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On the Cutting Edge of Diabetes Care
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Diabetes researchers are dancing with the stars and turning the spotlight on the true complexity of how we metabolize glucose. The pathophysiology of diabetes is proving far more complex than a tango between insulin and glucose and is being revealed as a full-scale Broadway musical production, featuring genetics, immunology, and many of the body’s systems.
“We are understanding [type 1] and [type 2] diabetes in a whole different way,” says Martha J. Price, RN, DNSc, ARNP, CDE, a diabetic educator from the Group Health Cooperative in Seattle. “There is a very complex circuit of dynamics that work in concert.”
•The hype about genotype
A sampling of current research includes a March 2008 report from an international team, including scientists from the National Human Genome Research Institute. They have discovered six new genetic variants involved in type 2 (T2) diabetes, boosting to 16 the total number of genetic risk factors associated with increased risk of the disease.
Researchers say the new genes provide insight into the pathophysiology of T2 diabetes and hope future genetic testing will identify people with an unusually high or low risk and lead to new modalities for treatment and prevention.
•Immunology
At the Joslin Diabetes Center in Boston, researchers are investigating the immune mechanisms that trigger the development of type 1 (T1) diabetes, an autoimmune disease caused by the destruction of insulin-secreting pancreatic islet-cells by T lymphocytes.
Researchers are hoping their work will lead to early prediction of disease and pre-onset treatment strategies. This includes immunomodulatory therapy, which hinders lymphocytes from attacking the pancreas, and a method to monitor the efficacy of immunomodulatory therapy.
•The brain and skeletal system
New studies are showing the brain itself contains its own insulin receptors and plays a big role in glucose control, and the skeletal system holds another key to understanding diabetes. Researchers at Columbia University Medical Center in New York have found bone cells release a hormone called osteocalcin, which boosts the number of insulin-producing beta cells, which are located in the pancreas.
Osteocalcin also directs fat cells to release a hormone called adiponectin, which improves insulin sensitivity. Scientists say an increase in osteocalcin activity prevents the development of T2 diabetes and obesity in mice. People with T2 diabetes have been shown to have low osteocalcin levels, suggesting that altering the activity of this molecule could become an effective therapy.
•New drugs
Recent discoveries of the roles other hormones and body systems play in glucose regulation have resulted in the development of new diabetes medications.
Byetta (exenatide) is used to treat T2 diabetes, and is an injectable, synthetic version of a hormone found in the saliva of the Gila monster. It is an incretin mimetic drug, which mimics the actions of naturally occurring human hormones produced by the intestines. Its effects include signaling the pancreas to make the right amount of insulin and blunting glucose release from the liver.
Januvia (sitagliptin) is used to treat T2 diabetes and is an oral DDP-4 inhibitor (blocker). DPP-4 blockers enhance the body’s own ability to control blood sugar levels by increasing insulin when blood sugar is high and reducing the amount of sugar made by the liver after eating.
Symlin is an injectable, synthetic form of the human hormone amylin, which is secreted by the pancreatic cells. People with T1 or T2 diabetes may produce too little amylin, which works in partnership with insulin to balance glucose levels.
•Surgical developments
Surgical treatments for diabetes are also on the cutting edge. Gastric banding, which treats morbid obesity by placing a band at the top of the stomach – thereby limiting food intake – can improve T2 diabetes through massive weight loss.
Even more exciting is the recent discovery that gastric bypass procedures, which reroute the GI tract to bypass the duodenum and jejunum, result in diabetes remission. This happens even when not accompanied by significant weight loss and even appears to work in patients who are not obese.
“With gastric banding, patients lose weight but may not always get the kind of glucose reduction that is desired,” says Price. “What we see after successful gastric bypass is that these patients often no longer require medication.”
An experimental surgical procedure to treat T1 diabetes is pancreatic islet transplantation. In this procedure, islets are taken from the pancreas of a deceased organ donor and transferred into another person. Beta cells in these islets then begin to make and release insulin.
•Self-management support
Another advance in the treatment of diabetes is in the arena of building evidence for patient self-management support.
“This is the one area that truly involves the RN,” says Price. “RN assessment and self-management care planning can be the key for patient success. Furthermore, it is most likely the RNs who will be following up and providing the consistency of care oversight that is needed.”
The American Association of Diabetes Educators (AADE) has developed a seven-point behaviors plan and fashioned it into a system called the National Diabetes Education Outcomes. Through this system, diabetes educators and other qualified professionals provide ongoing support for patients in the areas of food, activity, medication management, monitoring, coping, problem-solving, and risk-reduction behaviors.
The National Diabetes Education Outcomes system includes standardized data collection tools for the participant, educator, and program manager, and provides reports at the individual, program, and national levels.
“This is also the area where RNs can be most effective in helping patients with problem-solving, a critical skill, so that they learn their own glycemic patterns and how to make appropriate adjustments in food, activity, and meds,” says Price. “It is essential that these RN skills are valued, measured and associated with diabetes outcomes such as improved compliance and glycemic control.”
