Here's a breakdown of some of the highlights from Day 1 of the American Diabetes Association's (ADA) 82nd Scientific Sessions.
The American Diabetes Association’s (ADA) 82nd Scientific Sessions kicked off with a diverse array of educational and multidisciplinary sessions exploring a variety of topics and highlighting clinical strategies and emerging research in the field of endocrinology.
Below are some of the highlights from Day 1 of the ADA 82nd Scientific Sessions.
Top 5 Nutrition Controversies
Between misleading social media posts and flip-flopping news cycles, there’s a lot of confusion surrounding nutrition and health. That’s why it’s so important for healthcare professionals to provide evidence-based guidance to help patients, especially people with diabetes (PWD), make healthy food choices and optimize their overall health. To help clinicians do just that, the “Top 5 Nutrition Controversies” session featured Certified Diabetes Care and Education Specialists Ms. Maureen Chomko and Ms. Alison Evert, who discussed the following hot topics in diabetes care:
Meal & Snack Frequency: It’s often recommended for PWD to eat three meals and three snacks a day as eating more frequently is presumed to reduce hunger and body weight in addition to optimizing glucose management. But due to the lack of robust evidence, the effects of meal frequency on glucose management remain unclear. So to help translate the data that is known to clinical practice, Ms. Chomko stressed the importance of coordinating a patient’s eating plan with their medication since that can help reduce side effects. She also noted that high-energy breakfasts and low-energy dinners can improve glucose management, but when deciding on an appropriate approach, it’s important to consider the patient’s goals.
Macronutrients: According to data from the LOOK AHEAD trial, PWD eats similar amounts of macronutrients as the general public. But what further complicates this issue is that based on evidence from the ADA Nutrition Consensus Report, there’s not an ideal percentage of calories from carbohydrate, protein, and fat that can be recommended for all PWD. To help overcome this challenge, Ms. Chomko discussed shared decision-making. Even asking a simple question like “What are your nutrition goals?” can help clinicians individualize patients’ ideal macronutrient consumption based on health status and metabolic goals. Additionally, Ms. Chomko encouraged the referral of patients to Certified Diabetes Care and Education Specialists like herself, especially if the clinician doesn’t have the time to fully explore this topic with patients.
Food Labels: Ms. Evert began by noting that the term “net carbs” itself is misleading because it assumes that the blood glucose response from all fibers and sugar alcohols can be easily predicted and will have the same effect on everyone. But that just isn’t the case since not all fibers nor sugar alcohols are created equal. That’s why Ms. Evert stressed the importance of reminding patients to always look at food labels and to eat more fiber. This is especially important for PWD using insulin plans since they don’t need to subtract the grams of fiber from the total carbohydrate content to calculate their insulin doses. For sugar alcohols, Ms. Evert recommended educating patients on the glycemic effects of sugar alcohols and the importance of monitoring for GI effects.
Artificial Sweeteners: Artificial sweeteners are becoming more common in household products. And while the ADA notes that there’s not enough evidence to determine whether sugar substitute use definitely leads to a long-term reduction in body weight or cardiometabolic risk factors like glycemia, what we do know is that sugar-sweetened beverages are associated with a greater incidence of type 2 diabetes and cardiometabolic risk. Therefore, Ms. Evert noted that clinicians should encourage patients to drink water, coffee, or tea instead and that clinicians can further individualize their recommendations to patients by asking open-ended questions to learn more about their preferences and goals.
Very-Low-Carbohydrate/Ketogenic Diets (VLCKD): According to data, VLCKD works well for 6 months, as a study in PWD showed modest A1C reductions along with significant reductions in insulin and medication requirements for 6 to 12 months. But past the 12-month mark, no benefits were seen due to decreased adherence.
So to conclude, Ms. Evert said that VLCKD is safe for most PWD in the short term as long as their medication is adjusted and they are closely monitored. But when it comes to the long-term use of VLCKD, there’s scarce data on safety past two years, so it’s important to assess a patient’s goals to determine if it really is the best solution.
Discussing these five topics with patients can be challenging, but with the help of sessions and strategies like the above, clinicians can help clear up the confusion and help patients optimize their health.
COVID-19 & Diabetes
COVID-19 can impact several organs within the body, but do we understand the full scope of COVID-19’s impact on both diabetic patients and the pancreas in general? In a session titled “COVID-19 and Diabetes,” Dr. James Lo from the Weill Cornell School of Medicine led a discussion on the impact of COVID-19 on both pancreatic islets and macrophage-mediated inflammation to help us better understand this relationship.
Dr. Shuibing Chen from the Department of Surgery at Weill-Cornell Medical College began the session by reviewing Weill-Cornell Medical College’s ongoing research efforts using organoid models to study the impacts of COVID-19 on pancreatic islets, regions of the pancreas that contain its endocrine (hormone-producing) cells. Dr. Chen and her team used the analysis of several types of cells and organoids to study the following about COVID-19: disease permissiveness, host response, and immune-mediated host damage.
Based on clinical data, Dr. Chen concluded the following about each:
- Permissiveness: After examining which cells can be infected by COVID-19, Dr. Chen found that the disease infects primarily pancreatic islets, including pancreatic endocrine cells and pancreatic beta cells. After performing staining of a pancreatic sample for a COVID-19 patient, she also found that the beta cells can be infected.
- Host cellular response: Dr. Chen found that pancreatic islets respond to a COVID-19 infection in several ways, including a decrease in insulin production, significant changes in the EIF2 pathway, a significant increase in p-PKR and PRK, and an increase in both and intensity of and the number of stress granules in beta cells.
- Immune-mediated host damage: Based on the host cellular response and imaging mass cytometry of a COVID-19 pancreas, Dr. Chen found an increase in proinflammatory macrophage markers in COVID-19 infected pancreatic islets.
Following Dr. Chen’s results, Dr. W. James Melvin from the University of Michigan shared data on COVID-19 induced diabetic macrophage-mediated inflammation via SETDB2, a protein-coding gene.
Dr. Melvin began by explaining how COVID-19 patients experience something called a cytokine storm, or a profound inflammatory cytokine signature, and explained how high circulating levels of TNFa, IL-6, IL-8 correlate with disease severity and the chance of survival. And while managing pathologic inflammation can be a potential treatment for this kind of reaction, personalization of treatment and cell-specific therapy are needed to manage this storm.
But beyond the cytokine storm, patients with both COVID-19 and type 2 diabetes encountered even greater levels of inflammatory cytokines. And for these patients, macrophage-mediated inflammation has a key role in driving this cytokine response.
So to better understand this diabetic macrophage-mediated inflammation, Dr. Melvin and his team at the University of Michigan predicted a few hypotheses on histone methyltransferase SETDB2, IFNB regulation for macrophage-mediated; and the expression of SETDB2 in type 2 diabetes. He drew the following conclusions:
- The histone methyltransferase SETDB2 is downregulated in COVID-19 infection, which activates pathologic macrophage-mediated inflammation.
- IFNB regulates macrophage-mediated inflammation in part by increasing SETDB2 expression via a JAK/STAT3 pathway.
- Diminished expression of SETDB2 in T2D at baseline contributes to increased macrophage-mediated inflammation during COVID-19 infection, similar to a “double-hit,” and this can be reversed with administration of IFNB.
While there’s still plenty left for us to learn when it comes to understanding the relationship between COVID-19 and diabetes, the clinical data we’ve gathered can help us improve care for our COVID-19 patients.
Suicide and Self-Injury—Unveiling and Addressing the Hidden Nightmare in Diabetes
800,000 suicides occur globally every year, and suicide is three to four times more likely in patients with T1D. Identifying the relationship between suicide and diabetes and providing strategies to prevent suicide and self-harm was the topic on day 1 of the 2022 ADA in a session titled “Suicide and Self—Injury – Unveiling and Addressing the Hidden Nightmare in Diabetes.” Featuring Drs. Katherine Barnard, Yiduo Wu, Daniel Chernavvsky, and Ms. Kelly Close, this session helped shine a light on an important issue that is too rarely discussed.
Here is a breakdown of what each presenter discussed.
The Current Data Links Diabetes & Depression
First up, Dr. Katharine Barnard of the Southern Health NHS Foundation Trust outlined the relationship between depression and diabetes. Depression is diagnosed in 7 to 25 percent of the American and European population, and the risk of depression is 2-3 times higher in those with diabetes.
Several potential factors link depression and diabetes.
- Diabetes management is a complex burden for patients
- Diabetes may cause questions of self-worth and fear of the future
- The stigma of diabetes can be psychologically damaging
Dr. Barnard was quick to point out that technology and current diabetes treatment options are not to be blamed for an increased risk of suicide in diabetes patients. While diabetes patients suffering from suicidal thoughts may use insulin and self-administered treatment devices to commit suicide, it is the mental burden of diabetes that should be closely examined as the cause of these actions.
RESCUE Collaborative Community on Suicide & Self-Harm in Diabetes
The next presenter, Dr. Yiduo Wu of the U.S. Food and Drug Administration, highlighted the efforts of the RESCUE Collaborative Community, a group of medical professionals, academics, state and federal agencies, patients, industry leaders, and more dedicated to reducing suicide rates in diabetic patients.
Dr. Wu also outlined the FDA’s commitment to enhancing device safety through a better understanding of suicidal ideation.
Identifying & Addressing Risk Factors of Isolated Self-Injury or Suicide in Routine Clinical Care: Meeting Needs of HCPs in Supporting Their Patients
The next presenter, Dr. Daniel Chernavvsky of the University of Virginia, provided the results of a recent survey conducted among healthcare professionals who treat diabetic patients. This survey was focused on depression, self-injury, and suicide.
According to the survey, 38% of T1D patients and 35% of T2D patients experienced depression, and less than 10% of both T1D and T2D patients had suicidal ideation.
The survey showed that while most HCPs had at least a moderate level of comfort in asking patients about self-harm and suicide, some HCPs felt very uncomfortable asking such questions. These HCPs cited a lack of knowledge and resources as reasons why they felt uncomfortable asking patients about these issues.
Assessing Depression, Suicide, & Self-Harm: What Can We Do in Routine Care
Dr. Shideh Majidi, associate director of diabetes services at the Children’s National Hospital, was the next presenter and provided insight on screening for depression. Dr. Majidi emphasized the importance of regular depression screenings and recommends HCPs move away from the idea that depression screening is an added or extra step of diabetes treatment.
Dr. Majidi recommends the use of patient health questionnaire 9 (PHQ-9) as a tool for screening. She also illustrated the use of the Depression Screening Change Package, a practical guide designed to help HCPs make informed decisions.
Partnerships Among RESCUE: Advocacy & Industry to Address Suicide & Self-Harm in Diabetes
The final presenter, Kelly Close, founder, and president of Close Concerns, a diabetes consultancy, reiterated the need for greater mental health care. She emphasized the isolation and hopelessness some diabetic patients may feel could lead to ideations of self-injury and suicide.
According to Close, establishing a social community and normalizing diabetes will help eliminate the stigma surrounding the disease.
The First Steps to Prevent Self-Harm & Suicide in Diabetic Patients: Research & Resources
There is a clear link between diabetes and depression. To prevent suicide and self-injury HCPs should have open and honest discussions with their patients, accurately screen for depression, and be equipped with the resources necessary to make a positive impact on the lives of their patients.