with Type 1 (Nicole Johnson being one of them) the pregnancy growth factor is so powerful it can promote islet cell regeneration. (Lois Jovanovic, USA)

Doctors and nurses significantly over-estimate emotions like how afraid, angry and overwhelmed their patients are by diabetes, and under-estimate their willingness to take a more active role in their management. (William Polonsky, USA)

Family factors are a stronger predictor of A1c in children than gender, age or insulin regime (Chas Skinner, UK, for the Hvidoere Study Group)

Transferring responsibility for diabetes management to a child early is associated with worse self-care and more DKA (Chas Skinner, UK, for the Hvidoere Study Group)

“Brittle diabetes” is no more. People with recurrent self-destructive behaviours have for a long time been classified as “brittle diabetics” and are more likely suffering borderline personality disorder. (Kalida Ismail, London, UK referencing Gill, 2001)

Complex algorithms to calculate insulin doses are being developed, which could one day inform a closed-loop pump, but they have to be individualised. (C. Mathieu, Gent, Belgium)

Testing for diabetic kidney disease has progressed a lot and there appears to be a consensus now that instead of the 24 hour or 3-night urine we should be having a Glomerular Filtration test – and the result should be over 60. (Marg McGill, RPA, Sydney)

A new study, 18 years on, from the important DCCT trial, has been released. The original DCCT people have been followed, and the two groups (“intensive therapy” and normal therapy) have now had their Hba1cs merge to be pretty much the same. However, the group that had the super tight control and low HbA1c in the original study still have less complications despite their a1cs having risen over time – conclusion being low HbA1c at any time is beneficial – and some are also saying that earlier in your disease course is especially beneficial (though no big studies been done on people who tighten up control later). (Marg McGill, RPA, Sydney)

Ageing on its own can create hypo unawareness. A study comparing non-Ds who were 22-40 and another group 60-70 found the hormone responses the same (Glucagon, epinephrine (adrenaline)) but symptoms and cognitive dysfunction from induced hypos happened later and lower in the older group. (Stephanie Amiel, London, UK)

Hypo unawareness will affect 25% of people who have had Type 1 for 15 years (Stephanie Amiel, London, UK)

Non-invasive continuous glucose testing is being investigated by at least a dozen, probably many more, small companies in Canada, US, Israel, Germany, UK and others. Most promising so far is a finger ring and watch contraption – data was presented at American Diabetes Association conference 2006. (J.S. Christiansen, Aarhus, Denmark)

Diabetic retinopathy (eye disease) screening can be done by any diabetes trained health professional – your endo, optometrist, etc - BUT they MUST dilate your pupils (put drops in) to check properly. (Marg McGill, RPA, Sydney)

Professional unawareness of hypoglycaemia is as big a problem as patient unawareness, in that our HPs often don’t understand the impact of hypos and don’t ask us about it often enough. (Stephanie Amiel, London, UK)

Psychological interventions for diabetes have shown to be effective for improving glycaemic control in children (a1c reduce by 0.5%) but not adults (only 0.2% reduction which isn’t statistically significant). (Kalida Ismail, London, UK)

Every second Australian with Type 2 seeing a GP also has kidney disease according to the NEFRON study recently done in Oz. Type 1s weren’t looked at in this study. (M Thomas, Melbourne)

Pancreas transplantation should be considered for any diabetic requiring kidney transplantation, either at same time or soon after. Evidence is strengthening to also indicate pancreas transplantation on its own for people with Type 1 and poor metabolic control and d complications other than kidneys. Pancreas transplants have been shown to improve complications. (Professor Boggi, Pisa, Italy)

The principles of DAFNE (in short, carb counting and insulin adjustment) can be taught and learnt effectively in regular out-patient clinic appointments. (Deborah Foote and Jane Overland, Sydney)

A psychological intervention to improve Hba1cs in Type 1 has been developed in the UK– combining Cognitive Behavioural Therapy and Motivational Enhancement Therapy, making 12 sessions – and training diabetes educators to deliver it – and it achieved 0.4% reduction in a1c and therefore deemed successful. I wasn’t quite so convinced, and from the questions I wasn’t alone, but interesting nonetheless.

Other Interesting Things from Cape Town

Living with Diabetes as a Muslim was a terrific presentation by Fazlyn Samsodien from Cape Town. She discussed not being able to fast for Ramadan (and the alternative available that not everyone seems to be aware of – paying a fidiya which is calculated by the Muslin Judicial Council each year - approx. 10 Rand ($2) day to feed someone who is needy), the traditional foods that are very fatty and sweet such as Koeksisten, and the positives such as the discipline and control that Islam teaches as being nicely compatible with the demands of living with diabetes.

Stem Cells came to life when Wendy McFarlane from University of Brighton gave the most articulate and brilliant presentation on stem cells I have ever seen - very complex, and didn’t dumb it down at all – but somehow managed to pull it together so that this incredibly complex area was still comprehensible. Magical!

The future is in stem cells, implantable pumps and other such research, and according to Denis Daneman, immediate past President of the Int’l Society for Paed & Adolescent Diabetes (ISPAD), if you are a young health professional and want to make some significant contributions to diabetes, this is where the most exciting area of work is going to be in the coming years – exciting for us patients too!

“Skin and diabetes” was on the agenda - the first time such a session has made it into a diabetes conference – a surprise to those of us with necrobiosis! – I went to the session, and unfortunately it skimmed over necrobiosis very quickly. Was, however, given by a Sydney dermatologist who seemed to know a lot about diabetes and skin, and one assumes necrobiosis – Dr Stephen Lee.

Living with complications session – Again, the first time for such a session and the Chair in his opening congratulated the organising committee for having a session on this topic. Again, what the ??

Finnish Diabetes Association presented some very brave data that only 60% of their committee members who have diabetes and 66% of their health professional committee members who knew the organisation's policies actually supported them and some other amazingly honest feedback they received from a huge audit of their regional committees. Frank and honest. Nice.

Reality Check and The Type 1 Diabetes Network at WDC

I have now published the stuff I presented in Cape Town, a poster and a short talk, onto our website.

And just to prove I was truly there, look, here's a quick pic of me doing my talk!

Subjecting myself to the same, mean, summarising that I just did to everyone else, here are the two things that I presented in Cape Town:

Complication screening rates are too low, and seeing more doctors doesn’t mean we are likely to keep up with it at any better rates. Australian adults with Type 1 use all sorts of different medical models for managing our diabetes. Only 60% of people we surveyed in May had had tests for kidney, eyes and nerves in the last year, like the international guidelines say we should, which is very worrying.

Health professionals had very different, but helpful, ideas about what types of information should be given to adults newly-diagnosed with Type 1 than people who had recently been diagnosed themselves thought that they needed, but the Starter Kit which we developed included the information topics that both people with diabetes and health professionals nominated as being necessary, and has been very successful: adopted by 226 centres across Australia.

Both abstracts, and my slides for the presentation, are now at the link just here.