European Association for the Study of Diabetes 2020 Annual Meeting

EASD 2020

A study of more than 2250 patients from 10 hospitals is highlighting the benefits of weight loss surgery, particularly gastric bypass, on remission of 

Results of the study, which examined the effects of Roux-en-Y gastric bypass (RYGB) and laparoscopic gastric banding (LAGB), suggest more than half the patients undergoing RYGB achieved long-term remission and also offer insight into characteristics and predictors of diabetes remission in patients undergoing either procedure.

"If a patient with type 2 diabetes is considering weight loss surgery, choosing gastric bypass soon after diagnosis can increase their chance of remission or achieving a blood sugar level that does not need treatment," said lead investigator Jonathan Purnell, MD, of the Oregon Health & Science University, 

. "Our large study confirms the importance of weight loss on inducing diabetes remission, but also finds gastric bypass has benefits independent of weight. If we can understand what these benefits are, it could lead to new diabetes treatments."

After previously publishing data comparing 3-year diabetes remission rates following LAGB or RYGB, Purnell and a team of colleagues sought to evaluate long-term remission and predictors of diabetes remission in a cohort of severely obese patients. Their previous study, the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study, enrolled 2467 adult participants from 2006-2009 at 10 centers across the US. From this study, investigators identified a total of 2256 patients with at least one year of follow-up.

Of the 2256 included in the current study, 827 (37%) had diabetes and 50% of had information related to duration of diabetes available. Of those with diabetes, 43% reported taking one non-insulin medication, 32% reported taking 2 or more non-insulin medications, and 36% reported taking insulin. For the purpose of analysis, investigators defined being nondiabetic at follow-up as not taking diabetes medications, not self-reporting a diagnosis of diabetes, and must have an HbA1c of 5.7% or less or a fasting glucose of 5.6 mmol/L or less if HbA1c was not available.

Upon analysis, investigators found diabetes remission occurred in 57% (46% complete, 11% partial) after RYGB and in 22.5% (16.9% complete, 5.6% partial) after LAGB at 7 years. Compared to diabetics who did not achieve complete or partial remission during the first year of follow-up, results indicated those who did were more likely to be younger, have shorter diabetes duration, lower HbA1c levels, and were less likely to need more than one non-insulin diabetes medication or use insulin.

During the follow-up period, diabetes remission peak between 2-3 years after both procedures before declining during the 7-year follow-up period. The peak decline among those undergoing RYGB was 62% remission (51% complete, 11% partial) and this decline to 57% (46% complete, 11% partial) at year 7. Among those undergoing LAGB, diabetes remission peaked at 29.1% (22.6% complete, 6.5% partial) before declining to 22.5% (16.9% complete, 5.6% partial) at year 7. Results indicated post-operative diabetes remission for both RYGB and LAGB groups was more likely in patients who were younger, had shorter diabetes duration, and had better baseline HbA1c levels that required fewer diabetes medications or need for insulin at baseline.

Further analysis suggested reduced HOMA-IR could serve as a predictor of remission among patients undergoing LAGB while increased HOMA-B helped to predict remission in patients undergoing RYGB. In analyses adjusted for weight loss, results indicated the probability of diabetes remission was greater among those undergoing RYGB than LAGB at all follow-up time points, increasing from an adjusted relative risk of 1.86 the first post-operative year to 3.96 at 7 years.

Diabetes Remission Status During Seven-year Follow-up of the Longitudinal Assessment of Bariatric Surgery Study

The Journal of Clinical Endocrinology & Metabolism.

Articles

Analysis of 7-year follow-up data from an observational study of severely obese patients details the effects of gastric bypass and gastric banding on long-term diabetes remission. 

Study Finds Gastric Bypass Leads to Diabetes Remission in More than 50% of Patients

New research from an analysis of more 3500 patients with 

 is giving clinicians further insight into the relationship between HbA1c variability and risk of all-cause mortality in diabetic patients.

A secondary analysis of the Look AHEAD study, results suggested those in the highest quartile of HbA1c variability were at a 2-times greater risk of all-cause mortality and more than a 3-times greater risk of 

 when compared to those in the lowest quartile of glycemic variability.

“Our findings underscore the need of a consistent and less variable glycemic control over time and indicate that HbA1C variability is potentially a better marker of long-term glycemic variability than fasting plasma glucose variability,” wrote study investigators. “Our results also suggest that long-term glycemic variability, especially that measured by HbA1C may capture the metabolic memory effect, which has been shown to be detrimental in terms of outcomes in diabetes.”

With the burden of diabetes continuing to grow in the US and throughout the world, a team led by investigators from Johns Hopkins University sought to develop a greater understanding of how long-term variability of glycemic markers might predict negative outcomes in patients with type 2 diabetes. Using the Look AHEAD trial, which was designed to assess the effects of intensive lifestyle intervention versus an education intervention on cardiovascular outcomes, investigators had access to data from more than 5000 participants with a median follow-up of 9.6 years.

From the multicenter, randomized clinical trial, investigators identified a cohort of 3560 participants with data related to HbA1c and fasting plasma glucose (FPG) measurements at baseline, 12 months, 24 months, and 36 months. In addition to participants missing glycemic marker data, investigators also excluded those who had cardiovascular disease, heart failure events or died before the 36-month visit and those with consent restrictions or prevalent CVD at baseline.

The goal of the current analysis was to assess the effects of HbA1c and FPG variability, separately, on all-cause mortality, cardiovascular mortality, incident heart failure, and a composite cardiovascular endpoint of myocardial infarction, hospitalization for angina, stroke, and death from cardiovascular causes.

For the purpose of analysis, age, sex, race/ethnicity, randomization arm, cigarette smoking status, alcohol consumption, body mass index (BMI), use of antihypertensive medication, duration of diabetes, and eGFR were used as covariates in adjusted models. Investigators also noted data obtained from baseline through the 4 study visits were used to calculate average systolic and diastolic blood pressures, average ratio of total to HDL cholesterol, average FPG, and average HbA1c for study participants.

The 3560 participants included in the study had a median follow-up of 6.8 years. Over the follow-up period, 164 deaths from any cause, 33 cardiovascular-related deaths, 91 heart failure events, and 340 events meeting the composite cardiovascular endpoint.

In adjusted analyses comparing those in the highest quartile of standard deviation (SD) of HbA1c, results suggested those in the highest quartile were at increased risk of all-cause mortality (HR, 2.10; 95% CI, 1.26-3.51), cardiovascular mortality (HR, 3.43; 95% CI, 0.95-12.38), heart failure (HR, 1.71; 95% CI, 0.69-4.24), and the composite cardiovascular endpoint (HR, 1.01; 95% CI, 0.69-1.46). Analyses comparing highest to lowest quintiles of SD for FPG revealed equivalent HRs 1.66 (95% CI, 0.96-2.85) for all-cause mortality, 2.20 (95% CI, 0.67-7.25) for cardiovascular mortality, 2.05 (95% CI 0.80 to 5.31) for heart failure, and 0.94 (95% CI, 0.65-1.35) for the composite cardiovascular endpoint.

“Our findings have potential implications, as these add to the growing body of evidence on the prognostic value of glycemic variability,” investigators noted.

Investigators pointed out multiple limitations within their study. These included the observational design of the study, excluding patients who died during the first 36 months of follow-up, and the inability to evaluate 2-hour post oral load glucose level.

Long-term variability of glycemic markers and risk of all-cause mortality in type 2 diabetes: the Look AHEAD study

An analysis of the Look AHEAD study by investigators at Johns Hopkins details associations between long-term variability of glycemic markers and increased risk of all-cause and cardiovascular mortality.

Greater Long-Term HbA1c Variability Increases Risk of All-Cause, Cardiovascular Death

A 62-year-old man with a long history of type 2 diabetes went to a dermatologist after a rash that had been diagnosed as eczema by his primary care doctor failed to resolve with treatment after nine months. In fact, it seemed to have worsened despite his careful adherence to treatment recommendations. The lesions developed first on his lower extremities but were now widespread and included his face and perianal region. The lesions were annular and sometimes serpiginous with crusting and distinctive borders with central clearing. The patient said the lesions could be quite itchy. Over the same period of time he had also noticed some weight loss and a few bouts of abdominal pain and diarrhea. Blood tests revealed mild anemia but were otherwise normal.

Can you diagnose the patient? Use the Differential Builder in VisualDx to help you: 

Learn more about this diagnosis on the VisualDx site: 

Check out this month's Image IQ from VisualDx. This month's quiz features a 62-year-old patient with type 2 diabetes and a persistent rash that was originally diagnosed as eczema.

Image IQ: 62-Year-Old Diabetic with Persistent Rash


A 30-ish-year-old male with no prior surgeries or significant medical history presents to the emergency department for vomiting, generalized abdominal pain and tenesmus. He denies any fever, diarrhea, bleeding, or other complaints. He said that he has had this a few times in the past but never this bad. He was hospitalized for it once, about 3 months ago, and they did not find a cause.

Vital signs are normal except for a pulse of 118 and BP of 153/94. He is afebrile. A physical exam is otherwise normal except for severe apparent distress and retching into a bag. Except for mild epigastric tenderness the abdomen is benign.

: bicarb = 13, lactic = 6.5, glucose =181, potassium = 3.1, acetone level = 56

Our latest case report from Dr. Brady Pregerson features a man in his 30s presenting with vomiting, generalized abdominal pain, and tenesmus. Can you determine the correct diagnosis?

Case Report: Man in 30s w/ Vomiting, Abdominal Pain, & Tenesmus  

A new study from a team at Brigham and Women’s Hospital and Harvard Medical School details the benefit of adhering to a Mediterranean diet for preventing 

Results of the study, which assessed impact of dietary choices in a cohort of 25,000 women over 20 years, indicate greater adherence to a Mediterranean diet was associated with a 30% lower risk of type 2 diabetes.

"Our findings support the idea that by improving their diet, people can improve their future risk of type 2 diabetes, particularly if they are overweight or have obesity," said study investigator Samia Mora, MD, MHS, of the Brigham's divisions of Preventive Medicine and Cardiovascular Medicine and an associate professor at Harvard Medical School, 

. "A lot of the benefit we see can be explained through just a few pathways. And it's important to note that many of these changes don't happen right away -- while metabolism can change over a short period of time, our study indicates that there are longer term changes happening that may provide protection over decades."

With an interest in closing the knowledge gap related to diabetes onset and nutrition, investigators designed their study as an analysis of data from the Women’s Health Study. From the study, which included 28,345 women who voluntarily provided blood samples, investigators identified 25,317 women for inclusion in their study.

All patients included in the current study were free of diabetes and had completed validated semiquantitative food-frequency questionnaires, which assessed intake of 131 food items, at baseline. The mean age of the study population was 52.9 (9.9) years and they had a mean follow-up time of 198 (5.8)years.

For the purpose of the analysis, Mediterranean intake scores ranging from 0-9 were calculated for each patient. The primary endpoint of the study was incident cases of type 2 diabetes. Investigators also hoped to assess what proportion of risk reduction was explained by risk factors and biomarker changes.

Upon analysis, investigators found scores of 6 or more were associated with as much as a 30% lower risk of developing type 2 diabetes (age-adjusted and energy-adjusted HR, 0.70; 95% CI, 0.62-0.79; when regression models were additionally adjusted with BMI: HR, 0.85; 95% CI, 0.76-0.96) compared to those with scores of 3 or less. Further analysis indicated biomarkers of insulin resistance were responsible for the largest proportion of risk reduction (65.5%), followed by BMI (55.5%), high-density lipoprotein measures (53.0%), and inflammation (52.5%). Results suggested smaller contributions were linked to changes in branched-chain amino acids (34.5%), very low-density lipoprotein measures (32.0%), low-density lipoprotein measures (31.0%), blood pressure (29.0%), and apolipoproteins (23.5%)—changes in HbA1c accounted for less than 2% of the risk reduction.

In potshot analyses, investigators found the inverse associations of adherence to a Mediterranean diet and type 2 diabetes was only present in women with a BMI of 25 or greater at baseline (age- and energy-adjusted HR, 1.01; 95% CI, 0.77-1.33; 

"Most of this reduced risk associated with the Mediterranean diet and type 2 diabetes was explained through the biomarkers related to insulin resistance, adiposity, lipoprotein metabolism and inflammation," said study investigator Shafqat Ahmad, PhD, a researcher in the Molecular Epidemiology Unit at Uppsala University, Sweden, in the aforementioned statement. "This understanding may have important downstream consequences for the primary prevention of diabetes disease."

Association of the Mediterranean Diet With Onset of Diabetes in the Women’s Health Study

An analysis of data from more than 25k women suggests greater adherence to a Mediterranean diet was linked to a lower risk of developing diabetes.  

Mediterranean Diet Linked to 30% Lower Diabetes Risk in Women

This article was originally published on 

Results from an analysis of data from the Women’s Health Initiative is detailing the impact of increased sedentary behavior on heart failure risk in older women.

Results of the study suggest women spending 9.5 hours or more sitting or lying down each day had a 42% higher risk of being hospitalized with heart failure than women who spent 6.5 hours or less engaged in sedentary behavior, underlining the importance of emphasizing physical activity in aging patients.

"For heart failure prevention, we need to promote taking frequent breaks from prolonged sitting or lying down, in addition to trying to achieve guideline levels of physical activity, such as those recommended by the American Heart Association," said lead investigator Michael LaMonte, PhD, MPH, research associate professor of epidemiology in the School of Public Health and Health Professions at the University at Buffalo, in a 

statement from the American Heart Association

. "Very few studies have been published on sedentary time and heart failure risk, and even fewer have focused on older women in whom both sedentary behavior and heart failure are quite common."

With a knowledge gap related to associations of heart failure and sedentary behavior in older patient populations, LaMonte and a team of colleagues from institutions across the US designed their study with the aim of determining the impact of sedentary behaviors on heart failure risk in older women. Investigators designed their study as a prospective analysis of data from the Women’s Health Initiative, which contains data on more than nearly 90,000 postmenopausal women.

Eliminating women with heart failure at enrollment and those with the inability to walk one block without assistance, investigators identified a cohort of 80,982 women aged 50-79 years for inclusion in their analysis. Women included in the study were also required to have completed questionnaires, which included assessments of sedentary behavior, at baseline and years 3, 6, and 9.

Sedentary behavior was assessed using 2 questions. The first question assessed how many hours per day were spent sitting, including time at work, sitting at the table eating, driving or riding a car or bus, and sitting up watching TV or talking. The second question assessed how many hours per day were spent lying down or with their feet up, including time spent sleeping or trying to sleep at night, resting or napping, and lying down watching TV. Respondents were given 8 response options ranging from less than 4 hours to 16 or more hours per day.

The mean age of the study cohort was 63 years, 84.9% were White, 45% reported menopausal therapy use, and the mean reported time spent engaging in sedentary behavior per day was 7 hours. Investigators pointed out 11% of patients reported no recreational physical activity. A total of 1402 incident cases of heart failure hospitalization were observed over a mean follow-up of 9 years.

For the purpose of analysis, women were categorized according to sedentary time. These groups were defined as having less than 6.5, 6.6-9.5, or more than 9.5 hours per day of time spent sitting or lying down and, for additional analysis, as 4.5 or less, 4.6-8.5, or more than 8.5 hours per day spent sitting. Of note, the groups spending less than 6.5 hours per day sitting or lying down and those spending 4.5 or less hours per day sitting were used as reference groups.

When controlling for confounding factors, including age, race-ethnicity, education, income, smoking, alcohol, menopausal hormone therapy, and hysterectomy status, results of the analysis indicated heart failure risk increased across incremental trestles of total sedentary behavior ([6.6-9.5 hours: HR, 1.15; 95% CI, 1.01-1.31], [More than 9.5 hours: HR, 1.42; 95% CI, 1.25-1.61], 

 for trend <.001) and sitting time ([4.6-8.5 hours: HR, 1.14; 95% CI, 1.01-1.28], [More than 8.5 hours: HR, 1.54; 95% CI, 1.34-1.78], 

for trend<.001) compared to reference groups.

Further analysis indicated these trends remained significant after adjusting for additional factors, such as time-varying myocardial infarction and coronary revascularization (Total sedentary behavior HRs, 1.00, 1.11, 1.27; sitting HRs, 1.00, 1.09, 1.37; trend 

<.001 each) and for baseline physical activity (Total sedentary behavior HRs, 1.00, 1.10, 1.24; sitting HRs, 1.00, 1.08, 1.33; trend 

<.001 each). Investigators pointed out associations with sedentary behavior exposures did not differ based on age, race-ethnicity, BMI, physical activity, physical functioning, diabetes, hypertension, or coronary heart disease.

"These findings are consistent with other studies confirming that people with more daily sedentary time are more likely to develop chronic health conditions such as diabetes, high blood pressure, heart attack, stroke and premature death from heart disease and other causes," LaMonte added.

Association of Sedentary Time and Incident Heart Failure Hospitalization in Postmenopausal Women,

An analysis of data from the Women's Health Initiative suggests spending more than 6.5 hours engaged in sedentary behaviors each day was linked to a 42% increase in risk of heart failure in older women.

Increased Sedentary Behavior Raises Heart Failure Risk in Women

Improving treatment and diagnosis of osteoporosis is an issue that clinicians have been attempting to address for years. Unfortunately, what many specialists consider to be the most effective treatments can come with the potential for adverse side effects. However, some of these same specialists argue the risk of adverse events is sometimes misunderstood or overblown.

With an interest in learning more about this issue and the use of biphosphonates in treatment of osteoporosis, we reached out to Jeffrey Curtis, MD, MS, MPH, a professor of medicine at the University of Alabama at Birmingham.

Videos

Jeffrey Curtis, MD, MS, MPH, details how the perception of biphosphonates has been detrimental to efforts to improve treatment and diagnosis of osteoporosis.

Controversies in Using Biphosphonates for Treating Osteoporosis 

While politics in medicine may seem like a new trend in 2020. Some clinicians will tell you bluntly, there are a lot of politics going on in medicine. One of the areas where lines have been blurred the most in recent memory is the field of diabetes care.

In the year 2000, the thought of somebody besides an endocrinologist taking lead in the treatment of diabetes might have been a laughable notion, but now it is a serious discussion with input from a slew of parties. While everyone has their own opinion, there are multiple facts to account for when discussing the topic.

As it stands, endocrinologists are in short supply, they treat dozens of conditions, and the number of patients with diabetes is growing. Just based on this alone, some would suggest an intervention, such as the creation of a new subspecialty, is already overdue. However, many endocrinologists would argue they are still the best equipped to treat these patients and arguing for the creation of a cardiometabolic subspecialty only detracts from endocrinology as a field.

In this 3-part feature series, we attempt to tackle to topic from the perspective of the 3 specialists most often to be included in the conversation: an endocrinologist, a cardiologist, and an internal medicine practitioner. With their own unique viewpoints, each approaches the discussion from the outlook of specialists in their field and whether the creation of a cardiometabolic subspecialty would help in the management of these patients.


Cardiometabolic Health Fellowships: The Answer or Part of the Problem?

Gregory Weiss, MD: Has the Time Come for a Cardiometabolic Subspecialty?

Simon Murray, MD: Who Should Be Treating Patients with Diabetes?

In this 3-part feature series, an endocrinologist, a cardiologist, and an internist tackle the topic of who should be in charge of treating patients with diabetes and whether the creation of a cardiometabolic specialty is a worthwhile endeavor.

Cardiometabolic Health: The Future of Diabetes Care or an Unnecessary Diversion?

Simon Murray, MD, is a former internist with multiple decades of experience in clinical practice. 

“The art of medicine is keeping the patient amused while the disease runs its own course.”

If this quote, attributable to Voltaire, made you think of diabetes, you wouldn’t be wrong… until the last decade. Recently, new advances in diabetic medicines have improved the outcomes for people with diabetes, particularly those with cardiovascular disease.

Trends show declining mortality from diabetes with patients with cardiovascular disease in wealthy countries.

 SGLT2 inhibitors developed for type 2 diabetes have shown a cardioprotective effect due to reduction of plasma volume from continuous urine glucose excretion without activating renin-angiotensin system and sympathetic nervous system—recent trials demonstrate this improvement in heart failure risk is even seen in nondiabetic patients.

Due to previous failures among glucose-lowering medications, the US FDA mandated that new diabetes medications undergo trials for cardiac safety in 2008. The unexpected benefit of this was the discovery of several new diabetic medicines that worked by unique mechanisms other than simply lowering glucose levels. Traditional hypoglycemic drugs through various mechanisms of action lower blood glucose and effectively reduce microvascular target end-organ damage like retinopathy, nephropathy, and neuropathy. However, they do not improve macrovascular end organs like coronary arteries. Worse yet, some agents like thiazolidinediones increased the risk of congestive heart failure and myocardial infarction.

A pair of landmark trials, CANVAS and EMPA-REG outcome, both showed reductions in all-cause mortality, cardiac mortality, and admissions for congestive heart failure using SGLT2 inhibitors.

 The demonstrated benefit was independent of the favorable effect on serum glucose levels, and the low risk of hypoglycemia.

Glucagon-like peptide 1 (GLP-1) analogues are a class of injectable hypoglycemic drugs that activate the endogenous GLP-1 receptor. They promote glucose-dependent insulin release, inhibit glucagon secretion, and delay gastric emptying.

 The LEADER trial showed that liraglutide was superior to placebo in reducing the primary composite outcome of CV death, MI, and stroke (13% vs 14.9% in placebo; 

=.01). The reduction in the primary endpoint was driven by significantly lower CV mortality (4.7% vs. 6%; 

=.007). Moreover, liraglutide reduced all-cause mortality as well (8.2% vs. 9.6%; 

 SUSTAIN-6, also showed composite CV event reduction (6.6% vs 8.9%; 

=.02) with semaglutide, which was driven by a significant reduction in strokes (1.6% vs. 2.7%; 

Since most of the risk reduction is due to cardiac disease reduction, it raises the question: who should manage diabetes?

Several studies have shown that patients with diabetes fare better when treated by endocrinologists compared to primary care doctors. A retrospective, 4-year study was done comparing several measures of compliance with diabetes guidelines between primary care doctors and endocrinologists. In this study, the endocrinologists were better on every measure.

That study came as no great surprise since endocrinologists are better trained to treat diabetes.

Changing views about diabetes have begun to shift the focus on diabetes care from merely controlling blood sugar to treating all the metabolic dysfunctions that accompany diabetes. The protein adipsin, which is produced in body fat, helps protect insulin-secreting cells called pancreatic beta cells from destruction in type 2 diabetes, according to a study by researchers at Weill Cornell Medicine and New York-Presbyterian. By targeting this protein, beta cell function could be preserved, and insulin would remain normal.

So, should diabetes be managed by cardiometabolic specialists?

In practice, most people with diabetes are treated by their primary care doctor either by default or with whom they have a long-term relationship. They are better able to spot status changes and keep better track of complications. Shouldn’t the internist oversee managing diabetes? The following medical axioms may shed some light on this mostly theoretical discussion.

Good doctors treat people, not diseases. It makes the case that maybe we are all different and there is no right choice.

Patients do better with physicians they know and trust and who make them comfortable. People with long term relationships with primary care doctors generally live longer.

Until recently, the outcome in type 2 diabetes was dismal and many physicians, including some endocrinologists, didn’t want to treat diabetes. It is time-consuming and pays poorly. The outcome of people with type 1 diabetes changed dramatically in 1922 with the discovery of insulin but results for type 2 diabetes stagnated for decades. An endocrinologist told me the worst thing that happened to the treatment of Type 2 diabetics was insulin discovery. We thought insulin would solve all our problems, not realizing that T1D and T2D are completely different diseases and lowering blood glucose was not the only way to prevent complications. Four decades passed before new research into the pathophysiology of diabetes began. We now think of diabetes as a cardiometabolic syndrome, not just a blood sugar issue.

There are 6400 endocrinologists in the US with 123 new graduates every year. The supply is shrinking. These doctors are the best trained to treat diabetes, but they can’t do it and some may not want to treat diabetes. The CDC reports there are 25 million Americans with diabetes in the US and 79 million more with prediabetes. Endocrinologists are the lowest paid of all Internists, and it is challenging to attract top American students.

Cardiologists in the US are, generally, more interested in interventions than the prevention of cardiac disease. I know that comment may be unsettling to some, but, unfortunately, in my experience it is true. How will the cardiologist deal with a patient with urinary frequency, blurred vision, or unexplained weight loss? The answer is most likely that the patient will be referred to a urologist, an ophthalmologist, or a gastroenterologist, respectively, and all three of those conditions are common symptoms in diabetes.

The person most likely to see the big picture is the primary care doctor. People with diabetes get all kinds of odd symptoms, involving many organ systems. They are best managed by being seen by the same physician regularly with scheduled monitoring of the toenails, circulation in the feet, the urine albumin, the health of the retina, sexual functioning, body fat, mental status, blood pressure, lipoproteins, Adiponectin, TMAO, A1c, dietary habits, the 46 miles of nerves that feel like fire or being stung by a thousand bees when damaged, or the 6-8 meters of intestine that can be paralyzed by autonomic dysfunction. It’s a lot to remember and it takes regular follow-up—having the cooperation and trust of your patient will make this easier

Even asking which specialist should manage diabetes highlights the main problem facing people with chronic disease in our medical system. The question itself shows how little many physicians value collaboration and communication. Patients with diabetes ultimately see dozens of specialists who are slow to communicate their findings or quick to change medications and treatment plans, which fragments care and causes confusion. There has been a gradual deterioration in collegiality and respect between primary care and specialists. It is pervasive and real.

Many times, specialists communicate through a third party like a physician assistant or nurse practitioner because they are too busy to talk directly to the primary care doctor. There may not be any intentional disrespect, but I am offended when a doctor only speaks to me through a third party. If there were ever a disease that epitomized the need for all players to be on the same page, it’s diabetes. The patients do best with a primary care doctor for their quarterback who knows the game, understands the rules and cooperates, and communicates cohesively with his teammates of dieticians, nurse educators, psychologists, cardiologists, endocrinologists, and surgeons. No one can do it alone. Teamwork. That’s the way it works best.

There is one essential caveat. The primary care doctor must keep up with the quickly changing technology by reading, attending meetings, and asking questions. If the quarterback can’t call the right play at the right time, the game will indeed be lost. Diabetes is very patient and a rapacious predator that methodically destroys people’s lives right under the nose of the ill-informed physician; however, good his intentions.

In the last of our 3-part series examining the idea of a cardiometabolic subspecialty, Simon Murray, MD, offers his thoughts on who should be treating patients with type 2 diabetes. 

Few fields have experienced the growth in therapies and technologies as diabetes management in recent years. With such an explosion in therapies and constant growth in diabetes technology, picking and choosing what approaches are most appropriate for each patient has become a unique situation.

For more on the topic, check out this interview with Marie E. McDonnell, MD, an endocrinologist and director of the Brigham Diabetes Program at Brigham and Women’s Hospital and a lecturer on medicine at Harvard Medical School, from Medical Economics.

An endocrinologist from Brigham and Women’s Hospital discusses the latest in diabetes management. 